Description and indications

Ganzosteotomy
Description and indications
Dr. Jaak Roos - A.Z. Turnhout
Welcome
Turnhout
Flanders’ Cultural Capital 2012
Turnhout: “Stad van m’n hert”
Hip Dysplasia
Natural history of HD without subluxation:
40-50% OA before 50 y.
50% THA before 60 y.
LCE-angle < 16°
End-stage 0A
Acetabular index > 15°
Natural history of HD with subluxation:
ALL develop OA during 2° - 3° decade of
life
o 55 y. untreated hip dysplasia
Hip Dysplasia
Insufficient coverage of the femoral head by a
too small acetabulum
High loads at the acetabular roof
Maloriented steep acetabular roof
instability and migration of the femoral head
increase of load and shear stress at the
acetabular rim
Labral hypertrophy to maintain stability
failure labral soft tissue compensation: Tear
Hip Dysplasia
Goal of surgery:
alter the natural course
Goal of pelvic osteotomy :
increase the weigth bearing surface
transform shearing forces into
compressive forces
Pelvic Osteotomy
Coverage of the femoral head can be
increased by:
Augmentation of the acetabular roof
Changing the spatial orientation
Augmentation Procedures
Reduction of the joint-loading forces by
augmenting the weigth-bearing area.
Chiari-Osteotomy
Shelf Procedure
Chiari Osteotomy
Shelf Procedure
Augmentation Procedures
Can provide pain relief for some years
Should be regarded as salvage procedures
Reorienting Procedures
Change the orientation of the acetabular
articular surface
Correct the area of deficiency
Provide a greater surface area for load
transmission
reestablish or maintain joint stability
Procedures: single, double, triple, spheric and
periacetabular osteotomies
Single Pelvic Osteotomy:
Salter osteotomy
Children
Limited correction in adults
Retroversion
Lateralisation
Double, Triple Pelvic Osteotomies
Sutherland, Carlioz, Steel, Tönnis...
Limited range of displacement
Narrow the pelvic concavity
Create a pelvic discontinuity
Substantial internal fixation
Spheric Acetabular Osteotomy
Good lateral and anterior correction
Medialization is difficult
Osteotomy runs intraarticular
Vascularity
No simultaneous Capsulotomy
Spheric Acetabular Osteotomy
Good lateral and anterior correction
Medialization is difficult
Osteotomy runs intraarticular
Vascularity
No simultaneous Capsulotomy
Spheric Acetabular Osteotomy
Good lateral and anterior correction
Medialization is difficult
Osteotomy runs intraarticular
Vascularity
No simultaneous Capsulotomy
Ganz Periacetabular Osteotomy
Based on:
Mechanical considerations
Biological considerations
Limitations of the previous
techniques
Ganz Periacetabular Osteotomy
Single incision
Juxta-articular/Polygonal
Posterior column intact
Ganz Periacetabular Osteotomy
Extensive reorientation
version
mediolateral
Unchanged dimension
of the true pelvis
Anterior capsulotomy
Blood Supply Acetabulum
The acetabular bllood supply: implications for periacetabular osteotomies.
M. Beck, M. Leunig, T. Ellis, J.B. Sledge, R. Ganz
Surg Radiol Anat (2003) 25: 361–367
Blood Supply Acetabular
Fragment
The acetabular bllood supply: implications for periacetabular osteotomies.
M. Beck, M. Leunig, T. Ellis, J.B. Sledge, R. Ganz
Surg Radiol Anat (2003) 25: 361–367
4
Indications
can be a difficult subject in the practical
clinical situation
ideal case is easy
marginal cases sometimes difficult
Typical case
Female
about 30 years old
No knowledge of childhood problems
Gradual pain increase
Recent acute pain increase
“locking” or “hip going out”
Acetabular Rim Fracture
Basic Indications
Acetabular dysplasia
Triradiate cartilage closure
Presence of joint space
Mobile hip
Pain
Acetabular Dysplasia
Lateral center edge angle
Acetabular Dysplasia
Acetabular Dysplasia
Basic Indications
Acetabular dysplasia
Triradiate cartilage closure
Presence of joint space
Mobile hip
Pain
The patient should
derive at least
10 years of benefit
Osteoarthritis?
Osteoarthritis?
Tönnis Classification
grade 0:
No signs of OA
grade 1:
increased sclerosis, slight J.S. narrowing, no or slight loss of head sfericity
Grade 2:
small cysts, moderate J.S. narrowing, moderate loss of head sphericity
Grade 3:
Large cysts, severe J.S. narrowing, severe deformity of the head
Osteoarthritis?
Tönnis Classification
grade 0:
No signs of OA
grade 1:
increased sclerosis, slight J.S. narrowing, no or slight loss of head sfericity
Grade 2:
small cysts, moderate J.S. narrowing, moderate loss of head sphericity
Grade 3:
Large cysts, severe J.S. narrowing, severe deformity of the head
Most important arthritic
sign is cartilage space
narrowing
A Lot of PAO candidates
have some evidence of
OA
Ideal Candidate
Normal joint space
Minimal arthritic changes
Congruent joint
Spherical femoral head
Good congruence on the abduction view
Abduction View
Probable Candidate
Joint slightly narrowed
Congruence and joint space good on
the abduction view
Possible Candidate
Joint narrowed
Improved congruence and joint space
on the abduction view
Indication varies with
age
Under 30: “Push the indication”
Over 45: “more hesitant”
Indication varies with
the patient
Indication varies with
the patient
Other indications
Retroversion
secondary dysplasia: e.g. perthes disease...
selected cases of protrusio acetabuli
after acetabulumfracture
to “fix the bone”...
“to fix the bone”
Contraindications
Open triradiate cartilage
Marked Cephalad dislocation
Secondary acetabulum with fibrocartilage
(OA with a Tönnis grade > 1)
How urgent is the
surgery?
Typically a 2-year window of opportunity
Recommendation: surgery within 6 months
Varies with individual cases
Bilateral PAO?
Bilateral PAO?
No indication for bilateral PAO
Danger of separating the anterior
pelvic ring from the posterior pelvic
ring in case of a fracture.
Conclusion
beautiful surgery
effective surgery
difficult surgery
steep learning curve
Many thanks !
to my mentor, my friend
Minne Heeg
Dr. Eric Vanlommel:
“Dus...niet elke ganz is een
vogel ! ”
Thank You