Adult Hip, The
2nd Edition

51
Osteotomy: Overview
Robert T. Trousdale
Dennis Wenger
The treatment of the arthritic hip in the young patient remains a challenge for the reconstructive surgeon. Total hip arthroplasty remains a very successful operation for end-stage degenerative joint disease in the elderly patient, but historically both cemented and uncemented total hip replacements in young, active patients have been fraught with relatively high failure rates. Furthermore, young patients who present with hip pain often have conditions that are amenable to nonarthroplasty procedures. Osteotomies about the hip are most useful when there are morphological abnormalities present that can be corrected with an osteotomy in the presence of viable articular cartilage (1). Structural abnormalities about the hip joint may decrease the surface area and increase the unit load of articular cartilage to a point where it cannot function satisfactorily (10). Furthermore, impingement problems about the hip secondary to torsional abnormalities of the socket or femoral abnormalities can lead to secondary hip arthritis. Articular cartilage about the hip functions within a narrow range of tolerances. When exceeded, as in various structural abnormalities, failure of the cartilage will occur. Ewald and others have shown that when a unit load of 23 kg/inch2 (3.5 kg/cm2) is exceeded, articular cartilage viability and function are compromised. The primary goal of an osteotomy is either to increase the joint contact area, thereby decreasing the load about the hip to a level that is compatible with normal articular function, or to relieve an impingement problem. Osteotomy also allows one to improve joint mechanics and achieve a more functional range of motion by eliminating fixed deformities. The biological capacity of cartilage to regenerate is not fully understood and is difficult to estimate.
Patients who are best served by a hip osteotomy are those with structural abnormalities in which realignment of the hip will either increase the joint contact area, as in developmental hip dysplasia; unload a necrotic femoral head in patients with limited avascular necrosis; or relieve an impingement problem of the hip caused by torsional abnormalities of the femur and/or acetabulum (Fig. 51-1). Other less common indications for osteotomy include leg-length inequality, slipped capital femoral epiphysis, Legg–Calvé–Perthes disease (LCPD), protrusio acetabuli, epiphyseal dysplasia, and femoral neck nonunion. Contraindications include inflammatory arthritis, severe stiffness, active infection, and severe secondary arthritis. Age, weight, occupation, status of the ipsilateral knee, lumbar spine, and leg lengths should all be taken into account when considering a hip osteotomy.
Pelvic Osteotomy
Pelvic osteotomies are indicated for young patients who have structural problems about the hip that can be improved with reorientation pelvic osteotomy. The most common indication for a pelvic osteotomy is classic developmental hip dysplasia. Other indications for pelvic osteotomy include retrotorsion abnormalities of the acetabulum or post-traumatic developmental hip dysplasia (9). Pelvic osteotomy for classic hip dysplasia should be limited to young patients who have symptomatic hip dysplasia without excessive proximal migration of the hip center of rotation, a reasonably well preserved hip range of motion, and no more than mild to moderate secondary degenerative changes (Fig. 51-2) (25). Prognosis is poor for patients with severe secondary arthritis (22,23). In most patients with hip dysplasia, the primary anomaly is located on the acetabular side of the joint, and hence pelvic osteotomy permits correction of this abnormality.
Many types of pelvic osteotomies have been described for the treatment of hip dysplasia. Reconstructive osteotomy is intended to restore more normal hip anatomy and biomechanics, improve symptoms, and perhaps prevent secondary arthritis. Salvage osteotomy is performed to relieve pain when the articular surface congruity cannot be restored because of marked anatomic abnormality. Previously described reconstructive procedures have included single and double innominate osteotomies and various types of triple and periacetabular osteotomies. A single Salter innominate osteotomy is beneficial for children but is often insufficient for adolescents
P.774

and adults. It lateralizes the hip joint, which is undesirable in the dysplastic hip. Triple osteotomies were developed in an attempt to avoid lateralization and to increase the amount of correction that is obtainable. LeCour reported his technique of triple osteotomy in 1965 and recommended division of the pubis and ischium close to the symphysis pubis (13). Correction is limited by the size of the fragment and the attached muscles and ligament to the sacrum. One year later, Hoff described a technique that allowed all three osteotomies to be performed through a single anterior incision (11). The Steele osteotomy differs from the Hoff osteotomy in that the ischial cuts are quite far from the joint, and the Steele osteotomy is performed through three separate incisions (20). All of these various triple osteotomies can lead to a notable asymmetry of the pelvis if a substantial amount of correction is obtained. Tönnis and Sprafke, as well as Carlioz et al., described juxta-articular triple osteotomies that allow for increased correction with less resultant pelvic deformity (2,22). These techniques avoid the problems that can arise when the sacropelvic ligaments are left attached to the osteotomized fragment, which often limits the mobility of the fragment; however, they may result in the creation of a
P.775

large defect within the ischium and osteotomized acetabulum, necessitating special measures for stabilization postoperatively.
Figure 51-1 A: Plain radiograph of a 3-year-old girl with bilateral hip dysplasia. The degree of acetabular deficiency is difficult to determine on the plain film. B: Anteroposterior 3DCT image of both hips, taken at age 3.5 years, demonstrates bilateral hip dysplasia. C: The lateral view of the left hip demonstrates a type III (midsuperior) deficiency (21). This type of dysplasia can be seen only on the lateral view in a 3DCT. The inside of the acetabular roof can be visualized on the straight lateral 3DCT view. In a normal hip, this inner surface can barely be seen on the direct lateral view. D: After corrective surgery performed at age 4 years. Because the right hip had type I deficiency (21), we performed only a proximal femoral osteotomy. The more severe dysplasia in the left hip was treated with combined proximal femoral osteotomy plus Pemberton-type acetabuloplasty. The plain radiograph taken 1 year after surgery (at age 5) demonstrates nearly normal hip coverage bilaterally. This patient demonstrates our current goal for treatment of hip dysplasia, which is to produce a normal head–acetabular relationship by age 5 to 6 years in order to minimize the chance for premature arthritis in early adult life. Only with early osteotomies can very nearly normal hip morphology be achieved.
Figure 51-2 A: Anteroposterior pelvic radiograph in an 18-year-old man who had developed right LCPD at age 9 and was treated with a containment orthosis. He now complained of intermittent right hip pain. The film demonstrates the classic deformity of healed LCPD, with a “sagging rope” sign (short arrows) that extends from the inferior border of the neck medially to the superior border laterally, as well as a functional coxa vara on the right side. B: The anteroposterior 3DCT view of the pelvis shows a severely flattened femoral head with an externally rotated femur. The anterolateral inferior margin of the flattened femoral head exactly coincides with the shape and the site of the sagging rope sign noted on the plain radiograph. The 3DCT view of the hip combined with a 2DCT view of the distal femoral condyle demonstrated a functional retroversion of the true articulating posteromedial portion of the head (not illustrated). C: A valgus–flexion–(internal rotation) osteotomy and a triple innominate osteotomy (acetabulum also demonstrates dysplasia) were performed. At follow-up examination (radiograph taken 1 year and 4 months after operation), the patient was symptom free and walked with a normal gait. Anteroposterior pelvic radiograph in an 18-year-old woman with left hip pain. In infancy, she had been treated for bilateral hip dysplasia. Because of continued pain at age 18, she underwent a left proximal femoral varus derotational osteotomy in another hospital. She stated that her pain improved for a short time and then recurred.
Various periacetabular osteotomies that have been described by Eppright (7), Wagner (25), and Ninomiya and Tagawa (17) provide good lateral coverage, but the amount of anterior coverage and the extent that the joint can be medialized are often limited. These osteotomies often leave the teardrop in its original position and thus become intra-articular. All of these periacetabular osteotomies are juxta-articular and may deprive the acetabular fragment of its vascular blood supply except for that derived from the capsule. The risk of avascular necrosis of the osteotomized fragment is increased if the capsule is opened for the treatment of any associated lesions of the labrum. Ninomiya and Tagawa (17) reported the results of circumferential acetabular osteotomy in 41 patients who had been followed for an average of 4 years and 6 months. The authors concluded that in “the majority of the hips either limp or pain with exertion or both had disappeared and a satisfactory range of motion had been restored.” They did not discuss the degree of coverage obtained. The Bernese periacetabular osteotomy discussed in detail in Chapter 53 has many advantages compared with other periacetabular osteotomies (8). Avoiding the pitfalls of pelvic osteotomy is important in light of the fact that these procedures are complex (5,12). The surgeon’s overall experience and expertise are important factors affecting the prevalence of complications. The learning curve is long and the potential complication rate is high. Training with surgeons who routinely perform this procedure and practicing in a laboratory are recommended. Nerve dysfunction is a potential complication of pelvic osteotomy. If one does the osteotomy through an anterior exposure, the lateral femoral cutaneous nerve or some of its branches can be injured during the surgical
P.776

approach. Femoral nerve palsies have been reported with the use of a direct anterior approach or in patients with previous surgery. Pelvic osteotomies can be performed with intraoperative electromyographic monitoring. In one series, EMG changes developed in approximately 25% of patients, but usually there was no sequela. Most vascular complications that arise during pelvic osteotomies occur with anterior approaches, and thrombosis in the femoral or iliac artery can potentially threaten the viability of the limb.
Figure 51-3 A: This 17-year-old girl had painful right hip dysplasia despite prior treatment with open reduction and capsulorrhaphy, varus derotational osteotomy, and Salter innominate osteotomy on the right hip and Salter innominate osteotomy on the left. B: Plain radiograph after right hip triple innominate osteotomy. Acetabular coverage is improved, and the pattern of the sourcil is normalized. However, she continued to complain of dull groin pain. C: An anteroposterior 3DCT view of both hips demonstrates nearly normal coverage of the femoral head on the right but also demonstrates a frank nonunion of the superior pubic ramus. The inferior ischial ramus demonstrates a hypertrophic nonunion. D: An oblique 3DCT view of the right hip demonstrates a marked gap in the superior pubic ramus that is the likely cause of the groin pain. One of the disadvantages of triple innominate osteotomy is lateralization of the joint as well as external rotation of the acetabular fragment, which can produce a gap in the superior pubic ramus, resulting in nonunion. Careful bone graft or medialization of the acetabular fragment can minimize the risk of this complication. This patient had continued symptoms and was treated by bone grafting plus A-O reconstruction plate fixation of the superior ramus pseudarthrosis.
Pelvic osteotomy exiting through the posterior column or extension into the joint can occur. Intra-articular extension of a pelvic osteotomy has been reported, especially in hips with marked proximal femoral head migration or a laxed inferior capsule. Such intra-articular extension does not cause articular incongruity if it is low, but it can interrupt the blood supply to the acetabular fragment and contribute to necrosis of the osteotomized acetabular fragment. Extension of the iliac osteotomy into the weight-bearing surface of the joint can create an incongruent joint and should be avoided. Pelvic nonunion is relatively rare in iliac osteotomies, although pubic nonunions have been reported (Fig. 51-3). Heterotopic ossification is rare with the use of modified anterior approaches that leave the abductors unviolated. Improper correction is probably the most common error after pelvic osteotomy. Proper correction should be considered, with proper medialization of the hip center of rotation, proper anteversion of the acetabular fragment, proper lateral correction, and proper anteroposterior (AP) correction (Fig. 51-4). Overcorrection of a pelvic osteotomy can lead to anterolateral impingement and/or posterior subluxation of the femoral head. The results of pelvic osteotomies for hip dysplasia have been well described in the literature, and the majority of series report marked improvements in pain, femoral head coverage, and function (4,14,16,19,24).
Figure 51-4 A: This 24-year-old woman had bilateral symptomatic hip dysplasia. Scout film for the computerized tomographic analysis demonstrates upward oblique pattern of the sourcil (original radiograph lost). B: Anteroposterior 3DCT view of both hips demonstrates anterolateral deficiency of the acetabulum. C: Plain radiograph taken 2 years after Ganz osteotomy demonstrates increased coverage and congruency.
P.777

Femoral Osteotomy
Femoral osteotomy should be done for the rare patient with a dysplastic hip where the majority of the deformity is located on the femoral side of the joint. In most patients with dysplasia, the primary deformity lies on the acetabular side of the joint, and an acetabular osteotomy is the proper procedure, as discussed above (Fig. 51-5). In those few patients where the proximal femur is the primary site of deformity, an intertrochanteric osteotomy is a very reliable procedure. Radiographic improvement of the femoral head coverage should be seen on functional abduction views. One should assess anteroposterior head coverage to make sure anterior coverage is satisfactory before embarking on a femoral osteotomy. Patients should have at least 15° to 20° of abduction, and pain should be absent when the hip is placed in abduction. Mild anterior femoral head deficiencies can be accommodated for with slight extension of the osteotomy. Care should be taken not to extend the proximal fragment more than 15° or 20° or future hip arthroplasty may be more difficult. If varus correction of more than 25° is considered, a concurrent greater trochanteric advancement should be considered. Varus osteotomy invariably leads to shortening of the limb up to 1.5 cm, and this can be minimized by performing a straight osteotomy without significant wedge removal. Valgus osteotomy is also useful in some patients with developmental hip dysplasia. It is indicated when the femoral head is elliptical, with a large inferior-medial osteophyte. Bombelli referred to this osteophyte as a “capital drop osteophyte.” These hips often have a proximally migrated greater trochanter, a large periacetabular osteophyte, and increased neck shaft angles. Biomechanically a valgus producing osteotomy will open the superolateral joint space and load the medial osteophyte. It also displaces the center of rotation of the femoral head medially, favorably altering the lever arm of the hip joint. Intertrochanteric osteotomy is also a relatively attractive alternative for some carefully selected patients with avascular necrosis (6,15,18,21). The goal of the osteotomy in these patients is to move the necrotic segment away from the weight-bearing surface, bringing normal articular cartilage supported by healthy bone into the weight-bearing area. The ideal patient for an osteotomy is a young patient who has a relatively small necrotic lesion with no or minimal collapse. Patients who have large lesions or advanced disease are better served with arthrodesis or total hip arthroplasty, depending on their age and activity level. Plain radiographs and computed tomography are helpful in mapping the necrotic lesion. The size of the lesion may then be estimated on the anteroposterior and lateral radiographs. Necrotic arc angles can be obtained by taking a point in the middle of the femoral head and extending lines to the joint surface where the necrosis stops. Adding the angles on the anteroposterior and lateral
P.778

view is helpful in patient selection. Patients who have lesions with arc angles up to 200° have been shown to be favorable candidates for a proximal femoral osteotomy. Patients who are on steroids, have ongoing systemic disease, or have large lesions with necrotic arc angles more than 200° are not considered osteotomy candidates in our clinic. An uncommon but excellent indication for valgus intertrochanteric osteotomy is a femoral neck nonunion. Pauwels has shown that femoral neck fractures that have a high inclination angle from the horizontal have a higher risk of nonunion secondary to the large shear forces placed at the fracture site. The principle of valgus osteotomy is to convert the shear forces to compressive forces across the fracture line. The implant of choice for these osteotomies is a 110°, 120°, or 130° blade plate. The amount of correction is determined by the angulation of the nonunion. If a Pauwels angle of 60° exists, a 30° to 35° corrective osteotomy is
P.779

performed to get the Pauwels angle to 25° to 30°. This is the angle at which the resultant forces across the hip joint are perpendicular to the fracture site. Blade position in the head as well as entry of the blade in the lateral femur is critical. These patients also have often had previous internal fixation devices, and the blade should be placed in an area of solid bone. The majority of complications seen after proximal intertrochanteric osteotomy are technical in nature. Hemorrhage, hematoma, infection, and nerve palsy are all quite rare. Inaccurate seating of the chisel and blade can be avoided by careful technique and frequent radiographic checks. Occasionally one can have perfect chisel placement, but the blade is inserted and follows a different tract. Using fluoroscopy and taking care to slow down when excessive resistance is met when inserting a blade will minimize inadvertent placement. If the blade follows a different tract, poor correction or protrusion of the blade outside the femoral neck can occur. If one places the osteotomy and chisel tract within 1.5 cm of each other, a fragmentation of this bony bridge may occur. Nonunion or loss of fixation is relatively uncommon.
Figure 51-5 A: Preoperative plain radiograph demonstrates a typical dysplastic hip on the left. The left acetabular sourcil is represented as a short, upward oblique irregular radiodensity. The CE angle is negative. The proximal femur demonstrates coxa valga and caput valgum. B: Preoperative plain radiograph with the femur placed in abduction–internal rotation suggests improved coverage of the femoral head. (However, in retrospect, the oblique sourcil suggests that the primary problem is in the acetabulum, although the patient does have coxa valga.) C: Postoperative radiograph taken 1.5 years after proximal femoral varus osteotomy demonstrates a decreased neck–shaft angle and an improved CE angle. However, the patient continued to have hip pain. D: Faux profil view of the left hip performed at age 21 demonstrates anterolateral deficiency of the acetabulum. The smooth acetabular rim shadow is interrupted at the level of the midfemoral head. E: Anteroposterior 3DCT view of the left hip after the left femoral hip osteotomy confirms poor lateral coverage of the femoral head. F: A lateral 3DCT view of the left hip clarifies the anterolateral deficiency of the femoral head suggested by the faux profil view. G: Because of continued left hip pain, a triple innominate osteotomy of the left hip was performed. The radiograph demonstrates increased coverage of the femoral head and improved congruency of the hip joint. The orientation and shape of the sourcil are nearly normal. This case illustrates the need for combined femoral and acetabular osteotomy in those cases that show both femoral abnormalities and acetabular dysplasia. H: Lateral 3DCT view of the same hip, after triple innominate osteotomy, demonstrates markedly improved anterolateral coverage. Acetabular dysplasia can be corrected only by acetabular procedures.
Conclusion
Young patients with structural problems about the hip joint are often candidates for alternative procedures. Patients with classic hip dysplasia, impingement problems, torsional abnormalities of the socket, and femoral neck nonunions and selected patients with avascular necrosis are excellent candidates for osteotomies about the hip if the patients are young and there is viable articular cartilage remaining.
References
1. Bombeli R. Osteoarthritis of the Hip: Pathogenesis and Consequent Therapy. Berlin: Springer-Verlag; 1976.
2. Carlioz H, Khouri N, Hulin P. Osteotomie triple juxtacotyloidienne. Rev Chir Orthop. 1982;68:497–501.
3. Chiari K. Medial displacement osteotomy of the pelvis. Clin Orthop. 1974;98:55–71.
4. Crockarell J, Trousdale RT, Cabanela ME, et al. Early experience with the periacetabular osteotomy: the Mayo Clinic experience. Clin Orthop. 1999;363:45–53.
P.780

5. Davey JP, Santore RF. Complications of periacetabular osteotomy. Clin Orthop. 1999;363:33–37.
6. Dean MT, Cabanela ME. Transtrochanteric anterior rotational osteotomy for avascular necrosis of the femoral head: long term results. J Bone Joint Surg. 1993;75B:597–601.
7. Eppright RH. Dial osteotomy of the acetabulum in the treatment of dysplasia of the hip. J Bone Joint Surg. 1975;57A:1172.
8. Ganz R, Klaue K, Vinh TS, et al. A new periacetabular osteotomy for the treatment of hip dysplasias: technique and preliminary results. Clin Orthop. 1988;232:26–36.
9. Giori NJ, Trousdale RT. Acetabular retroversion is associated with osteoarthritis of the hip. Clin Orthop. 2003;417:263–269.
10. Harris WH. Etiology of the osteoarthritis of the hip. Clin Orthop. 1986;213:20–33.
11. Hopf A. Hüftpfannenverlagerung durch doppelte Beckenosteotomie zur Behandlung der Hüftgelenksdysplasie und Subluxation bei Jugendlichen und Erwachsenen. Z Orthop. 1966;101:559.
12. Hussell JG, Rodriquez JA, Ganz R. Technical complications of the Bernese periacetabular osteotomy. Clin Orthop. 1999;363:81–92.
13. LeCoeur P. Corrections des défauts d’orientation de l’articulation coxo-femorale par osteotomy de l’isthme iliaque. Rev Chir Orthop. 1965;51:211.
14. Matta JM, Stover MD, Siebenrock K. Periacetabular osteotomy through the Smith-Peterson approach. Clin Orthop. 1999;363:21–32.
15. Mont MA, Fairbank AC, Jinnah RH, et al. Varus osteotomy for avascular necrosis of the femoral head: results of long-term follow-up. Paper presented at the annual meeting of the American Academy of Orthopaedic Surgeons; New Orleans; February 26, 1994.
16. Murphy SB, Millis MB. Periacetabular osteotomy without abductor dissection using direct anterior exposure. Clin Orthop. 1999;364:92–98.
17. Ninomiya S, Tagawa H. Rotational acetabular osteotomy for the dysplastic hip. J Bone Joint Surg. 1984;66A:430–436.
18. Scher MA, Jakim I. Intertrochanteric osteotomy and autogenous bone grafting for avascular necrosis of the femoral head. J Bone Joint Surg. 1993;75A:1119–1133.
19. Siebenrock KA, Scholl E, Lottenbach M, et al. Bernese periacetabular osteotomy. Clin Orthop. 1999;363:9–20.
20. Steel HH. Triple osteotomy of the innominate bone. J Bone Joint Surg. 1973;55A:343–350.
21. Sugioka Y, Hotokebuchi T, Tsutsui H. Transtrochanteric anterior rotational osteotomy for idiopathic and steroid-induced necrosis of the femoral head: indications and long-term results. Clin Orthop. 1992;277:111–120.
22. Tönnis D. Congenital Dysplasia and Dislocation of the Hip in Children and Adults. Heidelberg: Springer-Verlag; 1987.
23. Trousdale RT, Ekkernkamp A, Ganz R, et al. Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips. J Bone Joint Surg. 1995;77A:73–85.
24. Trumble SJ, Mayo KA, Mast JW. The periacetabular osteotomy: minimum 2 year follow-up in more than 100 hips. Clin Orthop. 1999;363:54–63.
25. Wagner H. Osteotomies for congenital hip dislocation. In: The Hip: Proceedings of the Fourth Open Scientific Meeting of the Hip Society. St. Louis: CV Mosby; 1976:45.