Osteotomy around hip joint
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osteotomy hip joint preservation
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Osteotomies Around the Hip Joint
The goal of an osteotomy around the hip is to redistribute forces evenly across the joint, eliminating excessive point loading. This is achieved either on the femoral side or the acetabular side, depending on the deformity being corrected. The procedure is ideally suited for a young patient with a good range of motion and little or no degenerative change on imaging.
- Bailey and Love's Short Practice of Surgery 28th Ed., p. 576-577
- Campbell's Operative Orthopaedics 15th Ed. 2026
Classification
Osteotomies around the hip are broadly divided into:
- Femoral osteotomies - correcting abnormalities of the proximal femur
- Pelvic/Acetabular osteotomies - correcting acetabular orientation or coverage
Indications
| Femoral Osteotomy | Periacetabular/Pelvic Osteotomy |
|---|---|
| Perthes' disease | Developmental dysplasia of the hip (DDH) |
| Osteoarthritis (young patient) | Acetabular retroversion (reverse PAO) |
| Slipped capital femoral epiphysis (SCFE) | - |
| Avascular necrosis | - |
I. Femoral Osteotomies
A. Intertrochanteric / Subtrochanteric Osteotomy
Performed at the intertrochanteric region, these can correct:
- Varus (adduction osteotomy) - reduces the neck-shaft angle (e.g., coxa valga)
- Valgus (abduction osteotomy) - increases the neck-shaft angle (e.g., coxa vara)
- Derotation - corrects excessive anteversion or retroversion
- Flexion/Extension - corrects sagittal plane deformities
In cerebral palsy hip subluxation, a varus derotation osteotomy (VDRO) combined with femoral shortening is used to reduce the neck-shaft angle to ~120° in ambulatory patients. It is often done with a concurrent acetabular osteotomy.
B. Proximal Femoral Osteotomy for Osteonecrosis
Various proximal femoral osteotomies (flexion, varus, valgus, rotational) have been developed for osteonecrosis with the intent to move the necrotic segment of the femoral head away from the principal weight-bearing area. Best results are achieved in:
- Small/medium lesions (<30% femoral head involvement)
- Patients younger than 55 years
- Idiopathic or posttraumatic cases (better than alcohol/steroid-induced AVN)
Once collapse begins, the hip progresses to end-stage arthritis and arthroplasty is usually required.
C. Brackett Osteotomy
A specific intertrochanteric osteotomy for correcting biplanar deformities (flexion + adduction). The osteotomy is made convex superiorly and medially, starting at the lateral greater trochanter and ending at the lesser trochanter-neck junction. Abduction of the distal fragment corrects the deformity. Advantage: achieves stability without shortening the extremity, though extensive dissection is required.
II. Pelvic (Acetabular) Osteotomies
These are further classified based on whether the acetabulum is redirected (its orientation is changed) or augmented/salvaged (coverage is added without reorientation).
Summary Table (by age/indication)
| Osteotomy | Age | Key Indication |
|---|---|---|
| Salter innominate | 18 months - 6 years | Congruous hip; <10-15° correction of acetabular index needed |
| Pemberton acetabuloplasty | 18 months - 10 years | >10-15° correction needed; small femoral head, large acetabulum |
| Steel triple innominate | Late adolescence (open triradiate cartilage) | Residual acetabular dysplasia, congruous joint |
| Ganz/Bernese PAO | Skeletal maturity (closed triradiate) | Residual dysplasia, congruous joint, symptomatic |
| Shelf / Chiari | Any age; typically older children/adolescents | Incongruous joint; other osteotomies not possible (salvage) |
A. Salter Innominate Osteotomy
Salter observed that in DDH, the entire acetabulum faces more anterolaterally than normal. His osteotomy redirects the entire acetabulum so its roof covers the femoral head anteriorly and superiorly. The cut is made with a Gigli saw from the sciatic notch to just above the anterior inferior iliac spine. The entire acetabulum (with pubis and ischium) rotates as a unit using the symphysis pubis as a hinge. A full-thickness bone wedge from the iliac crest is inserted to hold the correction open anterolaterally.
- Contraindicated in non-concentric hips or severe dysplasia
- Provides mainly anterior and superior coverage
- Postoperative spica cast for 6-8 weeks
B. Pemberton Acetabuloplasty (Pericapsular Osteotomy)
Indicated when more correction (>10-15° of acetabular index) is needed than Salter can provide, or when a small femoral head sits in a large acetabulum. The osteotomy is made through the full thickness of ilium from just above the anterior inferior iliac spine posteriorly to the triradiate cartilage, which acts as a hinge. The acetabular roof is rotated anteriorly and laterally. This procedure decreases the volume of the acetabulum and produces joint incongruity that requires remodeling (unlike Salter). It can only be performed while the triradiate cartilage remains open.
C. Steel Triple Innominate Osteotomy
Cuts through the ischium, superior pubic ramus, and ilium superior to the acetabulum, freeing the acetabulum as a mobile segment with attached articular cartilage. Indicated for older children and adolescents with residual dysplasia when the triradiate cartilage is still open. Can provide more correction than Salter. The Steel procedure is preferred for open triradiate cartilage; the Ganz osteotomy for closed triradiate cartilage.
D. Bernese Periacetabular Osteotomy (PAO) - Ganz
The gold-standard hip-preserving procedure for symptomatic hip dysplasia in skeletally mature adults. It frees the acetabulum via multiple cuts around the acetabulum while preserving the posterior column of the pelvis (maintaining pelvic ring stability). The acetabular fragment is then reoriented to optimize femoral head coverage.
Surgical approach: The original technique used a Smith-Petersen approach. A modified abductor-sparing variant (Murphy-Millis) or a rectus-sparing approach (for patients without cam deformity or labral pathology) may also be used. A bikini-type skin incision can be used in thin females for cosmesis.
Outcomes: At 11-year follow-up, good-to-excellent results with no evidence of OA were reported (Siebenrock et al.). Longer-term studies show hip preservation rates of 73-76% at >9 years, 60% at 20 years, and 29% at 30 years. After PAO, if varus deformity of the proximal femur develops causing impingement, a secondary proximal femoral valgus osteotomy may be needed.
PAO is also used (reverse PAO) for acetabular retroversion, where the acetabulum is rotated in the opposite direction (anteverting the acetabulum to treat pincer-type femoroacetabular impingement).
E. Shelf Procedure (Staheli)
An augmentation (non-redirectional) procedure. An extra-articular shelf of bone is added to the lateral edge of the acetabulum, providing additional coverage. Indicated at any age when the joint is incongruous or when redirectional osteotomies are not feasible. The shelf acts as a load-bearing extension of the acetabular roof.
F. Chiari Medial Displacement Osteotomy
A salvage procedure. The osteotomy is made through the ilium just above the joint capsule, and the distal fragment (containing the hip joint) is displaced medially. The cut surface of the proximal fragment then acts as a roof, but because there is no articular cartilage, the intervening joint capsule undergoes fibrocartilaginous metaplasia to serve as the new articulating surface. Indicated in incongruous joints where better options are not available.
III. Combined Pelvic + Femoral Osteotomy
In older children with both femoral and acetabular abnormalities, a combined pelvic and varus femoral osteotomy may be required to address both deformities simultaneously, such as in DDH with associated high neck-shaft angle, or in cerebral palsy with combined coxa valga + acetabular dysplasia.
Preoperative Planning
Thorough preoperative planning is essential. Increasingly:
- 3D CT scans are used for planning
- 3D printing is used to understand the deformity
- Computer navigation and robotics are emerging adjuncts for accurate correction
The desired correction must be simulated preoperatively to confirm it is achievable.
Key Principles Summary
| Principle | Detail |
|---|---|
| Best candidate | Young patient, good ROM, minimal/no OA |
| Goal | Redistribute joint forces, delay arthroplasty |
| Femoral osteotomy | Corrects neck-shaft angle, anteversion |
| Redirectional acetabular osteotomy | Reorients acetabulum (Salter, Pemberton, Steel, Ganz PAO) |
| Salvage osteotomy | Adds coverage without true reorientation (Shelf, Chiari) |
| Fixation | Internal fixation (blades, plates, screws) + cast in children |
Sources: Bailey and Love's Short Practice of Surgery 28th Ed., p. 576-577; Campbell's Operative Orthopaedics 15th Ed. 2026, Chapters 7, 12, 13, 15; Miller's Review of Orthopaedics 9th Ed.
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