MODERATORS: PRESENTED BY:

DR MAHESHWARAPPA DR ROHIT KUMARPROFESSOR & UNIT HEAD

DR PRASANNA A.PROFESSOR DATED:24TH AUGUST ‘11

J.J.M. MEDICAL COLLEGE, DAVANGEREDEPARTMENT OF ORTHOPAEDICS

 SEMINAR ON

OSTEOTOMIES AROUND THE

HIP

WHAT IS OSTEOTOMY?

• 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.

HISTORY• First femoral osteotomy was performed by John-Rhea,

Barton in 1826 when tried to secure the motion of ankyloid hip.

• 1835 Sourvier performed first subtronchanteric osteotomy for the treatment of CDH.

• 1854 Langenback introduced sub-cutaneous osteotomy of the femur.

• 1918 and 19 Von Baeyer and Lorenz described bifurcation operation of upper femoral osteotomy to secure stability in old CDH.

• 1922 Schanz reported his low sub-trochanteric abduction osteotomy.

• 1935 Pauwels described osteotomy at intertrochanteric level adduction deformity.

• 1936 McMurry performed oblique displacement osteotomy for osteoarthritis of hip and non-union fracture neck of femur.

• 1955 Chiari did pelvic osteotomy for stable coverage of head.

• Blount and Moore described excellent blade plate for fixation of high sub-trochanteric osteotomy.

WHY DOES OSTEOTOMY WORK?

• Osteotomies :o Increases the contact area / congruency.

o Improves coverage of head.

o Moves normal articular cartilage into weight bearing zone.

o Restore biomechanical advantage.

2D STATIC ANALYSIS

• One legged stance 5/6 BODY WEIGHT on femoral head

• The force acting on the lever arm is thrice the body weight.

BIOMECHANICS• FORCES ACTING ON HIP JOINT ?

• A. BODY WEIGHT• B. GROUND REACTIVE FORCE• C. ABDUCTOR MECHANISM.

TYPESA…BASED ON LOCATION:• 1. CORRECTIVE OSTEO.. 2. COMPENSATORY

OSTEO..

B…BASED ON CONFIGURATION OF BONE CUT :

• 1: TRANSVERSE OSTEOTOMY:• Ideal for correction rotation

alone in metaphyseal and diaphysial region.

Adv : Easy to perform. Disadv : • It is unstable, not ideally suited

for inter fragmentary compression.

• Angular corrections are difficult to control.

• Requires extensive exposure and periosteal stripping.

• 2. OBLIQUE OSTEOTOMY:

• Gives superior bending and rotational stability.

• Easily compressed with inter-fragmentary lag screw.

• Oblique osteotomy is specially useful in metaphysial area .

• 3. CRESCENTRIC OSTEOTOMY:

Advantages :• Good bony contact and

preserve length.

Disadvantages : • Difficult to plan

quantitatively with technically difficult to perform.

• Useful in varus /valgus deformity close to joint.

• 4. DISPLACEMENT OSTEOTOMY:

• Consist of transverse metaphyseal osteotomy particular fragment is rotated and impacting one corner of metaphyseal into medullary canal of other fragment.

Advantages :• Changes bending & loading

force into compressive load.• Preserve length and involving

joint alignment.

CONTRAINDICATIONS OF

OSTEOTOMY

• NEUROPATHIC ARTHROPATHY• INFLAMMATORY ARTHROPATHY• ACTIVE INFECTIONS• SEVERE OSTEOPENIA• ADVANCED ARTHRITIS/ANKYLOSIS• ADVANCED AGE• SMOKING, OBESITY

• OSTEOTOMIES AROUND HIP JOINT CLASSIFIED AS –

1)OSTEOTOMIES OF PROXIMAL FEMUR

2) OSTEOTOMIES OF PELVIS

OSTEOTOMIES OF PROXIMAL FEMUR ARE CLASSIFIED ACCORDING TO:

1. DISPLACEMENT OF DISTAL FRAGMENT.

2. ANATOMICAL LOCATION OF OSTEOTOMY.

3. ACCORDING TO INDICATION.

I) DISPLACEMENT OF DISTAL FRAGMENT

1.TRANSPOSITIONAL OSTEOTOMY:

Longitudinal axis of distal fragment remains parallel to the longitudinal terminal axis of proximal fragment.

• Used in : Fracture neck of femur and OA.

• Eg: McMurray osteotomy, Pauwel’s osteotomy & Putti

osteotomy.

2. ANGULATION OSTEOTOMY :

Longitudinal axis of distal fragment forms an angle with that of proximal fragment . It is done in

• Sagittal plane – Extension osteotomy for FFD.

• Coronal plane - Adduction osteotomy

Abduction osteotomy

II) ANATOMICAL LOCATION :

1. HIGH CERVICAL

2. INTERTROCHANTERIC

3. GREATER TROCHANTERIC

4. SUBTROCHANTERIC

III) BASED ON INDICATION :

1. NON UNION # NECK OF FEMUR- McMurry’s osteotomy- Dickson’s osteotomy- Putti’s osteotomy- Schanz osteotomy

2. OSTEOARTHRITIS - Pauwel’s varus osteotomy- Pauwel’s valgus osteotomy- Mc Murrays osteotomy.

3. UNSTABLE INTERTROCHANTERIC #- Dimon Hughston osteotomy- Sarmiento’s osteotomy

4. UNREDUCED CDH- Lorenz bifurcation osteotomy- Schanz low sub trochanteric osteotomy.- Pemberten acetabuloplasty.

5. CONGENITAL COXA-VARA - Cuniform osteotomy by Fish- Pauwel’s Y osteotomy- Valgus osteotomy- Basilar osteotomy.

6. LEG-CALVE PERTHE’S DISEASE - Varus de-rotation osteotomy - Salter osteotomy- Shelf - Chiari osteotomy.

7. AVN - Sugioka – Trans trochanteric osteotomy- Varus de-rotation osteotomy.

8. SLIPPED CAPITAL FEMORAL EPIPHYSIS.• A) Closing wedge osteotomy of neck:

a. The technique of Fishb. Technique of Dunn just distal to slipc. Base of neck technique by Kramer et al d. d. Technique of Abraham et al

• B) Compensatory osteotomies: a. Ball and socket osteotomy

b. Biplanar IT osteotomy (Southwick)

9. OSTEOTOMIES IN PARALYTIC DISORDER OF HIP o Varus osteotomyo Rotation osteotomyo Extension osteotomy.

OSTEOTOMIES OF PELVIS DIVIDED

INTO :

a) SINGLE INNOMINATE - Salter osteotomy

b) DOUBLE INNOMINATE - Sutherland

c) TRIPLE INNOMINATE - Steel osteotomy - Tonnis

d) PERI-ACETABULAR - Wagner osteotomy

- Ganz osteotomy.

McMURRAY’S DISPLACEMENT

OSTEOTOMYINDICATIONS: 1. Nonunion of femoral neck2. Advanced osteoarthritis .

PREOPERATIVE PLANNING : Determination of the size of the bone wedge to be removed, the position of the seating chisel which will determine the size and angle of the blade plate to be used.

AIM : o Line of weight bearing is shifted mediallyo Shearing force at the nonunion is decreased,

because the fracture surface has become more horizontal

Degree of osteotomy req is estimated & guide pin is inserted in Proximal frag.

proximal cut

Distal cut

Ext rotation and medial displacement

Lag screw & plate given for compression

POSTOPERATIVE CARE:

• Mobilize the patient as soon as symptoms permit. • Maintain touch-down weight bearing until union

occurs.• Active and assisted range of motion exercises for

the hip and knee.• Once union occurs, unrestricted rehabilitation is

possible.

DICKSON’S HIGH GEOMETRIC

OSTEOTOMY

Line of osteotomy is changed from vertical (shearing) force to a horizontal (impacting) force. This osteotomy is done just below the greater trochanter, the distal fragment is abducted 60° and fixed with plate.

Gives high rate of unionImproves abductor strengthIncreases limb length.

SCHANZ ANGULATION OSTEOTOMY

AIM : To turn the shaft from the adducted to abducted position, so that the shearing stress of weight bearing and muscle retraction becomes an impaction force.

INDICATIONS:• Nonunion fracture neck of

femur• Congenital dislocation of hip

• The femur is cut transversely at ischial tuberosity level & the proximal fragment is adducted until it rests against the side wall of the pelvis.

• This lengthens the distance of the gluteus medius and provides a fulcrum so that adequate leverage of the muscle is obtained.

• A plate is prepared and angulated sufficiently. • At operation, the bone is sectioned and the plate

is attached to proximal fragment.

• Then, the distal fragment is abducted, extended and approximated to the distal half of the plate, which is then attached.

• This is a post op radiograph after SCHANZ OSTEOTOMY for neglected CDH…

OSTEOARTHRITIS OF HIP

• AIM OF OSTEOTOMY:1. RELIEF OF PAIN: Mechanical : reducing the ratio

between abductor and body weight, lever, relaxing capsule.

Haemodynamic: Also by decreasing the intra osseous pressure.2. CORRECTION OF DEFORMITY: flexion, adduction, external rotation.

3. REVERSAL OF DEGENERATIVE PROCESS: helped by increase in joint space.

CLINICALLY THE FOLLOWING SHOULD BE RECORDED :

• Limp – antalgic or trendelenberg• Position in which hip is least painful.• Amount of lengthening or shortening.• Fixed abduction/flexion and rotation deformity. • Degree of both active and passive movement of

joint.

PAUWEL’S VARUS OSTEOTOMYAIM :

Varus intertrochanteric femoral osteotomies are designed to elevate the greater trochanter and move it laterally, while moving the abductor and psoas muscles medially, to :

• Restore joint congruity • Decrease the force acting on the edge of the

acetabulum moves to the middle of weight bearing surface.

INDICATIONS: o Antalgic abductor limb o Abduction deformity o Painful adductiono Neck shaft angle > 135° .

• After insertion of guide wire & chisel 2cm proximal to osteotomy site similar to mc murray’s.

Oblique cut is made parallel to the chisel inserted

Proximal fragment is rotated in varus .

• TYPES OF WEDGE IN VARUS OSTEOTOMY:

Wedge being shifted to lateral side.

FINAL RESULT

Insertion of angled blade plate

CONTRAINDICATIONS:

o Fixed external rotation of > 25° o Flexion of 70° or less.

DISADVANTAGES:

• Shortens the limb to some degrees. • Creates a trendelenberg gait.• Increases the prominence of greater trochanter.• Overloading of the medial compartment of knee.

PAUWELS VALGUS OSTEOTOMY AIM:

Valgus intertrochanteric femoral osteotomies transfer the center of hip rotation medially from the superior aspect of the acetabulum to decrease the weight bearing area of femoral head .

• Normally 15° of correction is required.

INDICATIONS: o Trendelenburg Limb o Adduction deformityo Motion in adduction beyond adduction deformity o Painful abduction

CONTRAINDICATIONS:o Flexion of less than 60°o Knock knees as this will increase the deformity at

knee.

• After insertion of guide wire & chisel 2cm proximal to osteotomy site similar to explained before :-

UNREDUCED CDHAim:• To contain the femoral head within the acetabulum.• To improve the dynamic and static forces

maintaining reduction.• In CDH, the basic pathology is:

o A dysplastic acetabulum that is shallow and vertical. This permits the femoral head to slip out when the limb is in extension and adduction.

o A displaced head rests against the lateral wall of ilium. This constant pressure on the femoral head increases the degree of anteversion. An osteotomy in CDH is thus aimed at correcting these defects.

SALTER'S INNOMINATE OSTEOTOMY:

AIM : • In this, the entire acetabulum together with pubis

and ischium is rotated as a unit. INDICATIONS: • CDH in children from 18 months to 6 years of age

and in congenital subluxation upto early adult life.

• Before the osteotomy, femoral head should be positioned opposite the level of the acetabulum achieved by period of traction.

• Contractures of iliopsoas and adductor muscles must be released.

Osteotomy made from AIIS to Greater

Sciatic notch

Graft is taken from iliac crest and trained to the shape of a wedge.

The distal segment is shifted forward,

downward and outward

Place the graft into open segment anteriorly.

Secure it by passing a K-

wire from proximal

fragment through graft

into distal fragment taking

care not to enter

acetabulum.

ADVANTAGES:

• Relatively simple procedure.• No change in acetabular configuration.

DISADVANTAGES:

• Relatively unstable needs internal fixation.

• Second surgery for pin removal.• Possibility of joint penetration by pins.

• Subluxation in 4 yrs old girl of DDH

1yrs post op after SALTERS osteotomy

PEMBERTON ACETABULOPLASTYAIM: • This operation redirects the inclination of the

acetabular roof by an osteotomy of the ilium, superior to the acetabulum followed by levering of the roof inferiorly.

INDICATION:• In dysplastic hips between the age of 1 year and

the age when the tri-radiate cartilage became too inflexible to serve as a hinge (about 12 years in girls and 14 years in boys).

After exposing the hip through anterior Ilio femoral approach.

First cut is made from the outer cortex of the ilium,

starting just above the AIIS and extending backwards till it

reachestriradiate cartilage.

A similar cut is made in the medial cortex directing it posteriorly, parallel with the previous one until it reaches the triradiate cartilage.

With a wide curved osteotome lever the distal

fragment distally until anterior edges of two

fragments is at least 2-3cm apart.

Resect a wedge of bone from anterior part of ilium including ASIS. Place the wedge of bone in the groove made and drive

the wedge into place and impact it.

• Acetabular roof then should remain in a corrected position.

• Postoperatively a hip spica is given for 8-12 weeks.ADVANTAGES: 1. Osteotomy is incomplete, therefore more stable

2. Internal fixation is not required3. Greater degree of correction can be achieved with

less rotation of the acetabulum.DISADVANTAGES: 4. Technically more difficult5. It alters the configuration and capacity of the

acetabulum and can result in an incongruence relationship between it and femoral head.

Acetabular dysplasia in 8-year-old girl after treatment of CDH with Pemberton acetabuloplasty

on Right side.

TRIPLE INNOMINATE OSTEOTOMY BY STEEL

• 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 [chiari- fibrous cartilage], Better hip joint

stability, no need of spica cast.

1

2

3

1.Osteotomy made from AIIS to Greater

Sciatic notch

2. Ischial ramus is

divided

posterolaterally at 45°

from perpendicular.

3.Superior pubic ramus is divided

posteromedially 15° from perpendicular.

• NOW SIMILAR TO SALTERS THE ACETABULUM IS ROTATED ANTERO-LATERALLY AND A WEDGE GRAFT FROM ILIUM IS

PLACED AND TRANSFIXED WITH 2 K WIRES.

Immediate post op in 16yr old girl

After 1 yr of STEEL osteotomy

• DISADVANTAGES: 1. Difficult to perform.2. Does not change the size of the acetabulum.3. It distorts the pelvis so natural child birth is

impossible in adulthood.

MODIFIED BY LIPTON & BOWEN4. Resecting 1-1.5 cm bone from ischial tuberosity to

favor medialization.5. To resect a triangular wedge from outer part of

ilium which favors slot formation which serves as abutment.

6. Use 7.3mm cannulated screws instead of steinmann pins.

SHELF OSTEOTOMY BY

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 (WA)” using the CE angle of wiberg.

• Best to do after 5 years of age.

o CE ANGLE IS MEASURED IN STANDING AP RADIOGRAPH ..AT 35 DEG

o GRAFT LENGTH(GL)= WA + SLOT DEPTH

An acetabular slotis created exactly at the

acetabular margin by drilling a series of holes with 4.5mm drill bit. Slot

should be 1 cm deep.

Place the graft in the slot.

• After packing the graft the rectus femoris is sutured for stability of the graft .

• Postoperative: hip spica can be applied in 15 deg of abduction and 20° of flexion.

Pre operative 4 moths post op1 yr post op

• CONTRA-INDICATIONS:

1. DDH with spherical congruity suited for re-directional osteotomy.

2. Hips requiring concurrent open reduction that must have supplementary stability.

3. Patients un-suited for spica cast application.

CHIARI OSTEOTOMY• This is a capsular interposition osteotomy as the

capsule is interposed between the newly formed acetabular roof and femoral head.

• INDICATIONS:• Congenital subluxation in patients 4 to 6 years or

older, including adults. • Dysplastic hip with osteoarthritis• For Coxa magna after Perthes disease or avascular

necrosis after treatment of congenital dysplasia.• For paralytic dislocation caused by muscular

weakness or spasticity.

TECHNIQUE :ANT-LAT APPROACH

• The osteotomy is made precisely between the insertion of the capsule and reflected head of rectus femoris.

• Ending distal to the AIIS anteriorly and in sciatic notch posteriorly.

• With a straight narrow osteotome, start osteotomy on lateral table with plane directed 20° superiorly towards inner table.

• The distal fragment is now displaced medially by forcing the limb into abduction hinging at symphysis pubis.

• It is displaced enough medially so that the proximal fragment completely covers the femoral head

i.e. about half of the thickness of bone.

• If necessary the fragments may be transfixed by screw driven obliquely.

PRE OP POST OP WITH CHIARI

OVERVIEW OF PELVIC OSTEOTOMY

LEGG CALVE PERTHES DISEASE:

PATHOLOGY: • Self limited disease of avascular necrosis of

ossification center of the capital epiphysis, resulting in variable degree of deformity of femoral head.

AIM: • To prevent or minimize residual deformity of

femoral head by creating the biomechanical environment which is not detrimental to normal growth and remodeling of epiphysis.

• This is achieved by containing the femoral head within the acetabulum.

VARUS DE-ROTATION OSTEOTOMYAIM : • By reducing the ante-version and neck shaft angle

to obtain maximum coverage of the femoral head. • This osteotomy is done before 4 years of age, as

after this age, there are less chances of Acetabular remodeling.

DISADVANTAGES: 1. Excessive varus angulation that may not correct

with growth 2. Further shortening of already shortened extremity3. Possibility of a gluteus lurch produced by

decreasing the length of the lever arm of the gluteus musculature.

• The degree of de roration is estimated with the amount of internal rotation but furthur adjustments can be made during the surgery.

• If the internal rotation is severely limited even after 4 weeks of bed rest with traction :

• Varus osteotomy is done along with extension by giving slight backward tilt to the proximal segment.

TECHNIQUE: • With patient supine make

lateral incision from greater trochanter distally 8 to 12cm exposing lateral aspect of femur.

• Mark the level of osteotomy at the level of lesser trochanter or slightly distal.

• Insert the guide pin and do reaming of the femoral head.

• Insert the barrel guide into the back of the implanted lag screw.

• Make the osteotomy cut & tilt the head into varus .

• Using the side plate and screws firmly join the proximal and distal fragments.

• Spica cast is worn for 8-12 weeks and internal fixation can be removed after 1-2 years.

OTHER OSTEOTOMIES IN PERTHES

DISEASE

1. SALTER Innominate osteotomy:

2. SHELF procedure (Staheli): If the hip is congruous, it can be performed for coxa magna and lack of acetabular coverage for the femoral head.

3. CHIARI Osteotomy: It is used as a salvage procedure to accomplish coverage of large flattened femoral head.o Technique: Described in CDH.

4. VALGUS EXTENSION osteotomy: Indicated in malformed femoral head in residual Perthe's disease with hinge abduction. o Technique: Described in Osteoarthritis

AVASCULAR NECROSIS OF FEMORAL

HEAD

• AIM : To reposition the necrotic part of the

femoral head to a non-weight bearing area.

• INDICATIONS: Osteotomy is done in FICAT'S stage I and II of AVN.

PAUWEL'S `Y' OSTEOTOMY

• A guide pin is inserted from the greater trochanter to head of femur.

• One limb of osteotomy is made from the base of greater trochanter towards the base of neck medially and inferiorly.

• The distal limb of the Y then passes upwards and medially to reach the proximal limb and a wedge of bone with the required

from the proximal aspect of• its base directed laterally.

correction is

removed distal

fragment with

• The trochanter head segment is levered into valgus.

• The two fragments are apposed by displacing the proximal end of the shaft medially and abducting the limb.

• The nail is then attached by a plate to the shaft.

SUGIOKA TRANSTROCHANTRIC ROTATIONAL

OST.

• This is done for osteonecrosis to prevent progressive collapse of the articular surface and to improve the congruity of hip joint.

• To do this the femoral head and neck segment is rotated anteriorly around its longitudinal axis, though a trans-trochantric osteotomy.

• So that the weight bearing force is transmitted to the posterior articular surface of femoral head, which is not involved in the ischemic process.

TECHNIQUE :• Through lateral

approach expose the capsule, osteotomize the greater trochanter.

• Reflect it proximally

• Incise the joint capsule circumferentially.• Carefully protect the posterior branch of medial

circumflex femoral artery at inferior edge of Quadratus femoris.

along with the attached tendon of Gluteus medius, minimus and Piriformis.

• Place two pins in greater trochanter from lateral to

medial. in plane perpendicular to femoral

neck.• Make a trans-trochantric

osteotomy and a second osteotomy at right angle to the first, at superior edge of lesser trochanter, to leave the lesser trochanter with distal fragment.

• After completing second osteotomy use the proximal pin to rotate proximal fragment 45-90° depending on the size of necrotic area.

• Fix the osteotomy internally with large screws and washer.

• Re-attach the greater trochanter to proximal and distal fragment with screws.

• Post op after one yr

• Postoperative: skin traction is given for 2-3 weeks active range of motion exercises of hip are begun at 10-14 days.

SLIPPED CAPITAL FEMORAL

EPIPHYSIS

• In this condition, the epiphysis slowly displaces inferiorly and causing adduction and external rotation deformity of the limb.

AIM: Osteotomy is performed here to

reposition the femoral head concentrically within the acetabulum.

INDICATIONS: o Chronic slip with moderate to severe

displacement. o Malunited slip

TWO BASIC TYPES:• Closing wedge osteotomy of neck: Usually

associated with serious complications of AVN and chondrolysis, therefore these osteotomies are not recommended. These are of four types.

a. The technique of Fishb. Technique of Dunn just distal to slipc. Base of neck technique by Kramer et al d. d. Technique of Abraham et al

• Compensatory osteotomies through the Trochantric region: These osteotomies produce a deformity in the opposite direction. It includes

a. Ball and socket osteotomyb. Biplane intertrochanteric osteotomy

(Southwick)

1. CUNEIFORM OSTEOTOMY OF FEMORAL NECK (FISH):

• Fish recommended this in moderate to severe slips of more than 30°.

• The hip is exposed through Watson-Jones incision.

• Capsule is incised & femoral neck is exposed.

• Locate the physis.• Determine the size of wedge to

be removed by noting the degree of slip.

• Adjacent to the epiphyseal plate, a wedge shaped piece of bone is removed with its base directed anteriorly and superiorly with apex psotero-inferiorly.

• Take care that osteotome does not penetrate the intact posterior periosteum, damaging retinacular vessels.

• Reduce the epiphysis by flexion, abduction and internal rotation of limb, taking care to put much tension on the posterior periosteum, capsule and vessels.

After reduction fix the epiphysis to neck with 2-3 pins six inches long threaded on one half of their lengths with a nut on the thread. Do not penetrate articular cartilage.

2. CUNIEFORM OSTEOTOMY OF FEMORAL NECK (DUNN):

• Dunn described an osteotomy for severe chronic slips in children with open physis.

• This procedure should not be done if the physis is closed.

TECHNIQUE :• Through a lateral approach

• A. Greater trochanter is detached.• B. Synovium is elevated from anterior and

postero-lateral surface of femoral neck with periosteum elevator.

• C. Head is free of all fibrocartilage and callus.• D. Osteotomy line on upper end of femoral neck

is made for excision of trapezoid segment.

• E. Head of femur is replaced on femoral neck and three threaded Steinmann pins are used for fixation of shaft, head, and neck of femur.

• F. Two cancellous screws are used to fix greater trochanter in normal position.

• AFTER ALL SAID AND DONE ….

NO SURGERY IS EASY ….AS EASY IT MAY LOOK …

THANK YOU

BIBLIOGRAPHY

1. CAMPBELL’S OPERATIVE ORTHOPAEDICS, 11TH EDITION.

2. TEXT BOOK OF ORTHOPAEDICS – G.S. KULKARNI.

3. TUREK ORTHOPAEDICS.

4. STANDARD ORTHOPAEDICS OPERATIONS– ADAMS. 5. OPERATIVE ORTHOPAEDICS – CHAPMAN’S.

6. INTERNET