Osteotomies Around Hip Joint

Dr.Ankit Dr.B.L.Chandrakar

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.

OSTEOTOMY AROUND HIP -CLASSIFICATION

According to Anatomic Location

Femoral Osteotomy

High Cervical.

Intertrochanteric Osteotomy.

Subtrochanteric Osteotomy.

Greater Trochanteric

Pelvic Osteotomy

Salvage Osteotomies : eg. Chiari, Shelf,

Reconstructive Osteotomies : eg. Periacetabular, Single,

Double, Triple Innominate

Combined Osteotomy

INDICATIONS

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).

To obtain stability old unreduced dislocations.

Lorenz bifurcation osteotomy. Schanz low subtrochanteric.

Relief of pain osteoarathritis.

Pauwel’s type I varus osteotomy. Pauwel’s type II valgus osteotomy.

To obtain union Un-united fractures of femoral neck.

McMurry’s osteotomy. Dickson's high geometric osteotomy. Schanz Angulation Osteotomy.

unstable intertrochanteric fractures. Dimon Hughston Osteotomy. Sarmiento’s Osteotomy

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 of hip

Salters innominate osteotomy Pembertons innominate ostetomy Steels triple innominate osteotomy Shelf operation Chiari’s osteotomy

OVERVIEW OF PELVIC OSTEOTOMY

SALTER OSTEOTOMY INDICATIONS-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 wks,then partial weight

bearing on crutches ,followed by full weight bearing.result

assessed by center edge angle.

xrays

Salter osteotomy for congenital dislocation of hip. A, Residual acetabular dysplasia and subluxation of right hip in 4-year-old girl in whom open reduction had been performed at 9 months of age. B, One year after repeat open reduction and Salter innominate osteotomy.

PEMBERTON OSTEOTOMY

PROCEDURE- 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 anteroinferior 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.

Pemberton pericapsular osteotomy. A, Line of osteotomy beginning slightly superior to anterior inferior iliac spine and curving into triradiate cartilage. B, Completed osteotomy with acetabular roof in corrected position and wedge of bone impacted into open osteotomy site.

PEMBERTON OSTEOTOMY

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 produces joint incongruity that requires remodelling

AGE-18months- 10 yr AFTERCARE-spica cast for 8 to 12 weeks

PEMBERTON PERICAPSULAR OSTEOTOMY

PERIACETABULAR OSTEOTOMY OF ILIUM (PEMBERTON)

Pemberton acetabuloplasty. A, Symptomatic residual acetabular dysplasia in 8-year-old girl after treatment of congenital dislocation of right hip. B, After Pemberton acetabuloplasty

TRIPLE INNOMINATE OSTEOTOMY (STEEL)

STEEL OSTEOTOMY

The ischium, the superior pubic ramus and ilium superior to

the acetabulum are all divided and acetabulum is repositioned

and stabilized by bone graft and metal pins Objective- To establish a stable hip in anatomical position for

dislocation or subluxation of the hip in older children when

this is impossible by any one of the other osteotomies For the operation to be successful, the articular surfaces of the

joint must be congruous or become so when the acetabulum

has been redirected so that a functional, painless range of

motion is achieved and a Trendelenburg gait is absent

STEEL OSTEOTOMY

INDICATIONS-Adolescents and skeletally mature adults with

residual dysplasia and subluxation in whom remodelling of

acetabulum is no longer anticipated ADVANTAGES-Better coverage of femoral head by articular

cartilage. Better hip joint stability,no need of spica cast. DISADVANTAGES- Technically difficult, does not change

size of acetabulum, distorts the hip such that natural child birth

may be impossible in adulthood

STEEL OSTEOTOMY

A, Osteotomies to be performed in iliac wing and superior and inferior pubic rami. Note wedge of bone to be taken as graft from superiormost portion of ilium. B, Lateral view showing graft in place and fixation with two Kirschner wires.

STEEL OSTEOTOMY

Steel triple innominate osteotomy. A, Sixteen-year-old girl with painful right hip, subluxation, and acetabular dysplasia. B, After Steel osteotomy. C, One year after surgery

A

B

C

GANZ OSTEOTOMY: (BERNESE) PRIACETUBULAR OSTEOTOMY.

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 present a

proximal femoral osteotomy can be added.

Approach- Smith Peterson approach.

GANZ OSTEOTOMY

GANZ OSTEOTOMY

Advantages : 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.

Contd.

THE SHELF PROCEDURE (STAHELI)

SHELF OPERATION (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” from the CE angle. The shelf is put just above the acetabular margin. It secures 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 placement of the acetabular slot is the most critical part of the procedure; the slot must be created exactly at the acetabular margin

Approach- Iliofemoral approach using bikini incision parallel and 1cm below the Iliac crest

CENTER EDGE ANGLE/ACETABULAR INDEX

CE ANGLE-measured after 5 yr age, >25 normal, <20 severe dysplasia

AC IND- <27.5 normal, >30 dysplasia

CHIARI OSTEOTOMY PROCEDURE-It is performed at the superior margin of

the acetabulum and the pelvis inferior to the osteotomy

along with the femur is displaced medially.

This is also called as capsular interposition Arthroplasty

as the capsule is interposed between the shelf and the

femoral head.

INDICATIONS-incongruous joint, dysplastic hip with

osteoarthritis ,other osteotomy not possible

DISADVANTAGE-salvage osteotomy only, leaves

anterior acetabulum uncovered,abductor lurch common .

A, Line of osteotomy extending from immediately superior to lip of acetabulum into sciatic notch. Osteotomy can be curved to facilitate femoral head coverage. B, Completed osteotomy with medial displacement of distal fragment for interpositional capsular arthroplasty

CHIARI

PALLIATIVE OPERATION

Reserve for cases is which reduction is not possible by

either open or closed reduction as in old unreduced

congenital dislocation.

Designed to improve :

Stability.

Decrease lordosis.

Control pain arising from lower back/hip.

SURGICAL PLANNING

In surgical planning of an osteotomy, the most

important task is to determine whether the

patient is an appropriate candidate.

Determining factors are the patient’s age,

activities, goals, radiographic assessment,

range of motion, and leg lengths and the status

of the knee of same side.

FEMORAL OSTEOTOMY

Primary objective is deflection of wt. bearing by

angulation of femur to bring the axis of the femoral

shaft more in line with the direction of weight

transmission.

The osteotomy performed are Angulation

Osteotomy (Stabilizing osteotomy).

Schanz osteotomy.

Lorenz osteotomy.

SCHANZ OSTEOTOMY (LOW Subtrochanteric OSTEOTOMY)

(a)Femur is sectioned transversely a lower border of pelvis.(b)Upper end is angled inward until it rest against side wall of pelvis.

Schanz osteotomy : 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.

Contraindication : Before 15 years of age, because loss

of angulation during growth period.

Lorenz (Bifurcation osteotomy)

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.

LORENZ (BIFURCATION OSTEOTOMY)

(A) Plane of osteotomy – Distal end at posterolateral aspect towards proximal end at anteromedial aspect.

(B) Limb is Abducted and extended so proximal end of distal fragment directed medially and anteriorly in acetabulum.

OSTEOTOMY FOR COXA VARA The normal femoral neck shaft angle in infant is 1200 to 1400,

Reduction to a more acute angle constitute a coxa vara deformity.

The goal of treatment are To promote ossification of the defect and correct varus

deformity. Indication for surgery :

Increasing coxa vara Neck shaft angle less than 110°. Painful unilateral or associated with leg length

discrepancy Hilgenreiner - epiphy seal angle of more than 60° .

Surgery performed are

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.

Alternative Method : Pauwels Y shaped osteotomy :

Static forces are converted from shearing to impacting

forces

Prerequisites :

Viable femoral head.

Young vigorous patient.

Advantage :

Union is rapid.

Recurrence is less likely.

PAUWELS Y SHAPED OSTEOTOMY

COXA VERA

COXA VARA

OSTEOTOMY FOR RELIEF OF PAIN IN OSTEOARTHRITIS

Before the onset of osteoarthritis, if normal or near normal

function of the hip can be maintained, reconstructive

osteotomy can prevent or delay the development of

osteoarthritis; if mild or moderate osteoarthritis is present, a

salvage osteotomy can improve function and delay the need

for total hip Arthroplasty.

Factors Reconstructive Osteotomy Salvage Osteotomy

Age Generally < 25 years Generally < 50 years (Some biological Plasticity Remains)

Symptoms Minimal Moderate to Severe

Motion Near Normal > 600 Flexion

Function Near Normal Fair to Poor

Pathoanatomy No Irreversible Changes Irreversible Changes

Roentgenography Congruent but Malaligned Surfaces

Cartilage narrowing or incongruity or both

Prognosis if untreated

Poor Poor

THERAPEUTIC INTERVENTION IN HIP DIEASE :RECONSTRUCTIVE VERSES SALVAGE

OSTEOTOMY

The goal of reconstructive osteotomies, femoral or pelvic, is to

restore as nearly normal anatomy as possible, thus returning

joint pressures and loading patterns to normal.

The goal of salvage osteotomies are to relieve pain and

improve function enough to delay the need for total hip

Arthroplasty, especially in active patients younger than 50

years of age.

Pre –op planning

Xrays of hip in maximum adduction and abduction.

Tenotomy if necessary Determine in which position the head attains

best fit with the acetabulum Range of abduction and adduction will

determine the angle of the wedge so that the limb can attain in the neutral position

varus osteotomy :- Designed to elevate the greater trochanter and move it

laterally while moving the abductor and psoas muscles medially, to restore joint congruity and decrease muscle forces about the hip.

Indications- patients with a spherical femoral head, little or no acetabular dysplasia center-edge angle of at least 15 to 20 degrees),a valgus neck-shaft angle of more than 135 degrees,fixed abduction deformity.

C/I-fixed ext. rotation >25 deg,flexion of 70 deg Varus osteotomy with medial displacement of the femoral

shaft relaxes the abductor, psoas, and adductor muscles unloads the hip joint, and increases the weight-bearing surface.

Varus osteotomy increases weight bearing area of femoral head while relaxing all three important muscle groups around hip joint

Three types of wedges cut for varus osteotomy. A, Original technique of Pauwels with proximal osteotomy made transversely at distal end of greater trochanter. This type of osteotomy makes it more difficult to correct rotation and to use right-angled blade plate. B, Original Müller technique of excision of wide wedge based medially with distal osteotomy cut transversely across shaft at just above level of lesser trochanter. C, Later technique of Müller using small half wedge cut medially and transposed laterally.

VARUS OSTEOTOMIES

Most authors recommend medial displacement of 10 to

15 mm to keep the ipsilateral knee centered under the

femoral head and to maintain the mechanical axis of the

leg.

Varus osteotomy, however, shortens the limb to some

degree. creates a Trendelenburg gait that may persist for

months after surgery, and increases the prominence of the

greater trochanter.

Limb shortening can be minimized by making a smaller

medial osteotomy and transposing it to the lateral side.

VALGUS INTERTROCHANTERIC FEMORAL OSTEOTOMIES

Valgus Osteotomy - Increase weight bearing area of femur head. It does not produce muscle relaxation. Relaxation obtained by tenotomy of Iliopsos and adductor

muscle. Transfer the center of hip rotation medially from the superior

aspect of the acetabulum to increase joint congruity and the weight-bearing area of the femoral head.

Osteotomy of the greater trochanter often is performed with valgus femoral osteotomy to move the greater trochanter laterally.

INDICATIONS : FIXED ADDUCTION DEFORMITY

CONTRAINDICATIONS : FLEXION OF LESS THAN 60 DEGREES, KNOCK KNEES

Best result were obtained in patients younger than 40 years of age with unilateral involvement, good preoperative range of motion, and a mechanical (secondary) cause.

Most surgeons now advise that all osteotomies be fixed with rigid internal fixation, which offers several obvious advantages: The fragments are maintained in proper position; The danger of limitation of motion of the hip and knee is

greatly decreased;

The patient can be allowed out of bed early; and

Pulmonary, urological, and other medical complications

are decreased. A device frequently used for rigid internal

fixation of intertrochanteric osteotomies is the ASIF, or

right-angled, blade plate.

Nonunion has been a troublesome complication after

Osteotomy, and an incidence as high as 20% has been

reported.

BIOMECHANICAL TREATMENT OF OSTEOARTHRITIS

Therapy must be directed at reducing joint loads. This may

be by reducing the compressive forces directly or by

increasing the weight- bearing area, and thereby reducing

the load per unit area or ideally by combination of the two.

WHILE PERFORMING OSTEOTOMY

The distal cut must be perpendicular to the axis of the shaft

fragment. All cortical wages are taken form the proximal fragment to

avoid loss of apposition when the distal fragment is rotated. General contraindication of femoral osteotomies -

Poor motion Inflamatory joint condition Significant metabolic disease. Severe degenerative joint disease.

OSTEOTOMY TO CORRECT UNSTABLE INTERTROCHANTERIC FRACTURES

Sarmiento Technique

OSTEOTOMY TO CORRECT UNSTABLE INTERTROCHANTERIC FRACTURES

Dimon and Hughston :

Described technique of Trochanteric osteotomy with

valgus nailing and medial displacement to improve

stability there techniques are occasionally useful in some

extremely comminuted fractures.

Recent studies have indicated that anatomical reduction

allow greater load shearing by bone than medial

displacement osteotomy.

DIMON AND HUGHSTON METHOD OF INTERTROCHANTERIC OSTEOTOMY

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)

Is a disorder in which there is a displacement of the capital

femoral epiphysis form the metaphysis through the physeal

plate.

By this head is placed in posterior & downward position in

acetabulum.

The goal of treatment is

To prevent further displacement and

To promote closure of physeal plate.

The use of realignment procedure such as lntertrochameric,

Subtrochanteric Osteotomy & osteotomies the around neck is

in those situation in which restricted range of motion impairs

function after plate physeal closure.

Principle of Osteotomy

There are basically three type of Deformity present in SCFE.

These are-

Varus

Hyper extension

Moderate Severe external rotation

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)

The osteotomy to correct these

deformities work at two sites.

Through the femoral neck

(closing wedge osteotomy)

Through the trochanteric

area.

EXTRACAPSULAR BASE OF NECK OSTEOTOMY

types of femoral neck osteotomy are - The technique of Dunn - for severe chronic slip with open

physis. Base of the neck osteotomy - Compensatory Basilar most

of femoral neck. (Kramer) - correct the varus and

retroversion component of moderate to severe chronic

SCFE. It is safer than cuniform osteotomy of neck. Further slipping is prevented. Intertrochantric osteotomies

CORRECTIVE OSTOTOMIES

By these osteotomies one can correct angulation, rotation,

flexion, extension Deformity of bones to restore motion for

patient with stiff hip.

Like

Deformities in septic arthritis

Malunion of I/T femurs

Neuromuscular disorder

Cerebral palsy

Poliomyelitis

There are three types of corrective osteotomies Close wedge - transverse closing wedge provide good bony

apposition and is stable, however, it shortens the extremity. Open wedge - simple and lengthens the extremity however.

bony apposition is limited, union is delayed in adults and it is initially unstable.

Ball and Socket type - achieves stability without shortening the extremity; however, extensive dissection is required, and in severe biplame deformities an accurate and stable osteotomy is difficult to perform.

In Ball & socket type of osteotomy concave surface in created in the proximal fragment of convex surface at the distal fragment, at intertrochantaric level & fixed in place by plate.

CORRECTIVE OSTOTOMIES

Brackett ball and socketOsteotomy

Whitman closing wedgeOsteotomy

Gant-opening wedge

Osteotomy

FRACTURE NECK FEMUR In those case which present late (1-5 wks.), are difficult case

to treat because Close reduction is not possible. Open reduction is associated AVN

In young Pt. with viable femoral head & nonunion options are- Mcmurray & Pauwel’s ‘y’ osteotomy Angulation Osteotomy (Schanz) Dickson geometric osteotomy

In old Pt.- Mcmurray Displacement

OBLIQUE OSTEOTOMY

Extends from lateral aspect of shaft at level just below the

lower border of lesser trochanter and terminates medially

between lesser trochanter and lower border of neck.

Shaft is displaced medially.

Mechanical Advantage :-

Line of weight bearing shifted medially.

Shearing forces at the nounion is decrease because

fracture surface become more horizontal

These advantages are greater after angulation osteotomy.

McMURRAY

MC-MURRAY OSTEOTOMY

MC-MURRAY’S OSTEOTOMY The oblique osteotomy extends from the lateral aspect of

the shaft at a level just below the lower border of the lesser trochanter and lower border of neck.Then the limb is rotated inward and outward to remove any bony spike Fixation of osteotomy - By Compression nail

plate./Castle Plate. Disadvantages:

Instability - Degenerative changes in normal head Shortening - AVN when neck have been fractured Medial displacement of shaft compromise the

insertion of femoral stem of total hip. Advantage -Changes line of fracture to

horizontal,callus may incarporate fracture

DICKSON HIGH GEOMETRIC OSTEOTOMY

Principle - the line of vertical force

is converted to a horizontal

(impacting force). In this distal

fragment is abducted to 60° after

making osteotomy just below the

grater trochanter & fixed with plate.

High rate of union

Lengthens limb

Improves abductor strength

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.

AVN

TRANSTROCHANTRIC ANT. ROTATIONAL OSTEOTOMY [SUGIOKA]

TECHNIQUE FOR ROTATION

Femoral head is rotated anteriorly (450 - 900) by handling proximal pin.

OSTEOTOMY IN PERTHE'S DISEASE Salvage :

Varus Derotational Osteotomy Innominate Osteotomy. MRI / Arthrogram before surgery is mandatory. Varus/derotation osteotomy of this embodies the principle

of “containment” of the diseased femoral head in the treatment of Legg - Calve-Perthes disease.

Guide pin inserted compression screw is placed over guide wire.

Appropriate angled osteotomy is made.

Wedge is removed.

Make osteotomy as proximal as possible just below lag

screw for -

Better Healing

Better correction of deformity.

Reduce the osteotomy and fixed with plate and

compression screw.

SUBTROCHANTERIC DEROTATION AND VARUS OSTEOTOMY

The aim of surgery is to center the whole "plastic" epiphysis inside the joint cavity, keeping it well covered by the roof of the acetabulum and allowing the child to walk so that the redistributed intra-articular pressures will contribute the molding of a more normal joint.

A small 4-hole plate is bent to the desired angle, and a subtrochanteric osteotomy is done followed by derotation and yarns angulation of the shaft. A double hip spica is applied and the removed 2 months later. When the osteotomy site is united, the child is encouraged to walk, then with walking aids and finally without support.

VARUS DEROTATION OSTEOTOMY

The operation is best suited for early stage of Leg-Calve-

Perthes’ disease, preferably those under the age of 7 years.

Axer : Described lateral open wedge osteotomy for children

< 5 years with perthes disease. Defect laterally fills rapidly

in young children > 5 years of age delayed or non union may

occur.

RECONSTRUCTIVE SURGERY

Valgus subtrochanteric osteotomy – for Hinged

Abduction

Shelf Augmentation – Coxa Magna.

Chilectomy - Malformed head in late III Group.

Chiari's Pelvic Osteotomy - Large Malformed

Femoral Head with Subluxation laterally.

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