Pelvic Osteotomies - CHU Sainte-Justine - SAAC

PELVIC OSTEOTOMIES
Where, When and How ?
Reggie C. Hamdy ,MB, M.Sc., FRCS©
25th Sainte-Justine Paediatric Orthopaedic Review Course
March 8, 2012 Montreal, Quebec

Pelvic Osteotomies
• Rationale : why do we perform pelvic osteotomies ?
• Radiological assessment of hip dysplasia
• Types of pelvic ostetomies
• Planning and surgical decision making : how to decide
which type of pelvic ostetomy to perform

What are the consequences of untreated
hip dysplasia ?
About 75% of adult patients with end
stage osteo-arthritis of the hip had an
underlying hip pathology in their childhood
Developmental dislocation of the hip
Perthes disease
Slipped capital femoral epiphysis.
(Wedge 1978, Harris 1986)

Why does untreated Acetabular
Dysplasia lead to OA ?
Acetabular dysplasia leads to abnormal forces across the hip jpoint

Pelvic Osteotomies
Increase coverage of femoral head
Normalize pressure across hip joint
Prevent degenerative arthritis and
obviate the need for arthroplasty
at a relatively young age (Stulberg, Harris)

Therefore, Pelvic Osteotomies have a
Central and Key role in the management of
acetabular dysplasia by :
* re-orienting or
* reshaping or
* augmenting the existing acetabulum
in order to have a normal femoral head
coverage

What type of pelvic and/or femoral
osteotomy should be performed in
order to restore the normal
biomechanics of the hip joint?

Radiological assessment of hip
dysplasia – depends on age
• Ultrasound
• Plain X-rays …. Gold standard
• Arthrography
• Ct scan (2D and 3D)
• CT arthrography
• MRI

Radiological assessment of hip
• Acetabulum
dysplasia
• Proximal femur
• Relation between acetabulum and proximal
femur

Radiological Assessment
C. Relation between proximal femur and
acetabulum :
1. Amount of femoral head uncoverage
- Lateral coverage : Centre edge angle
- Anterior coverage : False profile view
2. Presence of subluxation :
- Presence of subluxation : Shenton line
- Abduction – internal rotation views of the hip

Relation between Acetabulum and femur

Radiological assessment of hip
dysplasia
1. Where is the pathology : in the acetabulum
or proximal femur or both ?
2. What is the exact pathology to be corrected ?

Where is the pathology : acetabulum
or femur or both ?

What is the exact bony pathology ?
• More than just malrotation or maldirection,
acetabular dysplasia is a combination of :
* acetabular maldirection,
* margin erosion
* torsion
* hypoplasia (localized or global)
* abnormal shape
* decreased acetabular surface area
J.Wedge, Editorial JPO 1997

In DDH : The key defect in the
acetabulum
ANTERO-LATERAL
Therefore, any pelvic osteotomy
planned has to address this deficiency

2 year F

Acetabular Dysplasia in Neuromuscular
conditions
• Global deficiency of the acetabulum
• DO NOT DECREASE POSTERIOR
COVERAGE

1 yr 8 mo 2 yrs 10 mo
3 yrs 7 mo
6 yrs 10 mo
4 yrs 3 mo
5 yrs

Planning for pelvic osteotomies
1. Where is the pathology : acetabulum or femur ?
2. What is the pathology to be corrected ?
3. What type of osteotomy should be performed ?

How to increase femoral head coverage by
pelvic osteotomies
Change the orientation
of the acetabulum
Change the shape and size
of the acetabulum
Redirectional osteotomies
Using extra-articular bone
To augment the existing
Acetabulum :Salvage procedures
Comp 1 Salter.wmv
Incomplete osteotomies
Using articular cartilage
Acetabuloplasties
Increase antero-lateral
Decrease posterior cov.
No effect on volume
Concentric reduction
Increase antero-lateral coverage
No effect on posterior cov.
Increase volume of Acetabulum
No concentric reduction required
*Lateral Acet. (Dega)
Global coverage
*Pemberton (Antero-Lat)
Increase Antero-late.cov

REDIRECTIONAL OSTEOTOMIES
A. Salter innominate
B. Double
C. Triple osteotomies
D. Spherical (Wagner 1, 2, 3)
E. Peri-acetabular (Ganz)

SALTER OSTEOTOMY
- Described by Robert Salter, Toronto 1961
- Initially developed to correct the maldirected
acetabulum in cases of DDH
- Increases anterior and lateral coverage
- Decreases posterior coverage,
- Contra-indicated in neuromuscular conditions

PRE-REQUISITES OF
SALTER OSTEOTOMY
(and all Redirectional osteotomies)
* Concentric reduction
* Abduction at least 30°
* Age: 18 months – 8 years (…. Adults)
(difficult to perform after 8-10 years)

Operative Technique

Maneuvre to help open the osteotomy

AVERAGE IMPROVEMENT
FOLLOWING SALTER
- Acetabular index : 10°
- Centre edge angle : 10°–15°
OSTEOTOMY
Therefore, Salter osteotomy is indicated for mild and
moderate dysplasia

2 year F

KM 7+3 male 7-01

Can Salter osteotomy be performed
in adolescents ?
• YES
• James McCarthy JBJS 1996

Outcome at Forty-five Years After Open Reduction
and Innominate Osteotomy for Late-Presenting
Developmental Dislocation of the Hip
By Simon R. Thomas, MA, FRCS(Tr&Orth), John H. Wedge, MD,
FRCS(C), and Robert B. Salter, MD, FRCS(C)
J Bone Joint Surg (Am) 2007

Double Osteotomy (Sutherland JBJS 1977)

Triple osteotomies
* Steel
* LeCoeur
* Carlioz
* Tonnis
Difference : ischial cut

Triple osteotomies : importance of the ischial cut

Workshop : Triple osteotomy

Maneuvre to help open the osteotomy in
Salter procedure
In Triple Osteotomy…. NO

Osteotomies that change the size
and shape of the acetabulum
A. ACETABULOPLASTIES
Principle:
Incomplete osteotomy of the ilium
Restore a normal inclination of the acetabular roof by
rotating cartilage-lined roof over the femoral head
Types:
A - Whole acetabular roof: DEGA(San Diego)
B - Anterolateral part: PEMBERTON

ACETABULOPLASTIES
Pre-requisite:
Concentric reduction of the hip joint
Age limit:
Theoritically, until fusion of the tri-radiate cartilage
(after fusion, cannot function anymore as a hinge)
However, can be performed after skeletal maturity

Dega osteotomy (Wenger – San Diego)
• Only the outer table of the ilium is cut
• The inner table in intact and acts as a hinge
• The cut extends to the sciatic notch

Workshop : Dega osteotomy

Residual Dysplasia after Closed reduction of DDH
KG DOB 27-10-2001
10-06-2003
15-07-2005 26-3-2007

6 yrs 10 mo

Can we perform DEGA osteotomy after skeletal
maturity ? YES
Inan – Dabney
Clin Orthop 2007

Does Dega osteotomy increase acetabular
volume in developmental dysplasia of the
hip?
Ahmet Fevzi Ozgura et al , J Paediatr Ortho B, 2006
Dega osteotomy increases the volume of the acetabulum

Pemberton Osteotomy

Pemberton ostetomy
13 year anterior dislocation
Gordon JBJS 1996

SHELF PROCEDURES
Augmentation Procedures (not osteotomies)
The main problem with the Shelf procedure
is that - in some cases - there is resorption
of the grafted bone that forms the shelf.

Workshop Shelf : Dr. W.MacKenzie

Shelf Procedure
2005-06-16
2007-03-27_2

CHIARI OSTEOTOMY
* Femoral head is covered with fibrous capsular
tissue - fibrocartilage (not hyaline cartilage)
* Non-concentric and incongruent hips,
subluxated and even dislocated hips
Biomechanical Advantage of Chiari Osteotomy:
Medial displacement of the hip joint

Chiari osteotomy

Planning for pelvic osteotomies
1. Where is the pathology : acetabulum or femur ?
2. What is the pathology to be corrected ?
3. What type of osteotomy should be performed ?

THANK YOU !

Perthes : Very large head – normal acetabulum

18 y/o, pre-op
progressive pain L hip
Post PAO/PFO
Clohisy JC, Schoenecker PL, et.
al. Periacetabular osteotomy for
Tx of acetab dysplasia assoc w/
major aspherical femoral head
deformities JBJS-A 89,
2007:1417-23
20+8 ~3 yrs post-op pain resolved

14 y MED JB
Chiari Osteotomy

PELVIC OSTEOTOMIES
I.Osteotomies that use bone to increase
coverage of the femoral head:
Shelf procedures
Chiari osteotomy
These two osteotomies (Shelf and Chiari) are
often referred to as salvage procedures
because bone and not articular cartilage is used
to increase coverage of the femoral head.

What is the natural history of hip
subluxation
• Is the subluxation progressive
In most cases …. YES

1 yr 8 mo 2 yrs 10 mo
3 yrs 7 mo
6 yrs 10 mo
4 yrs 3 mo
5 yrs

Residual Dysplasia after Closed reduction of DDH
KG DOB 27-10-2001
10-06-2003
15-07-2005 26-3-2007

REDIRECTIONAL OSTEOTOMIES
A. Salter innominate
B. Double and triple osteotomies
C. Spherical (Wagner 1, 2, 3)
D. Peri-acetabular (Ganz)

Gigli saw + silk suture
Lewin clamp

II. OSTEOTOMIES THAT USE ACETABULAR
CARTILAGE TO INCREASE COVERAGE OF
THE FEMORAL HEAD
1. Acetabuloplasties (Dega and Pemberton)
Acetabular roof is mobilized and
turned down to normal inclination
2. Redirectional osteotomies
Salter, Double, Triple, Spherical
(Wagner 1, 2, 3) and Peri-acetabular
(Ganz)

3 years old

Maldirected acetabulum Capacious acetabulum Lateralized acetabulum
2005-06-16_5

WHAT IS THE EXACT PATHOLOGY
THAT NEEDS TO BE CORRECTED?
A. If the acetabulum is affected, what is it
exactly that needs to be corrected?
Is it a:
maldirected acetabulum
a globally deficient acetabulum
a deficiency of the anterior or of the
posterior walls
a small acetabulum with a big femoral
head

Radiological assessment of hip
dysplasia
• Ultrasound
• Plain X-rays
• Arthrography
• Ct scan (2D and 3D)
• CT arthrography
• MRI

2005-06-16
2006-12-01 2007-03-27_2

J.Wedge, Editorial JPO 1997
• More than just malrotation or maldirection,
acetabular dysplasia is a combination of :
* acetabular maldirection,
* margin erosion
* torsion
* hypoplasia (localized or global)
* abnormal shape
* decreased acetabular surface area

Chiari : wrong operation

Pelvic Osteotomies
• Rationale : why do we perform pelvic osteotomies ?
• Pre-operative assessment
• Types of pelvic ostetomies
• Hip dysplasia : classification
• Radiological assessment of hip dysplasia
• Planning and surgical decision making : how to decide
which type of pelvic ostetomy to perform

PERI-ACETABULAR
OSTEOTOMY
A. Reinhold Ganz, Berne, Switzerland
B. Combines advantages of both triple and
spherical osteotomies
C. Unlike triple, maintains posterior
acetabular column with minimal
deformation of the pelvis
D. Like spherical, can rotate the acetabular
fragment to correct any degree of
acetabular dysplasia

KEY RADIOGRAPHIC LINES
(Immature Skeleton)
• Hilgenreiner’s line
• Perkin’s line

ACETABULAR INDEX OF
HILGENREINER
Normal Values
New Born - 28°
At age 2 - 20°
Good indicator of acetabular dysplasia

KEY RADIOGRAPHIC LINES
(Immature Skeleton)
• Hilgenreiner’s line
• Perkin’s line

ACETABULAR INDEX OF
HILGENREINER
Normal Values
New Born - 28°
At age 2 - 20°
Good indicator of acetabular dysplasia

KEY RADIOGRAPHIC
LANDMARKS
(Mature Skeleton)
• Sharp’s acetabular angle
• Upper normal limit = 43

CE ANGLE OF WIBERG
Normal Values
5-8 y. 25°
9-12 y 30°
>13 y. 35°
Assess the lateral
coverage of the femoral head

ANGLE OF LEQUESNE
AND DE SEZE
Classification
Degrees
Normal 25°
Mild dysplasia 21°-21°
Severe dysplasia

Workshop : Salter osteotomy

KK 5+4 female Untreated DDH 7-96

7-96 8-96
S/P bilateral staged open reductions and
Salter osteotomies plus shelf on the left hip

The anterior centre- edge angle
was termed VCA by Lequesne
and de Seze.1 The angle is composed
of a vertical line through
the centre of the femoral head
(line VC) and a second line
through the centre of the hip and
the foremost aspect of the acetabulum

Is the Acetabulum excessively
anteverted in DDH ?
• Salter 1961…… Yes
• Wenger 1997 …NO
– Maldirected acetabulum is only one of the
deformities present in DDH
– It does not occur in all cases

14+0 F, B DDH. L hip lateral fatigue pain