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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

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