Pelvic osteotomies

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Pelvic osteotomies

  1. 1. Pelvic Osteotomies Dr. Dale Williams
  2. 2. DDH Management Overview • 0-6 months – Pavlik harness • 6 Months – 2 years, failed Pavlik – Closed reduction ± tenotomies, hip spica cast 3 months • 2-3 years, failed closed reduction – Open reduction • 3+ years – Open reduction ± femoral osteotomy ± pelvic osteotomy
  3. 3. Overview • Four general types of osteotomies – – – – Single innominate (Salter) Acetabuloplasty (Pemberton) Triple innominate (Steel) Shelf (Chiari)
  4. 4. Salter Single Innominate • Age – 18 months – 6 years • Requires concentrically reduced hip – Open reduction at same time possible – Iliopsoas and adductor tenotomies often required • Covers antero-lateral acetabular deficiency – Up to 15o of acetabular index corrected
  5. 5. Salter • Anterior approach to acetabulum – Exposing inner and outer ilium – Expose hip capsule if reduction needed – Transverse osteotomy just above acetabulum • G. sciatic notch to AIIS – Rotate on pubic symphysis antero-lateral – Hold correction with bone graft wedge & K-wires
  6. 6. From: ATLAS OF PEDIATRIC ORTHOPAEDIC SURGERY, 3rd Edition
  7. 7. Pemberton Acetabuloplasty • Age – 18 months – 10 years • Requires reduced hip • Decreases acetabular volume (small head) – Remodeling of acetabulum required • Corrects >15o AI • Reduces antero-lateral acetabular defects – Cuts altered to cover more anteriorly or laterally
  8. 8. Pemberton • Anterior Approach - Exposure as for Salter – Cut inner and outer table with small osteotome • Anterior – transverse plane, lateral – lateral incline – 1cm above AIIS, staying 1 cm above capsule – Do not cut through to sciatic notch – Lever through cut until coverage acceptable • Levers on tri-radiate cartilage – Hold correction with bone graft wedge
  9. 9. From: ATLAS OF PEDIATRIC ORTHOPAEDIC SURGERY, 3rd Edition
  10. 10. Dega Acetabuloplasty • Similar to Pemberton • Larger posterior hinge – Hinges on horizontal tri-radiate limb • Less inner table osteotomized – More inner table – more anterior coverage – Less inner table – more lateral coverage
  11. 11. From: ATLAS OF PEDIATRIC ORTHOPAEDIC SURGERY, 3rd Edition
  12. 12. Albee Acetabuloplasty • Similar to Pemberton • Outer table only osteotomized – Cut into cancellous bone to tri-radiate cartilage – Lever outer table laterally, hinging on triradiate cartilage – Hold open with bone graft • Provides some posterior coverage – Cerebral palsy
  13. 13. From: ATLAS OF PEDIATRIC ORTHOPAEDIC SURGERY, 3rd Edition
  14. 14. Steel Triple Innominate Osteotomy • Age – Skeletally mature • Requires congruent hip joint • Divides ilium, ischium and superior ramus – Acetabulum rotationally free – Indicated when other osteotomies not possible • Rotates to cover any acetabular defect
  15. 15. Steel • Multiple incision technique – Posterior between gluteal and hamstrings • Allows osteotomy of ischium – Anterior freeing medial attachments • Allows Salter and superior ramus osteotomy – Rotate acetabulum as desired • Avoid externally rotating – Bone graft wedge, fix as per Salter type
  16. 16. From: ATLAS OF PEDIATRIC ORTHOPAEDIC SURGERY, 3rd Edition
  17. 17. Chiari Medial Displacement • Age – skeletally mature • Salvage operation only – Used when no other osteotomy possible – Possible with subluxed hip • Covers well laterally – Anterior and posterior augmentation may be necessary • May be useful in other conditions – Coxa magna, OA in dysplasic hips
  18. 18. Chiari Medial Displacement • Anterior approach – as per Salter – Identify superior extent of capsule – Cut from AIIS to notch following capsule curve • Angle osteotome 10-20o cephlad – Displace distal fragment medially 50-100% • Ensure complete head coverage • Leg abduction, hinges on pubic symphysis – Secure with hardware
  19. 19. From: ATLAS OF PEDIATRIC ORTHOPAEDIC SURGERY, 3rd Edition
  20. 20. Staheli Shelf Procedure • • • • Age – older child to skeletal maturity Salvage operation Indicated for non-concentric hips Augments supero-lateral deficency – Slotted bone graft over capsule deepening acetabulum
  21. 21. Staheli • Anterior approach, outer wall exposure only – Identify superior acetabular edge – Create slot 1cm deep along edge, angled cephlad – Remove 1 cm cortical strips from outer table • Insert into slot, cutting at desired lateral overhang • 2nd layer inserted lengthwise • Use remaining to fill in above slot edge – Hold in place with reflected fascia and adductors
  22. 22. From: ATLAS OF PEDIATRIC ORTHOPAEDIC SURGERY, 3rd Edition
  23. 23. Ganz Periacetabular Osteotomy • Age – adults • Osteoarthritis 2o to lateral acetabular defect – Decreased coverage increases articular surface stresses leading to early OA • Easily combined with trochanteric osteotomy • Technically extremely difficult
  24. 24. Ganz • Anterior approach – lateral wall exposed – Superior ramus osteotomy, Salter osteotomy • stopping 1 cm from posterior edge – Angle 120o along posterior acetabular edge • Stop 1cm from inferior edge – Cut along postero-inferior acetabular border into obturator foramen – Insert Shantz pin superior as a lever – Fix with screws, insert bone graft as needed
  25. 25. Summary • Most require remodeling – Not as useful in older child (age>8) • Careful match of procedure to patient needed • Steep learning curve for more complex types

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