Osteotomy



Introduction

Pre-operative planning is of utmost importance

Around joints designed to redistribute stress to a normal or less damaged part of the articular surface

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

Over or under correction of deformity
Non union
Joint stiffness
Infection

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Hip Osteotomy

Indications

Maintain near normal clinical function of the hip and restore a normal prognosis to the hip. Reconstructive osteotomy for a hip that is clinically normal but destined for OA.

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

Plain X-Rays (AP and Lat)
Profile views (ab/ad-duction, int/ext rotation)
Fluoroscopy +/- arthrography ® cover & congruency

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

Full ROM
No instability
Congruent Head

Principles of the technique

To increase the weight bearing surface
To decrease the muscle forces acting across the joint

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Femoral Osteotomies

Pauwells (1950 & 1968) introduced pre-operative X-Ray assessment in abduction and adduction in an attempt to determine whether varus or valgus osteotomy would increase the weight bearing area

Indications

  1. 90o 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 135o
  5. Improved congruency in abduction
  6. Not more than 20o as disrupts abductor mechanism
Medial displacement of shaft ® relax adductors and centre knee under femoral head. Abductors and psoas also relaxed ® reduce joint reaction forces.
Osteotomy will ®
Coxa vara
1cm shortening
Trendelenburg gait
Prominent greater trochanter.
Derotation often required in association with a varus osteotomy.
May require advancement of greater trochanter to balance abductors and limit the Trendelenburg gait

Valgus: (salvage)

Indications

  1. When head lost sphericity
  2. Congruency improved in adduction
Ideal patient less than 50 years, not obese, sedentary job, early OA and improved congruency following operation.
Performed in the presence of degenerative changes. Acts by changing contact bone to un-innervated osteophytes?.
Decreases lever arm by shifting the shaft towards centre of the femoral head. Results in improved congruency of the joint and weight bearing surface. Extension osteotomy (biplane) useful to correct a FFD
Varus or Valgus osteotomies require either medial or lateral displacement of the shaft of the femur to maintain the mechanical axis of the leg through the centre of the knee.

Southwick

Biplane osteotomy for slipped femoral capital epiphysis
AP and lateral X-Rays ® Angle of osteotomy required to correct alignment. Difference in the angle of the femoral neck to the femoral shaft on both AP and Lateral projections ® angles of the osteotomy to be performed.

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

Trans-trochanteric rotational osteotomy of the femoral head for idiopathic avascular necrosis to prevent collapse of the articular surface
Sugioka reports 70% excellent results from his series. Best results obtained if the surgery done early in the disease process, or in advanced cases in the absence of advanced collapse.

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

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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

CDH / CSH / Acetabular dysplasia
Perthes ® containment
Early OA in young patients

Chiari Osteotomy

Karl Chiari (Austria) First described osteotomy in 1955 and first published in English in 1974 (Clin Orth)
Salvage procedure ® increased coverage using bone and capsule

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 5-10o 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 20-30o 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

Robert B Salter (Canada) described osteotomy in 1961 JBJS
Believes instability secondary to the abnormal direction the acetabulum faces.
Concentric reduction of the hip is required before operation.
Osteotomy involves rotation of the acetabulum about the symphysis which due to the fixed axis of rotation limits correction to 25 - 30o improvement in acetabular orientation ® limited lateral cover.
Procedure lengthens limb about 1cm

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

Paul A Pemberton (Utah) described osteotomy in 1974 Clin Orthop
Rotation down of the acetabulum through the triradiate cartilage.
Changes the direction and shape of the acetabular roof ® lessen the capacity of the acetabulum

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

Lateralises the hip and shortens the abductors
Enables greater freedom of correction due to triple osteotomy

Operative Technique

Stage 1:
  1. Patient supine hip and knee flexed to 90o
  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 45o to the perpendicular
  6. Allow biceps femoris origin to fall back into place, approximate gluteus maximus and close skin
Stage 2:
  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 15o 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 20o Abduction and 5o 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

Osteotomy through pubis ® increased freedom for rotation

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

For truly dysplastic hips where the head is concentrically located but the CE angle of Wiberg is less than 15-20o.
Motion in the hip should be normal or close to it.

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 10o Flexion for 6/52 ® PWB and FWB when has active abduction against gravity (usually 4-6/52 after RO spica)
Can be managed in abducted traction for 6/52

Dial

 

Shelf Procedure (Staheli)

This is generally regarded as a salvage procedure
Assess the width of the shelf required by the amount needed to bring the CE angle out to normal (30-35o)

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 15o Abduction and 20o Flexion.
Spica on for 6/52 ® PWB until graft incorporated
Usually FWB at about 3-4 months

Shelf

 

Overview of pelvic osteotomies

Innominate best for 18/12 - 6 years (occasionally older)
Acetabuloplasty (Pemberton) best for 1 -12 yrs (girls) & 1 - 14 yrs (boys)
Osteotomy to free acetabulum (Steel / Sutherland) or dial (Eppright / Wagner) best if 6 yrs to young adults
Shelf (Wainwright / Chiari) salvage for 4 yrs to adult

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Knee Osteotomy

For unicompartmental change if less than 15o FFD and greater than 90o flexion

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 12o (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 15o
  7. The presence of patello femoral pain is not a contraindication (Aglietti symptoms often improved after osteotomy)
Employed to correct abnormal loading stresses on the knee that are caused by an abnormal tibio-femoral axis in the coronal plane

Varus Osteotomy

Pain must correlate with radiological findings (standing) ie not a neuropathic joint
Uni compartmental involvement with no ligament instability and less than 65 years old (? less than 55)
Physically active and want to remain so
The normal compartment should appear radiologically (and ? arthroscopically) normal before the osteotomy
Should be no disability associated with either the ipsilateral hip or ankle
Bone scan in the presence of normal X-Rays may indicate the presence of OA of one or both sides of the joint.
Aim of treatment to overcorrect the tibio-femoral angle to 3-5o of mechanical axis valgus (normal angle 5-7o valgus therefore aim for a tibio-femoral angle of ~ 9o)

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

Good short term results with 85% good at 5 years
40% still good (pain free) at 9 years (Install)
Some series say 60% good at 10 years (Coventry)

Complications

Peroneal nerve palsy
Vascular complications
Proximal tibial fracture or loss of fixation
Delayed or non union
DVT etc

Valgus Osteotomy

Valgus deformity of more than 12o better treated by a supra-condylar osteotomy of the distal femur
Tibio-fibular articulation does not need to be released
Do not overcorrect beyond 0o of tibio-femoral alignment

Results

(Shoji)
53% complete pain relief
14% partial relief
33% no relief

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