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Clinical Orthopaedics and Related Research®

, Volume 468, Issue 12, pp 3168–3180 | Cite as

Algorithm for Femoral and Periacetabular Osteotomies in Complex Hip Deformities

  • Reinhold Ganz
  • Kevin Horowitz
  • Michael Leunig
Symposium: Papers Presented at the 2009 Closed Meeting of the International Hip Society

Abstract

Background

Residual acetabular dysplasia of the hip in most patients can be corrected by periacetabular osteotomy. However, some patients have intraarticular abnormalities causing insufficient coverage, containment or congruency after periacetabular osteotomy, or extraarticular abnormalities that limit either acetabular correction or hip motion. For these patients, we believe an additional proximal femoral osteotomy can improve coverage, containment, congruency and/or motion.

Purposes

We provide algorithms for (1) identifying patients we believe will benefit from proximal femoral osteotomy, (2) selecting the appropriate osteotomy, and (3) choosing the sequence of these osteotomies.

Methods

Anteroposterior, false-profile and functional radiographs and MR can identify most patients we believe will benefit from periacetabular and femoral osteotomies. Recently described techniques, including relative femoral neck lengthening, femoral neck osteotomy and femoral head osteotomy have expanded indications for a combined procedure. Historically performed first, periacetabular osteotomy is now frequently performed following femoral osteotomy.

Results

The rate of intertrochanteric osteotomy performed with periacetabular osteotomy has decreased from approximately 10% in the first 500 surgeries to about 2% currently. Among 151 relative neck lengthenings (23 with PAO), 53 femoral neck osteotomies (4 with PAO) and 14 femoral head osteotomies (11 with PAO), eleven complications occurred including osteonecrosis in two and delayed unions in eight. No complication occurred following a combined procedure.

Conclusion

Although isolated periacetabular osteotomy can provide sufficient coverage, containment and congruency for most patients with residual hip dysplasia, some may benefit from an additional proximal femoral osteotomy. Knowing the appropriate indications, selection, and sequencing of these osteotomies is critical for enhancing patient outcomes.

Level of Evidence

Level V, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Keywords

Femoral Head Acetabular Index Periacetabular Osteotomy Intertrochanteric Osteotomy Medial Femoral Circumflex Artery 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Aronson J. Osteoarthritis of the young adult hip: etiology and treatment. Instr Course Lect. 1986;35:119–128.PubMedGoogle Scholar
  2. 2.
    Boos N, Krushell R, Ganz R, Muller ME. Total hip arthroplasty after previous proximal femoral osteotomy. J Bone Joint Surg Br. 1997;79:247–253.CrossRefPubMedGoogle Scholar
  3. 3.
    Clohisy JC, Barrett SE, Gordon JE, Delgado ED, Schoenecker PL. Periacetabular osteotomy for the treatment of severe acetabular dysplasia. J Bone Joint Surg Am. 2005;87:254–259.CrossRefPubMedGoogle Scholar
  4. 4.
    Clohisy JC, Nunley RM, Curry MC, Schoenecker PL. Periacetabular osteotomy for the treatment of acetabular dysplasia associated with major aspherical femoral head deformities. J Bone Joint Surg Am. 2007;89:1417–1423.CrossRefPubMedGoogle Scholar
  5. 5.
    Clohisy JC, St John LC, Nunley RM, Schutz AL, Schoenecker PL. Combined periacetabular and femoral osteotomies for severe hip deformities. Clin Orthop Relat Res. 2009;467:2221–2227.CrossRefPubMedGoogle Scholar
  6. 6.
    Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N, Berlemann U. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br. 2001;83:1119–1124.CrossRefPubMedGoogle Scholar
  7. 7.
    Ganz R, Huff TW, Leunig M. Extended retinacular soft-tissue flap for intra-articular hip surgery: surgical technique, indications, and results of application. Instr Course Lect. 2009;58:241–255.PubMedGoogle Scholar
  8. 8.
    Ganz R, Klaue K, Vinh TS, Mast JW. A new periacetabular osteotomy for the treatment of hip dysplasias. Technique and preliminary results. Clin Orthop Relat Res. 1988;232:26–36.PubMedGoogle Scholar
  9. 9.
    Ganz R, MacDonald SJ. Indications and modern techniques of proximal femoral osteotomies in the adult. Sem Arthroplasty. 1997;8:38–50.Google Scholar
  10. 10.
    Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;417:112–120.PubMedGoogle Scholar
  11. 11.
    Haverkamp D, de Jong PT, Marti RK. Intertrochanteric osteotomies do not impair long-term outcome of subsequent cemented total hip arthroplasties. Clin Orthop Relat Res. 2006;444:154–160.CrossRefPubMedGoogle Scholar
  12. 12.
    Hersche O, Casillas M, Ganz R. Indications for intertrochanteric osteotomy after periacetabular osteotomy for adult hip dysplasia. Clin Orthop Relat Res. 1998;347:19–26.CrossRefPubMedGoogle Scholar
  13. 13.
    Kalhor M, Beck M, Huff TW, Ganz R. Capsular and pericapsular contributions to acetabular and femoral head perfusion. J Bone Joint Surg Am. 2009;91:409–418.CrossRefPubMedGoogle Scholar
  14. 14.
    Leunig M, Puloski S, Beck M, Siebenrock K, Ganz R. Proximal femoral osteotomy: Current indications and techniques. Sem Arthroplasty. 2005;16:53–62.CrossRefGoogle Scholar
  15. 15.
    Leunig M, Rothenfluh D, Beck M, Nork SE, Gautier E, Kerboull M, Ganz R. Surgical dislocation and periacetabular osteotomy through a posterolateral approach: a cadaveric feasibility study and intial clinical experience. Oper Tech Orthop. 2004;14:49–57.CrossRefGoogle Scholar
  16. 16.
    Leunig M, Siebenrock KA, Ganz R. Rationale of periacetabular osteotomy and background work. Instr Course Lect. 2001;50:229–238.PubMedGoogle Scholar
  17. 17.
    Matta JM, Stover MD, Siebenrock K. Periacetabular osteotomy through the Smith-Petersen approach. Clin Orthop Relat Res. 1999;363:21–32.PubMedGoogle Scholar
  18. 18.
    Mayo KA, Trumble SJ, Mast JW. Results of periacetabular osteotomy in patients with previous surgery for hip dysplasia. Clin Orthop Relat Res. 1999;363:73–80.CrossRefPubMedGoogle Scholar
  19. 19.
    Miller NH, Krishnan SG, Kamaric E, Noble PC. Long-term results of the dial osteotomy in the treatment of high-grade acetabular dysplasia. Clin Orthop Relat Res. 2005;433:115–123.CrossRefPubMedGoogle Scholar
  20. 20.
    Millis MB, Kain M, Sierra R, Trousdale R, Taunton MJ, Kim YJ, Rosenfeld SB, Kamath G, Schoenecker P, Clohisy JC. Periacetabular osteotomy for acetabular dysplasia in patients older than 40 years: a preliminary study. Clin Orthop Relat Res. 2009;467:2228–2234.CrossRefPubMedGoogle Scholar
  21. 21.
    Millis MB, Murphy SB, Poss R. Osteotomies about the hip for the prevention and treatment of osteoarthrosis. Instr Course Lect. 1996;45:209–226.PubMedGoogle Scholar
  22. 22.
    Murphy SB, Millis MB. Periacetabular osteotomy without abductor dissection using direct anterior exposure. Clin Orthop Relat Res. 1999;364:92–98.CrossRefPubMedGoogle Scholar
  23. 23.
    Myers SR, Eijer H, Ganz R. Anterior femoroacetabular impingement after periacetabular osteotomy. Clin Orthop Relat Res. 1999;363:93–99.CrossRefPubMedGoogle Scholar
  24. 24.
    Ninomiya S, Tagawa H. Rotational acetabular osteotomy for the dysplastic hip. J Bone Joint Surg Am. 1984;66:430–436.PubMedGoogle Scholar
  25. 25.
    Notzli HP, Wyss TF, Stoecklin CH, Schmid MR, Treiber K, Hodler J. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br. 2002;84:556–560.CrossRefPubMedGoogle Scholar
  26. 26.
    Poss R. Intertrochanteric osteotomy in osteoarthritis of the hip. Instr Course Lect. 1986;35:129–143.PubMedGoogle Scholar
  27. 27.
    Rebello G, Spencer S, Millis MB, Kim YJ. Surgical dislocation in the management of pediatric and adolescent hip deformity. Clin Orthop Relat Res. 2009;467:724–731.CrossRefPubMedGoogle Scholar
  28. 28.
    Santore RF, Turgeon TR, Phillips WF, III, Kantor SR. Pelvic and femoral osteotomy in the treatment of hip disease in the young adult. Instr Course Lect. 2006;55:131–144.PubMedGoogle Scholar
  29. 29.
    Schatzker J. The intertrochnateric osteotomy. Berlin: Springer Verlag; 1984.Google Scholar
  30. 30.
    Siebenrock KA, Leunig M, Ganz R. Periacetabular osteotomy: the Bernese experience. Instr Course Lect. 2001;50:239–245.PubMedGoogle Scholar
  31. 31.
    Siebenrock KA, Scholl E, Lottenbach M, Ganz R. Bernese periacetabular osteotomy. Clin Orthop Relat Res. 1999;363:9–20.CrossRefPubMedGoogle Scholar
  32. 32.
    Steel HH. Triple osteotomy of the innominate bone. J Bone Joint Surg Am. 1973;55:343–350.PubMedGoogle Scholar
  33. 33.
    Steppacher SD, Tannast M, Ganz R, Siebenrock KA. Mean 20-year followup of Bernese periacetabular osteotomy. Clin Orthop Relat Res. 2008;466:1633–1644.CrossRefPubMedGoogle Scholar
  34. 34.
    Sutherland DH, Greenfield R. Double innominate osteotomy. J Bone Joint Surg Am. 1977;59:1082–1091.PubMedGoogle Scholar
  35. 35.
    Tönnis D. Congenital Dysplasia and Dislocation of the Hip in Children and Adults. New York, NY: Springer; 1987.Google Scholar
  36. 36.
    Tönnis D, Itoh K, Heinecke A, Behrens K. The management of congenital hip luxation with arthrographic control, an individual risk-reducing and time-saving method. I. Choice of method and risk assessment based on arthrographic findings [in German]. Z Orthop Ihre Grenzgeb. 1984;122:50–61.CrossRefPubMedGoogle Scholar
  37. 37.
    Tönnis D, Kasperczyk W. Acetabulum reorientation osteotomies: acetabuloplasty, spherical osteotomy, triple osteotomy of the pelvis. In: Reynolds D, Freeman M, eds. Osteoarthritis in the Young Adult Hip. Edinburgh, Scotland: Churchill Livingstone; 1989:85–119.Google Scholar
  38. 38.
    Trousdale RT, Ekkernkamp A, Ganz R, Wallrichs SL. Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips. J Bone Joint Surg Am. 1995;77:73–85.PubMedGoogle Scholar
  39. 39.
    Turgeon TR, Phillips W, Kantor SR, Santore RF. The role of acetabular and femoral osteotomies in reconstructive surgery of the hip: 2005 and beyond. Clin Orthop Relat Res. 2005;441:188–199.CrossRefPubMedGoogle Scholar
  40. 40.
    Wagner H. Femoral osteotomies for congenital hip dislocation. In: Weil UH, ed. Acetabular Dysplasia, Skeletal Dysplasias in Childhood. Vol 2. Berlin, Germany: Springer-Verlag; 1978:85–105.Google Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2010

Authors and Affiliations

  • Reinhold Ganz
    • 1
  • Kevin Horowitz
    • 2
  • Michael Leunig
    • 1
    • 2
  1. 1.University of BerneBerneSwitzerland
  2. 2.Department of OrthopedicsSchulthess ClinicZurichSwitzerland

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