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J Korean Hip Soc21(3): 202-210, 2009 Review Article

Osteotomies Around the Hip Joint

Jae Suk Chang, MD, Ji Wan Kim, MD

Department of Orthopedic Surgery, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea

The goal of an osteotomy around the hip joint for treating hip dysplasia is to delay or prevent osteoarthritis by reducing
the stress to the hip joint. This can be archived with anterolateral displacement of the acetabulum and an osteotomy
around the hip joint is indicated for the young and active patients, besides performing total hip arthroplasty.

As the osteotomy site is close to the hip joint, we can obtain more correction with performing this type of surgery than is
possible with other types of pelvic osteotomies and we can get excellent radiological and clinical outcomes. But
periacetabular rotational osteotomy is a rather difficult procedure, there may be complications and a long learning curve
is needed to learn the surgical technique. A dual approach for periacetabular rotational osteotomy is easier with direct
exposure of the osteotomy site and there are fewer complications than that with performing a Berneses periacetabular
rotational osteotomy, as described by Ganz. Therefore, it is recommended for beginners. The osteotomy site of the
proximal femur is usually around the lesser trochanter, but femoral neck osteotomy may be performed in rare cases. The
preoperative planning for obtaining a correction angle of the osteotomy site is the most important factor, and excellent
results can be archived by performing an accurate procedure.

Key Words: Hip dysplasia, Pelvic osteotomy, Periacetabular osteotomy, Proximal Femur osteotomy

westtheory Depending on whether it is hyaline cartilage or fibrocartilage, the former is

called a reconstructive osteotomy, and the latter is called a salvage

Osteotomy around the hip joint is proximal Deformity of the femur and acetabulum, or osteotomy, and the Chiari osteotomy belongs to this group.

It is performed to improve the mechanics of the hip joint and prevent it from

progressing to arthritis. If the lesion is the femur, proximal femur osteotomy is Periacetabular osteotomy

performed, and if the lesion is the acetabulum, pelvic osteotomy is performed.

Femur osteotomies can be classified by the location of the osteotomy (femoral The Salter osteotomy is the best known pelvic osteotomy for congenital hip

neck, trochanter, etc.) and direction (valgus, adduction, rotation, etc.), and pelvic dislocation and hip dysplasia. This is a procedure that covers the anterior part of

osteotomies are sometimes named after the person who designed them (Salter, the femoral head by performing an osteotomy from the proximal part of the

Chiari). It is classified by the number and shape of the osteotomy, and is very anterior superior iliac spine (ASIS) toward the greater sciatic notch. It is often

diverse when considering all cases where the surgical method has been changed. performed for congenital hip dislocation in children. This osteotomy requires

Meanwhile, the joint surface is normal after osteotomy. movement in the pubic symphysis and sacroiliac joint (especially the pubic

symphysis) to achieve correction. It is mainly performed in children, but there are

reports that satisfactory results were obtained when performed in adults.5,17).

Submitted: April 25, 2009 1st revision: June 18, 2009 Final
However, the Salter osteotomy technique increases posterior torsion of the
2nd revision: July 28, 2009 acceptance: August 17, 2009
acetabulum because it covers the anterior part of the hip joint by cutting only the
�Address reprint request toJae Suk Chang, MD
Department of Orthopedic Surgery, University of Ulsan, College of ilium. Therefore, in hip dysplasia accompanied by posterior torsion, the defect in

Medicine, Asan Medical Center, 388-1, Pungnap 2-dong, Sonapa-gu, the posterior part of the acetabulum becomes more severe, and in the anterior

Seoul, 138-736, Korea part of the hip joint, an impingement syndrome can occur where the femoral
TEL: +82-2-3010-3525 FAX: +82-2-488-7877 E- head and the acetabulum come into contact.
mail: jschang@amc.seoul.kr

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 Jae Suk Changet al.: Osteotomies Around the Hip Joint

In order to obtain sufficient correction through osteotomy, a method was Kinda. At this time, the only blood vessels that go to the osteotomy fragment are

developed in which not only the ilium but also the pubic bone was cut near the those that follow the joint capsule, so the joint is incised and no treatment is

pubic symphysis, and later, a triple osteotomy was developed in which an performed on the lesion within the joint. Shifting the hip joint medially is also

osteotomy was also made near the ischial tuberosity. In order to obtain more performed with the osteotomy performed by Ganz, and more corrections are

sufficient correction, the osteotomy is performed as close to the acetabulum as possible than with RAO. Therefore, RAO is also recently performed by making a

possible, and the sacrospinous ligament, which interferes with the movement of small incision in the inner cortical bone of the pelvis and positioning the femoral

the osteotomy fragment after the osteotomy, is not attached to the osteotomy head on the inner side. This is to slow down degenerative lesions by reducing the

fragment.nnis modified triple osteotomy. Compared with the previous triple force applied to the hip joint by reducing the lever distance from the center of the

osteotomy, Steel's triple osteotomy body to the hip joint. Another advantage of Bern's periacetabular osteotomy is

Therefore, when the osteotomy fragment is abducted, there is a tendency for that blood circulation in the osteotomy fragment is not impaired. On the other

the osteotomy fragment to be externally rotated at the same time, but this has hand, RAO may cause osteonecrosis of the fracture fragment due to impaired

almost disappeared in the periacetabular osteotomy after the Tn̈nnis triple blood circulation. Bern periacetabular osteotomy does not damage the outer side

osteotomy.One). In addition, Wagner et al. in Germany developed the spherical of the ilium, so the acetabulum and small vessels branching from the superior

osteotomy, but it was not widely practiced. Later, in 1988, Ganz in Switzerland gluteal artery, inferior gluteal artery, and obturator artery, and blood vessels

developed an osteotomy close to the acetabulum, but the posterior acetabular entering along the gluteus minimus muscle are not damaged. Therefore, even in

column in the greater sciatic notch area was not osteotomized. There are several cases of severe deformity that require very large displacement of the osteotomy

modified methods (Bernese Periacetabular Osteotomy), but they are currently fragment, it is said that blood circulation can be observed to be maintained

being widely used around the world.6,9,13). Meanwhile, in Japan, rotational through ultrasound examination performed during surgery.

acetabular osteotomy (RAO), which involves making a circular cut along the 3,6). And since the stability of the pelvis is maintained by leaving the posterior acetabular column,

acetabulum without cutting the inner cortical bone of the pelvis, was developed, movement is possible immediately after surgery (Fig. 1).

and several modified surgical techniques were published.28). There are several

differences between the osteotomy performed by Ganz and the RAO performed 1. Indications for surgery

in Japan. First, Ganz recommends performing an osteotomy by dissecting the

inner wall of the pelvic bone using the Smith-Peterson approach, opening the hip Osteotomy can maintain joint congruency by changing the

joint almost entirely, and observing the acetabular labrum and degenerative acetabular position, and is a good indication for young patients who

lesions within the joint. However, RAO exposes the area around the hip joint can increase the weight-bearing area. Points to be considered during

using the extended iliofemoral approach, performs an osteotomy along the hip osteotomy include age, joint movement, and joint consistency after

joint in a circular manner without touching the inner bone of the pelvic bone, and osteotomy, as well as the presence of concomitant diseases and

removes the inner cancellous bone of the osteotomy fragment to not only cover osteoporosis. Periacetabular osteotomy should not be performed in

the weight-bearing femoral head, but When the hip joint moves medially children before the triradiate cartilage is closed. In elderly people,

artificial joint replacement surgery is more common than osteotomy.

A B
Fig. One.(A) Posterior column of acetabulum around great sciatic notch are intact in Berneses periacetabular osteotomy, and the pevic
Stability after osteotomy is very good. (B) The osteotomized acetabular fragment is fixed with 2 screws, and a small screw is used
to fix left ASIS.

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J Korean Hip Soc21(3): 202-210, 2009

However, the patient's activity status should be considered rather than the age on In addition to the correction, the functional lower limb length difference (the lower limb

the family register.14,29). However, older patients have very weak skeletons, so length difference felt by the patient) is measured, the pelvic tilt is checked, and if

small fragments may occur during osteotomy, and the amount of cancellous necessary, the spine is bent to the left and right and an X-ray is taken to evaluate the

bone also decreases in postmenopausal women. After osteotomy, the femoral flexibility of the scoliosis.

head is covered to a large extent, so joint movement, especially flexion In an anteroposterior view of the pelvic bone, the sourcil is a hardened area of

movement, may be reduced compared to before surgery. Therefore, if hip joint subchondral bone formed due to stress from the femoral head in the weight-

flexion is less than 90°, joint movement reduction should be discussed with the bearing area of the acetabulum. Normally, the thickness should be constant, not

patient, and if hip joint flexion is less than 60°, osteotomy may be necessary. It is irregular, round, and appear horizontal overall, but in dysplasia, the length is

better not to do this. If a pseudoacetabulum is formed, osteotomy is not indicated short, irregular, and slanted. The extent to which the acetabulum covers the

because it is not a normal joint, and the radius of the acetabulum and femoral head is expressed as Center-Edge Angle (CEA), and the larger the CEA,

Difficult to change due to differences in the radius of the more the femoral head is covered. CEA is the angle formed between the line

Hope for good results too the femoral head14). At this time, abdomen-nai perpendicular to the line connecting the two tear-drops and the line passing from

Rotation and adduction - pronation x-ray Correct by carrying out the center of the femoral head to the lateral edge of the sourcil. If it is less than

The degree is planned, and the need for osteotomy along femur 20°, it can be considered acetabular dysplasia. The inclination of the acetabulum

with periacetabular osteotomy must be evaluated.

.
6)
is the angle formed by the line connecting the tear-drop and the line connecting

Periacetabular osteotomy can be performed not only in cases of hip the tear-drop on the outside of the acetabulum. Normally, it is less than 42°.

dysplasia but also in cases where there are symptoms of posterior Additionally, Shenton's line should be measured to determine the degree to

acetabular torsion even if CEA is normal on anteroposterior hip which the femoral head is displaced superiorly and laterally due to subluxation,

radiography. The increase in posterior acetabular torsion is contrary to the and whether the medial joint space has widened. If the 'cross-over sign', which

increase in anterior acetabular angle in partial hip dysplasia, and the defect indicates posterior torsion of the acetabulum, is observed, care must be taken

in the posterior part of the acetabulum is large. In very rare cases, there is during osteotomy to ensure that the osteotomy fragment does not rotate

a condition in which the hip joint is unstable posteriorly, but in dogs, the forward in a direction that increases posterior torsion.16,18,24). In frog-leg

acetabulum and femoral neck are affected anteriorly to the hip joint. photographs in many patients suspected of having impingement syndrome

Symptoms occur due to a collision with a vehicle (impact syndrome). Since Bone tissue in front of femoral neck

posterior acetabular torsion occurs only in the proximal part of the hip
8,16,24), go This elevation is observed. The level of infection in the femur is

joint, the anterior and posterior walls of the acetabulum are observed to Because it is difficult to measure on pure radiographs, if there is a significant

intersect (cross-over sign) on It can be implemented. difference in rotational movement, it must be confirmed with CT, and performing

As such, contraindications to periacetabular osteotomy include growing femur rotational osteotomy together should be considered. Congruency of the

adolescents at risk of growth plate damage, advanced degenerative joint after osteotomy can be confirmed using anteroposterior photographs of the

arthritis, severe limitations in joint movement, and cases where the head of pelvic bone in the abduction-internal rotation state of the femur. If subluxation of

the bone is within the pseudoacetabula. In other cases, X-ray and Surgery the femoral head persists, osteotomy is contraindicated. In addition, it is

can be performed by evaluating CT. necessary to compare the joint spacing by taking radiographs of adduction and

abduction, and to determine whether proximal femur osteotomy is performed by

2. Radiological examination confirming the adduction or abduction angle to the extent that the joint spacing

is appropriate and a smooth joint surface is achieved.

Radiographs include anteroposterior pelvic photographs taken while standing in a In hip dysplasia, the acetabular labrum is very developed, and if the

weight-bearing state, anterior and posterior photographs of both hip joints, frog-leg acetabular labrum ruptures in hip dysplasia, which has been tolerated due

photographs, and photographs with the hip joints adducted and abducted. False to the hypertrophied acetabular labrum, the pain worsens and rapidly

radiographs measure the degree to which the acetabulum covers the front of the hip progresses to degenerative arthritis. Additionally, cysts may form in the

joints. The profile view became less important with the implementation of 3D subchondral bone, and the acetabular margin near the acetabular labrum

tomography examination. Accurate photographs are required to evaluate the degree of may fall off (acetabular rim fracture). Therefore, the condition of the

dysplasia and the presence of posterior torsion in anteroposterior pelvic photographs. In acetabular labrum must be checked, but it is difficult to observe with a

other words, since the difference is due to the rotation of the pelvis, the coccyx and the simple CT or MRI, and it must be evaluated by performing a CT or MRI

pubic symphysis should be on the same line, and a photo in which the coccyx is located 1 immediately after arthroscopic surgery (CT arthrogram, MRarthrogram). In

to 2 cm above the pubic symphysis is preferable. In hip dysplasia, there may be a addition, the preparation can be injected intravenously and observed with

difference in the length of the lower extremities, which may cause pelvic tilt. Therefore, an indirect MR-arthrogram, which takes MRI about 20 minutes later.

radiological measurements of lower extremity length

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 Jae Suk Changet al.: Osteotomies Around the Hip Joint

3. Surgical technique of periacetabular osteotomy In order to cover it, rather than pulling the upper part of the osteotomy

fragment outward, the lower part of the osteotomy fragment must be

The periacetabular osteotomy introduced by Ganz initially used the extended moved inward, that is, in the direction of inserting it into the pelvis, but this

iliofemoral reach method, but due to ossicle formation and damage to the may be obstructed by the slope of the osteotomy surface. In addition, in

abductor muscles, it was modified to the Smith-Peterson reach method that does rare cases of severe subluxation, the subluxated femoral head may

not touch the outside of the pelvic bone. First, a partial osteotomy is performed interfere with rotation of the osteotomy fragment, and in this case, traction

on the area where the acetabulum connects to the ischium by passing the may be necessary. Correction must be achieved gradually using a laminar

osteotome below the hip joint capsule, and the pubis is obliquely osteotomized spreader, Shanz pin, bone hook, etc., and care must be taken as the bone

inside the iliopectineal eminence. The ilium is osteotomized posteriorly between holding the Shanz pin may break and fall out.

the anterior superior iliac spine and the anterior inferior iliac spine, the posterior Modified surgical methods were introduced to improve the visibility of

column of the acetabulum is osteotomized toward the ischial pole while leaving 1 the surgical site (osteion site). This includes using the ilioinguinal reaching

cm, and finally the ischium is osteotomized.9). At this time, the ilium method, the iliofemoral reaching method in the anterior region, and the

Except for one osteotomy, it is difficult to observe the osteotomy line, and the surgery Kocher-Langenbeck reaching method in the posterior region, and the

is known to be difficult because the osteotomy is performed without viewing. Therefore, length of the skin incision may also vary. In female patients, the

during osteotomy, care must be taken to ensure that the osteotomy line is not inserted quadrilateral surface may be visible because the pelvis is wide and the

into the joint and that comminuted fractures do not occur in the posterior column of the pelvic cavity is large. However, in some patients, especially men with

acetabulum, and a lot of experience is required. Although it is important to osteotomy developed muscles, it may be difficult to identify not only the quadrilateral

the desired area around the acetabulum, the most important part of periacetabular surface but also the greater sciatic notch, so it should not be assumed that

osteotomy is to rotate the osteotomy fragment as planned before surgery and correct it a good view will be obtained with the ilioinguinal approach. However, using

so that the osteotomy fragment sufficiently covers the femoral head. If it is difficult and two skin incisions, anterior and posterior, allows the surgery to be

time consuming to cut the pelvic bone around the acetabulum, realignment of the performed while visually confirming all osteotomy sites, making the

osteotomy fragment may be neglected, and sufficient correction may not be obtained. surgery much easier. It is very educational because not only the operator

When attempting to realign the osteotomy fragment after completing the osteotomy but also all doctors participating in the surgery can check the osteotomy

around the acetabulum, there are cases where the osteotomy fragment does not move. site. Additionally, when an osteotomy is performed simultaneously on the

The cause of this is that the periosteum on the inside of the first pelvic bone remains proximal femur, another skin incision is not necessary. Although it has the

attached, and if the pubic osteotomy is performed too medially, the muscles and disadvantage of creating a large scar due to two skin incisions, there does

phosphorus attached to the pubic bone may not be removed. Second, in cases where the not seem to be a significant difference in the overall surgery time because

osteotomy is not complete, it is necessary to check whether the osteotomy has been the time required for osteotomy is saved. When making an anterior-

completely made from the beginning with an osteotomy device. Third, the angle of the posterior skin incision, there is also a method of first cutting the pubis and

osteotomy surface is important. In particular, while adducting the hip joint, the head of ilium from the front and finishing the ischial osteotomy from the back. The

the femur is osteotomy is performed from the back first and then

A B
Fig. 2.This patient is a 45-year-old female. (A) Preoperative radiograph shows dysplasia at both hips. (B) Berneses periacetabular
osteotomy is performed.

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J Korean Hip Soc21(3): 202-210, 2009

All anterior osteotomy methods are possible. As shown, in cases where the femoral head is large, there is no impingement syndrome

At this time, the anterior and posterior osteotomy lines are sciatic notch even if a large amount of the front part of the hip joint is covered, so a good preoperative

It is encountered in the anterior area, and if this area is not properly identified, plan must be made regarding the degree of correction. When it is confirmed on X-ray

osteotomy fragments may form, but even large fragments do not affect the that the correction is good, two 4.5 mm long screws are inserted and fixed at the iliac

surgical results. If the osteotomy is performed from the posterior first, the crest, and the osteotomy is completed.

osteotomy line can be more easily confirmed from the anterior. . Also, since the After surgery, eat only after intestinal motility has fully returned. Otherwise,

Bern periacetabular osteotomy is angled rather than round, it is difficult to turn intestinal obstruction may occasionally occur. Since the patient is not elderly,

the osteotomy fragment, and if the osteotomy fragment is rotated to cover much there is no need to start moving very quickly, but painless activities can be

of the anterior area where the lesion is, the acetabulum (i.e. hip joint) will be allowed, and the patient can move around using a walker and begin rehabilitation

transferred anteriorly. To prevent this, the osteotomy fragment in the angled treatment 2-3 days after the surgery. Walking is performed in the following order:

area can be trimmed, and a round osteotomy can be performed using the standing on a tilting table, walking on parallel bars, walking using a walker, and

anterior-posterior reaching method (Fig. 2). walking with crutches. Weight bearing is done with partial weight bearing within

When surgery is performed only anteriorly, an image amplification device can the range of not feeling pain.

be used during surgery. However, the main area behind the acetabulum where

the osteotomy site cannot be identified is unclear even with an image proximal femur osteotomy

amplification device, and the image amplification device occupies a large area

during surgery. It is difficult to operate. Therefore, it is advisable to quickly learn The proximal femur has an interspinal angle of approximately 130° and

the surgical technique and avoid using phase amplification devices. Ganz uses an a transverse angle of approximately 10 to 15°. Osteotomy is mainly

angled osteotome, which does not seem to be able to keenly feel the feeling of performed for varus and valgus deformities, but since it is often

cutting the hemicortical bone during the osteotomy. If the osteotomy site can be accompanied by rotational deformity, as in femoral head epiphyseal

visually confirmed through an anterior-posterior skin incision, such an angled separation, both deformities are often corrected at the same time. Also, by

osteotome is not necessary. performing a valgus osteotomy in femoral neck nonunion, the shear force

If it is considered that the osteotomy fragment has been realigned, it is generated at the fracture site can be changed to a compressive direction to

temporarily fixed with Steinmann pins and an X-ray is taken. The degree of achieve fracture union.

correction can only be evaluated by performing an accurate anterior- Hip dysplasia can cause not only morphological abnormalities of the

posterior pelvic examination (ideally, the coccyx should be located acetabulum but also deformities of the femur. In principle, osteotomy should be

approximately 1 cm perpendicular to the pubic symphysis). In correction, performed at the site of the main deformity, and if there is deformity in both the

the CEA becomes normal at 25° or more, the saucil that bears the weight of acetabulum and proximal femur, osteotomy should be performed on both sides.

the acetabulum is horizontal (the inclination of the acetabulum has been . Acetabular dysplasia accompanied by deformation of the femoral head may
20,21)

corrected), and the femoral head has moved medially, but is more lateral occur after the sequelae of LCP and separation of the epiphysis of the femoral

than the ilioischial line. Ideally, it is located at the right level, Shenton's line head, and may occur as avascular necrosis of the femoral head due to

is well maintained, and there is no cross-over sign indicating posterior developmental hip dysplasia in childhood or as a secondary change due to

torsion of the acetabulum. One of the problems with periacetabular subluxation of the femoral head. there is20). Acetabular dysplasia accompanied by

osteotomy is that it cannot be accurately corrected under X-ray to the deformation of the femoral head is known to progress to degenerative arthritis

preoperatively planned angle as in proximal femoral osteotomy. It is relatively early, and the postoperative results are poor compared to patients with

relatively easy to turn the osteotomy fragment anteriorly, but beginners normal femoral head shape. Nakamura et al.20)compared the deformation of the

tend to turn it anterolaterally. Therefore, it is possible to create posterior proximal femur between rotational acetabular osteotomy and femoral abduction

acetabular torsion and create impingement syndrome. However, it is osteotomy in patients with increased femoral shaft angle and in patients with

difficult to normalize CEA and metastasize to my side. Just as it is difficult to superior displacement of the trochanter and decreased femoral shaft angle. It is

reduce the metastasized fracture fragment in a pelvic bone fracture, but it reported that if the femoral shaft angle is increased, the prognosis is not good

does not easily return to its original state after general reduction, medial because the medialization effect of the femoral head is small and the force

metastasis is difficult in osteotomy, but once metastasized, there is no applied to the hip joint cannot be biomechanically reduced.

great difficulty in maintaining it. Recently, the soft tissues on the outside of

the pelvis are not touched, so overcorrection of what covers the outside of Before surgery, the suitability of the joint should be evaluated using radiographs showing the

the acetabulum does not occur often in adults. However, you should keep hip joint in adduction and abduction, and a preoperative plan should be made based on the

in mind that overcorrection is possible when you are young. However, degree of correction. In addition, the selection of available internal fixators should be considered,

Legg-Calve-Perthes' disease (LCP) especially the medialization of the knee joint after femoral valgus osteotomy.

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 Jae Suk Changet al.: Osteotomies Around the Hip Joint

This may result in changes in the lower mechanical axis. 1. Osteotomy for avascular necrosis of the femoral head

Preoperative evaluation is required. While femoral osteotomy can be corrected

accurately as planned before surgery, the degree of correction in acetabular osteotomy The prognosis of avascular necrosis of the femoral head is related to

cannot be clearly known at the operating room, and there are cases where the expected the size and location of the necrotic area. If the necrotic area is in a weight-

correction cannot be achieved. Therefore, there may be differences of opinion about the bearing position (especially if it is located on the outer part of the upper

order of osteotomy of the acetabulum and femur, but the peri-acetabular osteotomy is part of the femoral head), the larger the necrotic area, the more prone to

performed first and then corrected with femoral osteotomy to obtain appropriate depression and arthritis. Proceed with Accordingly, osteotomy can be

retention of the hip joint and compatibility of the joint according to the newly determined performed to move the necrotic area to a non-weight bearing area. An

position and shape of the acetabulum. It is believed that this can prevent major mistakes internal hemi-osteotomy of the femur can be performed, but the better

(Fig. 3)
10). known one is an intertrochanteric rotation osteotomy (sugioka osteotomy).

When performing an osteotomy of the proximal femur, one must keep in mind Sugioka osteotomy is widely performed in Japan and produces relatively

that the direction of force applied to the knee joint may change. Therefore, good results.26,27), the results are not good in the West. Sugioka osteotomy is

surgical planning should be made by referring to preoperative weight-bearing Rotate the head of the femur forward and also cause it to become varus.

and standing lower extremity radiographs to ensure that the mechanics applied Even if good results are obtained with no collapse of the femoral head on

to the knee joint do not change after surgery. In other words, in my bandage postoperative X-ray, the patient complains of poor lower extremity and

Therefore, when performing a valgus osteotomy, the distal part after the osteotomy internal rotation, and a toe-out gait. And Atzumi introduces a method of

should be moved outward so that the center of the hip joint, center of the knee joint, and rotating the anteromedial part of the femoral head without femoral head

center of the ankle joint are aligned in a straight line in the direction of weight bearing. In necrosis into a weight-bearing area.2), to the rear

varus osteotomy performed for valgus high, the distal part of the valgus must be moved Since the femoral head is rotated, it has the advantage of not pulling on the

medially. important medial femoral circumflex artery and the rotation angle can be corrected

The osteotomy site is the upper part of the lesser trochanter, because it is by more than 130°. However, the soft tissue incision is relatively large and has the

desirable to have a wide osteotomy surface to achieve good bone union, and the disadvantage of cutting the external rotator and iliopsoas muscles, including the

proximal osteotomy fragment must be large enough to firmly insert an internal joint capsule.

fixation. Internal fixation mainly uses 95° and 130° blade metal plates, which are In addition to There is a method of osteotomy at the femoral neck. This is a

inserted into the femoral head using a chiesle using an upper C-arm in the area Ganz surgery developed for retro-acetabular impingement syndrome.

determined according to the preoperative plan, then an osteotomy is performed This method is used (aka surgical dislocation technique). In other words, if

and the deformity is corrected. . When satisfactory correction is achieved, the the hip joint is exposed while preserving the blood vessels leading to the

bone is fixed with a bladed metal plate, the proximal osteotomy fragment is femoral head, avascular necrosis will not occur even if hip joint surgery is

screwed, and the distal part is screwed. If there is a gap at the osteotomy site, performed while dislocating the hip joint. In this way, the femoral neck can

bone grafting can be performed. be exposed and an osteotomy can be performed on the femoral neck.

B C D
Fig. 3.This patient is a 13-year-old female. (A) Both hips AP radiograph shows dysplasia of right hip and deformed right femoral
head. (B) Both hips AP radiograph with abduction and internal rotation of both hips reveals good congruity of right hip. (C)
Preoperative radiograph shows dysplasia of right hip and deformed femoral head. (D) Berneses periacetabular osteotomy and
varization osteotomy of proximal femur is performed.

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J Korean Hip Soc21(3): 202-210, 2009

In case of femoral head epiphyseal separation, osteotomy can also be performed However, it did not occur in even one case with the double reach method, and

at the epiphysis between the femoral head and the femoral neck. When
15). this
the room the great advantage of the double reach method is that the osteotomy can be

method is applied to perform osteotomy of the femoral head for avascular performed accurately. Recently, there have been attempts to perform osteotomy

necrosis, and when the femoral head is turned posteriorly, a capsulotomy is also with computer assistance. It is thought to be useful for osteotomy of invisible

performed. There is no need to do much, but when rotating the femoral head areas, but the results need to be observed further. Regarding nerve damage,

forward, a large incision in the joint capsule is required, as well as cutting of the damage to the lateral femoral cutaneous nerve and rarely damage to the femoral

external rotator muscles that interfere with rotation (Fig. 4). and sciatic nerves have been reported in 30% of patients. However, the nerves

can be safely protected by cutting the ASIS from the outside and sending it to the

complications medial side. Nonunion at the osteotomy site is mainly observed in the pubic area,

but since there are no associated symptoms, it can be ignored. In very rare cases,

Various complications may occur after Bern periacetabular osteotomy nonunion of the ilium has also been reported.7,12). Since the screw that fixed the

surgery, and Hussel et al.12)According to it, cases of intra-articular osteotomy fragment may enter the joint, it should be checked while moving the

osteotomy as a complication of surgical technique are related to the joint after fixation. If it is difficult to confirm with X-ray imaging, it is advisable to

osteotomy being made without looking at the posterior column and ischial perform CT imaging to confirm the position of the screw. . Recently, since the

osteotomy site. Since osteotomy is mainly performed on the quadrilateral outside of the pelvic bone is not exposed, ossicle formation is rare. In addition,

surface inside the pelvic bone, the landmark area related to the hip joint excessive and insufficient correction, subluxation of the femoral head, avascular

must be identified in this area and the osteotomy line must be determined. necrosis, fracture of the posterior column, and displacement of the osteotomy

22). Since the anterior acetabular wall is lateral to the iliopectineal eminence, fragment have been reported.12), there are reports that the degree to which

the pubic osteotomy is performed medially and obliquely relative to the complications occur is very related to experience, initially being over 10%, but

iliopectineal eminence. It is safe to perform the ilium above the AIIS and at decreasing to around 3% after more than 30 surgeries.7). Also, there are cases

the same level as the greater sciatic notch. It is safe to perform posterior where surgery is attempted and causes problems even when the indications for

acetabular rotation up to the ischial pole, leaving 1 cm behind, and to cut surgery are difficult. For example, a lot of transfer is needed to create articular

the ischium from the ischial pole toward the obturator foramen. Shiramizu cartilage that can withstand weight bearing.

et al.22)The above relationship can be seen in a study that examined the

anatomical characteristics of the acetabulum and quadrilateral surface Osteotomy is performed when it can be placed on the femoral

while drilling the pelvic bone with an acetabular reamer for this of head or when the femoral head is not of a normal shape.

periacetabular osteotomy. Additionally, in cases where a pseudoacetabula

is formed superiorly, the joint may be exposed if osteotomy is performed texture theory

close to the AIIS. In the authors' case, when the anterior reach method was

performed, posterior column fractures occurred in 2 patients and 4 cases. The purpose of periacetabular osteotomy in acetabular dysplasia is to increase the joint contact surface

by displacing the acetabulum anterolaterally and to increase the joint contact surface of the hip joint.

C
Fig. 4.This patient is a 49-year-old male. (A) Both hips AP radiographs are taken with neutral, 90�flexion, and 130�flexion. (B)CT
sagittal image demonstrates 90 posterior rotation of femoral head. (C) Left hip AP radiograph reveals the change of necrotic area.

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It is a treatment that prevents or delays the progression of degenerative arthritis
by medializing the hip joint and reducing the stress on the hip joint, thus allowing
artificial joint replacement surgery in active young patients.
Compared to other acetabular osteotomies, periacetabular osteotomy is performed
close to the hip joint, so a large amount of correction can be obtained, and good clinical
and radiological results have been reported. However, complications are prone to occur
and it takes time to learn the surgical technique. It takes a long time. The double-reach
method is easy to operate because the osteotomy surface can be seen, and
complications can be reduced, so it can be recommended to orthopedic surgeons
performing Bernese periacetabular osteotomy for the first time. Proximal femur
osteotomy is mainly done in the lesser trochanter area, but a method of osteotomy in the
femoral neck has also been introduced. Preoperative planning for correcting the
osteotomy site angle is most important, and good results can be achieved by following
the correct technique.
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