Presentation Osteotomy

8/3/2019 Presentation Osteotomy

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Dr.N.KIRE,PGT

MEDICAL COLLEGE AND HOSPITAL


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(1)Osteotomy of the innominate bone (Salter),

(2) Acetabuloplasty (Pemberton),

(3) Osteotomies that free the acetabulum (Steeltriple innominate osteotomy or dial

acetabular osteotomy),

(4) Shelf operation (Staheli), and(5) Innominate osteotomy with medial

displacement of the acetabulum (Chiari).

PELVIC OSTEOTOMIES


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Useful only when subluxated or dislocated is reduced or can be

reduce by open reduction.

The entire acetabulum together with the pubis and ischium is rotated

as a unit with symphysis pubis as a hinge.

The acetabulum is redirected without changing either its capacity or

shape.

Illiopsoas & adductor tenotomies common Recommended :18 months to 6years old child.


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Indications:Subluxation of the femoral head from true acetabulum.Reasonable congruity present or can be obtained.Radiological cartilage space atleast of normal thickness for thepatient age.

Atleast 60% of normal flexion/abduction.

contraindication:Absence of any of the above indication in a young patient.

Pre-requisites:Femoral pull down upto the level of acetabulum.All contractures released.Concentric and congruent reduction of femoral headGood ROM


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Uses:

DDH. Kochs Arthritis. -

Complication

- Deep infection.

- Transient femoral nerve paresis.AFTER TREATMENT:

At 8 to 12 weeks: the spica cast and the Kirschnerwires are removed. The position of the osteotomy

and of the hip is checked by radiographs.


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It redirect the inclination of the acetabular roof by an osteotomy of

the ilium superior to the acetabulum.

Pericapsular ilium osteotomywith triradiate cartilage acting as a

hinge.

Acetabular roof is rotated anteriorly and laterally.

Recommended for any dysplastic hip in age of 1yr and when thetriradiate cartilage fuses ( 12yrs for female ;14 for male.)


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Pre-requisite : Reducible or reduced hip at the time of osteotomy.

Internal fixation is not required.

Greater degree of correction can be obtained with less acetabularrotation because it is nearer the site of correction.

Technically more demanding.

Changes the capacity and configuration of the acetabulum

may lead to incongruence

remodelling of the acetabulum required.


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AFTER TREATMENT :

With the hip in neutral position or inslight abduction and internal rotation

( favorable position for closure of thewound),

a spica cast is appliedfrom the nippleline to the toes on the affected side and

to above the knee on the opposite side. At 8 to 12 weeks, the cast is removed,

and the osteotomy is checked byradiographs


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Tripleinnominate osteotomy. Ischium ,the superior pubic ramus and the ilium

superior to acetabulum are all divided and theacetabulum is repositioned and stablised by graft and pinfixation.

Gives a stable hip in dislocated /subluxated hip in olderchildren.

Pre-requisite is a congruent articular surface.


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AFTER TREATMENT:

A spica cast is applied

with the hip in 20 degrees of abduction,

5 degrees of flexion, and

neutral rotation.

At 8 to 10 weeks, the cast and pins areremoved, and active and passive motionof the hip are started.

All three osteotomies usually unite by 12weeks after surgery, at which timeprogressive weight bearing on crutches isstarted.


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The entire acetabulum superiorly, posteriorly, inferiorly andanteriorly is freed by an osteotomy and a single bone unit is

transferred to appropriately cover the femoral head.

Useful in residual dysplasia in older children or young adultwith painful hip due to arthritis, easily fatigued and unstablewith +ve Trendelenbergs gait.

Pre-requisite:

Almost normal cartilage thickness with normal hip ROMexcept some restriction of external rotation.


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Performed to enlarge the acetabular volume.

Done in case where redirectional osteotomies may lead toincongruency in hip with femur and acetabulummisshapen.

Slotted acetabular augmentation procedure.

Contraindications include 1)dysplastic hip with sphericalcongruity suitable for redirectional osteotomy, 2)hipsrequiring concurrent open reduction that must havesupplementary stability ,and 3)patients unsuited for spicaimmobilization.


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AFTER TREATMENT:

The cast is removed after 6 weeks, and

crutch walking is permitted with partial weightbearing on the affected side until the graft isincorporated, usually at 3 to 4 months


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Capsular interposition medial displacement pelvicarthroplasty.

Places the femoral head beneath a surface of cancellousbone with the capacity for fibrocartilaginous regenerationand corrects lateral pathological displacement of femur.

Osteotomy performed at the superior margin of the

acetabulum and the pelvis inferior to the osteotomyalong with the femur which is displaced medially, sothat the superior half overhangs and forms anextension of acetabulum.

Also decreases stresses on the hip jointby shorteningthe medial arm of the abductor level system.

Because of the limb shortening which is associated ,lesslikely to increase pressure over the femoral head.


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Pre-requisite:-Hip must have a satisfactory range of over 90 degree flexion with outsignificant flexion contracture.

-Outer rim of the true acetabulum must be high.

Indications: Congenital subluxations in patients 4 to 6 years old or older,

including adults (including subluxations that persist afterconservative treatment of dislocations and subluxationspreviously not treated);

Untreated congenital dislocations in patients older than 4 yearsold, soon after open or closed reduction;

Dysplastic hips with osteoarthritis;

Paralytic dislocations caused by muscular weakness orspasticity; and

Coxa magna after Perthes disease orosteonecrosis aftertreatment of congenital dysplasia.


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AFTER TREATMENT :

In children and adults, the cast isremoved at 6 to 8 weeks, and active andpassive exercises of the hip are started.

Partial weight bearing on crutches isallowed and progressed as tolerated.


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Osteotomy AgeIndications

Salter innominate 18 months-6 years Congruous

hip reduction;osteotomy > 10-

15 degrees

correction of acetabular index

requiredPemberton

acetabuloplasty 18 months-10 years > 10-15degrees correction of

acetabular index required;

smallfemoral head, large

acetabulum

Steel or

Ganz osteotomy Late adolescence to Residual

acetabular dysplasia;


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Presentation Osteotomy

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