DEPARTMENT OF

ORTHOPAEDICS & TRAUMATOLOGY

GANDHI MEDICAL COLLEGE, BHOPAL

SEMINAR ON
OSTEOTOMIES AROUND HIP
PRESENTED BY :
Dr. Vaibhav Gandhi
MODERATOR :
Dr. A. Gohiya
Dr. S. Tandon

CONSULTANTS :
Prof. & HOD Dr. N. Shrivastava
Prof.Dr. A. Mehrotra
Dr. S. Gaur
Dr. J. Shukla
Dr. S. Tandon
Dr. S. A. Faruqui
Dr. A Gohiya
Dr. A. Varshney
Dr. D. Maravi
Dr. R. Verma
Dr. A. Pathak

DEFINITION

An

osteotomy

procedure

is

used

a
to

surgical
obtain

corrective
a

correct

biomechanical alignment of the extremity so

as to achieve equivocal load transmission,
performed with or without removal of a
portion of the bone.

HIP BIOMECHANIC

Hip designed to support BW permit mobility

Max ROM 140- Fle/Ext,75-Abd/Add

Functional ROM 50-Fle/Ext

Forces acting around hip can be measured with

Mathematical model calculations 2D static
analysis

2D STATIC ANALYSIS

One legged stance

5/6 BW on femoral
head

Ratio of lever arms

to BW 3:1

BIO MECHANICS
Forces across hip joint

BW

Ground rection forces

Abductor muscle forces

Improving abductor function

will decrease joint reaction
forces

HIP BIOMECHANICS

As the ratio of length of the lever arm of body

weight to that of the abductor musculature is @
2.5:1,the force of abductor muscle must approx
2.5 times the body weight to maintain the pelvis
level when standing on one leg
In an arthritic hip , the ratio of lever arm of the
body weight to that of the abductors may be 4:1.
The length of two lever arms can be surgically
changed to make their ratio 1:1

OSTEOTOMY AROUND HIP CLASSIFICATION

According to Anatomic Location

Femoral Osteotomy

High Cervical.

Intertrochanteric Osteotomy.

Subtrochanteric Osteotomy.

Greater Trochanteric.

Pelvic Osteotomy.

Salvage Osteotomies : eg. Chiari, Shelf.

Reconstructive Osteotomies : eg. Periacetabular, Single,

Double, Triple Innominate.

Based on Indications
To obtain stability

old unreduced dislocations.

Lorenz bifurcation osteotomy.
Schanz low subtrochanteric.

To obtain union
ununited fractures of femoral neck.
McMurrys osteotomy.
Dickson's high geometric osteotomy.
Schanz Angulation Osteotomy.
unstable intertrochanteric fractures.
Dimon Hughston Osteotomy.
Sarmientos Osteotomy

Contd.

Contd.

Relief of pain

osteoarathritis.
Pauwels type I varus osteotomy.
Pauwels type II valgus osteotomy.

To Correct deformities
coxa vara
slipped upper femoral epiphysis
Intracapsular cuneiform osteotomy by dunn.
Compensatory Basilar Osteotomy of Femoral Neck.
Extracapsular Base-of-Neck osteotomy.
Ball-and-Socket Trochanteric Osteotomy.
Pauwels osteotomy (Y).

Contd.

In Osteonecrosis of femoral head

Sugiokas transtrochanteric osteotomy.

Varus deroation osteotomy of Axer.

- In paralytic disorders of hip.

Varus Osteotomy.

Rotational Osteotomy

In congenital dislocation.

OVERVIEW OF PELVIC OSTEOTOMY

SALTER OSTEOTOMY

SALTER OSTEOTOMY

INDI-Congruous hip reduction,<10-15 degrees correction of

acetabular index required ,paralytic disorder,subluxation after
septic arthritis

PREREQUISITES- femoral head must be positioned opposite

the level of acetabulum,contracture of iliopsoas and adductor
muscles must be released, range of motion of the hip must be
good specially in abduction ,int rotation flexion

AGE-18 months-6years

AFTERCARE-hip spica for 8 to 12 week,then partial weight

bearing on crutches ,followed by full weight bearing.result
assesed by center edge angle.

CASE-abdulla,2yr /m, B/L DDH, operated at GMC BHOPAL, O/D

SALTER osteotomy with k-wire fix with femoral shortening

PEMBERTON OSTEOTOMY

PEMBERTON OSTEOTOMY

PROCEDURE- Pemberton described a pericapsular

osteotomy of the ilium in which the osteotomy is
made through the full thickness of the bone from just
superior to the anteroinferior iliac spine anteriorly to
the triradiate cartilage posteriorly : the triradiate
cartilage acts as a hinge on which the acetabular roof
is rotated anteriorly and laterally.

PEMBERTON PERICAPSULAR OSTEOTOMY

INDICATION- >10-15 degrees correction of acetabular

index required ,small femoral head ,large acetabulum.
ADV- internal fixation not required .greater degree of
rotation can be achieved with less rotation of
acetabulum
DISADV- Technically more difficult . Alters the
configuration and capacity of acetabulum and produce
joint incongruity that requires remodeling
AGE-18months- 10 yr
AFTERCARE-spica cast for 8 to 12 weeks

PERIACETABULAR OSTEOTOMY OF ILIUM

(PEMBERTON)

TRIPLE INNOMINATE OSTEOTOMY

(STEEL)

STEEL OSTEOTOMY

INDI-Adolescents and skeletally mature adults with residual

dysplasia and subluxation in whom remodelling of acetabulum is no
longer anticipated

ADV-Better coverage of femoral head by articular cartilage [chiarifibrous cartilage], Better hip joint stability,no need of spica cast.

DIS- Technically difficuilt, does not change size of acetabulum,

distort the hip such that natural child birth may be impossible in
adulthood

PROC-The ischium, the sup pubic ramus and ilium superior to the
acetabulum is reposition and stabilized by bone graft

GANZ OSTEOTOMY: (BERNESE)

PRIACETUBULAR OSTEOTOMY.

This Triplaner osteotomy is for adolescent and adult

dysplastic hip that required correction of congruency
& containment of the femoral head with little or no
arthritis.

If significant degenerative changes are presents a

proximal femoral osteotomy can be added.

Approach Smith Peterson approach.

GANZ OSTEOTOMY

Contd.

Advantages :

Only one approach is used.

A large amount of correction can be obtained in all

directions, including the medial and lateral planes.

Blood supply to the acetabulum is preserved.

The posterior column of the hemipelvis remains

mechanically intact, allowing immediate crutch walking
with minimal internal fixation.

The shape of the true pelvis is unaltered, permitting a

normal child delivery.

Can be combined with trochanteric osteotomy if needed.

THE SHELF PROCEDURE (STAHELI)

SHELF OPERATION (STAHELI)

Have commonly been performed to enlarge the volume of the

acetabulum.
The objective is to create a shelf, the size of which is decided by
measuring the width of augmentation form the CE angle. The
shelf is put just above the acetabular margin. It secure two layers
of cancellous grafts bringing the reflected head of rectus femoris
forward over the graft and suturing it in its original position.
Best to do after 5 years of age.
Indication : A deficient acetabulum that cannot be corrected by
redirectional, osteotomy is the primary indication.
Contraindication :
Dysplastic
hip with spherical congruity suitable for
redirectional osteotomy
Hip requiring open reduction.

CENTER EDGE
ANGLE/ACETABULAR INDEX

CE ANGLE-measured after 5 yr age, >25 normal,

<20 severe dysplasia
AC IND- <27.5 normal, >30 dysplasia

CHIARI

CHIARI

INNOMINATE OSTEOTOMY WITH MEDIAL

DISPLACEMENT OF ACETABULUM (CHIARI)

CHIARI OSTEOTOMY

PROC-It is performed at the superior margin of the

acetabulum and the pelvis inferior to the osteotomy along
with the femur is displaced medially.
This is also called as capsular interposition Arthroplasty
as the capsule is interposed between the shelf and the
femoral head.

INDI-incongruous

joint,

dysplastic

hip

with

osteoarthritis ,other osteotomy not possible

DISADV-salvage osteotomy only, leaves anterior

acetabulum uncovered,abductor lurch common .

PALLIATIVE OPERATION

Reserve for cases is which reduction is not possible by

either open or closed reduction as in old unreduced
congenital dislocation.

Designed to improve :

Stability.

Decrease lordosis.

Control pain arising from lower back/hip.

REVIEW OF PELVIC OSTEOTOMIES

SURGICAL PLANNING

In surgical planning of an osteotomy, the most

important task is to determine whether the
patient

is

an

appropriate

candidate.

Determining factors are the patients age,

activities, goals, radiographic assessment,
range of motion, and leg lengths and the status
of the knee of same side.

OSTEOTOMY

Primary objective is deflection of wt. bearing by

angulation of femur to bring the axis of the femoral
shaft more in line with the direction of weight
transmission.

The

osteotomy

performed

are

Osteotomy (Stabilizing osteotomy).

Schanz osteotomy.

Lorenz osteotomy.

Angulation

SCHANZ OSTEOTOMY (LOW S/T OSTEOTOMY)

(a)Femur is sectioned transversely a lower border of pelvis.

(b)Upper end is angled inward until it rest against side wall of pelvis.

Contd.

Schanz osteotomy (Low S/T Osteotomy) :

In this osteotomy the deformity flexion, adduction &
external Rotation is corrected by making the osteotomy at
tuber ischii level.
Preparation :
X-ray are taken with full adduction to measure angle
medially.
Thomas Test - measure degree of flexion to be corrected.
Advantages :
Lurching gait will be diminished.
The depression of the trochanter also improves the
leverage of the glutei.

Contd.

Contraindication : Before 15 years of age, because loss

of angulation during growth period.

Lorenz (Bifurcation osteotomy)

In this upper end of the lower fragment is abducted and

inserted in to the acetabulum after making on
intertrochanteric osteotomy plane of osteotomy below
& outward to above & inward.

Disadvantage :

Increased shortening.

Less mobility and arthritic pain.

LORENZ (BIFURCATION OSTEOTOMY)

(A)
Plane
of
osteotomy Distal
end at posterolateral
aspect
towards
proximal
end
at
anteromedial aspect.

(B) Limb is Abducted

and extended so proximal
end of distal fragment
directed medially and
anteriorly in acetabulum.

OSTEOTOMY FOR COXA VERA

The normal femoral neck shaft angle in infant is 120 0 to 1400,

Reduction to a more acute angle constitute a coxa vara
deformity.

The goal of treatment are

To promote ossification of the defect and correct varus

deformity.

Indication for surgery :

Increasing coxa vara

Neck shaft angle less than 110.

Painful unilateral
discrepancy

Hilgenreiner - epiphy seal angle of more than 60 .

or

associated

with

leg

length

Contd.

Surgery performed are

Valgus

Subtrochanteric

Osteotomy

or

abduction

osteotomy-with Internal Fixation.

A transverse osteotomy at about the level of lesser

trochanter.

If necessary take a small lateral wedge to correct neck

shaft angle to 135-150.

The surgery may be delayed till child is 4 to 5 year old

to make internal fixation easier.

Contd.

Alternative Method : Pauwels Y shaped osteotomy :

Static forces are converted from shearing to impacting

forces

Prerequisites :

Viable femoral head.

Young vigorous patient.

Advantage :

Union is rapid.

Recurrence is less likely.

PAUWELS Y SHAPED OST

COXA VERA

COXA VERA

OSTEOTOMY FOR RELIEF OF PAIN IN

OSTEOARTHRITIS

Before the onset of osteoarthritis, if normal or near normal

function of the hip can be maintained, reconstructive
osteotomy can prevent or delay the development of
osteoarthritis; if mild or moderate osteoarthritis is present, a
salvage osteotomy can improve function and delay the need
for total hip Arthroplasty.

THERAPEUTIC INTERVENTION IN HIP DIEASE

:RECONSTRUCTIVE VERSES SALVAGE OSTEOTOMY
Factors

Reconstructive Osteotomy

Salvage Osteotomy

Age

Generally < 25 years

Generally < 50 years (Some

biological Plasticity
Remains)

Symptoms

Minimal (Out Progressive)

Moderate to Severe

Motion

Near Normal

> 600 Flexion

Function

Near Normal

Fair to Poor

Pthoanatomy

No Irreversible Changes

Irreversible Changes

Roentgenography Congruent but Malaligned

Surfaces

Cartilage narrowing or
incongruity or both

Prognosis if
untreated

Poor

Poor

Contd.

The goal of reconstructive osteotomies, femoral or pelvic, is to

restore as nearly normal anatomy as possible, thus returning
joint pressures and loading patterns to normal.

The goal of salvage osteotomies are to relieve pain and

improve function enough to delay the need for total hip
Arthroplasty, especially in active patients younger than 50
years of age.

Roentgenographic evaluation also should include a standing

anteroposterior view and a false profile view.

VARUS/VALGUS/DEROTATION FEMORAL
OSTEOTOMIES ARE -

VARUS OSTEOTOMIES

FEMORAL OSTEOTOMY

Contd.

varus osteotomy : Designed to elevate the greater trochanter and move it

laterally while moving the abductor and psoas muscles
medially, to restore joint congruity and decrease muscle forces
about the hip.
Varus osteotomy alone is indicated for patients with a
spherical femoral head, little or no acetabular dysplasia centeredge angle of at least 15 to 20 degrees), signs lateral
overloading, and a valgus neck-shaft angle of more than 135
degrees.
Varus osteotomy with medial displacement of the femoral
shaft relaxes the abductor, psoas, and adductor
musclesunloads the hip joint, and increases the weight-bearing
surface.

Contd.

Most authors recommend medial displacement of 10 to

15 mm to keep the ipsilateral knee centered under the
femoral head and to maintain the mechanical axis of the
leg.

Varus osteotomy, however, shortens the limb to some

degree. creates a Trendelenburg gait that may persist for
months after surgery, and increases the prominence of the
greater trochanter.

Limb shortening can be minimized by making a smaller

medial osteotomy and transposing it to the lateral side.

VALGUS INTERTROCHANTERIC FEMORAL

OSTEOTOMIES

Valgus Osteotomy - Increase weight bearing area of femur

head.

It does not produce muscle relaxation.

Relaxation obtained by tenotomy of Iliopsos and adductor

muscle.

Transfer the center of hip rotation medially from the superior

aspect of the acetabulum to increase joint congruity and the
weight-bearing area of the femoral head.

Osteotomy of the greater trochanter often is performed with

valgus femoral osteotomy to move the greater trochanter
laterally.

VALGUS INTERTROCHANTERIC FEMORAL

OSTEOTOMIES :

Contd.
Best result were obtained in patients younger than 40 years of
age with unilateral involvement, good preoperative range of
motion, and a mechanical (secondary) cause.
Unsatisfactory results occurred in patients with limited
preoperative flexion, they cited preoperative flexion of less
than 60 degrees as a relative contraindication to valgus
osteotomy.
Most surgeons now advise that all osteotomies be fixed with
rigid internal fixation, which offers several obvious
advantages:
The fragments are maintained in proper position;

The danger of limitation of motion of the hip and knee is

greatly decreased;

Contd.

The patient can be allowed out of bed early; and

Pulmonary, urological, and other medical complications

are decreased. A device frequently used for rigid internal
fixation of intertrochanteric osteotomies is the ASIF, or
right-angled, blade plate. Our experience with this device
has been quite favorable.

Nonunion has been a troublesome complication after

Osteotomy, and an incidence as high as 20% has been
reported.

BLOUNT ABDUCTION
OSTEOTOMY

Trendelenburg limp
Adduction deformity
Motion in adduction beyond adduction
deformity
Painful abduction

BLOUNT ADDUCTION
OSTEOTOMY

Antalgic abductor limp

Abduction deformity
Motion in abduction beyond the abduction
deformity
Painful adduction

BIOMECHANICAL TREATMENT OF
OSTEOARTHRITIS

Therapy must be directed at reducing joint loads. This may

be by reducing the compressive forces directly or by
increasing the weight- bearing area, and thereby reducing
the load per unit area or ideally by combination of the two.

WHILE PERFORMING OSTEOTOMY

The distal cut must be perpendicular to the axis of the shaft

fragment.

All cortical wages are taken form the proximal fragment to

avoid loss of apposition when the distal fragment is rotated.

General contraindication of femoral osteotomies

Poor motion

Inflamatory joint condition

Significant metabolic disease.

Severe degenerative joint disease.

OSTEOTOMY TO CORRECT UNSTABLE

INTERTROCHANTERIC FRACTURES

Sarmiento Technique

OSTEOTOMY TO CORRECT UNSTABLE

INTERTROCHANTERIC FRACTURES

Dimon and Hughston :

Described technique of Trochanteric osteotomy with

valgus nailing and medial displacement to improve
stability there techniques are occasionally useful in some
extremely comminuted fractures.

Recent studies have indicated that anatomical reduction

allow greater load shearing by bone than medial
displacement osteotomy.

DIMON AND HUGHSTON METHOD OF

INTERTROCHANTERIC OSTEOTOMY

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)

Is a disorder in which there is a displacement of the capital

femoral epiphysis form the metaphysis through the physeal
plate.

By this head is placed in posterior & downward position in

acetabulum.

The goal of treatment is

To prevent further displacement and

To promote closure of physeal plate.

Contd.

The use of realignment procedure such as lntertrochameric,

Subtrochanteric Osteotomy & osteotomies the around neck is
in those situation in which restricted range of motion impairs
function after plate physeal closure.

Principle of Osteotomy

There are basically three type of Deformity present in SCFE.

These are

Varus

Hyper extension

Moderate Severe external rotation

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)

The osteotomy to correct these

deformities work at two sites.

Through the femoral neck

(closing wedge osteotomy)

Through the trochanteric

area.

EXTRACAPSULAR BASE OF NECK

OSTEOTOMY

types of femoral neck osteotomy are

The technique of Dunn - for severe chronic slip with open

physis.

Base of the neck osteotomy - Compensatory Basilar most

of femoral neck. (Kramer) - correct the varus and
retroversion component of moderate to severe chronic
SCFE.

It is safer than cuniform osteotomy of neck.

Further slipping is prevented.

Intertrochantric osteotomies

CORRECTIVE OSTOTOMIES

By these osteotomies one can correct angulation, rotation,

flexion, extension Deformity of bones to restore motion for
patient with stiff hip.

Like

Deformities in septic arthritis

Malunion of I/T femurs

Neuromuscular disorder

Cerebral palsy

Poliomyelitis

Contd.

There are three types of corrective osteotomies

Close wedge - transverse closing wedge provide good bony

apposition and is stable, however, it shortens the extremity.

Open wedge - simple and lengthens the extremity however.

bony apposition is limited, union is delayed in adults and it
is initially unstable.

Ball and Socket type - achieves stability without shortening

the extremity; however, extensive dissection is required,
and in severe biplame deformities an accurate and stable
osteotomy is difficult to perform.

In Ball & socket type of osteotomy concave surface in created

in the proximal fragment of convex surface at the distal
fragment, at intertrochantaric level & fixed in place by plate.

CORRECTIVE OSTOTOMIES

Brackett ball and socket

Osteotomy

Whitman closing wedge

Osteotomy

Gant-opening wedge
Osteotomy

FRACTURE NECK FEMUR

In those case which present late (1-5 wks.), are difficult case
to treat because
Close reduction is not possible.
Open reduction is associated AVN
In young Pt. with viable femoral head & nonunion options
are Mcmurray & Pauwels y osteotomy
Angulation Osteotomy (Schanz)
Dickson geometric osteotomy
In old Pt. Girdle stone osteotomy
Mcmurray Displacement

OBLIQUE OSTEOTOMY

Extends from lateral aspect of shaft at level just below the

lower border of lesser trochanter and terminates medially
between lesser trochanter and lower border of neck.

Shaft is displaced medially.

Mechanical Advantage :

Line of weight bearing shifted medially.

Shearing forces at the nounion is decrease because

fracture surface become more horizontal

These advantages are greater after angulation osteotomy.

McMURRAY

MC-MURRAY OSTEOTOMY

MC-MURRAYS OSTEOTOMY

The oblique osteotomy extends from the lateral aspect of

the shaft at a level just below the lower border of the
lesser trochanter and lower border of neck.Then the limb
is rotated inward and outward to remove any bony spike
Fixation of osteotomy - By Compression nail
plate./Castle Plate.
Disadvantages:
Instability - Degenerative changes in normal head
Shortening - AVN when neck have been fractured
Medial displacement of shaft compromise the
insertion of femoral stem of total hip.
Advantage
-Changes
line
of
fracture
to
horizontal,callus may incarporate fracture

DICKSON HIGH GEOMETRIC

OSTEOTOMY

Principle - the line of vertical force is

converted to a horizontal (impacting
force). In this distal fragment is abducted
to 60 after making osteotomy just below
the grater trochanter & fixed with plate.

High rate of union

Lengthens limb

Improves abductor strength

GIRDLESTONE OSTEOTOMY

GIRDLE STONE OSTEOTOMY

In this head & neck of femur are excised at Inter trochanteric

level to create pseudo arthrosis in order to improve stability.
Angulations Osteotomy is added.

Indication

T.B. Hip

Pyogenic Hip

Non union #.neck femur [in elderly pt.]

AVN of femoral head.

Advantages :

Painless mobile hip joint.

AVN

OSTEOTOMIES
These procedure have achieved best result for small and
medium sized lesion. 1<30% femoral head involvement in
young pt.
Intertrochanteric varus/valgus - osteotomies
Transtrochantric ant. Rotational osteotomy (Sugioka) Technically Demanding procedures.
PRINCIPLE:
All osteotomies are designed to transfer the weight
bearing forces form the necrotic area to the cartilage on
the sound part of the femoral head to allow healing of
necrotic area by hyper vascularisation of upper part of
femur.

TRANSTROCHANTRIC ANT. ROTATIONAL

OSTEOTOMY [SUGIOKA]

TECHNIQUE FOR ROTATION

Femoral head is rotated anteriorly (450 - 900) by handling

proximal pin.

OSTEOTOMY IN PERTHE'S DISEASE

Salvage :

Varus Derotational Osteotomy

Innominate Osteotomy.

Combined Procedure -

MRI / Arthrogram before surgery is mandatory.

Varus/derotation osteotomy of this embodies the principle

of containment of the diseased femoral head in the
treatment of Legg - Calve-Perthes disease.

Guide pin inserted compression screw is placed over

guide wire.

PERTHES DIEASES

Contd.

Appropriate angled osteotomy is made.

Wedge is removed.

Make osteotomy as proximal as possible just below lag

screw for -

Better Healing

Better correction of deformity.

Reduce the osteotomy and fixed with plate and

compression screw.

SUBTROCHANTERIC DEROTATION
AND VARUS OSTEOTOMY

The aim of surgery is to center the whole "plastic" epiphysis

inside the joint cavity, keeping it well covered by the roof of
the acetabulum and allowing the child to walk so that the
redistributed intra-articular pressures will contribute the
molding of a more normal joint.

A small 4-hole plate is bent to the desired angle, and a

subtrochanteric osteotomy is done followed by derotation and
yarns angulation of the shaft. A double hip spica is applied and
the removed 2 months later. When the osteotomy site is united,
the child is encouraged to walk, at first in warm water pool,
then with walking aids and finally without support.

VARUS DEROTATION OSTEOTOMY

Contd.

The operation is best suited for early stage of Leg-CalvePerthes disease, preferably those under the age of 7 years.

Axer : Described lateral open wedge osteotomy for children

< 5 years with perthes disease. Defect laterally fills rapidly
in young children > 5 years of age delayed or non union may
occur.

RECONSTRUCTIVE SURGERY

Valgus subtrochanteric osteotomy - for Hing

Abduction

Shelf Augmentation Coxa Megna.

Chilectomy - Malformed head in late III Group.

Chiar's Pelvic Osteotomy - Large Malformed Femoral

Head with Subluxation laterally.

BIBLIOGRAPHY

Apley's System of Orthopaedics and Fractures - Loui's Soloman

8th Edition.

Campbell's Operative Orthopaedics - 11th Edition. Vol.-2.

Text Book of Orthopaedics - John Ebnezar - IInd Edition.

Orthopaedic Knowledge Update 7.

Samuel L Turek Orthopaedics principles & their applications

volume