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

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.

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

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

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

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

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.

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

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.

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.

OVERVIEW OF PELVIC OSTEOTOMYOVERVIEW OF PELVIC OSTEOTOMY

SALTER OSTEOTOMYSALTER OSTEOTOMY

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.

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

PEMBERTON OSTEOTOMYPEMBERTON OSTEOTOMY

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.

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

PERIACETABULAR OSTEOTOMY OF ILIUM PERIACETABULAR OSTEOTOMY OF ILIUM (PEMBERTON)(PEMBERTON)

TRIPLE INNOMINATE OSTEOTOMY TRIPLE INNOMINATE OSTEOTOMY (STEEL)(STEEL)

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

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.

GANZ OSTEOTOMYGANZ OSTEOTOMY

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.

THE SHELF PROCEDURE (STAHELI)THE SHELF PROCEDURE (STAHELI)

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.

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

CHIARICHIARI

CHIARICHIARI

INNOMINATE OSTEOTOMY WITH MEDIAL INNOMINATE OSTEOTOMY WITH MEDIAL DISPLACEMENT OF ACETABULUM (CHIARI)DISPLACEMENT OF ACETABULUM (CHIARI)

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 .

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.

REVIEW OF PELVIC OSTEOTOMIESREVIEW OF PELVIC OSTEOTOMIES

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.

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.

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.

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.

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.

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.

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° .

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.

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.

PAUWELS Y SHAPED OST

COXA VERACOXA VERA

COXA VERACOXA VERA

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.

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

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.

VARUS/VALGUS/DEROTATION FEMORAL VARUS/VALGUS/DEROTATION FEMORAL OSTEOTOMIES ARE -OSTEOTOMIES ARE -

VARUS OSTEOTOMIESVARUS OSTEOTOMIES

FEMORAL OSTEOTOMYFEMORAL OSTEOTOMY

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.

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.

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.

VALGUS INTERTROCHANTERIC FEMORAL VALGUS INTERTROCHANTERIC FEMORAL OSTEOTOMIES :OSTEOTOMIES :

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.

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.

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

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

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.

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.

OSTEOTOMY TO CORRECT UNSTABLE OSTEOTOMY TO CORRECT UNSTABLE INTERTROCHANTERIC FRACTURES INTERTROCHANTERIC FRACTURES

Sarmiento TechniqueSarmiento Technique

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.

DIMON AND HUGHSTON METHOD OF DIMON AND HUGHSTON METHOD OF INTERTROCHANTERIC OSTEOTOMYINTERTROCHANTERIC OSTEOTOMY

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.

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.

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.

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

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

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.

CORRECTIVE OSTOTOMIESCORRECTIVE OSTOTOMIES

Brackett ball and socketOsteotomy

Whitman closing wedge

Osteotomy Gant-opening wedge

Osteotomy

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

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.

McMURRAY

MC-MURRAY OSTEOTOMYMC-MURRAY OSTEOTOMY

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

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

GIRDLESTONE OSTEOTOMY

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.

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

TRANSTROCHANTRIC ANT. ROTATIONAL TRANSTROCHANTRIC ANT. ROTATIONAL OSTEOTOMY OSTEOTOMY [SUGIOKA][SUGIOKA]

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.

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.

PERTHES DIEASESPERTHES DIEASES

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.

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.

VARUS DEROTATION OSTEOTOMY

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.

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.

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