OSTEOTOMIES AROUND HIP

OSTEOTOMIES AROUND HIP

DEFINITION

nAn 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.

HIP BIOMECHANICs

n Hip designed to support BW permit mobility

nMax ROM 140- Fle/Ext,75-Abd/Add

nFunctional ROM 50-Fle/Ext

nForces acting around hip can be measured with –Mathematical model calculations – 2D static analysis

2D STATIC ANALYSIS

nOne legged stance 5/6 BW on femoral head

nRatio of lever arms to BW 3:1

BIO MECHANICS

Forces across hip joint

nBW

nGround rection forces

nAbductor muscle forces

nImproving abductor function will decrease joint reaction forces

HIP BIOMECHANICS

nAs the ratio of length of the leverarm of body weight to that of the abductor musculature is @ 2.5:1,the force of abductor muscle must approx 2.5 times the body weight to maintain the pelvis level when standing on one leg

nIn an arthritic hip , the ratio of lever arm of the body weight to that of the abductors may  be 4:1.

nThe length of two lever arms can be surgically changed  to make their ratio 1:1

OSTEOTOMY AROUND HIP CLASSIFICATION

nAccording to Anatomic Location

nFemoral Osteotomy

nHigh Cervical.

nIntertrochanteric Osteotomy.

nSubtrochanteric Osteotomy.

nGreater Trochanteric.

nPelvic Osteotomy.

nSalvage Osteotomies : eg. Chiari, Shelf.

nReconstructive Osteotomies : eg. Periacetabular, Single, Double, Triple Innominate.

nContd.

nBased on Indications

nTo obtain stability

n old unreduced dislocations.

nLorenz bifurcation osteotomy.

nSchanz low subtrochanteric.

nTo obtain union

nununited fractures of femoral neck.

nMcMurry’s osteotomy.

nDickson's high geometric osteotomy.

nSchanz Angulation Osteotomy.

nunstable intertrochanteric fractures.

nDimon Hughston Osteotomy.

nSarmiento’s Osteotomy

n

nRelief of pain

nosteoarathritis.

nPauwel’s type I varus osteotomy.

nPauwel’s type II valgus osteotomy.

nTo Correct deformities

ncoxa vara

nslipped upper femoral epiphysis

nIntracapsular cuneiform osteotomy by dunn.

nCompensatory Basilar Osteotomy of Femoral Neck.

nExtracapsular Base-of-Neck osteotomy.

nBall-and-Socket Trochanteric Osteotomy.

nPauwel’s osteotomy (Y).

n

nIn Osteonecrosis of femoral head

nSugioka’s transtrochanteric osteotomy.

nVarus deroation osteotomy of Axer.

- In paralytic disorders of hip.

nVarus Osteotomy.

nRotational Osteotomy

nIn congenital dislocation.

OVERVIEW OF PELVIC OSTEOTOMY

SALTER OSTEOTOMY

SALTER OSTEOTOMY

nINDI-Congruous hip reduction,<10-15 degrees correction of acetabular index required ,paralytic disorder,subluxation after septic arthritis

nPREREQUISITES- 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

nAGE-18 months-6years

nAFTERCARE-hip spica for 8 to 12 week,then partial weight bearing on crutches ,followed by full weight bearing.result assesed by center edge angle. 

PEMBERTON OSTEOTOMY

nPEMBERTON OSTEOTOMY

nPROCEDURE- 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.

nINDICATION- >10-15 degrees correction of acetabular index required ,small femoral head ,large acetabulum.
nADV- internal fixation not required .greater degree of rotation can be achieved with less rotation of acetabulum
nDISADV- Technically more difficult . Alters the configuration and capacity of acetabulum and produce joint incongruity that requires remodeling
nAGE-18months- 10 yr
nAFTERCARE-spica cast for 8 to 12 weeks

TRIPLE INNOMINATE OSTEOTOMY (STEEL)

nSTEEL OSTEOTOMY

nINDI-Adolescents and skeletally mature adults with residual dysplasia and subluxation in whom remodelling of acetabulum is no longer anticipated

n ADV-Better coverage of femoral head by articular cartilage  [chiari- fibrous cartilage], Better hip joint stability,no need of spica cast.

nDIS- Technically difficuilt, does not change size of acetabulum, distort the hip such that natural child birth may be impossible in adulthood

n PROC-The ischium, the sup pubic ramus and ilium superior to the acetabulum is reposition and stabilized by bone graft

GANZ OSTEOTOMY: (BERNESE) PRIACETUBULAR OSTEOTOMY.

nThis Triplaner osteotomy is for adolescent and adult dysplastic hip that required correction of congruency & containment of the femoral head with little or no arthritis.

nIf significant degenerative changes are presents a proximal femoral osteotomy can be added.

nApproach Smith Peterson approach.

nAdvantages :

nOnly one approach is used.

nA large amount of correction can be obtained in all directions, including the medial and lateral planes.

nBlood supply to the acetabulum is preserved.

nThe posterior column of the hemipelvis remains mechanically intact, allowing immediate crutch walking with minimal internal fixation.

nThe shape of the true pelvis is unaltered, permitting a normal child delivery.

nCan be combined with trochanteric osteotomy if needed.

THE SHELF PROCEDURE (STAHELI)

nSHELF OPERATION (STAHELI)

nHave commonly been performed to enlarge the volume of the acetabulum.

nThe 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.

nBest to do after 5 years of age.

nIndication : A deficient acetabulum that cannot be corrected by redirectional, osteotomy is the primary indication.

nContraindication :

nDysplastic hip with spherical congruity suitable for redirectional osteotomy

nHip requiring open reduction.

nCENTER EDGE ANGLE/ACETABULAR INDEX

nCE ANGLE-measured after 5 yr age, >25 normal, 

<20 severe dysplasia

nAC IND- <27.5 normal, >30 dysplasia

CHIARI OSTEOTOMY

INNOMINATE OSTEOTOMY WITH MEDIAL DISPLACEMENT OF ACETABULUM (CHIARI)

qPROC-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.

qINDI-incongruous joint, dysplastic hip with osteoarthritis ,other osteotomy   not possible

q DISADV-salvage osteotomy only, leaves anterior acetabulum  uncovered,abductor lurch common .

OSTEOTOMY

nPrimary 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.

nThe osteotomy performed are Angulation Osteotomy (Stabilizing osteotomy).

nSchanz osteotomy.

nLorenz osteotomy.

SCHANZ OSTEOTOMY (LOW S/T OSTEOTOMY)

Schanz osteotomy (Low S/T Osteotomy) :

nIn this osteotomy the deformity flexion, adduction & external Rotation is corrected by making the osteotomy at tuber ischii level. 

nPreparation : nX-ray are taken with full adduction – to measure angle medially.nThomas Test - measure degree of flexion to be corrected. 

nAdvantages : nLurching gait will be diminished.nThe depression of the trochanter also improves the leverage of the glutei. 

 nContraindication : Before 15 years of age, because loss of angulation during growth period.

Lorenz (Bifurcation osteotomy)

nIn 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 : 

nIncreased shortening.

nLess mobility and arthritic pain.