Archives of Orthopaedic and Trauma Surgery

, Volume 139, Issue 2, pp 173–180 | Cite as

Risk factors associated with non-union after triple pelvic osteotomy (Toennis and Kalchschmidt technique): a case–control study and review of the literature

  • Emre YilmazEmail author
  • Halil Damla
  • Daniel C. Norvell
  • Klaus Kalchschmidt
  • Christian Luering
  • Andre R. Zahedi
Orthopaedic Surgery



Dysplasia of the hip is a well known cause of secondary osteoarthritis of the hip. The triple pelvic osteotomy (TPO), according to the technique described by Toennis and Kalchschmidt, is a well established procedure to address dysplasia of the hip joint. Non-unions after triple pelvic osteotomies are rare and can occur at each of these osteotomies. The literature is lacking in studies investigating larger group of patients with non-unions after triple pelvic osteotomy. The aim of this study is to evaluate risk factors leading to a non-union after triple pelvic osteotomy.


A total of 53 patients with a non-union after triple pelvic osteotomy were included in this retrospective case–control. In addition, we identified a cohort of randomly selected patients undergoing hardware removal after triple pelvic osteotomy (“union” group) but had not developed non-union as the control group. This control group underwent the same procedure by the same group of surgeons in the same time period. The variables obtained from the review of the two groups were analyzed using appropriate statistical methods including Bivariable Analysis (p < 0.005) and Multivariable logistic regression analysis (p < 0.015).


We identified a total of 53 patients out of the 3269 who had undergone TPO and had developed a non-union. The control group consisted of 117 patients who did not experience a non-union. Bivariable analysis of basic demographic characteristics demonstrated that gender, BMI, smoking, preoperative CE angle and degree of surgical correction did not differ significantly between the groups. There was a statistically significant (p < 0.05) difference between age (31.5 ± 9.4 vs. 27.5 ± 9.0 in the non-union and union groups, respectively; p = < 0.001) and postoperative CE angle (34.4 ± 5.0 vs. 32.8 ± 3.5 in the non-union and union groups, respectively; p = 0.02). Multivariable analysis demonstrated that an age over 30 was significantly associated with non-union (p = 0.01, OR 2.6, 95% CI 1.3–5.3).


Non-unions after TPO are rare. A higher age and higher degree of surgical correction might be associated risk factors for developing a non-union. Furthermore, smoking, obesity and previous hip surgeries might also contribute to developing a non-union after triple pelvic osteotomy.


Triple pelvic osteotomy Non-union Pseudarthrosis Complication 



The authors received no financial support for the research, authorship, and/or publication of this article.

Compliance with ethical standards

Conflict of interest

The authors declare no potential conflict of interest with respect to the research, authorship, and/or publication of this article.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.


  1. 1.
    Vukasinovic Z, Pelillo F, Spasovski D, Seslija I, Zivkovic Z, Matanovic D (2009) Triple pelvic osteotomy for the treatment of residual hip dysplasia. Analysis of complications. Hip Int 4:315–322CrossRefGoogle Scholar
  2. 2.
    Renner L, Perka C, Zahn R (2014) [Complications after hip osteotomy]. Orthopade 1:16–23CrossRefGoogle Scholar
  3. 3.
    Hailer NP, Soykaner L, Ackermann H, Rittmeister M (2005) Triple osteotomy of the pelvis for acetabular dysplasia: age at operation and the incidence of nonunions and other complications influence outcome. J Bone Joint Surg Br 12:1622–1626CrossRefGoogle Scholar
  4. 4.
    Tschauner C, Sylkin A, Hofmann S, Graf R (2003) Painful nonunion after triple pelvic osteotomy. Report of five cases. J Bone Joint Surg Br 7:953–955CrossRefGoogle Scholar
  5. 5.
    Cooperman DR, Wallensten R, Stulberg SD (1983) Acetabular dysplasia in the adult. Clin Orthop Relat Res 175:79–85Google Scholar
  6. 6.
    Mimura T, Mori K, Kawasaki T, Imai S, Matsusue Y (2014) Triple pelvic osteotomy: Report of our mid-term results and review of literature. World J Orthop 1:14–22CrossRefGoogle Scholar
  7. 7.
    Tönnis D, Behrens K, Tscharani F (1981) A modified technique of the triple pelvic osteotomy: early results. J Pediatr Orthop 3:241–249CrossRefGoogle Scholar
  8. 8.
    Hsin J, Saluja R, Eilert RE, Wiedel JD (1996) Evaluation of the biomechanics of the hip following a triple osteotomy of the innominate bone. J Bone Joint Surg Am 6:855–862CrossRefGoogle Scholar
  9. 9.
    Kirschner S, Raab P, Wild A, Krauspe R (2002) [Clinical and radiological short- and mid-term results of triple pelvic osteotomy according to Tönnis in adolescents and adults]. Z Orthop Ihre Grenzgeb 5:523–526CrossRefGoogle Scholar
  10. 10.
    Frick SL, Kim SS, Wenger DR (2000) Pre- and postoperative three-dimensional computed tomography analysis of triple innominate osteotomy for hip dysplasia. J Pediatr Orthop 1:116–123Google Scholar
  11. 11.
    Vukasinovic Z, Spasovski D, Kralj-Iglic V, Marinkovic-Eric J, Seslija I, Zivkovic Z et al (2013) Impact of triple pelvic osteotomy on contact stress pressure distribution in the hip joint. Int Orthop 1:95–98CrossRefGoogle Scholar
  12. 12.
    Janssen D, Kalchschmidt K, Katthagen BD (2009) Triple pelvic osteotomy as treatment for osteoarthritis secondary to developmental dysplasia of the hip. Int Orthop 6:1555–1559CrossRefGoogle Scholar
  13. 13.
    Peters CL, Fukushima BW, Park TK, Coleman SS, Dunn HK (2001) Triple innominate osteotomy in young adults for the treatment of acetabular dysplasia: a 9-year follow-up study. Orthopedics 6:565–569Google Scholar
  14. 14.
    Dungl P, Rejholec M, Chomiak J, Grill F (2007) The role of triple pelvic osteotomy in therapy of residual hip dysplasia and sequel of AVN: long-term experience. Hip Int: S51-64Google Scholar
  15. 15.
    Abdulmonem A (2007) Painless nonunion after triple pelvic osteotomy. Int J Health Sci (Qassim) 2:287–291Google Scholar
  16. 16.
    van Hellemondt GG, Sonneveld H, Schreuder MH, Kooijman MA, de Kleuver M (2005) Triple osteotomy of the pelvis for acetabular dysplasia: results at a mean follow-up of 15 years. J Bone Joint Surg Br 7:911–915CrossRefGoogle Scholar
  17. 17.
    de Kleuver M, Kapitein PJ, Kooijman MA, van Limbeek J, Pavlov PW, Veth RP (1999) Acetabular coverage of the femoral head after triple pelvic osteotomy: no relation to outcome in 51 hips followed for 8–15 years. Acta Orthop Scand 6:583–588CrossRefGoogle Scholar
  18. 18.
    Zahedi AR, Kalchschmidt K, Katthagen BD (2013) Tönnis and Kalchschmidt triple pelvic osteotomy. Oper Orthop Traumatol 5:457–468CrossRefGoogle Scholar
  19. 19.
    Zahedi AR, Lüring C, Janßen D (2016) Tönnis and Kalchschmidt triple pelvic osteotomy. Orthopade 8:673–677CrossRefGoogle Scholar
  20. 20.
    von Bremen-Kühne R, de la Vega-Salgado H, Steffen R (2006) Triple pelvic osteotomy (according to Tönnis and Kalchschmidt) in the treatment of acetabular dysplasia–medium-term results. Z Orthop Ihre Grenzgeb 5:484–491CrossRefGoogle Scholar
  21. 21.
    Rebello G, Zilkens C, Dudda M, Matheney T, Kim YJ (2009) Triple pelvic osteotomy in complex hip dysplasia seen in neuromuscular and teratologic conditions. J Pediatr Orthop 6:527–534CrossRefGoogle Scholar
  22. 22.
    Tönnis D, Bruning K, Heinecke A (1994) Lateral acetabular osteotomy. J Pediatr Orthop BGoogle Scholar
  23. 23.
    Thevendran G, Shah K, Pinney SJ, Younger AS (2017) Perceived risk factors for nonunion following foot and ankle arthrodesis. J Orthop Surg (Hong Kong) 1:2309499017692703Google Scholar
  24. 24.
    Ghanem A, Abduljabbar T, Akram Z, Vohra F, Kellesarian SV, Javed F (2017) A systematic review and meta-analysis of pre-clinical studies assessing the effect of nicotine on osseointegration. Int J Oral Maxillofac Surg 4:496–502CrossRefGoogle Scholar
  25. 25.
    Sherwin MA, Gastwirth CM (1990) Detrimental effects of cigarette smoking on lower extremity wound healing. J Foot Surg 1:84–87Google Scholar
  26. 26.
    Møller AM, Pedersen T, Villebro N, Munksgaard A (2003) Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg Br 2:178–181CrossRefGoogle Scholar
  27. 27.
    Wang A, Powell A (2009) The effects of obesity surgery on bone metabolism: what orthopedic surgeons need to know. Am J Orthop (Belle Mead NJ) 2:77–79Google Scholar
  28. 28.
    Lee RJ, Hsu NN, Lenz CM, Leet AI (2013) Does obesity affect fracture healing in children? Clin Orthop Relat Res 4:1208–1213CrossRefGoogle Scholar
  29. 29.
    Histing T, Andonyan A, Klein M, Scheuer C, Stenger D, Holstein JH et al (2016) Obesity does not affect the healing of femur fractures in mice. Injury 7:1435–1444CrossRefGoogle Scholar
  30. 30.
    Rolfson O, Dahlberg LE, Nilsson JA, Malchau H, Garellick G (2009) Variables determining outcome in total hip replacement surgery. J Bone Joint Surg Br 2:157–161CrossRefGoogle Scholar
  31. 31.
    Guerini F, Morghen S, Lucchi E, Bellelli G, Trabucchi M (2010) Depressive symptoms and one year mortality among elderly patients discharged from a rehabilitation ward after orthopaedic surgery of the lower limbs. Behav Neurol 3:117–121CrossRefGoogle Scholar
  32. 32.
    Klement MR, Bala A, Blizzard DJ, Wellman SS, Bolognesi MP, Seyler TM (2016) Should We Think Twice About Psychiatric Disease in Total Hip Arthroplasty? J Arthroplasty 9(Suppl):221–226CrossRefGoogle Scholar
  33. 33.
    Renner L, Drwal V, Boettner F (2015) [Hip replacement in patients with neuromuscular disorders]. Orthopade 7:546–554CrossRefGoogle Scholar
  34. 34.
    Toennis D (2008) Hüftdysplasie—was ist bei der dreifachen Beckenosteotomie zu beachten? pp 564–569Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of OrthopedicsKlinikum Dortmund-MitteDortmundGermany
  2. 2.Swedish Neuroscience InstituteSwedish Medical CenterSeattleUSA
  3. 3.Department of Trauma Surgery, BG University Hospital BergmannsheilRuhr University BochumBochumGermany
  4. 4.Spectrum Research, IncTacomaUSA

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