The Hip: Preservation, Replacement and Revision Tracking Pixel
Duke Orthopaedics
presents
Wheeless' Textbook of Orthopaedics

Pelvic Osteotomy for DDH


- See: DDH:

- Indications for Treatment:
    - age: pelvic osteotomies are usually performed between ages 3-8 years;
           - in children > 3 years, open reduction, femoral shortening, & acetabular redirection will provide concentric reduction, will reduce AVN, & will achieve a functional range of motion;
                  - some will even consider pelvic osteotomy in children as young as 2 years of age;
           - after 8 years of age consider salvage osteotomy since in older children there is little potential for remodeling & natural history of untreated dislocation is probably better than surgical correction;
                  - see natural history of DDH;
                  - w/ bilateral dislocation, there is probably little benefit  to osteotomy after the age of 5-6 years;
           - exception is the ganz osteotomy which is indicated for residual dysplasia in adolescents and young adults;
    - femoral head subluxation after reduction;
    - failure of acetabular development;
           - osteotomies should be done when DDH results in more acetabular pathology than femoral pathology (increased acetabular index);
                  - DDH changes on the femoral side should be treated w/ femoral osteotomies;
    - complete and incomplete transiliac osteotomies:
           - complete osteotomies: Salter1, Steel2, and Sutherland and Greenfield;


- PreOp Requirements:
    - sufficient articular cartilage;
          - if CT scan shows that congruence cannot be achieved by acetabular redirection or femoral varus derotation osteotomy, then consider salvage procedure;
    - satisfactory ROM;
    - congruent reduction w/ femoral head concentrically seataed in dysplastic acetabulum must be achieved prior to osteotomy;

- Radiographs:
    - increased acetabular index;
    - failure of lateral acetabular ossification;
    - false lateral view:
           - assesses anterior coverage of the femoral head.
           - obtained with the patient standing with the affected hip on the cassette, the ipsilateral foot parallel to the cassette, and the pelvis rotated 65 degrees from the plane of the cassette; 
    - references:
           - The anterior center edge angle in Lequesne's false profile view: interrater correlation, dependence on pelvic tilt and correlation to anterior acetabular coverage in the sagital plane. A cadaver study
           - Anatomical and radiological correlation of Lequesne's "false profile".
           - Early results of the Bernese periacetabular osteotomy: the learning curve at an academic medical center  
           - Clinical and radiographic assessment of the young adult with symptomatic hip dysplasia


- Surgical Options:
    - salter osteotomy (single innominate osteotomy):
    - steele triple innominate osteotomy:
           - indicated for children w/ DDH who have immobile symphysis pubis (over the age of 6-8 yrs);
           - in addition to an osteotomy from the ASIS to the notch (as in the salter osteotomy), there is also osteotomies of the inferior and superior pubic rami (which allows rotation);
           - this osteotomy tends to create a large deformity in the ischium which can lead to non union;
           - requires three separate incisions;
    - pemberton osteotomy:
           - incomplete transiliac osteotomy is that described by Pemberton;
           - osteotomy starts approximately 10 to 15 mm above the AIIS, procedes posteriorly, and ends at the level of the ilioischial limb of the triradiate cartilage (halfway between the sciatic notch and the posterior acetabular rim)
           - osteotomy may hinge at the triradiate cartilage and / or at the symphysis pubis;
    - spherical acetabular osteotomy:
    - ganz osteotomy:
    - ref: Pelvic Osteotomy Techniques and Comparative Effects on Biomechanics of the Hip: A Kinematic Study


- Salvage Pelvic Osteotomies:
    - include Shelf & Chiari osteotomies;
    - patients older than 8 years (or younger patients w/ bilateral CDH) may not benefit from reduction since acetabulum has no little of remodeling;
    - indications:
          - for severely incongruous & unstable hip joints;
          - need to ensure that hip is incongruent on both AP and Lateral views;
    - alteranative procedures:
          - if posterior-inferior portion of the acetabulum is normal it may be rotated superiorly in order to improve joint congruenty;
    - chiari osteotomy:
    - shelf:
          - in this osteotomy, cortical bone graft is applied to anterolateral aspect of the ilium between the indirect head of the rectus and the capsule;
          - relationship of the femoral head to the true acetabulum is not changed;
          - acetabular roof is extended laterally,  posteriorly, or anteriorly, either by graft or by turning distally over femoral head acetabular roof and part of the lateral cortex of the ilium superior to it;
          - main indication:
                 - aspherical dysplastic joint which is too deformed for reconstructive acetabular realignment but is not deformed enough to necessitate a chiari osteotomy;
          - requirements:
                 - requires an intact labrum;
          - performed through an anterior approach



Dome osteotomy of the pelvis for osteoarthritis secondary to hip dysplasia. An over five-year follow-up study.

Pelvic displacement osteotomy for chronic hip dislocation in myelodysplasia.

A combination pelvic osteotomy for acetabular dysplasia in children.

Rotational acetabular osteotomy for the dysplastic hip.

Triple osteotomy of the pelvis. A review of 51 cases.

Rotational acetabular osteotomy for the severely dysplastic hip in the adolescent and adult.

A new periacetabular osteotomy for the treatment of hip dysplasias. Technique and preliminary results.

Factors influencing the results of acetabuloplasty in children.

Osteotomy of the hip in children: posterior approach.

The hip-shelf procedure. A long-term evaluation.

Pericapsular osteotomy of the ilium for treatment of congenital subluxation and dislocation of the hip

Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips.

Surgical Correction of Residual Hip Dysplasia in Two Pediatric Age-Groups

A New Minimally Invasive Transsartorial Approach for Periacetabular Osteotomy

Pemberton Osteotomy for Acetabular Dysplasia.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, August 13, 2012 11:33 am