An osteotomy is a surgical procedure to correct biomechanical alignment of the extremity. Osteotomies around the hip can be femoral or pelvic osteotomies. Femoral osteotomies include intertrochanteric, subtrochanteric, and greater trochanteric osteotomies. Pelvic osteotomies include Salter, Pemberton, Steel, and Chiari osteotomies. Osteotomies are used to treat conditions like osteoarthritis, developmental dysplasia of the hip, osteonecrosis, and fractures. Common femoral osteotomies described were Pauwels' varus and valgus osteotomies, and Sugioka

1. OSTEOTOMIES AROUNDTHE
HIP
DR. SIDHARTH YADAV
JR 2 ORTHOPAEDICS
NKPSIMS

2. DEFINITION
 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

3. HISTORY
 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.

4. HISTORY
 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.

5. BIO MECHANICS
Fo rce s acro ss hip jo int
 Body Weight
 Ground reaction forces
 Abductor muscle forces

6. 2 D STATIC ANALYSIS
 One legged stance
5/6 BODY
WEIGHT on
femoral head
 The force acting
on the lever arm is
thrice the body
weight.

7.  Osteotomies :
 Increases the contact area / congruency.
 Improves coverage of head.
 Moves normal articular cartilage into weight
bearing zone.
 Restore biomechanical advantage.

8. OSTEOTOMY AROUND HIP
 According to Anatomic Location
 Femoral Osteotomy
 High Cervical.
 Intertrochanteric Osteotomy.
 Subtrochanteric Osteotomy.
 Greater Trochanteric.
 Pelvic Osteotomy.
 Salvage Osteotomies : e g . Chiari, She lf.
 Reconstructive Osteotomies : e g . Pe riace tabular,
Sing le , Do uble , Triple Inno m inate .

9. Co ntd.
 Based on Indications
 To obtain stability
 old unreduced dislocations.
 Lorenz bifurcation osteotomy.
 Schanz low subtrochanteric.
 To obtain union
 fractures of femoral neck.
 McMurry’s osteotomy.
 Dickson's high geometric osteotomy.
 Schanz Angulation Osteotomy.
 unstable intertrochanteric fractures.
 Dimon Hughston Osteotomy.
 Sarmiento’s Osteotomy

10.  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).
Co ntd.Co ntd.

11.  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.
Co ntd.Co ntd.

12. CONTRAINDICATIONS OF
OSTEOTOMY
 NEUROPATHIC ARTHROPATHY
 INFLAMMATORY ARTHROPATHY
 ACTIVE INFECTIONS
 SEVERE OSTEOPENIA
 ADVANCED ARTHRITIS/ANKYLOSIS
 ADVANCED AGE
 SMOKING, OBESITY

13. Principles of Osteotomy
 Ostoeotomy can be viewed as either
 Reconstructive
 Salvage
 Femoral osteotomy to correct proximal femoral
abnormalities.

14. FactorsFactors Reconstructive OsteotomyReconstructive Osteotomy Salvage OsteotomySalvage Osteotomy
AgeAge Generally < 25 yearsGenerally < 25 years Generally < 50 yearsGenerally < 50 years
(Some biological Plasticity(Some biological Plasticity
Remains)Remains)
SymptomsSymptoms Minimal (Out Progressive)Minimal (Out Progressive) Moderate to SevereModerate to Severe
MotionMotion Near NormalNear Normal > 60> 6000
FlexionFlexion
FunctionFunction Near NormalNear Normal Fair to PoorFair to Poor
PthoanatomyPthoanatomy No Irreversible ChangesNo Irreversible Changes Irreversible ChangesIrreversible Changes
RoentgenograpRoentgenograp
hyhy
Congruent but MalalignedCongruent but Malaligned
SurfacesSurfaces
Cartilage narrowing orCartilage narrowing or
incongruity or bothincongruity or both
Prognosis ifPrognosis if
untreateduntreated
PoorPoor PoorPoor
DIFFERENCE

15. PAUWEL’S VARUS OSTEOTOMY
Varus intertrochanteric femoral osteotomies
are designed to elevate the greater
trochanter and move it laterally, while
moving the abductor and psoas muscles
medially, to :
 Restore joint congruity
 Decrease the force acting on the edge of the
acetabulum moves to the middle of weight
bearing surface.

16. INDICATIONS
 Antalgic abductor limb
 Abduction deformity
 Painful adduction
 Neck shaft angle > 135°

17. Oblique cut is
made parallel to
the chisel
inserted
Proximal fragment is
rotated in varus .

18. Wedge being
shifted to
lateral side.
FINAL RESULT
Insertion of
angled blade
plate

19. TYPES OF WEDGE IN VARUS OSTEOTOMY

20. DISADVANTAGES
 Shortens the limb to some degrees.
 Creates a trendelenberg gait.
 Increases the prominence of greater
trochanter.
 Overloading of the medial compartment of
knee.

21. PAUWELS VALGUS OSTEOTOMY
Valgus intertrochanteric femoral osteotomies transfer the center
of hip rotation medially from the superior aspect of the
acetabulum to decrease the weight bearing area of femoral
head .
 Normally 15° of correction is required.
INDICATIONS:
 Trendelenburg Limb
 Adduction deformity
 Motion in adduction beyond adduction deformity
 Painful abduction
CONTRAINDICATIONS:
 Flexion of less than 60°
 Knock knees as this will increase the deformity at knee.

22.  After insertion of guide wire & chisel 2cm proximal to
osteotomy site similar to explained before :-

23. Pelvic Osteotomies
 Reconstructive
 Salter 18m – 6y
 Pemberton 18m – 10y
 Steel skeletal maturity
 PAO (Ganz) skeletal maturity
 Salvage
 Chiari skeletal maturity

24. SALTER'S INNOMINATE OSTEOTOMY
 In this, the entire acetabulum together with pubis and
ischium is rotated as a unit.
INDICATIONS:
 CDH in children from 18 months to 9 years of age and in
congenital subluxation upto early adult life.
 Before the osteotomy, femoral head should be positioned
opposite the level of the acetabulum achieved by period of
traction.
 Contractures of iliopsoas and adductor muscles must be
released.

25. Osteotomy made from
AIIS to Greater Sciatic
notch

26. Graft is taken from iliac
crest and trained to the
shape of a wedge.
The distal segment is
shifted forward,
downward and outward

27. Place the graft into
open segment
anteriorly.
anteriorlyanteriorly

28. Secure it by passing a K-
wire from proximal
fragment through graft into
distal fragment taking care
not to enter acetabulum.

29.  Subluxation in DDH After SALTERS
osteotomy

30. ADVANTAGES:
 Relatively simple procedure.
 No change in acetabular configuration.
DISADVANTAGES:
 Relatively unstable needs internal fixation.
 Second surgery for pin removal.
 Possibility of joint penetration by pins.

31. PEMBERTON ACETABULOPLASTY
 This operation redirects the inclination of the
acetabular roof by an osteotomy of the ilium,
superior to the acetabulum followed by levering
of the roof inferiorly.
INDICATION:
 In dysplastic hips between the age of 1 year and
the age when the tri-radiate cartilage became too
inflexible to serve as a hinge (about 12 years in
girls and 14 years in boys).

32. First cut is made from the
outer cortex of the ilium,
starting just above the AIIS
and extending backwards till it
reaches
triradiate cartilage.
A similar cut is made in the
medial cortex directing it
posteriorly, parallel with the
previous one until it reaches
the triradiate cartilage.

33. With a wide curved
osteotome lever the distal
fragment distally until
anterior edges of two
fragments is at least 2-3cm
apart.
Resect a wedge of bone from
anterior part of ilium including
ASIS. Place the wedge of bone in
the groove made and drive the
wedge into place and impact it.

34. ADVANTAGES:
1. Osteotomy is incomplete, therefore more stable
2. Internal fixation is not required
3. Greater degree of correction can be achieved with
less rotation of the acetabulum.
DISADVANTAGES:
1. Technically more difficult
2. It alters the configuration and capacity of the
acetabulum and can result in an incongruence
relationship between it and femoral head.

35. Acetabular dysplasia after treatment of CDH with Pemberton
acetabuloplasty on Right side.

36. TRIPLE INNOMINATE OSTEOTOMY BY
STEEL
 INDICATIONS- :-
Adolescents & skeletally mature
adults with residual dysplasia &
subluxation in whom remodelling
of acetabulum is no longer
anticipated.
 ADVANTAGE –
Better coverage of femoral head by
articular cartilage , Better hip
joint stability, no need of spica
cast.
1
2
3

38. 1.Osteotomy made from
AIIS to Greater Sciatic
notch

39. 2. Ischial ramus is
divided posterolaterally
at 45° from
perpendicular.

40. 3.Superior pubic ramus
is divided
posteromedially 15°
from perpendicular.

41.  DISADVANTAGES:
1. Difficult to perform.
2. Does not change the size of the acetabulum.
3. It distorts the pelvis so natural child birth is impossible
in adulthood.
MODIFIED BY LIPTON & BOWEN
1. Resecting 1-1.5 cm bone from ischial tuberosity to favor
medialization.
2. To resect a triangular wedge from outer part of ilium
which favors slot formation which serves as abutment.
3. Use 7.3mm cannulated screws instead of steinmann
pins.

42. SHELF OSTEOTOMY BY
STAHELI
 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
(WA)” using the CE angle
of wiberg.
 Best to do after 5 years of
age.

43.  CE Angle is measured in standing AP
radiograph.

44.  After packing the graft the rectus femoris is sutured
for stability of the graft .
 Postoperative: hip spica can be applied in 15 deg of
abduction and 20° of flexion.
Pre operative post op

45.  CONTRA-INDICATIONS:
1. DDH with spherical congruity suited for
re-directional osteotomy.
2. Hips requiring concurrent open reduction
that must have supplementary stability.
3. Patients un-suited for spica cast
application.

46. CHIARI OSTEOTOMY
 This is a capsular interposition osteotomy as
the capsule is interposed between the newly
formed acetabular roof and femoral head.
 INDICATIONS:
1. Congenital subluxation in patients 4 to 6 years
or older, including adults.
2. Dysplastic hip with osteoarthritis
3. For Coxa magna after Perthes disease or
avascular necrosis after treatment of congenital
dysplasia.
4. For paralytic dislocation caused by muscular
weakness or spasticity.

47. TECHNIQUE :ANT-LAT
APPROACH
 The osteotomy is made precisely
between the insertion of the capsule
and reflected head of rectus femoris.
 Ending distal to the AIIS anteriorly
and in sciatic notch posteriorly.
 With a straight narrow osteotome,
start osteotomy on lateral table with
plane directed 20° superiorly towards
inner table.

48.  The distal fragment is now displaced
medially by forcing the limb into
abduction hinging at symphysis
pubis.
 It is displaced enough medially so
that the proximal fragment
completely covers the femoral head
i.e. about half of the thickness of
bone.
 If necessary the fragments may be
transfixed by screw driven obliquely.

49. PRE OP POST OP WITH CHIARI

50. OSTEOTOMIES IN PERTHES
DISEASE
1. SALTER Innominate osteotomy:
2. SHELF procedure (Staheli): If the hip is congruous, it can be
performed for coxa magna and lack of acetabular coverage for
the femoral head.
1. CHIARI Osteotomy: It is used as a salvage procedure to
accomplish coverage of large flattened femoral head.
1. VALGUS EXTENSION osteotomy: Indicated in malformed
femoral head in residual Perthe's disease with hinge
abduction.

51. PAUWEL'S `Y' OSTEOTOMY
 A guide pin is inserted from the
greater trochanter to head of femur.
 One limb of osteotomy is made from
the base of greater trochanter
towards the base of neck medially
and inferiorly.
 The distal limb of the Y then passes
upwards and medially to reach the
proximal limb and a wedge of bone
with the required correction is
removed from the proximal aspect of
distal fragment with its base
directed laterally.

52.  The trochanter head segment is
levered into valgus.
 The two fragments are apposed
by displacing the proximal end
of the shaft medially and
abducting the limb.
 The nail is then attached by a
plate to the shaft.

53. SUGIOKA TRANSTROCHANTRIC
ROTATIONAL OST.
 This is done for osteonecrosis to prevent
progressive collapse of the articular surface and to
improve the congruity of hip joint.
 To do this the femoral head and neck segment is
rotated anteriorly around its longitudinal axis,
though a trans-trochantric osteotomy.
 So that the weight bearing force is transmitted to
the posterior articular surface of femoral head,
which is not involved in the ischemic process.

54.  Through lateral approach expose the capsule, osteotomize the
greater trochanter.
 Reflect it proximally along with the attached tendon of
Gluteus medius, minimus and Piriformis.
 Incise the joint capsule circumferentially.
 Carefully protect the posterior branch of medial circumflex
femoral artery at inferior edge of Quadratus femoris

55.  After completing second osteotomy use the
proximal pin to rotate proximal fragment 45-90°
depending on the size of necrotic area.

56. THANK YOU…