J Korean Orthop Assoc.  2017 Dec;52(6):500-513. 10.4055/jkoa.2017.52.6.500.

Pelvic Osteotomy in Adults

• Cho YJ
• Ko YW

• KMID: 2421343
• DOI: http://doi.org/10.4055/jkoa.2017.52.6.500

Abstract

Pelvic osteotomy is a surgery for correcting acetabular deformity, which causes incomplete coverage of the femoral head or biomechanically abnormal load to the hip joint. Pelvic osteotomy can be divided into two categories: reconstructive or realignment osteotomy and salvage osteotomy. Reconstructive osteotomy can be performed to correct the dysplastic hip with good congruency, and include most pelvic osteotomies, except Chiari osteotomy. Among these, Bernese osteotomy, rotational acetabular osteotomy, and periacetabular rotational osteotomy are commonly being used. Salvage osteotomy, which include Chiari osteotomy only, can be performed to increase the coverage of the femoral head of hip joint with joint incongruency due to the severely deformed femoral head and acetabulum or advanced osteoarthritis. Chiari osteotomy is a kind of arthroplasty reducing the pressure applied to the head, and increasing the bone coverage on the upper part of the femoral head. It is effective in reducing hip pain and slowing degenerative changes; however, as the surface is covered by fibrous cartilage, it is vulnerable to degenerative changes. The pelvic osteotomy is a very important and useful surgical technique to preserve joints, despite being a difficult procedure that is technically demanding.

Keyword

pelvic osteotomy; Bernese osteotomy; rotational acetabular osteotomy; periacetabular rotational osteotomy; Chiari osteotomy

MeSH Terms

Acetabulum
Adult*
Arthroplasty
Cartilage
Congenital Abnormalities
Head
Hip
Hip Joint
Humans
Joints
Osteoarthritis
Osteotomy*

Figure

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  Figure 1 Skin incision and approach of rotational acetabular osteotomy. Cited from Ninomiya and Tagawa (J Bone Joint Surg Am. 1984;66:430-6).9)

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  Figure 2 Approach of rotational acetabular osteotomy. This approach combines the anterior iliofemoral and posterior approaches through a single skin incision. Cited from Ninomiya and Tagawa (J Bone Joint Surg Am. 1984;66:430-6).9)

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  Figure 3 Schematic drawing of the operative procedure. The freed acetabulum should be shifted anterolaterally, medially, and downward. (A) Preoperative view. (B) Anterolateral shift. (C) Downward and medial shift after removal of the excess bone. Cited from Ninomiya and Tagawa (J Bone Joint Surg Am. 1984;66:430-6).9)

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  Figure 4 Transpositional osteotomy. Rotation of the acetabulum is focused on anterior rotation.

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  Figure 5 Drawing of skin incision line of modified Ollier transtrochanteric approach. ASIS, anterior superior iliac spine; GT, greater trochanter

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  Figure 6 Osteotomy greater trochanter using a Gigli saw. (A) Draw an osteotomy line and perform osteotomy along the line using Gigli saw. (B) After osteotomy, the fragment of the greater trochanter and abductor muscle is retracted proximally.

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  Figure 7 Draw a completely circular osteotomy line 1 cm away from acetabular rim.

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  Figure 8 (A) Perform osteotomy of the ilium along the osteotomy line, first using a round osteotome. (B) Perform osteotomy ischium along the osteotomy line.

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  Figure 9 Osteotomy of the pubis is performed blindly by an approach between the hip joint capsule and rectus femoris. (A) Release rectus femoris muscle from the hip joint capsule using a periosteum elevator. (B) Osteotomy site of the pubis is pectineal eminence of the pubis. Iliopsoas tendon should be retracted medially by a small Hohman retractor during osteotomy of the pubis.

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  Figure 10 Rotate acetbular fragment anteriorly and laterally using bone hook.

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  Figure 11 Fix the acetabular fragment using 2, 3, or 3.5 mm cortical screws.

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  Figure 12 (A) Preoperative both hip anteroposterior radiograph of a 45-year-old woman showing bilaterally advanced osteoarthritis due to hip dysplasia, Tönnis grade III. Rotational acetabular osteotomy was performed on the right hip. (B) Seventeen-year postoperative follow-up radiograph shows a well restored joint space and no progression of osteoarthritis.

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  Figure 13 (A) Preoperative radiographs show decreased lateral center-edge angle (CEA), severe joint space narrowing and superolateral subluxation of the femoral head. (B) Periacetabular rotational osteotomy was performed and postoperative radiographs show increased lateral CEA, slightly restored joint space, reduced femoral head, excellent bony contact between acetabular fragment and pelvis.

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  Figure 14 Bernese periacetabular osteotomy. (A) External surface. (B) Internal surface. GM, gluteus medius tubercle; SM, sartorius muscle attachment; RFM, rectus femoris muscle (direct and indirect) heads.

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  Figure 15 Kirshner wire (K-wire) or Steinmann pin is inserted as a guide at the middle of the superior acetabular rim at the proposed level and angle.

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  Figure 16 Line of osteotomy which is marked by multiple drill holes.

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  Figure 17 Ideal level of osteotomy is just above the capsular attachment between the capsule and the reflected head of rectus femoris. Osteotomy angle is the angle between the plane of the pelvic osteotomy and the horizontal plane (10°–15° upward and medially). Roof angle is the angle formed between the horizontal plane and a line joining the original outer acetabular lip to the new acetabular lip.

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  Figure 18 (A) Preoperative both hip anteroposterior (AP) radiograph of a 32-year-old man shows bilateral deformed femoral head with huge subchondral cyst due to multiple epiphyseal dysplasia. (B) Chiari osteotomy was performed. (C) Both hip AP radiograph taken at 6 years and 9 months (right hip), and at 2 years (left hip) after the operation show complete healing of subchondral cyst of the right femoral head.

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