Osteotomies around the hip in DDH

1. OSTEOTOMIES AROUND THE HIP
IN DDH
PRESENTED BY : DR VIVEK VIJAYAKUMAR
CO-MODERATOR : DR MUTHUKUMARAN
MODERATOR : PROF SHAH ALAM KHAN

2. TERMINOLOGY
CONGENITAL DISLOCATION OF HIP
DEVELOPMENTAL DYSPLASIA OF HIP
(Klisic 1989)
Klisic PJ. Congenital dislocation of the hip--a misleading term: brief report. The Journal of bone and
joint surgery. British volume. 1989 Jan;71(1):136-.

3. OVERVIEW OF MANAGEMENT OF DDH
NEONATE 1-6 Months 6-18 Months 18-24 Months > 2 Yrs
CLOSED REDUCTION
OR
OPEN REDUCTION
OPEN REDUCTION
+/-
ACETABULAR
PROCEDURE
OPEN REDUCTION
+/-
ACETABULAR
PROCEDURE
+/-
FEMORAL
PROCEDURE

4. WHY IS OSTEOTOMY REQUIRED IN ADDITION TO
OPEN REDUCTION ?
 Unstable reduction
 Improper orientation of the femoral head and acetabulum
 Lack of congruency of the hip joint
 Excessively tight reduction

5. OBJECTIVES OF AN OSTEOTOMY IN DDH
Improve coverage of head and achieve containment
Redistribute joint forces
Improve motion and relieve pain

6. OSTEOTOMIES AROUND THE HIP
FEMORAL OSTEOTOMY PELVIC OSTEOTOMY

7. RE-ORIENT THE
FEMORAL HEAD
PREVENT EXCESSIVE PRESSURE ON
THE HEAD OF FEMUR
INTERVENTIONS TO ALTER THE
MECHANICAL EFFECTS OF AVN
FEMORAL OSTEOTOMY- REORIENTATION OF HIP MECHANICS

8. FEMORAL SHORTENING
Excessive pressure on the femoral head after
reduction leads to AVN (usually >2 yrs age)
Pressure can be reduced by femoral shortening
Intra-operative assessment by longitudinal
traction and assessment of soft tissue
tone around the hip
*Post-reduction avascular necrosis in congenital dislocation of the hip. Cooperman et al :JBJS (Am) 01 Mar 1980, 62(2):247-258

9. Distance from base of femoral head to
base of the acetabulum is roughly
the amount of shortening required
(Not to exceed 2.5 cm)
Shortening is done in the sub-
trochanteric region via a separate
lateral incision
HOW MUCH SHORTENING ?

10. DEROTATION AND VARUS OSTEOTOMY
Helps to re-orient the
limb according to the
position of reduction
Usually combined with
femoral shortening
osteotomy

11. WHAT TO DO?
FEMORAL
OSTEOTOMY
REQUIRED

12. WHAT TO DO?
PELVIC SIDE
OSTEOTOMY
BOTH SIDE
OSTEOTOMY

13. INTERTROCHANTERIC VARUS OSTEOTOMY

14. FEMORAL SHORTENING + DEROTATION OSTEOTOMY

15. INTERVENTIONS TO ALTER THE MECHANICAL EFFECTS OF AVN
 TROCHANTERIC EPIPHYSIODESIS
 TROCHANTERIC ADVANCEMENT OSTEOTOMY
 INTERTROCHANTERIC DOUBLE OSTEOTOMY
 LATERAL CLOSING WEDGE VALGUS OSTEOTOMY

16. PELVIC OSTEOTOMIES

17. TYPES OF PELVIC OSTEOTOMIES
ACETABULAR
REDIRECTIONAL
OSTEOTOMIES
ACETABULAR VOLUME
REDUCING OSTEOTOMIES
SALVAGE OSTEOTMIES

18. TYPES OF PELVIC OSTEOTOMIES
CONCENTRIC HIP REDUCTION POSSIBLE
ACETABULAR REDIRECTIONAL OSTEOTOMIES
Salter, Steel, Sutherland, Ganz , Tonnis , Spherical Osteotomies (Wagner,
Eppright)
ACETABULAR RESHAPING OSTEOTOMIES (VOLUME REDUCING)
Pemberton, Dega
CONCENTRIC HIP REDUCTION NOT POSSIBLE
SALVAGE OSTEOTOMIES
Chiari, Shelf procedures

19. SALTER’S INNOMINATE OSTEOTOMY
Age: 2-8 years
Advantage: Technically Easy
Age group: 18 m to 6 yrs
Inferior portion of pelvis tilted antero-inferiorly
Anterior Inferior Iliac Spine to Greater
Sciatic notch
HINGE : Pubic Symphysis
(Hence suboptimum in bilateral dysplasia)
Joint Stress redistributed but joint Pressure
increased (head pushed downwards)

21. INDICATIONS:
Primary treatment of DDH
Secondarily in residual/recurrent dislocation
Dislocation after septic arthritis
Subluxation of hip in pelvic obliquities
as in uncorrected scoliosis
Paralytic dislocations/subluxations
Salter RB. Innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip.
J Bone Joint Surg Br. 1961;43(3):518–539.
SALTER’S INNOMINATE OSTEOTOMY

22. SALTER’S INNOMINATE OSTEOTOMY
ADVANTAGES:
No effect on acetabular capacity
Technically less demanding
DISADVANTAGES:
Increases Limb length
Femoral Nerve stretch

23. KALAMCHI’S MODIFICATION OF SALTER’S OSTEOTOMY
Posterior triangular notch is
created in the proximal side of
the osteotomy to engage the
distal iliac segment
Increases stability and prevents
the medial and posterior
displacement.
Limb length discrepancy is
eliminated.
Kalamchi A. Modified Salter osteotomy. The Journal of bone and
joint surgery. American volume. 1982 Feb;64(2):183-7.

24. SUTHERLAND OSTEOTOMY (DOUBLE INNOMINATE
OSTEOTOMY)
Age > 8 yrs
Pubic Osteotomy is made
medial to obturator foramen
Pubic Osteotomy gives better redirection
than Salter’s
Wedge of bone is removed allowing
medialization of acetabulum
Sutherland DH, Greenfield R. Double innominate osteotomy.
The Journal of bone and joint surgery. American volume. 1977 Dec;59(8):1082-91.

25. SUTHERLAND OSTEOTOMY (DOUBLE INNOMINATE
OSTEOTOMY)

26. PEMBERTON OSTEOTOMY Age: 12m – 12 yrs
Advantage: Better Coverage
Age group : 12 m - 12 yrs
Peri-Acetabular osteotomy directed postero-inferiorly
from the AIIS
Improves anterior & lateral acetabular coverage
Volume reducing -----> large acetabulum and small femoral head
HINGE: Triradiate Cartilage
Osteotomy reaches upto posterior limb of triradiate cartilage & does not
enter the sciatic notch
Pemberton PA. Pericapsular osteotomy of the ilium for treatment of congenital subluxation and
dislocation of the hip. JBJS. 1965 Jan 1;47(1):65-86.

27. PEMBERTON OSTEOTOMY

28. PEMBERTON OSTEOTOMY
ADVANTAGES:
Osteotomy is incomplete, more stable
Internal fixation is not required
Greater degree of correction can be
achieved with less rotation of the acetabulum.
DISADVANTAGES:
Osteotomy limited by mobility of
Triradiate cartilage
May cause early fusion of triradiate cartilage

29. PEMBERTON VS SALTER
Salter redirects the acetabulum
Greater correction of AI (>15º )
Fixation not required
Pemberton is technically challenging

30. • Age group : 12m – 12 yrs
• Trans-Iliac osteotomy with an intact posteromedial cortex
• Acetabular coverage can be increased anteriorly, centrally or posteriorly
depending on the placement of the bone graft wedges
• Similar to Pemberton but has large posterior hinge
• Decreases acetabular volume
• HINGE: Triradiate Cartilage
• San Diego Modification : Osteotomy
advances into the sciatic notch
DEGA’S OSTEOTOMY Age: 12m – 12 yrs
Advantage: Better Coverage globally
Dega W. Selection of surgical methods in the treatment of congenital dislocation of the hip in children.
Chirurgia narzadow ruchu i ortopedia polska. 1969;34(3):357.

31. DEGA’S OSTEOTOMY

32. DEGA’S OSTEOTOMY

34. STEEL OSTEOTOMY (TRIPLE INNOMINATE OSTEOTOMY)
Age > 8-12 yrs
Salter osteotomy+ pubic rami osteotomy + ischial osteotomy
Allows for free motion & redirection of acetabulum
Indicated in irreducible subluxations and in failure of other
osteotomies
The amount of rotation is
limited by sacropelvic ligaments
Pubic rami approached through a
separate groin incision
Age: >8 yrs
Advantage: free motion & redirection
Steel HH. Triple osteotomy of the innominate bone. A procedure to accomplish coverage of the dislocated or subluxated
femoral head in the older patient. Clinical orthopaedics and related research. 1977(122):116-27.

35. STEEL OSTEOTOMY (TRIPLE INNOMINATE OSTEOTOMY)

36. TONNIS OSTEOTOMY
Modification of STEEL osteotomy, greater correction than STEEL
Long curved ischial cut connects the obturator foramen to sciatic
notch
This prevents the sacrospinous ligament from
tethering the fragment during correction
Both STEEL & TONNIS osteotomies alter
the true pelvis dimensions and render
normal delivery difficult
Tönnis D, Behrens K, Tscharani F. A modified technique of the triple pelvic osteotomy: early results.
Journal of pediatric orthopedics. 1981;1(3):241-9.

37. STEEL OSTEOTOMY TONNIS OSTEOTOMY
Tönnis D, Behrens K, Tscharani F. A modified technique of the triple pelvic osteotomy: early results.
Journal of pediatric orthopedics. 1981;1(3):241-9.

38. GANZ (BERNESE) OSTEOTOMY
Correction without breaking the posterior column.
Intact posterior column Allows minimal internal fixation and early
mobilization
Allows both anterior and lateral rotation as well as medialization
Indicated for residual dysplasias in adolescents and young adults
Good improvement in the CEA
Only a single approach is required
Allows for maximum correction
Age: >8-12 yrs
Advantage: better redirection & stability
Ganz R, Klaue KA, Vinh TS, Mast JW. A new periacetabular osteotomy for the treatment of hip dysplasias
technique and preliminary results. Clinical Orthopaedics and Related Research®. 1988 Jul 1;232:26-36.

39. GANZ (BERNESE) OSTEOTOMY
Osteotomy cuts:
partial (incomplete) osteotomy of the ischium
complete osteotomy of the pubis
biplanar roof shaped osteotomy of the ilium
 Does not change the diameter of the true pelvis -birth canal not
affected-advantage in young women
Contraindicated if the triradiate cartilage is still open (interferes with
acetabulum growth).

42. GANZ (BERNESE) OSTEOTOMY

43. SPHERICAL ACETABULAR OSTEOTOMIES
Allows rotational repositioning of the acetabulum
Does not disrupt the pelvic ring and hence stable
3 Spherical osteotomies described
Wagner’s osteotomy
Eppright’s Dial osteotomy
Ninomiya osteotomy

44. SPHERICAL ACETABULAR OSTEOTOMIES- NINOMIYA
Ninomiya et al.; JBJS Am 1984 Mar;66(3):430-6.

45. SALVAGE OSTEOTOMIES

46. Attempted when concentric reduction of hip is not possible
These procedures do not provide a hyaline cartilage covered articulation
The capsule under the new acetabulum transforms
to fibrocartilage : SALVAGE
Intra articular or Extra articular
Intra-articular : Chiari Osteotomy
Extra- articular : Shelf procedures, Tectoplasty
Indicated:
 Neurological causes of DDH
lateralized severely dysplastic hip
SALVAGE ACETABULAR OSTEOTOMIES

47. CHIARI ACETABULAR OSTEOTOMY
Tranverse osteotomy of pelvis above the level of the cranial insertion of
the capsule with medial displacement of the acetabular fragment
In essence, a controlled fracture through the ilium
Head completely covered by acetabular roof
Hip jt. pivot closer to body axis
May cause abductor laxity
Chiari K. Medial displacement osteotomy of the pelvis.
Clinical Orthopaedics and Related Research®. 1974 Jan 1;98:55-71.

49. SHELF ACETABULAR AUGMENTATION
Extra articular containment procedure
Provides buttress/stabilising force for the femoral head
Older children 10-18yrs with severe dysplasia
No capacity of remodelling
Post op traction until bony consolidation.

50. SHELF ACETABULAR AUGMENTATION

51. SHELF ACETABULAR AUGMENTATION

52. TECTOPLASTY
Tectum = Roof (latin)
Tectoplasty provides an extra-articular acetabular roof in an adolescent or
young adult
Lateral wall of the iliac bone is raised as a proximally-based flap
Massive bone grafts are inserted to provide a congruous,
non-absorbable roof for the femoral head.
Takaoka et al :JBJS VOL 68-B January 1986

53. TECTOPLASTY

54. SUMMARY - PELVIC OSTEOTOMIES
CONCENTRIC REDUCTION ?
POSSIBLE NOT POSSIBLE
<8 yrs 8- 15 yrs >15 yrs
 SALTER
 DEGA
 PEMBERTON
 STEEL
 SUTHERLAND
 STEEL
 GANZ
 SPHERICAL
OSTEOTOMY
 CHIARI
 SHELF Techniques
 TECTOPLASTY

55. A 15-year-old soccer player complains of hip pain. The pain is worse
with activity and she notices that she has fatigue and pain that extends
to the thighs and knees following a soccer match. A radiograph of the
right hip is shown in Figure . Which of the following surgical
interventions is best indicated?
A.Single innominate osteotomy (Salter)
B. Double innominate osteotomy
C. Ganz Periacetabular osteotomy
D.Triple innominate osteotomy (Steele)
E. Dega osteotomy

56. THANK YOU !