Osteotomy

Introduction

Pre-operative planning is of utmost importance

Determine

1. Site of osteotomy, ie local geometry
2. Amount of correction required (angular & rotational)
3. Method of correction (opening, closing or complex wedge)
4. Method of fixation

Complications

Hip Osteotomy

Indications

After development of OA to improve function and delay the need for arthroplasty. Salvage osteotomy. If there is incongruency, improved congruency must be demonstrated to be achievable prior to surgery.

Beneficial effects of osteotomy in treatment of OA are produced by decreasing unit load by restoring congruency, decreasing muscle forces and restoring a functional arch of motion.

Patients who undergo osteotomy usually neither gain or lose overall range of motion.
Hip dysplasia ® osteoarthritis by age 50 in 50% of patients
Perthes ® OA in 50% of patients
Slipped epiphysis ® OA in 15-20% of patients
Femoral osteotomies are indicated for primary femoral problems eg osteonecrosis, slipped epiphysis and Perthes disease.
Pelvic osteotomies are indicated for primary hip pathology eg hip dysplasia +/- femoral osteotomy.

Radiological Assessment

Decision Pelvic vs Femoral: ® consider

1. Position of greater trochanter
2. Sphericity of femoral head
3. Neck shaft angle
4. Quality of bone
5. Leg length discrepancy
6. CE angle
7. Head coverage in AP and Lateral plane

Require

Principles of the technique

Femoral Osteotomies

Indications

1. 90^o passive movement
2. No bone collapse
3. Well contained head at least on abduction films ( more than 70% acetabular cover)
4. OA or dysplasia in a young patient
5. Joint space more than 2mm
6. ? Rheumatoid ® contraindicated also the presence of cysts or rapid progression in the months prior to surgery
7. Presence of advanced degenerative disease (dont fit the criteria above ® salvage eg valgus femoral osteotomy, Chiari or shelf procedure)

Varus

Indications

1. Spherical femoral head
2. Moderate or absent acetabular dysplasia
3. Signs of overload (acetabular subchondral plate)
4. Valgus neck shaft angle of more than 135^o
5. Improved congruency in abduction
6. Not more than 20^o as disrupts abductor mechanism

Osteotomy will ®

Coxa vara
1cm shortening
Trendelenburg gait
Prominent greater trochanter.

Valgus: (salvage)

Indications

1. When head lost sphericity
2. Congruency improved in adduction

Southwick

Operative Technique

1. Lateral approach to femur (sub-trochanteric)
2. Mark femur at junction of flat anterior and curved lateral surface
3. Place a transverse mark at the level of the lesser trochanter
4. Place a longitudinal line in the central lateral axis
5. Use a template to indicate anterior and lateral angles
6. Resect segment, reduce, compress and hold with a plate
7. Spica cast for 6-8/52

Sugioka Rotational Osteotomy of the Femur

Operative Technique

1. Lateral approach
2. Osteotomise the greater trochanter with its muscular attachments and reflect it proximally
3. Transect the short external rotators attached to the inter-trochanteric fossa
4. Protect the posterior branch of the medial femoral circumflex artery at the inferior edge of quadratus femoris
5. Circumferentially incise the hip capsule near the acetabular rim
6. Insert two pins into the greater trochanter perpendicular to the neck from lateral to medial
7. Make a trochanteric osteotomy perpendicular to the neck 10mm distal to the inter-trochanteric line
8. Make a second osteotomy perpendicular to the first at the superior edge of the lesser trochanter
9. Using the proximal pin rotate the proximal fragment anteriorly between 45 and 90o depending on the size of the necrotic fragment
10. Fix the osteotomy with large screws and then reattach the greater trochanter with either screws or wires. The area for reattachment of this fragment may need to be flattened after rotation
11. Traction for the first week and then only at night (2kg) PWB with crutches begun after 8/52 which continues for 6/12

Pelvic Osteotomies

Aims

1. To correct structural deformities and prevent development of OA
2. To alter the course of established degenerative changes

Pain relief secondary to

1. Increased weight bearing area and move to unworn cartilage
2. Reduce venous hypertension (trochanteric) thought to ® rest pain in OA
3. Alteration of muscle forces about the hip

Indications

Chiari Osteotomy

Operative Technique

1. Apply adhesive tape to each leg for post op skin traction
2. Position supine on orthopaedic traction table with leg in slight abduction and external rotation
3. Position image intensifier centred over the hip
4. Limited anterior approach to hip, 5cm over iliac crest and 5cm extending down the thigh from the ASIS
5. Fascia incised in line of tensor and gluteus medius
6. Reflected head of rectus femoris identified
7. Retractor placed into sciatic notch and muscle freed on inner and outer aspect of pelvis
8. Reflected head of rectus raised from the capsule
9. Osteotome placed deep to rectus and image intensifier used to check level and angle which should be angled up at 5-10^o from the horizontal
10. Osteotome cuts to conform to the proximal curve of the acetabulum and extended into the sciatic notch with care
11. Detach leg from the foot piece ® abduct leg fully ® medial displacement of acetabulum. If difficult either wrong angle or incomplete cut
12. At least 2cm displacement usually required (for each 2cm displacement ® decrease load by13%)
13. Reattach foot in 20-30^o abduction and close wound
14. No fixation used, maintain abduction in traction 3/52 (or use a spica)
    FWB when power and comfort permit
    Limp usually gone by 6/12

Chiari

Maximal improvement reached 2-3 years post surgery
Results in proximal migration of the femur of 1.5cm
Results of operation depend primarily in the condition of the hips prior to surgery.

Salter Osteotomy

Operative Technique

1. Patient supine on operating table with sand-bag under thorax
2. Free drape operative leg
3. Adductor tenotomy performed if required
4. Smith-Perterson approach along iliac crest to ASIS and then distally to AIIS. Iliac apophysis incised and periosteum stripped to the sciatic notch
5. Anterior hip capsule exposed by dissection between tensor fascialatae and sartorius
6. Open reduction of hip performed at this time if necessary
7. Gigili saw passed sub-periosterally around sciatic notch
8. Osteotomy performed in a straight line from notch to AIIS
9. Generous full thickness graft obtained from anterior part iliac crest and trimmed to a wedge
10. Towel clips used to stabilise proximal segment and displace distal segment forwards, downwards and outwards to open the osteotomy antero-laterally
11. Bone graft then inserted and stabilised with a stout K wire
12. Wound then closed after capsular repair if open reduction performed and approximation and suture of apophysis
13. Hip spica applied in slight abduction, flexion and medial rotation
    Spica and K wire removed removed at 6/52
    PWB for 2/52 then FWB
    95% excellent or good result when performed at 18/12 - 4 years
    50% excellent or good result when performed at more than 4 years
    60-70% excellent or good result when performed less than 6 years

Salter

Pemberton Osteotomy

Operative Technique

1. Smith-Peterson approach
2. Glutei and tensor stripped from anterior 1/3 ilium to margin of acetabulum and sciatic notch with iliac apophysis displaced medially
3. Hip capsule opened and joint inspected
4. Osteotomy through both tables of the ilium, the outer table starting just below the AIIS. The osteotome directed back towards the ilio ischial limb of the triradiate cartilage.
5. Osteotome then used to make a similar cut on the inner table
6. Broad curved osteotome used to complete the osteotomy and direct the superior rim of the acetabulum downwards
7. Osteotomy held open with a laminectomy spreader
8. Graft cut from iliac crest and driven into the cleft
9. Capsule is then closed and overlapped if necessary
10. The wound is closed in layers
11. Hip spica in slight abduction for 8/52 ® FWB

Pemberton

Steele Osteotomy

Operative Technique

1. Patient supine hip and knee flexed to 90^o
2. Transverse incision 1cm proximal to gluteal crease
3. Retract gluteus maximus laterally to expose hamstrings
4. Free biceps femoris from origin and expose space between semimembranosis and semitendinosus
5. Pass haemostat around ischium between these muscles and osteotomise bone. Direct osteotome postero-laterally and at 45^o to the perpendicular
6. Allow biceps femoris origin to fall back into place, approximate gluteus maximus and close skin

1. Using second operative set up
2. Ilio-femoral approach reflecting iliac and gluteal muscles and detach lateral attachment of inguinal ligament and sartorius from ASIS
3. Extend periosteal elevation to pectineal tubercle and elevate pectineus sub-periosteally
4. Pass a curved haemostat around superior pubic ramus ~ 1cm lateral to the pubic tubercle
5. Osteotomise ramus at inclination of 15^o to perpendicular
6. Osteotomise innominate as for Salter osteotomy through the sciatic notch
7. Perform open reduction of femoral head if necessary
8. Harvest graft from anterior iliac crest
9. Reduce acetabulum to desired position, insert graft and stabilise with 2x K wires
10. Allow ilio-psoas and pectineus to fall back into place, reattach sartorius and inguinal ligament and close the wound
11. Post op ® spica in 20^o Abduction and 5^o Flexion for 8-10/52,
    Osteotomies usually unite by 12/52
    WB on crutches after 12-14/52 and independent in 6/12
    

Steele

Sutherland Osteotomy

Operative Technique

1. Ensure bladder empty
2. Patient supine with sand bag under effected hip
3. Smith-Peterson approach and perform innominate osteotomy as for a Salter
4. Transverse supra-pubic incision retracting spermatic cord / round ligament laterally
5. Release rectus abdonimus and pyramidalis muscles from pubis and adductor longus from anterior surface
6. Place needle in symphysis and take an X-Ray to confirm location.
7. Elevate periosteum and protect tissues ie internal pudental artery on medial margin of inferior ramus and the dorsal vein and artery of the penis in the midline
8. Resect a wedge of bone 7-13mm in diameter just lateral to the symphysis parallel to it
9. Using a towel clip displace lateral segment medially, posteriorly and superiorly
10. Displace acetabular fragment distally and anteriorly and insert triangular graft to stabilise innominate osteotomy
11. Transfix the osteotomy with 2 heavy K wires
12. Insert drains and close the wound
13. Apply a spica cast for 8/52, pins left in place until the osteotomies have united.

Sutherland

Dial Osteotomy

Operative Technique

1. Patient supine, sand bag under the buttock / sacrum and free drape the affected leg
2. Expose the hip through a Smith-Peterson approach, divide the lateral cutaneous nerve of the thigh and separate sartorius and tensor from the ilium sub-periosteally
3. Divide rectus femoris at the AIIS
4. Expose capsule of the hip joint over as much circumference as possible
5. Reflect periosteum from the acetabular margin
6. Flex hip and divide ilio-psoas from the lesser trochanter
7. Incise capsule of hip joint in line with the neck
8. Identify exactly the acetabular margins and examine the articular surface of the femoral head
9. Perform circumferential osteotomy ideally taking 1cm of bone with the cartilage
10. Once osteotomy complete ® traction to the leg to allow rotation of the acetabulum to the desired position, then abduct the hip and release traction to maintain the desired position.
11. A Stienman pin may be used to stabilise the osteotomy
12. Spica in slight abduction and 10^o Flexion for 6/52 ® PWB and FWB when has active abduction against gravity (usually 4-6/52 after RO spica)

Dial

Shelf Procedure (Staheli)

Operative Technique

1. Patient supine tilted to side or on traction table
2. Incision 2-3cm below and parallel to iliac crest and then expose the hip through and ilio-femoral approach
3. Divide tendon of reflected head of rectus femoris and displace this anteriorly (ie divide below the AIIS to give length)
4. If capsule excessively thick, thin it with a scouple
5. Placement of acetabular slot at the margin of the acetabulum is the most important part of the operation. Should be 1cm deep with articular cartilage in the base
6. Make thin strips of cortico-cancellous bone from lateral ilium extending decortication of the outer wall of the ilium to the lateral lip of the slot above the acetabulum
7. Apply first layer of bone graft radially from the slot, second layer at right angles to the first to provide a well defined lateral margin of the shelf
8. Replace and secure the reflected head of rectus over these layers and suture to the capsule
9. Fill in Space above using the remaining graft which is then held in place by the abductors
10. Close the wound and apply a spica in 15^o Abduction and 20^o Flexion.

Shelf

Overview of pelvic osteotomies

Knee Osteotomy

Contraindications

1. Age more than 70 years is a relative contraindication due to problems with mobility
2. Rheumatoid arthritis (bicompartmental disease)
3. Valgus of more than 12^o (femoral osteotomy better as joint surface remains parallel to the floor)
4. Fixed adduction of the hip with a valgus knee (fix the hip first)
5. Instability or lateral luxation of more than 1cm
6. Varus of more than 15^o
7. The presence of patello femoral pain is not a contraindication (Aglietti symptoms often improved after osteotomy)

Varus Osteotomy

Operative Technique

1. Level of osteotomy between tibial tubercle and joint surface ® correction near the deformity and pull of quads tendon compresses the osteotomy
2. Plan size of wedge and through a transverse incision (staples) or longitudinal incision (plate) perform a closing wedge of the appropriate size
3. Must shorten fibula or divide tibio-fibular ligaments. Excision of segment of fibula in proximal 1/3 associated with EHL & Tib Ant weakness. Better to resect part of the neck or head and reattach the LCL and biceps tendon if necessary

Results

Complications

Valgus Osteotomy

Results

(Shoji)

53% complete pain relief
14% partial relief
33% no relief