Osteotomies around the hip

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The aim of an osteotomy is to realign the weight bearing surfaces of the joint to allow normal areas to articulate, moving the abnormal area away from the weight bearing axis. 

= reduce point loading & improve congruity.

This can be achieved by either performing a proximal femoral osteotomy or pelvic osteotomy (or both)

Proximal femoral osteotomy increases blood flow to the femoral head & neck & increases venous drainage.

For early disease results of 80-90% relief of pain.

Success rates = 70% over 11 years follow-up

However, conversion to THR can be difficult due to alignment of femur & metalwork which can be difficult to remove.

 Indications

  1. Reserved for young patients with advanced degenerative changes in whom THR is not wise

  2. Non-union of a femoral neck fracture

  3. Dysplasia (varus osteotomy)

  4. Post-Perthes hinge abduction (valgus extension osteotomy)

  5. SCFE (flexion osteotomy)

  6. AVN (flexion osteotomy)

  7. Idiopathic protrusio (valgus extension osteotomy)

Clinical

  • Pain in certain hip positions only (e.g. adduction WBing)

  • Arc of Movement – which part of the arc is painful

  • Leg lengths (effect of FFD)

Planning

  • Careful pre-operative planning required to find the position in which there is least pain and the joint is congruent

  • Femoral osteotomiesFor varus osteotomy must have >15deg. abduction preop. Femoral osteotomies

  • For Valgus osteotomy must have >15deg. adduction preop.

  • AP and lateral X-rays are taken in adduction/abduction

  • Berne or Faux profile view (WBing 25deg. profile) – shows anterior uncovering.

  • CT or MR can give additional information

  • Best results are in young, non obese patients with a good range of motion (minimum 90º flexion, 15º abduction/adduction)

  • Femoral osteotomy may distort the anatomy which may jeopardise a future THR

  • Need to determine:

    1. The amount & direction of correction

    2. choice of implant

Varus Osteotomy

  • generally indicated where lateral subluxation is associated with coxa valga.

  • Require good range of abduction prior to surgery.

  • Relaxes adductors, abductors & flexors.

  • Disadv- shortens leg.

  • must have >15deg. abduction preop

Valgus Osteotomy

  • Indic: 

    1. uncovered head made worse by abducting hip

    2. deformed head with lateral osteophyte (post Perthes)

    3. fixed adduction deformity

  • can add lateral displacement of greater trochanter to reduce hip joint reaction forces

  • must have >15deg. adduction preop.

Contraindications:

  1. Stiff

  2. Obese

  3. Gross narrowing with sclerosis & no normal joint surface

  4. Atrophic inflammatory features

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