The Hip: Preservation, Replacement and Revision

Spherical Acetabular Osteotomy for DDH



- See: DDH

- Discussion:
    - provides excellent congruity at site of osteotomy, rapid healing, & intrinsic stability with only minimum internal fixation;
    - performed through anterior approach;
    - specially curved gouges are used to divide acetabulum from surrounding pelvis through osteotomy site 15 mm from articular surface;
    - hip capsule is not violated inorder to preserve femoral head blood supply;
    - type I osteotomy:
         - single spherical osteotomy and simple rotatory  displacement;
         - more spherical osteotomies provide good lateral and anterior coverage but are limited with regard to the correction of version and mediolateral displacement;
         - there is no lengthening, shortening, medialization, or lateralization;
         - quadrilateral plate remains intact & prevents medialization;
         - in the study by Schramm M, et al (1999), the authors noted that a spherical acetabular osteotomy improved
                  the center edge angle from - 3 to + 15 deg;
         - these patients require sufficient articular surface in the posteroinferior quadrant to allow reorientation;
         - osteotomies may result in a defect between the osteotomized fragment and the ischium if major corrections are performed;
                  - Long-term results of spherical acetabular osteotomy.
         - Dega Osteotomy:
                  - incomplete transiliac osteotomy which penetrates the anterior and middle portions of the inner cortex of the ilium, leaving an intact posterior hinge (intact posteromedial iliac cortex and sciatic notch);
                  - supine position w/ involved hip rotated 30-40 deg;
                  - anterolateral incision is made from 1 cm inferior and posterior to ASIS and extending distally over the proximal femur;
                  - define interval between tensor fasciae latae muscle and sartorius;
                  - sartorius is released from its origin on the anterior superior iliac spine;
                  - abductor muscles are dissected off lateral wall of the ilium, distal to the iliac apophysis (apophysis itself is not split);
                  - abductor muscles and the periosteum are completely separated from the ilium and the hip capsule;
                  - sciatic notch is exposed and visualized with Hohman retractor inserted into the notch;
                  - soft tissues along inner wall are left undisturbed;
                  - rectus femoris muscle is dissected off hip capsule;
                  - rectus femoris muscle may be detached from the AIIS when necessary;
                  - psoas tendon is dissected from the capsule and is transected;
                  - open reduction of the hip and/or concomitant femoral osteotomy with shortening and rotation to correct excessive anteversion can be performed if necessary;
                  - osteotomy:
                          - just above the middle of the acetabulum is the most cephalad portion of the osteotomy;
                          - very steep acetabular inclinations require a correspondingly
                          - flouroscopy is used to help plan the osteotomy;
                          - when more anterior coverage is required, the inner cortex is transected over the anterior and middle portion, which leaves posterior sciatic notch hinge intact;
                          - when lateral coverage is required, more of the medial cortex is left intact, which creates the posteromedial hinge based on the posteromedial inner cortex and the entire sciatic notch;
                          - hinge portion is variable and may include sciatic notch, the posterior aspect of the inner pelvic cortex, the horizontal limb of the triradiate cartilage, and the symphysis pubis;
         - outcomes:
                  - in the report by Grudziak JS and Ward WT, the authors evaluated 22 children (24 hips) with
                        an average age of 5 years and 10 months and varying degrees of congenital hip dysplasia, subluxation, or dislocation were treated with a Dega osteotomy;
                        - 20 hips (83%) had a concomitant femoral osteotomy and thirteen (54%) had an anterior open reduction of the hip in addition to the Dega osteotomy;
                        - radiographs were reviewed to determine the acetabular index, the center-edge angle, whether the Shenton line was intact or broken, and any change in the projection of the obturator foramen;
                        - at an average of 55 months postoperatively, all patients demonstrated unlimited physical activity and no limp;
                        - average acetabular index changed from 33° preoperatively to 12° at the time of follow-up;
                        - center-edge angle ranged from less than -30° to 18° preoperatively and from 18° to 40° (average, 31°) at the time of follow-up;
                        - change in the obturator foramen was observed in fourteen hips (58%)p
                        - Shenton line was broken in seventeen hips preoperatively but in none postoperatively.
                        - ref: Dega Osteotomy for the Treatment of Congenital Dysplasia of the Hip 

       - type-II osteotomy:
         - involves combination of rotation of acetabular fragment & lengthening;
         - accomplished thru placement of an iliac bone graft in the cleft between rotated acetabular fragment and the overlying ilium;
         - indicated for dysplastic limb w/ shortening;
    - type-III osteotomy:
         - involves both acetabular realignment and medialization;
         - performed by creating a spherical acetabular osteotomy along w/ a Chiari-like cut proximally;
         - this allows both realignment and medial displacement to be performed;
         - stabilization utilizes K wires connected by a semitubular plate



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



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

Last updated by Data Trace Staff on Monday, August 13, 2012 11:47 am