Dr.N.

KIRE,PGT MEDICAL COLLEGE AND HOSPITAL

PELVIC OSTEOTOMIES
(1) Osteotomy of the innominate bone (Salter), (2) Acetabuloplasty (Pemberton), (3) Osteotomies that free the acetabulum (Steel

triple innominate osteotomy or dial acetabular osteotomy),

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

displacement of the acetabulum (Chiari).

 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.

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

Indications: Subluxation of the femoral head from true acetabulum. Reasonable congruity present or can be obtained. Radiological cartilage space atleast of normal thickness for the patient age. Atleast 60% of normal flexion/abduction.

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

 Uses: DDH. Kochs Arthritis.

Complication - Deep infection. - Transient femoral nerve paresis.

AFTER TREATMENT:

At 8 to 12 weeks: the spica cast and the Kirschner wires are removed. The position of the osteotomy and of the hip is checked by radiographs.

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

the ilium superior to the acetabulum. Pericapsular ilium osteotomy with triradiate cartilage acting as a hinge. Acetabular roof is rotated anteriorly and laterally. Recommended for any dysplastic hip in age of 1yr and when the triradiate cartilage fuses ( 12yrs for female ;14 for male.)

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 acetabular

rotation 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.

 AFTER TREATMENT :

With the hip in neutral position or in slight abduction and internal rotation ( favorable position for closure of the wound), a spica cast is applied from the nipple line 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 by radiographs

 Triple innominate osteotomy. Ischium ,the superior pubic ramus and the ilium

superior to acetabulum are all divided and the acetabulum is repositioned and stablised by graft and pin fixation. Gives a stable hip in dislocated /subluxated hip in older children. Pre-requisite is a congruent articular surface.

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 are removed, and active and passive motion of the hip are started.
All three osteotomies usually unite by 12 weeks after surgery, at which time progressive weight bearing on crutches is started.

 The entire acetabulum superiorly, posteriorly, inferiorly and

anteriorly 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 adult

with painful hip due to arthritis, easily fatigued and unstable with +ve Trendelenbergs gait. Pre-requisite: Almost normal cartilage thickness with normal hip ROM except some restriction of external rotation.

 Performed to enlarge the acetabular volume. Done in case where redirectional osteotomies may lead to

incongruency in hip with femur and acetabulum misshapen. Slotted acetabular augmentation procedure. Contraindications include 1)dysplastic hip with spherical congruity suitable for redirectional osteotomy, 2)hips requiring concurrent open reduction that must have supplementary stability ,and 3)patients unsuited for spica immobilization.

AFTER TREATMENT: The cast is removed after 6 weeks, and crutch walking is permitted with partial weight bearing on the affected side until the graft is incorporated, usually at 3 to 4 months

 Capsular interposition medial displacement pelvic

arthroplasty. Places the femoral head beneath a surface of cancellous bone with the capacity for fibrocartilaginous regeneration and corrects lateral pathological displacement of femur.
Osteotomy performed at the superior margin of the

acetabulum and the pelvis inferior to the osteotomy along with the femur which is displaced medially, so that the superior half overhangs and forms an extension of acetabulum.
Also decreases stresses on the hip joint by shortening

the medial arm of the abductor level system.

Because of the limb shortening which is associated ,less

likely to increase pressure over the femoral head.

Pre-requisite: -Hip must have a satisfactory range of over 90 degree flexion with out significant 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 after conservative treatment of dislocations and subluxations previously not treated);
Untreated congenital dislocations in patients older than 4 years

old, soon after open or closed reduction;

Dysplastic hips with osteoarthritis; Paralytic dislocations caused by muscular weakness or spasticity; and treatment of congenital dysplasia.

Coxa magna after Perthes disease or osteonecrosis after

AFTER TREATMENT : In children and adults, the cast is removed at 6 to 8 weeks, and active and passive exercises of the hip are started. Partial weight bearing on crutches is allowed and progressed as tolerated.

Osteotomy Indications Salter innominate hip reduction; osteotomy 15 degrees

Age 18 months-6 years Congruous > 10-

correction of acetabular index required Pemberton acetabuloplasty degrees correction of

18 months-10 years

> 10-15

acetabular index required; femoral head, large acetabulum Steel or Ganz osteotomy acetabular dysplasia; small

Late adolescence to

Residual