Then Why am I delivering this lecture ? -Write an answer in the DNB/MS exam - Get a VERY BASIC understanding…. - Stimulate further reading if you care

I HAVE

NO EXPERIENCE WITH

HIP OSTETOMIES

Campbells 10 edition Tachdigian :Peadiatric Orthopaedics Mc nicoll :Hip Osteotomies Roger Dee: Prinicples & PracticeOrthopaedics AAOS: ICL Tronzo : Hip Surgery OCNA : Pediatric Hip Disorders

Hip with hope Vs Hip with out hope?

Hip with hope ?

Biomechanics Asessment General Overview Specific aetiology FAI

Hip designed to- support BW - permit mobility

Max ROM 140 flex/ext, 75 add/abd Functional ROM 50-60 flex/ext 1.8-4.3 x BW through hip Highest ascending stairs

One legged stance 5/6 BW on femoral head

Ratio of lever arms to BW 3:1

Cane in Contralateral hand decreases JRF

Long moment arm makes iteffective

15% BW to cane reduces joint contact forces by 50%

Dynamic analysis much more complex

Forces across hip joint combination of:◦ Body weight◦ Ground reaction forces◦ Abductor muscle forces

Improving abductor function will decrease joint reactive forces

Physical exam to ensure ROM Plain films

◦ Standing AP◦ Frog leg lateral◦ False profile (anterior lip cover.)◦ Full abduction/adduction

CT scan +/- 3D reconstruction

True lateral view made with the patientstanding,the pelvis turned 25 degrees toward the beam the ipsilateral foot and knee &the radiographic film perpendicular to the beam

Osteotomies improve hip function◦ Increasing contact area / congruency ◦ Improve coverage of head◦ Moving normal articular cartilage into weight

bearing zone◦ Restore biomechanical advantage / Decreasing

joint reactive forces ◦ ?? Stimulating cartilage repair

Ostoeotomy can be viewed as either◦ Reconstructive ◦ Salvage

Femoral osteotomy to correct proximal femoral abnormalities and vice versa

Femoral Varus,Valgus,Derotation,Ext,Flex Neck, Intertrochanteric,Sub troch Pelvic Re orientation Salvage Combined

Goal of reconstructive osteotomy, femoral or pelvic are

-Restore as nearly normal anatomy as possible -Return joint pressures and loading patterns to normal

primary problem is malalignment

Goal of salvage osteotomies are

-Relieve pain and improve function enough to delay the THR in active patients <50

Neuropathic arthropathy Inflammatory arthropathy Active infections Severe osteopenia Advanced arthritis/ankylosis Advanced age *smoking, obesity

Intact lateral portion of femoral head is prerequisite

Can be combined with either flexion or extension component

Indications: hip joint instability b/c femoral deformity which corrects with internal rotation & abduction view

Pelvic osteotomy should be performed in pts with CEA < 15 degrees

Useful some DDH, SCFE, LCP, AVN and femoral neck non-union/malunion

Potential to shorten limb

Weaken abductors

Trendelenburg gait

Potential difficulty with stem insertion in future arthroplasty

Coxa vara

Performed if adduction film reveals concentric reduction

Moves non-inervated inferior cervical osteophytes into contact with floor of acetabulum

Lateral traction on superior capsule may stimulatefibrocartilage transformation

Reconstructive◦ Salter 18m – 6y◦ Pemberton 18m – 10y◦ Steel skeletal maturity◦ PAO (Ganz) skeletal maturity

Salvage◦ Chiari skeletal maturity

Single Innominate osteotomy Acetabulum together with ilium and pubis

rotated Held by wedge of bone Illiopsoas & adductor tenotomies common 18 mon to 6 years

Pericapsular osteotomy for residual dysplasia

Hinges through the triradiate cartilage – must be open!!

Changes the volume & orientation of acetabulum

Although good results up to 10 most recommend 6 to 8 years

Indication : DDH in older child

Need good ROM

Secure with bone graft & AO screw fixation

Contraindications◦ Limited ROM◦ Incongrous reduction◦ Significant joint space

narrowing / degenerative arthritis

Two incision approach

Devised by Ganz Indication – DDH in

adolescents & adults

Achieves containment & congruency

Permits extensive reorientation Preserves blood supply Posterior column remains intact – true

pelvis unchanged Single incision Preferred reconstructive osteotomy for

acetabular dysplasia

Devised by Chiari 1950’s Salvage procedure Relief of pain in incongrous hip Increases coverage by medializing hip

centre Fibrocartilage transformation of superior

capsule

Chiari reported 200 procedures◦ 2/3 good to excellent outcome◦ 1/3 improved

Similar results by others While pain relief is predictable,

trendelenburg gait remains Trochanteric advancement may alleviate

trendelenburg gait

•Hip Dysplasia

•Legg-Calve-Perthes Disease

•Slipped Capital Femoral Epiphysis

•Post septic sequeale

•TB Hip

•Epi/met dysplasias

Prevalence of OA by age 50 ◦ DDH 40-50%◦ LCP 50%◦ SCFE 20%

Despite many recent advances arthroplasty has many limitations in younger patients

Femoral: Varus+/- Shortening +/- Derotation

Pelvic Salters & Modifications Pemberton Steels

Combined

Persistent dysplasia can be corrected by

Redirectional proximal femoral osteotomy in very young children.

If the primary dysplasia is acetabular, pelvic redirectional osteotomy alone is more appropriate.

Many older children require femoral and pelvic osteotomies.

Pre req for Pelvic osteotomy

• Femoral head has been concentrically seated in the dysplastic acetabulum

• the joint has failed to develop satisfactorily,• growth potential of the acetabulum no longer exists

If primary acetabular dysplasia then Pelvic osteotomy

Age : 4 – 8 : Femoral , if persistent dysplasia then Pelvic added

>8 yrs : pelvic + Femoral shortening

Important to correct soft-tissue anomaly and bony deformity to prevent redislocation

DDH Zadeh et al. 82 children (95 hips)

  1.   

Hip stable in neutral position—no osteotomy

  2.   

Hip stable in flexion and abduction—innominate osteotomy

  3.   

Hip stable in internal rotation and abduction—proximal femoral derotational varus osteotomy

  4.   

“Double-diameter” acetabulum with anterolateral deficiency—Pemberton-type osteotomy

Non Union Neck Femur

Pauwels Valgus with Fixation +/- Fibula/Vas Fibula/TFL MPG( Bakhis )/Quad Fem

( Meyers)

Salvage: Mc Murrays Arm Chair effect Not aiming at fracture union Biological effects Mechanical effects Schanz : PSO

Schanz

Pelvic osteo: Chiari , Salter Proximal femur: Schanz PSO: Dec lurch Inc Legth Trochanteric Arthroplasty Colonas El episcopos/Harmons Corrective osteotomy

Stage 1 Greater trochanter is placed into the acetabulum Hip abductors are moved distally on the femur

Stage 2 A proximal femoral osteotomy 1 month later, +/- acetabuloplasty

Ideal in children younger than 10 years

Femoral : Shortening +/- VDRO

Pelvic : Roomy acetabulum: Pembertons

Open Femoral: VERO Closed

Pelvic: Salters innominate

Valgus + Extension Works if healthy bone can be reoriented

under wt bearing zone

Sugiokas : Transtrochanteric reorientation

Sugioka Osteotomy

Indications Types Location: Sub capital: Fish & Dunn Base of neck( IA) : Kramer Extra articular base: Abrams

Intertrochateric : Southwick: ValIn Rot Flex O

Complications AVN Chondrolysis

Femoral: Valgus,Varus,=/- Ext , flex

Pelvic Ganz Salters

Mullers principles: Advanced OA < 50 degrees of motion in flexion Not a good candidate for intertrochanteric osteotomy.

RA : Poor prog

Intertrochanteric osteotomy in AVN effective only if healthy bone can be brought into the weight bearing area. Extensive involvement and collapse of the femoral head are contraindications.Osteotomy should increase and not decrease the weight bearing area of the femoral head.

Fixed adduction deformity is CI to varus osteotomy and fixed abduction deformity to valgus osteotomy.

Stable internal fixation is important, permits early motion, and enhances union of the osteotomy.

Recurrence of hip pain from arthritis may be simulated by bursitis over a protruding internal fixation device.

If it fits better with the hip in abduction, an adduction (varus) osteotomy is appropriate.

If the head fits better in the acetabulum with the hip in adduction, an abduction (valgus) osteotomy is appropriate.

Early secondary arthritis of the hip -primary acetabular dysplasia Small center-edge angle leaves the lateral aspect of the articular surface of the femoral head uncovered

This results in high stresses at the weight bearing portion of the articular surfaces of the hip, leading to early degenerative changes

Varus osteotomy alone is indicated in -spherical femoral head, -little or no acetabular dysplasia (a center-edge angle of at least 15 to 20 ) -signs of lateral overloading -valgus neck-shaft angle of more than 135 degrees

-Medial displacement of the shaft by 10 – 15mm Centre the knee Relax the abduc, adduc , flex Increase the wt bearing area

-Causes shortening-Trenedelenberg gait

Advantages of periacetabular osteotomy :

(1) Only one approach is used

(2) large amount of correction can be obtained in all directions

(3) blood supply to the acetabulum is preserved

(4) posterior column of the hemipelvis remains mechanically intact, immediate crutch walking with minimal internal fixation

(5) the shape of the true pelvis is unaltered-normal delivery

(6) it can be combined with trochanteric osteotomy if needed

Shelf Osteotomies Vs Chiari Osteotomy in

Acetabular dysplasia

Shelf osteotomy : Moderate dysplasia without severe arthrosis,

Chiari osteotomy :Severe dysplasias, with or without arthrosis.

Excellent results with Middle path regimen ? Thomas test of recovery

Pelvic suppport osteotomy(PSO) -Shanz

Milch Bachelor Osteotomy: PSO+Girdlestone

Girdlestone Arthroplasty

•Coxa profunda – floor of

fossa acetabuli overlaps

ilioischial line medially

•Pincer type FAI

•Creates deep acetabulum

•General overcoverage

•Normal

•Protrusio acetabuli – occurs when the femoral head overlaps the ilioischial line medially

•Pincer type FAI

•Creates deep acetabulum

•General overcoverage

•Normal

•Lateral center edge angle – pincer type FAI

•Normal is between 25 and 39 degrees

•Increases with deeper acetabulum and more overcoverage

Protrusio acetabuli

•Acetabular retroversion – pincer type FAI

•Cross over sign

•Focal acetabular overcoverage

•Cranial anterior wall line projects laterally

•Anterior/anterolateral labrum is obstacle to flexion and internal rotation

•Distinguish from deficient posterior wall

•Posterior wall sign – pincer type FAI

•PW line should descend through center of femoral head

•Medial – deficient

•Lateral – prominent

•Pistol grip deformity - Cam type FAI

•Loss of normal concavity

•Etiology

•Growth abnormality of the capital femoral epiphysis

•SCFE

•LCPD

•Fracture healing

•Horizontal growth plate sign - Cam type FAI

•Some predisposing factors to FAI

•Legg-Calve-Perthes disease

•Congenital hip dysplasia

•Slipped capital femoral ephiphysis

•Avascular necrosis

•Malunited fractures

•Acetabular protrusion

•Elliptical femoral head

•Retroverted acetabulum

•Prominent femoral head-neck junction

•Proposed etiologies

•Abnormal anatomy

•Prominent femoral head neck junction

•Acetabular overcoverage

•Middle to older aged women (40)

•Seen in ballet dancers

•Close approximation of acetabular rim and femoral neck – acetabular abnormality

•Acetabular overcoverage

•Focal articular damage

•Acetabular damage can propagate

•Primary radiographic signs

•Coxa profunda

•Protrusio acetabuli

•Acetabular retroversion

•Decreased extrusion index

•Neutral acetabular index

•Posterior wall sign

•Posterior inferior cartilage abrasion due to contracoup injury

•Young males (32 years)

•Primary femoral abnormality

•Aspherical femoral head

•Femoral head jams into acetabular rim

•Shear forces on labrum and cartilage

•Diffuse articular damage

•Primary radiographic signs

•Pistol grip deformity

•CCD angle less than 125 degrees

•Horizontal growth plate sign

•Alpha angle greater than 50 degrees

•Femoral head-neck offset less than 8 mm

•Femoral retrotorsion