osteotomies arounf the hip

1. DEPARTMENT OF ORTHOPAEDIC
SUREGERY
MAULANA AZAD MEDICAL COLLEGE
AND LOK NAYAK HOSPITAL
OSTEOTOMIES AROUND
THE HIP
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Presented by : Moderator :
Dr. Hemant kumar pippal Dr. Mudasir malik
3/10/2013

2. What is osteotomy?
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 An osteotomy is a surgical corrective
procedure done 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.

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Valgus osteotomy
Ganz osteotomy

4. How does osteotomy work?
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 Increases the contact area / congruency
 Improves coverage of the femoral head.
 Moves normal articular cartilage into weight
bearing zone.
 Restores biomechanical alignment.
 Promotes cartilage regeneration(doubtful)??

5. Biomechanics of the hip
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Ratio of lever arms
3:1

6. Classification of osteotomies
around hip
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 Pelvic Osteotomy
Reorientation Osteotomies : eg. Single,
Double, Triple Innominate, Periacetabular,
spherical
Salvage Osteotomies : eg. Chiari, Shelf
Femoral Osteotomy
Transcervical
Intertrochanteric Osteotomy
Subtrochanteric Osteotomy

7. Pelvic osteotomies
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 Commonly employed in developmental
dysplasia of the hip, leading to a shallow
acteabular cavity and subluxed or dislocated
joint.
 Early reports stated that, acetabular
development was completed by 18 months of
age, others have found that acetabulum
develops till 8 yrs, if reduced before 4 yrs of
age.
 There is a good evidence if significant dysplasia
persists at 5 yrs of age, an osteotomy should
be performed.

8. Osteotomy at work
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Pemberton osteotomy

9. Pelvic osteotomies
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 Reorientation procedure
 Pemberton
 Salter
 Steel
 Dega
 Ganz
 Tonnis
 Spherical/dial osteotomies
 Wagner/ Eppright
 Ninomiya
 Salvage procedure
 Chiari
 Shelf

10. CENTER EDGE ANGLE &
ACETABULAR INDEX
 CE ANGLE-measured after 5 yr age, >25 normal,
<20 severe dysplasia
 AC IND- <27.5 normal, >30 dysplasia
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11. Pemberton osteotomy
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 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.
 INDICATION: In dysplastic hips between the age of
18 months and 6 yrs, the age when triradiate
cartilage becomes too inflexible.
 >10-15 degrees correction of acetabular index
required.
 Small femoral head ,large acetabulum.

12. 12 Medial cut inferior to the level of the outer cut

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 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, if its
larger
3. Premature closer of triradiate cartilage.

15. Salter innominate osteotomy
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 INDICATIONS:
 <10-15 degrees correction of acetabular index required.
 DDH, paralytic disorder, subluxation after septic arthritis
 PREREQUISITES-
 the hip should be concentrically reduceable.
 Contracture of iliopsoas and adductor muscles must be
released,
 range of motion of the hip must be good specially in
abduction internal rotation, flexion.
 AGE- 2-9years

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 Advantages
 No affect on acetabular capacity
 Technically less demanding
 Complications
 Neurovasulcar bundle damage
lateral femoral cutaneous
sciatic, femoral, obturator nerve
nutrient vessels to tensor fasciae lata.
 Faulty positioning of pins can happen.

25. TRIPLE INNOMINATE OSTEOTOMY BY
STEEL
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 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.
 DISADVANTAGE- Technically
difficuilt, does not change size of
acetabulum, distort the hip such
that natural child birth may be
impossible in adulthood
1
2
3

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29. 1.Osteotomy made from
AIIS to Greater Sciatic
notch
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30. Steel osteotomy
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Immediate post op in 16yr old girl
After 1 yr of STEEL osteotomy

32. GANZ (BERNESE) PRIACETUBULAR
OSTEOTOMY.
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 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 presents a
proximal femoral osteotomy can be added.
 Approach Smith Peterson approach.

33. Ganz osteotomy
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34. GANZ OSTEOTOMY
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 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.

36. Spherical osteotomy
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Ninomiya osteotomy

37. CHIARI OSTEOTOMY
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 PROC-It is performed at the superior margin of the
acetabulum ,where capsule of hip joint ends, and
acetabulum is pushed medially along, length of iliac
bone
This is also called as capsular interposition
Arthroplasty as the capsule is interposed between
the shelf and the femoral head.
 INDI-incongruous joint, dysplastic hip with
osteoarthritis other osteotomy not possible
 DISADV-salvage osteotomy only, leaves anterior

38. Chiari osteotomy
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39. Chiari xray
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40. Chiari
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Komal, 17 yr female

41. SHELF OPERATION (STAHELI)
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 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”
form the CE angle. Normally around 35 degrees
 Best to do after 5 years of age.
 Indication : A deficient acetabulum that cannot be
corrected by reorientation osteotomy is the primary
indication.
 Contraindication :
 Dysplastic hip with spherical congruity suitable for
reorientational osteotomy
 Hip requiring open reduction.

42. Shelf procedure
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Width of
augmentation to be
calculated from
centre edge angle
Objective is to
achieve a normal
centre edge angle
of 35 degrees.

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Pre operative 1 yr post op

44. OVERVIEW OF PELVIC
OSTEOTOMY
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45. Review of pelvic osteotomy
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46. Femoral osteotomy
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Technically can be of four types only
 Lineal
 Torsional/derotation
 Trans positional
 Angulation
 adductional/varus
 abductional/valgus

47. Lineal osteotomy
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 Can be done after skeletal
maturity has been achieved
 Usually done to correct limb
length disparities.
 Maximum lengthening 2-3
inches
 Shortening 4-5 inches.

48. Torsional/ derotation osteotomy
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 Altering the angular
relationship of femur neck
and bicondylar axis
 Important to differentiate
between rotation and torsion.

49. Transpositional osteotomies
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 Longitudinal axis of the distal
fragment is parallel to
longitudinal axis of proximal
 Almost invariably, only medial
displacement is done
 Putti osteotomy
 Mcmurray osteotomy

50. McMurray osteotomy
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 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.
 Fixation by blade plate, spline may be required.
INDICATIONS:
 Nonunion of femoral neck
 Advanced osteoarthritis .
AIM :
 Mechanical axis shifted medially
 Shearing force at the nonunion is decreased,
because the fracture surface has become more
horizontal

51. McMurray osteotomy
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 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 incorporate fracture

52. Angulational osteotomies
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 Mechanical axis along with
relationship of articular surfaces
at the opposite end of the bone
is also altered
 shortening of the effective length
of the bone, which is maximal ,
at center.
 Osteotomy should ideally be
performed at the site of deformity
itself.

53. Angulational osteotomies
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54. Angulational osteotomies
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55. Basic principles of ostetotomy
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56. Angulational ostotomies
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 Femur, when viewed
from side, straight in
anteropostrior, bent at
intertrochantric line to
produce femoral neck….
 Effectively, in abduction,
the shortening resulting
from angulation is offset
by increase in effective
length till the head of the
femur lies in extended
longitudnal axis of distal
fragment.

57. Adductional / varus osteotomy
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 May be performed at intertrochantric or
subtrochantric levels
 Indications
 Correction of abductional malalignments
 Broomstick femur( sequale of osteomyelitis)
Congenital hip dislocations
 Hip osteoarthritis ???? Mechanism unclear
 Length discripancies
 Free abduction and adduction should be
possible in all angulation osteotomies.

62. Varus osteotomy

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64. VARUS OSTEOTOMIES

65. 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.
 Varus osteotomy alone is indicated for patients with a
spherical femoral head, little or no acetabular dysplasia
center-edge angle of at least 15 to 20 degrees), signs
lateral overloading, and a valgus neck-shaft angle of
more than 135 degrees.
 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.

66.  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.

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68. Abductional/valgus/pelvic support
osteotomy
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 Distal osteotomised fragment is tilted away
from midline, increasing the femoral neck
angle
 Abductional ostetomy when anatomical axis
comes medially and mechanical axis comes
laterally
 At a point it touches ischial tuberosity, acting
now as pelvic support osteotomy.
 lorenz bifurcation osteotomy
 Schanz osteotomy

73. Valgus osteotomy
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75. Lorenz bifurcation osteotomy
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 Described for congenital dislocation of hip
 In this upper end of the osteotomised fragment is
abducted and inserted in to the acetabulum or make
contact with ischium forming a spike with or without
intertrochanteric osteotomy.
 Disadvantage :
 Increased shortening.
 Less mobility and arthritic pain.
 Peculiar waddling gait, adduction restriction

76. Lorenz bifurcation osteotomy
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77. Schanz osteotomy
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 Schanz osteotomy
 Similar to lorenz ostetotomy, but no spike is made as
such, ostetomised fragments do not make conatct
with ischium.
 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.
 Better adduction as compared to lorenz, and no
arthritc pain

78. Schanz osteotomy
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79. Postosteotomy angle
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 Apart from the degree of abduction, many
factors affect the lateralisation of mechanical
axis; namely site of osteotomy and previuosly
present femoral neck angle
 It has been defined as the angle formed
between, line drawn along inner aspect of
cortex of distal fragment, and oblique
linedrwan from upper end of distal fragment to
most medial part of proximal fragment.
 Considered as neck angle of osteotomised
femur

80. Postosteotomy angle
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