osteotomies around hip by dr gandhi
TRANSCRIPT
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DEPARTMENT OF DEPARTMENT OF ORTHOPAEDICS & TRAUMATOLOGYORTHOPAEDICS & TRAUMATOLOGY
GANDHI MEDICAL COLLEGE, BHOPALGANDHI MEDICAL COLLEGE, BHOPAL
SEMINAR ONSEMINAR ON
OSTEOTOMIES AROUND HIPOSTEOTOMIES AROUND HIPPRESENTED BY :PRESENTED BY :Dr. Vaibhav GandhiDr. Vaibhav Gandhi
MODERATOR :MODERATOR :Dr. A. GohiyaDr. A. GohiyaDr. S. TandonDr. S. Tandon
CONSULTANTS :CONSULTANTS :Prof. & HOD Dr. N. ShrivastavaProf. & HOD Dr. N. ShrivastavaProf.Dr. A. MehrotraProf.Dr. A. MehrotraDr. S. GaurDr. S. GaurDr. J. ShuklaDr. J. ShuklaDr. S. TandonDr. S. TandonDr. S. A. FaruquiDr. S. A. FaruquiDr. A GohiyaDr. A GohiyaDr. A. VarshneyDr. A. VarshneyDr. D. MaraviDr. D. MaraviDr. R. VermaDr. R. VermaDr. A. PathakDr. A. Pathak
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DEFINITIONDEFINITION
An osteotomy is a surgical corrective An osteotomy is a surgical corrective
procedure used to obtain a correct procedure used to obtain a correct
biomechanical alignment of the extremity so biomechanical alignment of the extremity so
as to achieve equivocal load transmission, as to achieve equivocal load transmission,
performed with or without removal of a performed with or without removal of a
portion of the bone.portion of the bone.
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HIP BIOMECHANICHIP BIOMECHANIC
Hip designed to support BW permit mobilityHip designed to support BW permit mobility
Max ROM 140- Fle/Ext,75-Abd/AddMax ROM 140- Fle/Ext,75-Abd/Add
Functional ROM 50-Fle/ExtFunctional ROM 50-Fle/Ext
Forces acting around hip can be measured with Forces acting around hip can be measured with
–Mathematical model calculations – 2D static –Mathematical model calculations – 2D static
analysis analysis
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2D STATIC ANALYSIS2D STATIC ANALYSIS
One legged stance One legged stance
5/6 BW on femoral 5/6 BW on femoral
headhead
Ratio of lever arms Ratio of lever arms
to BW 3:1to BW 3:1
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BIO MECHANICSBIO MECHANICS
Forces across hip jointForces across hip joint
BWBW
Ground rection forcesGround rection forces
Abductor muscle forcesAbductor muscle forces Improving abductor function Improving abductor function will decrease joint reaction will decrease joint reaction forcesforces
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HIP BIOMECHANICSHIP BIOMECHANICS
As the ratio of length of the lever arm of body As the ratio of length of the lever arm of body weight to that of the abductor musculature is weight to that of the abductor musculature is @ 2.5:1,the force of abductor muscle must @ 2.5:1,the force of abductor muscle must approx 2.5 times the body weight to maintain approx 2.5 times the body weight to maintain the pelvis level when standing on one legthe pelvis level when standing on one leg
In an arthritic hip , the ratio of lever arm of the In an arthritic hip , the ratio of lever arm of the body weight to that of the abductors may be body weight to that of the abductors may be 4:1.4:1.
The length of two lever arms can be surgically The length of two lever arms can be surgically changed to make their ratio 1:1 changed to make their ratio 1:1
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OSTEOTOMY AROUND HIP CLASSIFICATION OSTEOTOMY AROUND HIP CLASSIFICATION
According to Anatomic LocationAccording to Anatomic Location
Femoral OsteotomyFemoral Osteotomy
High Cervical.High Cervical.
Intertrochanteric Osteotomy.Intertrochanteric Osteotomy.
Subtrochanteric Osteotomy.Subtrochanteric Osteotomy.
Greater Trochanteric.Greater Trochanteric.
Pelvic Osteotomy.Pelvic Osteotomy.
Salvage Osteotomies : Salvage Osteotomies : eg. Chiari, Shelf.eg. Chiari, Shelf.
Reconstructive Osteotomies : Reconstructive Osteotomies : eg. Periacetabular, Single, eg. Periacetabular, Single,
Double, Triple Innominate.Double, Triple Innominate.
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Contd.Contd. Based on IndicationsBased on Indications
To obtain stabilityTo obtain stability old unreduced dislocations.old unreduced dislocations.
Lorenz bifurcation osteotomy.Lorenz bifurcation osteotomy. Schanz low subtrochanteric.Schanz low subtrochanteric.
To obtain unionTo obtain union ununited fractures of femoral neck.ununited fractures of femoral neck.
McMurry’s osteotomy.McMurry’s osteotomy. Dickson's high geometric osteotomy.Dickson's high geometric osteotomy. Schanz Angulation Osteotomy.Schanz Angulation Osteotomy.
unstable intertrochanteric fractures.unstable intertrochanteric fractures. Dimon Hughston Osteotomy.Dimon Hughston Osteotomy. Sarmiento’s OsteotomySarmiento’s Osteotomy
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Relief of painRelief of pain osteoarathritis.osteoarathritis.
Pauwel’s type I varus osteotomy.Pauwel’s type I varus osteotomy. Pauwel’s type II valgus osteotomy.Pauwel’s type II valgus osteotomy.
To Correct deformitiesTo Correct deformities coxa varacoxa vara slipped upper femoral epiphysisslipped upper femoral epiphysis
Intracapsular cuneiform osteotomy by dunn.Intracapsular cuneiform osteotomy by dunn. Compensatory Basilar Osteotomy of Femoral Neck.Compensatory Basilar Osteotomy of Femoral Neck. Extracapsular Base-of-Neck osteotomy.Extracapsular Base-of-Neck osteotomy. Ball-and-Socket Trochanteric Osteotomy.Ball-and-Socket Trochanteric Osteotomy. Pauwel’s osteotomy (Y).Pauwel’s osteotomy (Y).
Contd.Contd.
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In Osteonecrosis of femoral headIn Osteonecrosis of femoral head
Sugioka’s transtrochanteric osteotomy.Sugioka’s transtrochanteric osteotomy.
Varus deroation osteotomy of Axer.Varus deroation osteotomy of Axer.
- In paralytic disorders of hip.- In paralytic disorders of hip.
Varus Osteotomy.Varus Osteotomy.
Rotational OsteotomyRotational Osteotomy
In congenital dislocation.In congenital dislocation.
Contd.Contd.
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OVERVIEW OF PELVIC OSTEOTOMYOVERVIEW OF PELVIC OSTEOTOMY
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SALTER OSTEOTOMYSALTER OSTEOTOMY
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SALTER OSTEOTOMYSALTER OSTEOTOMY INDIINDI-Congruous hip reduction,<10-15 degrees correction of -Congruous hip reduction,<10-15 degrees correction of
acetabular index required ,paralytic disorder,subluxation after acetabular index required ,paralytic disorder,subluxation after
septic arthritisseptic arthritis
PREREQUISITES-PREREQUISITES- femoral head must be positioned opposite femoral head must be positioned opposite
the level of acetabulum,contracture of iliopsoas and adductor the level of acetabulum,contracture of iliopsoas and adductor
muscles must be released, range of motion of the hip must be muscles must be released, range of motion of the hip must be
good specially in abduction ,int rotation flexiongood specially in abduction ,int rotation flexion
AGE-AGE-18 months-6years18 months-6years
AFTERCARE-AFTERCARE-hip spica for 8 to 12 week,then partial weight hip spica for 8 to 12 week,then partial weight
bearing on crutches ,followed by full weight bearing.result bearing on crutches ,followed by full weight bearing.result
assesed by center edge angle.assesed by center edge angle.
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CASECASE-abdulla,2yr /m, B/L DDH, operated at -abdulla,2yr /m, B/L DDH, operated at GMC BHOPALGMC BHOPAL, O/D , O/D – SALTER osteotomy with k-wire fix with femoral shortening– SALTER osteotomy with k-wire fix with femoral shortening
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PEMBERTON OSTEOTOMYPEMBERTON OSTEOTOMY
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PEMBERTON OSTEOTOMYPEMBERTON OSTEOTOMY
PROCEDURE-PROCEDURE- Pemberton described a pericapsular Pemberton described a pericapsular
osteotomy of the ilium in which the osteotomy is osteotomy of the ilium in which the osteotomy is
made through the full thickness of the bone from just made through the full thickness of the bone from just
superior to the anteroinferior iliac spine anteriorly to superior to the anteroinferior iliac spine anteriorly to
the triradiate cartilage posteriorly : the triradiate the triradiate cartilage posteriorly : the triradiate
cartilage acts as a hinge on which the acetabular roof cartilage acts as a hinge on which the acetabular roof
is rotated anteriorly and laterally.is rotated anteriorly and laterally.
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INDICATION-INDICATION- >10-15 degrees correction of >10-15 degrees correction of acetabular index required ,small femoral head ,large acetabular index required ,small femoral head ,large acetabulum.acetabulum.
ADV-ADV- internal fixation not required .greater degree of internal fixation not required .greater degree of rotation can be achieved with less rotation of rotation can be achieved with less rotation of acetabulum acetabulum
DISADV-DISADV- Technically more difficult . Alters the Technically more difficult . Alters the configuration and capacity of acetabulum and produce configuration and capacity of acetabulum and produce joint incongruity that requires remodeling joint incongruity that requires remodeling
AGE-AGE-18months- 10 yr18months- 10 yr AFTERCARE-AFTERCARE-spica cast for 8 to 12 weeks spica cast for 8 to 12 weeks
PEMBERTON PERICAPSULAR OSTEOTOMYPEMBERTON PERICAPSULAR OSTEOTOMY
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PERIACETABULAR OSTEOTOMY OF ILIUM PERIACETABULAR OSTEOTOMY OF ILIUM (PEMBERTON)(PEMBERTON)
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TRIPLE INNOMINATE OSTEOTOMY TRIPLE INNOMINATE OSTEOTOMY (STEEL)(STEEL)
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STEEL OSTEOTOMYSTEEL OSTEOTOMY
INDI-INDI-Adolescents and skeletally mature adults with residual Adolescents and skeletally mature adults with residual
dysplasia and subluxation in whom remodelling of acetabulum is no dysplasia and subluxation in whom remodelling of acetabulum is no
longer anticipatedlonger anticipated
ADV-ADV-Better coverage of femoral head by articular cartilage [chiari- Better coverage of femoral head by articular cartilage [chiari-
fibrous cartilage], Better hip joint stability,no need of spica cast.fibrous cartilage], Better hip joint stability,no need of spica cast.
DIS-DIS- Technically difficuilt, does not change size of acetabulum, Technically difficuilt, does not change size of acetabulum,
distort the hip such that natural child birth may be impossible in distort the hip such that natural child birth may be impossible in
adulthoodadulthood
PROC-PROC-The ischium, the sup pubic ramus and ilium superior to the The ischium, the sup pubic ramus and ilium superior to the
acetabulum is reposition and stabilized by bone graft acetabulum is reposition and stabilized by bone graft
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GANZ OSTEOTOMY: (BERNESE) GANZ OSTEOTOMY: (BERNESE) PRIACETUBULAR OSTEOTOMY.PRIACETUBULAR OSTEOTOMY.
This Triplaner osteotomy is for adolescent and adult This Triplaner osteotomy is for adolescent and adult
dysplastic hip that required correction of congruency dysplastic hip that required correction of congruency
& containment of the femoral head with little or no & containment of the femoral head with little or no
arthritis.arthritis.
If significant degenerative changes are presents a If significant degenerative changes are presents a
proximal femoral osteotomy can be added.proximal femoral osteotomy can be added.
Approach Smith Peterson approach.Approach Smith Peterson approach.
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GANZ OSTEOTOMYGANZ OSTEOTOMY
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Advantages :Advantages :
Only one approach is used.Only one approach is used.
A large amount of correction can be obtained in all A large amount of correction can be obtained in all
directions, including the medial and lateral planes.directions, including the medial and lateral planes.
Blood supply to the acetabulum is preserved.Blood supply to the acetabulum is preserved.
The posterior column of the hemipelvis remains The posterior column of the hemipelvis remains
mechanically intact, mechanically intact, allowing immediate crutch walkingallowing immediate crutch walking
with minimal internal fixation.with minimal internal fixation.
The shape of the true pelvis is unaltered, permitting a The shape of the true pelvis is unaltered, permitting a
normal child delivery.normal child delivery.
Can be combined with trochanteric osteotomy if needed.Can be combined with trochanteric osteotomy if needed.
Contd.Contd.
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THE SHELF PROCEDURE (STAHELI)THE SHELF PROCEDURE (STAHELI)
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SHELF OPERATION (STAHELI) SHELF OPERATION (STAHELI) Have commonly been performed to enlarge the volume of the Have commonly been performed to enlarge the volume of the
acetabulum.acetabulum. The objective is to create a shelf, the size of which is decided by The objective is to create a shelf, the size of which is decided by
measuring the “width of augmentation” form the CE angle. The measuring the “width of augmentation” form the CE angle. The shelf is put just above the acetabular margin. It secure two layers shelf is put just above the acetabular margin. It secure two layers of cancellous grafts bringing the reflected head of rectus femoris of cancellous grafts bringing the reflected head of rectus femoris forward over the graft and suturing it in its original position.forward over the graft and suturing it in its original position.
Best to do after 5 years of age.Best to do after 5 years of age. Indication Indication :: A deficient acetabulum that cannot be corrected by A deficient acetabulum that cannot be corrected by
redirectional, osteotomy is the primary indication.redirectional, osteotomy is the primary indication. Contraindication :Contraindication :
Dysplastic hip with spherical congruity suitable for Dysplastic hip with spherical congruity suitable for redirectional osteotomyredirectional osteotomy
Hip requiring open reduction. Hip requiring open reduction.
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CENTER EDGE CENTER EDGE ANGLE/ACETABULAR INDEXANGLE/ACETABULAR INDEX
CE ANGLE-measured after 5 yr age, >25 normal, CE ANGLE-measured after 5 yr age, >25 normal, <20 severe dysplasia<20 severe dysplasia
AC IND- <27.5 normal, >30 dysplasiaAC IND- <27.5 normal, >30 dysplasia
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CHIARICHIARI
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CHIARICHIARI
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INNOMINATE OSTEOTOMY WITH MEDIAL INNOMINATE OSTEOTOMY WITH MEDIAL DISPLACEMENT OF ACETABULUM (CHIARI)DISPLACEMENT OF ACETABULUM (CHIARI)
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CHIARI OSTEOTOMYCHIARI OSTEOTOMY PROC-PROC-It is performed at the superior margin of the It is performed at the superior margin of the
acetabulum and the pelvis inferior to the osteotomy acetabulum and the pelvis inferior to the osteotomy
along with the femur is displaced medially.along with the femur is displaced medially.
This is also called as capsular interposition Arthroplasty This is also called as capsular interposition Arthroplasty
as the capsule is interposed between the shelf and the as the capsule is interposed between the shelf and the
femoral head.femoral head.
INDI-INDI-incongruous joint, dysplastic hip with incongruous joint, dysplastic hip with
osteoarthritis ,other osteotomy not possibleosteoarthritis ,other osteotomy not possible
DISADV-DISADV-salvage osteotomy only, leaves anterior salvage osteotomy only, leaves anterior
acetabulum uncovered,abductor lurch common . acetabulum uncovered,abductor lurch common .
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PALLIATIVE OPERATION PALLIATIVE OPERATION
Reserve for cases is which reduction is not possible by Reserve for cases is which reduction is not possible by
either open or closed reduction as in old unreduced either open or closed reduction as in old unreduced
congenital dislocation.congenital dislocation.
Designed to improve :Designed to improve :
Stability.Stability.
Decrease lordosis.Decrease lordosis.
Control pain arising from lower back/hip.Control pain arising from lower back/hip.
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REVIEW OF PELVIC OSTEOTOMIESREVIEW OF PELVIC OSTEOTOMIES
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SURGICAL PLANNING SURGICAL PLANNING
In surgical planning of an osteotomy, the most In surgical planning of an osteotomy, the most
important task is to determine whether the important task is to determine whether the
patient is an appropriate candidate. patient is an appropriate candidate.
Determining factors are the patient’s age, Determining factors are the patient’s age,
activities, goals, radiographic assessment, activities, goals, radiographic assessment,
range of motion, and leg lengths and the status range of motion, and leg lengths and the status
of the knee of same side.of the knee of same side.
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OSTEOTOMYOSTEOTOMY
Primary objective is deflection of wt. bearing by Primary objective is deflection of wt. bearing by
angulation of femur to bring the axis of the femoral angulation of femur to bring the axis of the femoral
shaft more in line with the direction of weight shaft more in line with the direction of weight
transmission.transmission.
The osteotomy performed are Angulation The osteotomy performed are Angulation
Osteotomy (Stabilizing osteotomy).Osteotomy (Stabilizing osteotomy).
Schanz osteotomy.Schanz osteotomy.
Lorenz osteotomy.Lorenz osteotomy.
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SCHANZ OSTEOTOMY (LOW S/T 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.
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Schanz osteotomy (Low S/T Osteotomy) :Schanz osteotomy (Low S/T Osteotomy) : In this osteotomy the deformity flexion, adduction & In this osteotomy the deformity flexion, adduction &
external Rotation is corrected by making the osteotomy at external Rotation is corrected by making the osteotomy at tuber ischii level.tuber ischii level.
Preparation :Preparation : X-ray are taken with full adduction – to measure angle X-ray are taken with full adduction – to measure angle
medially.medially. Thomas Test - measure degree of flexion to be Thomas Test - measure degree of flexion to be
corrected.corrected. Advantages :Advantages :
Lurching gait will be diminished.Lurching gait will be diminished. The depression of the trochanter also improves the The depression of the trochanter also improves the
leverage of the glutei.leverage of the glutei.
Contd.Contd.
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Contraindication Contraindication :: Before 15 years of age, because loss Before 15 years of age, because loss
of angulation during growth period.of angulation during growth period.
Lorenz (Bifurcation osteotomy)Lorenz (Bifurcation osteotomy)
In this upper end of the lower fragment is abducted and In this upper end of the lower fragment is abducted and
inserted in to the acetabulum after making on inserted in to the acetabulum after making on
intertrochanteric osteotomy “plane of osteotomy” below intertrochanteric osteotomy “plane of osteotomy” below
& outward to above & inward.& outward to above & inward.
Disadvantage :Disadvantage :
Increased shortening.Increased shortening.
Less mobility and arthritic pain.Less mobility and arthritic pain.
Contd.Contd.
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LORENZ (BIFURCATION OSTEOTOMY)LORENZ (BIFURCATION OSTEOTOMY)
(A) Plane of (A) Plane of osteotomy – Distal osteotomy – Distal end at posterolateral end at posterolateral aspect towards aspect towards proximal end at proximal end at anteromedial aspect.anteromedial aspect.
(B) Limb is Abducted (B) Limb is Abducted and extended so proximal and extended so proximal end of distal fragment end of distal fragment directed medially and directed medially and anteriorly in acetabulum.anteriorly in acetabulum.
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OSTEOTOMY FOR COXA VERAOSTEOTOMY FOR COXA VERA The normal femoral neck shaft angle in infant is 120The normal femoral neck shaft angle in infant is 1200 0 to 140to 14000, ,
Reduction to a more acute angle constitute a coxa vara Reduction to a more acute angle constitute a coxa vara deformity.deformity.
The goal of treatment areThe goal of treatment are To promote ossification of the defect and correct varus To promote ossification of the defect and correct varus
deformity.deformity. Indication for surgery :Indication for surgery :
Increasing coxa vara Increasing coxa vara Neck shaft angle less than 110°.Neck shaft angle less than 110°. Painful unilateral or associated with leg length Painful unilateral or associated with leg length
discrepancydiscrepancy Hilgenreiner - epiphy seal angle of more than 60° .Hilgenreiner - epiphy seal angle of more than 60° .
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Surgery performed areSurgery performed are
Valgus Subtrochanteric Osteotomy or abduction Valgus Subtrochanteric Osteotomy or abduction
osteotomy-with Internal Fixation.osteotomy-with Internal Fixation.
A transverse osteotomy at about the level of lesser A transverse osteotomy at about the level of lesser
trochanter.trochanter.
If necessary take a small lateral wedge to correct neck If necessary take a small lateral wedge to correct neck
shaft angle to 135-150.shaft angle to 135-150.
The surgery may be delayed till child is 4 to 5 year old The surgery may be delayed till child is 4 to 5 year old
to make internal fixation easier.to make internal fixation easier.
Contd.Contd.
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Alternative Method : Pauwels Y shaped osteotomy :Alternative Method : Pauwels Y shaped osteotomy :
Static forces are converted from shearing to impacting Static forces are converted from shearing to impacting
forcesforces
Prerequisites :Prerequisites :
Viable femoral head.Viable femoral head.
Young vigorous patient.Young vigorous patient.
Advantage :Advantage :
Union is rapid.Union is rapid.
Recurrence is less likely.Recurrence is less likely.
Contd.Contd.
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PAUWELS Y SHAPED OST
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COXA VERACOXA VERA
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COXA VERACOXA VERA
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OSTEOTOMY FOR RELIEF OF PAIN IN OSTEOTOMY FOR RELIEF OF PAIN IN OSTEOARTHRITIS OSTEOARTHRITIS
Before the onset of osteoarthritis, if normal or near normal Before the onset of osteoarthritis, if normal or near normal
function of the hip can be maintained, reconstructive function of the hip can be maintained, reconstructive
osteotomy can prevent or delay the development of osteotomy can prevent or delay the development of
osteoarthritis; if mild or moderate osteoarthritis is present, a osteoarthritis; if mild or moderate osteoarthritis is present, a
salvage osteotomy can improve function and delay the need salvage osteotomy can improve function and delay the need
for total hip Arthroplasty. for total hip Arthroplasty.
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FactorsFactors Reconstructive OsteotomyReconstructive Osteotomy Salvage OsteotomySalvage Osteotomy
Age Age Generally < 25 years Generally < 25 years Generally < 50 years (Some Generally < 50 years (Some
biological Plasticity biological Plasticity
Remains) Remains)
Symptoms Symptoms Minimal (Out Progressive) Minimal (Out Progressive) Moderate to Severe Moderate to Severe
Motion Motion Near Normal Near Normal > 60> 6000 Flexion Flexion
Function Function Near Normal Near Normal Fair to Poor Fair to Poor
Pthoanatomy Pthoanatomy No Irreversible Changes No Irreversible Changes Irreversible Changes Irreversible Changes
Roentgenography Roentgenography Congruent but Malaligned Congruent but Malaligned
SurfacesSurfaces
Cartilage narrowing or Cartilage narrowing or
incongruity or both incongruity or both
Prognosis if Prognosis if
untreateduntreated
Poor Poor Poor Poor
THERAPEUTIC INTERVENTION IN HIP THERAPEUTIC INTERVENTION IN HIP DIEASE :RECONSTRUCTIVE VERSES SALVAGE DIEASE :RECONSTRUCTIVE VERSES SALVAGE
OSTEOTOMYOSTEOTOMY
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The goal of reconstructive osteotomies, femoral or pelvic, is to The goal of reconstructive osteotomies, femoral or pelvic, is to
restore as nearly normal anatomy as possible, thus returning restore as nearly normal anatomy as possible, thus returning
joint pressures and loading patterns to normal.joint pressures and loading patterns to normal.
The goal of salvage osteotomies are to relieve pain and The goal of salvage osteotomies are to relieve pain and
improve function enough to delay the need for total hip improve function enough to delay the need for total hip
Arthroplasty, especially in active patients younger than 50 Arthroplasty, especially in active patients younger than 50
years of age.years of age.
Roentgenographic evaluation also should include a standing Roentgenographic evaluation also should include a standing
anteroposterior view and a “false profile” view.anteroposterior view and a “false profile” view.
Contd.Contd.
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VARUS/VALGUS/DEROTATION FEMORAL VARUS/VALGUS/DEROTATION FEMORAL OSTEOTOMIES ARE -OSTEOTOMIES ARE -
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VARUS OSTEOTOMIESVARUS OSTEOTOMIES
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FEMORAL OSTEOTOMYFEMORAL OSTEOTOMY
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varus osteotomy :-varus osteotomy :- Designed to elevate the greater trochanter and move it Designed to elevate the greater trochanter and move it
laterally while moving the abductor and psoas muscles laterally while moving the abductor and psoas muscles medially, to restore joint congruity and decrease muscle forces medially, to restore joint congruity and decrease muscle forces about the hip.about the hip.
Varus osteotomy alone is indicated for patients with a Varus osteotomy alone is indicated for patients with a spherical femoral head, little or no acetabular dysplasia center-spherical femoral head, little or no acetabular dysplasia center-edge angle of at least 15 to 20 degrees), signs lateral edge angle of at least 15 to 20 degrees), signs lateral overloading, and a valgus neck-shaft angle of more than 135 overloading, and a valgus neck-shaft angle of more than 135 degrees.degrees.
Varus osteotomy with medial displacement of the femoral Varus osteotomy with medial displacement of the femoral shaft relaxes the abductor, psoas, and adductor shaft relaxes the abductor, psoas, and adductor musclesunloads the hip joint, and increases the weight-bearing musclesunloads the hip joint, and increases the weight-bearing surface.surface.
Contd.Contd.
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Most authors recommend medial displacement of 10 to Most authors recommend medial displacement of 10 to
15 mm to keep the ipsilateral knee centered under the 15 mm to keep the ipsilateral knee centered under the
femoral head and to maintain the mechanical axis of the femoral head and to maintain the mechanical axis of the
leg.leg.
Varus osteotomy, however, shortens the limb to some Varus osteotomy, however, shortens the limb to some
degree. creates a Trendelenburg gait that may persist for degree. creates a Trendelenburg gait that may persist for
months after surgery, and increases the prominence of the months after surgery, and increases the prominence of the
greater trochanter.greater trochanter.
Limb shortening can be minimized by making a smaller Limb shortening can be minimized by making a smaller
medial osteotomy and transposing it to the lateral side.medial osteotomy and transposing it to the lateral side.
Contd.Contd.
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VALGUS INTERTROCHANTERIC VALGUS INTERTROCHANTERIC FEMORAL OSTEOTOMIES FEMORAL OSTEOTOMIES
Valgus Osteotomy Valgus Osteotomy - Increase weight bearing area of femur - Increase weight bearing area of femur head.head. It does not produce muscle relaxation.It does not produce muscle relaxation. Relaxation obtained by tenotomy of Iliopsos and adductor Relaxation obtained by tenotomy of Iliopsos and adductor
muscle.muscle. Transfer the center of hip rotation medially from the superior Transfer the center of hip rotation medially from the superior
aspect of the acetabulum to increase joint congruity and the aspect of the acetabulum to increase joint congruity and the weight-bearing area of the femoral head.weight-bearing area of the femoral head.
Osteotomy of the greater trochanter often is performed with Osteotomy of the greater trochanter often is performed with valgus femoral osteotomy to move the greater trochanter valgus femoral osteotomy to move the greater trochanter laterally.laterally.
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VALGUS INTERTROCHANTERIC FEMORAL VALGUS INTERTROCHANTERIC FEMORAL OSTEOTOMIES :OSTEOTOMIES :
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Best result were obtained in patients younger than 40 years of Best result were obtained in patients younger than 40 years of age with unilateral involvement, good preoperative range of age with unilateral involvement, good preoperative range of motion, and a mechanical (secondary) cause.motion, and a mechanical (secondary) cause.
Unsatisfactory results occurred in patients with limited Unsatisfactory results occurred in patients with limited preoperative flexion, they cited preoperative flexion of less preoperative flexion, they cited preoperative flexion of less than 60 degrees as a relative contraindication to valgus than 60 degrees as a relative contraindication to valgus osteotomy.osteotomy.
Most surgeons now advise that all osteotomies be fixed with Most surgeons now advise that all osteotomies be fixed with rigid internal fixation, which offersrigid internal fixation, which offers several obvious several obvious advantages:advantages: The fragments are maintained in proper position;The fragments are maintained in proper position; The danger of limitation of motion of the hip and knee is The danger of limitation of motion of the hip and knee is
greatly decreased;greatly decreased;
Contd.Contd.
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The patient can be allowed out of bed early; andThe patient can be allowed out of bed early; and
Pulmonary, urological, and other medical complications Pulmonary, urological, and other medical complications
are decreased. A device frequently used for rigid internal are decreased. A device frequently used for rigid internal
fixation of intertrochanteric osteotomies is the ASIF, or fixation of intertrochanteric osteotomies is the ASIF, or
right-angled, blade plate. Our experience with this device right-angled, blade plate. Our experience with this device
has been quite favorable.has been quite favorable.
Nonunion has been a troublesome complication after Nonunion has been a troublesome complication after
Osteotomy, and an incidence as high as 20% has been Osteotomy, and an incidence as high as 20% has been
reported.reported.
Contd.Contd.
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BLOUNT ABDUCTION BLOUNT ABDUCTION OSTEOTOMYOSTEOTOMY
Trendelenburg limpTrendelenburg limp Adduction deformityAdduction deformity Motion in adduction beyond adduction Motion in adduction beyond adduction
deformitydeformity Painful abductionPainful abduction
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BLOUNT ADDUCTION BLOUNT ADDUCTION OSTEOTOMYOSTEOTOMY
Antalgic abductor limpAntalgic abductor limp Abduction deformityAbduction deformity Motion in abduction beyond the abduction Motion in abduction beyond the abduction
deformitydeformity Painful adductionPainful adduction
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BIOMECHANICAL TREATMENT OF BIOMECHANICAL TREATMENT OF OSTEOARTHRITIS OSTEOARTHRITIS
Therapy must be directed at reducing joint loads. This may Therapy must be directed at reducing joint loads. This may
be by reducing the compressive forces directly or by be by reducing the compressive forces directly or by
increasing the weight- bearing area, and thereby reducing increasing the weight- bearing area, and thereby reducing
the load per unit area or ideally by combination of the two.the load per unit area or ideally by combination of the two.
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WHILE PERFORMING OSTEOTOMYWHILE PERFORMING OSTEOTOMY
The distal cut must be perpendicular to the axis of the shaft The distal cut must be perpendicular to the axis of the shaft
fragment.fragment.
All cortical wages are taken form the proximal fragment to All cortical wages are taken form the proximal fragment to
avoid loss of apposition when the distal fragment is rotated.avoid loss of apposition when the distal fragment is rotated.
General contraindication of femoral osteotomies -General contraindication of femoral osteotomies -
Poor motionPoor motion
Inflamatory joint conditionInflamatory joint condition
Significant metabolic disease.Significant metabolic disease.
Severe degenerative joint disease.Severe degenerative joint disease.
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OSTEOTOMY TO CORRECT UNSTABLE OSTEOTOMY TO CORRECT UNSTABLE INTERTROCHANTERIC FRACTURES INTERTROCHANTERIC FRACTURES
Sarmiento TechniqueSarmiento Technique
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OSTEOTOMY TO CORRECT UNSTABLE OSTEOTOMY TO CORRECT UNSTABLE INTERTROCHANTERIC FRACTURESINTERTROCHANTERIC FRACTURES
Dimon and Hughston :Dimon and Hughston :
Described technique of Trochanteric osteotomy with Described technique of Trochanteric osteotomy with
valgus nailing and medial displacement to improve valgus nailing and medial displacement to improve
stability there techniques are occasionally useful in some stability there techniques are occasionally useful in some
extremely comminuted fractures.extremely comminuted fractures.
Recent studies have indicated that anatomical reduction Recent studies have indicated that anatomical reduction
allow greater load shearing by bone than medial allow greater load shearing by bone than medial
displacement osteotomy.displacement osteotomy.
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DIMON AND HUGHSTON METHOD OF DIMON AND HUGHSTON METHOD OF INTERTROCHANTERIC OSTEOTOMYINTERTROCHANTERIC OSTEOTOMY
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SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
Is a disorder in which there is a displacement of the capital Is a disorder in which there is a displacement of the capital
femoral epiphysis form the metaphysis through the physeal femoral epiphysis form the metaphysis through the physeal
plate.plate.
By this head is placed in posterior & downward position in By this head is placed in posterior & downward position in
acetabulum.acetabulum.
The goal of treatment isThe goal of treatment is
To prevent further displacement andTo prevent further displacement and
To promote closure of physeal plate.To promote closure of physeal plate.
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The use of realignment procedure such as lntertrochameric, The use of realignment procedure such as lntertrochameric,
Subtrochanteric Osteotomy & osteotomies the around neck is Subtrochanteric Osteotomy & osteotomies the around neck is
in those situation in which restricted range of motion impairs in those situation in which restricted range of motion impairs
function after plate physeal closure.function after plate physeal closure.
Principle of OsteotomyPrinciple of Osteotomy
There are basically three type of Deformity present in SCFE. There are basically three type of Deformity present in SCFE.
These are-These are-
VarusVarus
Hyper extensionHyper extension
Moderate Severe external rotationModerate Severe external rotation
Contd.Contd.
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SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
The osteotomy to correct these The osteotomy to correct these
deformities work at two sites.deformities work at two sites.
Through the femoral neck Through the femoral neck
(closing wedge osteotomy)(closing wedge osteotomy)
Through the trochanteric Through the trochanteric
area.area.
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EXTRACAPSULAR BASE OF NECK EXTRACAPSULAR BASE OF NECK OSTEOTOMYOSTEOTOMY
types of femoral neck osteotomy are -types of femoral neck osteotomy are -
The technique of Dunn - for severe chronic slip with open The technique of Dunn - for severe chronic slip with open
physis.physis.
Base of the neck osteotomy - Compensatory Basilar most Base of the neck osteotomy - Compensatory Basilar most
of femoral neck. (Kramer) - correct the varus and of femoral neck. (Kramer) - correct the varus and
retroversion component of moderate to severe chronic retroversion component of moderate to severe chronic
SCFE.SCFE.
It is safer than cuniform osteotomy of neck.It is safer than cuniform osteotomy of neck.
Further slipping is prevented.Further slipping is prevented.
Intertrochantric osteotomiesIntertrochantric osteotomies
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CORRECTIVE OSTOTOMIESCORRECTIVE OSTOTOMIES
By these osteotomies one can correct angulation, rotation, By these osteotomies one can correct angulation, rotation,
flexion, extension Deformity of bones to restore motion for flexion, extension Deformity of bones to restore motion for
patient with stiff hip.patient with stiff hip.
LikeLike
Deformities in septic arthritisDeformities in septic arthritis
Malunion of I/T femursMalunion of I/T femurs
Neuromuscular disorderNeuromuscular disorder
Cerebral palsyCerebral palsy
PoliomyelitisPoliomyelitis
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There are three types of corrective osteotomiesThere are three types of corrective osteotomies Close wedgeClose wedge - transverse closing wedge provide good bony - transverse closing wedge provide good bony
apposition and is stable, however, it shortens the extremity.apposition and is stable, however, it shortens the extremity. Open wedgeOpen wedge - simple and lengthens the extremity however. - simple and lengthens the extremity however.
bony apposition is limited, union is delayed in adults and it bony apposition is limited, union is delayed in adults and it is initially unstable.is initially unstable.
Ball and Socket typeBall and Socket type - achieves stability without shortening - achieves stability without shortening the extremity; however, extensive dissection is required, the extremity; however, extensive dissection is required, and in severe biplame deformities an accurate and stable and in severe biplame deformities an accurate and stable osteotomy is difficult to perform.osteotomy is difficult to perform.
In Ball & socket type of osteotomy concave surface in created In Ball & socket type of osteotomy concave surface in created in the proximal fragment of convex surface at the distal in the proximal fragment of convex surface at the distal fragment, at intertrochantaric level & fixed in place by plate.fragment, at intertrochantaric level & fixed in place by plate.
Contd.Contd.
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CORRECTIVE OSTOTOMIESCORRECTIVE OSTOTOMIES
Brackett ball and socketOsteotomy
Whitman closing wedge
Osteotomy Gant-opening wedge
Osteotomy
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FRACTURE NECK FEMURFRACTURE NECK FEMUR In those case which present late (1-5 wks.), are difficult case In those case which present late (1-5 wks.), are difficult case
to treat becauseto treat because Close reduction is not possible.Close reduction is not possible. Open reduction is associated AVNOpen reduction is associated AVN
In young Pt. with viable femoral head & nonunion options In young Pt. with viable femoral head & nonunion options are-are- Mcmurray & Pauwel’s ‘y’ osteotomyMcmurray & Pauwel’s ‘y’ osteotomy Angulation Osteotomy (Schanz)Angulation Osteotomy (Schanz) Dickson geometric osteotomyDickson geometric osteotomy
In old Pt.-In old Pt.- Girdle stone osteotomyGirdle stone osteotomy Mcmurray DisplacementMcmurray Displacement
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OBLIQUE OSTEOTOMY OBLIQUE OSTEOTOMY
Extends from lateral aspect of shaft at level just below the Extends from lateral aspect of shaft at level just below the
lower border of lesser trochanter and terminates medially lower border of lesser trochanter and terminates medially
between lesser trochanter and lower border of neck.between lesser trochanter and lower border of neck.
Shaft is displaced medially.Shaft is displaced medially.
Mechanical Advantage :-Mechanical Advantage :-
Line of weight bearing shifted medially.Line of weight bearing shifted medially.
Shearing forces at the nounion is decrease because Shearing forces at the nounion is decrease because
fracture surface become more horizontalfracture surface become more horizontal
These advantages are greater after angulation osteotomy.These advantages are greater after angulation osteotomy.
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McMURRAY
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MC-MURRAY OSTEOTOMYMC-MURRAY OSTEOTOMY
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MC-MURRAY’S OSTEOTOMYMC-MURRAY’S OSTEOTOMY The oblique osteotomy extends from the lateral aspect of The oblique osteotomy extends from the lateral aspect of
the shaft at a level just below the lower border of the the shaft at a level just below the lower border of the lesser trochanter and lower border of neck.Then the limb lesser trochanter and lower border of neck.Then the limb is rotated inward and outward to remove any bony spikeis rotated inward and outward to remove any bony spike Fixation of osteotomyFixation of osteotomy - By Compression nail - By Compression nail
plate./Castle Plate.plate./Castle Plate. Disadvantages:Disadvantages:
Instability - Degenerative changes in normal headInstability - Degenerative changes in normal head Shortening - AVN when neck have been fracturedShortening - AVN when neck have been fractured Medial displacement of shaft compromise the Medial displacement of shaft compromise the
insertion of femoral stem of total hip.insertion of femoral stem of total hip. AdvantageAdvantage -Changes line of fracture to -Changes line of fracture to
horizontal,callus may incarporate fracture horizontal,callus may incarporate fracture
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DICKSON HIGH GEOMETRIC DICKSON HIGH GEOMETRIC OSTEOTOMY OSTEOTOMY
Principle - the line of vertical force is Principle - the line of vertical force is
converted to a horizontal (impacting converted to a horizontal (impacting
force). In this distal fragment is force). In this distal fragment is
abducted to 60° after making osteotomy abducted to 60° after making osteotomy
just below the grater trochanter & fixed just below the grater trochanter & fixed
with plate.with plate.
High rate of unionHigh rate of union
Lengthens limb Lengthens limb
Improves abductor strengthImproves abductor strength
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GIRDLESTONE OSTEOTOMY
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GIRDLE STONE OSTEOTOMY GIRDLE STONE OSTEOTOMY In this head & neck of femur are excised at Inter trochanteric In this head & neck of femur are excised at Inter trochanteric
level to create pseudo arthrosis in order to improve stability. level to create pseudo arthrosis in order to improve stability.
Angulations Osteotomy is added.Angulations Osteotomy is added.
IndicationIndication
T.B. HipT.B. Hip
Pyogenic HipPyogenic Hip
Non union #.neck femur [in elderly pt.]Non union #.neck femur [in elderly pt.]
AVN of femoral head.AVN of femoral head.
Advantages :-Advantages :-
Painless mobile hip joint. Painless mobile hip joint.
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OSTEOTOMIES OSTEOTOMIES – – These procedure have achieved best result for small and These procedure have achieved best result for small and
medium sized lesion. 1<30% femoral head involvement in medium sized lesion. 1<30% femoral head involvement in young pt.young pt.
Intertrochanteric varus/valgus - osteotomiesIntertrochanteric varus/valgus - osteotomies Transtrochantric ant. Rotational osteotomy (Sugioka) - Transtrochantric ant. Rotational osteotomy (Sugioka) -
Technically Demanding procedures.Technically Demanding procedures. PRINCIPLE:PRINCIPLE:
All osteotomies are designed to transfer the weight All osteotomies are designed to transfer the weight bearing forces form the necrotic area to the cartilage on bearing forces form the necrotic area to the cartilage on the sound part of the femoral head to allow healing of the sound part of the femoral head to allow healing of necrotic area by hyper vascularisation of upper part of necrotic area by hyper vascularisation of upper part of femur.femur.
AVNAVN
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TRANSTROCHANTRIC ANT. ROTATIONAL TRANSTROCHANTRIC ANT. ROTATIONAL OSTEOTOMY OSTEOTOMY [SUGIOKA][SUGIOKA]
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TECHNIQUE FOR ROTATIONTECHNIQUE FOR ROTATION
Femoral head is rotated anteriorly (45Femoral head is rotated anteriorly (4500 - 90 - 9000) by handling ) by handling proximal pin.proximal pin.
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OSTEOTOMY IN PERTHE'S DISEASE OSTEOTOMY IN PERTHE'S DISEASE Salvage :Salvage :
Varus Derotational OsteotomyVarus Derotational Osteotomy Innominate Osteotomy. Innominate Osteotomy. Combined Procedure -Combined Procedure - MRI / Arthrogram before surgery is mandatory.MRI / Arthrogram before surgery is mandatory. Varus/derotation osteotomy of this embodies the principle Varus/derotation osteotomy of this embodies the principle
of “containment” of the diseased femoral head in the of “containment” of the diseased femoral head in the treatment of Legg - Calve-Perthes disease.treatment of Legg - Calve-Perthes disease.
Guide pin inserted compression screw is placed over Guide pin inserted compression screw is placed over guide wire.guide wire.
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PERTHES DIEASESPERTHES DIEASES
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Appropriate angled osteotomy is made.Appropriate angled osteotomy is made.
Wedge is removed.Wedge is removed.
Make osteotomy as proximal as possible just below lag Make osteotomy as proximal as possible just below lag
screw for -screw for -
Better HealingBetter Healing
Better correction of deformity.Better correction of deformity.
Reduce the osteotomy and fixed with plate and Reduce the osteotomy and fixed with plate and
compression screw.compression screw.
Contd.Contd.
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SUBTROCHANTERIC DEROTATION SUBTROCHANTERIC DEROTATION AND VARUS OSTEOTOMYAND VARUS OSTEOTOMY
The aim of surgery is to center the whole "plastic" epiphysis The aim of surgery is to center the whole "plastic" epiphysis inside the joint cavity, keeping it well covered by the roof of inside the joint cavity, keeping it well covered by the roof of the acetabulum and allowing the child to walk so that the the acetabulum and allowing the child to walk so that the redistributed intra-articular pressures will contribute the redistributed intra-articular pressures will contribute the molding of a more normal joint.molding of a more normal joint.
A small 4-hole plate is bent to the desired angle, and a A small 4-hole plate is bent to the desired angle, and a subtrochanteric osteotomy is done followed by derotation and subtrochanteric osteotomy is done followed by derotation and yarns angulation of the shaft. A double hip spica is applied and yarns angulation of the shaft. A double hip spica is applied and the removed 2 months later. When the osteotomy site is the removed 2 months later. When the osteotomy site is united, the child is encouraged to walk, at first in warm water united, the child is encouraged to walk, at first in warm water pool, then with walking aids and finally without support.pool, then with walking aids and finally without support.
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VARUS DEROTATION OSTEOTOMY
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The operation is best suited for early stage of Leg-Calve-The operation is best suited for early stage of Leg-Calve-
Perthes’ disease, preferably those under the age of 7 years.Perthes’ disease, preferably those under the age of 7 years.
Axer : Described lateral open wedge osteotomy for children Axer : Described lateral open wedge osteotomy for children
< 5 years with perthes disease. Defect laterally fills rapidly < 5 years with perthes disease. Defect laterally fills rapidly
in young children > 5 years of age delayed or non union may in young children > 5 years of age delayed or non union may
occur.occur.
Contd.Contd.
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RECONSTRUCTIVE SURGERYRECONSTRUCTIVE SURGERY
Valgus subtrochanteric osteotomyValgus subtrochanteric osteotomy - for Hing - for Hing
AbductionAbduction
Shelf AugmentationShelf Augmentation – Coxa Megna. – Coxa Megna.
ChilectomyChilectomy - Malformed head in late III Group. - Malformed head in late III Group.
Chiar's Pelvic OsteotomyChiar's Pelvic Osteotomy - Large Malformed Femoral - Large Malformed Femoral
Head with Subluxation laterally.Head with Subluxation laterally.
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BIBLIOGRAPHYBIBLIOGRAPHY
Apley's System of Orthopaedics and Fractures - Loui's Soloman Apley's System of Orthopaedics and Fractures - Loui's Soloman
8th Edition.8th Edition.
Campbell's Operative Orthopaedics - 11th Edition. Vol.-2.Campbell's Operative Orthopaedics - 11th Edition. Vol.-2.
Text Book of Orthopaedics - John Ebnezar - IInd Edition.Text Book of Orthopaedics - John Ebnezar - IInd Edition.
Orthopaedic Knowledge Update – 7.Orthopaedic Knowledge Update – 7.
Samuel L Turek Orthopaedics principles & their applications Samuel L Turek Orthopaedics principles & their applications
volume volume
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