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A Modified Approach In The Triple Pelvic Osteotomy

Introduction. Salter osteotomy remains the gold standard surgical treatment for DDH in children younger than 5 years of age. As children grow older, rotation of the acetabular fragment and the degree of coverage achieved by Salter osteotomy become less due to stiffness of the symphysis pubis.. In

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A Modified Approach In The Triple Pelvic Osteotomy

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    2. Introduction Salter osteotomy remains the gold standard surgical treatment for DDH in children younger than 5 years of age. As children grow older, rotation of the acetabular fragment and the degree of coverage achieved by Salter osteotomy become less due to stiffness of the symphysis pubis.

    3. Introduction When higher degrees of coverage are needed in elder children, double (Sutherland) and triple (Steel) osteotomies can be used. Osteotomizing the iliac, pubic and ischial bones allows free rotation of the acetabular fragment in all planes. Is this a true statement?

    4. Triple Pelvic Osteotomy The Steel triple pelvic osteotomy remains fraught with technical difficulties in approaching the ischium from the prone position, yet performing the iliac osteotomy from an anterior approach in the supine position, is technically demanding.

    5. Triple Pelvic Osteotomy The almost percutaneous triple pelvic osteotomy allows approaching the iliac bone from an anterior incision, and the pubic and ischial bones from an adductor incision; both in the supine position.

    6. Triple Pelvic Osteotomy

    10. Triple Pelvic Osteotomy It involves however, osteotomizing the pubic and ischial bones away from the acetabulum. Is this really desirable?

    11. Triple Pelvic Osteotomy

    12. Triple Osteotomy In DDH

    14. Triple Osteotomy In DDH

    17. Triple Osteotomy In Perthes Disease

    21. Quadruple Pelvic Osteotomy This involves osteotomy of the iliac, pubic, ischial bones and of the ischial spine to release the acetabular fragment from the constraint of the sacrospinous ligament. The four osteotomies are juxta-articular. They can be peformed using a single anterior approach.

    22. Quadruple Pelvic Osteotomy The ischium is approached anteriorly, with the hip in flexion, through the space between the capsule and psoas tendon anteriorly, and the obturator externus posteriorly.

    23. Quadruple Pelvic Osteotomy A curved chisel is introduced through this space to access the ischium, just above the ischial tuberosity.

    24. Quadruple Pelvic Osteotomy The ischial spine is accessed by mobilizing the acetabular fragment externally (after the iliac, pubic and ischial osteotomies are done) as if opening a book. With this superior view, the ischial spine is easy to access at the inner iliac wing.

    25. Quadruple Pelvic Osteotomy The post-operative x-ray of a 13 year old boy showing the osteotomy of the ischial spine (arrow).

    26. Quadruple Pelvic Osteotomy This osteotomy allows full mobilization of the acetabular fragment to achieve adequate coverage anteriorly and laterally, without external rotation in the transverse plane (produced by conventional figure-of-four maneuveres) which leads to acetabular retroversion. It also avoids distal migration of the acetabulum which leads to limb lengthening.

    27. Quadruple Pelvic Osteotomy Pre-op x-ray of a 2 year old girl with DDH.

    28. Quadruple Pelvic Osteotomy The most two observed complications include: The risk of sciatic nerve injury with the anterior approach to the ischium. Increased risk of ischial non-union (with greater defect at the osteotomy site with the greater allowable mobilization of the acetabular fragment.

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