Which Acetabuloplasty in DDH

Which Acetabuloplasty in DDH - Which Acetabuloplasty in DDH...

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Unformatted text preview: Which Acetabuloplasty in DDH ? Prof. Mamoun Kremli , FRCS Prof. Consultant Pediatric Orthopedics College of Medicine & King Khaled University Hospital Riyadh, Saudi Arabia Which Acetabuloplasty in DDH Objectives Indications for acetabulo­plasty. Types of Acetabulo­plasties. Characteristics, hints and limitations. Factors to consider when choosing which acetabulo­plasty to perform. Practical Algorithm. Prof. M Kremli, King Saud Univ , Riyad 2 Which Acetabuloplasty in DDH Indications for Acetabuloplasty CDH discovered after 18 m. ± open reduction. Prof. M Kremli, King Saud Univ , Riyad 3 Which Acetabuloplasty in DDH Indications for Acetabuloplasty Clear Acetabular dysplasia after 18m of age. (antero lateral uncoverage of femoral head). Increased AI. Reduced CE angle (in older age group). 30o 20o 12o 42o Prof. M Kremli, King Saud Univ , Riyad 4 Which Acetabuloplasty in DDH Indications for Acetabuloplasty 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 ). Prof. M Kremli, King Saud Univ , Riyad 5 Which Acetabuloplasty in DDH Acetabular development Acetabular development occurs most rapidly in the first 6m after closed reduction, and continues at a slower pace over the next year. Lindstrom et al . J Bone Joint Surg, Am 1979: 61 : 112­) Lindstrom et al . J Bone Joint Surg, Am 1979: 61 : 112­ (118 Prof. M Kremli, King Saud Univ , Riyad 6 Which Acetabuloplasty in DDH Indications for Acetabuloplasty Pattern of Acetabular Development From Staheli, Practice of pediatric Orthopedics, 2001 Lidstrom et al:JBJS Am 1979;61 Prof. M Kremli, King Saud Univ , Riyad 7 Which Acetabuloplasty in DDH Acetabular development 95% cnfidence interval intraobserver reading of AI after closed reduction is 5o ( Skaggs et al J Ped Orthop 1998; 18:799­801 ) Prof. M Kremli, King Saud Univ , Riyad 8 Which Acetabuloplasty in DDH Indications for Acetabuloplasty Recently discovered acet. dysplasia in adolescents. Asymptomatic. Fatigue pain after activity. Prof. M Kremli, King Saud Univ , Riyad 9 Which Acetabuloplasty in DDH Indications for Acetabuloplasty Acet. dysplasia causing hip subluxation. 18 m 3 yrs Prof. M Kremli, King Saud Univ ,1Riyad 0 Which Acetabuloplasty in DDH Types of Acetabuloplasties Lateral Acetabuloplasties. Redirectional Acetabuloplasties. Restructural Acetabuloplasties. Augmentation Acetabuloplasties. Prof. M Kremli, King Saud Univ ,1Riyad 1 Which Acetabuloplasty in DDH Types of Common Acetabulo­plasties Redirectional: Restructural: Changes the direction/rotation of the acetabulum. Changes the shape/size of the acetabulum. Augmentation: Increases the cover/size of the acetabulum Prof. M Kremli, King Saud Univ ,1Riyad 2 Which Acetabuloplasty in DDH Redirectional Acetabulo­plasties 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 ) Prof. M Kremli, King Saud Univ ,1Riyad 3 Which Acetabuloplasty in DDH Salter’s Innominate Osteotomy Prof. M Kremli, King Saud Univ ,1Riyad 4 Salter’s Which Acetabuloplasty in DDH 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. Prof. M Kremli, King Saud Univ ,1Riyad 5 Salter’s Which Acetabuloplasty in DDH Pre­requisites Age 18m ­ 9yrs – Adolescence ! (flexible symphysis pubis). Good range of motion = Congruent joint. Concentric reduction (present / achievable). X­rays in abduction, flexion, and internal rotation shows improved cover. No posterior wall deficiency. Prof. M Kremli, King Saud Univ ,1Riyad 6 Salter’s Which Acetabuloplasty in DDH Reported Corrections Range in literature : A.I. : 8o – 21o (average 12o ). C.E. : 15o – 30o Gulman , et al: J Pediatr Orthop Part B, Vol. 10, No. 1, 2001 Prof. M Kremli, King Saud Univ ,1Riyad 7 Salter’s Which Acetabuloplasty in DDH Limitations Severe acetabular dysplasia. ( AI > 40o ). Straight acetabulum. ( Saucer shaped ). Posterior wall deficiency. Coxa magna : Salter’s osteotomy does NOT enlarge acetabulum. May cause posterior uncoverage. Prof. M Kremli, King Saud Univ ,1Riyad 8 Which Acetabuloplasty in DDH 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. between Sartorius and Iliacus !! Careful of Femoral N. Split iliac apophysis, sub­periosteal dissection to sciatic notch, pack notch sub­periosteally. Ilopsoas tenotomy (intra­pelvic) – diathermy – biopolar. Prof. M Kremli, King Saud Univ ,1Riyad 9 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure: Adductor tenotomy Prof. M Kremli, King Saud Univ ,2Riyad 0 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure: Adductor tenotomy Prof. M Kremli, King Saud Univ ,2Riyad 1 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure: Exploration Prof. M Kremli, King Saud Univ ,2Riyad 2 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure: Exploration Prof. M Kremli, King Saud Univ ,2Riyad 3 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure: Splittimg apophysis Prof. M Kremli, King Saud Univ ,2Riyad 4 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure: Sub­periosteal packing Prof. M Kremli, King Saud Univ ,2Riyad 5 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure: Psoas tenotomy Prof. M Kremli, King Saud Univ ,2Riyad 6 Which Acetabuloplasty in DDH Salter’s Osteotomy with Open Reduction Procedure: Rectus Femoris tenotomy Prof. M Kremli, King Saud Univ ,2Riyad 7 Which Acetabuloplasty in DDH Salter’s Osteotomy with Open Reduction Procedure: Capsular release Prof. M Kremli, King Saud Univ ,2Riyad 8 Which Acetabuloplasty in DDH Salter’s Osteotomy with Open Reduction Procedure: Arthrotomy Prof. M Kremli, King Saud Univ ,2Riyad 9 Which Acetabuloplasty in DDH Salter’s Osteotomy with Open Reduction Procedure: Arthrotomy Prof. M Kremli, King Saud Univ ,3Riyad 0 Which Acetabuloplasty in DDH Salter’s Osteotomy with Open Reduction Procedure: Excising Ligamentum Teres Prof. M Kremli, King Saud Univ ,3Riyad 1 Which Acetabuloplasty in DDH Salter’s Osteotomy with Open Reduction Procedure: Removing Pulvinar, cleaning acetabulum, and cutting Transverse Acetabular Ligament Prof. M Kremli, King Saud Univ ,3Riyad 2 Which Acetabuloplasty in DDH Salter’s Osteotomy with Open Reduction Procedure: Everting Limbus Prof. M Kremli, King Saud Univ ,3Riyad 3 Which Acetabuloplasty in DDH Salter’s Osteotomy with Open Reduction Procedure: T incision in Capsule Prof. M Kremli, King Saud Univ ,3Riyad 4 Which Acetabuloplasty in DDH Salter’s Osteotomy with Open Reduction Procedure: Reduction trial Prof. M Kremli, King Saud Univ ,3Riyad 5 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure: Detaching capsular adhesions Prof. M Kremli, King Saud Univ ,3Riyad 6 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure: Exploring Sciatic Notch Prof. M Kremli, King Saud Univ ,3Riyad 7 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure: Insertion of Gigli Saw Insertion of Gigli saw sub­ periosteally. Curved foreceps. Insert tape first. Tie tape to tip of saw. Curve tip and narrow loop handle of saw. Pull other end of tape. Use scialastic tube to protect skin. Prof. M Kremli, King Saud Univ ,3Riyad 8 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure ­ Osteotomy Osteotomy anteriorly and vertical. At right angle to iliac bone (medial handle more proximal than lateral handle). To just proximal to AIIS. Assistant stabilises the pelvis. Keep saw hands well seperated – protect skin. Move saw to and fro with minimal pulling to avoid jamming. Graft taken from ASIS or triangular from iliac bone above with an angle of 30­40o at apex. Prof. M Kremli, King Saud Univ ,3Riyad 9 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure: Graft harvesting Prof. M Kremli, King Saud Univ ,4Riyad 0 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure: Graft harvesting Prof. M Kremli, King Saud Univ ,4Riyad 1 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure ­ Osteotomy Opening the osteotomy: Pull distal segment forewards using a towel clip. (tends to slip posteriorly). Figure of four and press on knee – if Salter’s alone. Pull forewards, laterally, and inferiorly – if with open reduction. Keep posterior cotices in contact. Prof. M Kremli, King Saud Univ ,4Riyad 2 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure ­ Osteotomy Inserting and stabilizing the graft: Over insertion too deep opens posterior coricces. Stabilize with two threaded/unthreaded pins. Check hip range of motion to confirm pins outside joint. Check position of pins/wires and osteotomy by x­ray. Prof. M Kremli, King Saud Univ ,4Riyad 3 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure: Closing apophysis Prof. M Kremli, King Saud Univ ,4Riyad 4 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure: Closure Prof. M Kremli, King Saud Univ ,4Riyad 5 Which Acetabuloplasty in DDH Salter’s Osteotomy Procedure: End Prof. M Kremli, King Saud Univ ,4Riyad 6 Which Acetabuloplasty in DDH Salter’s Osteotomy Tips The aim is to rotate the acetabulum: Avoid exessive traction on distal fragment (may break). Pull distal fragment forwards using a bone hook from posterior aspect. 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. JPO 2000, Prof. M Kremli, King Saud Univ ,4Riyad 7 Which Acetabuloplasty in DDH Salter’s Osteotomy Pitfalls / Drawbacks / Complications Open osteotomy at sciatic notch. Unstable. Loss of correction. Prof. M Kremli, King Saud Univ ,4Riyad 8 Which Acetabuloplasty in DDH Salter’s Osteotomy Pitfalls / Drawbacks / Complications Miss­placed pins/wires. Unstable ­ Loss of correction. Intra­articular in the hip joint – chondro­ lysis. Prof. M Kremli, King Saud Univ ,4Riyad 9 Which Acetabuloplasty in DDH Salter’s Osteotomy Pitfalls / Drawbacks / Complications Operating on children below 18 m of age: Too thin innominate bone and graft: Unstable – may loose correction and displace. Should allow for possible normal acetabular development. Prof. M Kremli, King Saud Univ ,5Riyad 0 Which Acetabuloplasty in DDH Salter’s Osteotomy Pitfalls / Drawbacks / Complications Failure to perform tenotomy of: ilio­psoas / adductors Causes incomplete rotation of acetabulum. Increases pressure on femoral head ­AVN Prof. M Kremli, King Saud Univ ,5Riyad 1 Which Acetabuloplasty in DDH Salter’s Osteotomy Pitfalls / Drawbacks / 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. Prof. M Kremli, King Saud Univ ,5Riyad 2 Which Acetabuloplasty in DDH Salter’s Osteotomy Pitfalls / Drawbacks / Complications Carefull when posterior wall deficient Prof. M Kremli, King Saud Univ ,5Riyad 3 Which Acetabuloplasty in DDH 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 Prof. M Kremli, King Saud Univ ,5Riyad 4 Which Acetabuloplasty in DDH Salter’s Osteotomy Specific guidelines in the application of the principles of innominate osteotomy. Salter RB. Orthop Clin North Am 1972; 3:149 Prof. M Kremli, King Saud Univ ,5Riyad 5 Which Acetabuloplasty in DDH Salter’s Osteotomy Modification s Kalamchi 1982 / lengthening / preserving medial cortical periosteum – more stable, ? No k­wire. Kalamchi A., JBJS, A982,64A: 183 Prof. M Kremli, King Saud Univ ,5Riyad 6 Which Acetabuloplasty in DDH Salter’s Osteotomy Modifications Kalamchi (1982) Notch in proximal fragment: more stable – no leg lengthening. JBJS 1982. 64A: 183­5 Prof. M Kremli, King Saud Univ ,5Riyad 7 Which Acetabuloplasty in DDH Salter’s Osteotomy Modifications Trans­iliac lengthening (1972) Open posteriorly, quadrangular graft JBJS 1979; 61A: 1182 Prof. M Kremli, King Saud Univ ,5Riyad 8 Salter’s Tips The aim is to rotate the acetabulum: Which Acetabuloplasty in DDH 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. JPO­B, Vol.11, No. 2, 2002 Prof. M Kremli, King Saud Univ ,5Riyad 9 Salter’s Which Acetabuloplasty in DDH Pitfalls / Complications Open osteotomy at sciatic notch. Unstable. Loss of correction. Prof. M Kremli, King Saud Univ ,6Riyad 0 Salter’s Which Acetabuloplasty in DDH Pitfalls / Complications Miss­placed pins/wires. Unstable : Loss of correction. Intra­articular in the hip joint : chondrolysis. Prof. M Kremli, King Saud Univ ,6Riyad 1 Salter’s Osteotomy Salter’s Which Acetabuloplasty in DDH Pitfalls / Complications Failure to perform tenotomy of ilio­psoas and adductors : Causes incomplete rotation of acetabulum. Increases pressure on femoral head = AVN. Prof. M Kremli, King Saud Univ ,6Riyad 2 Salter’s Osteotomy Salter’s Which Acetabuloplasty in DDH Pitfalls / Complications Sciatic N injury – during passage/use of Gigli saw. Pass tape first. Bend tip of saw. Stay strictly sub­periosteal. Prof. M Kremli, King Saud Univ ,6Riyad 3 Salter’s Osteotomy Salter’s Which Acetabuloplasty in DDH 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. Prof. M Kremli, King Saud Univ ,6Riyad 4 Salter’s Osteotomy Salter’s Which Acetabuloplasty in DDH Contraindications / Complications Careful when posterior wall deficient. Prof. M Kremli, King Saud Univ ,6Riyad 5 Salter’s Osteotomy Salter’s Which Acetabuloplasty in DDH Modifications Kalamchi 1982. Lengthening. Preserving medial cortical periosteum. More stable, ? No k­wire. Prof. M Kremli, King Saud Univ ,6Riyad 6 Which Acetabuloplasty in DDH Triple Steel Cuts in ilium ,pubic ramus, and ischium Prof. M Kremli, King Saud Univ ,6Riyad 7 Which Acetabuloplasty in DDH Triple Osteotomies Steel : First case 10 yrs girl (1963). Attempted Salter’s – did not open Triple : worked well. Two years follow­up. Shrines Surgeons Meeting (Montereal 1965). Published 10 yrs follow­up 1973. Steel HH: Triple Osteotomy of the innominate bone. J Bone Joint Surg 1973; 55A: 343­ 50. Le Coeur 1965 was the first to describe Triple. Prof. M Kremli, King Saud Univ ,6Riyad 8 Which Acetabuloplasty in DDH Triple Steel Good in older age group (stiff symph. Pubis) Two incisions. Allows rotation more than Salter’s. Hint : Insert large pin/schanz screw in distal fragment to control rotation and amount of displacement. Prof. M Kremli, King Saud Univ ,6Riyad 9 Which Acetabuloplasty in DDH Triple Steel Prof. M Kremli, King Saud Univ ,7Riyad 0 Which Acetabuloplasty in DDH Tonnis Modified Triple 1979. Direct approach to ischium ­ in prone position. Long ischial cut ensures good contact after displacement preventing pseudo­arthrosis. Prof. M Kremli, King Saud Univ ,7Riyad 1 Which Acetabuloplasty in DDH Triple Osteotomy Modifications Pubic osteotomy near symph. Pubis (separate incision). long arm of pubic fragment displaces anteriorly against femoral n. & vessels. Removal of ischial wedge or allowing ischial cut to override adds medialisation of acetabulum – better. Kumar et al 1986. Use of southern exposure – separate ischial approach. Prof. M Kremli, King Saud Univ ,7Riyad 2 Which Acetabuloplasty in DDH Triple Osteotomy Modifications Tonnis 1979 Direct approach to ischium ­ in prone position. Long ischial cut ensures good contact after displacement, preventing pseudo­arthrosis. Pubic osteotomy near symphysis Pubis (separate incision). long arm of pubic fragment displaces anteriorly against femoral n. & vessels. Removal of ischial wedge or allowing ischial cut to override adds medialisation of acetabulum – better. Kumar et al 1986. Use of southern exposure – separate ischial approach. Prof. M Kremli, King Saud Univ ,7Riyad 3 Which Acetabuloplasty in DDH Triple Osteotomy Successful Triple which position of acetabulum should be ?produced Sclerotic line of weight­bearing (Saurcil) should be horizontal (CE 30­35°). Tear drop not rotated to level higher than center of fermoral head. ( Macnicol 1996 ) Prof. M Kremli, King Saud Univ ,7Riyad 4 Which Acetabuloplasty in DDH Ganz / Berne (early 1980s) Does not transect all three ‘spokes’ of acetabular ‘wheel’. Preserves integrity of posterior column (pelvic ring). Iliac & Ischial osteotomies : Extend into posterior column – not through it. Connected by vertical ost. of posterior column. Prof. M Kremli, King Saud Univ ,7Riyad 5 Which Acetabuloplasty in DDH Bernese Osteotomy From Macnicol : Colour Atlas and Text of Osteotomy of The Hip 1996 Prof. M Kremli, King Saud Univ ,7Riyad 6 Which Acetabuloplasty in DDH Bernese Osteotomy Acetabulum disconnected from bony bed and all ligaments → mobile. Prerequisite : Must be able to rotate acetabulum freely over femoral head. Prof. M Kremli, King Saud Univ ,7Riyad 7 Which Acetabuloplasty in DDH Ganz / Berne’s Allows greater displacement of acetabulum. Indicated for more severe acetabular dysplasia in hip that can be concentrically reduced. Advantages : Single approach. Large degree of correction : Anterior rotation / lateral rotation / Medial displacement No alteration of pelvic birth outlet. Series of straight relatively reproducible extra­ articular cuts. Prof. M Kremli, King Saud Univ ,7Riyad 8 Which Acetabuloplasty in DDH Ganz / Berne’s Demanding – practice in lab. Needs special instruments. Image intensifier. Long / steep learning curve. Can easily go intra­articular. Complications : Intra­articular osteotomy. Displacement by allowing early weight­bearing. Delayed union. Ectopic bone formation. Neuro­vascular injury – all ! Prof. M Kremli, King Saud Univ ,7Riyad 9 Which Acetabuloplasty in DDH Spherical Osteotomies Eppright – dial 1975 : JBJS Am 1975;57 Wagner :Weil UH (ed) 1978 Ninomiya and Tagawa 1984 : JBJS Am 1984;66 After closure of tri­radiate cartilage. Good lateral coverage. Limited anterior coverage. No medialisation. Difficult. Blood supply to acetabulum only from capsule. Prof. M Kremli, King Saud Univ ,8Riyad 0 Which Acetabuloplasty in DDH Restructural Acetabulo­plasties Pemberton ( <8 y ) Dega ( >8 y ) Prof. M Kremli, King Saud Univ ,8Riyad 1 Which Acetabuloplasty in DDH Pemberton’s (Pericapsular) Osteotomy Prof. M Kremli, King Saud Univ ,8Riyad 2 Which Acetabuloplasty in DDH Pemberton’s (Pericapsular) Osteotomy Publicatio n 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 Prof. M Kremli, King Saud Univ ,8Riyad 3 Pemberton’s Which Acetabuloplasty in DDH Characteristics Prof. M Kremli, King Saud Univ ,8Riyad 4 Pemberton’s Which Acetabuloplasty in DDH Characteristics Medial Lateral Prof. M Kremli, King Saud Univ ,8Riyad 5 Pemberton’s Which Acetabuloplasty in DDH Characteristics Greater versatility c.f. most other pelvic osteotomies. Successfully used in : CDH / AD Excessive ligament Laxity. Paralytic disorders. Prof. M Kremli, King Saud Univ ,8Riyad 6 Pemberton’s Which Acetabuloplasty in DDH Pre­requisites Age 18 m – 11 yrs. ( open tri­radiate cartilage ). Congruent joint = Good ROM. Concentric reduction. ( present / achievable ). Open tri­radiate cartilage. Experienced surgeon! Prof. M Kremli, King Saud Univ ,8Riyad 7 Pemberton’s Which Acetabuloplasty in DDH Characteristics Fulcrum of rotation at tri­radiate cartilage closer to hip joint. (greater correction). Prof. M Kremli, King Saud Univ ,8Riyad 8 Pemberton’s Which Acetabuloplasty in DDH Characteristics Stable (incomplete osteotomy of ilium). no need for internal fixation. can be performed bilaterally simultaneously. Prof. M Kremli, King Saud Univ ,8Riyad 9 Pemberton’s 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. Which Acetabuloplasty in DDH Good for paralytic dislocation. Good when there is posterior wall deficiency. Technically more difficult. Prof. M Kremli, King Saud Univ ,9Riyad 0 Pemberton’s Which Acetabuloplasty in DDH Characteristics 50o Saucer shaped / Need for a lot of improvement in cover Pemberton / femoral shortening Prof. M Kremli, King Saud Univ ,9Riyad 1 Which Acetabuloplasty in DDH Pemberton’s Osteotomy Procedure: Position and exploration Similar to Salter’s Increase inferior exposure: Medially by cutting periosteum on inner wall towards the tri­radiate cartilage. Prof. M Kremli, King Saud Univ ,9Riyad 2 Which Acetabuloplasty in DDH Pemberton’s Osteotomy Procedure: Position and exploration Similar to Salter’s Increase inferior exposure: Laterally above the reflected head of rectus around the capsule as far posteriorly as possible. Prof. M Kremli, King Saud Univ ,9Riyad 3 Which Acetabuloplasty in DDH Pemberton’s Osteotomy Procedure: Planning The Osteotomy Lateral corticotomy: Above AIIS by ~1 cm. Curving following the capsule and 1 cm. above. Prof. M Kremli, King Saud Univ ,9Riyad 4 Which Acetabuloplasty in DDH Pemberton’s Osteotomy Procedure: Planning The Osteotomy Medial corticotomy: Parallel to outer cut. At a lower level c.f lateral cut. Prof. M Kremli, King Saud Univ ,9Riyad 5 Which Acetabuloplasty in DDH Pemberton’s Osteotomy Tips Use Pemberton curved osteotome or Schaghliatti chisel. Avoid going intra­articular: Stay close to sciatic notch. Use intra­operative x­rays. Use of laminar spreader to open the osteotomy and assist completing the posterior and inferior parts. Avoid spreading osteotomy too much to maintain stability. Prof. M Kremli, King Saud Univ ,9Riyad 6 Which Acetabuloplasty in DDH Pemberton’s Osteotomy Tips Versatility provided by varying relation of lateral and medial cuts Lateral cut higher than medial: More lateral cover. Prof. M Kremli, King Saud Univ ,9Riyad 7 Which Acetabuloplasty in DDH Pemberton’s Osteotomy Tips Versatility provided by varying relation of lateral and medial cuts Lateral cut at level of medial: More anterior cover. Prof. M Kremli, King Saud Univ ,9Riyad 8 Which Acetabuloplasty in DDH Pemberton’s Osteotomy Tips Relation of lateral to medial corticotomies More lateral cover More anterior cover Prof. M Kremli, King Saud Univ ,9Riyad 9 Which Acetabuloplasty in DDH Pemberton’s Osteotomy Procedure: Proper direction of osteotome Connect medial and lateral osteotomies Prof. M Kremli, King Saud Univ1,00 Riyad Which Acetabuloplasty in DDH Pemberton’s Osteotomy Procedure: Graft harvesting Prof. M Kremli, King Saud Univ1,01 Riyad Which Acetabuloplasty in DDH Pemberton’s Osteotomy Procedure: Graft insertion Prof. M Kremli, King Saud Univ1,02 Riyad Which Acetabuloplasty in DDH Pemberton’s Osteotomy Procedure: Checking stability Prof. M Kremli, King Saud Univ1,03 Riyad Which Acetabuloplasty in DDH Pemberton’s Osteotomy Limitation s Reduces size of acetabulum : Contra­indicated in coxa­magna (head larger than acetabulum). Distorts shape of the acetabulum : May cause incongruity and stiffness Prof. M Kremli, King Saud Univ1,04 Riyad Pemberton’s Which Acetabuloplasty in DDH Procedure : Relation of Cuts More lateral cover More anterior cover Prof. M Kremli, King Saud Univ1,05 Riyad Pemberton’s Which Acetabuloplasty in DDH Tips Use Pemberton curved osteotome or Schaghliatti chisel. Prof. M Kremli, King Saud Univ1,06 Riyad Pemberton’s Which Acetabuloplasty in DDH Tips Avoid spreading osteotomy too much to maintain inherited recoil. Avoid going intra­articular by : Staying close to sciatic notch. Using intra­operative x­rays. Prof. M Kremli, King Saud Univ1,07 Riyad Pemberton’s Which Acetabuloplasty in DDH Pitfalls / Complications Can over correct easily – may cause: Hinges on tri­radiate cartilage – may cause: AVN. Redislocation. Distorts shape of the acetabulum causing incongruity and stiffness. Premature closure / injury to tri­radiate cartilage. Reduces size of acetabulum : Contraindicated in coxamagna – head larger than acetabulum. Prof. M Kremli, King Saud Univ1,08 Riyad Pemberton’s Which Acetabuloplasty in DDH Complications May cause Intra­articular fracture. Prof. M Kremli, King Saud Univ1,09 Riyad Which Acetabuloplasty in DDH 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 Prof. M Kremli, King Saud Univ1,10 Riyad Which Acetabuloplasty in DDH 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 Prof. M Kremli, King Saud Univ1,11 Riyad Which Acetabuloplasty in DDH Modified Pemberton’s Pembersal across post limb into body of iscium Marafioti, Westin : 1980 JBJS, 62­A:765,1980. Perlik, Westin, Marafioti : 1985 JBJS 1985, 67A:842. Modified Pemberton Osteotomy (MPA) Woolf, Gross : 2003 J Ped Orthop, 23, No 6:708­713 wedge posterior in Tavares : 2004 J Ped Orthop, 24, No 5:501­507 between salter and posterior def downs. pembersal at sciatic notch not through and not reaching trirad cart seen throughout. Prof. M Kremli, King Saud Univ1,12 Riyad Which Acetabuloplasty in DDH Modified Pemberton’s Tavares : 2004 J Ped Orthop, 24, No 5:501­507 Prof. M Kremli, King Saud Univ1,13 Riyad Which Acetabuloplasty in DDH Dega Similar to Pemberton. Versatile : improves cover anteriorly /centrally /posteriorly. Good in failed closed reduction – bad. May reduce acetabular volume. Hinges through tri­radiate cartilage. Better posterior cover. Best for C.P. where posterior acet. wall deficient. (Macnicol 1996) Prof. M Kremli, King Saud Univ1,14 Riyad Which Acetabuloplasty in DDH Redirectional Vs. Restrutural Salter’s 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. Prof. M Kremli, King Saud Univ1,15 Riyad Which Acetabuloplasty in DDH 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 Prof. M Kremli, King Saud Univ1,16 Riyad Which Acetabuloplasty in DDH Augmentation Shelf – modifications ( >10 y) Chiari ( >12 y) Prof. M Kremli, King Saud Univ1,17 Riyad Which Acetabuloplasty in DDH Redirectional Vs. Restrutural Salter’s Unstable: Vs. Needs k­wires. 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. Prof. M Kremli, King Saud Univ1,18 Riyad Which Acetabuloplasty in DDH Salter’s Summary Redirectional. Similar pre­requisites. Pivots on symphysis pubis. Easy to perform / Common. Less serious complications. Unstable / Unilateral. Needs k­wires and re­admission. Improves AI by about 150. Not good in saucer shaped acetabulum. Not with posterior wall defeciency and paralytic disorders. Not with coxa magna. Pemberton’s Restructural. Similar pre­requisites. Pivots on tri­radiate cartilage. More difficult / Uncommon. More serious complications. Stable / Possible bilaterally. No k­wires / No re­admission. Improves any angle / My overdo. Perfect for saucer shaped acetabulum. Good for posteroir wall defeciency and paralytic disorders. Not with coxa magna. Prof. M Kremli, King Saud Univ1,19 Riyad Which Acetabuloplasty in DDH Augmentation Acetabulo­plasties Shelf – modifications ( >10 y) Chiari ( >12 y) Prof. M Kremli, King Saud Univ1,20 Riyad Which Acetabuloplasty in DDH Shelf Deny’s Wainwright, 1976 Many modifications : Wilson / slotted Staheli …. Tactoplasty (Saito & Co­workers, Japan,1976). Salvage. Subluxed hip. Fibro­cartilagenous cover. Can be placed anteriorly / centrally / superio­ posteriorly. Can be used to augment another osteotomy, e.g.. Salter, Triple, Chiari … Prof. M Kremli, King Saud Univ1,21 Riyad Which Acetabuloplasty in DDH Shelf Osteotomies Indications Large fermoral head. Mismatch with size of acetabulum. Acet. dysplasia – significant bony un­coverage. Age 10 – 20 yrs. No significant OA. Augmentation of other redirectional acetabuloplasties and Chiari. Prof. M Kremli, King Saud Univ1,22 Riyad Which Acetabuloplasty in DDH Shelf Prof. M Kremli, King Saud Univ1,23 Riyad Which Acetabuloplasty in DDH Shelf Macnicol : Colour Atlas and Text of Osteotomy of The Hip 1996 Prof. M Kremli, King Saud Univ1,24 Riyad Which Acetabuloplasty in DDH Shelf Prof. M Kremli, King Saud Univ1,25 Riyad Which Acetabuloplasty in DDH Shelf Prof. M Kremli, King Saud Univ1,26 Riyad Which Acetabuloplasty in DDH Shelf Many types and modifications. Salvage. Fibro­cartilagenous cover. Can be performed on subluxed hips. Can be placed anteriorly / centrally / superio­ posteriorly. Can be used to augment another osteotomy, e.g.. Salter, Triple, Chiari … Prof. M Kremli, King Saud Univ1,27 Riyad Which Acetabuloplasty in DDH Shelf Large fermoral head. Indications Mismatch with size of acetabulum. Acet. dysplasia – significant bony un­coverage. Age 10 – 20 yrs. No significant OA. Augmentation of other redirectional acetabuloplasties and Chiari. Prof. M Kremli, King Saud Univ1,28 Riyad Which Acetabuloplasty in DDH Shelf Osteotomies Pitfalls Graft melts/resolves if inadequate bone buttress above the pelvis. If too anterior may cause impingement. Prof. M Kremli, King Saud Univ1,29 Riyad Which Acetabuloplasty in DDH Lateral Iliac Osteotomy Incomplete division of ilium­ only outer table turned down. Trevor et al 1975. Tonnis 1977, 1987. Jacquemier et al 1989. Prof. M Kremli, King Saud Univ1,30 Riyad Which Acetabuloplasty in DDH Chiari Salvage. Cover with tissue that changes to fibrocartilage. Can be performed on subluxed hips. Improves biomechanics – medialisation. Cut should be curved to match acet. contour ! Level of cut and slope must be precise. Can/should add anterior graft to cover if needed. Sanchez­Sotelo et al: J Am Ac Orthop Surg, 2002, Vol 10 No.5. May affect normal delivery especially if bilateral. Prof. M Kremli, King Saud Univ1,31 Riyad Which Acetabuloplasty in DDH Chiari Prof. M Kremli, King Saud Univ1,32 Riyad Which Acetabuloplasty in DDH Chiari Prof. M Kremli, King Saud Univ1,33 Riyad Chiari Which Acetabuloplasty in DDH Pitfalls / Complications Inaccurate starting point : High, does not provide needed support. Low, does not allow adequate joint space development. Inaccurate slope of cut : Too great angle causes impingement. If enter sacro­iliac joint can not displace. Failure to add anterior bone graft. Prof. M Kremli, King Saud Univ1,34 Riyad Which Acetabuloplasty in DDH Chiari Long­term Results Windhager et al : JBJS B 1991;73:890­895. 236 long term follow­up. 8.9% revision after mean of 15.4 yrs. 50% of remaining : good or excellent at mean of 24.8 yrs. Lack et al : JBJS B 1991;73:229­234. 100 long term follow­up. 20% to THR at mean of 11.5 yrs. 75% of remainig satisfactory at mean 15.5 yrs. Prof. M Kremli, King Saud Univ1,35 Riyad Which Acetabuloplasty in DDH Chiari’s Osteotomy Best results >10 yrs of age. Worse results < 10 yrs of age. ? Affection of lateral growth of acetabulum. (Gamal A. Hosny, Guy Febry, J. Pediatr Orthop 2001; 1: 37­47) Prof. M Kremli, King Saud Univ1,36 Riyad Which Acetabuloplasty in DDH Shelf Comparison Simple Not stable for immediate weight bearing No medialisation Can choose placement of cover. Can combine with other redirectional osteotomies (Pemberton/Salter/Triple..) Can combine with Chiari Chiari More difficult Immediately stable for weight bearing Medialisation Good for lateralised hip (Center head to center pelvic >2cm differ.) Can not choose placement of cover. Stand alone procedure. Stand alone procedure Prof. M Kremli, King Saud Univ1,37 Riyad Which Acetabuloplasty in DDH How to Choose an Acetabulo­plasty ? Factors to Consider Age of patient. Site of deformity. Type of deformity. Severity of deformity. Congruity. Experience of surgeon. Prof. M Kremli, King Saud Univ1,38 Riyad Which Acetabuloplasty in DDH Factors to consider Age 18 m – 6 y : Mild – Moderate : Severe : Unilateral : Salter Bilateral : Pemberton simultaneously – Salter one at a time Pemberton 6 – 12 y : Mild : Salter Moderate – Severe : Pemberton Complicated with uncoverage / coxa magna : Shelf Prof. M Kremli, King Saud Univ1,39 Riyad Which Acetabuloplasty in DDH Factors to consider Age Adolescent : Spherical Head : Mild : Salter ? – Triple. Moderate : Triple. Severe : Ganz / Bernese. Aspherical Head : Lateralized : Chiari. Not lateralized : Shelf. Prof. M Kremli, King Saud Univ1,40 Riyad Which Acetabuloplasty in DDH Factors to consider Site of Deformity Bilateral : Simultaneous surgery and pelvic stability. Incomplete cut of pelvic ring. Pemberton – modified pemberton. Unilateral : Complete cut in pelvic ring. Salter – pemberSal – Triple … Prof. M Kremli, King Saud Univ1,41 Riyad Which Acetabuloplasty in DDH Factors to consider Type of Deformity Large capacious acetabulum : Pemberton – pemberSal. Coxa magna : Should enlarge the acetabulum Shelf – Chiari. Prof. M Kremli, King Saud Univ1,42 Riyad Which Acetabuloplasty in DDH Factors to consider Severity of Deformity Mild – moderate dysplasia : Salter – Triple. Severe dysplasia : Pemberton – Ganz –Berne. Prof. M Kremli, King Saud Univ1,43 Riyad Which Acetabuloplasty in DDH Factors to consider Congruent: Redirectional. Congruity Salter – Triple – Dial … Incongruent : Augmentation. Shelf – Chiari. Prof. M Kremli, King Saud Univ1,44 Riyad Which Acetabuloplasty in DDH Factors to consider Congruity Prof. M Kremli, King Saud Univ1,45 Riyad Which Acetabuloplasty in DDH Role of Arthrography Assessment of True cartilaginous acetabular cover can only be done by arthrography. Just before surgery could be very valuable in decision making regarding which osteotomy to perform, especially if uncertain about : Shape ( femoral head / acetabulum ) Coverage. Stability. Prof. M Kremli, King Saud Univ1,46 Riyad Which Acetabuloplasty in DDH Problem of Posterior Wall Deficiency When : In neuromuscular. In Down’s. In failed treatment of DDH. Failed closed reduction. Post Salter & re­dislocated. Solutions : Posterior shelf ! Dega. Modified Pemberton. (Shane K Woolf, Richard H Gross. J.Pediatr Orthop 2003; Vol. 23, No. 6; 708­713). Prof. M Kremli, King Saud Univ1,47 Riyad Which Acetabuloplasty in DDH Algorithm for Acetabulo­plasties y 6 – 1.5 y 12 – 6 Adolescent Incongr. Congr. Salter Salter Salter Pemberton Pemberton Triple Chiari Shelf Ganz/Berne Modified from Staheli : Practice of Pediatric Orthopedics, 2001 Prof. M Kremli, King Saud Univ1,48 Riyad Which Acetabuloplasty in DDH Which Acetabuloplasty ? Prof. M Kremli, King Saud Univ1,49 Riyad Which Acetabuloplasty in DDH Which Acetabuloplasty ? 38o 28o Prof. M Kremli, King Saud Univ1,50 Riyad Which Acetabuloplasty in DDH Which Acetabuloplasty ? Prof. M Kremli, King Saud Univ1,51 Riyad Which Acetabuloplasty in DDH Prof. M Kremli, King Saud Univ1,52 Riyad Which Acetabuloplasty in DDH Prof. M Kremli, King Saud Univ1,53 Riyad ...
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