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

23. PEMBERTON = OVERZEALOUS DEGA
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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