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 .
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
• 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
•
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
).
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
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.
