1. DEPARTMENT OFDEPARTMENT OF
ORTHOPAEDICS & TRAUMATOLOGYORTHOPAEDICS & TRAUMATOLOGY
GANDHI MEDICAL COLLEGE, BHOPALGANDHI MEDICAL COLLEGE, BHOPAL
SEMINAR ONSEMINAR ON
OSTEOTOMIES AROUND HIPOSTEOTOMIES AROUND HIP
PRESENTED BY :PRESENTED BY :
Dr. Vaibhav GandhiDr. Vaibhav Gandhi
MODERATOR :MODERATOR :
Dr. A. GohiyaDr. A. Gohiya
Dr. S. TandonDr. S. Tandon
CONSULTANTS :CONSULTANTS :
Prof. & HOD Dr. N. ShrivastavaProf. & HOD Dr. N. Shrivastava
Prof.Dr. A. MehrotraProf.Dr. A. Mehrotra
Dr. S. GaurDr. S. Gaur
Dr. J. ShuklaDr. J. Shukla
Dr. S. TandonDr. S. Tandon
Dr. S. A. FaruquiDr. S. A. Faruqui
Dr. A GohiyaDr. A Gohiya
Dr. A. VarshneyDr. A. Varshney
Dr. D. MaraviDr. D. Maravi
Dr. R. VermaDr. R. Verma
Dr. A. PathakDr. A. Pathak

2. DEFINITIONDEFINITION
 An osteotomy is a surgical correctiveAn osteotomy is a surgical corrective
procedure used to obtain a correctprocedure used to obtain a correct
biomechanical alignment of the extremity sobiomechanical alignment of the extremity so
as to achieve equivocal load transmission,as to achieve equivocal load transmission,
performed with or without removal of aperformed with or without removal of a
portion of the bone.portion of the bone.

3. HIP BIOMECHANICHIP BIOMECHANIC
 Hip designed to support BW permit mobilityHip designed to support BW permit mobility
 Max ROM 140- Fle/Ext,75-Abd/AddMax ROM 140- Fle/Ext,75-Abd/Add
 Functional ROM 50-Fle/ExtFunctional ROM 50-Fle/Ext
 Forces acting around hip can be measured withForces acting around hip can be measured with
–Mathematical model calculations – 2D static–Mathematical model calculations – 2D static
analysisanalysis

4. 2D STATIC ANALYSIS2D STATIC ANALYSIS
 One legged stanceOne legged stance
5/6 BW on femoral5/6 BW on femoral
headhead
 Ratio of lever armsRatio of lever arms
to BW 3:1to BW 3:1

5. BIO MECHANICSBIO MECHANICS
Forces across hip jointForces across hip joint
 BWBW
 Ground rection forcesGround rection forces
 Abductor muscle forcesAbductor muscle forces  Improving abductor functionImproving abductor function
will decrease joint reactionwill decrease joint reaction
forcesforces

6. HIP BIOMECHANICSHIP BIOMECHANICS
 As the ratio of length of the lever arm of bodyAs the ratio of length of the lever arm of body
weight to that of the abductor musculature isweight to that of the abductor musculature is
@ 2.5:1,the force of abductor muscle must@ 2.5:1,the force of abductor muscle must
approx 2.5 times the body weight to maintainapprox 2.5 times the body weight to maintain
the pelvis level when standing on one legthe pelvis level when standing on one leg
 In an arthritic hip , the ratio of lever arm of theIn an arthritic hip , the ratio of lever arm of the
body weight to that of the abductors may bebody weight to that of the abductors may be
4:1.4:1.
 The length of two lever arms can be surgicallyThe length of two lever arms can be surgically
changed to make their ratio 1:1changed to make their ratio 1:1

7. OSTEOTOMY AROUND HIP CLASSIFICATIONOSTEOTOMY AROUND HIP CLASSIFICATION
 According to Anatomic LocationAccording to Anatomic Location
 Femoral OsteotomyFemoral Osteotomy
 High Cervical.High Cervical.
 Intertrochanteric Osteotomy.Intertrochanteric Osteotomy.
 Subtrochanteric Osteotomy.Subtrochanteric Osteotomy.
 Greater Trochanteric.Greater Trochanteric.
 Pelvic Osteotomy.Pelvic Osteotomy.
 Salvage Osteotomies :Salvage Osteotomies : eg. Chiari, Shelf.eg. Chiari, Shelf.
 Reconstructive Osteotomies :Reconstructive Osteotomies : eg. Periacetabular,eg. Periacetabular,
Single, Double, Triple Innominate.Single, Double, Triple Innominate.

8. Contd.Contd.
 Based on IndicationsBased on Indications
 To obtain stabilityTo obtain stability
 old unreduced dislocations.old unreduced dislocations.
 Lorenz bifurcation osteotomy.Lorenz bifurcation osteotomy.
 Schanz low subtrochanteric.Schanz low subtrochanteric.
 To obtain unionTo obtain union
 ununited fractures of femoral neck.ununited fractures of femoral neck.
 McMurry’s osteotomy.McMurry’s osteotomy.
 Dickson's high geometric osteotomy.Dickson's high geometric osteotomy.
 Schanz Angulation Osteotomy.Schanz Angulation Osteotomy.
 unstable intertrochanteric fractures.unstable intertrochanteric fractures.
 Dimon Hughston Osteotomy.Dimon Hughston Osteotomy.
 Sarmiento’s OsteotomySarmiento’s Osteotomy

9.  Relief of painRelief of pain
 osteoarathritis.osteoarathritis.
 Pauwel’s type I varus osteotomy.Pauwel’s type I varus osteotomy.
 Pauwel’s type II valgus osteotomy.Pauwel’s type II valgus osteotomy.
 To Correct deformitiesTo Correct deformities
 coxa varacoxa vara
 slipped upper femoral epiphysisslipped upper femoral epiphysis
 Intracapsular cuneiform osteotomy by dunn.Intracapsular cuneiform osteotomy by dunn.
 Compensatory Basilar Osteotomy of Femoral Neck.Compensatory Basilar Osteotomy of Femoral Neck.
 Extracapsular Base-of-Neck osteotomy.Extracapsular Base-of-Neck osteotomy.
 Ball-and-Socket Trochanteric Osteotomy.Ball-and-Socket Trochanteric Osteotomy.
 Pauwel’s osteotomy (Y).Pauwel’s osteotomy (Y).
Contd.Contd.

10.  In Osteonecrosis of femoral headIn Osteonecrosis of femoral head
 Sugioka’s transtrochanteric osteotomy.Sugioka’s transtrochanteric osteotomy.
 Varus deroation osteotomy of Axer.Varus deroation osteotomy of Axer.
- In paralytic disorders of hip.- In paralytic disorders of hip.
 Varus Osteotomy.Varus Osteotomy.
 Rotational OsteotomyRotational Osteotomy
 In congenital dislocation.In congenital dislocation.
Contd.Contd.

11. OVERVIEW OF PELVIC OSTEOTOMYOVERVIEW OF PELVIC OSTEOTOMY

21. SALTER OSTEOTOMYSALTER OSTEOTOMY

22. SALTER OSTEOTOMYSALTER OSTEOTOMY
 INDIINDI-Congruous hip reduction,<10-15 degrees correction of-Congruous hip reduction,<10-15 degrees correction of
acetabular index required ,paralytic disorder,subluxation afteracetabular index required ,paralytic disorder,subluxation after
septic arthritisseptic arthritis
 PREREQUISITES-PREREQUISITES- femoral head must be positioned oppositefemoral head must be positioned opposite
the level of acetabulum,contracture of iliopsoas and adductorthe level of acetabulum,contracture of iliopsoas and adductor
muscles must be released, range of motion of the hip must bemuscles must be released, range of motion of the hip must be
good specially in abduction ,int rotation flexiongood specially in abduction ,int rotation flexion
 AGE-AGE-18 months-6years18 months-6years
 AFTERCARE-AFTERCARE-hip spica for 8 to 12 week,then partial weighthip spica for 8 to 12 week,then partial weight
bearing on crutches ,followed by full weight bearing.resultbearing on crutches ,followed by full weight bearing.result
assesed by center edge angle.assesed by center edge angle.

23.  CASECASE-abdulla,2yr /m, B/L DDH, operated at-abdulla,2yr /m, B/L DDH, operated at GMC BHOPALGMC BHOPAL, O/D, O/D
– SALTER osteotomy with k-wire fix with femoral shortening– SALTER osteotomy with k-wire fix with femoral shortening

24. PEMBERTON OSTEOTOMYPEMBERTON OSTEOTOMY

25. PEMBERTON OSTEOTOMYPEMBERTON OSTEOTOMY
 PROCEDURE-PROCEDURE- Pemberton described a pericapsularPemberton described a pericapsular
osteotomy of the ilium in which the osteotomy isosteotomy of the ilium in which the osteotomy is
made through the full thickness of the bone from justmade through the full thickness of the bone from just
superior to the anteroinferior iliac spine anteriorly tosuperior to the anteroinferior iliac spine anteriorly to
the triradiate cartilage posteriorly : the triradiatethe triradiate cartilage posteriorly : the triradiate
cartilage acts as a hinge on which the acetabular roofcartilage acts as a hinge on which the acetabular roof
is rotated anteriorly and laterally.is rotated anteriorly and laterally.

26.  INDICATION-INDICATION- >10-15 degrees correction of>10-15 degrees correction of
acetabular index required ,small femoral head ,largeacetabular index required ,small femoral head ,large
acetabulum.acetabulum.
 ADV-ADV- internal fixation not required .greater degree ofinternal fixation not required .greater degree of
rotation can be achieved with less rotation ofrotation can be achieved with less rotation of
acetabulumacetabulum
 DISADV-DISADV- Technically more difficult . Alters theTechnically more difficult . Alters the
configuration and capacity of acetabulum and produceconfiguration and capacity of acetabulum and produce
joint incongruity that requires remodelingjoint incongruity that requires remodeling
 AGE-AGE-18months- 10 yr18months- 10 yr
 AFTERCARE-AFTERCARE-spica cast for 8 to 12 weeksspica cast for 8 to 12 weeks
PEMBERTON PERICAPSULAR OSTEOTOMYPEMBERTON PERICAPSULAR OSTEOTOMY

27. PERIACETABULAR OSTEOTOMY OF ILIUMPERIACETABULAR OSTEOTOMY OF ILIUM
(PEMBERTON)(PEMBERTON)

28. TRIPLE INNOMINATE OSTEOTOMYTRIPLE INNOMINATE OSTEOTOMY
(STEEL)(STEEL)

29. STEEL OSTEOTOMYSTEEL OSTEOTOMY
 INDI-INDI-Adolescents and skeletally mature adults with residualAdolescents and skeletally mature adults with residual
dysplasia and subluxation in whom remodelling of acetabulumdysplasia and subluxation in whom remodelling of acetabulum
is no longer anticipatedis no longer anticipated
 ADV-ADV-Better coverage of femoral head by articular cartilageBetter coverage of femoral head by articular cartilage
[chiari- fibrous cartilage], Better hip joint stability,no need of[chiari- fibrous cartilage], Better hip joint stability,no need of
spica cast.spica cast.
 DIS-DIS- Technically difficuilt, does not change size ofTechnically difficuilt, does not change size of
acetabulum, distort the hip such that natural child birth may beacetabulum, distort the hip such that natural child birth may be
impossible in adulthoodimpossible in adulthood
 PROC-PROC-The ischium, the sup pubic ramus and ilium superiorThe ischium, the sup pubic ramus and ilium superior
to the acetabulum is reposition and stabilized by bone graftto the acetabulum is reposition and stabilized by bone graft

30. GANZ OSTEOTOMY: (BERNESE)GANZ OSTEOTOMY: (BERNESE)
PRIACETUBULAR OSTEOTOMY.PRIACETUBULAR OSTEOTOMY.
 This Triplaner osteotomy is for adolescent and adultThis Triplaner osteotomy is for adolescent and adult
dysplastic hip that required correction of congruencydysplastic hip that required correction of congruency
& containment of the femoral head with little or no& containment of the femoral head with little or no
arthritis.arthritis.
 If significant degenerative changes are presents aIf significant degenerative changes are presents a
proximal femoral osteotomy can be added.proximal femoral osteotomy can be added.
 Approach Smith Peterson approach.Approach Smith Peterson approach.

31. GANZ OSTEOTOMYGANZ OSTEOTOMY

32.  Advantages :Advantages :
 Only one approach is used.Only one approach is used.
 A large amount of correction can be obtained in allA large amount of correction can be obtained in all
directions, including the medial and lateral planes.directions, including the medial and lateral planes.
 Blood supply to the acetabulum is preserved.Blood supply to the acetabulum is preserved.
 The posterior column of the hemipelvis remainsThe posterior column of the hemipelvis remains
mechanically intact,mechanically intact, allowing immediate crutch walkingallowing immediate crutch walking
with minimal internal fixation.with minimal internal fixation.
 The shape of the true pelvis is unaltered, permitting aThe shape of the true pelvis is unaltered, permitting a
normal child delivery.normal child delivery.
 Can be combined with trochanteric osteotomy if needed.Can be combined with trochanteric osteotomy if needed.
Contd.Contd.

33. THE SHELF PROCEDURE (STAHELI)THE SHELF PROCEDURE (STAHELI)

34. SHELF OPERATION (STAHELI)SHELF OPERATION (STAHELI)
 Have commonly been performed to enlarge the volume of theHave commonly been performed to enlarge the volume of the
acetabulum.acetabulum.
 The objective is to create a shelf, the size of which is decided byThe objective is to create a shelf, the size of which is decided by
measuring the “width of augmentation” form the CE angle. Themeasuring the “width of augmentation” form the CE angle. The
shelf is put just above the acetabular margin. It secure two layersshelf is put just above the acetabular margin. It secure two layers
of cancellous grafts bringing the reflected head of rectus femorisof cancellous grafts bringing the reflected head of rectus femoris
forward over the graft and suturing it in its original position.forward over the graft and suturing it in its original position.
 Best to do after 5 years of age.Best to do after 5 years of age.
 IndicationIndication :: A deficient acetabulum that cannot be corrected byA deficient acetabulum that cannot be corrected by
redirectional, osteotomy is the primary indication.redirectional, osteotomy is the primary indication.
 Contraindication :Contraindication :
 Dysplastic hip with spherical congruity suitable forDysplastic hip with spherical congruity suitable for
redirectional osteotomyredirectional osteotomy
 Hip requiring open reduction.Hip requiring open reduction.

35. CENTER EDGECENTER EDGE
ANGLE/ACETABULAR INDEXANGLE/ACETABULAR INDEX
 CE ANGLE-measured after 5 yr age, >25 normal,CE ANGLE-measured after 5 yr age, >25 normal,
<20 severe dysplasia<20 severe dysplasia
 AC IND- <27.5 normal, >30 dysplasiaAC IND- <27.5 normal, >30 dysplasia

36.  CHIARICHIARI

37.  CHIARICHIARI

38. INNOMINATE OSTEOTOMY WITH MEDIALINNOMINATE OSTEOTOMY WITH MEDIAL
DISPLACEMENT OF ACETABULUM (CHIARI)DISPLACEMENT OF ACETABULUM (CHIARI)

40. CHIARI OSTEOTOMYCHIARI OSTEOTOMY
 PROC-PROC-It is performed at the superior margin of theIt is performed at the superior margin of the
acetabulum and the pelvis inferior to the osteotomy alongacetabulum and the pelvis inferior to the osteotomy along
with the femur is displaced medially.with the femur is displaced medially.
This is also called as capsular interposition ArthroplastyThis is also called as capsular interposition Arthroplasty
as the capsule is interposed between the shelf and theas the capsule is interposed between the shelf and the
femoral head.femoral head.
 INDI-INDI-incongruous joint, dysplastic hip withincongruous joint, dysplastic hip with
osteoarthritis ,other osteotomy not possibleosteoarthritis ,other osteotomy not possible
 DISADV-DISADV-salvage osteotomy only, leaves anteriorsalvage osteotomy only, leaves anterior
acetabulum uncovered,abductor lurch common .acetabulum uncovered,abductor lurch common .

41. PALLIATIVE OPERATIONPALLIATIVE OPERATION
 Reserve for cases is which reduction is not possible byReserve for cases is which reduction is not possible by
either open or closed reduction as in old unreducedeither open or closed reduction as in old unreduced
congenital dislocation.congenital dislocation.
 Designed to improve :Designed to improve :
 Stability.Stability.
 Decrease lordosis.Decrease lordosis.
 Control pain arising from lower back/hip.Control pain arising from lower back/hip.

42. REVIEW OF PELVIC OSTEOTOMIESREVIEW OF PELVIC OSTEOTOMIES

43. SURGICAL PLANNINGSURGICAL PLANNING
 In surgical planning of an osteotomy, the mostIn surgical planning of an osteotomy, the most
important task is to determine whether theimportant task is to determine whether the
patient is an appropriate candidate.patient is an appropriate candidate.
Determining factors are the patient’s age,Determining factors are the patient’s age,
activities, goals, radiographic assessment,activities, goals, radiographic assessment,
range of motion, and leg lengths and the statusrange of motion, and leg lengths and the status
of the knee of same side.of the knee of same side.

44. OSTEOTOMYOSTEOTOMY
 Primary objective is deflection of wt. bearing byPrimary objective is deflection of wt. bearing by
angulation of femur to bring the axis of the femoralangulation of femur to bring the axis of the femoral
shaft more in line with the direction of weightshaft more in line with the direction of weight
transmission.transmission.
 The osteotomy performed are AngulationThe osteotomy performed are Angulation
Osteotomy (Stabilizing osteotomy).Osteotomy (Stabilizing osteotomy).
 Schanz osteotomy.Schanz osteotomy.
 Lorenz osteotomy.Lorenz osteotomy.

45. SCHANZ OSTEOTOMY (LOW S/T OSTEOTOMY)SCHANZ OSTEOTOMY (LOW S/T OSTEOTOMY)
(a)(a)Femur is sectioned transversely a lower border of pelvis.Femur is sectioned transversely a lower border of pelvis.
(b)(b)Upper end is angled inward until it rest against side wall of pelvis.Upper end is angled inward until it rest against side wall of pelvis.

46.  Schanz osteotomy (Low S/T Osteotomy) :Schanz osteotomy (Low S/T Osteotomy) :
 In this osteotomy the deformity flexion, adduction &In this osteotomy the deformity flexion, adduction &
external Rotation is corrected by making the osteotomyexternal Rotation is corrected by making the osteotomy
at tuber ischii level.at tuber ischii level.
 Preparation :Preparation :
 X-ray are taken with full adduction – to measureX-ray are taken with full adduction – to measure
angle medially.angle medially.
 Thomas Test - measure degree of flexion to beThomas Test - measure degree of flexion to be
corrected.corrected.
 Advantages :Advantages :
 Lurching gait will be diminished.Lurching gait will be diminished.
 The depression of the trochanter also improves theThe depression of the trochanter also improves the
leverage of the glutei.leverage of the glutei.
Contd.Contd.

47.  ContraindicationContraindication :: Before 15 years of age, because lossBefore 15 years of age, because loss
of angulation during growth period.of angulation during growth period.
 Lorenz (Bifurcation osteotomy)Lorenz (Bifurcation osteotomy)
 In this upper end of the lower fragment is abducted andIn this upper end of the lower fragment is abducted and
inserted in to the acetabulum after making oninserted in to the acetabulum after making on
intertrochanteric osteotomy “plane of osteotomy” belowintertrochanteric osteotomy “plane of osteotomy” below
& outward to above & inward.& outward to above & inward.
 Disadvantage :Disadvantage :
 Increased shortening.Increased shortening.
 Less mobility and arthritic pain.Less mobility and arthritic pain.
Contd.Contd.

48. LORENZ (BIFURCATION OSTEOTOMY)LORENZ (BIFURCATION OSTEOTOMY)
(A) Plane of(A) Plane of
osteotomy – Distalosteotomy – Distal
end at posterolateralend at posterolateral
aspect towardsaspect towards
proximal end atproximal end at
anteromedial aspect.anteromedial aspect.
(B) Limb is Abducted(B) Limb is Abducted
and extended so proximaland extended so proximal
end of distal fragmentend of distal fragment
directed medially anddirected medially and
anteriorly in acetabulum.anteriorly in acetabulum.

49. OSTEOTOMY FOR COXA VERAOSTEOTOMY FOR COXA VERA
 The normal femoral neck shaft angle in infant is 120The normal femoral neck shaft angle in infant is 12000
to 140to 14000
,,
Reduction to a more acute angle constitute a coxa varaReduction to a more acute angle constitute a coxa vara
deformity.deformity.
 The goal of treatment areThe goal of treatment are
 To promote ossification of the defect and correct varusTo promote ossification of the defect and correct varus
deformity.deformity.
 Indication for surgery :Indication for surgery :
 Increasing coxa varaIncreasing coxa vara
 Neck shaft angle less than 110°.Neck shaft angle less than 110°.
 Painful unilateral or associated with leg lengthPainful unilateral or associated with leg length
discrepancydiscrepancy
 Hilgenreiner - epiphy seal angle of more than 60° .Hilgenreiner - epiphy seal angle of more than 60° .

50.  Surgery performed areSurgery performed are
 Valgus Subtrochanteric Osteotomy or abductionValgus Subtrochanteric Osteotomy or abduction
osteotomy-with Internal Fixation.osteotomy-with Internal Fixation.
 A transverse osteotomy at about the level of lesserA transverse osteotomy at about the level of lesser
trochanter.trochanter.
 If necessary take a small lateral wedge to correct neckIf necessary take a small lateral wedge to correct neck
shaft angle to 135-150.shaft angle to 135-150.
 The surgery may be delayed till child is 4 to 5 year oldThe surgery may be delayed till child is 4 to 5 year old
to make internal fixation easier.to make internal fixation easier.
Contd.Contd.

51.  Alternative Method : Pauwels Y shaped osteotomy :Alternative Method : Pauwels Y shaped osteotomy :
 Static forces are converted from shearing to impactingStatic forces are converted from shearing to impacting
forcesforces
 Prerequisites :Prerequisites :
 Viable femoral head.Viable femoral head.
 Young vigorous patient.Young vigorous patient.
 Advantage :Advantage :
 Union is rapid.Union is rapid.
 Recurrence is less likely.Recurrence is less likely.
Contd.Contd.

52. PAUWELS Y SHAPED OST

53. COXA VERACOXA VERA

54. COXA VERACOXA VERA

55. OSTEOTOMY FOR RELIEF OF PAIN INOSTEOTOMY FOR RELIEF OF PAIN IN
OSTEOARTHRITISOSTEOARTHRITIS
 Before the onset of osteoarthritis, if normal or near normalBefore the onset of osteoarthritis, if normal or near normal
function of the hip can be maintained, reconstructivefunction of the hip can be maintained, reconstructive
osteotomy can prevent or delay the development ofosteotomy can prevent or delay the development of
osteoarthritis; if mild or moderate osteoarthritis is present, aosteoarthritis; if mild or moderate osteoarthritis is present, a
salvage osteotomy can improve function and delay the needsalvage osteotomy can improve function and delay the need
for total hip Arthroplasty.for total hip Arthroplasty.

56. FactorsFactors Reconstructive OsteotomyReconstructive Osteotomy Salvage OsteotomySalvage Osteotomy
AgeAge Generally < 25 yearsGenerally < 25 years Generally < 50 years (SomeGenerally < 50 years (Some
biological Plasticitybiological Plasticity
Remains)Remains)
SymptomsSymptoms Minimal (Out Progressive)Minimal (Out Progressive) Moderate to SevereModerate to Severe
MotionMotion Near NormalNear Normal > 60> 6000
FlexionFlexion
FunctionFunction Near NormalNear Normal Fair to PoorFair to Poor
PthoanatomyPthoanatomy No Irreversible ChangesNo Irreversible Changes Irreversible ChangesIrreversible Changes
RoentgenographyRoentgenography Congruent but MalalignedCongruent but Malaligned
SurfacesSurfaces
Cartilage narrowing orCartilage narrowing or
incongruity or bothincongruity or both
Prognosis ifPrognosis if
untreateduntreated
PoorPoor PoorPoor
THERAPEUTIC INTERVENTION IN HIP DIEASETHERAPEUTIC INTERVENTION IN HIP DIEASE
:RECONSTRUCTIVE VERSES SALVAGE OSTEOTOMY:RECONSTRUCTIVE VERSES SALVAGE OSTEOTOMY

57.  The goal of reconstructive osteotomies, femoral or pelvic, is toThe goal of reconstructive osteotomies, femoral or pelvic, is to
restore as nearly normal anatomy as possible, thus returningrestore as nearly normal anatomy as possible, thus returning
joint pressures and loading patterns to normal.joint pressures and loading patterns to normal.
 The goal of salvage osteotomies are to relieve pain andThe goal of salvage osteotomies are to relieve pain and
improve function enough to delay the need for total hipimprove function enough to delay the need for total hip
Arthroplasty, especially in active patients younger than 50Arthroplasty, especially in active patients younger than 50
years of age.years of age.
 Roentgenographic evaluation also should include a standingRoentgenographic evaluation also should include a standing
anteroposterior view and a “false profile” view.anteroposterior view and a “false profile” view.
Contd.Contd.

58. VARUS/VALGUS/DEROTATION FEMORALVARUS/VALGUS/DEROTATION FEMORAL
OSTEOTOMIES ARE -OSTEOTOMIES ARE -

65. VARUS OSTEOTOMIESVARUS OSTEOTOMIES

66. FEMORAL OSTEOTOMYFEMORAL OSTEOTOMY

67.  varus osteotomy :-varus osteotomy :-
 Designed to elevate the greater trochanter and move itDesigned to elevate the greater trochanter and move it
laterally while moving the abductor and psoas muscleslaterally while moving the abductor and psoas muscles
medially, to restore joint congruity and decrease muscle forcesmedially, to restore joint congruity and decrease muscle forces
about the hip.about the hip.
 Varus osteotomy alone is indicated for patients with aVarus osteotomy alone is indicated for patients with a
spherical femoral head, little or no acetabular dysplasia center-spherical femoral head, little or no acetabular dysplasia center-
edge angle of at least 15 to 20 degrees), signs lateraledge angle of at least 15 to 20 degrees), signs lateral
overloading, and a valgus neck-shaft angle of more than 135overloading, and a valgus neck-shaft angle of more than 135
degrees.degrees.
 Varus osteotomy with medial displacement of the femoralVarus osteotomy with medial displacement of the femoral
shaft relaxes the abductor, psoas, and adductorshaft relaxes the abductor, psoas, and adductor
musclesunloads the hip joint, and increases the weight-bearingmusclesunloads the hip joint, and increases the weight-bearing
surface.surface.
Contd.Contd.

68.  Most authors recommend medial displacement of 10 toMost authors recommend medial displacement of 10 to
15 mm to keep the ipsilateral knee centered under the15 mm to keep the ipsilateral knee centered under the
femoral head and to maintain the mechanical axis of thefemoral head and to maintain the mechanical axis of the
leg.leg.
 Varus osteotomy, however, shortens the limb to someVarus osteotomy, however, shortens the limb to some
degree. creates a Trendelenburg gait that may persist fordegree. creates a Trendelenburg gait that may persist for
months after surgery, and increases the prominence of themonths after surgery, and increases the prominence of the
greater trochanter.greater trochanter.
 Limb shortening can be minimized by making a smallerLimb shortening can be minimized by making a smaller
medial osteotomy and transposing it to the lateral side.medial osteotomy and transposing it to the lateral side.
Contd.Contd.

74. VALGUS INTERTROCHANTERICVALGUS INTERTROCHANTERIC
FEMORAL OSTEOTOMIESFEMORAL OSTEOTOMIES
 Valgus OsteotomyValgus Osteotomy - Increase weight bearing area of femur- Increase weight bearing area of femur
head.head.
 It does not produce muscle relaxation.It does not produce muscle relaxation.
 Relaxation obtained by tenotomy of Iliopsos and adductorRelaxation obtained by tenotomy of Iliopsos and adductor
muscle.muscle.
 Transfer the center of hip rotation medially from the superiorTransfer the center of hip rotation medially from the superior
aspect of the acetabulum to increase joint congruity and theaspect of the acetabulum to increase joint congruity and the
weight-bearing area of the femoral head.weight-bearing area of the femoral head.
 Osteotomy of the greater trochanter often is performed withOsteotomy of the greater trochanter often is performed with
valgus femoral osteotomy to move the greater trochantervalgus femoral osteotomy to move the greater trochanter
laterally.laterally.

75. VALGUS INTERTROCHANTERIC FEMORALVALGUS INTERTROCHANTERIC FEMORAL
OSTEOTOMIES :OSTEOTOMIES :

76.  Best result were obtained in patients younger than 40 years ofBest result were obtained in patients younger than 40 years of
age with unilateral involvement, good preoperative range ofage with unilateral involvement, good preoperative range of
motion, and a mechanical (secondary) cause.motion, and a mechanical (secondary) cause.
 Unsatisfactory results occurred in patients with limitedUnsatisfactory results occurred in patients with limited
preoperative flexion, they cited preoperative flexion of lesspreoperative flexion, they cited preoperative flexion of less
than 60 degrees as a relative contraindication to valgusthan 60 degrees as a relative contraindication to valgus
osteotomy.osteotomy.
 Most surgeons now advise that all osteotomies be fixed withMost surgeons now advise that all osteotomies be fixed with
rigid internal fixation, which offersrigid internal fixation, which offers several obviousseveral obvious
advantages:advantages:
 The fragments are maintained in proper position;The fragments are maintained in proper position;
 The danger of limitation of motion of the hip and knee isThe danger of limitation of motion of the hip and knee is
greatly decreased;greatly decreased;
Contd.Contd.

77.  The patient can be allowed out of bed early; andThe patient can be allowed out of bed early; and
 Pulmonary, urological, and other medical complicationsPulmonary, urological, and other medical complications
are decreased. A device frequently used for rigid internalare decreased. A device frequently used for rigid internal
fixation of intertrochanteric osteotomies is the ASIF, orfixation of intertrochanteric osteotomies is the ASIF, or
right-angled, blade plate. Our experience with this deviceright-angled, blade plate. Our experience with this device
has been quite favorable.has been quite favorable.
 Nonunion has been a troublesome complication afterNonunion has been a troublesome complication after
Osteotomy, and an incidence as high as 20% has beenOsteotomy, and an incidence as high as 20% has been
reported.reported.
Contd.Contd.

78. BLOUNT ABDUCTIONBLOUNT ABDUCTION
OSTEOTOMYOSTEOTOMY
 Trendelenburg limpTrendelenburg limp
 Adduction deformityAdduction deformity
 Motion in adduction beyond adductionMotion in adduction beyond adduction
deformitydeformity
 Painful abductionPainful abduction

79. BLOUNT ADDUCTIONBLOUNT ADDUCTION
OSTEOTOMYOSTEOTOMY
 Antalgic abductor limpAntalgic abductor limp
 Abduction deformityAbduction deformity
 Motion in abduction beyond the abductionMotion in abduction beyond the abduction
deformitydeformity
 Painful adductionPainful adduction

80. BIOMECHANICAL TREATMENT OFBIOMECHANICAL TREATMENT OF
OSTEOARTHRITISOSTEOARTHRITIS
 Therapy must be directed at reducing joint loads. This mayTherapy must be directed at reducing joint loads. This may
be by reducing the compressive forces directly or bybe by reducing the compressive forces directly or by
increasing the weight- bearing area, and thereby reducingincreasing the weight- bearing area, and thereby reducing
the load per unit area or ideally by combination of the two.the load per unit area or ideally by combination of the two.

81. WHILE PERFORMING OSTEOTOMYWHILE PERFORMING OSTEOTOMY
 The distal cut must be perpendicular to the axis of the shaftThe distal cut must be perpendicular to the axis of the shaft
fragment.fragment.
 All cortical wages are taken form the proximal fragment toAll cortical wages are taken form the proximal fragment to
avoid loss of apposition when the distal fragment is rotated.avoid loss of apposition when the distal fragment is rotated.
 General contraindication of femoral osteotomies -General contraindication of femoral osteotomies -
 Poor motionPoor motion
 Inflamatory joint conditionInflamatory joint condition
 Significant metabolic disease.Significant metabolic disease.
 Severe degenerative joint disease.Severe degenerative joint disease.

82. OSTEOTOMY TO CORRECT UNSTABLEOSTEOTOMY TO CORRECT UNSTABLE
INTERTROCHANTERIC FRACTURESINTERTROCHANTERIC FRACTURES
 Sarmiento TechniqueSarmiento Technique

83. OSTEOTOMY TO CORRECT UNSTABLEOSTEOTOMY TO CORRECT UNSTABLE
INTERTROCHANTERIC FRACTURESINTERTROCHANTERIC FRACTURES
 Dimon and Hughston :Dimon and Hughston :
 Described technique of Trochanteric osteotomy withDescribed technique of Trochanteric osteotomy with
valgus nailing and medial displacement to improvevalgus nailing and medial displacement to improve
stability there techniques are occasionally useful in somestability there techniques are occasionally useful in some
extremely comminuted fractures.extremely comminuted fractures.
 Recent studies have indicated that anatomical reductionRecent studies have indicated that anatomical reduction
allow greater load shearing by bone than medialallow greater load shearing by bone than medial
displacement osteotomy.displacement osteotomy.

84. DIMON AND HUGHSTON METHOD OFDIMON AND HUGHSTON METHOD OF
INTERTROCHANTERIC OSTEOTOMYINTERTROCHANTERIC OSTEOTOMY

85. SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
 Is a disorder in which there is a displacement of the capitalIs a disorder in which there is a displacement of the capital
femoral epiphysis form the metaphysis through the physealfemoral epiphysis form the metaphysis through the physeal
plate.plate.
 By this head is placed in posterior & downward position inBy this head is placed in posterior & downward position in
acetabulum.acetabulum.
 The goal of treatment isThe goal of treatment is
 To prevent further displacement andTo prevent further displacement and
 To promote closure of physeal plate.To promote closure of physeal plate.

86.  The use of realignment procedure such as lntertrochameric,The use of realignment procedure such as lntertrochameric,
Subtrochanteric Osteotomy & osteotomies the around neck isSubtrochanteric Osteotomy & osteotomies the around neck is
in those situation in which restricted range of motion impairsin those situation in which restricted range of motion impairs
function after plate physeal closure.function after plate physeal closure.
 Principle of OsteotomyPrinciple of Osteotomy
 There are basically three type of Deformity present in SCFE.There are basically three type of Deformity present in SCFE.
These are-These are-
 VarusVarus
 Hyper extensionHyper extension
 Moderate Severe external rotationModerate Severe external rotation
Contd.Contd.

87. SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
 The osteotomy to correct theseThe osteotomy to correct these
deformities work at two sites.deformities work at two sites.
 Through the femoral neckThrough the femoral neck
(closing wedge osteotomy)(closing wedge osteotomy)
 Through the trochantericThrough the trochanteric
area.area.

89. EXTRACAPSULAR BASE OF NECKEXTRACAPSULAR BASE OF NECK
OSTEOTOMYOSTEOTOMY
 types of femoral neck osteotomy are -types of femoral neck osteotomy are -
 The technique of Dunn - for severe chronic slip with openThe technique of Dunn - for severe chronic slip with open
physis.physis.
 Base of the neck osteotomy - Compensatory Basilar mostBase of the neck osteotomy - Compensatory Basilar most
of femoral neck. (Kramer) - correct the varus andof femoral neck. (Kramer) - correct the varus and
retroversion component of moderate to severe chronicretroversion component of moderate to severe chronic
SCFE.SCFE.
 It is safer than cuniform osteotomy of neck.It is safer than cuniform osteotomy of neck.
 Further slipping is prevented.Further slipping is prevented.
 Intertrochantric osteotomiesIntertrochantric osteotomies

90. CORRECTIVE OSTOTOMIESCORRECTIVE OSTOTOMIES
 By these osteotomies one can correct angulation, rotation,By these osteotomies one can correct angulation, rotation,
flexion, extension Deformity of bones to restore motion forflexion, extension Deformity of bones to restore motion for
patient with stiff hip.patient with stiff hip.
 LikeLike
 Deformities in septic arthritisDeformities in septic arthritis
 Malunion of I/T femursMalunion of I/T femurs
 Neuromuscular disorderNeuromuscular disorder
 Cerebral palsyCerebral palsy
 PoliomyelitisPoliomyelitis

91.  There are three types of corrective osteotomiesThere are three types of corrective osteotomies
 Close wedgeClose wedge - transverse closing wedge provide good bony- transverse closing wedge provide good bony
apposition and is stable, however, it shortens the extremity.apposition and is stable, however, it shortens the extremity.
 Open wedgeOpen wedge - simple and lengthens the extremity however.- simple and lengthens the extremity however.
bony apposition is limited, union is delayed in adults and itbony apposition is limited, union is delayed in adults and it
is initially unstable.is initially unstable.
 Ball and Socket typeBall and Socket type - achieves stability without shortening- achieves stability without shortening
the extremity; however, extensive dissection is required,the extremity; however, extensive dissection is required,
and in severe biplame deformities an accurate and stableand in severe biplame deformities an accurate and stable
osteotomy is difficult to perform.osteotomy is difficult to perform.
 In Ball & socket type of osteotomy concave surface in createdIn Ball & socket type of osteotomy concave surface in created
in the proximal fragment of convex surface at the distalin the proximal fragment of convex surface at the distal
fragment, at intertrochantaric level & fixed in place by plate.fragment, at intertrochantaric level & fixed in place by plate.
Contd.Contd.

92. CORRECTIVE OSTOTOMIESCORRECTIVE OSTOTOMIES
Brackett ball and socket
Osteotomy
Whitman closing wedge
Osteotomy
Gant-opening wedge
Osteotomy

93. FRACTURE NECK FEMURFRACTURE NECK FEMUR
 In those case which present late (1-5 wks.), are difficult caseIn those case which present late (1-5 wks.), are difficult case
to treat becauseto treat because
 Close reduction is not possible.Close reduction is not possible.
 Open reduction is associated AVNOpen reduction is associated AVN
 In young Pt. with viable femoral head & nonunion optionsIn young Pt. with viable femoral head & nonunion options
are-are-
 Mcmurray & Pauwel’s ‘y’ osteotomyMcmurray & Pauwel’s ‘y’ osteotomy
 Angulation Osteotomy (Schanz)Angulation Osteotomy (Schanz)
 Dickson geometric osteotomyDickson geometric osteotomy
 In old Pt.-In old Pt.-
 Girdle stone osteotomyGirdle stone osteotomy
 Mcmurray DisplacementMcmurray Displacement

94. OBLIQUE OSTEOTOMYOBLIQUE OSTEOTOMY
 Extends from lateral aspect of shaft at level just below theExtends from lateral aspect of shaft at level just below the
lower border of lesser trochanter and terminates mediallylower border of lesser trochanter and terminates medially
between lesser trochanter and lower border of neck.between lesser trochanter and lower border of neck.
 Shaft is displaced medially.Shaft is displaced medially.
 Mechanical Advantage :-Mechanical Advantage :-
 Line of weight bearing shifted medially.Line of weight bearing shifted medially.
 Shearing forces at the nounion is decrease becauseShearing forces at the nounion is decrease because
fracture surface become more horizontalfracture surface become more horizontal
 These advantages are greater after angulation osteotomy.These advantages are greater after angulation osteotomy.

95. McMURRAY

96. MC-MURRAY OSTEOTOMYMC-MURRAY OSTEOTOMY

97. MC-MURRAY’S OSTEOTOMYMC-MURRAY’S OSTEOTOMY
 The oblique osteotomy extends from the lateral aspect ofThe oblique osteotomy extends from the lateral aspect of
the shaft at a level just below the lower border of thethe shaft at a level just below the lower border of the
lesser trochanter and lower border of neck.Then the limblesser trochanter and lower border of neck.Then the limb
is rotated inward and outward to remove any bony spikeis rotated inward and outward to remove any bony spike
 Fixation of osteotomyFixation of osteotomy - By Compression nail- By Compression nail
plate./Castle Plate.plate./Castle Plate.
 Disadvantages:Disadvantages:
 Instability - Degenerative changes in normal headInstability - Degenerative changes in normal head
 Shortening - AVN when neck have been fracturedShortening - AVN when neck have been fractured
 Medial displacement of shaft compromise theMedial displacement of shaft compromise the
insertion of femoral stem of total hip.insertion of femoral stem of total hip.
 AdvantageAdvantage -Changes line of fracture to-Changes line of fracture to
horizontal,callus may incarporate fracturehorizontal,callus may incarporate fracture

98. DICKSON HIGH GEOMETRICDICKSON HIGH GEOMETRIC
OSTEOTOMYOSTEOTOMY
 Principle - the line of vertical forcePrinciple - the line of vertical force
is converted to a horizontalis converted to a horizontal
(impacting force). In this distal(impacting force). In this distal
fragment is abducted to 60° afterfragment is abducted to 60° after
making osteotomy just below themaking osteotomy just below the
grater trochanter & fixed with plate.grater trochanter & fixed with plate.
 High rate of unionHigh rate of union
 Lengthens limbLengthens limb
 Improves abductor strengthImproves abductor strength

99. GIRDLESTONE OSTEOTOMY

100. GIRDLE STONE OSTEOTOMYGIRDLE STONE OSTEOTOMY
 In this head & neck of femur are excised at Inter trochantericIn this head & neck of femur are excised at Inter trochanteric
level to create pseudo arthrosis in order to improve stability.level to create pseudo arthrosis in order to improve stability.
Angulations Osteotomy is added.Angulations Osteotomy is added.
 IndicationIndication
 T.B. HipT.B. Hip
 Pyogenic HipPyogenic Hip
 Non union #.neck femur [in elderly pt.]Non union #.neck femur [in elderly pt.]
 AVN of femoral head.AVN of femoral head.
 Advantages :-Advantages :-
 Painless mobile hip joint.Painless mobile hip joint.

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

103. TRANSTROCHANTRIC ANT. ROTATIONALTRANSTROCHANTRIC ANT. ROTATIONAL
OSTEOTOMYOSTEOTOMY [SUGIOKA][SUGIOKA]

104. TECHNIQUE FOR ROTATIONTECHNIQUE FOR ROTATION
 Femoral head is rotated anteriorly (45Femoral head is rotated anteriorly (4500
- 90- 9000
) by handling) by handling
proximal pin.proximal pin.

105. OSTEOTOMY IN PERTHE'S DISEASEOSTEOTOMY IN PERTHE'S DISEASE
 Salvage :Salvage :
 Varus Derotational OsteotomyVarus Derotational Osteotomy
 Innominate Osteotomy.Innominate Osteotomy.
 Combined Procedure -Combined Procedure -
 MRI / Arthrogram before surgery is mandatory.MRI / Arthrogram before surgery is mandatory.
 Varus/derotation osteotomy of this embodies the principleVarus/derotation osteotomy of this embodies the principle
of “containment” of the diseased femoral head in theof “containment” of the diseased femoral head in the
treatment of Legg - Calve-Perthes disease.treatment of Legg - Calve-Perthes disease.
 Guide pin inserted compression screw is placed overGuide pin inserted compression screw is placed over
guide wire.guide wire.

106. PERTHES DIEASESPERTHES DIEASES

107.  Appropriate angled osteotomy is made.Appropriate angled osteotomy is made.
 Wedge is removed.Wedge is removed.
 Make osteotomy as proximal as possible just below lagMake osteotomy as proximal as possible just below lag
screw for -screw for -
 Better HealingBetter Healing
 Better correction of deformity.Better correction of deformity.
 Reduce the osteotomy and fixed with plate andReduce the osteotomy and fixed with plate and
compression screw.compression screw.
Contd.Contd.

108. SUBTROCHANTERIC DEROTATIONSUBTROCHANTERIC DEROTATION
AND VARUS OSTEOTOMYAND VARUS OSTEOTOMY
 The aim of surgery is to center the whole "plastic" epiphysisThe aim of surgery is to center the whole "plastic" epiphysis
inside the joint cavity, keeping it well covered by the roof ofinside the joint cavity, keeping it well covered by the roof of
the acetabulum and allowing the child to walk so that thethe acetabulum and allowing the child to walk so that the
redistributed intra-articular pressures will contribute theredistributed intra-articular pressures will contribute the
molding of a more normal joint.molding of a more normal joint.
 A small 4-hole plate is bent to the desired angle, and aA small 4-hole plate is bent to the desired angle, and a
subtrochanteric osteotomy is done followed by derotation andsubtrochanteric osteotomy is done followed by derotation and
yarns angulation of the shaft. A double hip spica is applied andyarns angulation of the shaft. A double hip spica is applied and
the removed 2 months later. When the osteotomy site is united,the removed 2 months later. When the osteotomy site is united,
the child is encouraged to walk, at first in warm water pool,the child is encouraged to walk, at first in warm water pool,
then with walking aids and finally without support.then with walking aids and finally without support.

109. VARUS DEROTATION OSTEOTOMY

110.  The operation is best suited for early stage of Leg-Calve-The operation is best suited for early stage of Leg-Calve-
Perthes’ disease, preferably those under the age of 7 years.Perthes’ disease, preferably those under the age of 7 years.
 Axer : Described lateral open wedge osteotomy for childrenAxer : Described lateral open wedge osteotomy for children
< 5 years with perthes disease. Defect laterally fills rapidly< 5 years with perthes disease. Defect laterally fills rapidly
in young children > 5 years of age delayed or non union mayin young children > 5 years of age delayed or non union may
occur.occur.
Contd.Contd.

111. RECONSTRUCTIVE SURGERYRECONSTRUCTIVE SURGERY
 Valgus subtrochanteric osteotomyValgus subtrochanteric osteotomy - for Hing- for Hing
AbductionAbduction
 Shelf AugmentationShelf Augmentation – Coxa Megna.– Coxa Megna.
 ChilectomyChilectomy - Malformed head in late III Group.- Malformed head in late III Group.
 Chiar's Pelvic OsteotomyChiar's Pelvic Osteotomy - Large Malformed Femoral- Large Malformed Femoral
Head with Subluxation laterally.Head with Subluxation laterally.

112. BIBLIOGRAPHYBIBLIOGRAPHY
 Apley's System of Orthopaedics and Fractures - Loui's SolomanApley's System of Orthopaedics and Fractures - Loui's Soloman
8th Edition.8th Edition.
 Campbell's Operative Orthopaedics - 11th Edition. Vol.-2.Campbell's Operative Orthopaedics - 11th Edition. Vol.-2.
 Text Book of Orthopaedics - John Ebnezar - IInd Edition.Text Book of Orthopaedics - John Ebnezar - IInd Edition.
 Orthopaedic Knowledge Update – 7.Orthopaedic Knowledge Update – 7.
 Samuel L Turek Orthopaedics principles & their applicationsSamuel L Turek Orthopaedics principles & their applications
volumevolume