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Pelvic Osteotomies

Aims

  1. To correct structural deformities and prevent development of OA
  2. To alter the course of established degenerative changes

Pain relief secondary to

  1. Increased weight bearing area and move to unworn cartilage
  2. Reduce venous hypertension (trochanteric) thought to decrease rest pain in OA
  3. Alteration of muscle forces about the hip

Indications

  • CDH / CSH / Acetabular dysplasia
  • Perthes to attain containment
  • Early OA in young patients

Chiari Osteotomy

Karl Chiari (Austria) First described osteotomy in 1955 and first published in English in 1974 (Clin Orth). Salvage procedure with increased coverage using bone and capsule. Maximal improvement reached 2-3 years post surgery. Results in proximal migration of the femur of 1.5 cm. Results of operation depend primarily in the condition of the hip prior to surgery.
Operative Technique

  1. Apply adhesive tape to each leg for post operative skin traction
  2. Position supine on orthopaedic traction table with leg in slight abduction and external rotation
  3. Position image intensifier centred over the hip
  4. Limited anterior approach to hip, 5 cm over iliac crest and 5 cm extending down the thigh from the ASIS
  5. Fascia incised in line of tensor and gluteus medius
  6. Reflected head of rectus femoris identified
  7. Retractor placed into sciatic notch and muscle freed on inner and outer aspect of pelvis
  8. Reflected head of rectus raised from the capsule
  9. Osteotome placed deep to rectus and image intensifier used to check level and angle which should be angled up at 5-10o from the horizontal
  10. Osteotome cuts to conform to the proximal curve of the acetabulum and extended into the sciatic notch with care
  11. Abduct leg fully ? medial displacement of acetabulum. If difficult either wrong angle or incomplete cut
  12. At least 2 cm displacement usually required (for each 2 cm displacement, load decreases by 13%)
  13. Reattach foot in 20-30o abduction and close wound
  14. No fixation used, maintain abduction in traction 3/52 (or use a spica)
  15. FWB when power and comfort permit
  16. Limp usually gone by 6/12

Salter Osteotomy

Robert B Salter (Canada) described osteotomy in 1961 (JBJS). Believes instability be secondary to the abnormal direction the acetabulum faces. Concentric reduction of the hip is required before operation. Osteotomy involves rotation of the acetabulum about the symphysis, which due to the fixed axis of rotation limits correction to 25 - 30o improvement in acetabular orientation and limited lateral cover. Procedure lengthens limb about 1 cm.

Operative Technique

  1. Patient supine on operating table with sand-bag under thorax
  2. Free drape operative leg
  3. Adductor tenotomy performed if required
  4. Smith-Perterson approach along iliac crest to ASIS and then distally to AIIS
  5. Iliac apophysis incised and periosteum stripped to the sciatic notch
  6. Anterior hip capsule exposed by dissection between tensor fascia latae and sartorius
  7. Open reduction of hip performed at this time if necessary
  8. Gigili saw passed subperiosteally around sciatic notch
  9. Osteotomy performed in a straight line from notch to AIIS
  10. Generous full thickness graft obtained from anterior part iliac crest and trimmed to a wedge
  11. Towel clips used to stabilise proximal segment and displace distal segment forwards, downwards and outwards to open the osteotomy anterolaterally
  12. Bone graft then inserted and stabilised with a stout K wire
  13. Wound then closed after capsular repair if open reduction performed and approximation and suture of apophysis
  14. Hip spica applied in slight abduction, flexion and medial rotation
  15. Spica and K wire removed removed at 6/52
  16. PWB for 2/52 then FWB
  17. 95% excellent or good result when performed at 18 months - 4 years
  18. 50% excellent or good result when performed at more than 4 years
  19. 60-70% excellent or good result when performed less than 6 years

Pemberton Osteotomy

Paul A Pemberton (Utah) described osteotomy in 1974 (Clin Orthop). Rotation down of the acetabulum through the triradiate cartilage. Changes the direction and shape of the acetabular roof lessen the capacity of the acetabulum.

Operative Technique

  1. Smith-Peterson approach
  2. Glutei and tensor stripped from anterior 1/3 ilium to margin of acetabulum and sciatic notch with iliac apophysis displaced medially
  3. Hip capsule opened and joint inspected
  4. Osteotomy through both tables of the ilium, the outer table starting just below the AIIS
  5. The osteotome directed back towards the ilio ischial limb of the triradiate cartilage
  6. Osteotome then used to make a similar cut on the inner table
  7. Broad curved osteotome used to complete the osteotomy and direct the superior rim of the acetabulum downwards
  8. Osteotomy held open with a laminectomy spreader
  9. Graft cut from iliac crest and driven into the cleft
  10. Capsule is then closed and overlapped if necessary
  11. The wound is closed in layers
  12. Hip spica in slight abduction for 8/52 ? FWB

Steele Osteotomy

Lateralises the hip and shortens the abductors. Enables greater freedom of correction due to triple osteotomy.

Operative Technique

Stage 1:

  1. Patient supine hip and knee flexed to 90o
  2. Transverse incision 1 cm proximal to gluteal crease
  3. Retract gluteus maximus laterally to expose hamstrings
  4. Free biceps femoris from origin and expose space between semimembranosis and semitendinosus
  5. Pass hemostat around ischium between these muscles and osteotomise bone
  6. Direct osteotome postero-laterally and at 45o to the perpendicular
  7. Allow biceps femoris origin to fall back into place, approximate gluteus maximus and close skin

Stage 2:

  1. Using second operative set up
  2. Ilio-femoral approach reflecting iliac and gluteal muscles 
  3. Detach lateral attachment of inguinal ligament and sartorius from ASIS
  4. Extend periosteal elevation to pectineal tubercle and elevate pectineus sub-periosteally
  5. Pass a curved haemostat around superior pubic ramus ~ 1 cm lateral to the pubic tubercle
  6. Osteotomise ramus at inclination of 15o to perpendicular
  7. Osteotomise innominate as for Salter osteotomy through the sciatic notch
  8. Perform open reduction of femoral head if necessary
  9. Harvest graft from anterior iliac crest
  10. Reduce acetabulum to desired position, insert graft and stabilise with 2x K wires
  11. Allow iliopsoas and pectineus to fall back into place, reattach sartorius and inguinal ligament and close the wound
  12. Post operative spica in 20o Abduction and 5o Flexion for 8-10/52
  13. Osteotomies usually unite by 12/52
  14. WB on crutches after 12-14/52 and independent in 6/12

Steele

Sutherland Osteotomy

Osteotomy through pubis brings increased freedom for rotation

Operative Technique

  1. Ensure bladder empty
  2. Patient supine with sand bag under effected hip
  3. Smith-Peterson approach and perform innominate osteotomy as for a Salter
  4. Transverse supra-pubic incision retracting spermatic cord / round ligament laterally
  5. Release rectus abdonimus and pyramidalis muscles from pubis and adductor longus from anterior surface
  6. Place needle in symphysis and take an X-Ray to confirm location
  7. Elevate periosteum and protect tissues, i.e. internal pudental artery on medial margin of inferior ramus and the dorsal vein and artery of the penis in the midline
  8. Resect a wedge of bone 7-13 mm in diameter just lateral to the symphysis parallel to it
  9. Using a towel clip displace lateral segment medially, posteriorly and superiorly
  10. Displace acetabular fragment distally and anteriorly and insert triangular graft to stabilise innominate osteotomy
  11. Transfix the osteotomy with 2 heavy K wires
  12. Insert drains and close the wound
  13. Apply a spica cast for 8/52, pins left in place until the osteotomies have united

Sutherland

Dial Osteotomy

For truly dysplastic hips where the head is concentrically located but the CE angle of Wiberg is less than 15-20o. Motion in the hip should be normal or close to it.

Operative Technique

  1. Patient supine, sand bag under the buttock / sacrum and free drape the affected leg
  2. Expose the hip through a Smith-Peterson approach, divide the lateral cutaneous nerve of the thigh and separate sartorius and tensor from the ilium subperiosteally
  3. Divide rectus femoris at the AIIS
  4. Expose capsule of the hip joint over as much circumference as possible
  5. Reflect periosteum from the acetabular margin
  6. Flex hip and divide ilio-psoas from the lesser trochanter
  7. Incise capsule of hip joint in line with the neck
  8. Identify exactly the acetabular margins and examine the articular surface of the femoral head
  9. Perform circumferential osteotomy ideally taking 1 cm of bone with the cartilage
  10. Once osteotomy complete put traction to the leg to allow rotation of the acetabulum to the desired position, then abduct the hip and release traction to maintain the desired position
  11. A Stienman pin may be used to stabilise the osteotomy
  12. Spica in slight abduction and 10o Flexion for 6/52 
  13. PWB and FWB when gains active abduction against gravity (usually 4-6/52 after RO spica)
  14. Can be managed in abducted traction for 6/52

Dial

Shelf Procedure (Staheli)

This is generally regarded as a salvage procedure. Assess the width of the shelf required by the amount needed to bring the CE angle out to normal (30-35o)

Operative Technique

  1. Patient supine tilted to side or on traction table
  2. Incision 2-3 cm below and parallel to iliac crest and then expose the hip through and ilio-femoral approach
  3. Divide tendon of reflected head of rectus femoris and displace this anteriorly, i.e. divide below the AIIS to give length
  4. If capsule excessively thick, thin it with a scouple
  5. Placement of acetabular slot at the margin of the acetabulum is the most important part of the operation. Should be 1 cm deep with articular cartilage in the base
  6. Make thin strips of cortico-cancellous bone from lateral ilium extending decortication of the outer wall of the ilium to the lateral lip of the slot above the acetabulum
  7. Apply first layer of bone graft radially from the slot, second layer at right angles to the first to provide a well defined lateral margin of the shelf
  8. Replace and secure the reflected head of rectus over these layers and suture to the capsule
  9. Fill in Space above using the remaining graft which is then held in place by the abductors
  10. Close the wound and apply a spica in 15o Abduction and 20o Flexion
  11. Spica on for 6/52 
  12. PWB until graft incorporated
  13. Usually FWB at about 3-4 months


                                   Shelf


Overview of pelvic osteotomies

  • Innominate best for 18 months - 6 years (occasionally older)
  • Acetabuloplasty (Pemberton) best for 1 -12 years (girls) & 1 - 14 yrs (boys)
  • Osteotomy to free acetabulum (Steel / Sutherland) or dial (Eppright / Wagner) best if 6 years to young adults
  • Shelf (Wainwright / Chiari) salvage for 4 years to adult
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