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Arthroplasty Rounds: Pelvic Osteotomies

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1 Arthroplasty Rounds: Pelvic Osteotomies
S. Rodriguez-Elizalde, MD The University of Ottawa Division of Orthopaedic Surgery

2 Pelvic Osteotomies Three Main Types: Redirectional Reshaping Salvage

3 Pelvic Osteotomies Redirectional: Salter Innominate
Triple Innominate (Steel) Ganz Periacetabular Reshaping: Degas Pemberton Salvage: Chiari Shelf

4 Redirectional Pelvic Osteotomies
Salter Innominate Osteotomy Triple Innominate Osteotomy (Steel) Ganz Periacetabular Osteotomy

5 Salter Innominate Osteotomy
First described by Salter in 1961 Acetabular fragment mobility obtained with the single innominate osteotomy Rotation is through the pliable fulcrum of the pubic symphysis Primary indication for a Salter osteotomy is a deficiency of anterolateral femoral head coverage in an otherwise concentrically reduced hip

6 Salter Osteotomy Technique
Anterior approach Expose inner and outer tables of ilium Periosteum elevated off sciatic notch Forceps used to pass Gigli saw though sciatic notch Osteotomize from notch to just above AIIS Take bone graft from iliac crest Intramuscular (pelvic brim) tenotomy of iliopsoas

7 Salter Osteotomy Technique
Towel clip to pull distal fragment anterior and rotate downwards Insert graft K-wires from proximal fragment to distal fragment; check to ensure not in joint Hip spica cast in young or untrustworthy kids x 6 weeks

8 Salter Osteotomy A shallow acetabulum is a relative contraindication.
Expected improvements: Center-edge angle of 20 to 22 degrees Acetabular index of 10-degrees

9 Triple Innomiate Osteotomy
The triple osteotomy first described by Steel in 1965 Osteotomies of the ischium and pubis in addition to a Salter innominate osteotomy For older children (there is less symphyseal rotation due to skeletal maturity) Concentric hip reduction is a prerequisite

10 Triple Osteotomy Technique
Lateral decubitus position Prep buttocks and leg Initial incision 1 cm proximal to buttock crease down to gluteus maximus Release medial attachment to reveal muscles attached to tuberosity Release biceps femoris go between semi-T and semi-M

11 Triple Osteotomy Technique
Subperiosteal dissection of ischial ramus Protect pudendal NV bundle osteotomize ramus Smith-Petersen approach (expose pectineal tubercle) Osteotomize pubis medial to tubercle Perform Salter osteotomy Can use screws instead of k-wires Avoid over rotation

12 Ganz Osteotomy Introduced in 1988 by Ganz
Allows extensive acetabular reorientation, including medial and lateral displacement. Osteotomies performed in the pubis, ilium, and ischium. Vertical posterior column osteotomy connects the posterior extremes of the iliac and ischial osteotomies 1 cm anterior to the sciatic notch Done after skeletal maturity, because it (crosses the tri-radiate cartilage)

13 Ganz Osteotomy Stable; No complete cut is made into the sciatic notch (the posterior column is split vertically) Advantages: No postoperative cast is required Immediate crutch weight bearing Preservation of the blood supply to the acetabular fragment Single surgical approach Preservation of the shape of the pelvis, which permits normal vaginal delivery Disadvantage is that the procedure is difficult to learn

14 Ganz Technique Smith-Petersen
Partial osteotomy of ischium back to where the posterior limb of the ilial osteotomy will go Pubis is osteotomized as with the triple innominate Biplanar osteotomy of ilium (split the posterior column vertically, then along the top of capsule to just above AIIS) Rotate fragment and secure with screws

15 Ganz Pelvic Osteotomy

16 Re-Shapping Pelvic Osteotomies
Dega Pelvic Osteotomy Pemberton Osteotomy

17 DEGAS? Dega Pelvic Osteotomy
Acetabuloplasty that changes acetabular configuration and shape The primary indication is presence of a capacious acetabulum with posterolateral deficiency: Often done in children with cerebral palsy Also used for persistent acetabular dysplasia in DDH Provides increased postero-lateral coverage: osteotomy of the lateral cortex of the ilium hinging through the tri-radiate cartilage DEGAS?

18 Dega Osteotomy: Technique
Anterior approach Osteotomy of outer cortex above AIIS, curves posteriorly just above acetabulum to 1 cm from sciatic notch Straight osteotome directed medially to a point just above the horizontal part of the triradiate cartilage

19 Dega Osteotomy: Technique
Amount of inner cortex divided determines fragment rotation (ie more posterior sciatic notch hinge or medial cortex hinge) Open with lamina spreaded and insert tricortical graft from iliac crest No internal fixation needed Spica cast for 6-12 weeks

20 Dega Osteotomy

21 Pemberton Pelvic Osteotomy
First reported in 1958 by Dr. Paul Pemberton The tri-radiate cartilage must be open and flexible (before 6 years of age) Femoral head must be concentrically reduced Hip motion must be normal: good flexion, abduction and inward rotation Osteotomy tends to place the acetabulum forward and outward

22 Pemberton: Technique Anterior approach, division of psoas may be beneficial Split iliac apophysis and expose inner and outer tables of ilium Starting just above AIIS, osteotomize in a curvilinear fashion, staying in ilium, to the tri- radiate cartilage

Pemberton: Technique Expose the sciatic notch and combine with this exposure and fluoro to stay in bone to tri- radiate Need special right-angle osteotome to connect the inner and outer cuts near triradiate Insert triangular tricortical graft from crest Spica for 6 weeks then protected weight bearing and physio PEMBERTON = OVERZEALOUS DEGA

24 Pemberton Osteotomy

25 Salvage Osteotomies Chiari Pelvic Osteotomy Shelf Osteotomy

26 Chiari Pelvic Osteotomy
Medial displacement osteotomy that uses cancellous bone with interposed capsule for articulating surface May be augmented with a shelf procedure

27 Chiari Osteotomy Technique
Displace distal fragment medially (abduct leg) Secure osteotomy, augmented as necessary Spica cast or protected weight bearing fragment medially (abduct leg)

28 Chiari Osteotomy Technique
Displace distal fragment medially (abduct leg) Secure osteotomy, augmented as necessary Spica cast or protected weight bearing

29 Chiari Pelvic Osteotomy

30 Chiari Pelvic Osteotomy

31 Shelf Osteotomy AKA Staheli Osteotomy
Bone graft placed just above the hip joint Creates a wider roof / shelf over the acetabulum Keeps the femoral head from sliding up and out of the socket When healed, makes a larger weight-bearing surface Not a true osteotomy of the pelvis

32 Shelf Osteotomy Technique
Anterior approach, identify reflected head of rectus and divide it at midpoint Identify edge of acetabulum (may need to thin capsule slightly) Use drill to make 1 cm holes at acetabular edge aiming about 20° cephalad Use rongeur to connect holes and make slot

33 Shelf Osteotomy Technique
Get 1 cm wide cancellous graft strips from outer ilium Insert strips into slot, followed by layer superior at 90° Repair rectus overtop to secure graft Spica cast at 15° abduction, 20° flexion and neutral rotation for 6 weeks, then protected weight bearing for another 6

34 Shelf Osteotomy

35 Pelvic Osteotomies -SUMMARY
Remember: Redirectional Reshaping Salvage

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