Osteotomies Around Hip Pdf 13
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A history of previous varus ITO can be a particular problem when a PAO is indicated for the treatment of residual acetabular dysplasia. Paper drawings made from functional abduction and adduction views are completed with the desired position of the acetabulum after PAO. An additional paper drawing of the femoral side is rotated around the center of the head until impingement with the acetabulum is encountered. This determines the clearance angle for abduction. This process may be repeated with a revalgization ITO. If the measured abduction is over 20, a PAO alone is sufficient. If abduction is 20 or less, the clearance may be increased by adding a PFO. In the situation of a unilateral former varus ITO, a revalgization ITO is preferred to equalize limb lengths. When bilateral varus osteotomies are present and one side is asymptomatic and expected to remain so, RFNL with resultant relative valgus is preferred.
Historically, PFOs have been intertrochanteric or subtrochanteric osteotomies, which have been used extensively [9, 14, 21, 26, 29] and are accepted as techniques that effectively alter proximal femoral anatomy with low rates and severity of complications. However, since these osteotomies are performed at a distance from the deformity, they produce several side effects. They either medialize or lateralize the femoral shaft and alter the mechanical axis of the lower extremity. They also shorten or lengthen the limb depending on whether a varus or valgus osteotomy is implemented. The more distal these osteotomies are executed, the larger these side effects. In certain circumstances these may be desired effects; however, in the majority of cases, they are undesired consequences. Although most of these side effects can be minimized by choosing an appropriate implant and modifying the surgical technique, unilateral shortening of the femur by varus ITO remains a major problem, especially for female patients.
Recently, intracapsular osteotomies have increased the spectrum of treatable conditions to now include hips with severe intracapital step deformities [7]. These osteotomies have the distinct advantage of increased comfort for the patient as compared to classic ITO. The ability to perform these osteotomies with low rates of ON is a result of a detailed understanding of the vascularity of the femoral head [13] and the capacity to maintain this blood supply with an extended retinacular soft-tissue flap [7]. All intracapsular osteotomies, particularly the FNO, are susceptible to technical errors, leading others to discontinue performing these procedures [27]. In our experience, the morbidity of surgical hip dislocation, RFNL, FNO, and even FHRO (0% to 17% depending on the osteotomy) [7] is low and continues to decrease with experience. We had two unfortunate cases of ON during our early series of FNO, but have had no additional cases for the last 5 years. Due to prolonged consolidation time, opening-wedge FNO is performed infrequently.
Thus, pelvic osteotomy forms an integral part of surgical management of hip dysplasia. The ultimate goal of these osteotomies is to preclude or postpone the development of osteoarthritis and add more years of life to the native hip.
This article attempts to review the current indications for various pelvic osteotomies with a brief description of their techniques along with the outcomes and complications published thus far. Besides, the guidelines to choose the right pelvic osteotomy are also provided.
The Bernese peri-acetabular osteotomy (PAO) technique has been described in detail and has not changed significantly over time (39). Most surgeons use a single anterior approach that spares the abductor muscles, performing the osteotomies from the inner aspect of the pelvis. These include an incomplete osteotomy of the ischium, a complete osteotomy of the pubis and a biplanar osteotomy of the ilium. The continuity of the posterior column of the acetabulum is maintained (Fig. 2E and F). The intact posterior column makes this osteotomy very stable, and postoperative immobilization is not required. Additional advantages include preserving the blood supply to the acetabular fragment and preserving the shape of the pelvis, which permit normal vaginal delivery. The major disadvantage is the technical difficulty and steep learning curve.
Ali Aydin, in 2012, reported results of OR and PPO in 91 hips with a mean age of 34 months. In their series, type-1 AVN was seen in 9.9%, type-2 in 7.7% and type-3 in 1.1% and one had type-4 AVN. They observed that complication rate increased in patients with Tonnis type-4 hip dislocation, in patients over 3 years and in cases where a second surgery was necessary (42). Wada et al. reported excellent and good results with PPO in 82.3% of 17 hips, all over 7 years of age (43). Wang et al. compared radiographic results of SIO and PPO at >10-year follow-up and found that patients with PPO had improved anterior acetabular coverage. The functional outcomes were good and equivalent with both osteotomies (44).
PO is an essential part of the surgical management of hip dysplasia, and the literature is loaded with various types with modifications. A thorough understanding of the principles of pelvic osteotomies is essential to choose the right intervention for the right patient. The guidelines provided based on the type of dysplasia, the age of the patient and the status of the tri-radiate cartilage help in choosing the right type of PO. With the advent of the 3D technology in the field of orthopedics, in future, 3D planning and printing may be of immense use in planning and executing these complex osteotomies.
Despite the fact that osteotomies around the knee represent well-established treatment options for the redistribution of loads and forces within and around the knee joint, unforeseen effects of these osteotomies on the ankle are still to be better understood. It was therefore the aim of this study to determine the influence of osteotomies around the knee on the coronal alignment of the ankle. We hypothesize that osteotomies around the knee for correction of genu varum or valgum lead to a change of the ankle orientation in the frontal plane by valgisation or varisation.
Osteotomies around the knee represent powerful modalities for the treatment of bony deformities and degenerative joint disease [1,2,3,4]. The intended effects of these osteotomies act on joints by redistributing loads and force vectors [5, 6]. Despite the fact that osteotomies around the knee represent well-established treatment options for the redistribution of loads and forces within and around the knee joint, unforeseen effects of these osteotomies on the ankle are still to be better understood. Although osteotomies around the knee are successful orthopaedic standard procedures, it is not known to what extent coronal ankle alignment might be intentionally or unintentionally altered.
It was therefore the aim of this study to determine the influence of osteotomies around the knee on the coronal alignment of the ankle. We hypothesize that osteotomies around the knee for correction of genu varum or valgum lead to a change of the ankle orientation in the frontal plane by valgisation or varisation. This new knowledge would help to treat patient better by improving the planning of osteotomies and avoiding unwanted effects on the adjacent ankle joint.
All osteotomies were planned using a landmark based deformity analysis [7, 8]. A high tibial osteotomy was performed as described by Staubli and Lobenhoffer using a TomoFix MHT plate fixator (DePuy Synthes, Solothurn, Switzerland) [9,10,11]. Distal femoral osteotomy was performed using a medial subvastus approach and the technique described by Lobenhoffer [12,13,14]. For fixation, a TomoFix MDF plate (DePuy Synthes, Solothurn, Switzerland) was used [15]. Double level osteotomy was performed as described by Schröter et al. [16].
Illustration of the radiographic parameters measured on a long-leg standing X-ray with the knees pointing forward. Measures around the hip and the knee, HKA, Hip Knee Ankle angle, mLDFA, Mechanical lateral distal femoral angle; mLPFA, Mechanical lateral proximal femoral angle, mMPTA, Mechanical medial proximal tibial angle
Illustration of the radiographic parameters measured on a long-leg standing X-ray with the knees pointing forward. Measures around the ankle. a mLDTA: angle between tibiaplafond and mechanical tibia axis. b mMA: angle between malleolar tips and mechanical tibia axis. c MHA: angle between malleolar tips and floor. d TPHA: angle between tibiaplafond and floor. e TTTA: angle between tibio-talar joint surfaces. mLDTA, Mechanical Lateral Distal Tibia Angle; mMA, Mechanical Malleolar Angle; MHA, Malleolar Horizontal Orientation Angle; TPHA, Tibia Plafond Horizontal Orientation Angle; TTTA, Tibio Talar Tilt Angle
High tibial open wedge osteotomy for valgisation of the coronal limb alignment led to a corresponding valgisation of the ankle (Fig. 5). Varisation osteotomies around the knee led to corresponding varisation of the ankle (Fig. 6).
Varisation osteotomies around the knee. a Mechanical tibio-femoral angle. b Frontal alignment of the distal femur. c Coronal alignment of the ankle. HKA, Hip Knee Ankle angle; MHA, Malleolar Horizontal Orientation Angle; mLDFA, Mechanical Lateral Distal Femoral Angle
We determined the effects of osteotomies around the knee on the corresponding frontal alignment of the ankle. The most important findings of this study demonstrate that an osteotomy around the knee for valgisation or varisation of the long leg axis leads to a reorientation of the ankle in the coronal plane. This can be measured using the MHA (Figs. 4, 5, 6, Tables 1, 2). 153554b96e
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