OSTEOTOMIES AROUND THE HIP JOINT

Actetabular and proximal femur osteotomies

1. OSTEOTOMIES AROUND THE HIP Maj Archit Garg Resident, Orthopaedics Armed Forces Medical College

2. History John Rhea Barton 1826 - 1 st subtrochanteric osteotomy (in 7 minutes). 1827 - F emoral osteotomy between the greater and lesser trochanters to secure motion in an ankylosed hip. This was hailed the first successful arthroplasty.

3. History 1835 - Sourvier performed first subtronchanteric osteotomy for the treatment of DDH. 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 DDH. 1922 - Schanz reported his low sub-trochanteric abduction osteotomy.

4. History Friedrich Pauwels Performed extensive research on the biomechanical impact of varus and valgus configuration of proximal femur Influence of Neck shaft angle on the reaction force of the hip and thereby magnitude of stress on the femoral head 1935 - Described osteotomy at intertrochanteric level adduction deformity.

5. History 1936 - McMurray 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.

6. Osteotomies around the hip: Definition 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

7. CONTENTS Biomechanics of hip Radiological parameters Acetabular Osteotomies Proximal Femur Osteotomies

8. The neck of the Femur Angulated in relation to the shaft in 2 planes : sagittal & coronal Neck Shaft angle 150 deg at birth 120-135 deg in adult Ante version Anteverted 40 deg at birth 12-15 deg in adults

9. Acetabular direction Long axis of acetabulum points – forwards : At birth: 30 deg At 1 year: 20 deg 15-20 deg ante version 45 deg inferior inclination

10. Biomechanics Forces acting across hip joint Body weight (BW) Abductor muscles force Joint R eaction Force (JRF) One legged stance 5/6 BW on femoral head Ratio of lever arms to BW 3:1

11. Normal Hip JRF calculation 1 st class lever Effort (Muscle force) Fulcrum (Hip joint) Load (Resistance ) Determinants of JRF Body weight Body weight moment arm Abductor force (muscles) Abductor force moment arm

12. Biomechanics in neck deformities

13. Coxa Valga Increased neck shaft angle GT is at lower level Shortened abductor lever arm Body weight arm remains same Increased joint forces in hip during one leg stance Less muscle force required to keep pelvis horizontal Resultant force R is more than a normal hip

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

15. Radiographic parameters To assess acetabular dysplasia: Acetabular index Acetabular index of Sharp Acetabular depth The sourcil The teardrop

16. Radiographic parameters To assess proximal femoral dysplasia: Neck-shaft angle Hilgenreiner epiphyseal angle Femoral neck changes: coxa vara and coxa valga Changes in the femoral head: coxa breva and coxa magna Relation between the greater trochanter and the femoral head

17. Radiographic parameters To assess the relationship between the acetabulum and proximal femur: Shenton’s line Center-edge angle for lateral coverage of the femoral head False-profile view for anterior coverage of the femoral head AP of the pelvis in neutral and in maximum abduction/internal rotation Migration index of Reimers Acetabular protrusion

18. Radiographic parameters Hilgenreiner line H orizontal line running through the triradiate cartilage of both sides of the pelvis. Perkins line Vertical line running from the lateral edge of the acetabulum and perpendicular to the Hilgenreiner line

19. Radiographic parameters Acetabular Index used to measure acetabular dysplasia in young children prior to the ossification of the triradiate cartilage. It is the angle between the Hilgenreiner line and a line connecting the lateral edge of the acetabulum and the triradiate cartilage. Values more than 20° after the age of 2 years represent acetabular dysplasia Acetabular index of Sharp U sed to measure acetabular dysplasia after ossification of the triradiate cartilage. It is the angle between Hilgenreiner and a line connecting the lateral edge of the acetabulum and the inferior part of the teardrop. Values greater than 42° represent acetabular dysplasia

20. Radiographic parameters Sourcil ( eyebrow in French) A rea of subchondral osseous condensation in the acetabular roof represents a response to the articular portion of the ileum to the stress provoked by the compressive forces acting on it. Length is usually about 80% of the width of the femoral head. Acetabular teardrop The teardrop is a radiographic condensation of the innominate bone at the inferior end of the acetabulum. A normal teardrop is U-shaped . The medial border of the teardrop is continuous with the ilio -ischial line (named the Kohler line), and the lateral wall is continuous superiorly with the floor of the acetabulum. The width of the teardrop varies with rotation of the pelvis. A wide teardrop is associated with a shallow acetabulum . A very narrow teardrop where the medial and lateral wall touch each other at the floor of the acetabulum or crossover is a sign of a deeper than normal acetabulum causing over coverage of the head called coxa profunda .

21. Radiographic parameters Shenton Line Imaginary line joining the inferior border of the superior pubic ramus to the inferomedial border of the proximal femur. It should be a smooth line . In cases of subluxation, this line is “broken.”

22. Radiographic parameters Hilgenreiner epiphyseal angle is between the Hilgenreiner line and a line along the upper femoral epiphysis . Values >60° signify coxa vara

23. Radiographic parameters Shape of the Femoral Head The femoral head is approximately spherical in normal anatomy. Loss of sphericity (e.g., coxa plana , epiphyseal overgrowth) leads to incongruity and predisposes to articular cartilage degeneration . Coxa magna may be asymptomatic if congruous, but can cause FAI, labral tears, and early osteoarthritis. Coxa breva results in reduced abductor lever arm, increased joint reaction force, abductor insufficiency, and Trendelenburg gait. (a) The left hip demonstrates coxa breva with varus and high-riding greater trochanter . (b) The right hip demonstrates coxa magna and coxa irregularis

24. Radiographic parameters Articulo -trochanteric Height The tip of the greater trochanter normally lies at the level of the center of the femoral head. Distance between the trochanteric tip and the superior aspect of the femoral head . In coxa vara : Trochanter lies superior to femoral head center . In coxa valga : Trochanter lies inferior to femoral head center . This relationship is minimally affected by hip rotation.

25. Radiographic parameters Center-edge angle The angle between the lateral edge of the acetabulum, the center of the femoral head , and a vertical line. Helps determine the lateral coverage of the femoral head by the acetabulum. A center-edge angle of more than 25 ° is normal, and <20° represents hip dysplasia. Values of 20–25° are considered borderline dysplasia

26. Radiographic parameters False-profile view H elps determine the anterior coverage of the femoral head by the acetabulum. The patient is standing 25° to the lateral view. The measurement is made similar to the center-edge angle. Normal anterior coverage is present when the angle is >25 °. An angle <20° represents hip dysplasia, and values between 20–25 ° represent borderline dysplasia

27. Radiographic parameters Migration index of Reimer Three lines are drawn —the Perkins line and two parallel lines: one on the most medial margin of the femoral head and another on the most lateral margin of the femoral head. A and B distances are measured and divided and converted to a percentage (A/B*100 ). Above 33% is considered displaced, and above 40% usually requires surgery

28. Osteotomies around the hip Proximal femoral deformity and hip dysplasia are interrelated Proximal femoral deformity can affect the final shape of the acetabulum The shape of the acetabulum affects the proximal femur

29. Indications for osteotomies Osteotomies improve hip function To Increases the contact area/congruency To Improves coverage of femoral head To Move normal articular cartilage into weight bearing zone To Restore biomechanical relationship

30. Contraindications for osteotomies Neuropathic arthropathy Inflammatory arthropathy Active infections Severe osteopenia Advanced arthritis/ ankylosis Advanced age Smoking Obesity

31. Classification of osteotomies around the hip Pelvic osteotomies Proximal Femur Osteotomies

32. Pelvic Osteotomies Re-directional Single Innominate: Salter Double Innominate: Sutherland Triple Innominate: Steel, Tonnis , Hopf , Pol Le Coeur Periacetabular : Ganz (Bernese) Spherical: Ninomiya , Dial, Wagner Reshaping (Volume reducing) Pemberton and Pembersal Dega San Diego Salvage (Greater load bearing surface) Shelf Operation (STAHELI) Chiari Osteotomy Lateral Acetubaloplasty

33. Proximal Femur Osteotomies Anatomical location High Cervical Intertrochanteric Subtrochanteric Greater Trochanteric Displacement of distal fragment Torsional/ Derotation Transpositional Angulation Adductional /Varus Abductional /Valgus Flexion/Extension

34. PART-I: ACETABULAR OSTEOTOMIES

35. Re-directional Osteotomies

36. Salter’s Single Innominate Osteotomy E ntire acetabulum together with pubis and ischium is rotated as a unit Indications: <10–15° of correction of acetabular index is needed D DH in children from 18 months to 6 years of age Anterolateral acetabular insufficiency Concentrically reducible hip Congenital subluxation upto early adult life. LCPD onset of disease after 6 yrs age moderate–severely affected head loss of containment

37. Salter’s Innominate Osteotomy Contraindications: Age <18 months Posterior acetabular insufficiency Closed triradiate cartilage Neuromuscular hip disease Prerequisites: Before the osteotomy, femoral head should be positioned opposite the level of the acetabulum (which can be achieved by period of traction) Contractures of iliopsoas and adductor muscles must be released. ROM of hip must be good

38. Salter’s Innominate Osteotomy A limited Smith-Peterson approach is used. The oblique portion of the incision is made 2 cm distal to the ASIS overlying the hip joint

39. Salter’s Innominate Osteotomy

40. Salter’s Innominate Osteotomy

41. Salter’s Innominate Osteotomy

42. Salter’s Innominate Osteotomy

43. Salter’s Innominate Osteotomy

44. Salter’s Innominate Osteotomy

45. Salter’s Innominate Osteotomy Advantages No effect on acetabular capacity Technically less demanding Corrects abnormal direction Does not alter congruity (structure) of the acetabulum Articular cartilage of the femoral head and acetabulum are in contact in the functional position of weight bearing Femoral head is better covered by the acetabulum preventing degenerative changes Gain in limb length

46. Salter’s Innominate Osteotomy Disadvantages Relatively unstable Needs internal fixation with K-wires Needs second surgery for pin removal Complications Neurovascular damage: Sciatic nerve, LFCN, Nutrient vessels to TFL Joint penetration of K-wires Re-dislocation- Posterior AVN

47. Kalamchi modification of Salter’s Innominate Osteotomy A posterior triangular area is removed from the proximal side of the osteotomy site to allow engagement of the distal iliac segment after displacement of the osteotomized bone. Increased stability: The triangular wedge allows for better interlocking of the bone fragments and prevents the medial and posterior displacement that occasionally is seen after a Salter osteotomy, Reduced risk of medial and posterior displacement: The modification helps to prevent the lower portion of the ilium from shifting backward and inward after the surgery. Reduced limb length discrepancy

48. Sutherland Double Innominate Osteotomy Indications: Age 8 – 15 yrs DDH Procedure: Following Salter’s osteotomy, 2nd osteotomy – Pubic osteotomy medial to obturator foramen in the interval between 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

49. Sutherland Double Innominate Osteotomy

50. Sutherland Double Innominate Osteotomy Advantages: Addition of pubic osteotomy increases the amount of acetabular rotation & coverage of femoral head Femoral head could be shifted medially, reducing the length of femoral lever arm

51. Steel Triple Innominate Osteotomy Indications Symptomatic acetabular dysplasia with open triradiate cartilage Failure of Salters Preserved congruity and reducibility Contraindications Incongruent or irreducible hip Posterior acetabular wall deficiency Closed triradiate cartilage

52. Steel Triple Innominate Osteotomy

53. Steel Triple Innominate Osteotomy

54. Steel Triple Innominate Osteotomy

55. Steel Triple Innominate Osteotomy

56. Steel Triple Innominate Osteotomy Advantages Better coverage of femoral head by articular cartilage Better hip joint stability No need of spica cast Applicable regardless of whether the triradiate cartilage remains fused or not No shortening of lower limb

57. Steel Triple Innominate Osteotomy Disadvantages Difficult to perform It distorts the pelvis so natural child birth is impossible in adulthood. Difficulty and limitation of sufficient acetabular correction and femoral head medicalization Require the long period before weight bearing

58. Steel Triple Innominate Osteotomy Lipton & Bowen Modification Resecting 1-1.5 cm bone from ischial tuberosity to favor medialization. To resect a triangular wedge from outer part of ilium which favors slot formation which serves as abutment. The resection of the wedge from the outer cortex created a slot, with the intact inner cortex serving as a stabilizing buttress where the distal posterior aspect of the ilium fits. This osteotomy allows for extensive coverage of the femoral head along with a greater stability. Use 7.3mm cannulated screws instead of steinmann pins.

59. Tonnis Triple Innominate Osteotomy Long ischial cut connects obturator foramen with the sciatic notch so that the cut finishes proximal to the sacrospinous ligament, preventing it tethering from the acetabular fragment during correction Long cut provides good contact after displacement to prevent pseudoarthrosis The iliac cut is slightly curved and the pubis 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.

60. Tonnis Triple Innominate Osteotomy Indications Symptomatic hip dysplasia Center-edge angle <20° Acetabular index >40 Spherical femoral head Contraindications Tönnis osteoarthritis grade ≥2 Incongruent or irreducible hip Range of motion <70° arc

61. Tonnis Triple Innominate Osteotomy

62. Tonnis Triple Innominate Osteotomy

63. Hopf Triple Innominate Osteotomy The ischial tuberosity is osteotomized closer to the center of the hip joint than in Steel’s procedure.

64. Pol Le Coeur Triple Innominate Osteotomy The pubis and ischial ramus are osteotomized closer to the pubic symphysis as compared with Steel’s procedure . Indications Hip dysplasia ages 5–10 years Legg- Calvé - Perthes disease Sequelae of septic arthritis N eurological hips (anterior/lateral deficiency with normal posterior coverage) Contraindications Stiff hip Lack of congruency Posterior acetabular deficiency

65. Triple Innominate Osteotomy

66. Periacetabular Osteotomy (Ganz/Bernese) Dr. Reinhold Ganz, pioneered the procedure and is credited with its development and refinement. ‘Bernese’ refers to the region where the procedure was developed (Bern, Switzerland) 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 present a proximal femoral osteotomy can be added. Approach – Smith Peterson/ Ilioinguinal

67. Periacetabular Osteotomy (Ganz/Bernese) Indications Hip dysplasia Symptomatic acetabular retroversion Active hip pain, congruent joint, skeletal maturity (closed triradiate ) Contraindications Tönnis grade osteoarthritis >2 Age >35y Hip incongruency Open triradiate cartilage

68. Periacetabular Osteotomy (Ganz/Bernese) First cut – Ischial cut M ade 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 Between Medial capsule and Obturator externus Second cut - Superior ramus cut B egins just medial to the iliopectineal eminence

69. Periacetabular Osteotomy (Ganz/Bernese) Third cut - made just inferior to the anterior superior iliac spine C ut 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

70. Periacetabular Osteotomy (Ganz/Bernese)

71. Periacetabular Osteotomy (Ganz/Bernese)

72. Periacetabular Osteotomy (Ganz/Bernese)

73. Periacetabular Osteotomy (Ganz/Bernese) Ganz et al. (Original Technique):Used the Smith-Petersen approach . Required exposure of both inner and outer tables of ilium . Involved abductor stripping to access the posterior column . Murphy & Millis Modification : Abductor-sparing variant of the Smith-Petersen approach . Osteotomy from internal pelvic surface with minimal lateral stripping . Introduced the bikini-type skin incision along the inguinal crease .

74. Periacetabular Osteotomy (Ganz/Bernese) Current Practice Preferences: Bikini incision used selectively in thin female patients. Standard Smith-Petersen approach preferred in most cases due to: Better access for labral repair. Easier femoral osteochondroplasty . Matheney et al. Approach (Current Standard): Abductor-sparing technique routinely employed. Novais et al. (Rectus-Sparing Approach): Used when no cam deformity/labral pathology on imaging. Rectus femoris origin (both heads) preserved. No anterior arthrotomy made.Aims to reduce postoperative pain.

75. Periacetabular Osteotomy (Ganz/Bernese) Advantages: 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.

76. Periacetabular Osteotomy (Ganz/Bernese) Disadvantages: 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

77. 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 Examples: Ninomiya spherical osteotomy Wagner spherical osteotomy Eppright – DIAL osteotomy

78. Spherical acetabular Osteotomies Year Technique Developer Key Innovation 1965 Wagner Spherical Osteotomy Heinz Wagner First true circumferential spherical osteotomy 1975 Eppright Dial Osteotomy R.H. Eppright Spherical axis rotation ("dial" concept) 1984 Ninomiya RAO Ninomiya & Tagawa Curved rotational with posterior column preservation

79. Spherical acetabular Osteotomies Feature Ninomiya (RAO) Wagner Eppright (Dial) Approach Anterolateral Lateral/Posterolateral Anterolateral Osteotomy Pattern Curved, incomplete Nearly circumferential Spherical axis Posterior Column Preserved Compromised Partially preserved Fragment Mobility Controlled rotation Maximum freedom Limited rotation Pelvic Stability Maintained Significantly reduced Moderately reduced

80. Indications Criteria Ninomiya RAO Wagner Eppright Age Range 27-53 years ( mean) Adolescent/Young adult Children/Young adults CE Angle 10-20° ( preop ) <20° Variable Joint Congruency Essential Essential Important Tönnis Grade 0-1 preferred 0-1 0-1 Symptoms >6 months pain Symptomatic Symptomatic

81. Contraindications (All techniques) Advanced osteoarthritis ( Tönnis >2) Poor joint congruency on abduction views Significant femoral head deformity Active infection

82. Ninomiya (and Tagawa ) Spherical Osteotomy Osteotomy Line: Anterior: One fingerbreadth above joint space Posterior: Horizontal at ischial base level Greater sciatic notch: Mid-level between joint and notch

83. Eppright (DIAL) Osteotomy Pericapsular Entire acetabulum superiorly, posteriorly, inferiorly and anteriorly is freed by osteotomy and as a single segment of bone is redirected to cover the femoral head appropriately.

84. How much to rotate the acetabulum? Avoid Figure-of-4 position: Acetabular retroversion Pay attention to transverse plane rotation Avoid too much anterior rotation: Flexion restricted Rotate Acetabular fragment till: CE angle: ~ 30-35 deg (avoid less and more) Angle of Weight Bearing Surface: ~(-5) to (+5) deg Migration index of Reimer: 10-15% of head remains uncovered

85. Reshaping (Volume reducing) Osteotomies

86. Reshaping (Volume reducing) 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

87. Reshaping (Volume reducing) Osteotomies Pemberton Osteotomy cuts both the inner and the outer tables of the ilium, and hinges on the ischial limb of the triradiate cartilage Pembersal Osteotomy extends past the ischial limb of the triradiate cartilage, freeing the acetabulum to rotate more.

88. Reshaping (Volume reducing) Osteotomies Dega osteotomy preserves the inner table of the pelvis posterior to the iliopectineal line. It also preserves the entire cortex of the sciatic notch. 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

89. Pemberton Osteotomy (Anterolateral Acetabuloplasty ) Indications : 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 A cetabular dysplasia with open triradiate Anterosuperior deficiency (may include neuromuscular/acquired dysplasia or Perthes ) Some sequelae of infection Contraindications: Closed triradiate Unreduced/deformed femoral head Small acetabular volume, active infection

90. Pemberton Osteotomy Procedure P ericapsular 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

91. Pemberton Osteotomy

92. Pemberton Osteotomy

93. Pemberton Osteotomy 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 closure of triradiate cartilage.

94. Lateral Acetabuloplasty ( Dega and San Dieago Modification) Concentric reduction of femoral head achieved by Soft tissue release Open reduction Femoral osteotomy Indications: Neuromuscular acetabular dysplasia (open triradiate ) Acetabular index >25°, volume increase Age 2–10 years Contraindications: Skeletal maturity (closed triradiate )

95. Dega Osteotomy Surgical Technique Ilium exposed as for Salter’s Osteotomy line is marked on lateral cortex of ilium; G uidewire is inserted to exit just above horizontal limb of triradiate cartilage . The iliac apophysis is split, the outer wall exposed to the sciatic notch posteriorly and to the AIIS anteriorly

96. Dega Osteotomy Started 0.5-1.0 cm above the lateral margin of the acetabulum From AIIS to sciatic notch

97. Dega Osteotomy A unicortical cut made through outer table Straight osteotome first

98. Dega Osteotomy A curved osteotome used to deepen medially and caudally behind acetabulum Between medial wall of acetabulum and medial wall of ilium Stop several mm away from the triradiate cartilage

99. Dega Osteotomy Wedge securely in the osteotomy site Usually the largest graft is anterior Quite stable and no internal fixation is necessary

100. Dega Osteotomy

101. Comparison of San Diego with Dega Osteotomy Medial Cortex: The San Diego osteotomy preserves the medial cortex of the ilium, whereas the Dega osteotomy cuts through both cortices.  Hinging: The San Diego osteotomy utilizes a hinge mechanism on the medial cortex, allowing for more precise shaping of the acetabulum with bone grafts.  Coverage: The San Diego osteotomy may offer more targeted correction for specific coverage deficiencies, particularly in the posterior direction

102. Comparison of San Diego with Dega Osteotomy

103. Comparison of San Diego with Dega Osteotomy

104. Comparison of San Diego with Dega Osteotomy

105. Comparison of San Diego with Dega Osteotomy Surgical Technique Hinges symmetrically on or slightly above the triradiate cartilage Use bone grafts that provide posterior coverage e qual to anterior coverage

106. Pembersal Osteotomy Done accidentally for the first time while attempting Pemberton Combines Salter’s ad Pemberton Curved osteotomy Inner table kept intact Passes across the triradiate cartilage

107. Pembersal Osteotomy Indications: Ages 4–10 years Dysplastic or dislocated hip with capacious acetabulum needing reshaping/reorientation Contraindications: Age <4y Lack of congruence/stiff hip

108. Salvage Osteotomy (Greater load bearing surface)

109. 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 R ecommended 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 P revention or treatment of pain, rather than primary improvement in hip function, is the principal objective of this procedure Salvage procedure in adolescent/young adult Closed triradiate cartilage

110. Chiari Osteotomy Contraindications: Moderate-advanced osteoarthritis Severe proximal migration/deformity unamenable to translation

111. Chiari Osteotomy O blique osteotomy in a proximal and medial direction, beginning at the lateral margin of the dysplastic acetabulum, at an angle of 10° O ptimal location to begin the osteotomy is within 1 cm or less of the capsular insertion on the lateral margin of the dysplastic acetabulum.

112. Chiari Osteotomy 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

113. Chiari Osteotomy 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.

114. Chiari Osteotomy 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.

115. Chiari Osteotomy

116. Chiari Osteotomy Disadvantages I nsertions of the hip abductor muscles are displaced medially and proximally as the hip is displaced along the slope of the osteotomy Reduces the strength of the hip abductor muscles and decrease their mechanical advantage

117. Chiari Osteotomy 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 R ecommended that 80% of the femoral head should be covered following displacement

118. Shelf Procedures- Staheli Primary indication: H ip dysplasia with aspherical hip congruity not amenable to redirectional osteotomies. Secondary indication: A nterolateral 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-Calve- Perthes disease, who typically present with coxa magna and early lateralization of the femoral head. Certain storage/epiphyseal disorders (e.g. Morquio ) Contraindication: Classic DDH in young child (where reorientation possible)

119. Shelf Procedures- Staheli Objective: 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

120. Shelf Procedures- Staheli Shelf is constructed over the femoral head, particularly anteriorly and laterally C reated by using local shavings of iliac bone along with a large segment of bone from the iliac wing An acetabular slot is created exactly at the acetabular margin by drilling a series of holes with 4.5 mm drill bit. Slot should be 1 cm deep.

121. Shelf Procedures- Staheli 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 hypertrophy

122. Shelf Procedures- Staheli

123. Shelf Procedures- Staheli

124. Indications Pelvic osteotomy for DDH

125. Key Principles Salter, Pemberton, Dega , and variants are generally indicated for open triradiate cartilage and congruent, reducible hips. Triple and periacetabular osteotomies permit larger corrections, are more suited to older children/adolescents, and may be used when the triradiate is closing/closed; contraindications revolve around joint congruency and arthritis. Shelf and Chiari are salvage procedures reserved for irreducible or incongruent hips, especially in the setting of closed triradiate cartilage or failed prior procedures. Neuromuscular conditions (e.g., CP) often require procedures targeting posterior-superior coverage and may necessitate combined soft tissue and bony procedures. Age, triradiate status, hip congruence/reducibility, and presence of arthritis are the most important factors in osteotomy selection.

126. PART-II: PROXIMAL FEMUR OSTEOTOMIES

127. Proximal Femur Osteotomies Anatomical location High Cervical Intertrochanteric Subtrochanteric Greater Trochanteric Displacement of distal fragment Lineal osteotomy Torsional/ De-rotation Translational/Trans positional/Displacement Angulation Adductional /Varus Abductional /Valgus Flexion/Extension

128. Lineal Osteotomy Aims to shorten or lengthen a bone

129. Translational Osteotomy Longitudinal axis of distal fragment remains parallel to the longitudinal terminal axis of proximal fragment. Distal fragment is displaced medially or laterally at the osteotomy site. Used in : Fracture neck of femur Osteoarthritis McMurray osteotomy, Pauwel’s osteotomy

130. Angulation Osteotomy Longitudinal axis of distal fragment forms an angle with that of proximal fragment. Aims at correcting an angular deformity. Sagittal plane: Extension osteotomy for FFD Coronal plane : Varus osteotomy, Valgus osteotomy

131. Torsional Osteotomy Aims to correct rotational deformities. Internal or external rotation deformities

132. Indications Osteoarthritis Pauwels varus osteotomy Pauwels valgus osteotomy McMurrays osteotomy AVN Sugioka – Trans trochanteric osteotomy Varus de-rotation osteotomy Pauwels Y osteotomy

133. Indications Proximal femur fractures Non-union Fracture Neck of Femur McMurray’s Osteotomy Dickson’s high geometric osteotomy Schanz Angulation osteotomy Unstable Intertrochanteric fractures Dimon Hughston Osteotomy Sarmiento’s Osteotomy

134. Indications Unreduced DDH Lorenz bifurcation Schanz low sub trochanteric osteotomy Haas osteotomy Pemberton acetabuloplasty Salter Osteotomy Legg-calve Perthes Disease Varus de-rotation osteotomy Salter osteotomy Shelf Chiari osteotomy.

135. Indications Congenital Coxa Vara Pauwel’s Y osteotomy Valgus Intertrochanteric osteotomy: Borden, Wagner Osteotomies in Paralytic disorder of Hip Varus osteotomy Rotation osteotomy Extension osteotomy

136. Indications Slipped Capital Femoral Epiphysis (SCFE) Closing wedge (Cuneiform) osteotomy of neck: The technique of Fish Technique of Dunn (just distal to slip) Base of neck technique by Kramer et al Technique of Abraham et al Compensatory osteotomies: Ball and socket (Campbell) osteotomy Biplanar Intertochanteric osteotomy (Southwick)

137. Osteoarthritis Aim of Osteotomy Relief of Pain: Mechanical: reducing the ratio between abductor and body weight lever arm, relaxing capsule. Hemodynamic: Also by decreasing the intra osseous pressure. Correction of Deformity: F lexion , Ad duction , Ex ternal rotation. Reversal of Degenerative Process: helps by increase in joint space.

138. Osteoarthritis MCMURRAY’S DISPLACEMENT OSTEOTOMY Aim : Line of weight bearing is shifted medially Shearing force at the nonunion is decreased, because the fracture surface has become more horizontal Indications : Nonunion of femoral neck Advanced osteoarthritis Preoperative Planning : Determination of the size of the bone wedge to be removed T he position of the seating chisel which will determine the size and angle of the blade plate to be used.

139. Osteoarthritis MCMURRAY’S DISPLACEMENT OSTEOTOMY 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

140. Osteoarthritis MCMURRAY’S DISPLACEMENT OSTEOTOMY Post operative 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.

141. Osteoarthritis PAUWELS VARUS OSTEOTOMY Aim : 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 : Antalgic abductor limb Abduction deformity Painful adduction Neck shaft angle > 135 °

142. Osteoarthritis PAUWELS VARUS OSTEOTOMY Contra-indications : Fixed external rotation of > 25° – Flexion of 70° or less. Disadvantages : Shortens the limb to some degrees. Creates a Trendelenburg gait. Increases the prominence of greater trochanter. Overloading of the medial compartment of knee.

143. Osteoarthritis PAUWELS VALGUS OSTEOTOMY Aim : To transfer the center of hip rotation medially from the superior aspect of the acetabulum To increase 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.

144. Non-union Fracture 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

145. Non-union Fracture Neck of Femur and DDH 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 : Non-union fracture neck of femur Congenital dislocation of hip

146. Non-union Fracture Neck of Femur and DDH SCHANZ ANGULATION OSTEOTOMY 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 . Abduction → Apparent limb lengthening. Internal rotation → Corrects malrotation . Extension → Addresses flexion deformity.

147. Non-union Fracture Neck of Femur and DDH SCHANZ ANGULATION OSTEOTOMY For DDH

148. Non-union Fracture Neck of Femur and DDH SCHANZ ANGULATION OSTEOTOMY

149. Unreduced DDH LORENZ BIFURCATION OSTEOTOMY In this , the 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

150. Osteotomy For Congenital Coxa Vara 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 °

151. Osteotomy For Congenital Coxa Vara 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 deg - 150 deg. The surgery may be delayed till child is 4 to 5 year old to make internal fixation easier.

152. Osteotomy For Congenital Coxa Vara PAUWEL’S “ Y” OSTEOTOMY Objective: To place the capital femoral physis perpendicular to the resultant compressive force To decrease the bending stress in the femoral neck Technique Medial displacement of femoral shaft to bridge nonunion Historical fixation: Hip spica in early days

153. A, The angle of bone wedge to be resected is determined from tracings of the preoperative radiograph . B, Under image intensifier control, the lines of osteotomy are defined by drilling guiding Kirschner wires parallel to the intended bone cuts above and below the wedge resection lines. The upper Kirschner wire should stop short of the capital physis and the defect of the femoral neck, and the tip of the lower Kirschner wire should be just below the upper osteotomy line and terminate medial to point X (the apex of the wedge of bone to be resected).

154. C, With an oscillating saw, the upper intertrochanteric osteotomy is performed, and the wedge of bone is resected. D, The wedge of bone is removed with flat osteotomes .

155. E, A hook over the greater trochanter is used to pull the upper segment distally, and the two Kirschner wires are made parallel to each other, to close the gap. F, Pauwels recommended fixing the fragments with a tension band wire loop passed through drill holes in each fragment.

156. G, Preferable alternatives for internal fixation are to use either a contoured plate and screws over the greater trochanter to the distal fragment or a blade plate or sliding compression screw and plate fixation device.

157. Osteotomy For Congenital Coxa Vara PAUWEL’S “ Y” OSTEOTOMY Drawbacks (Classical Method) Shortening due to medialization of distal fragment (similar to McMurray osteotomy) Limp post-operatively Risk of Genu valgum as mechanical axis shifts lateral to knee Modern Fixation: 120° Double-Angle Osteotomy Blade Plate Places defect in medial neck at right angle to bodyweight forces Corrects coxa vara and promotes healing Allows lateralization of distal fragment → prevents genu valgum Enables limb-length equalization

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

159. Osteotomies in AVN Femoral head SUGIOKA TRANSTROCHANTERIC OSTEOTOMY 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.

160. Osteotomies in AVN Femoral head SUGIOKA TRANSTROCHANTERIC OSTEOTOMY Place two pins in greater trochanter from lateral to medial in a plane perpendicular to femoral neck. Make a trans-trochanteric 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 .

161. Osteotomies in AVN Femoral head SUGIOKA TRANSTROCHANTERIC OSTEOTOMY After completing second osteotomy use the proximal pin to rotate proximal fragment 45-90° depending on the size of necrotic area.

162. Osteotomies in AVN Femoral head SUGIOKA TRANSTROCHANTERIC OSTEOTOMY Fix the osteotomy internally with large screws and washer. Re-attach the greater trochanter to proximal and distal fragment with screws. Postoperative : skin traction is given for 2-3 weeks A ctive range of motion exercises of hip are begun at 10-14 days.

163. 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.

164. Legg Calve Perthes Disease 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.

165. Legg Calve Perthes Disease VARUS DE-ROTATION OSTEOTOMY The degree of de roration is estimated with the amount of internal rotation but further 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 .

166. Legg Calve Perthes Disease VARUS DE-ROTATION OSTEOTOMY 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.

167. Legg Calve Perthes Disease VARUS DE-ROTATION OSTEOTOMY Technique: 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 .

168. Legg Calve Perthes Disease VARUS DE-ROTATION OSTEOTOMY Technique: Use the side plate and screws to 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

169. 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. Mal-united slip

170. Slipped Capital Femoral Epiphysis Two basic types: Closing wedge (Cuneiform) osteotomy of neck: Neck The technique of Fish Technique of Dunn just distal to slip Basilar Base of neck technique by Kramer et al Technique of Abraham et al Usually associated with serious complications of AVN and chondrolysis , therefore these osteotomies are not recommended.

171. Slipped Capital Femoral Epiphysis Compensatory osteotomies through the Trochanteric region: Ball and socket (Campbell) osteotomy Biplane intertrochanteric osteotomy (Southwick) These osteotomies produce a deformity in the opposite direction.

172. Slipped Capital Femoral Epiphysis CUNEIFORM OSTEOTOMY OF FEMORAL NECK (FISH): In moderate to severe slips of more than 30°. Technique : Capsule is incised & femoral neck is exposed. Locate the physis . Determine the size of wedge to be removed by noting the degree of slip.

173. Slipped Capital Femoral Epiphysis CUNEIFORM OSTEOTOMY OF FEMORAL NECK (FISH): Adjacent to the epiphyseal plate, a wedge shaped piece of bone is removed with its base directed anteriorly and superiorly with apex postero -inferiorly . Take care that osteotome does not penetrate the intact posterior periosteum, damaging retinacular vessels.

174. Slipped Capital Femoral Epiphysis CUNEIFORM OSTEOTOMY OF FEMORAL NECK (FISH): Reduce the epiphysis by flexion, abduction and internal rotation of limb, taking care not 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.

175. Slipped Capital Femoral Epiphysis CUNEIFORM 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. Antero-superior wedge of the most superior part of the femoral neck is removed

176. Slipped Capital Femoral Epiphysis CUNEIFORM OSTEOTOMY OF FEMORAL NECK (DUNN): Technique: Lateral approach Greater trochanter is detached (A). Synovium is elevated from anterior and postero -lateral surface of femoral neck with periosteum elevator (B).

177. Slipped Capital Femoral Epiphysis CUNEIFORM OSTEOTOMY OF FEMORAL NECK (DUNN): Technique: Head is freed of all fibrocartilage and callus . (C) Osteotomy line on upper end of femoral neck is made for excision of trapezoid segment. ( antero -superior wedge) (D)

178. Slipped Capital Femoral Epiphysis CUNEIFORM OSTEOTOMY OF FEMORAL NECK (DUNN): Technique: Head of femur is replaced on femoral neck and three threaded Steinmann pins are used for fixation of shaft, head, and neck of femur. (E) Two cancellous screws are used to fix greater trochanter in normal position . (F)

179. Slipped Capital Femoral Epiphysis OSTEOTOMIES AT BASE OF NECK – KRAMER, BARMADA Intra-capsular 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

180. Slipped Capital Femoral Epiphysis INTERTROCHANTERIC OSTEOTOMY - SOUTHWICK Biplane osteotomy Anterolaterally based wedge At the level of lesser trochanter Indications: F or 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

181. Osteotomy to Correct Unstable Intertrochanteric Fractures DIMON AND HUGHSTON: Medial displacement osteotomy to stabilise unstable 4-part IT fracture In 4-part IT fracture 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.

182. Osteotomy to Correct Unstable Intertrochanteric Fractures DIMON AND HUGHSTON: Technique : If GT remains attached to femur, a transverse osteotomy needs to be made at a level 2 cm 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

183. Osteotomy to Correct Unstable Intertrochanteric Fractures DIMON AND HUGHSTON: Technique : 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 – 135 deg short barrel Release traction and apply the compression screw Reattach the GT fragment with wires

184. Osteotomy to Correct Unstable Intertrochanteric Fractures SARMIENTO OSTEOTOMY Involves creating an oblique osteotomy of the distal fragment (valgus osteotomy) Changes fracture plane from vertical to near horizontal Creates contact b/w medial and posterior cortex of proximal and distal fragments Goal- to obtain medial stability Advantage- valgus realignment of proximal fragment makes up for less of length at osteotomy site so that limb lengths are equal

185. Osteotomy to Correct Unstable Intertrochanteric Fractures SARMIENTO OSTEOTOMY 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 fracture Guide wire and then implant are inserted at 90° to plane of fracture of proximal fragment With more vertical alignment of fracture, insert guide pin so that it ends up more inferiorly in the femoral head (other wise, the osteotomy will be placed in varus )

186. Osteotomy to Correct Unstable Intertrochanteric Fractures SARMIENTO OSTEOTOMY Technique : Insert 135 deg sliding screw in usual manner Fracture is reduced and impacted Medial cortex opposition and hence stability are restored