2. Then Why am I delivering this lecture ?
-Write an answer in the DNB/MS exam
- Get a VERY BASIC understanding….
- Stimulate further reading if you care

3. I HAVE
NO EXPERIENCE
WITH
HIP OSTETOMIES

4.  Campbells 10 edition
 Tachdigian :Peadiatric Orthopaedics
 Mc nicoll :Hip Osteotomies
 Roger Dee: Prinicples & PracticeOrthopaedics
 AAOS: ICL
 Tronzo : Hip Surgery
 OCNA : Pediatric Hip Disorders

5. Hip with hope Vs Hip with out hope?

6. Hip with hope ?

7.  Biomechanics
 Asessment
 General Overview
 Specific aetiology
 FAI

8.  Hip designed to- support BW
- permit mobility
 Max ROM 140 flex/ext, 75 add/abd
 Functional ROM 50-60 flex/ext
 1.8-4.3 x BW through hip
 Highest ascending stairs

9.  One legged stance 5/6 BW
on femoral head
 Ratio of lever arms to BW
3:1

10.  Cane in Contralateral
hand decreases JRF
 Long moment arm
makes iteffective
 15% BW to cane
reduces joint contact
forces by 50%

11.  Dynamic analysis much more complex
 Forces across hip joint combination of:
◦ Body weight
◦ Ground reaction forces
◦ Abductor muscle forces

12. Improving
abductor
function will
decrease joint
reactive
forces

13.  Physical exam to ensure ROM
 Plain films
◦ Standing AP
◦ Frog leg lateral
◦ False profile (anterior lip cover.)
◦ Full abduction/adduction
 CT scan +/- 3D reconstruction

16. True lateral view made with the patient
standing,the pelvis turned 25 degrees
toward the beam the ipsilateral foot and knee &
the radiographic film perpendicular
to the beam

18.  Osteotomies improve hip function
◦ Increasing contact area / congruency
◦ Improve coverage of head
◦ Moving normal articular cartilage into weight bearing
zone
◦ Restore biomechanical advantage / Decreasing joint
reactive forces
◦ ?? Stimulating cartilage repair

19.  Ostoeotomy can be viewed as either
◦ Reconstructive
◦ Salvage
 Femoral osteotomy to correct proximal femoral
abnormalities and vice versa

20.  Femoral
Varus,Valgus,Derotation,Ext,Flex
Neck, Intertrochanteric,Sub troch
 Pelvic
Re orientation
Salvage
 Combined

22. Goal of reconstructive osteotomy, femoral or pelvic are
-Restore as nearly normal anatomy as possible
-Return joint pressures and loading patterns to normal
primary problem is malalignment
Goal of salvage osteotomies are
-Relieve pain and improve function enough to delay the THR
in active patients <50

23.  Neuropathic arthropathy
 Inflammatory arthropathy
 Active infections
 Severe osteopenia
 Advanced arthritis/ankylosis
 Advanced age
 *smoking, obesity

25.  Intact lateral portion
of femoral head is
prerequisite
 Can be combined with
either flexion or
extension component

27.  Indications: hip joint instability b/c femoral
deformity which corrects with internal
rotation & abduction view
 Pelvic osteotomy should be performed in pts
with CEA < 15 degrees
 Useful some DDH, SCFE, LCP, AVN and
femoral neck non-union/malunion

28.  Potential to shorten limb
 Weaken abductors
 Trendelenburg gait
 Potential difficulty with stem insertion in
future arthroplasty

29.  Coxa vara
 Performed if
adduction film
reveals concentric
reduction

31.  Moves non-inervated
inferior cervical
osteophytes into contact
with floor of acetabulum
 Lateral traction on
superior capsule may
stimulatefibrocartilage
transformation

33.  Reconstructive
◦ Salter 18m – 6y
◦ Pemberton 18m – 10y
◦ Steel skeletal maturity
◦ PAO (Ganz) skeletal maturity
 Salvage
◦ Chiari skeletal maturity

36.  Single Innominate osteotomy
 Acetabulum together with ilium and pubis
rotated
 Held by wedge of bone
 Illiopsoas & adductor tenotomies common
 18 mon to 6 years

37.  Pericapsular osteotomy for residual dysplasia
 Hinges through the triradiate cartilage – must be
open!!
 Changes the volume & orientation of acetabulum
 Although good results up to 10 most recommend 6
to 8 years

38.  Indication : DDH in
older child
 Need good ROM
 Secure with bone
graft & AO screw
fixation

39.  Contraindications
◦ Limited ROM
◦ Incongrous reduction
◦ Significant joint space
narrowing / degenerative
arthritis
 Two incision approach

40.  Devised by Ganz
 Indication –
DDH in adolescents
& adults
 Achieves
containment &
congruency

42.  Permits extensive reorientation
 Preserves blood supply
 Posterior column remains intact – true pelvis
unchanged
 Single incision
 Preferred reconstructive osteotomy for
acetabular dysplasia

45.  Devised by Chiari 1950’s
 Salvage procedure
 Relief of pain in incongrous hip
 Increases coverage by medializing hip centre
 Fibrocartilage transformation of superior
capsule

47.  Chiari reported 200 procedures
◦ 2/3 good to excellent outcome
◦ 1/3 improved
 Similar results by others
 While pain relief is predictable,
trendelenburg gait remains
 Trochanteric advancement may alleviate
trendelenburg gait

48. •Hip Dysplasia
•Legg-Calve-Perthes Disease
•Slipped Capital Femoral Epiphysis
•Post septic sequeale
•TB Hip
•Epi/met dysplasias

49.  Prevalence of OA by age 50
◦ DDH 40-50%
◦ LCP 50%
◦ SCFE 20%
 Despite many recent advances arthroplasty has
many limitations in younger patients

52.  Femoral:
Varus+/- Shortening +/- Derotation
 Pelvic
Salters & Modifications
Pemberton
Steels
 Combined

53. Persistent dysplasia can be corrected by
Redirectional proximal femoral osteotomy in
very young children.
If the primary dysplasia is acetabular, pelvic
redirectional osteotomy alone is more
appropriate.
Many older children require femoral and pelvic
osteotomies.

54. Pre req for Pelvic osteotomy
• Femoral head has been concentrically seated in the
dysplastic acetabulum
• the joint has failed to develop satisfactorily,
• growth potential of the acetabulum no longer exists
If primary acetabular dysplasia then Pelvic osteotomy
Age : 4 – 8 : Femoral , if persistent dysplasia then Pelvic added
>8 yrs : pelvic + Femoral shortening
Important to correct soft-tissue anomaly and bony deformity to
prevent redislocation

55. DDH
Zadeh et al. 82 children (95 hips)
1.
Hip stable in neutral position—no
osteotomy
2.
Hip stable in flexion and abduction—innominate
osteotomy
3.
Hip stable in internal rotation and abduction—proximal femoral
derotational varus osteotomy
4.
“Double-diameter” acetabulum with anterolateral deficiency—
Pemberton-type osteotomy

60. Non Union Neck Femur

61. Pauwels Valgus with Fixation
+/- Fibula/Vas Fibula/TFL MPG( Bakhis )/Quad Fem ( Meyers)
Salvage: Mc Murrays
Arm Chair effect
Not aiming at fracture union
Biological effects
Mechanical effects
Schanz : PSO

64. Schanz

69.  Pelvic osteo: Chiari , Salter
 Proximal femur: Schanz
PSO: Dec lurch
Inc Legth
 Trochanteric Arthroplasty
Colonas
El episcopos/Harmons
 Corrective osteotomy

70.  Stage 1
Greater trochanter is placed into the acetabulum
Hip abductors are moved distally on the femur
 Stage 2
A proximal femoral osteotomy 1 month later,
+/- acetabuloplasty
Ideal in children younger than 10 years

74.  Femoral : Shortening +/- VDRO
 Pelvic : Roomy acetabulum: Pembertons

75. Open
 Femoral: VERO
Closed
 Pelvic: Salters innominate

76.  Valgus + Extension
Works if healthy bone can be reoriented
under wt bearing zone
 Sugiokas : Transtrochanteric reorientation

77. Sugioka Osteotomy

79.  Indications
 Types
Location: Sub capital: Fish & Dunn
Base of neck( IA) : Kramer
Extra articular base: Abrams
Intertrochateric : Southwick: ValIn Rot Flex O
 Complications
AVN
Chondrolysis

83.  Femoral: Valgus,Varus,=/- Ext , flex
 Pelvic
Ganz
Salters

84. Mullers principles:
Advanced OA < 50 degrees of motion in flexion Not a good candidate for
intertrochanteric osteotomy.
RA : Poor prog
Intertrochanteric osteotomy in AVN effective only if healthy bone can be
brought into the weight bearing area.
Extensive involvement and collapse of the femoral head are
contraindications.
Osteotomy should increase and not decrease the weight bearing area of
the femoral head.
Fixed adduction deformity is CI to varus osteotomy and fixed abduction
deformity to valgus osteotomy.
Stable internal fixation is important, permits early motion, and enhances
union of the osteotomy.
Recurrence of hip pain from arthritis may be simulated by bursitis over a
protruding internal fixation device.

85. If it fits better with the hip in abduction, an adduction (varus) osteotomy
is appropriate.
If the head fits better in the acetabulum with the hip in adduction, an
abduction (valgus) osteotomy is appropriate.
Early secondary arthritis of the hip -primary acetabular dysplasia
Small center-edge angle leaves the lateral aspect of the articular surface
of the femoral head uncovered
This results in high stresses at the weight bearing portion of the articular
surfaces of the hip, leading to early degenerative changes

86. Varus osteotomy alone is indicated in
-spherical femoral head,
-little or no acetabular dysplasia (a center-edge angle of at least 15 to 20 )
-signs of lateral overloading
-valgus neck-shaft angle of more than 135 degrees
-Medial displacement of the shaft by 10 – 15mm
Centre the knee
Relax the abduc, adduc , flex
Increase the wt bearing area
-Causes shortening
-Trenedelenberg gait

87. Advantages of periacetabular osteotomy :
(1) Only one approach is used
(2) large amount of correction can be obtained in all directions
(3) blood supply to the acetabulum is preserved
(4) posterior column of the hemipelvis remains mechanically intact,
immediate crutch walking with minimal internal fixation
(5) the shape of the true pelvis is unaltered-normal delivery
(6) it can be combined with trochanteric osteotomy if needed

88. Shelf Osteotomies Vs Chiari Osteotomy in
Acetabular dysplasia
Shelf osteotomy : Moderate dysplasia without severe arthrosis,
Chiari osteotomy :Severe dysplasias, with or without arthrosis.

90.  Excellent results with Middle path regimen
? Thomas test of recovery
 Pelvic suppport osteotomy(PSO)
-Shanz
 Milch Bachelor Osteotomy:
PSO+Girdlestone

91. Girdlestone Arthroplasty

94. •Coxa profunda – floor of
fossa acetabuli overlaps
ilioischial line medially
•Pincer type FAI
•Creates deep acetabulum
•General overcoverage
•Normal

95. •Protrusio acetabuli – occurs when
the femoral head overlaps the
ilioischial line medially
•Pincer type FAI
•Creates deep acetabulum
•General overcoverage
•Normal

96. •Lateral center edge angle – pincer type FAI
•Normal is between 25 and 39 degrees
•Increases with deeper acetabulum and more overcoverage
Protrusio
acetabuli

97. •Acetabular retroversion – pincer type FAI
•Cross over sign
•Focal acetabular overcoverage
•Cranial anterior wall line projects laterally
•Anterior/anterolateral labrum is obstacle to flexion and internal rotation
•Distinguish from deficient posterior wall

98. •Posterior wall sign – pincer type FAI
•PW line should descend through center of femoral head
•Medial – deficient
•Lateral – prominent

99. •Pistol grip deformity - Cam type FAI
•Loss of normal concavity
•Etiology
•Growth abnormality of the capital femoral epiphysis
•SCFE
•LCPD
•Fracture healing

100. •Horizontal growth plate sign - Cam type FAI

101. •Some predisposing factors to FAI
•Legg-Calve-Perthes disease
•Congenital hip dysplasia
•Slipped capital femoral ephiphysis
•Avascular necrosis
•Malunited fractures
•Acetabular protrusion
•Elliptical femoral head
•Retroverted acetabulum
•Prominent femoral head-neck junction
•Proposed etiologies
•Abnormal anatomy
•Prominent femoral head neck junction
•Acetabular overcoverage

102. •Middle to older aged women (40)
•Seen in ballet dancers
•Close approximation of acetabular rim and femoral neck –
acetabular abnormality
•Acetabular overcoverage
•Focal articular damage
•Acetabular damage can propagate
•Primary radiographic signs
•Coxa profunda
•Protrusio acetabuli
•Acetabular retroversion
•Decreased extrusion index
•Neutral acetabular index
•Posterior wall sign
•Posterior inferior cartilage abrasion due to contracoup injury

103. •Young males (32 years)
•Primary femoral abnormality
•Aspherical femoral head
•Femoral head jams into acetabular rim
•Shear forces on labrum and cartilage
•Diffuse articular damage
•Primary radiographic signs
•Pistol grip deformity
•CCD angle less than 125 degrees
•Horizontal growth plate sign
•Alpha angle greater than 50 degrees
•Femoral head-neck offset less than 8 mm
•Femoral retrotorsion