osteotomies around hip by Dr.Rahul Mohan

1. Osteotomies Around HipOsteotomies Around Hip
Dr.Rahul mohanDr.Rahul mohan

2. OsteotomyOsteotomy is a surgical procedureis a surgical procedure
used to obtain a correct biomechanicalused to obtain a correct biomechanical
alignment of the extremity.alignment of the extremity.
Osteotomy can beOsteotomy can be
[1] of[1] of femurfemur&&
[2] of[2] of pelvispelvis around the acetabulumaround the acetabulum

3. CLASSIFICATIONCLASSIFICATION
[A][A] according to displacementaccording to displacement
1. Transposition osteotomy1. Transposition osteotomy—longitudinal—longitudinal
axis of distal fragment displaced parallel toaxis of distal fragment displaced parallel to
proximal fragment.proximal fragment.
2.Angulation osteotomy2.Angulation osteotomy—distal fragment—distal fragment
angulated---can be in saggital plane orangulated---can be in saggital plane or
coronal planecoronal plane

4. [B][B] according to anatomic locationaccording to anatomic location
1.1. High cervicalHigh cervical
2.2. IntertrochantricIntertrochantric
3.3. SubtrochantricSubtrochantric
4.4. Greater trochantricGreater trochantric
[C][C] according to indicationaccording to indication

5. NON-UNION NECK OF FEMURNON-UNION NECK OF FEMUR

6. Transposition osteotomyTransposition osteotomy—— Mc MurrayMc Murray
Angulation osteotomyAngulation osteotomy—— schanzschanz [better][better]
line of weight bearing shifted medially,line of weight bearing shifted medially,
shearing forces at the non union site isshearing forces at the non union site is
decreased, and fracture becomes moredecreased, and fracture becomes more
horizontal.horizontal.

7. Schanz osteotomySchanz osteotomy
Femur sectioned transversly at theFemur sectioned transversly at the
level of ischial tuberosity—upperlevel of ischial tuberosity—upper
fragment angulated—hitches againstfragment angulated—hitches against
pelvis—thus provides support &shiftspelvis—thus provides support &shifts
line of weight mediallyline of weight medially
Used in non union #NOF, CDH etcUsed in non union #NOF, CDH etc

9. Mc Murray osteotomyMc Murray osteotomy
At the level of base of GT upwards andAt the level of base of GT upwards and
inwards to a point just above LT distalinwards to a point just above LT distal
fragment displaced medially belowfragment displaced medially below
headhead
Totally abandoned now due toTotally abandoned now due to
instability & shorteninginstability & shortening..

12. Pauwels Y osteotomyPauwels Y osteotomy
 Produce valgus neck shaft angleProduce valgus neck shaft angle
 Vascular proximal end of shaftVascular proximal end of shaft
displaced medially to bridge non uniondisplaced medially to bridge non union
sitesite
 Ind -Ind - Nonunion # NOF with absorptionNonunion # NOF with absorption
of neck & proximal displacement ofof neck & proximal displacement of
distal fragment .contact neck &headdistal fragment .contact neck &head
minimalminimal

14. OSTEOARTHRITIS HIPOSTEOARTHRITIS HIP

15.  AIMAIM
To relive painTo relive pain
Restoration of motionRestoration of motion
Correction of deformityCorrection of deformity
Restoration of stabilityRestoration of stability
Reversal of degenerative processReversal of degenerative process

16. TO RELIEVE PAINTO RELIEVE PAIN
BiomechanicalBiomechanical
reducing muscle forcereducing muscle force
displacing fulcrumdisplacing fulcrum
relaxing capsulerelaxing capsule
restoring acetabulo femoralrestoring acetabulo femoral
congruencycongruency

17.  Detailed physical examinationDetailed physical examination
 Pre op x raysPre op x rays
standing AP & latstanding AP & lat
hip in maximum ABD & ADDhip in maximum ABD & ADD
 if head fit in abd – varus osteotomyif head fit in abd – varus osteotomy
 If head fit in add – valgus ostetomyIf head fit in add – valgus ostetomy
 Atleast 70* free flexionAtleast 70* free flexion

18. 2 types—2 types— Inter trochantericInter trochanteric
periacetabularperiacetabular
Inter trochanteric osteotomyInter trochanteric osteotomy
Reconstuctive— to delay/prevent OA byReconstuctive— to delay/prevent OA by
restoring near normal jtrestoring near normal jt
SalvageSalvage– to relieve pain and– to relieve pain and
function to delay THRfunction to delay THR

19. Reconstructive SalvageReconstructive Salvage
<25 years <50 years<25 years <50 years
Minimal sympt Moderate to severMinimal sympt Moderate to sever
Near-normal mvt >60 degrees flexionNear-normal mvt >60 degrees flexion
Near-normal funtn Fair to poorNear-normal funtn Fair to poor
No irreversibleNo irreversible
changes Irreversible changchanges Irreversible chang
Congruent butCongruent but
malaligned-xray Cartilage narrowing ormalaligned-xray Cartilage narrowing or

20. A patient with advanced osteoarthritisA patient with advanced osteoarthritis
of the hip who hasof the hip who has less than 50 degreesless than 50 degrees
of motion in flexion is not a goodof motion in flexion is not a good
candidate for intertrochantericcandidate for intertrochanteric
osteotomy.osteotomy.
A hip joint withA hip joint with rheumatoid arthritisrheumatoid arthritis
rarely benefits from intertrochantericrarely benefits from intertrochanteric
osteotomy.osteotomy.

21. Intertrochanteric osteotomy forIntertrochanteric osteotomy for
treatment of osteonecrosis of thetreatment of osteonecrosis of the
femoral head is effective onlyfemoral head is effective only if healthyif healthy
bone can be brought into the weightbone can be brought into the weight
bearing areabearing area. Extensive involvement. Extensive involvement
and collapse of the femoral head areand collapse of the femoral head are
contraindications.contraindications.

22. Osteotomy shouldOsteotomy should increase and notincrease and not
decreasedecrease the weight bearing area of thethe weight bearing area of the
femoral head.femoral head.
Careful study ofCareful study of abduction andabduction and
adduction radiographic viewsadduction radiographic views is crucialis crucial
Fixed adduction deformity is aFixed adduction deformity is a
contraindication to varus osteotomycontraindication to varus osteotomy
and fixed abduction deformity toand fixed abduction deformity to
valgus osteotomy.valgus osteotomy.

23. Stable internal fixationStable internal fixation is important,is important,
permits early motion, and enhancespermits early motion, and enhances
union of the osteotomyunion of the osteotomy
Recurrence of hip pain from arthritisRecurrence of hip pain from arthritis
may be simulated bymay be simulated by bursitis over abursitis over a
protruding internal fixation deviceprotruding internal fixation device..
Removal of the fixation device usuallyRemoval of the fixation device usually
relieves painrelieves pain

24. BLOUNTS INDICATIONSBLOUNTS INDICATIONS
VALGUS OSTE..YVALGUS OSTE..Y
Trendelenberg limpTrendelenberg limp
Add deformityAdd deformity
Add beyond addAdd beyond add
deformitydeformity
Painful abdPainful abd
VARUS OSTEO..YVARUS OSTEO..Y
Antalgic gaitAntalgic gait
Abd deformityAbd deformity
Abd beyond abdAbd beyond abd
deformitydeformity
Painful addPainful add

25. Varus ost alone done forVarus ost alone done for
 Spherical headSpherical head
 Little or no acetabular dysplasiaLittle or no acetabular dysplasia
 Sign of lateral overloadingSign of lateral overloading
 Valgus neck shaft angle > 135*Valgus neck shaft angle > 135*

26. Varus osteotomy increases weight bearing area of
femoral head while relaxing all three important muscle
groups around hip joint.

27. Muller osteotomyMuller osteotomy

29. Pauwels osteotomy

30. Valgus osteotomy aloneValgus osteotomy alone
 < 50 yrs OA hip dysplasia to delay THR< 50 yrs OA hip dysplasia to delay THR
 66THTH
decade with medial headdecade with medial head
osteophyte & subchondral sclerosis inosteophyte & subchondral sclerosis in
lat rooflat roof
 77thth
decade with OA for pain relief wheredecade with OA for pain relief where
THR is C/ITHR is C/I
 Protrusive OAProtrusive OA

31. Valgus osteotomy increases weight bearing area of femoral
head but does not produce muscle relaxation. Muscle relaxation
can be obtained by tenotomy of iliopsoas and adductor muscles.

33. Extension osteotomyExtension osteotomy
In patients with acetabular dysplasiaIn patients with acetabular dysplasia
according to Bombelliaccording to Bombelli

34. Periacetabular osteotomy-Periacetabular osteotomy-
GanzGanz

35. One cause of early secondary arthritisOne cause of early secondary arthritis
of the hip is believed to be primaryof the hip is believed to be primary
acetabular dysplasiaacetabular dysplasia in which lateralin which lateral
aspect of the articular surface of theaspect of the articular surface of the
femoral head uncovered.femoral head uncovered.
This results in high stresses at theThis results in high stresses at the
weight bearing portion of the articularweight bearing portion of the articular
surfaces of the hip, leading tosurfaces of the hip, leading to earlyearly
degenerative changesdegenerative changes

36. To contain the head within theTo contain the head within the
acetabulumacetabulum
Improve the mechanical environment.Improve the mechanical environment.
Ganz procedure for adults or adolescentGanz procedure for adults or adolescent
with closed physiswith closed physis
If changes seen in the head also,femoralIf changes seen in the head also,femoral
osteotomy can be addedosteotomy can be added

39. AdvantagesAdvantages
1.Only one approach1.Only one approach
2.large amount of correction attained.2.large amount of correction attained.
3.Blood supply to acetabulum preserved.3.Blood supply to acetabulum preserved.
4.Minimal internal fixation.4.Minimal internal fixation.
5.Shape of pelvis unaltered.5.Shape of pelvis unaltered.
6.Can b combined with trochantric osteotmy6.Can b combined with trochantric osteotmy

40. ComplicationsComplications
TechnicallyTechnically
demandingdemanding
InsuffucientInsuffucient
/eccessive/eccessive
correctioncorrection
NeurovascularNeurovascular
damagedamage
OsteonecrosisOsteonecrosis
non-unionnon-union
HeterotropicHeterotropic
ossificationossification
Loss of fixationLoss of fixation

41. AVN FEMORAL HEADAVN FEMORAL HEAD

42. Aim is to move the necrotic portion ofAim is to move the necrotic portion of
femoral head from weight bearing area.femoral head from weight bearing area.
Indicated in Ficat stage 2 & 3 with <30%Indicated in Ficat stage 2 & 3 with <30%
head involvement.head involvement.
Young ,<55yrs better resultsYoung ,<55yrs better results
Post traumatic &idiopathic better thanPost traumatic &idiopathic better than
steroid and alcohol induced.steroid and alcohol induced.

43. Transtrochantric rotationalTranstrochantric rotational
osteotomyosteotomy
Head & Neck rotated anteriorly so thatHead & Neck rotated anteriorly so that
weight bearing area is changed.Normalweight bearing area is changed.Normal
area should be >1/3area should be >1/3rdrd
of total articularof total articular
surface.surface.
technique—technique—Sugioka.Sugioka.
..

46.  Intertrochanteric flexion, extension, varus ,Intertrochanteric flexion, extension, varus ,
valgusvalgus
 CICI – stage 4 EXCEPT WHEN THR CI– stage 4 EXCEPT WHEN THR CI
 Valgus extension osteotomyValgus extension osteotomy
 varus derotation osteotomy ofvarus derotation osteotomy of AxerAxer

47. DDHDDH

48. Treatment > 2 yrs challenging because,Treatment > 2 yrs challenging because,
head is more proximal and severehead is more proximal and severe
contracture of the muscles.contracture of the muscles.
So femoral shortening is an essentialSo femoral shortening is an essential
part, still if coverage is insufficientpart, still if coverage is insufficient
pelvic osteotomy is needed.pelvic osteotomy is needed.
Varus derotation osteotomy—enoughVarus derotation osteotomy—enough
in 18-36 monthsin 18-36 months

49. Femoral osteotomyFemoral osteotomy
1.1. Intertrochantric varus osteotomy andIntertrochantric varus osteotomy and
blade plate fixation.blade plate fixation.
2.2. Femoral shortening andFemoral shortening and
derotation,combined with openderotation,combined with open
reduction of hipreduction of hip
3.3. Lloyd-roberts technique ofLloyd-roberts technique of
intertrochantric osteotomy andintertrochantric osteotomy and
fixation with coventry apparatus.fixation with coventry apparatus.

50. Femoral shortening andFemoral shortening and
derotation,combined withderotation,combined with
open reduction of hipopen reduction of hip

51. Femoral shortening is necessary toFemoral shortening is necessary to
reduce pressure on the reducedreduce pressure on the reduced
femoral head.femoral head.
The amount of shortening may beThe amount of shortening may be
estimated from the preoperative supineestimated from the preoperative supine
radiograph by measuring the distanceradiograph by measuring the distance
from the bottom of the femoral head tofrom the bottom of the femoral head to
the floor of the acetabulumthe floor of the acetabulum

52. The femur is transected just below theThe femur is transected just below the
lesser trochanter.lesser trochanter.
The hip is reduced and the distal femoralThe hip is reduced and the distal femoral
shaft is aligned with the proximal shaft.shaft is aligned with the proximal shaft.
The amount of overlap is noted and thatThe amount of overlap is noted and that
much shortening donemuch shortening done

53. The degree of hip decompression isThe degree of hip decompression is
adequate if the surgeon can, with aadequate if the surgeon can, with a
moderate force, distract the reducedmoderate force, distract the reduced
femoral head 3 or 4 mm from thefemoral head 3 or 4 mm from the
acetabulumacetabulum
The position of the lower extremity shouldThe position of the lower extremity should
be in moderate internal rotation.be in moderate internal rotation.
Derotation is done only when the internalDerotation is done only when the internal
rotation position is severerotation position is severe

55. Intertrochantric varusIntertrochantric varus
osteotomy and blade plateosteotomy and blade plate
fixationfixation

58. Lloyd-roberts technique ofLloyd-roberts technique of
intertrochantric osteotomyintertrochantric osteotomy
and fixation with coventryand fixation with coventry
apparatusapparatus

62. Pelvic osteotomyPelvic osteotomy
1.Salter innominate osteotomy1.Salter innominate osteotomy--
Used when head has been reduced or isUsed when head has been reduced or is
reduced by open reduction,when<15*reduced by open reduction,when<15*
correction of acetabular index needed.correction of acetabular index needed.

63. PrerequisitesPrerequisites
contracture releasedcontracture released
Head must be reducedHead must be reduced completely &completely &
concentricallyconcentrically
Congruous jointCongruous joint
Good ROMGood ROM

64. The Salter innominate osteotomy is basedThe Salter innominate osteotomy is based
onon redirection of the acetabulumredirection of the acetabulum as a unitas a unit
by hinging and rotation through theby hinging and rotation through the
symphysis pubissymphysis pubis
It is performed by making a transverseIt is performed by making a transverse
linear cut above the acetabulum at thelinear cut above the acetabulum at the
level of the greater sciatic notch and thelevel of the greater sciatic notch and the
anterior inferior iliac spine.anterior inferior iliac spine.
Fulcrum of rotation atFulcrum of rotation at pubic symphysispubic symphysis

65. The whole acetabulum with the distalThe whole acetabulum with the distal
fragment of the innominate bone isfragment of the innominate bone is tiltedtilted
downward and laterallydownward and laterally by rotating it.by rotating it.
The new position of the distal fragment isThe new position of the distal fragment is
maintained by amaintained by a triangular bone grafttriangular bone graft
taken from the proximal portion of the iliumtaken from the proximal portion of the ilium
and inserted in the open wedge osteotomyand inserted in the open wedge osteotomy
site.site.
Internal fixation is provided by twoInternal fixation is provided by two
threadedthreaded Kirschner wiresKirschner wires

67. Kalamchi modification of the Salter osteotomy.
The distal fragment is displaced into a notch on
the proximal fragment.

68. Pembertons pericapsular osteotomyPembertons pericapsular osteotomy
The Pemberton osteotomyThe Pemberton osteotomy repositions therepositions the
acetabulumacetabulum to improve anterior and lateralto improve anterior and lateral
coverage of the femoral headcoverage of the femoral head
The osteotomy begins anteriorly at theThe osteotomy begins anteriorly at the
anterior inferior iliac spine and proceedsanterior inferior iliac spine and proceeds
posteriorly and inferiorly to enter theposteriorly and inferiorly to enter the
triradiate cartilage posterior to thetriradiate cartilage posterior to the
acetabulum.acetabulum.

69. The path of the osteotome is controlledThe path of the osteotome is controlled
with image-intensified radiography.with image-intensified radiography.
As the osteotomy is opened, theAs the osteotomy is opened, the
acetabular fragment is pried into anacetabular fragment is pried into an
anterolateral positionanterolateral position and held there with aand held there with a
bone graft.bone graft.
Fulcrum of rotation atFulcrum of rotation at triradiate cartilagetriradiate cartilage
This osteotomy is quite stable andThis osteotomy is quite stable and doesdoes
not require fixationnot require fixation

70. The osteotomy hinges through theThe osteotomy hinges through the
triradiate cartilage, whichtriradiate cartilage, which reduces thereduces the
volume of the acetabulumvolume of the acetabulum
Contraindicated if the acetabulum is smallContraindicated if the acetabulum is small
relative to the size of the femoral head. Inrelative to the size of the femoral head. In
such cases the procedure may preventsuch cases the procedure may prevent
proper reductionproper reduction

71. A potential complication of the PembertonA potential complication of the Pemberton
osteotomy isosteotomy is premature closure of thepremature closure of the
triradiate cartilagetriradiate cartilage caused by thecaused by the
osteotomy's passing through the triradiateosteotomy's passing through the triradiate
cartilage.cartilage.
Another possible complication of theAnother possible complication of the
procedure isprocedure is damage to the acetabulardamage to the acetabular
growth centersgrowth centers caused by an osteotomycaused by an osteotomy
made too close to the acetabulammade too close to the acetabulam

73. Steel osteotomySteel osteotomy
For adolescents and skeletally matureFor adolescents and skeletally mature
With residual dysplasia and congruous jt.With residual dysplasia and congruous jt.
No remodelling.No remodelling.
So free a part of pelvis,creating a movableSo free a part of pelvis,creating a movable
segment .segment .

76. Dega osteotomyDega osteotomy
Trans iliac osteotomy to correct residualTrans iliac osteotomy to correct residual
acetabular dysplasia,secondary to DDH.acetabular dysplasia,secondary to DDH.
They divide the anterior and middleThey divide the anterior and middle
portion of inner cortex,with an intactportion of inner cortex,with an intact
posterior cortexposterior cortex

78. Sherical [dial] osteotomy-Eppright

79. Augmentation of acetabulamAugmentation of acetabulam
Chiari oseotomyChiari oseotomy
when it iswhen it is no longer possible to achieve ano longer possible to achieve a
concentric reductionconcentric reduction of the hip.of the hip.
a controlled fracture through the ilium, witha controlled fracture through the ilium, with
medial displacement of the acetabularmedial displacement of the acetabular
fragment and the intact hip capsule underfragment and the intact hip capsule under
the iliumthe ilium

80. Over time, theOver time, the hip capsule transforms intohip capsule transforms into
fibrocartilagefibrocartilage, which becomes the new, which becomes the new
acetabular coverage.acetabular coverage.
Because the femoral head is covered byBecause the femoral head is covered by
fibrocartilage instead of repositionedfibrocartilage instead of repositioned
acetabular cartilage, the Chiari osteotomyacetabular cartilage, the Chiari osteotomy
is considered ais considered a salvage proceduresalvage procedure..

82. Shelf proceduresShelf procedures
Numerous proceduresNumerous procedures
Slotted acetabular augmentation OfSlotted acetabular augmentation Of
StaheliStaheli
Wilson shelf procedureWilson shelf procedure

83. Slotted acetabular augmentation

86. THANK YOU

93. CEREBRAL PALSYCEREBRAL PALSY
Most common deformity—adductionMost common deformity—adduction
deformity, can lead to scissoringdeformity, can lead to scissoring
gait,subluxation or dislocation.gait,subluxation or dislocation.
Technique—Root & SeigalTechnique—Root & Seigal

95. ADOLESCENT COXA VARAADOLESCENT COXA VARA
Crawford criteria for surgeryCrawford criteria for surgery——
problems with gait or sitting, cosmeticproblems with gait or sitting, cosmetic
appearance after 1yr,after stabilization,appearance after 1yr,after stabilization,
also in c/c slipalso in c/c slip
2 types --through femoral neck and other2 types --through femoral neck and other
through trochantric reigion.through trochantric reigion.

96. Osteotomy through femoral neckOsteotomy through femoral neck
1.Cuneiform osteotomy of Fish1.Cuneiform osteotomy of Fish—assosciated with—assosciated with
high AVN & chondrolysishigh AVN & chondrolysis
2.2. 1.Cuneiform osteotomy of Dunn1.Cuneiform osteotomy of Dunn—based on the—based on the
fact that—in SLIP, new bone is laid in theback offact that—in SLIP, new bone is laid in theback of
the neck and the main blood supply runsthe neck and the main blood supply runs
posteriorly.posteriorly.
3.Kramer /Barmada osteotomy-3.Kramer /Barmada osteotomy- at the base of theat the base of the
neck,safer as line of cut is distal to blood supply.neck,safer as line of cut is distal to blood supply.
4.Extra capsular base of neck [Abraham et al]4.Extra capsular base of neck [Abraham et al]——
AVN practically nil.AVN practically nil.

97. Cuneiform osteotomy of FishCuneiform osteotomy of Fish

99. Intertrochantric osteotomyIntertrochantric osteotomy
In chronic slip, produces the oppositeIn chronic slip, produces the opposite
deformitydeformity
1.Biplane osteotomy of Southwick.1.Biplane osteotomy of Southwick.
2.Ball and socket trochantric osteotomy2.Ball and socket trochantric osteotomy

100. INFECTIOUS ARTHRITISINFECTIOUS ARTHRITIS
Result is a bony ankylosis.Result is a bony ankylosis.
Trochantric osteotomy usedTrochantric osteotomy used
1.Gant opening wedge osteotomy1.Gant opening wedge osteotomy
2.Whitman closing wedge osteotomy2.Whitman closing wedge osteotomy
3.Brackett ball and socket osteotomy.3.Brackett ball and socket osteotomy.

102. #NOF IN CHILDREN#NOF IN CHILDREN
Can be used to treatCan be used to treat
the complicationthe complication
coxa vara .coxa vara .
Valgus subtrochantricValgus subtrochantric
osteotomy by Ratliff.osteotomy by Ratliff.

103. OTHER INDICATIONSOTHER INDICATIONS
Perthes diseasePerthes disease
Unstable trochantric fracturesUnstable trochantric fractures
Congenital coxa vara.Congenital coxa vara.

104. Thanxxxxxxxxxxx 2Thanxxxxxxxxxxx 2
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