Pelvic Osteotomies for Developmental Hip Dysplasia

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Pelvic Osteotomies for Developmental Hip Dysplasia - DDH

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we recommended routine pelvic osteotomy at the time of open reduction for all patients over the age of 18 months.
Salter Osteotomy.
Salter Osteotomy is performed in younger patients between 18 months and 8 years of age, typically with open triradiate cartilage.
The primary indication for an Salter Osteotomy is an anterolateral acetabular deficiency in an otherwise concentrically reduced hip.
The Salter Osteotomy is a transverse iliac cut from just above the acetabulum, extending to the sciatic notch.
The distal acetabular fragment is rotated laterally and provided anterior and/or lateral coverage of the femoral head.
A triangular wedge of bone is cut from the iliac crest and placed into the osteotomy site and fixed with two- or three-threaded K-wires.
Triple osteotomy (Steele).
The primary indications are in older children and adolescents with open triradiate cartilage because their symphysis pubis does not rotate well.
The three separate osteotomies are performed.
On the lower portion of the ischium.
On the ilium above the acetabulum.
and on the superior pubic ramus.
then the acetabulum is reoriented by rotating the fragment created by these osteotomies.
It is an unstable osteotomy requiring rigid fixation and immobilization.
The drawback of Steele osteotomy is it violating the posterior column and creating pelvic discontinuity.
It leads to pelvic asymmetry and affects the birth canal negating the possibility of a normal vaginal delivery.
Pemberton osteotomy.
Pemberton osteotomy is recomented for moderate to severe hip dysplasia in children under 6 years old with open triradiate cartilage.
In this, a bicortical iliac osteotomy is done, which starts just above the anterior inferior iliac spine,
and proceeds posteriorly to end at the level of the ilioischial limb of the triradiate cartilage.
The osteotomy is curvilinear, parallel to and approximately 1 cm above the joint capsule.
the correction is maintained by a wedge of bone taken from the iliac crest.
periacetabular osteotomy (Ganz).
The primary indication of Ganz osteotomy is to improve the congruency and coverage of hip with acetabular dysplasia in patients with closed triradiate cartilage.
Ganz osteotomy is a complete reorientation osteotomy with bone cuts made close to the acetabulum that can allow for the maximum correction of lateral and anterior coverage.
These include an incomplete osteotomy of the ischium.
a complete osteotomy of the pubis.
and a biplanar osteotomy of the ilium in which the continuity of the posterior column of the acetabulum is maintained.
which permits early return to mobilization and wheight bearing.
Additional advantage includes preserving the shape of the pelvis, which permit normal vaginal delivery.
The major disadvantage is the technical difficulty.
Dega osteotomy.
Dega osteotomy is favored in neuromuscular dislocations such as Cerebral Palsy.
and patients with posterior acetabular deficiency.
and for severe cases.
The osteotomy begins anteriorly on the interspinous ridge between the anterior superior and anterior inferior iliac spine.
The orientation of the osteotomy is curvilinear when viewed from the lateral cortex, starting just above the anterior inferior iliac spine,
curving gently cephalad and posteriorly to end approximately 1-1.5 cm in front of the sciatic notch.
The osteotomy is bicortical anteriorly, and a variable amount of posteromedial cortex of the inner table of the pelvis in front of the sciatic notch is left intact.
Bone graft is shaped according to the gap at the osteotomy site.
the cut does not enter the sciatic notch and is therefore stable and does not need internal fixation.
it Improves anterior, central, or posterior coverage but reduces the acetabular volume.
Chiari osteotomy.
it is a salvage procedure, which aims mainly to achieve lateral coverage of femoral head in adolescents with acetabular dysplasia if a concentric reduction is not possible.
The level of pelvic osteotomy is very important and crucial.
It should be less than five mm from the joint space and directed with a cephalic inclination of 10° toward the sacroiliac joint.
It is a single pericapsular osteotomy through the iliac bone of the pelvis with medialization of the acetabulum and hip joint to improve posterior and lateral coverage.
The ilium forms a shelf over the dysplastic, subluxated hip.
Shelf procedure.
it is a Salvage procedure performed in patients older than 8 years old with acetabular dysplasia if a concentric reduction is not possible.
In this procedure, iliac crest bone grafts are placed into the lateral portion of the ilium at the acetabular margin.
It improves support of the femoral head by widening the roof of the acetabulum over the joint capsule and thus prevents subluxation.