OSTEOTOMIES AROUND THE HIP

IN DDH

Dr Wasim R. Issa
Orthopedic Resident
EGH
 OVERVIEW OF MANAGEMENT OF DDH

Neonate 1-6 months 6-18 months 18-24 months > 2 yrs

OPEN
REDUCTION
OPEN +/-
Close reduction REDUCTION ACETABULAR
Or +/- PROCEDURE
Open reduction ACETABULAR +/-
PROCEDURE FEMORAL
PROCEDURE
WHY IS OSTEOTOMY REQUIRED IN ADDITION TO
OPEN REDUCTION ?

 Unstable reduction

 Improper orientation of the femoral head and acetabulum

 Lack of congruency of the hip joint

 Excessively tight reduction

OBJECTIVES OF AN OSTEOTOMY IN DDH

Improve coverage of head and achieve containment

Redistribute joint forces

Improve motion and relieve pain

TYPES OF PELVIC OSTEOTOMIES
CONCENTRIC HIP REDUCTION POSSIBLE

ACETABULAR REDIRECTIONAL OSTEOTOMIES

Salter, Steel, Sutherland, Ganz , Tonnis , Spherical Osteotomies (Wagner,
Eppright)

ACETABULAR RESHAPING OSTEOTOMIES (VOLUME REDUCING)

Pemberton, Dega

CONCENTRIC HIP REDUCTION NOT POSSIBLE

SALVAGE OSTEOTOMIES

Chiari, Shelf procedures

 SALTER’S INNOMINATE OSTEOTOMY

• Age group: 18 m to 6 yrs

Inferior portion of pelvis tilted antero-inferiorly

Anterior Inferior Iliac Spine to Greater Sciatic notch

HINGE : Pubic Symphysis

(Hence suboptimum in bilateral dysplasia)

Joint Stress redistributed but joint Pressure

increased (head pushed downwards)
• ADVANTAGES:
No effect on acetabular capacity
Technically less demanding

DISADVANTAGES:
Increases Limb length
Sciatic Nerve injury
Femoral Nerve stretch
Loss of position may occur, especially when the fixation pins are not
appropriately placed.
• The indications for the Salter osteotomy are acetabular dysplasia that
persists after primary treatment and acetabular dysplasia discovered in
an untreated child.

• The failure of the acetabular angle to improve within 2 years after

reduction and persistent dysplasia after the age of 5 years are definite
indications for the procedure.
• Young children with acetabular dysplasia are asymptomatic and function
normally, which makes the decision to perform surgery difficult.

• However, the likelihood of degenerative disease without treatment is

high, and the treatment is effective.

• Thus children who meet the indications should undergo an osteotomy.

• The Salter osteotomy is appropriate for children who are between 2 and
9 years old.

• Children who are younger than 18 months old usually do not have iliac
wings that are thick enough to support the bone graft.
• For children who are older than 9 or 10 years, the surgeon may not be
able to achieve enough movement of the acetabular fragment to cover
the femoral head adequately.
• It has been reported that the acetabular angle will be improved by an
average of 10 degrees with the use of the Salter osteotomy.
• Older children should undergo a complex osteotomy, especially when
the dysplasia is severe .
KALAMCHI’S MODIFICATION OF SALTER’S OSTEOTOMY

Posterior triangular notch is created in the proximal side of

the osteotomy to engage the distal iliac segment

Increases stability and prevents the medial and posterior

displacement.

Limb length discrepancy is eliminated.

• SUTHERLAND OSTEOTOMY (DOUBLE INNOMINATE
OSTEOTOMY)

• Age > 8 yrs

Pubic Osteotomy is made
medial to obturator foramen
Pubic Osteotomy gives better redirection
than Salter’s
Wedge of bone is removed allowing
medialization of acetabulum
 PEMBERTON OSTEOTOMY

Age group : 12 m - 12 yrs

The osteotomy begins anteriorly at the anterior inferior iliac spine and
proceeds posteriorly and inferiorly to enter the triradiate cartilage
posterior to the acetabulum.

Improves anterior & lateral acetabular coverage

Volume reducing -----> large acetabulum and small femoral head
HINGE: Triradiate Cartilage
Osteotomy reaches up to posterior limb of triradiate cartilage & does
not
enter the sciatic notch
held there with a bone graft.
quite stable and does not require fixation
ADVANTAGES:
Osteotomy is incomplete, more stable
Internal fixation is not required
Greater degree of correction can be achieved with less
rotation of the acetabulum.

DISADVANTAGES:
Osteotomy limited by mobility of Triradiate cartilage
May cause early fusion of triradiate cartilage
• PEMBERTON VS SALTER

Salter redirects the acetabulum

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

Advantage: Better Coverage globally

• Age group : 12m – 12 yrs

• Trans-Iliac osteotomy with an intact posteromedial cortex

• Acetabular coverage can be increased anteriorly, centrally or posteriorly depending on the

placement of the bone graft wedges

• Similar to Pemberton but has large posterior hinge

• Decreases acetabular volume

• HINGE: Triradiate Cartilage

• San Diego Modification : Osteotomy advances into the sciatic notch

 STEEL OSTEOTOMY (TRIPLE INNOMINATE OSTEOTOMY)

Age > 8-12 yrs

Salter osteotomy+ pubic rami osteotomy + ischial osteotomy
Allows for free motion & redirection of acetabulum
• to provide anterolateral coverage of the femoral head

Indicated in irreducible subluxations and in failure of other

osteotomies
The amount of rotation is limited by sacropelvic ligaments
Pubic rami approached through a separate groin incision
Complications include the painful nonunion of osteotomy sites and
the excessive external rotation of the acetabulum.
 TONNIS OSTEOTOMY
Modification of STEEL osteotomy, greater correction than STEEL

Long curved ischial cut connects the obturator foramen to sciatic

notch

This prevents the sacrospinous ligament from tethering the fragment

during correction .

Both STEEL & TONNIS osteotomies alter the true pelvis dimensions
and render normal delivery difficult .
GANZ (BERNESE) OSTEOTOMY
Correction without breaking the posterior column.
Intact posterior column Allows minimal internal fixation and early
mobilization
Allows both anterior and lateral rotation as well as medialization
Indicated for residual dysplasias in adolescents and young adults
Good improvement in the CEA
Only a single approach is required
Allows for maximum correction
GANZ (BERNESE) OSTEOTOMY
Osteotomy cuts:
partial (incomplete) osteotomy of the ischium
complete osteotomy of the pubis
biplanar roof shaped osteotomy of the ilium

Does not change the diameter of the true pelvis -birth canal not
affected-advantage in young women

Contraindicated if the triradiate cartilage is still open (interferes with

acetabulum growth)
SPHERICAL ACETABULAR
OSTEOTOMIES
Allows rotational repositioning of the acetabulum
Does not disrupt the pelvic ring and hence stable
3 Spherical osteotomies described
Wagner’s osteotomy
Eppright’s Dial osteotomy
Ninomiya osteotomy
SALVAGE ACETABULAR OSTEOTOMIES

Attempted when concentric reduction of hip is not possible

These procedures do not provide a hyaline cartilage covered
articulation
The capsule under the new acetabulum transforms to fibrocartilage :
SALVAGE
Intra articular or Extra articular
Intra-articular : Chiari Osteotomy
Extra- articular : Shelf procedures, Tectoplasty
Indicated:
Neurological causes of DDH
lateralized severely dysplastic hip
 CHIARI ACETABULAR OSTEOTOMY
Transverse osteotomy of pelvis above the level of the cranial insertion
of the capsule with medial displacement of the acetabular fragment .

In essence, a controlled fracture through the ilium

Head completely covered by acetabular roof

Hip jt. pivot closer to body axis

May cause abductor laxity

SHELF ACETABULAR AUGMENTATION
Extra articular containment procedure
Provides buttress/stabilizing force for the
femoral head
Older children 10-18yrs with severe dysplasia
No capacity of remodeling
Post op traction until bony consolidation.
• Open Reduction With Femoral Shortening

Femoral shortening should be considered when an open reduction has been performed and if excessive pressure is
placed on the femoral head when it is reduced.

• It should also be considered when a dislocated hip is reduced in a child who is older than 2 years.
• One way to assess the tightness of the reduction is to attempt to distract the femoral head away from the
acetabulum after reduction.
• If the reduction is safe, the surgeon should be able to distract the joint a few millimeters without much force.
• We prefer to perform the shortening through a separate lateral incision. A blade plate or a simple lateral plate
fixation may be used with an intertrochanteric or subtrochanteric osteotomy .
• In the past, femoral osteotomies were also used to reduce anteversion and to place the femoral neck into a
varus position. However, we have not found excessive anteversion or valgus of the upper femur to be
common, and therefore we do not usually do either derotation or varus correction.
• A follow-up study by Spence and colleagues showed better acetabular development in patients after
innominate osteotomy as compared with varus derotational osteotomy.

• A reduction of anteversion in combination with innominate osteotomy may result in the posterior dislocation
of the femoral head .
• Open Reduction With Innominate Osteotomy

• An innominate osteotomy may be indicated at the time of an open reduction, especially in children who are
18 months old or older.

• Whichever procedure is used, it is important to place the osteotomy high enough to avoid
injury to the cartilaginous margin of the acetabulum, which is a major growth center for the acetabulum. If
there is undue tension on the reduction, a concomitant femoral shortening should be considered .
• Treatment of the Older Child (2 Years Old and Older)

• The femoral head is usually in a more proximal location in the older child, and the muscles that cross the hip are
more severely contracted.

• Femoral shortening is an essential part of the management of the older child, and, with higher dislocations,
greater shortening is necessary.

• In the past, long periods of skeletal traction were used in this age group, but femoral shortening has produced better
results with less morbidity.

• In addition, the older child is more likely to need a primary acetabular reorienting osteotomy (e.g., a Salter or
Pemberton procedure).

• A potential complication when combining an acetabular procedure with a femoral shortening procedure is the
posterior dislocation of the hip. Dislocation is most likely to occur when the femur is derotated.
• During surgery, however, there is usually little increase in true anteversion. Thus derotation is unnecessary, and it
may predispose the hip to posterior dislocation if it is performed.
Reconstructive Procedures for Dysplasia
Simple Pelvic Osteotomies That Reposition

the Acetabulum

• Most of these pelvic osteotomies can be performed through a bikini incision and an anterior tensor–sartorius
interval approach as described by Salter (Table 16-5).
• This incision results in minimal scarring. Because the traditional Smith-Petersen skin incision leaves a wide
and deep scar and offers no better exposure, the procedure should be abandoned.
Pemberton Osteotomy
Salter Innominate Osteotomy
Dega Osteotomy
Complex Osteotomies That Reposition the Acetabulum

Steel Osteotomy
Tönnis Osteotomy
Ganz Osteotomy

• The Ganz osteotomy, which is also known as the Bernese periacetabular osteotomy, has gained popularity because it allows for
the greater displacement and medialization of the acetabulum while maintaining an intact posterior column42 (Fig. 16-74).
• It is indicated for all degrees of acetabular dysplasia in a hip that can be concentrically reduced, either with standard radiographs
or with fluoroscopy and repositioning.
• The advantages, as noted by Ganz and colleagues,include a single approach, a large degree of correction in all planes, the
maintenance of blood supply to the acetabulum, an intact posterior column, the minimal disruption of the hip abductors, and no
alteration of the pelvic birth outlet (Videos 16-11 and 16-12).79

• The procedure is indicated for symptomatic acetabular dysplasia in the skeletally mature individual.
• The degree of dysplasia should be evaluated on both standing AP radiographs and false-profile views.
• Acetabular anteversion can be estimated with the use of the AP view.182 The femoral head should be able to be concentrically
reduced, although the presence of a false acetabulum is not a contraindication.
• When necessary, a femoral osteotomy (usually varus producing) may be performed to obtain an optimal relationship of the
femoral head with the acetabulum.4
• During the performance of the operation, a single incision is made along the iliac crest, and it can be extended
slightly over the anterior aspect of the thigh. An anterior
superior iliac spine osteotomy is created to allow for the
retraction of the sartorius and the fascia of the tensor fasciae
latae. The direct and indirect heads of the rectus femoris
are dissected sharply, and the iliocapsularis muscle is sharply
dissected off of the anterior and medial capsule.
The first cut is the ischial cut, which is approached
through the iliopsoas–capsule interval; it is made down to
the ischium at the infracotyloid groove. A 50-degree–angled
special osteotome is then used to create this cut, which
begins distal to the acetabulum and which is directed posteriorly, aiming toward the ischial spine ( Fig. 16-75, A). The
cut ends just at the posterior aspect of the acetabulum, and
it will connect with the distal extent of the fourth cut.
These cuts can be nicely visualized during surgery with a
false-profile fluoroscopic image on a radiolucent operating
room table.101,186 The second cut is the superior ramus cut,
which is made after subperiosteal dissection around the
obturator foramen and protection with the Hohmann
retractors of the obturator neurovascular bundle. A sharp
Hohmann retractor is placed medial to the cut to allow for
full visualization of this angled cut, which begins just medial
to the iliopectineal eminence (see Fig. 16-75, B). The third
cut is made just inferior to the anterior superior iliac spine,
and a small lateral window is made via the subperiosteal
resection of the abductors to allow the saw to penetrate the
lateral cortex. The 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 (see Fig. 16-75, C).
The fourth cut is made with a curved osteotome, and it
travels down the posterior column to meet with the first
cut (see Fig. 16-75, D). This cut should be visualized under
fluoroscopy with the use of a false-profile–type trajectory
of the image intensifier.
A Schanz pin is then placed into the acetabular fragment
to assist with the positioning of the acetabular fragment.
The first step in positioning the acetabular fragment is to
move the superior ramus proximally and slightly posteriorly
to allow the fragment to rotate around the center of rotation
of the hip center and to ensure that normal version is maintained during the correction. The fragment is then provisionally fixed, and radiographs are obtained to ensure that
the correct medialization of the joint center, the normalization of the lateral and anterior acetabular coverage, and the
maintenance of version are seen (Fig. 16-76). Final fixation involves the use of 3.5-mm–diameter long cortical screws,
with two or three screws running proximal to distal and one
screw going from the acetabular fragment toward the posterior column.
A proximal femoral osteotomy is indicated less often
today when a Ganz osteotomy is performed. The general
indications are when significant valgus is seen in the proximal femur and when severe acetabular dysplasia is seen in
which the reorientation of the acetabulum fails to result
in normal hip congruency. The decision to perform the
varus osteotomy should be made before surgery, and we
generally perform the varus osteotomy at the same sitting,
before the Ganz osteotomy so that the rotation of the
acetabulum can be dialed into the new position of the
femoral head.
• All series report excellent improvement in symptoms
and function after the Ganz osteotomy.79,80,187,192,224 Preoperative evidence of impingement of the femoral
head with
a lack of concentricity and joint-space narrowing are associated with poor results and are considered
contraindications
to the procedure.
Our experience demonstrates a significant improvement
in the lateral center–edge angle from -4 degrees to 23
degrees and in the ventral center–edge angle from -2
degrees to 33 degrees, with functional improvements in
Harris hip scores from 76 to 90 points at 2 years. Gait
analysis demonstrated improvements at 2 years in walking
speed, hip adductor moment impulse, and maximum hip
abductor torque, which reflect an improvement in the
medialization of the hip joint center
• Complications of the Ganz osteotomy can be serious,
and the learning curve for this procedure has been described
as “long and steep.”283 Early weight bearing may displace the osteotomy, and delayed union has
occurred.79 Other
complications include the nonunion of the pubic and ischial
osteotomies and the loss of fixation; lateral femoral cutaneous nerve damage is common, having
occurred in as many
as 50% of patients.108,224 Femoral nerve palsy, ectopic bone
formation, and necrosis of the acetabular fragment have also
been reported.52,108 A significant (77%) decrease in blood
flow after the separation of the acetabular fragment has
been reported96; however, avascular changes within the
acetabulum are rare. The surgeon is well advised to obtain
as much instruction and practice in the laboratory as possible before undertaking this surgical
procedure.
Spherical Acetabular Osteotomy