Osteotomies around the hip

osteotomies around the hip is a very important topic for postgraduates

1. Department of Orthopaedics Siddhartha Medical College,Vijayawada OSTEOTOMIES AROUND THE HIP Dr.T.Anil kumar Final year postgraduate

2. Surgical corrective procedure used to - obtain a correct biomechanical alignment of the extremity - achieve equivocal load transmission + / - removal of a portion of bone .

3. Objectives Improve coverage of head Containment of head Moves normal articular cartilage into weight bearing zone Improves motion Relieves pain To correct leg length inequality by shortening / lengthening

4. The Neck of Femur Angulated in relation to the shaft in 2 planes : sagittal & coronal Neck Shaft angle 140 deg at birth 120-135 deg in adult Ante version Anteverted 40 deg at birth 12-15 deg in adults

5. Acetabular Direction long axis of acetabulum points forwards : 15-20 ante version 45 inferior inclination ante version

6. Biomechanics Forces acting across hip joint Body weight Abductor muscles force Joint reaction force

7. defined as force generated within a joint in response to forces acting on the joint in the hip, it is the result of the need to balance the moment arms of the body weight and abductor tension maintains a level pelvis Joint reaction force -2W during SLR - 3W in single leg stance -5W in walking -10W while running Joint reaction force

8. Biomechanics in neck deformities : Coxa valga Increased neck shaft angle GT is at lower level Shortened abductor lever arm Body wt arm remains same Increased joint forces in hip during one leg stance Less muscle force required to keep pelvis horizontal

9. Coxa valga Resultant force R is more than a normal hip

10. Coxa Vara Decreased neck shaft angle GT is higher than normal Increased abductor lever arm Abductor muscle length is shortened Decreased joint forces across the hip during one leg stance Higher muscle force is required to keep pelvis horizontal

11. Coxa Vara Resultant force R is less than a normal hip

12. Radiographic parameters used Centre Edge Angle Acetabular Index formed b/w Hilgenreiner line and a line drawn along the acetabular surface Newborns : 27.5° 6 months age : 23.5° 2yrs age : 20° Maximum upper limit : 30° Formed b/w Perkin line & a line that connects lateral acetabular margin to the centre of the femoral head Measures the position of hip 6-13 yrs : >19 ° >14 yrs : >25° Angle increases with age

13. CE ANGLE of WILBERG ACETABULAR INDEX

14. FALSE PROFILE VIEW patient standing 65 degrees oblique to the x-ray beam with the foot parallel to the cassette . center –edge angle is constructed from the intersection of a vertical line ( V ) through the center of the femoral head ( C ) with a line (A) from the anterior edge of the sourcil to the center of the femoral head .

15. Osteotomies around the hip are classified as Proximal Femoral Osteotomies According to Anatomical location High cervical Intertrochanteric Subtrochanteric Greater Trochanteric Based on displacement of distal fragment Torsional / derotation Trans positional Angulation adductional / varus abductional / valgus flexion/ extension osteotomies Pelvic osteotomies 1 .Redirectional : Single Innominate – Salter Double Innominate – Sutherland Triple Innominate - Steel, Tonnis Periacetabular Osteotomies Ganz (Bernese) Sherical acetabular osteotomies – Ninomiya - Dial,Wagner 2.Volume reducing : Pemberton,Dega , San Diego 3.Greater Load bearing surface : Shelf operation ( STAHELI) Chiari Osteotomy

16. Based on Indications To obtain pain relief Osteoarthritis. Pauwels varus osteotomy . Pauwels valgus osteotomy . McMurrays osteotomy In proximal femur fractures ununited fractures of femoral neck . McMurry’s osteotomy . Dickson's high geometric osteotomy . Schanz Angulation Osteotomy . unstable intertrochanteric fractures. Dimon Hughston Osteotomy . Sarmiento’s Osteotomy

17. UNREDUCED CDH - Lorenz bifurcation osteotomy - Schanz low sub trochanteric osteotomy . - Pemberten acetabuloplasty . - Salter Osteotomy CONGENITAL COXA-VARA - Pauwel’s Y osteotomy - ValgusIntertrochanteric osteotomy – Borden,Wagner LEG-CALVE PERTHE’S DISEASE - Varus de-rotation osteotomy - Salter osteotomy - Shelf - Chiari osteotomy .

18. . AVN - Sugioka – Trans trochanteric osteotomy - Varus de-rotation osteotomy - Pauwels Y osteotomy SLIPPED CAPITAL FEMORAL EPIPHYSIS . A) Closing wedge osteotomy of neck: a. The technique of Fish b. Technique of Dunn just distal to slip c. 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) OSTEOTOMIES IN PARALYTIC DISORDER OF HIP Varus osteotomy Rotation osteotomy Extension osteotomy .

19. Pelvic Osteotomies – SALTER INNOMINATE the entire acetabulum together with pubis and ischium is rotated as a unit INDICATIONS: <10–15° of correction of acetabular index is needed CDH in children from 18 months to 6 years of age Congenital subluxation upto early adult life. LCPD – onset of disease after 6 yrs age - moderate – Severely affected head - loss of containment PREREQUISITIES: -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 . - ROM of hip must be good

20. Osteotomy made from AIIS to Greater Sciatic notch notch

21. Graft is taken from iliac crest and trained to the shape of a wedge The distal segment is shifted forward, downward and outward

22. Place the graft into open segment anteriorly

23. Secure it by passing K-wires from proximal fragment through graft into distal fragment taking care not to enter acetabulum

24. Advantages: No effect on acetabular capacity Technically less demanding Disadvantages : Relatively unstable Needs internal fixation – k wires Needs second surgery for pin removal Complications : Neurovascular damage – Sciatic nerve, - lateral femoral cutaneous nerve - nutrient vessels to tensor fascia lata Joint penetration of k-wires

25. Kalamchi modification of Salter Osteotomy Displacing the distal fragment into the posterior notch in the proximal fragment To avoid increased pressure on the femoral head

26. SUTHERLAND Double Innominate Osteototmy Indication: age 8 – 15 yrs, DDH following Salter osteotomy , - 2 nd osteotomy – Pubic osteotomy - medial to obturator foramen in the interval b/w symphysis pubis and pubic tubercle - wedge of bone 7- 13mm in diameter just lateral to symphysis parallel to it Displace the acetabular fragment distally and anteriorly

27. Advantages: Addition of pubic osteotomy increased the amount of acetabular rotation & coverage of femoral head Femoral head could be shifted medially , reducing the length of femoral lever arm

28. Triple Innominate Osteotomy - STEEL INDICATIONS- Adolescents & skeletally mature adults with residual dysplasia & subluxation in whom remodelling of acetabulum is no longer anticipated PROCEDURE- The ischium , the sup pubic ramus and ilium superior to the acetabulum is repositioned and stabilized by bone graft

29. 1.Osteotomy made from AIIS to Greater Sciatic notch 1.Osteotomy made from AIIS to Greater Sciatic notch

30. 2.Superior pubic ramus is divided posteromedially 15° from perpendicular.

31. . 3. Ischial ramus is divided posterolaterally at 45° from perpendicular

32. ADVANTAGE S – Better coverage of femoral head by articular cartilage Better hip joint stability, no need of spica cast . DISADVANTAGES: Difficult to perform. Does not change the size of the acetabulum . It distorts the pelvis so natural child birth is impossible in adulthood .

33. TONNIS TRIPLE INNOMINATE OSTEOTOMY Long ischial cut connects obturator foramen with the sciatic notch so that the cut finishes proximal to the sacrospinous lig ., preventing it tethering from the acetabular fragment durnig correction Long cut provides good contact after displacement to prevent pseudoarthrosis The iliac cut is slightly curved and the pubic is cut as in Steel procedure Fixation is with screws and attaching a cerclage wire from a screw in the pubis to a pin in the ilium .

34. Periacetabular Osteotomy – GANZ (BERNESE) Triplaner osteotomy 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

35. First cut – Ischial cut , made down to the ischium , at the infracotyloid groove , begins distal to acetabulum ,directed posteriorly aiming at the ischial spine and ends at the posterior aspect of acetabulum Second cut - Superior ramus cut - begins just medial to the iliopectineal eminence Third cut - made just inferior to the anterior superior iliac spine - cut ends just lateral to the pelvic brim at the apex between the third and fourth cuts, midway between the posterior aspect of the posterior column and the posterior wall of the acetabulum Fourth cut - travels down the posterior column to meet the first cut

36. GANZ / BERNESE OSTEOTOMY …

37. 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.

38. Disadavntages : - learning curve is long and steep - serious complications Complications : Displacement of fragments Delayed , nonunion of pubic and ischial osteotomies Loss of fixation Damage to lateral femoral cutaneous nerve( 50% pts ) Femoral nerve palsy, Ectopic bone formation

39. Spherical Acetabular osteotomies Allows rotational repositioning of acetabulum through a wide range Stable – no disruption of pelvic ring Medialisation of acetabulum is difficult if not impossible Anterior rotation of acetabulum – loss of flexion common Pain relief ,improvement in acetabular coverage in majority cases Ex: 1.Ninomiya spherical osteotomy 2.Wagner spherical osteotomy 3.Eppright – DIAL osteotomy

40. NINOMIYA SPHERICAL OSTEOTOMY

41. VOLUME REDUCING PELVIC OSTEOTOMIES These osteotomies correct the acetabulum while hinging on portions of the symphysis pubis and the triradiate cartilage Because of this second point of hinging, these osteotomies have the potential to not only reorient the acetabulum but also to reshape it They differ in the extent of the bone cut on the inner and outer tables of the acetabulum , the extent of the remaining hinge

42. Pemberton cuts both the inner and the outer tables of the ilium , and hinges on the ischial limb of the triradiate cartilage Pembersal extends past the ischial limb of the triradiate cartilage, freeing the acetabulum to rotate more. San Diego osteotomy preserves the entire medial cortex and cuts through the cortical bone of the sciatic notch in an attempt to produce equal anterior and posterior coverage Dega osteotomy preserves the inner table of the pelvis posterior to the iliopectineal line. It also preserves the entire cortex of the sciatic notch.

43. PEMBERTON OSTEOTOMY INDICATION: In dysplastic hips between the age of 18 months and 6 yrs, >10-15 degrees correction of acetabular index required. Small femoral head ,large acetabulum PROCEDURE- pericapsular osteotomy of the ilium 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

44. ADVANTAGES : Osteotomy is incomplete, therefore more stable Internal fixation is not required Greater degree of correction can be achieved with less rotation of the acetabulum . DISADVANTAGES: Technically more difficult It alters the configuration and capacity of the acetabulum and can result in an incongruence relationship between it and femoral head, if its larger Premature closer of triradiate cartilage.

45. DEGA OSTEOTOMY Age : 2 – 12 yrs - lower age limit for the osteotomy is primarily determined by bone quality,which must be strong enough (on the younger end) to support the hinge process ,yet not too stiff (on the older end) to hinge plastically. For the bone to be adequately plastic, the triradiate cartilage should ideally be open. Contraindications : acetabulum that is too small to adequately contain the femoral head, even after reorientation

46. Osteotomy starts above the acetabulum and proceeds into the triradiate cartilage behind and beneath the acetabulum placement of the wedges determines the area of acetabular coverage that is improved Wedges placed posteriorly – posterior acetabular coverage is augmented wedges are placed anteriorly and superiorly, coverage is improved anterolaterally acetabular volume may be decreased by the displacement of the osteotomy .

47. DEGA OSTEOTOMY

48. CHIARI OSTEOTOMY Greater load bearing osteotomy Indications: Unique - only pelvic osteotomy that is indicated primarily when the hip is incongruous and when femoral head coverage cannot be achieved by other methods of reconstruction recommended when the femoral head is irregular or cannot be centered in the acetabulum by abduction and internal rotation of the hip Can also be performed in the presence of severe instability prevention or treatment of pain , rather than primary improvement in hip function, is the principal objective of this procedure

49. oblique osteotomy in a proximal and medial direction, beginning at the lateral margin of the dysplastic acetabulum , at an angle of 10° optimal location to begin the osteotomy is within 1 cm or less of the capsular insertion on the lateral margin of the dysplastic acetabulum . osteotomy that is too distal may enter the joint or place increased pressure on the femoral head when the hip is displaced medially . osteotomy that is too proximal may fail to provide adequate load bearing for the femoral head

50. TECHNIQUE : 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 10 ° superiorly towards inner table .

51. 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.

52. Disadv antages insertions of the hip abductor muscles are displaced medially and proximally as the hip is displaced along the slope of the osteotomy reduce the strength of the hip abductor muscles and decrease their mechanical advantage

53. Technical considerations Risk of Posterior displacement of the distal osteotomy fragment Greater risk when the osteotomy is more horizontal osteotomy that is curved from anterior to posterior will help resist posterior displacement of the acetabulum A dome-shaped osteotomy also provides more anterior and posterior support to the hip capsule and femoral head recommended that 80% of the femoral head should be covered following displacement

54. SHELF PROCEDURES - STAHELI Primary indication : hip dysplasia with aspherical hip congruity not amenable to redirectional osteotomies . Secondary indication : anterolateral acetabular extension in dysplastic hips in which femoral head coverage cannot be achieved by the more commonly performed pelvic osteotomies Patients aged 8 years or older with Legg- Calvà ©- Perthes disease, who typically present with coxa magna and early lateralization of the femoral head .

55. objective is to create a shelf, the size of which is decided by measuring the “ width of augmentation (WA)” using the CE angle of Wilberg . Graft length( gl )= wa + slot depth Achieving a center -edge angle of 35 degrees is optimal

56. Shelf is constructed over the femoral head, particularly anteriorly and laterally created by using local shavings of iliac bone along with a large segment of bone from the iliac wing A concave slab of bone is fixed over the femoral head and placed over the hip capsule and beneath the reflected head of the rectus femoris A buttress of cancellous bone is then constructed between this slab and the pelvis, over the acetabulum As the shelf matures, the contour will remodel from the pressure of the femoral head, and the bone of the shelf will hypertroph

57. Overview of Pelvic Osteotomies

58. PROXIMAL FEMORAL OSTEOTOMIES Based on the 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, OA . Eg : McMurray osteotomy , Pauwel’s osteotomy

59. 2.ANGULATION OSTEOTOMY : Longitudinal axis of distal fragment forms an angle with that of proximal fragment . Sagittal plane : Extension osteotomy for FFD Coronal plane : varus osteotomy valgus osteotomy

60. Based on INDICATION – Osteoarthritis of hip AIM OF OSTEOTOMY : RELIEF OF PAIN : Mechanical : reducing the ratio between abductor and body weight lever arm, 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.

61. Osteotomies in Osteoarthritis of hip : Pauwels varus osteotomy . Pauwels valgus osteotomy . McMurrays osteotomy

62. McMurray’s Displacement Osteotomy INDICATIONS: Nonunion of femoral neck 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 : Line of weight bearing is shifted medially Shearing force at the nonunion is decreased, because the fracture surface has become more horizontal

63. Oblique osteotomy made in the shaft of the femur - Its lower border on the outer margin being slightly below the level of lesser trochanter Terminates on the inner side b/w lesser trochanter and neck Shaft of femur is displaced inwards by abduction of the limb & digital pressure on the upper and outer aspect of lower fragment – complete inward displacement

64. 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 .

65. Pauwels Varus Osteotomy AIM : T o 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: Antalgic abductor limb Abduction deformity Painful adduction Neck shaft angle > 135° .

66. CONTRAINDICATIONS : Fixed external rotation of > 25° 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.

67. PAUWELS VALGUS OSTEOTOMY AIM: To 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: Trendelenburg Limb Adduction deformity Motion in adduction beyond adduction deformity Painful abduction CONTRAINDICATIONS: Flexion of less than 60° Knock knees as this will increase the deformity at knee.

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

69. Osteotomies in Nonunion neck of femur DICKSON HIGH GEOMETRIC OSTEOTOMY Principle - the line of vertical SHEAR 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

70. 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

71. 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 .

72. Lorenz bifurcation osteotomy 92 Described for congenital dislocation of hip In this,upper end of the distal 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

73. OSTEOTOMY FOR COXA VARA The normal femoral neck shaft angle in infant is 120 to 140 , Reduction to a more acute angle constitute a coxa vara deformity . Goals of treatment : 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 - epiphyseal angle of more than 60° .

74. Surgeries performed are Valgus Subtrochanteric Osteotomy or abduction osteotomy -with Internal Fixation. – Borden ,Wagner 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. Contd.

75. OSTEOTOMIES FOR CONGENITAL COXA VARA PAUWEL’S “ Y “ OSTEOTOMY Objective : - To place the capital femoral physis perpendicular to the resultant compresive force - To decrease the bending stress in the femoral neck

76. Osteotomies in AVN – Femoral head SUGIOKA TRANSTROCHANTERIC OSTEOTOMY Aim : To move the involved necrotic anteosuperior segment of the femoral head from the principal weight bearing area - Transtrochanteric rotational osteotomy Best results for small / medium sized lesions ( <30% femoral head involvement ) in young adults Idiopathic / posttraumatic osteonecrosis ( compared to alcohol, steroid induced AVN )

77. 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 .

78. Place two pins in greater trochanter from lateral to medial in a 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.

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

80. 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.

81. 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 .

82. VARUS DE-ROTATION OSTEOTOMY AIM : 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: Excessive varus angulation that may not correct with growth Further shortening of already shortened extremity Possibility of a gluteus lurch produced by decreasing the length of the lever arm of the gluteus musculature.

83. The degree of de roration is estimated with the a mount 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.

84. 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.

85. 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 .

86. 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.

87. OTHER OSTEOTOMIES IN PERTHES DISEASE SALTER Innominate osteotomy: SHELF procedure ( Staheli ): If the hip is congruous, it can be performed for coxa magna and lack of acetabular coverage for the femoral head. CHIARI Osteotomy: It is used as a salvage procedure to accomplish coverage of large flattened femoral head. Technique: Described in CDH . VALGUS EXTENSION osteotomy: Indicated in malformed femoral head in residual Perthe's disease with hinge abduction. Technique: Described in Osteoarthritis

88. SLIPPED CAPITAL FEMORAL EPIPHYSIS In this condition, the epiphysis is displaced inferiorly causing adduction and external rotation deformity of the limb. AIM: Osteotomy is performed here to reposition the femoral head (epiphysis) concentrically within the acetabulum. INDICATIONS: Chronic slip with moderate to severe displacement. Malunited slip

89. 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 Fish b. Technique of Dunn just distal to slip c. Base of neck technique by Kramer et al d. d. Technique of Abraham et al Compensatory osteotomies through the T rochantric region: These osteotomies produce a deformity in the opposite direction. It includes a. Ball and socket osteotomy b. Biplane intertrochanteric osteotomy (Southwick)

90. CUNEIFORM OSTEOTOMY OF FEMORAL NECK (FISH): Fish recommended this in moderate to severe slips of more than 30°. Capsule is incised & femoral neck is exposed. Locate the physis . D etermine the size of wedge to be removed by noting the degree of slip.

91. 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.

92. 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.

93. 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. Anterosuperior wedge of the most superior part of the femoral neck is removed

94. 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.

95. C . Head is freed of all fibrocartilage and callus . D . Osteotomy line on upper end of femoral neck is made for excision of trapezoid segment . ( anterosuperior wedge )

96. 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 .

97. Osteotomies at base of neck – KRAMER,BARMADA Intracapsular base of neck osteotomy – for chronic slips with > 20 ° of deformity Extracapsular base of neck osteotomy – for moderate to severe chronic slips with > 30 ° of head shaft angle

98. Intertrochanteric Osteotomy - SOUTHWICK BIPLANE osteotomy Anterolaterally based wedge At the level of lesser trochanter Indications : - for chronic / healed slips with head shaft deformities between 30 – 70 ° Corrects extension / varus deformity with flexion / extension of the distal fragment , and internal rotation as needed

99. Southwick Intertrochanteric Osteotomy

100. OSTEOTOMY TO CORRECT UNSTABLE INTERTROCHANTERIC FRACTURES Dimon and Hughston : Medial displacement osteotomy to stabilise unstable 4 part IT fracture In 4part # adductors tend to displace fracture into varus secondary to lack of medial cortical opposition Chang et al - anatomical reduction allow greater load shearing by bone than medial displacement osteotomy . (CORR 1987 Dec;(225):141-6)

101. Technique: If GT remains attached to femur ,a transverse osteotomy needs to be made at a level 2cm below LT GT fragment is reflected superiorly Steinman pin inserted into the superior third of femoral head Key the calcar spike (proximal fragment )into the medially displaced distal fragment Guide wire is placed into the lower half of femoral head The wire position will ensure a more valgus orientation of femoral neck ,once the screw and side plate have been applied Determine and insert the appropriate compression screw Abduct the thigh to bring the reduction into valgus Apply the side plate – 135deg, short barrel Release traction and apply the compression screw Reattach the GT fragment with wires

102. DIMON AND HUGHSTON INTERTROCHANTERIC OSTEOTOMY

103. SARMIENTO OSTEOTOMY Involves creating an oblique osteotomy of the distal fragment( valgus osteotomy ) to obtain stability in unstable IT # Changes # plane from verticle to near horizontal Creates contact b/w medial and posterior cortex of proximal and distal fragments Goal – to obtain medial stability Adv – valgus realignment of proximal fragment makes up for less of length at osteotomy site so that limb lengths are equal

104. Technique: A 45° oblique osteotomy of distal fragment begins just below flare of GT & crosses distally and medially to exit about 1cm distal to the apex of # Guide wire and then implant are inserted at 90° to plane of # of proximal fragment With more vertical alignment of # ,insert guide pin so that it ends up more inferiorly in the femoral head ( other wise ,the osteotomy will be placed in varus ) Insert 135 sliding screw in usual manner # is reduced and impacted Medial cortex opposition and hence stability are restored

105. OSTEOTOMY TO CORRECT UNSTABLE INTERTROCHANTERIC FRACTURES Sarmiento Technique

106. Referrences Tachdjian’s Paediatric Orthopaedics – 5 th edition Master techniques in Orthopaedic surgery – Paediatrics , - Vernon.T.Tolo,David L Skaggs 1 st edition Campbell’s Operative Orthopaedics -12 th edition Wheeless ’ text book of Orthopaedics - www.wheelessonline.com.ortho – Clifford R.Wheeless,III,M.D Ramond g.Tronzo ,Surgery of hip joint 2012. – volume 1 Reinhold Ganz MD,Kevin Horowitz MD,Micheal Leunig MD- Algorithm for femoral and periacetabular osteotomies in complex hip deformities- CORR(2010) 468;3168-3180

107. 7 . Intertrochanteric femoral osteotomies for developmental and post traumatic conditions – Santore ,Richard F;Kantor,Stephen R . JBJS;Nov 2004;86,11 8. Internet : WWW.ORTHOPAEDICSONE.COM – Pelvic osteotomies;Sutherland osteotomy 9. Double Innominate osteotomy –DH Sutherland , JBJS Am,1977