Pelvic Support Osteotomy

SITA       14 yrs /fe             BAGLUNG  District

Chief Complaint - Limping and pain while walking for a year 

HOPI –

                                Apparently well until 2 yrs back

                                pain Priyanka Patel         14 yrs /fe            

Chief Complaint –

                                Limping and pain while walking for a year

HOPI –

                                Apparently well until 2 yrs back

                                pain while playing on rt hip spontaneously .Gradually pain worsened   and she                                     became bed ridden . She had pus discharge from her rt gluteal  region and it                                         healed after 3 months .

                                She can only walk half an hour now with limping.

                                Denies history of trauma .

Birth History – NORMAL

 

 

Examination –

 General Examination

                G.C. – Anxious looking,conscious well oriented to TPP , lying comfartably on bed .

                Build Up – thin .

                Vitals – stable

                Lymph Nodes – not palpable , Skar on bak

   Trendelenburg gait

•       Apparent Leg Length Measurement (Xyphoid to middle of medial malleolus )

 Lt           104 cm                                  Rt            98 cm                    LLD = 6 CM

•       True Leg Length Measurement (ASIS to medial malleolus )

 Lt           78 cm                                    Rt            74 cm                    LLD = 4 CM

True LLD  >  Apparent LLD                                         some additional deformity 

•       Galleazi test

                Lt knee further forward compared to rt .

•       Measurement from ASIS to  tibial tuberosity

 Lt   45 cm                                    Rt            41 cm

 

Femoral Shortening  = 4 cm 

HIENE'S TEST AND BRYANT'S ANGLE 

•       ROM – Hip Joint

                                                                                                                                                                                Rt                                            Lt

Flexion                                                                                                                                 140                                         130

Extension                                                                                                                            15                                           20

Abduction                                                                                                                           40                                           40

Adduction                                                                                                                           30                                           30

•       Conclusion – Physical Examination

True LLD (4 cm )  >  Apparent LLD (6cm) ,  some additional deformity ( from fixed adduction contracture )  .

LLD comes from Supratrochanteric region .

Judgement from X-rays

Mangement

Intervention to address Pain

 Options –

1 ) Hip Arthrodesis - it has adverse

•       effects on the lower back, contralateral hip and knee . Donot address the issue of abductor insufficiency or of limb length discrepancy completely .

2)Total Hip Arthroplasty –

                                                                                                                                   For a deficient hip - significant complication rate of excessive shortening, sciatic or femoral nerve palsy, fracture of the femoral shaft, and early postoperative dislocation and

                                                                                                                                   aseptic loosening . Revision of a total hip arthroplasty in a patient with previous hip deficiency is often more difficult than a standard revision operation

3) Pelvic Support Osteotomy 

•       double level femoral osteotomy with the objective of eliminating a Trendelenburg and short limb gait in young patients with severe hip joint destruction as a consequence of neonatal septic arthritis  

 (a) the more proximal valgus-extension osteotomy is performed with the femur in

maximum adduction and at a level where the femoral shaftis seen to abut the pelvis;

 

(b) the second, more distal, osteotomy restores the orientation of the knee and ankle

joint lines in the coronal plane and also provides a focus for femoral lengthening if warranted.

The proximal osteotomy lateralises and distally displaces the greater trochanter and

in so doing increases the action of the abductor muscles.

 To this is added the elimination of any further adduction between femur and pelvis which then prevents pelvic drop during the single stance phase of gait.

 A successful pelvic support osteotomy reduces limp through abolishing the Trendelenburg lurch, equalises limb length and, through the stability provided to the hemipelvis, facilitates a more energy-efficient gait.

Translating the findings from clinical and X-ray

Planning Proximal femoral osteotomy:  Level, degree and direction of osteotomy

Level of osteotomy

undiagnosed hip dislocations, where there can be greater proximal migration of the femur, at a level coincident with the superior border of the obturator foramen; in other scenarios lies coincident with part of the projection of the ischial tuberosity.

 

                                                                    Valgus  -  an abduction angle that is either equal to the single stance pelvic drop angle or the measured range of adduction, plus an overcorrection factor of 15-25 ( to prevent from remodelling ).

                                                          40 + 25 Degrees

    

                           

                                                                                        

Distal femoral osteotomy: level, degree and direction of osteotomy Level of osteotomy This second osteotomy is Ilizarov’s contribution to the pelvic support technique that addresses the excessive valgus of the proximal osteotomy and allows for derotation

 

Level Of Osteotomy  -  manipulation software or trigonometry .

 

Sine θ  = (x 1 – x 2 ) / y

where

x1 distance to centre of knee from midline (on contralateral side)

x2 distance to level of first osteotomy from midline

y distance along the shaft of the femur to second osteotomy

θ  angle of overcorrection—9where

Amount of varus

It was described that, in single stance, the ankle and knee

joint inclinations in the coronal plane should be horizontal

and parallel to the pelvis. Therefore this osteotomy serves tobring the inclination of the knee joint parallel with that of the horizontal line of the pelvis. However doing this will effectively remove any degree of overcorrection that is

Amount of derotation

amount will depend of the findings of the clinical examination described.

Amount of lengthening

The new parallel beam scanogram provided an estimate of the length discrepancy between the limbs. Over-lengthening is to be avoided as it is poorlytolerated in a hip that is already in full adduction

Summary

Pelvic support osteotomies offer a significant improvement in posture, gait and walking tolerance to those adolescents and young adults who have hips destroyed by neonatal sepsis or through untreated congenital dislocations.

The preoperative considerations involve a careful clinical and radiological assessment together with a discussion of alternative surgical solutions.

Surgical planning is based on data obtained from clinical and X-ray assessment; both will provide the surgeon with answers to: (a) the level of the proximal osteotomy; (b) the amount of valgus, extension and derotation at the proximal osteotomy; (c) the level of the distal osteotomy, and (d) the amount of varus and lengthening at the distal osteotomy.