osteotomies around hip

Osteotomies around Hip jointOsteotomies around Hip joint
Dr Gaurav Singh
Central Institute Of Orthopaedics
VMMC & SJH

DEFINITION
 An osteotomy is a 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.

BIO MECHANICS
Forces across hip joint
 BW
 Ground rection forces
 Abductor muscle forces  Improving abductor function will
decrease joint reaction forces

Why does Osteotomy work?
 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

Contraindications to
Osteotomy
 Neuropathic arthropathy
 Inflammatory arthropathy
 Active infections
 Severe osteopenia
 Advanced arthritis/ankylosis
 Advanced age
 *smoking, obesity

OSTEOTOMY AROUND HIP CLASSIFICATION
 According to Anatomic Location
 Femoral Osteotomy.
 Subtrochanteric Osteotomy.
 Greater Trochanteric.
 High Cervical
 Intertrochanteric Osteotomy
 Pelvic Osteotomy.
 Salvage Osteotomies : eg. Chiari, Shelf.
 Reconstructive Osteotomies : eg. Periacetabular, Single,
Double, Triple Innominate.

Contd.
 Based on Indications
 To obtain stability
 old unreduced dislocations.
 Lorenz bifurcation osteotomy.
 Schanz low subtrochanteric.
 To obtain union
 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

 Relief of pain
 osteoarathritis.
 Pauwel’s type I varus osteotomy.
 Pauwel’s type II valgus osteotomy.
 To Correct deformities
 coxa vara
 slipped upper femoral epiphysis
 Intracapsular cuneiform osteotomy by dunn.
 Compensatory Basilar Osteotomy of Femoral Neck.
 Extracapsular Base-of-Neck osteotomy.
 Ball-and-Socket Trochanteric Osteotomy.
 Pauwel’s osteotomy (Y).
Contd.Contd.

 In Osteonecrosis of femoral head
 Sugioka’s transtrochanteric osteotomy.
 Varus derotation osteotomy of Axer.
- In paralytic disorders of hip.
 Varus Osteotomy.
 Rotational Osteotomy
 In congenital dislocation.
Contd.Contd.

SALTER OSTEOTOMY
 INDI-Congruous hip reduction,<10-15 degrees correction of
acetabular index required ,paralytic disorder,subluxation after septic
arthritis
 PREREQUISITES- femoral head must be positioned opposite the
level of acetabulum, contracture of iliopsoas and adductor
muscles must be released, range of motion of the hip must be
good specially in abduction , int. rotation flexion
 PROC.- Single Innominate osteotomy
Acetabulum together with ilium and pubis rotated
Held by wedge of bone
 AGE-18 months-6years
 AFTERCARE-hip spica for 8 to 12 week,then partial weight bearing
on crutches ,followed by full weight bearing.result assesed by center
edge angle.

 INDICATION- >10-15 degrees correction of acetabular index
required ,small femoral head ,large acetabulum.
 ADV- internal fixation not required .greater degree of rotation can
be achieved with less rotation of acetabulum
 DISADV- Technically more difficult . Alters the configuration and
capacity of acetabulum and produce joint incongruity that requires
remodeling
 AGE-18months- 10 yr
 AFTERCARE-spica cast for 8 to 12 weeks
PEMBERTON PERICAPSULAR OSTEOTOMYPEMBERTON PERICAPSULAR OSTEOTOMY

PEMBERTON OSTEOTOMY
 PROCEDURE- Pemberton described a pericapsular osteotomy
of the ilium in which the 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.

STEEL OSTEOTOMY
 INDI-Adolescents and skeletally mature adults with residual
dysplasia and subluxation in whom remodelling of acetabulum is
no longer anticipated
 ADV-Better coverage of femoral head by articular cartilage ,
Better hip joint stability, no need of spica cast.
 DIS- Technically difficuilt, does not change size of acetabulum,
distort the hip such that natural child birth may be impossible in
adulthood
 PROC-The ischium, the sup pubic ramus and ilium superior to
the acetabulum is reposition and stabilized by bone graft

TRIPLE INNOMINATE OSTEOTOMY (STEEL)

GANZ OSTEOTOMY: (BERNESE)
PRIACETUBULAR OSTEOTOMY.
 This Triplaner osteotomy is 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.

 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.
Contd.Contd.

SHELF OPERATION (STAHELI)
 Have commonly been performed to enlarge the volume of the
acetabulum.
 The objective is to create a shelf, the size of which is decided by
measuring the “width of augmentation” form the CE angle. The
shelf is put just above the acetabular margin. It secure two layers
of cancellous grafts bringing the reflected head of rectus femoris
forward over the graft and suturing it in its original position.
 Best to do after 5 years of age.
 Indication : A deficient acetabulum that cannot be corrected by
redirectional, osteotomy is the primary indication.
 Contraindication :
 Dysplastic hip with spherical congruity suitable for
redirectional osteotomy
 Hip requiring open reduction.

CENTER EDGE
ANGLE/ACETABULAR INDEX
 CE ANGLE-measured after 5 yr age, >25 normal,
<20 severe dysplasia
 AC IND- <27.5 normal, >30 dysplasia

CHIARI OSTEOTOMY
 PROC-It is performed at the superior margin of the
acetabulum and the pelvis inferior to the osteotomy
along with the femur is displaced medially.
This is also called as capsular interposition Arthroplasty
as the capsule is interposed between the shelf and the
femoral head.
 INDI-incongruous joint, dysplastic hip with osteoarthritis ,
other osteotomy not possible
 DISADV-salvage osteotomy only, leaves anterior
acetabulum uncovered,abductor lurch common .

OSTEOTOMY
 Primary objective is deflection of wt. bearing by
angulation of femur to bring the axis of the
femoral shaft more in line with the direction of
weight transmission.
 The osteotomy performed are Angulation
Osteotomy (Stabilizing osteotomy).
 Schanz osteotomy.
 Lorenz osteotomy.

SCHANZ OSTEOTOMY (LOW S/T OSTEOTOMY)
(a)(a)Femur is sectioned transversely a lower border of pelvis.Femur is sectioned transversely a lower border of pelvis.
(b)(b)Upper end is angled inward until it rest against side wall of pelvis.Upper end is angled inward until it rest against side wall of pelvis.

 Schanz osteotomy (Low S/T Osteotomy) :
 In this osteotomy the deformity flexion, adduction &
external Rotation is corrected by making the osteotomy at
tuber ischii level.
 Preparation :
 X-ray are taken with full adduction – to measure
angle medially.
 Thomas Test - measure degree of flexion to be
corrected.
 Advantages :
 Lurching gait will be diminished.
 The depression of the trochanter also improves the
leverage of the glutei.
Contd.Contd.

 Contraindication : Before 15 years of age, because loss
of angulation during growth period.
 Lorenz (Bifurcation osteotomy)
 In this upper end of the lower fragment is abducted and
inserted in to the acetabulum after making on
intertrochanteric osteotomy “plane of osteotomy” below &
outward to above & inward.
 Disadvantage :
 Increased shortening.
 Less mobility and arthritic pain.
Contd.Contd.

LORENZ (BIFURCATION OSTEOTOMY)
(A) Plane of
osteotomy – Distal
end at posterolateral
aspect towards
proximal end at
anteromedial aspect.
(B) Limb is Abducted(B) Limb is Abducted
and extended so proximaland extended so proximal
end of distal fragmentend of distal fragment
directed medially anddirected medially and
anteriorly in acetabulum.anteriorly in acetabulum.

OSTEOTOMY FOR COXA VERA
 The normal femoral neck shaft angle in infant is 1200
to 1400
,
Reduction to a more acute angle constitute a coxa vara
deformity.
 The goal of treatment are
 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 - epiphy seal angle of more than 60° .

 Surgery performed are
 Valgus Subtrochanteric Osteotomy or abduction
osteotomy-with Internal Fixation.
 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.Contd.

 Alternative Method : Pauwels Y shaped osteotomy :
 Static forces are converted from shearing to
impacting forces
 Prerequisites :
 Viable femoral head.
 Young vigorous patient.
 Advantage :
 Union is rapid.
 Recurrence is less likely.
Contd.Contd.

OSTEOTOMY FOR RELIEF OF PAIN IN
OSTEOARTHRITIS
 Before the onset of osteoarthritis, if normal or near normal
function of the hip can be maintained, reconstructive
osteotomy can prevent or delay the development of
osteoarthritis; if mild or moderate osteoarthritis is present, a
salvage osteotomy can improve function and delay the need
for total hip Arthroplasty.

VARUS/VALGUS/DEROTATION FEMORAL
OSTEOTOMIES ARE -

varus osteotomy
 Designed to elevate the greater trochanter and move it
laterally while moving the abductor and psoas muscles
medially, to restore joint congruity and decrease muscle forces
about the hip.
 Varus osteotomy alone is indicated for patients with a
spherical femoral head, little or no acetabular dysplasia
center-edge angle of at least 15 to 20 degrees), signs lateral
overloading, and a valgus neck-shaft angle of more than 135
degrees.
 Varus osteotomy with medial displacement of the femoral
shaft relaxes the abductor, psoas, and adductor
musclesunloads the hip joint, and increases the weight-
bearing surface.
Contd.Contd.

 Most authors recommend medial displacement of 10 to
15 mm to keep the ipsilateral knee centered under the
femoral head and to maintain the mechanical axis of the
leg.
 Varus osteotomy, however, shortens the limb to some
degree. creates a Trendelenburg gait that may persist for
months after surgery, and increases the prominence of
the greater trochanter.
 Limb shortening can be minimized by making a smaller
medial osteotomy and transposing it to the lateral side.
Contd.Contd.

VALGUS INTERTROCHANTERIC FEMORAL
OSTEOTOMIES
 Valgus Osteotomy - Increase weight bearing area of femur
head.
 It does not produce muscle relaxation.
 Relaxation obtained by tenotomy of Iliopsos and adductor
muscle.
 Transfer the center of hip rotation medially from the superior
aspect of the acetabulum to increase joint congruity and the
weight-bearing area of the femoral head.
 Osteotomy of the greater trochanter often is performed with
valgus femoral osteotomy to move the greater trochanter
laterally.

 Best result were obtained in patients younger than 40 years of
age with unilateral involvement, good preoperative range of
motion, and a mechanical (secondary) cause.
 Unsatisfactory results occurred in patients with limited
preoperative flexion, they cited preoperative flexion of less than
60 degrees as a relative contraindication to valgus osteotomy.
 Most surgeons now advise that all osteotomies be fixed with rigid
internal fixation, which offers several obvious advantages:
 The fragments are maintained in proper position;
 The danger of limitation of motion of the hip and knee is
greatly decreased;
Contd.Contd.

 The patient can be allowed out of bed early; and
 Pulmonary, urological, and other medical complications
are decreased. A device frequently used for rigid internal
fixation of intertrochanteric osteotomies is the ASIF, or
right-angled, blade plate. Our experience with this device
has been quite favorable.
 Nonunion has been a troublesome complication after
Osteotomy, and an incidence as high as 20% has been
reported.
Contd.Contd.

OSTEOTOMY TO CORRECT UNSTABLE
INTERTROCHANTERIC FRACTURES
 Sarmiento Technique

OSTEOTOMY TO CORRECT UNSTABLE
INTERTROCHANTERIC FRACTURES
 Dimon and Hughston :
 Described technique of Trochanteric osteotomy with
valgus nailing and medial displacement to improve
stability there techniques are occasionally useful in
some extremely comminuted fractures.
 Recent studies have indicated that anatomical reduction
allow greater load shearing by bone than medial
displacement osteotomy.

DIMON AND HUGHSTON METHOD OF
INTERTROCHANTERIC OSTEOTOMY

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
 Is a disorder in which there is a displacement of the capital
femoral epiphysis form the metaphysis through the physeal
plate.
 By this head is placed in posterior & downward position in
acetabulum.
 The goal of treatment is
 To prevent further displacement and
 To promote closure of physeal plate.

 The use of realignment procedure such as lntertrochameric,
Subtrochanteric Osteotomy & osteotomies the around neck is
in those situation in which restricted range of motion impairs
function after plate physeal closure.
 Principle of Osteotomy
 There are basically three type of Deformity present in SCFE.
These are-
 Varus
 Hyper extension
 Moderate Severe external rotation
Contd.Contd.

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
 The osteotomy to correct theseThe osteotomy to correct these
deformities work at two sites.deformities work at two sites.
 Through the femoral neckThrough the femoral neck
(closing wedge osteotomy)(closing wedge osteotomy)
 Through the trochantericThrough the trochanteric
area.area.

EXTRACAPSULAR BASE OF NECK
OSTEOTOMY
 types of femoral neck osteotomy are -
 The technique of Dunn - for severe chronic slip with open
physis.
 Base of the neck osteotomy - Compensatory Basilar
most of femoral neck. (Kramer) - correct the varus and
retroversion component of moderate to severe chronic
SCFE.
 It is safer than cuniform osteotomy of neck.
 Further slipping is prevented.
 Intertrochantric osteotomies

CORRECTIVE OSTOTOMIES
 By these osteotomies one can correct angulation, rotation,
flexion, extension Deformity of bones to restore motion for
patient with stiff hip.
 Like
 Deformities in septic arthritis
 Malunion of I/T femurs
 Neuromuscular disorder
 Cerebral palsy
 Poliomyelitis

 There are three types of corrective osteotomies
 Close wedge - transverse closing wedge provide good
bony apposition and is stable, however, it shortens the
extremity.
 Open wedge - simple and lengthens the extremity
however. bony apposition is limited, union is delayed in
adults and it is initially unstable.
 Ball and Socket type - achieves stability without
shortening the extremity; however, extensive dissection is
required, and in severe biplame deformities an accurate
and stable osteotomy is difficult to perform.
 In Ball & socket type of osteotomy concave surface in created in
the proximal fragment of convex surface at the distal fragment,
at intertrochantaric level & fixed in place by plate.
Contd.Contd.

CORRECTIVE OSTOTOMIES
Brackett ball and socket
Osteotomy
Whitman closing wedge
Osteotomy
Gant-opening wedge
Osteotomy

FRACTURE NECK FEMUR
 In those case which present late (1-5 wks.), are difficult case to
treat because
 Close reduction is not possible.
 Open reduction is associated AVN
 In young Pt. with viable femoral head & nonunion options are-
 Mcmurray & Pauwel’s ‘y’ osteotomy
 Angulation Osteotomy (Schanz)
 Dickson geometric osteotomy
 In old Pt.-
 Girdle stone osteotomy
 Mcmurray Displacement

MC-MURRAY’S OSTEOTOMY
 The oblique osteotomy extends from the lateral aspect of
the shaft at a level just below the lower border of the lesser
trochanter and lower border of neck.Then the limb is
rotated inward and outward to remove any bony spike
 Fixation of osteotomy - By Compression nail
plate./Castle Plate.
 Disadvantages:
 Instability - Degenerative changes in normal head
 Shortening - AVN when neck have been fractured
 Medial displacement of shaft compromise the
insertion of femoral stem of total hip.
 Advantage -Changes line of fracture to horizontal,callus
may incarporate fracture

DICKSON HIGH GEOMETRIC OSTEOTOMY
 Principle - the line of vertical 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

GIRDLE STONE OSTEOTOMY
 In this head & neck of femur are excised at Inter trochanteric
level to create pseudo arthrosis in order to improve stability.
Angulations Osteotomy is added.
 Indication
 T.B. Hip
 Pyogenic Hip
 Non union #.neck femur [in elderly pt.]
 AVN of femoral head.
 Advantages :-
 Painless mobile hip joint.

 OSTEOTOMIES –
 These procedure have achieved best result for small and
medium sized lesion. 1<30% femoral head involvement in
young pt.
 Intertrochanteric varus/valgus - osteotomies
 Transtrochantric ant. Rotational osteotomy (Sugioka) -
Technically Demanding procedures.
 PRINCIPLE:
 All osteotomies are designed to transfer the weight
bearing forces form the necrotic area to the cartilage on
the sound part of the femoral head to allow healing of
necrotic area by hyper vascularisation of upper part of
femur.
AVNAVN

TRANSTROCHANTRIC ANT. ROTATIONAL
OSTEOTOMY [SUGIOKA]

TECHNIQUE FOR ROTATION
 Femoral head is rotated anteriorly (450
- 900
) by handling
proximal pin.

OSTEOTOMY IN PERTHE'S DISEASE
 Salvage :
 Varus Derotational Osteotomy
 Innominate Osteotomy.
 Combined Procedure -
 MRI / Arthrogram before surgery is mandatory.
 Varus/derotation osteotomy of this embodies the principle
of “containment” of the diseased femoral head in the
treatment of Legg - Calve-Perthes disease.
 Guide pin inserted compression screw is placed over
guide wire.

 Appropriate angled osteotomy is made.
 Wedge is removed.
 Make osteotomy as proximal as possible just below lag
screw for -
 Better Healing
 Better correction of deformity.
 Reduce the osteotomy and fixed with plate and
compression screw.
Contd.Contd.

SUBTROCHANTERIC DEROTATION AND
VARUS OSTEOTOMY
 The aim of surgery is to center the whole "plastic" epiphysis
inside the joint cavity, keeping it well covered by the roof of the
acetabulum and allowing the child to walk so that the
redistributed intra-articular pressures will contribute the molding
of a more normal joint.
 A small 4-hole plate is bent to the desired angle, and a
subtrochanteric osteotomy is done followed by derotation and
yarns angulation of the shaft. A double hip spica is applied and
the removed 2 months later. When the osteotomy site is united,
the child is encouraged to walk, at first in warm water pool, then
with walking aids and finally without support.

 The operation is best suited for early stage of Leg-Calve-
Perthes’ disease, preferably those under the age of 7 years.
 Axer : Described lateral open wedge osteotomy for children <
5 years with perthes disease. Defect laterally fills rapidly in
young children > 5 years of age delayed or non union may
occur.
Contd.Contd.

RECONSTRUCTIVE SURGERY
 Valgus subtrochanteric osteotomy - for Hing
Abduction
 Shelf Augmentation – Coxa Megna.
 Chilectomy - Malformed head in late III Group.
 Chiar's Pelvic Osteotomy - Large Malformed
Femoral Head with Subluxation laterally.

BIBLIOGRAPHY
 Apley's System of Orthopaedics and Fractures - Loui's Soloman
8th Edition.
 Campbell's Operative Orthopaedics - 11th Edition. Vol.-2.
 Text Book of Orthopaedics - John Ebnezar - IInd Edition.
 Orthopaedic Knowledge Update – 7.
 Samuel L Turek Orthopaedics principles & their applications
volume

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