Osteotomies around the hip
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The document discusses osteotomies around the hip, including pelvic and proximal femoral osteotomies. It covers indications, classifications, principles, techniques for various osteotomies like Salter, Steel, Ganz, Pemberton, Dega, Chiari, Schanz, Lorenz, and femoral osteotomies for conditions like slipped capital femoral epiphysis, Perthes disease, congenital coxa vara and non-unions. Post-operative principles and complications of osteotomies are also discussed.
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Osteotomies around the hip
- 1. DISCUSS OSTEOTOMIES AROUND THE HIP By Dr Kabiru Salisu Senior Registrar NOH Dala Kano 16th Feb. 2018
- 2. OUTLINE • Introduction • Biomechanics of hip joint • Indications / Contraindications • Classification • Principles of osteomy around the hip • Pelvic osteotomies • Proximal femoral osteotomies • Complications • Conclusion • References Discuss Osteotomies Around the Hip
- 3. INTRODUCTION • An osteotomy is a surgical corrective procedure used to obtain a correct biomechanical alignment of the extremity so as to achieve equivocal load transmission, performed with or without removal of a portion of the bone. Discuss Osteotomies Around the Hip
- 4. • Hip joint preserving osteotomy is the treatment of choice for young patients with early symptomatic structural abnormalities of the acetabulum and proximal femur • To change the shape or redirect load trajectories so as to influence joint function. Discuss Osteotomies Around the Hip
- 5. • It preserve biomechanics, functions and prevent early degeneration Discuss Osteotomies Around the Hip
- 6. HISTORY • John-Rhea Barton 1826 • Chiari 1955 Discuss Osteotomies Around the Hip
- 7. BIOMECHANICS OF HIP JOINT • One legged stance • 5/6 BW on femoral head Discuss Osteotomies Around the Hip
- 8. Forces across hip joint • Body weight • Ground reaction forces • Abductor muscle forces Discuss Osteotomies Around the Hip
- 9. INDICATIONS • Osteotomies improve hip function • To Increases the contact area / congruency • To Improves coverage of femoral head • To Moves normal articular cartilage into weight bearing zone • To Restore biomechanical relationship Discuss Osteotomies Around the Hip
- 10. CONTRAINDICATIONS • Neuropathic arthropathy • Inflammatory arthropathy • Active infections • Severe osteopenia • Advanced arthritis/ankylosis • Advanced age • Smoking • Obesity Discuss Osteotomies Around the Hip
- 11. CLASSIFICATION Pelvic Osteotomy 1- Redirection Osteotomies - Salter - Steel (triple) - Ganz 2- Reshaping Osteotomies - Pemberton - Dega - Dail 3- Salvage Osteotomies - Chiari - Shelf Discuss Osteotomies Around the Hip
- 12. Femoral Osteotomies Anatomical 1- CERVICAL 2- INTERTROCHANTERIC 3 -GREATER TROCHANTERIC 4- SUBTROCHANTERIC Discuss Osteotomies Around the Hip
- 13. Base on indications 1- UNREDUCED DDH - Lorenz bifurcation - Schanz 2- CONGENITAL COXA- VARA - Cuniform osteotomy by Fish - Pauwel’s Y osteotomy - Valgus osteotomy - Basilar osteotomy. Discuss Osteotomies Around the Hip
- 14. 3. LEG-CALVE PERTHE’S DISEASE - Varus de-rotation osteotomy 4. SLIPPED CAPITAL FEMORAL EPIPHYSIS. A - Closing wedge osteotomy of neck: - The technique of Fish - Technique of Dunn just distal to slip - Base of neck technique by Kramer et al d. - Technique of Abraham et al B- Compensatory osteotomies: - Ball and socket osteotomy Discuss Osteotomies Around the Hip
- 15. 5- NON UNION # NECK OF FEMUR - McMurry’s osteotomy - Dickson’s osteotomy - Putti’s osteotomy 6- UNSTABLE INTERTROCHANTERIC # - Dimon Hughston osteotomy - Sarmiento’s osteotomy Discuss Osteotomies Around the Hip
- 16. 7. OSTEOARTHRITIS - Pauwel’s varus osteotomy - Pauwel’s valgus osteotomy - Mc Murrays osteotomy 8- AVN - Sugioka – Trans trochanteric osteotomy - Varus de-rotation osteotomy - Varus / Valgus intertrochanteric Discuss Osteotomies Around the Hip
- 17. 9- OSTEOTOMIES IN PARALYTIC DISORDER OF HIP • Varus osteotomy • Rotation osteotomy • Extension osteotomy. Discuss Osteotomies Around the Hip
- 18. PRINCIPLES OF OSTEOTOMY AROUND THE HIP Preoperative principles - Extablish a clear indication by detailed history, examination and investigation - Get a recent radiographs AP pelvis and both lateral view Scanogram CT- scan with 3D reconstruction / MRI Discuss Osteotomies Around the Hip
- 19. PREOPERATIVE PLANNING Discuss Osteotomies Around the Hip
- 20. TEMPLATING • Study radiographs • Decide type of osteotomy • Determine site of osteotomy • Determine size of cut • Decide type of internal fixation • Rehears fixation in mind and on paper Discuss Osteotomies Around the Hip
- 21. Discuss Osteotomies Around the Hip
- 22. SURGICAL TACTICS - Outline of procedure from anaesthesia to closure - Equipments / implant list and check Discuss Osteotomies Around the Hip
- 23. Final plan • The surgical tactic outline • The annotated drawing • The equipment list Discuss Osteotomies Around the Hip
- 24. Discuss Osteotomies Around the Hip
- 25. • Obtained informed consent • Blood grouping and cross matching Discuss Osteotomies Around the Hip
- 26. Intraoperative principle • Appropriate Anaesthesia and positioning • Prophylactic antibiotics • C- arm • Protect soft tissues from cutting tools eg oscillating saw • Prevent thermal injuries from powered instruments Discuss Osteotomies Around the Hip
- 27. Discuss Osteotomies Around the Hip • Apply angle devices or sliding screws before osteotomy cuts
- 28. POST – OPERATIVE PRINCIPLES - Analgesia - Antibiotics - Wound care - Physiotherapy Discuss Osteotomies Around the Hip
- 29. Pelvic Osteotomies Redirection Osteotomies - Salter - Steel (triple) - Ganz Discuss Osteotomies Around the Hip
- 30. Salter steotomy • Osteotomy of the innominate bone • Aimed at reducing acetabular index • AGE-18 months – 6 years Discuss Osteotomies Around the Hip
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- 39. • AFTERCARE - Hip spica for 8 to 12 week then partial weight Bearing on crutches - Result assesed by center edge angle Discuss Osteotomies Around the Hip
- 40. Steel osteotomy In the triple innominate osteotomy (Steel) • The ischium • The superior pubic ramus • The ilium superior to the acetabulum Discuss Osteotomies Around the Hip
- 41. • Adolescents and skeletally mature adults with residual dysplasia and subluxation in whom remodelling of acetabulum is no longer anticipated Discuss Osteotomies Around the Hip
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- 46. Ganz osteotomy • Periacetabular osteotomy (POA) • Adolescent and adult dysplastic hip that required correction of congruency & containment of the femoral head with little or no arthritis Discuss Osteotomies Around the Hip
- 47. Discuss Osteotomies Around the Hip
- 48. RESHAPING OSTEOTOMIES • Pemberton • Dega • Dail Discuss Osteotomies Around the Hip
- 49. Pemberton Osteotomy • Pericapsular osteotomy INDICATION- - >10-15 degrees correction of acetabular index required - Small femoral head - Large acetabulum • AGE-18months- 10 yr Discuss Osteotomies Around the Hip
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- 52. • AFTERCARE- Spica cast for 8 to 12 weeks Discuss Osteotomies Around the Hip
- 53. Dega osteotomy • unlike the Pemberton osteotomy, which increases anterolateral coverage, the Dega osteotomy involves cutting only the lateral aspect of the ilium and thus provides posterolateral coverage Discuss Osteotomies Around the Hip
- 54. Discuss Osteotomies Around the Hip
- 55. SALVAGE OSTEOTOMIES • Shelf • Chiari Discuss Osteotomies Around the Hip
- 56. SHELF OSTEOTOMY (STAHELI) • Performed to enlarge the volume of the acetabulum. Indication : A deficient acetabulum that cannot be corrected by redirectional, osteotomy is the primary indication. Discuss Osteotomies Around the Hip
- 57. • The shelf is put just above the acetabular margin • It secure two layers of cancellous grafts Discuss Osteotomies Around the Hip
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- 59. CHIARI OSTEOTOMY • The Chiari osteotomy is made just above the acetabulum • It slopes upward from lateral to medial • The displaced iliac wing to cover the femoral head without impinging on it • The acetabular fragment is displaced medially Discuss Osteotomies Around the Hip
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- 61. FEMORAL OSTEOTOMIES Discuss Osteotomies Around the Hip
- 62. 1- UNREDUCED DDH - Schanz - Lorenz bifurcation - De rotation osteotomy Discuss Osteotomies Around the Hip
- 63. SCHANZ OSTEOTOMY • Low subtrochanteric osteotomy • Femur is sectioned transversely a lower border of pelvis • Upper end is angled inward until it rest against side wall of pelvis Discuss Osteotomies Around the Hip
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- 66. Lorenz osteotomy • Bifurcation osteotomy • Intertrochanteric osteotomy • In this upper end of the lower fragment is abducted and inserted in to the acetabulum Discuss Osteotomies Around the Hip
- 67. Discuss Osteotomies Around the Hip
- 69. CONGENITAL COXA-VARA - Valgus osteotomy - Pauwel’s Y osteotomy Discuss Osteotomies Around the Hip
- 70. Valgus Subtrochanteric Osteotomy • A lateral wedge is remove to correct neck shaft angle to 135-150 Discuss Osteotomies Around the Hip
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- 75. Pauwel’s Y osteotomy • Y- shaped wedge is removed from intertrochanteric region • Indication - Coxa Vara - Non-union fracture neck Discuss Osteotomies Around the Hip
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- 78. LEG-CALVE PERTHE’S DISEASE - Varus de-rotation osteotomy - Pelvic osteotomies Discuss Osteotomies Around the Hip
- 79. SLIPPED CAPITAL FEMORAL EPIPHYSIS. A - Closing wedge osteotomy of neck: - The technique of Fish - Technique of Dunn just distal to slip - Base of neck technique by Kramer et al - Technique of Abraham et al B- Compensatory osteotomies: - Ball and socket osteotomy Discuss Osteotomies Around the Hip
- 80. Dunn’s osteotomy • A small segment of the femoral neck is removed so that the epiphysis can be reduced and pinned without placing tension on the posterior vessels. Discuss Osteotomies Around the Hip
- 81. Discuss Osteotomies Around the Hip
- 82. NON UNION # NECK OF FEMUR - McMurry’s osteotomy - Dickson’s osteotomy Discuss Osteotomies Around the Hip
- 83. McMurry’s osteotomy • Aim Shearing force at the nonunion site are converted to compression at fracture site Discuss Osteotomies Around the Hip
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- 85. NON UNION INTERTROCHANTERIC FRACTURE Discuss Osteotomies Around the Hip
- 86. Sarmiento Technique Discuss Osteotomies Around the Hip
- 87. AVN OF FEMORAL HEAD - Sugioka – Trans trochanteric osteotomy - Varus de-rotation osteotomy - Varus / Valgus intertrochanteric Discuss Osteotomies Around the Hip
- 88. SUGIOKA OSTEOTOMY Discuss Osteotomies Around the Hip
- 89. COMPLICATION EARLY - Injury to neurovascular bundles - Soft tissues injury - Haemorrhage - Thermal injury - Physeal injuries - SSI - DVT LATE Non-union Malunion Infected nonunion Failed implant Overcorrection Under correction AVN of femoral Head Discuss Osteotomies Around the Hip
- 90. CONCLUSION Virtually all hip pathologies may require a form of osteotomy to restore biomechanical relationship between articulating surfaces. Sound knowledge, skills and adherence to principles are paramount to a successful osteotomy around the hip. Discuss Osteotomies Around the Hip
- 91. REFERANCES • Soloman L. Apley's System of Orthopaedics and Fractures 9th Edition. • Canale & Beaty. Campbell's Operative Orthopaedics - 11th Edition • Ebnezar J. textbook of Orthopaedics 4th Edition • Gandhi V. Seminar on osteotomies around the hip. Ppt Discuss Osteotomies Around the Hip
- 92. • John AH. Tachjian’s Paediatric Orthopaedics 5th edition • Thawrani D. Pelvic osteotomies. Medscape;2015 • Tannast M, Siebenrock KA. Femoral osteotomies • KUMAR R. seminar on osteotomies around the hip. Ppt Discuss Osteotomies Around the Hip
- 93. • Newton CD. Principles And Techniques Of Osteotomy • Rüedi TP, Buckley RE, Moran GC. AO Principles of Fracture Management. 2nd edition • Fragomen TA. Femoral Osteotomy . emedicine Discuss Osteotomies Around the Hip
- 94. Thank you Discuss Osteotomies Around the Hip
Editor's Notes
- First femoral osteotomy was performed by John-Rhea, Barton in 1826 when tried to secure the motion of ankyloid hip. • 1835 Sourvier performed first subtronchanteric osteotomy for the treatment of CDH. • 1854 Langenback introduced sub-cutaneous osteotomy of the femur. • 1918 and 19 Von Baeyer and Lorenz described bifurcation operation of upper femoral osteotomy to secure stability in old CDH 1922 Schanz reported his low sub-trochanteric abduction osteotomy. • 1935 Pauwels described osteotomy at intertrochanteric level adduction deformity. • 1936 McMurry performed oblique displacement osteotomy for osteoarthritis of hip and non-union fracture neck of femur. • 1955 Chiari did pelvic osteotomy for stable coverage of head. • Blount and Moore described excellent blade plate for fixation of high sub-trochanteric osteotomy
- As the ratio of length of the lever arm of body weight to that of the abductor musculature is @ 2.5:1,the force of abductor muscle must approx 2.5 times the body weight to maintain the pelvis level when standing on one leg In an arthritic hip , the ratio of lever arm of the body weight to that of the abductors may be 4:1. The length of two lever arms can be surgically changed to make their ratio 1:1
- Based on Indications To obtain stability old unreduced dislocations. Lorenz bifurcation osteotomy. Schanz low subtrochanteric. To obtain union ununited fractures of femoral neck. McMurry’s osteotomy. Dickson's high geometric osteotomy. Schanz Angulation Osteotomy. unstable intertrochanteric fractures. Dimon Hughston Osteotomy. Sarmiento’s Osteotomy Relief of pain osteoarathritis. Pauwel’s type I varus osteotomy. Pauwel’s type II valgus osteotomy. To Correct deformities coxa vara slipped upper femoral epiphysis Intracapsular cuneiform osteotomy by dunn. Compensatory Basilar Osteotomy of Femoral Neck. Extracapsular Base-of-Neck osteotomy. Ball-and-Socket Trochanteric Osteotomy. Pauwel’s osteotomy (Y). In Osteonecrosis of femoral head Sugioka’s transtrochanteric osteotomy. Varus deroation osteotomy of Axer. - In paralytic disorders of hip. Varus Osteotomy. Rotational Osteotomy In congenital dislocation.
- Implant selection and availability Ensure availability of instrumentation
- Another useful measurement is the acetabular index, which is an angle formed by the juncture of the Hilgenreiner line and a line drawn along the acetabular surface. In normal newborns, the acetabular index averages 27.5 degrees. At 6 months of age, the mean is 23.5 degrees. By 2 years of age, the index usually decreases to 20 degrees. Thirty degrees is considered the upper limit of normal The Wilberg center–edge angle, which is the angle that is formed between the Perkin line and a line drawn from the lateral lip of the acetabulum through the center of the femoral head. This angle, which is a useful measure of hip position in older children, is considered normal if it is more than 10 degrees in children between the ages of 6 and 13 years. It increases with age
- INDI-Congruous hip reduction,<10-15 degrees correction of acetabular index required ,paralytic disorder,subluxation after septic arthritis PREREQUISITES- femoral head must be positioned opposite the level of acetabulum,contracture of iliopsoas and adductor muscles must be released, range of motion of the hip must be good specially in abduction ,int rotation flexion AGE-18 months-6years AFTERCARE-hip spica for 8 to 12 week,then partial weight bearing on crutches ,followed by full weight bearing.result assesed by center edge angle.
- In the triple innominate osteotomy (Steel), the ischium, the superior pubic ramus, and the ilium superior to the acetabulum all are divided, and the acetabulum is repositioned and stabilized by a bone graft and metal pins. In the pericapsular dial osteotomy of the acetabulum (Eppright), the entire acetabulum superiorly, posteriorly, inferiorly, and anteriorly is freed by osteotomy and as a single segment of bone is redirected to cover the femoral head appropriately. INDI-Adolescents and skeletally mature adults with residual dysplasia and subluxation in whom remodelling of acetabulum is no longer anticipated ADV-Better coverage of femoral head by articular cartilage [chiari- fibrous cartilage], Better hip joint stability,no need of spica cast. DIS- Technically difficuilt, does not change size of acetabulum, distort the hip such that natural child birth may be impossible in adulthood PROC-The ischium, the sup pubic ramus and ilium superior to the acetabulum is reposition and stabilized by bone graft
- This Triplaner osteotomy is for adolescent and adult dysplastic hip that required correction of congruency & containment of the femoral head with little or no arthritis. If significant degenerative changes are presents a proximal femoral osteotomy can be added. Approach Smith Peterson approach
- Only one approach is used. A large amount of correction can be obtained in all directions, including the medial and lateral planes. Blood supply to the acetabulum is preserved. The posterior column of the hemipelvis remains mechanically intact, allowing immediate crutch walking with minimal internal fixation. The shape of the true pelvis is unaltered, permitting a normal child delivery. Can be combined with trochanteric osteotomy if needed
- INDICATION- >10-15 degrees correction of acetabular index required ,small femoral head ,large acetabulum. ADV- internal fixation not required .greater degree of rotation can be achieved with less rotation of acetabulum DISADV- Technically more difficult . Alters the configuration and capacity of acetabulum and produce joint incongruity that requires remodeling AGE-18months- 10 yr AFTERCARE-spica cast for 8 to 12 weeks
- Acetabuloplasty also is useful only when any subluxation or dislocation has been reduced or can be reduced by open reduction at the time of operation in children at least 18 months old. In acetabuloplasty, the inclination of the acetabular roof is decreased by an osteotomy of the ilium made superior to the acetabulum. Pemberton described a pericapsular osteotomy of the ilium in which the osteotomy is made through the full thickness of the bone from just superior to the anterior inferior iliac spine anteriorly to the triradiate cartilage posteriorly; the triradiate cartilage acts as a hinge on which the acetabular roof is rotated anteriorly and laterally. This procedure decreases the volume of the acetabulum and produces joint incongruity that requires remodeling
- Dega osteotomy The concept of the Dega osteotomy [37] is similar to that of the Pemberton osteotomy—that is, to change the configuration or shape of the capacious acetabulum by hinging the fragment through the open triradiate cartilage. However, unlike the Pemberton osteotomy, which increases anterolateral coverage, the Dega osteotomy involves cutting only the lateral aspect of the ilium and thus provides posterolateral coverage
- Have commonly been performed to enlarge the volume of the acetabulum. The objective is to create a shelf, the size of which is decided by measuring the “width of augmentation” form the CE angle. The shelf is put just above the acetabular margin. It secure two layers of cancellous grafts bringing the reflected head of rectus femoris forward over the graft and suturing it in its original position. Best to do after 5 years of age. Indication : A deficient acetabulum that cannot be corrected by redirectional, osteotomy is the primary indication. Contraindication : Dysplastic hip with spherical congruity suitable for redirectional osteotomy Hip requiring open reduction
- The Chiari osteotomy is made just above the acetabulum, in the region of insertion of the hip capsule.‖ The osteotomy curves to match the acetabular contour, and it slopes upward from lateral to medial. The level of the osteotomy and the slope of the cut must be precise for the displaced iliac wing to cover the femoral head without impinging on it. The acetabular fragment is displaced medially almost the full width of the ilium at that level, and it is held there with pin or screw fixation
- In this osteotomy the deformity flexion, adduction & external Rotation is corrected by making the osteotomy at tuber ischii level. Preparation : X-ray are taken with full adduction – to measure angle medially. Thomas Test - measure degree of flexion to be corrected. Advantages : Lurching gait will be diminished. The depression of the trochanter also improves the leverage of the glutei.
- In this upper end of the lower fragment is abducted and inserted in to the acetabulum after making on intertrochanteric osteotomy “plane of osteotomy” below & outward to above & inward. Disadvantage : Increased shortening. Less mobility and arthritic pain
- Valgus Subtrochanteric Osteotomy or abduction osteotomy-with Internal Fixation. A transverse osteotomy at about the level of lesser trochanter. If necessary take a small lateral wedge to correct neck shaft angle to 135-150. The surgery may be delayed till child is 4 to 5 year old to make internal fixation easier.
- McMurry’s osteotomy
- OSTEOTOMIES – These procedure have achieved best result for small and medium sized lesion. 1<30% femoral head involvement in young pt. Intertrochanteric varus/valgus - osteotomies Transtrochantric ant. Rotational osteotomy (Sugioka) - Technically Demanding procedures. PRINCIPLE: All osteotomies are designed to transfer the weight bearing forces form the necrotic area to the cartilage on the sound part of the femoral head to allow healing of necrotic area by hyper vascularisation of upper part of femur.