Pelvic and acetabular osteotomies for hip dysplasia in children and adults

Focus On
Pelvic and acetabular osteotomies
for hip dysplasia in children and adults
Acetabular dysplasia is an established cause of hip arthritis.1-3
In dysplasia, abnormal loading occurs at the edge of a steep and
shallow acetabulum which may lead to osteoarthritis. Stulberg
and Harris,4 in their classic study of 130 patients with total hip
replacement, found that 63 (48%) patients with degenerative
arthritis had acetabular dysplasia. Early recognition of dysplasia
of the hip is important to allow the opportunity for timely intervention. This article will consider the various pelvic and acetabular osteotomies used to treat dysplasia of the hip, together with
their relative advantages and limitations.
Treatment of acetabular dysplasia
The goal of treatment in acetabular dysplasia is to establish
normal biomechanical forces around the hip joint. Acetabular
osteotomies aim to increase the contact area, reduce the contact stresses and normalise the weight-bearing forces.
In terms of treatment options patients may be split into two
main groups. Those patients with concentric hips and minimal
osteoarthritis require reorientation procedures. This is where
the acetabulum is rotated into a better position to increase the
contact area. These include Salter, Triple Innominate, Double
Innominate and Periacetabular osteotomies.
In contrast, salvage or augmentation procedures are
designed for patients with incongruent hips. The deficient
acetabulum is supplemented by a buttress of bone to increase
the area of support for the femoral head; examples include the
Chiari osteotomy and Shelf procedures.
Re-orientation osteotomies
Salter single innominate osteotomy. Salter described his
innominate osteotomy for acetabular dysplasia in children older
than 18 months of age.5 The osteotomy is transverse and perpendicular to the iliac axis from just above the anterior inferior
iliac spine to the sciatic notch. Salter stated that after the osteotomy, the symphysis pubis can be used as a flexible hinge and
the acetabulum can be redirected to cover the anterolateral deficiency in a concentrically reduced hip. Salter recommended this
procedure in patients up to ten years of age.
In a review of 15-year data on 140 patients, Salter and
Dubos6 reported 93.6% excellent or good results in patients
from 18 months to four years of age with no failures. In the fourto ten-year-old age group, the results were excellent or good in
only 56.7%. The Salter osteotomy is, therefore, generally not recommended in older children.
Triple innominate osteotomy. In older children the symphysis is
less flexible and Steel recommended a triple innominate osteotomy.7 This comprises osteotomies to the ischium and pubis in
addition to a Salter osteotomy. The procedure allows increased
mobility of the acetabulum for correction. In Steel's original
series, the results were satisfactory in 19 out of 23 patients with
a follow-up from 2–10 years. Joseph et al8 also reported favorable biomechanical and functional outcomes in 17 patients
(22 hips) with follow-up from 2.2 to 13.8 years.
Steel's triple osteotomy requires two separate incisions for
the three osteotomies. The resulting acetabular fragment is
quite big and the attached soft tissues, especially the sacropelvic ligaments, limit the amount of correction that can be
achieved. The large size of the acetabular fragment also makes
it difficult to maintain the desired correction. Steel, therefore,
used a combination of internal fixation and a spica cast in the
initial post-operative period.
Double Innominate Osteotomy. Sutherland and Greenfield9
described their double osteotomy in 1977. They thought the addition of a pubic osteotomy to a Salter osteotomy would be enough
to obtain correction. They recommended placing the pubic osteotomy medial to the obturator foramen in the interval between the
pubic tubercle and the symphysis pubis. They explained that
medial displacement of the acetabulum was possible by removing
a bony segment from the pubis at the osteotomy site with the rotation achieved through the iliac osteotomy. There was areported
improvement in the centre-edge angle of 27° and a decrease in
the acetabular index of 19.5°. However, he also reported significant complications including inadequate correction requiring revision, non-union and iatrogenic urological injuries.9
Dial or Spherical osteotomy. Multiple centres have described
spherical or dial osteotomies, each with different modifications.1013
The osteotomy described by Eppright11 is barrel shaped along
the anteroposterior axis. It allows excellent lateral coverage but
limited anterior coverage. The other spherical osteotomies provide
good lateral and anterior coverage but allow only limited correction of version and mediolateral displacement of the acetabulum.
Spherical osteotomies require extensive operative exposure.
The resulting acetabular fragment relies on the capsular blood
supply and is, therefore, at significant risk of avascular necrosis.14,15 Furthermore, there is the potential for intra-articular
extension of the osteotomy. Hence, spherical osteotomies are
technically challenging. However, satisfactory results are
reported in several studies. Michael et al16 reported 84%
©2010 British Editorial Society of Bone and Joint Surgery
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MUJAHID J KHATTAK, JOHAN D WITT
survival in 22 hips at 20 years, with total hip replacement as
the end-point.
Periacetabular osteotomy. The Bernese periacetabular osteotomy was described in 1988.17 Three osteotomies are performed
through the ischium, pubis and ilium. A vertical posterior cut
then connects the posterior extremes of the iliac and the ischial
osteotomies, anterior to the sciatic notch. The result is an extraarticular polygonal osteotomy.
This procedure has well-established advantages. The supraacetabular and acetabular branches of the superior gluteal
artery remain intact and preserve the acetabular blood supply.18
The correction is not limited by the sacropelvic ligaments or muscles. Extensive acetabular re-orientation is possible including
version and mediolateral displacement. As the posterior column
of the acetabulum remains intact, it protects the sciatic nerve
during the procedure and allows for minimal internal fixation and
early mobilisation. Furthermore, the dimensions of the true
pelvis remain unchanged.19 This is important as most patients
are females in the reproductive age group and this maintains
their ability to have vaginal deliveries.
Unlike other procedures, all the osteotomies can be performed through a single incision via a modified Smith-Petersen
or ilioinguinal approach. An anterior capsulotomy can be done
through the same approach for inspection of the joint and correction of impingement. The procedure can also be combined
with a femoral osteotomy if required.
The effectiveness of the Bernese periacetabular osteotomy is
well established.20-22 Follow-up of 20 years has been reported,
showing a cumulative survivorship of 60.5% (48.8% to 72.2%)
with total hip replacement or hip fusion as the end point.23
Although significant osteoarthritis (Tönnis grade 2) is a relative
contra-indication, satisfactory medium-term outcome has been
reported in patients with congruent hips.24 Moreover, periacetabular osteotomies do not compromise the result of a subsequent total hip replacement.25
The Bernese periacetabular osteotomy is a technically
demanding procedure. Inadvertent extension of the ischial osteotomy can interrupt the blood supply and cause acetabular
osteonecrosis. Extension of the iliac osteotomy into the hip can
result in incongruence and osteoarthritis. The iliac osteotomy
can also extend into the sciatic notch destabilising the pelvic
ring.26 Nerve dysfunction is the most common complication. Up
to 35% of the patients have paraesthesiae over the anterolateral
aspect of the thigh, in the territory of the lateral femoral cutaneous nerve, although this rarely requires formal treatment.27 Femoral nerve palsies have also been reported.28,29
One of the most important factors affecting the incidence of
complications is the surgeon's experience.30 The learning curve
with this procedure is steep and training in the anatomy laboratory is extremely helpful. In units with sufficient volume, major
complications are rare and the operation can be performed
through relatively small incisions.
Salvage osteotomies
Shelf arthroplasty. This procedure was first described by König
in 1891.31 It was later modified by both Albee32 and Spitzy.33
Local bone is used to augment the deficient lateral acetabulum
and to act as a buttress. The hip capsule separates the femoral
articular cartilage from this buttress. With time the capsule is
said to undergo metaplastic deformation to fibrocartilage,
although there is now good evidence that this does not occur.34
Hamanishi, Tanaka and Yamamuro35 and Nishimatsu et al36
reported good results in patients with minimal osteoarthritis.
Staheli and Chew37 also reported favourable results in 83% of
patients over a period of 18 years. More recently, survival of 86%
at five years and 46% at ten years has been reported, with hip
replacement as the end point.38
However, shelf arthroplasty is limited by the amount of femoral
head coverage that can be achieved. The procedure also fails to
address the underlying biomechanical abnormality leading to poor
abductor function. The surgical exposure can also cause damage to
the abductors, thereby further exacerbating this problem.
Chiari medial displacement osteotomy. Chiari39 recognised
the limitations of the shelf arthroplasty and its failure to address the
subluxation of the femur. Using a curved osteotomy through the
isthmus of the ilium, just proximal to the hip capsule, he described
how the entire ilium could be used to increase coverage and prevent subluxation. Furthermore, as the hip is medialised, the joint
reaction forces and stress on the abductor muscles are reduced.
Windhager40 reported 236 Chiari osteotomies followed for a
mean of 24.8 years with 52% clinically rated excellent or good,
30% fair and 18% poor. Increasing age and osteoarthritis were
related to poor outcomes.
Summary
Hip dysplasia is a significant cause of hip pain and disability.
Early recognition is important so that intervention can be
planned before the development of degenerative changes,
which can prejudice the outcome of surgery. Where possible,
surgical treatment aims to re-orientate the articular hyaline cartilage in order to reduce the forces through the weight-bearing
zone of the acetabulum. The Bernese periacetabular osteotomy
is now considered the most versatile of the acetabular osteotomies and can produce both excellent pain relief and a return to
high levels of activity. Development or progression of osteoarthritis may still occur and is dependent on congruency of the hip and
the extent of degenerative change present at the time of surgery.
Mr. Mujahid J Khattak FCPS Orth., FRCS Orth, Hip Surgery Fellow
Johan D Witt FRCS Orth, Consultant Orthopaedic Surgeon
University College London Hospitals
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