OSTEOTOMIES AROUND THE HIP

IN DDH
PRESENTED BY : DR VIVEK VIJAYAKUMAR
CO-MODERATOR : DR MUTHUKUMARAN
MODERATOR : PROF SHAH ALAM KHAN
TERMINOLOGY

CONGENITAL DISLOCATION OF HIP

DEVELOPMENTAL DYSPLASIA OF HIP

(Klisic 1989)

Klisic PJ. Congenital dislocation of the hip--a misleading term: brief report. The Journal of bone and
joint surgery. British volume. 1989 Jan;71(1):136-.
 OVERVIEW OF MANAGEMENT OF DDH

NEONATE 1-6 Months 6-18 Months 18-24 Months > 2 Yrs

OPEN REDUCTION
+/-
OPEN REDUCTION
CLOSED REDUCTION ACETABULAR
+/-
OR PROCEDURE
ACETABULAR
OPEN REDUCTION +/-
PROCEDURE
FEMORAL
PROCEDURE
WHY IS OSTEOTOMY REQUIRED IN ADDITION TO
OPEN REDUCTION ?

 Unstable reduction

 Improper orientation of the femoral head and acetabulum

 Lack of congruency of the hip joint

 Excessively tight reduction

OBJECTIVES OF AN OSTEOTOMY IN DDH

Improve coverage of head and achieve containment

Redistribute joint forces

Improve motion and relieve pain

 OSTEOTOMIES AROUND THE HIP

FEMORAL OSTEOTOMY PELVIC OSTEOTOMY

FEMORAL OSTEOTOMY- REORIENTATION OF HIP MECHANICS

RE-ORIENT THE
FEMORAL HEAD

PREVENT EXCESSIVE PRESSURE ON

THE HEAD OF FEMUR

INTERVENTIONS TO ALTER THE

MECHANICAL EFFECTS OF AVN
 FEMORAL SHORTENING

Excessive pressure on the femoral head after

reduction leads to AVN (usually >2 yrs age)

Pressure can be reduced by femoral shortening

Intra-operative assessment by longitudinal

traction and assessment of soft tissue
tone around the hip

*Post-reduction avascular necrosis in congenital dislocation of the hip. Cooperman et al :JBJS (Am) 01 Mar 1980, 62(2):247-258
HOW MUCH SHORTENING ?

Distance from base of femoral head to

base of the acetabulum is roughly
the amount of shortening required
(Not to exceed 2.5 cm)

Shortening is done in the sub-

trochanteric region via a separate
lateral incision
DEROTATION AND VARUS OSTEOTOMY

Helps to re-orient the

limb according to the
position of reduction

Usually combined with

femoral shortening
osteotomy
WHAT TO DO?

FEMORAL
OSTEOTOMY
REQUIRED
WHAT TO DO?

PELVIC SIDE
OSTEOTOMY

BOTH SIDE
OSTEOTOMY
INTERTROCHANTERIC VARUS OSTEOTOMY
FEMORAL SHORTENING + DEROTATION OSTEOTOMY
INTERVENTIONS TO ALTER THE MECHANICAL EFFECTS OF AVN

 TROCHANTERIC EPIPHYSIODESIS

 TROCHANTERIC ADVANCEMENT OSTEOTOMY

 INTERTROCHANTERIC DOUBLE OSTEOTOMY

 LATERAL CLOSING WEDGE VALGUS OSTEOTOMY

PELVIC OSTEOTOMIES
TYPES OF PELVIC OSTEOTOMIES

ACETABULAR
REDIRECTIONAL
OSTEOTOMIES

ACETABULAR VOLUME
REDUCING OSTEOTOMIES

SALVAGE OSTEOTMIES
TYPES OF PELVIC OSTEOTOMIES

CONCENTRIC HIP REDUCTION POSSIBLE

ACETABULAR REDIRECTIONAL OSTEOTOMIES
Salter, Steel, Sutherland, Ganz , Tonnis , Spherical Osteotomies (Wagner,
Eppright)
ACETABULAR RESHAPING OSTEOTOMIES (VOLUME REDUCING)
Pemberton, Dega
CONCENTRIC HIP REDUCTION NOT POSSIBLE
SALVAGE OSTEOTOMIES
Chiari, Shelf procedures
SALTER’S INNOMINATE OSTEOTOMY

Age group: 18 m to 6 yrs

Inferior portion of pelvis tilted antero-inferiorly
Anterior Inferior Iliac Spine to Greater
Sciatic notch
HINGE : Pubic Symphysis
(Hence suboptimum in bilateral dysplasia)
Joint Stress redistributed but joint Pressure
Age: 2-8 years
increased (head pushed downwards) Advantage: Technically Easy
SALTER’S INNOMINATE OSTEOTOMY
INDICATIONS:
Primary treatment of DDH
Secondarily in residual/recurrent dislocation
Dislocation after septic arthritis
Subluxation of hip in pelvic obliquities
as in uncorrected scoliosis
Paralytic dislocations/subluxations

Salter RB. Innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip.
J Bone Joint Surg Br. 1961;43(3):518–539.
SALTER’S INNOMINATE OSTEOTOMY

ADVANTAGES:
No effect on acetabular capacity
Technically less demanding

DISADVANTAGES:
Increases Limb length
Femoral Nerve stretch
KALAMCHI’S MODIFICATION OF SALTER’S OSTEOTOMY
Posterior triangular notch is
created in the proximal side of
the osteotomy to engage the
distal iliac segment
Increases stability and prevents
the medial and posterior
displacement.
Limb length discrepancy is
eliminated.

Kalamchi A. Modified Salter osteotomy. The Journal of bone and

joint surgery. American volume. 1982 Feb;64(2):183-7.
 SUTHERLAND OSTEOTOMY (DOUBLE INNOMINATE
OSTEOTOMY)
Age > 8 yrs
Pubic Osteotomy is made
medial to obturator foramen
Pubic Osteotomy gives better redirection
than Salter’s
Wedge of bone is removed allowing
medialization of acetabulum

Sutherland DH, Greenfield R. Double innominate osteotomy.

The Journal of bone and joint surgery. American volume. 1977 Dec;59(8):1082-91.
SUTHERLAND OSTEOTOMY (DOUBLE INNOMINATE
OSTEOTOMY)
 Age: 12m – 12 yrs
PEMBERTON OSTEOTOMY Advantage: Better Coverage

Age group : 12 m - 12 yrs

Peri-Acetabular osteotomy directed postero-inferiorly
from the AIIS
Improves anterior & lateral acetabular coverage
Volume reducing -----> large acetabulum and small femoral head
HINGE: Triradiate Cartilage
Osteotomy reaches upto posterior limb of triradiate cartilage & does not
enter the sciatic notch

Pemberton PA. Pericapsular osteotomy of the ilium for treatment of congenital subluxation and
dislocation of the hip. JBJS. 1965 Jan 1;47(1):65-86.
PEMBERTON OSTEOTOMY
PEMBERTON OSTEOTOMY
ADVANTAGES:
Osteotomy is incomplete, more stable
Internal fixation is not required
Greater degree of correction can be
achieved with less rotation of the acetabulum.
DISADVANTAGES:
Osteotomy limited by mobility of
Triradiate cartilage
May cause early fusion of triradiate cartilage
PEMBERTON VS SALTER

Salter redirects the acetabulum

Greater correction of AI (>15º )
Fixation not required
Pemberton is technically challenging
 Age: 12m – 12 yrs
DEGA’S OSTEOTOMY Advantage: Better Coverage globally

• Age group : 12m – 12 yrs

• Trans-Iliac osteotomy with an intact posteromedial cortex
• Acetabular coverage can be increased anteriorly, centrally or posteriorly
depending on the placement of the bone graft wedges
• Similar to Pemberton but has large posterior hinge
• Decreases acetabular volume
• HINGE: Triradiate Cartilage
• San Diego Modification : Osteotomy
advances into the sciatic notch
Dega W. Selection of surgical methods in the treatment of congenital dislocation of the hip in children.
Chirurgia narzadow ruchu i ortopedia polska. 1969;34(3):357.
DEGA’S OSTEOTOMY
DEGA’S OSTEOTOMY
STEEL OSTEOTOMY (TRIPLE INNOMINATE OSTEOTOMY)
Age > 8-12 yrs
Salter osteotomy+ pubic rami osteotomy + ischial osteotomy
Allows for free motion & redirection of acetabulum
Indicated in irreducible subluxations and in failure of other
osteotomies
The amount of rotation is
limited by sacropelvic ligaments
Pubic rami approached through a Age: >8 yrs
separate groin incision Advantage: free motion & redirection

Steel HH. Triple osteotomy of the innominate bone. A procedure to accomplish coverage of the dislocated or subluxated
femoral head in the older patient. Clinical orthopaedics and related research. 1977(122):116-27.
STEEL OSTEOTOMY (TRIPLE INNOMINATE OSTEOTOMY)
 TONNIS OSTEOTOMY

Modification of STEEL osteotomy, greater correction than STEEL

Long curved ischial cut connects the obturator foramen to sciatic
notch
This prevents the sacrospinous ligament from
tethering the fragment during correction
Both STEEL & TONNIS osteotomies alter
the true pelvis dimensions and render
normal delivery difficult
Tönnis D, Behrens K, Tscharani F. A modified technique of the triple pelvic osteotomy: early results.
Journal of pediatric orthopedics. 1981;1(3):241-9.
STEEL OSTEOTOMY TONNIS OSTEOTOMY

Tönnis D, Behrens K, Tscharani F. A modified technique of the triple pelvic osteotomy: early results.
Journal of pediatric orthopedics. 1981;1(3):241-9.
GANZ (BERNESE) OSTEOTOMY Age: >8-12 yrs
Advantage: better redirection & stability

Correction without breaking the posterior column.

Intact posterior column Allows minimal internal fixation and early
mobilization
Allows both anterior and lateral rotation as well as medialization
Indicated for residual dysplasias in adolescents and young adults
Good improvement in the CEA
Only a single approach is required
Allows for maximum correction
Ganz R, Klaue KA, Vinh TS, Mast JW. A new periacetabular osteotomy for the treatment of hip dysplasias
technique and preliminary results. Clinical Orthopaedics and Related Research®. 1988 Jul 1;232:26-36.
 GANZ (BERNESE) OSTEOTOMY

Osteotomy cuts:
partial (incomplete) osteotomy of the ischium
complete osteotomy of the pubis
biplanar roof shaped osteotomy of the ilium
 Does not change the diameter of the true pelvis -birth canal not
affected-advantage in young women
Contraindicated if the triradiate cartilage is still open (interferes with
acetabulum growth).
GANZ (BERNESE) OSTEOTOMY
SPHERICAL ACETABULAR OSTEOTOMIES

Allows rotational repositioning of the acetabulum

Does not disrupt the pelvic ring and hence stable
3 Spherical osteotomies described
Wagner’s osteotomy
Eppright’s Dial osteotomy
Ninomiya osteotomy
SPHERICAL ACETABULAR OSTEOTOMIES- NINOMIYA

Ninomiya et al.; JBJS Am 1984 Mar;66(3):430-6.

SALVAGE OSTEOTOMIES
SALVAGE ACETABULAR OSTEOTOMIES
Attempted when concentric reduction of hip is not possible
These procedures do not provide a hyaline cartilage covered articulation
The capsule under the new acetabulum transforms
to fibrocartilage : SALVAGE
Intra articular or Extra articular
Intra-articular : Chiari Osteotomy
Extra- articular : Shelf procedures, Tectoplasty
Indicated:
 Neurological causes of DDH
lateralized severely dysplastic hip
CHIARI ACETABULAR OSTEOTOMY

Tranverse osteotomy of pelvis above the level of the cranial insertion of

the capsule with medial displacement of the acetabular fragment

In essence, a controlled fracture through the ilium

Head completely covered by acetabular roof

Hip jt. pivot closer to body axis

May cause abductor laxity

Chiari K. Medial displacement osteotomy of the pelvis.
Clinical Orthopaedics and Related Research®. 1974 Jan 1;98:55-71.
SHELF ACETABULAR AUGMENTATION

Extra articular containment procedure

Provides buttress/stabilising force for the femoral head

Older children 10-18yrs with severe dysplasia

No capacity of remodelling

Post op traction until bony consolidation.

SHELF ACETABULAR AUGMENTATION
SHELF ACETABULAR AUGMENTATION
TECTOPLASTY
Tectum = Roof (latin)
Tectoplasty provides an extra-articular acetabular roof in an adolescent or
young adult
Lateral wall of the iliac bone is raised as a proximally-based flap
Massive bone grafts are inserted to provide a congruous,
non-absorbable roof for the femoral head.

Takaoka et al :JBJS VOL 68-B January 1986

TECTOPLASTY
 SUMMARY - PELVIC OSTEOTOMIES
CONCENTRIC REDUCTION ?

POSSIBLE NOT POSSIBLE

<8 yrs 8- 15 yrs >15 yrs

 SALTER  STEEL  CHIARI

 STEEL
 DEGA  GANZ  SHELF Techniques
 SUTHERLAND
 PEMBERTON  SPHERICAL  TECTOPLASTY
OSTEOTOMY
A 15-year-old soccer player complains of hip pain. The pain is worse
with activity and she notices that she has fatigue and pain that extends
to the thighs and knees following a soccer match. A radiograph of the
right hip is shown in Figure . Which of the following surgical
interventions is best indicated?
A. Single innominate osteotomy (Salter)

B. Double innominate osteotomy

C. Ganz Periacetabular osteotomy

D.Triple innominate osteotomy (Steele)

E. Dega osteotomy
THANK YOU !