Between Salter's And Pemberton's Osteotomy

Between Salter's And Pemberton's Osteotomy - Between...

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Unformatted text preview: Between Salter’s and Pemberton’s Between Osteotomy in DDH Osteotomy Prof. Mamoun Kremli , FRCS Prof. Consultant Pediatric Orthopedics College of Medicine & King Khaled University Hospital Riyadh, Saudi Arabia Introduction Objectives Indications for acetabulo­plasty. Characteristics of Salter’s Osteotomy. Characteristics of Pemberton’s Osteotomy. Differences between Salter’s and Pemberton’s Osteotomies. Between Salter’s and Pemberton’s Osteotomy in DDH 2 Introduction Indications for Acetabuloplasty 1) CDH discovered after 18 m. ± open reduction. Between Salter’s and Pemberton’s Osteotomy in DDH 3 Introduction Indications for Acetabuloplasty 2) Acetabular dysplasia. (antero lateral uncoverage of femoral head). 20o Increased AI. Reduced CE angle. 42o 30o 12o Between Salter’s and Pemberton’s Osteotomy in DDH 4 Introduction Indications for Acetabuloplasty 3) Residual acetabular dysplasia in treated CDH not satisfactorily correcting : Serial follow­up x­rays. (acetabular angle / shape). No improvement after two years of observation. (best before age 5 years ). Between Salter’s and Pemberton’s Osteotomy in DDH 5 Introduction Indications for Acetabuloplasty Pattern of Acetabular Development From Staheli, Practice of pediatric Orthopedics, 2001 Between Salter’s and Pemberton’s Osteotomy in DDH 6 Introduction Indications for Acetabuloplasty 4) Recently discovered acet. dysplasia in adolescents. Asymptomatic. Fatigue pain after activity. Between Salter’s and Pemberton’s Osteotomy in DDH 7 Introduction Indications for Acetabuloplasty 5) Acet. dysplasia causing hip subluxation. 18 m 3 yrs Between Salter’s and Pemberton’s Osteotomy in DDH 8 Salter’s Innominate Osteotomy Between Salter’s and Pemberton’s Osteotomy in DDH 9 Salter’s Osteotomy A Redirectional Acetabuloplasty Salter and modifications e.g. Kalamchi ( < 8 y ) Double innominate – Sutherland ( > 8 y ) Triple – Steel – Tonnis ( > 8 y ) Ganz – Bernese ( >15 y ) Wagner – Eppright ­ dial ( >15 y ) Between Salter’s and Pemberton’s Osteotomy in DDH 10 Salter’s Osteotomy Characteristics First published: JBJS 1961, 43B: 518­39 For mal­directed acetabulum (ante­torsion): (Acet. faces more anteriorly and laterally than normal). Pivots on the flexible symphysis pubis. Provides hyaline cartilage (physiological) cover. Does not disturb acetabular growth. Between Salter’s and Pemberton’s Osteotomy in DDH 11 Salter’s Osteotomy Pre­requisites 1) Age 18m ­ 9yrs – Adolescence ! (flexible symphysis pubis) 1) Good range of motion = Congruent joint. 2) Concentric reduction (present / achievable). 3) X­rays in abduction, flexion, and internal rotation shows improved cover. 4) No posterior wall deficiency. Between Salter’s and Pemberton’s Osteotomy in DDH 12 Salter’s Osteotomy Reported Corrections Range in literature : A.I. : 8o – 21o (average 12o ). C.E. : 15o – 30o Between Salter’s and Pemberton’s Osteotomy in DDH 13 Salter’s Osteotomy Limitations 1) Severe acetabular dysplasia. ( AI > 40o ) 2) Straight acetabulum. ( Saucer shaped ) 3) Posterior wall deficiency. 4) Coxa magna : Salter’s osteotomy does NOT enlarge acetabulum May cause posterior uncoverage. Between Salter’s and Pemberton’s Osteotomy in DDH 14 Salter’s Osteotomy Procedure: Position and exploration Position: semi­lateral with sand bag under buttock or shoulder. Per­cutanuous adductor tenotomy. Incision: oblique inguinal parallel to iliac crest. Identify and protect the Lateral Cut. N. of the thigh. Space between Sartorius and Tensor Fascia Lata. Split iliac apophysis, sub­periosteal dissection to sciatic notch, pack notch sub­periosteally. Ilopsoas tenotomy (intra­pelvic) by diathermy ( biopolar ). Between Salter’s and Pemberton’s Osteotomy in DDH 15 Salter’s Osteotomy Procedure: Adductor Tenotomy Between Salter’s and Pemberton’s Osteotomy in DDH 16 Salter’s Osteotomy Procedure: Adductor Tenotomy Between Salter’s and Pemberton’s Osteotomy in DDH 17 Salter’s Osteotomy Procedure: Exploration Between Salter’s and Pemberton’s Osteotomy in DDH 18 Salter’s Osteotomy Procedure: Exploration Between Salter’s and Pemberton’s Osteotomy in DDH 19 Salter’s Osteotomy Procedure: Splitting Apophysis Between Salter’s and Pemberton’s Osteotomy in DDH 20 Salter’s Osteotomy Procedure: Sub­periosteal packing Between Salter’s and Pemberton’s Osteotomy in DDH 21 Salter’s Osteotomy Procedure: Psoas Tenotomy Between Salter’s and Pemberton’s Osteotomy in DDH 22 Salter’s Osteotomy Procedure: Detaching capsular adhesions Without open reduction With open reduction Between Salter’s and Pemberton’s Osteotomy in DDH 23 Salter’s Osteotomy Procedure: Exploring Sciatic Notch medially laterally Between Salter’s and Pemberton’s Osteotomy in DDH 24 Salter’s Osteotomy Procedure: Preparation of Gigli Saw Between Salter’s and Pemberton’s Osteotomy in DDH 25 Salter’s Osteotomy Procedure: Insertion of Gigli Saw Between Salter’s and Pemberton’s Osteotomy in DDH 26 Salter’s Osteotomy Procedure: Insertion of Gigli Saw Between Salter’s and Pemberton’s Osteotomy in DDH 27 Salter’s Osteotomy Procedure: Insertion of Gigli Saw Between Salter’s and Pemberton’s Osteotomy in DDH 28 Salter’s Osteotomy Procedure – Performing the Osteotomy Osteotomy direction vertical & at right angle to iliac bone. To just proximal to AIIS. Assistant stabilizes the pelvis. Between Salter’s and Pemberton’s Osteotomy in DDH 29 Salter’s Osteotomy Procedure – Performing the Osteotomy Keep saw hands well separated – protect skin. Move saw to and fro with minimal pulling to avoid jamming. Between Salter’s and Pemberton’s Osteotomy in DDH 30 Salter’s Osteotomy Procedure: Graft harvesting Between Salter’s and Pemberton’s Osteotomy in DDH 31 Salter’s Osteotomy Procedure : Opening the Osteotomy If Salter’s alone : Figure of four and press down on knee. If with open reduction : Pull forewords, laterally, and inferiorly. Keep posterior cortices in contact. Between Salter’s and Pemberton’s Osteotomy in DDH 32 Salter’s Osteotomy Procedure : Inserting & stabilizing graft Over insertion too deep opens posterior cortices. Stabilize with two threaded/unthreaded pins. Check position of pins outside joint. By : hip range of motion. x­ray. Between Salter’s and Pemberton’s Osteotomy in DDH 33 Salter’s Osteotomy Procedure: Closing apophysis Between Salter’s and Pemberton’s Osteotomy in DDH 34 Salter’s Osteotomy Procedure: Closure Between Salter’s and Pemberton’s Osteotomy in DDH 35 Salter’s Osteotomy Procedure: End Between Salter’s and Pemberton’s Osteotomy in DDH 36 Salter’s Osteotomy The aim is to rotate the acetabulum: Tips Avoid excessive traction on distal fragment (may break). Add lateral shift to distal fragment to increase lateral cover. Position of pins: best both medial to acetabulum. Use absorbable pins to avoid a second operation. Between Salter’s and Pemberton’s JPO­B, Vol.11, No. 2, 2002 Osteotomy in DDH 37 Salter’s Osteotomy Pitfalls / Drawbacks / Complications Open osteotomy at sciatic notch. Unstable. Loss of correction. Between Salter’s and Pemberton’s Osteotomy in DDH 38 Salter’s Osteotomy Pitfalls / Drawbacks / Complications Miss­placed pins/wires. Unstable : Loss of correction. Intra­articular in the hip joint : chondrolysis. Between Salter’s and Pemberton’s Osteotomy in DDH 39 Salter’s Osteotomy Pitfalls / Drawbacks / Complications Operating on children below 18 m of age: Too thin innominate bone and graft : Displacement of graft and osteotomy. Should allow for possible normal acetabular development. Between Salter’s and Pemberton’s Osteotomy in DDH 40 Salter’s Osteotomy Pitfalls / Drawbacks / Complications Failure to perform tenotomy of ilio­psoas / adductors : Causes incomplete rotation of acetabulum. Increases pressure on femoral head = AVN. Between Salter’s and Pemberton’s Osteotomy in DDH 41 Salter’s Osteotomy Contraindications / Complications Salter’s osteotomy causes partial posterior femoral head uncoverage by re­directing acetabulum anteriorly. If pre­existing posterior acetabular wall deficiency: Posterior dislocation of femoral head. Caution when combined with femoral derotation for ante­version. Between Salter’s and Pemberton’s Osteotomy in DDH 42 Salter’s Osteotomy Pitfalls / Drawbacks / Complications Careful when posterior wall deficient. Between Salter’s and Pemberton’s Osteotomy in DDH 43 Salter’s Osteotomy Other Complications Nerve injury: Sciatic (avoided by staying sub­periosteal and using gigli saw) Femoral Wire problems: Migration (avoided by using threaded wires) Breakage Penetration into joint Between Salter’s and Pemberton’s Osteotomy in DDH 44 Salter’s Osteotomy Specific guidelines in the application of the principles of innominate osteotomy. Salter RB. Orthop Clin North Am 1972; 3:149 Between Salter’s and Pemberton’s Osteotomy in DDH 45 Salter’s Osteotomy Modification s Kalamchi 1982 / lengthening / preserving medial cortical periosteum – more stable, ? No k­wire. Kalamchi A., JBJS, A982,64A: 183 Between Salter’s and Pemberton’s Osteotomy in DDH 46 Salter’s Osteotomy Modifications Kalamchi (1982) Notch in proximal fragment: more stable – no leg lengthening. JBJS 1982. 64A: 183­5 Between Salter’s and Pemberton’s Osteotomy in DDH 47 Salter’s Osteotomy Modifications Trans­iliac lengthening (1972) Open posteriorly, quadrangular graft JBJS 1979; 61A: 1182 Between Salter’s and Pemberton’s Osteotomy in DDH 48 Pemberton’s (Pericapsular) Osteotomy Between Salter’s and Pemberton’s Osteotomy in DDH 49 Pemberton’s Osteotomy A Pericapsular, Restructural Acetabuloplasty. Between Salter’s and Pemberton’s Osteotomy in DDH 50 Pemberton’s Osteotomy Publication First published in 1958 ( Pemberton,P.A.: Osteotomy of the ilium with rotation of the acetabular roof for congenital dislocation of the hip ) JBJS 1958, 40A: 724 Pericapsular osteotomy of the ilium for congenital subluxation and dislocation of the hip. JBJS 1965, 47A: 65­86 Pericapsular osteotomy of the ilium for the treatment of congenitally dislocated hips. Clin. Orthop., 1974, 98:41 Between Salter’s and Pemberton’s Osteotomy in DDH 51 Pemberton’s Osteotomy Characteristics Between Salter’s and Pemberton’s Osteotomy in DDH 52 Pemberton’s Osteotomy Characteristics Medial Lateral Between Salter’s and Pemberton’s Osteotomy in DDH 53 Pemberton’s Osteotomy Characteristics Greater versatility c.f. most other pelvic osteotomies. Successfully used in : CDH / AD Excessive ligament Laxity. Paralytic disorders. Between Salter’s and Pemberton’s Osteotomy in DDH 54 Pemberton’s Osteotomy Pre­requisites 1) Age 18 m – 11 yrs. ( open tri­radiate cartilage ). 2) Congruent joint = Good ROM. 3) Concentric reduction. ( present / achievable ). 4) Open tri­radiate cartilage. 5) Surgeon with experience ! Between Salter’s and Pemberton’s Osteotomy in DDH 55 Pemberton’s Osteotomy Characteristics Fulcrum of rotation at tri­radiate cartilage closer to hip joint. (greater correction) Between Salter’s and Pemberton’s Osteotomy in DDH 56 Pemberton’s Osteotomy Characteristics Stable (incomplete osteotomy of ilium). no need for internal fixation. can be performed bilaterally simultaneously. Between Salter’s and Pemberton’s Osteotomy in DDH 57 Pemberton’s Osteotomy Characteristics Improves anterior and lateral covers. Improves acetabular contour. Can achieve almost any degree of correction of A.I. (definitely > 15°). Best osteotomy for saucer­shaped acetabulum. Does not affect posterior acetabular cover. Between Salter’s and Pemberton’s Osteotomy in DDH 58 Pemberton’s Osteotomy Characteristics 50o Saucer shaped / Need for a lot of improvement in cover Pemberton / femoral shortening Between Salter’s and Pemberton’s Osteotomy in DDH 59 Pemberton’s Osteotomy Procedure: Exploration Similar to Salter’s Increase inferior exposure medially by cutting periosteum on inner wall towards the tri­radiate cartilage. Between Salter’s and Pemberton’s Osteotomy in DDH 60 Pemberton’s Osteotomy Procedure: Exploration Similar to Salter’s Increase inferior exposure laterally above the reflected head of rectus around the capsule as far posteriorly as possible. Between Salter’s and Pemberton’s Osteotomy in DDH 61 Pemberton’s Osteotomy Procedure: Planning The Osteotomy Lateral corticotomy : Above AIIS by ~1 cm. Curving following the capsule and 1 cm. above. Between Salter’s and Pemberton’s Osteotomy in DDH 62 Pemberton’s Osteotomy Procedure: Planning The Osteotomy Medial corticotomy: Parallel to outer cut. At a lower level c.f lateral cut. Between Salter’s and Pemberton’s Osteotomy in DDH 63 Pemberton’s Osteotomy Procedure :Relation of Medial & Lateral Cuts More lateral cover More anterior cover Between Salter’s and Pemberton’s Osteotomy in DDH 64 Pemberton’s Osteotomy Procedure: Performing The Osteotomy Direction of inferior cuts Connect medial and lateral cuts Between Salter’s and Pemberton’s Osteotomy in DDH 65 Pemberton’s Osteotomy Procedure : Graft harvesting Between Salter’s and Pemberton’s Osteotomy in DDH 66 Pemberton’s Osteotomy Procedure : Graft insertion Lateral view Medial view Between Salter’s and Pemberton’s Osteotomy in DDH 67 Pemberton’s Osteotomy Tips Use Pemberton curved osteotome or Schaghliatti chisel. Between Salter’s and Pemberton’s Osteotomy in DDH 68 Pemberton’s Osteotomy Tips Use of laminar spreader to open the osteotomy and assist completing the posterior and inferior parts. Avoid spreading osteotomy too much to maintain inherited recoil. Avoid going intra­articular by : Staying close to sciatic notch. Using intra­operative x­rays. Between Salter’s and Pemberton’s Osteotomy in DDH 69 Pemberton’s Osteotomy Limitations Reduces size of acetabulum. ( contra­indicated the femoral head is larger than the acetabulum ­ coxa magna ). Between Salter’s and Pemberton’s Osteotomy in DDH 70 Pemberton’s Osteotomy Pitfalls Can over correct easily. AVN. Redislocation. Distorts shape of the acetabulum incongruity and stiffness. Between Salter’s and Pemberton’s Osteotomy in DDH 71 Pemberton’s Osteotomy Pitfalls Increases pressure more than Salter’s. may need femoral shortening if a lot of acetabular correction is needed. Between Salter’s and Pemberton’s Osteotomy in DDH 72 Pemberton’s Osteotomy Complications Hinges on tri­radiate cartilage. (? injury/premature closure of tri­radiate cartilage). May cause Intra­ articular fracture. Between Salter’s and Pemberton’s Osteotomy in DDH 73 Pemberton’s Osteotomy Modifications Pembersal Across posterior limb into body of iscium. Marafioti, Westin :1980 JBJS, 62­A:765,1980. Perlik, Westin, Marafioti : 1985 JBJS 1985, 67A:842. Tavares : 2004 J Ped Orthop, 24, No 5:501­507 Between Salter’s and Pemberton’s Osteotomy in DDH 74 Pemberton’s Osteotomy Modifications Modified Pemberton Osteotomy (MPA) Woolf, Gross : 2003 wedge posterior in posterior wall deficiency / Downs. J Ped Orthop, 23, No 6:708­713 Tavares : 2004 between salter and pembersal at sciatic notch not through and not reaching tri­ radiate Cartilage ­ seen throughout. J Ped Orthop, 24, No 5:501­507 Tavares : 2004 J Ped Orthop, 24, No 5:501­507 Between Salter’s and Pemberton’s Osteotomy in DDH 75 Dega Osteotomy Characteristics Similar to Pemberton. Versatile : improves cover anteriorly /centrally /posteriorly. Good in failed closed reduction – complicated. May reduce acetabular volume. Hinges through tri­radiate cartilage. Better posterior cover. Best for C.P. where posterior acet. wall deficient. (Macnicol 1996) Between Salter’s and Pemberton’s Osteotomy in DDH 76 Important Literature Mckay D W. A comparison of the innominate and the pericapsular osteotomy in the treatment of congenital dislocation of the hip. Clin Orthop, 1984. 98: 124­32. Rab G T. Biomechanical aspects of Salter osteotomy. Clin Ortop, 1978, 132: 82­7 Between Salter’s and Pemberton’s Osteotomy in DDH 77 Factors to consider Age : 18 m – 6 y : Mild – Moderate : Severe : Unilateral : Salter. Bilateral : Pemberton simultaneously / Salter one at a time. Pemberton. Age : 6 y – 12 y : Mild : Salter Moderate – Severe : Pemberton. Complicated with uncoverage / coxa magna : Shelf. Between Salter’s and Pemberton’s Osteotomy in DDH 78 Problem of Posterior Wall Deficiency In neuromuscular. In Down’s. In failed treatment of DDH. Failed closed reduction. Post Salter’s & re­dislocated. Solutions : Posterior shelf ! Dega. Modified Pemberton. Between Salter’s and Pemberton’s Osteotomy in DDH Shane K Woolf, Richard H Gross. J.Pediatr Orthop 2003; Vol. 23, No. 6; 708­713. 79 Salter’s Summary Vs. Redirectional. Similar pre­requisites. Pivots on symphysis pubis. Easy to perform. Common. Improves AI by about 150. Not good in saucer­shaped acetabulum. Pemberton’s Restructural. Similar pre­requisites. Pivots on tri­radiate cartilage. More difficult. Uncommon. Improves any angle. Ideal for saucer­shaped acetabulum. Between Salter’s and Pemberton’s Osteotomy in DDH 80 Salter’s Unstable: Summary Vs. Needsk­wires. Needs re­admission. Only unilaterally. Not with posterior wall deficiency and paralytic disorders. Not with Coxa magna. Less serious complications. Pemberton’s Stable: No k­wires. No re­admission. Possible bilaterally. Good for posterior wall deficiency and paralytic disorders. Not with Coxa magna. More serious complications. Between Salter’s and Pemberton’s Osteotomy in DDH 81 Salter’s Pemberton’s Between Salter’s and Pemberton’s Osteotomy in DDH 82 Between Salter’s and Pemberton’s Osteotomy in DDH 83 Case examples Which Acetabuloplasty ? Between Salter’s and Pemberton’s Osteotomy in DDH 84 Case examples Which Acetabuloplasty ? 38o 28o Between Salter’s and Pemberton’s Osteotomy in DDH 85 Case examples Which Acetabuloplasty ? 43o 25o Between Salter’s and Pemberton’s Osteotomy in DDH 86 Case examples Which Acetabuloplasty ? Between Salter’s and Pemberton’s Osteotomy in DDH 87 ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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