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

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Presentation on theme: "Arthroplasty Rounds: Pelvic Osteotomies S. Rodriguez-Elizalde, MD The University of Ottawa Division of Orthopaedic Surgery."— Presentation transcript:

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

2 Pelvic Osteotomies ‣ Three Main Types: 1. Redirectional 2. Reshaping 3. Salvage

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

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

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 ‣ 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 Triple Innomiate Osteotomy

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 ‣ Dega Pelvic Osteotomy ‣ Pemberton Osteotomy Re-Shapping Pelvic Osteotomies

17 ‣ 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 Dega Pelvic Osteotomy DEGAS? D E G A S ?

18 ‣ 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 Dega Osteotomy: Technique

19 ‣ 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 Dega Osteotomy: Technique

20 Dega Osteotomy

21 ‣ 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 Pemberton Pelvic Osteotomy

22 ‣ 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

23 ‣ 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 Pemberton: Technique

24 Pemberton Osteotomy

25 ‣ Chiari Pelvic Osteotomy ‣ Shelf Osteotomy Salvage Osteotomies

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

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

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

29 Chiari Pelvic Osteotomy

30

31 ‣ 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 Shelf Osteotomy

32 ‣ 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 Shelf Osteotomy Technique

33 ‣ 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 Shelf Osteotomy Technique

34 Shelf Osteotomy

35 Pelvic Osteotomies - SUMMARY ‣ Remember: 1. Redirectional 2. Reshaping 3. Salvage

36 ‣ Powerpoint presentations to date: THANK YOU


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