Arthroplasty Rounds:Pelvic Osteotomies

S. Rodriguez-Elizalde, MD

The University of OttawaDivision of Orthopaedic Surgery

Pelvic OsteotomiesPelvic Osteotomies‣Three Main Types:Three Main Types:

1.1. RedirectionalRedirectional

2.2. Reshaping Reshaping

3.3. SalvageSalvage

Pelvic OsteotomiesPelvic Osteotomies‣ Redirectional:Redirectional:

- Salter InnominateSalter Innominate

- Triple Innominate (Steel)Triple Innominate (Steel)

- Ganz PeriacetabularGanz Periacetabular

‣ Reshaping:Reshaping:

- DegasDegas

- PembertonPemberton

‣ Salvage:Salvage:

- ChiariChiari

- ShelfShelf

‣ Salter Innominate OsteotomySalter Innominate Osteotomy

‣ Triple Innominate Osteotomy (Steel)Triple Innominate Osteotomy (Steel)

‣ Ganz Periacetabular OsteotomyGanz Periacetabular Osteotomy

Redirectional Pelvic Redirectional Pelvic OsteotomiesOsteotomies

Salter Innominate Salter Innominate OsteotomyOsteotomy‣ First described by Salter in 1961First described by Salter in 1961

‣ Acetabular fragment mobility obtained Acetabular fragment mobility obtained with the single innominate osteotomy with the single innominate osteotomy

‣ Rotation is through the pliable fulcrum of Rotation is through the pliable fulcrum of the pubic symphysisthe pubic symphysis

‣ Primary indication for a Salter osteotomy Primary indication for a Salter osteotomy is a deficiency of anterolateral femoral is a deficiency of anterolateral femoral head coverage in an otherwise head coverage in an otherwise concentrically reduced hipconcentrically reduced hip

Salter Osteotomy Salter Osteotomy TechniqueTechnique

‣ Anterior approachAnterior approach

‣ Expose inner and outer tables of iliumExpose inner and outer tables of ilium

‣ Periosteum elevated off sciatic notchPeriosteum elevated off sciatic notch

‣ Forceps used to pass Gigli saw though Forceps used to pass Gigli saw though sciatic notchsciatic notch

‣ Osteotomize from notch to just above AIISOsteotomize from notch to just above AIIS

‣ Take bone graft from iliac crestTake bone graft from iliac crest

‣ Intramuscular (pelvic brim) tenotomy of Intramuscular (pelvic brim) tenotomy of iliopsoasiliopsoas

Salter Osteotomy Salter Osteotomy TechniqueTechnique

‣ Towel clip to pull distal fragment Towel clip to pull distal fragment anterior and rotate downwards anterior and rotate downwards

‣ Insert graftInsert graft

‣ K-wires from proximal fragment to K-wires from proximal fragment to distal fragment; check to ensure not distal fragment; check to ensure not in jointin joint

‣ Hip spica cast in young or Hip spica cast in young or untrustworthy kids x 6 weeksuntrustworthy kids x 6 weeks

Salter OsteotomySalter Osteotomy

‣ A shallow acetabulum is a relative A shallow acetabulum is a relative contraindication. contraindication.

‣ Expected improvements:Expected improvements:

- Center-edge angle of 20 to 22 degrees Center-edge angle of 20 to 22 degrees

- Acetabular index of 10-degreesAcetabular index of 10-degrees

‣ The triple osteotomy first described by The triple osteotomy first described by Steel in 1965 Steel in 1965

‣ Osteotomies of the ischium and pubis in Osteotomies of the ischium and pubis in addition to a Salter innominate osteotomyaddition to a Salter innominate osteotomy

‣ For older children (there is less For older children (there is less symphyseal rotation due to skeletal symphyseal rotation due to skeletal maturity)maturity)

‣ Concentric hip reduction is a prerequisiteConcentric hip reduction is a prerequisite

Triple Innomiate Triple Innomiate OsteotomyOsteotomy

Triple Osteotomy Triple Osteotomy TechniqueTechnique

‣ Lateral decubitus positionLateral decubitus position

‣ Prep buttocks and legPrep buttocks and leg

‣ Initial incision 1 cm proximal to buttock Initial incision 1 cm proximal to buttock crease down to gluteus maximuscrease down to gluteus maximus

‣ Release medial attachment to reveal Release medial attachment to reveal muscles attached to tuberositymuscles attached to tuberosity

‣ Release biceps femoris go between semi-T Release biceps femoris go between semi-T and semi-M and semi-M

Triple Osteotomy Triple Osteotomy TechniqueTechnique

‣ Subperiosteal dissection of ischial ramusSubperiosteal dissection of ischial ramus

‣ Protect pudendal NV bundle osteotomize Protect pudendal NV bundle osteotomize ramusramus

‣ Smith-Petersen approach (expose Smith-Petersen approach (expose pectineal tubercle) pectineal tubercle)

‣ Osteotomize pubis medial to tubercleOsteotomize pubis medial to tubercle

‣ Perform Salter osteotomyPerform Salter osteotomy

‣ Can use screws instead of k-wiresCan use screws instead of k-wires

‣ Avoid over rotationAvoid over rotation

Ganz OsteotomyGanz Osteotomy

‣ Introduced in 1988 by Ganz Introduced in 1988 by Ganz

‣ Allows extensive acetabular reorientation, Allows extensive acetabular reorientation, including medial and lateral displacement. including medial and lateral displacement.

‣ Osteotomies performed in the pubis, ilium, Osteotomies performed in the pubis, ilium, and ischium. and ischium.

‣ Vertical posterior column osteotomy Vertical posterior column osteotomy connects the posterior extremes of the connects the posterior extremes of the iliac and ischial osteotomies 1 cm anterior iliac and ischial osteotomies 1 cm anterior to the sciatic notch to the sciatic notch

‣ Done after skeletal maturity, because it Done after skeletal maturity, because it (crosses the tri-radiate cartilage)(crosses the tri-radiate cartilage)

Ganz OsteotomyGanz Osteotomy‣ Stable; No complete cut is made into the Stable; No complete cut is made into the

sciatic notch (the posterior column is split sciatic notch (the posterior column is split vertically)vertically)

‣ Advantages:Advantages:

- No postoperative cast is requiredNo postoperative cast is required

- Immediate crutch weight bearingImmediate crutch weight bearing

- Preservation of the blood supply to the Preservation of the blood supply to the acetabular fragmentacetabular fragment

- Single surgical approach Single surgical approach

- Preservation of the shape of the pelvis, Preservation of the shape of the pelvis, which permits normal vaginal deliverywhich permits normal vaginal delivery

‣ Disadvantage is that the procedure is Disadvantage is that the procedure is difficult to learndifficult to learn

Ganz TechniqueGanz Technique‣ Smith-PetersenSmith-Petersen

‣ Partial osteotomy of ischium Partial osteotomy of ischium back to where the posterior limb back to where the posterior limb of the ilial osteotomy will goof the ilial osteotomy will go

‣ Pubis is osteotomized as with Pubis is osteotomized as with the triple innominatethe triple innominate

‣ Biplanar osteotomy of ilium Biplanar osteotomy of ilium (split the posterior column (split the posterior column vertically, then along the top of vertically, then along the top of capsule to just above AIIS)capsule to just above AIIS)

‣ Rotate fragment and secure Rotate fragment and secure with screwswith screws

Ganz Pelvic OsteotomyGanz Pelvic Osteotomy

‣ Dega Pelvic OsteotomyDega Pelvic Osteotomy

‣ Pemberton Osteotomy Pemberton Osteotomy

Re-Shapping Pelvic Re-Shapping Pelvic OsteotomiesOsteotomies

‣ AcetabuloplastyAcetabuloplasty that changes acetabular that changes acetabular configuration and shape configuration and shape

‣ The primary indication is presence of a The primary indication is presence of a capacious acetabulum with posterolateral capacious acetabulum with posterolateral deficiency:deficiency:

- Often done in children with cerebral palsyOften done in children with cerebral palsy

- Also used for persistent acetabular Also used for persistent acetabular dysplasia in DDHdysplasia in DDH

‣ Provides increased postero-lateral coverage:Provides increased postero-lateral coverage:

- osteotomy of the lateral cortex of the ilium osteotomy of the lateral cortex of the ilium hinging through the tri-radiate cartilagehinging through the tri-radiate cartilage

Dega Pelvic OsteotomyDega Pelvic Osteotomy

DEGAS?

DEGAS?

‣ Anterior approachAnterior approach

‣ Osteotomy of outer cortex above AIIS, Osteotomy of outer cortex above AIIS, curves posteriorly just above acetabulum curves posteriorly just above acetabulum to 1 cm from sciatic notchto 1 cm from sciatic notch

‣ Straight osteotome directed medially to a Straight osteotome directed medially to a point just above the horizontal part of the point just above the horizontal part of the triradiate cartilagetriradiate cartilage

Dega Osteotomy: Dega Osteotomy: TechniqueTechnique

‣ Amount of inner cortex divided Amount of inner cortex divided determines fragment rotation (ie more determines fragment rotation (ie more posterior sciatic notch hinge or medial posterior sciatic notch hinge or medial cortex hinge)cortex hinge)

‣ Open with lamina spreaded and insert Open with lamina spreaded and insert tricortical graft from iliac cresttricortical graft from iliac crest

‣ No internal fixation neededNo internal fixation needed

‣ Spica cast for 6-12 weeksSpica cast for 6-12 weeks

Dega Osteotomy: Dega Osteotomy: TechniqueTechnique

Dega OsteotomyDega Osteotomy

‣ First reported in 1958 by Dr. Paul First reported in 1958 by Dr. Paul PembertonPemberton

‣ The tri-radiate cartilage must be open and The tri-radiate cartilage must be open and flexible (before 6 years of age)flexible (before 6 years of age)

‣ Femoral head must be concentrically Femoral head must be concentrically reduced reduced

‣ Hip motion must be normal: good flexion, Hip motion must be normal: good flexion, abduction and inward rotationabduction and inward rotation

‣ Osteotomy tends to place the acetabulum Osteotomy tends to place the acetabulum forward and outwardforward and outward

Pemberton Pelvic Pemberton Pelvic OsteotomyOsteotomy

‣ Anterior approach, division of psoas may Anterior approach, division of psoas may be beneficialbe beneficial

‣ Split iliac apophysis and expose inner and Split iliac apophysis and expose inner and outer tables of iliumouter tables of ilium

‣ Starting just above AIIS, osteotomize in a Starting just above AIIS, osteotomize in a curvilinear fashion, staying in ilium, to the curvilinear fashion, staying in ilium, to the tri-radiate cartilagetri-radiate cartilage

Pemberton: TechniquePemberton: Technique

‣ Expose the sciatic notch and combine Expose the sciatic notch and combine with this exposure and fluoro to stay in with this exposure and fluoro to stay in bone to tri-radiatebone to tri-radiate

‣ Need special right-angle osteotome to Need special right-angle osteotome to connect the inner and outer cuts near connect the inner and outer cuts near triradiatetriradiate

‣ Insert triangular tricortical graft from Insert triangular tricortical graft from crest crest

‣ Spica for 6 weeks then protected Spica for 6 weeks then protected weight bearing and physioweight bearing and physio

PEMBERTON = OVERZEALOUS DEGAPEMBERTON = OVERZEALOUS DEGA

Pemberton: TechniquePemberton: Technique

Pemberton OsteotomyPemberton Osteotomy

‣ Chiari Pelvic OsteotomyChiari Pelvic Osteotomy

‣ Shelf Osteotomy Shelf Osteotomy

Salvage OsteotomiesSalvage Osteotomies

‣ Medial displacement osteotomy that uses Medial displacement osteotomy that uses cancellous bone with interposed capsule cancellous bone with interposed capsule for articulating surfacefor articulating surface

‣ May be augmented with a shelf procedureMay be augmented with a shelf procedure

Chiari Pelvic Chiari Pelvic OsteotomyOsteotomy

‣ Displace distal fragment medially Displace distal fragment medially (abduct leg)(abduct leg)

‣ Secure osteotomy, augmented as Secure osteotomy, augmented as necessarynecessary

‣ Spica cast or protected weight Spica cast or protected weight bearing fragment medially (abduct bearing fragment medially (abduct leg)leg)

Chiari Osteotomy Chiari Osteotomy TechniqueTechnique

‣ Displace distal fragment medially (abduct Displace distal fragment medially (abduct leg)leg)

‣ Secure osteotomy, augmented as Secure osteotomy, augmented as necessarynecessary

‣ Spica cast or protected weight bearingSpica cast or protected weight bearing

Chiari Osteotomy Chiari Osteotomy TechniqueTechnique

Chiari Pelvic Chiari Pelvic OsteotomyOsteotomy

Chiari Pelvic Chiari Pelvic OsteotomyOsteotomy

‣ AKA Staheli Osteotomy AKA Staheli Osteotomy

‣ Bone graft placed just above Bone graft placed just above the hip joint the hip joint

‣ Creates a wider roof / shelf Creates a wider roof / shelf over the acetabulumover the acetabulum

‣ Keeps the femoral head from Keeps the femoral head from sliding up and out of the sliding up and out of the socket socket

‣ When healed, makes a larger When healed, makes a larger weight-bearing surfaceweight-bearing surface

‣ Not a true osteotomy of the Not a true osteotomy of the pelvispelvis

Shelf OsteotomyShelf Osteotomy

‣ Anterior approach, identify reflected head Anterior approach, identify reflected head of rectus and divide it at midpointof rectus and divide it at midpoint

‣ Identify edge of acetabulum (may need to Identify edge of acetabulum (may need to thin capsule slightly)thin capsule slightly)

‣ Use drill to make 1 cm holes at acetabular Use drill to make 1 cm holes at acetabular edge aiming about 20° cephaladedge aiming about 20° cephalad

‣ Use rongeur to connect holes and make Use rongeur to connect holes and make slotslot

Shelf Osteotomy Shelf Osteotomy TechniqueTechnique

‣ Get 1 cm wide cancellous graft strips Get 1 cm wide cancellous graft strips from outer iliumfrom outer ilium

‣ Insert strips into slot, followed by layer Insert strips into slot, followed by layer superior at 90°superior at 90°

‣ Repair rectus overtop to secure graftRepair rectus overtop to secure graft

‣ Spica cast at 15° abduction, 20° flexion Spica cast at 15° abduction, 20° flexion and neutral rotation for 6 weeks, then and neutral rotation for 6 weeks, then protected weight bearing for another 6protected weight bearing for another 6

Shelf Osteotomy Shelf Osteotomy TechniqueTechnique

Shelf OsteotomyShelf Osteotomy

Pelvic Osteotomies -Pelvic Osteotomies -SUMMARYSUMMARY‣Remember:Remember:

1.1. RedirectionalRedirectional

2.2. Reshaping Reshaping

3.3. SalvageSalvage

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