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Pemberton's Osteotomy for Acetabular Dysplasia
The document discusses the Pemberton osteotomy technique for treating acetabular dysplasia, outlining its historical background, procedural steps, and advantages over other methods like the Salter innominate osteotomy. It emphasizes the importance of careful surgical technique to avoid complications such as damage to the triradiate cartilage. The document also covers the indications and expected outcomes of this surgical approach.
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Pemberton's Osteotomy for Acetabular Dysplasia
- 1. PEMBERTON OSTEOTOMY FOR ACETABULARDYSPLASIA JBJS- ESSENTIAL SURGICAL TECHNIQUES INDIAN EDITION OCTOBER 2015, VOL.4, NO. 3, SPECIAL EDITION Shier- Chieg Huang, MD, PhD Ting- Ming Wang, MD, PhD Kuan- Wen Wu, MD Ken N. Kuo, MD PRESENTED BY Dr. LIBIN THOMAS MANATHARA
- 2. INTRODUCTION • More than550 operations of Pemberton's osteotomy done as primary treatment for developmental dysplasia of hip since 1993 • Originally described by Pemberton in 1965 • Pericapsular Osteotomy of the Ilium for Treatment of Congenital Subluxation and Dislocation of the Hip, PAUL A. PEMBERTON, J Bone Joint Surg Am, 1965 Jan; 47 (1): 65 -86 . http://dx.doi.org/
- 3. INTRODUCTION • Characterised bya redirection of the acetabular roof, hinged on the triradiate cartilage after an incomplete iliac osteotomy
- 4. INTRODUCTION • The shapeof the acetabulum is modified by rotating the acetabular fragment caudally and anteriorly to improve the anterior and lateral coverage of the femoral head • Two similar modifications, the Dega osteotomy and the San Diego osteotomy were designed for the same purpose
- 5. INTRODUCTION • With theDega, the osteotomy penetrates the anterior and middle portions of the inner cortex of the ilium and leaves an intact posteromedial iliac cortex and sciatic notch as a posterior hinge • The San Diego utilises complete bicortical osteotomies both anteriorly and posteriorly, to provide increased superior and posterior coverage
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- 8. INTRODUCTION • Most experiencedpediatric orthopedic surgeons can expect the Pemberton acetabuloplasty to yield greater correction of acetabular dysplasia than the Salter innonimate osteotomy , without the need for internal fixation of the osteotomy site • Salter innonimate osteotomy- a type of open wedge innominate osteotomy which extends and retroverts acetabulum around fixed axis, it redirects entire acetabulum so that its roof covers femoral head both anteriorly and superiorly, it extends and retroverts acetabulum around fixed axis
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- 10. INTRODUCTION • Although someauthors have cautioned against the use of the Pemberton osteotomy in children older than 7yrs because of concerns about decreasing remodeling potential and a less flexible triradiate cartilage, some investigators have reported that the Pemberton osteotomy can be done at a later age with good results, when combined with a proximal femoral osteotomy
- 11. INTRODUCTION • Nevertheless theiatrogenic injury to the triradiate cartilage resulting from an incorrectly performed Pemberton's osteotomy is a possible serious complication which may cause premature closure of the triradiate cartilage resulting in a shallow acetabulum
- 12. STEPS • 1) Exposure •2) Perform iliopsoas tenotomy • 3) Perform open reduction and osteotomy • 4) Insert iliac bone graft • 5) Postoperative management
- 13. STEP 1- EXPOSURE •Place the patient in supine position with a towel roll under the buttock and chest on the side on which the operation is to be performed • Make an anterior iliofemoral incision that is not directly on the iliac crest
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- 15. An anterior iliofemoralincision is used, caudal to the anterior superior iliac spine (ink outline to the right of the incision line mark) and the iliac crest. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
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- 17. Exposure • Dissect thesubcutaneous tissue • Identify the muscle interval between Sartorious and Tensor Fascia Lata (TFL) • In this intermuscular interval, beneath the deep fascia you can find the fatty tissue around the lateral femoral cutaneous nerve (LFCN)
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- 20. Exposure • Incise thisdeep fascia carefully • Identify the nerve clearly and protect it with gentle traction • Retract it medially after it is well mobilised both proximally and distally
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- 22. "Gray826-LFC" by DanHoey - Edited version of PD image Image:Gray826.png. Licensed under Public Domain via Commons - https://commons.wikimedia.org/wiki/File:Gray826- LFC.png#/media/File:Gray826-LFC.png http://thepainsource.com/meralgia-paresthetica-lateral-femoral-cutaneous- neuropathy/
- 23. Exposure • Expose theiliac crest • Releasing the external oblique muscles on the crest facilitates the exposure of the cartilagenous iliac apophysis • Identify the anterior superior iliac spine (ASIS)
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- 26. Exposure • Divide thecartilage at the iliac crest by identifying it with thumb and index finger and incising directly in the midline • Strip off each half of the iliac apophysis with a periosteal elevator to expose the ilium subperiosteally both medially and laterally
- 27. The iliac crestcartilaginous apophysis is split sharply, with the thumb and the index finger used to gauge the thickness and direction of the iliac wing. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
- 28. Exposure • Pack agauze sponge on the inner and outer cortices to facilitate subperiosteal dissection and provide hemostasis • Expose the anterior inferior iliac spine (AIIS) by elevating the periosteum with the hip abductor muscles from the outer cortex of the ilium until the AIIS is clearly defined
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- 34. STEP 2- PERFORMILIOPSOAS TENOTOMY • Identify the tendon of the straight head of the rectus femoris at its origin on the AIIS • Transect the tendon close to the AIIS but leave a short stump for later tendon reattachment
- 35. http://www.anatomy-physiotherapy.com/27-systems/musculoskeletal/lower-extremity/hip/1055-origin-of-the-direct-and- reflected-rectus-femoris-head from Arthroscopy. 2014Jul;30(7):796-802. doi: 10.1016/j.arthro.2014.03.003. Epub 2014 May 2. Origin of the direct and reflected head of the rectus femoris: an anatomic study. Ryan JM1, Harris JD2, Graham WC1, Virk SS1, Ellis TJ3 http://www.ncbi.nlm.nih.gov/pubmed/?term=Origin+of+the+Direct+and+Reflected+Head+of+the+Rectus+Femoris:+An+ Anatomic+Study
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- 37. The tendon ofthe straight head of the rectus femoris muscle is isolated and is divided just caudal to the anterior inferior iliac spine (AIIS). Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
- 38. PERFORM ILIOPSOAS TENOTOMY •Protect and preserve the ascending branch of the anterior/ lateral femoral circumflex artery (LFCA), which may be visible in the surgical field at this time
- 39. "Thigh arteries schema"by Human_leg_bones_labeled.svg: Original uploader was Jecowa at en.wikipediaderivative work: Mcstrother (talk) - Human_leg_bones_labeled.svg. Licensed under CC BY 3.0 via Commons - https://commons.wikimedia.org/wiki/File:Thigh_arteries_schema.svg#/media/File:Thigh_arteries_schema.svg
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- 41. PERFORM ILIOPSOAS TENOTOMY •Bluntly dissect the iliacus muscle belly medial to the ilium and identify the psoas tendon at the level of the anterior pelvic rim • Release the tendinous part of the iliopsoas muscle
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- 43. The iliopsoas tendonis identified at the pelvic rim, and the tendinous portion is divided, leaving the muscular portion intact. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
- 44. PERFORM ILIOPSOAS TENOTOMY •Be careful of the femoral neurovascular bundle, which is located immediately medial to the psoas muscle but on the anterior aspect • The femoral NV bundle can be retracted and protected with a blunt retractor
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- 46. PERFORM ILIOPSOAS TENOTOMY •Identify the acetabulum- hip capsule junction • If the femoral head is well reduced in the acetabulum, you can identify the edge of the acetabulum and the reflected head of the rectus femoris mucle easily • Dissect the soft tissue overlying the capsule and then identify the margin of the joint capsule at the acetabular rim
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- 49. PERFORM ILIOPSOAS TENOTOMY •Sometimes the capsule becomes redundant and adherent to the ilium as the result of a previous femoral head dislocation • In this situation, dissect the abductor muscle from the capsule and use a periosteal elevator to strip off any soft tissue from the anterior aspect of the ilium to reveal the junction of the hip capsule and cartilagenous labrum
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- 52. STEP 3- PERFORMOPEN REDUCTION AND OSTEOTOMY • Perform an open reduction • If the femoral head is dislocated, perform a T- shaped capsulotomy near the acetabular rim, including the upper and lower margins of the hip capsule
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- 54. Capsular incision outlinewith the stem of the T parallel with the femoral neck. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
- 55. PERFORM OPEN REDUCTION ANDOSTEOTOMY • Make the stem of the T- shaped capsulotomy parallel to the femoral neck, slightly superiorly to avoid a small inferior capsular flap, which will make the capsulorrhaphy more difficult
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- 57. PERFORM OPEN REDUCTION ANDOSTEOTOMY • Remove the ligamentum teres sharply and remove all of the fibrofatty tissue (pulvinar tissue) from the true acetabulum • Identify and palpate the tension of the transverse acetabular ligament with your finger before releasing it with scissors
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- 61. PERFORM OPEN REDUCTION ANDOSTEOTOMY • Recheck to ensure that there is no tension of the transverse acetabular ligament after release, as remaining transverse acetabular ligament can impede complete reduction of the femoral head
- 62. PERFORM OPEN REDUCTION ANDOSTEOTOMY • Check hip stability • Reduce the femoral head into the acetabulum under direct vision and test the hip stability in a neutral position as well as in abduction and internal rotation
- 63. PERFORM OPEN REDUCTION ANDOSTEOTOMY • If the hip is unstable in a neutral position but is stable in abduction and internal rotation, a Pemberton acetabuloplasty is indicated • If hip stability cannot be maintained even in abduction and internal rotation, an additional proximal femoral varus and/ or rotational osteotomy should be considered
- 64. Varus osteotomy ofthe femur Open Reduction, Pelvic Osteotomy, Femoral Shortening and Varus Osteotomy - See more at: http://hipdysplasia.org/developmental-dysplasia-of-the-hip/child-treatment- methods/osteotomy/#sthash.BArftDsO.dpuf http://hipdysplasia.org/developmental-dysplasia-of-the-hip/child-treatment-methods/osteotomy/
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- 66. PERFORM OPEN REDUCTION ANDOSTEOTOMY • Make medial and lateral cut lines • Remove the gauze sponge on either side of the iliac bone • Check bleeding from perforating vessels from the iliac wing
- 67. PERFORM OPEN REDUCTION ANDOSTEOTOMY • Once hemostasis is achieved, you can proceed with the Pemberton osteotomy • Locate the sciatic notch first with a small periosteal elevator and protect the adjacent soft tissue, including the sciatic nerve, with a retractor
- 68. PERFORM OPEN REDUCTION ANDOSTEOTOMY • Begin with the medial iliac cut first • Outline the cut line with the electrocautery tip • Using a small straight osteotome, begin the medial cut line about 1 to 1.5cm above the superior hip joint line and curve it inferiorly and posteriorly, aiming at the sciatic notch
- 69. Medial cut line:outline on a skeletal model. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
- 70. Medial cut line:outline on a reconstructed three-dimensional computed tomography (CT) scan. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
- 71. Medial cut linein the surgical field. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
- 72. PERFORM OPEN REDUCTION ANDOSTEOTOMY • The cut line extends halfway to the sciatic notch and ends at the ridge of the pelvic inlet of the ilium • The lateral cut line has the same starting point as the medial cut • With the medial cut line as a reference, use the same osteotome to make the lateral cut line along the joint capsule
- 73. Lateral cut line:outline on a skeletal model. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
- 74. Lateral cut line:outline on a reconstructed three-dimensional computed tomography (CT) scan. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
- 75. Lateral cut linein the surgical field. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
- 76. PERFORM OPEN REDUCTION ANDOSTEOTOMY • Complete the osteotomy • Use wider curved osteotomes to complete the osteotomy, beginning anteriorly and following the medial and lateral cut lines • As this osteotomy advances, push the osteotome against the distal fragment to check the degree of downward displacement
- 77. Iliac osteotomy withuse of a large curved osteotome. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
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- 79. PERFORM OPEN REDUCTION ANDOSTEOTOMY • If the osteotomy site opens more than 2 to 3cm and the distal fragment hinges on the triradiate cartilage, there is no need to further advance the osteotome • If the opening is insufficient, advance the osteotome and check the amount of osteotomy opening again
- 80. STEP 4- INSERTILIAC BONE GRAFT • Harvest a wedge shaped iliac crest bone graft (about a 35 degree wedge) from the iliac wing • Reduce the femoral head and place a towel roll under the knee to help maintain the hip in an abducted and flexed position
- 81. INSERT ILIAC BONEGRAFT • Hold the inferior osteotomy fragment open anteriorly and inferiorly with a towel clip to cover the femoral head • Then insert the triangularly shaped bone graft into the osteotomy opening site
- 82. INSERT ILIAC BONEGRAFT • Usually, the osteotomy bone fragment is stable and there is no need for internal fixation • If the bone graft is not stable, fixation with one or two Kirschner wires may be necessary
- 83. Surgical field inwhich a bone graft is maintaining the opening of the osteotomy site. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
- 84. Postoperative reconstructed three-dimensionalcomputed tomography (CT) scan from the anterior view showing the bone graft in place. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
- 85. Postoperative reconstructed three-dimensionalcomputed tomography (CT) scan from the posterior view showing the bone graft in place. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
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- 87. INSERT ILIAC BONEGRAFT • Repair the hip capsule by bringing the two flaps of the T- capsulotomy to the acetabular flap of the capsule • It is not necessary to resect the redundant capsule
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- 89. INSERT ILIAC BONEGRAFT • Repair the tendon of the straight head of the rectus femoris muscle to the AIIS • Suture the iliac apophysis over the remaining ilium and close the wound
- 90. STEP 5- POSTOPERATIVE MANAGEMENT •Apply a hip spica cast after skin closure • An assistant should hold both hips in about 20 degrees of flexion, 30 degrees of abduction and neutral or slight internal rotation while the cast is applied • The spica cast is worn for four weeks after a simple Pemberton osteotomy
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- 92. POSTOPERATIVE MANAGEMENT • If acombined open hip reduction procedure was done, the hip spica cast is used for 6 weeks, this is followed by use of 4 weeks of a hip abduction brace or a bilateral cylinder cast with a spreader bar to hold the hips in 60 degrees of abduction (30 degrees of abduction for each hip)
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- 94. RESULTS • In theirclinical and radiological review of 49 patients followed up for more than 10years after treatment of DDH of hip with a unilateral PO, there were no redislocations and no patient required additional surgery for residual hip dysplasia after the original PO
- 95. RESULTS • If therewas overcorrection or inferior displacement of the reduced femoral head , there was a high risk of femoral head osteonecrosis • X rays of a patient treated at 20months and followed up for 14yrs after the surgery are shown
- 96. Anteroposterior pelvic radiographof a twenty-month-old girl with developmental dysplasia of the left hip. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
- 97. Immediate postoperative anteroposteriorradiograph showing the reduced hip after the Pemberton osteotomy. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
- 98. When the patientwas fifteen years old, the left hip had an excellent result. Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2 ©2011 by The Journal of Bone and Joint Surgery, Inc.
- 99. INDICATIONS • Developmental dysplasiaof the hip • Acetabular dysplasia • Legg- Calve- Perthe's disease with femoral head subluxation/ lateral protrusion • Anterosuperior deficiency of the acetabulum secondary to neuromuscular disease • Sequelae of an infected hip with femoral head subluxation
- 100. CONTRAINDICATIONS • Closed triradiatecartilage • Deformed femoral head • Small acetabular volume • Active infection/ Osteomyelitis
- 101. PITFALLS AND CHALLENGES •Bone graft dislodgement • Overcorrection may cause femoral head impingement and osteonecrosis • Premature triradiate cartilage closure • Transiliac lengthening of the ipsilateral limb at the time of the opening wedge osteotomy
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