Bowen-A New Modified Technique of Triple Osteotomy

CLINICAL ORTHOPAEDICS AND RELATED RESEARCH

Number434,pp.78–85

©2005Lippincott Williams&Wilkins

A New Modified Technique of Triple Osteotomy of the

Innominate Bone for Acetabular Dysplasia

Glenn E.Lipton,MD*;and J.Richard Bowen,MD*†

A new modified technique of triple osteotomy of the innomi-

nate bone has been devised and implemented for the treat-

ment of residual acetabular dysplasia in children with devel-opmental dysplasia of the hip.The procedure is done through a two-incision approach.The ischium,pubis,and iliac bones are osteotomized,with resection of a triangular wedge of bone from the outer cortex of the proximal part of the ilium.The resection of the triangular wedge of bone from the outer cortex alone creates a slot with the intact inner cortex serving as a stabilizing abutment where the distal posterior aspect of the ilium fits.This osteotomy allows for extensive coverage of the femoral head with greater stability. The stable construct of the osteotomy and pelvic fixation facilitates early weight bearing and obviates the need for hip spica cast immobilization.Since its conception the new triple osteotomy has been done in11children(13hips).The pre-operative vertical center edge angle of Weiberg was8.9°(range,5°–17°).The postoperative vertical center edge angle was a mean of45.6°(range,31°–58°).The last followup vertical center edge angle was a mean of44.9°(range,29°–58°).The mean preoperative acetabular angle of Sharp was 53°(range,48°–61°).The postoperative acetabular angle was a mean of25.4°(range,19°–40°).The last followup ac-etabular angle was a mean of28°(range,18°–41°).All pa-tients went on to have bony unions on their innominate bone.We describe the technique for the osteotomy and presents preliminary results of all patients who had the procedure.Guidelines for Authors for a complete description of levels

of evidence.

Persistent acetabular dysplasia and hip subluxation in chil-dren leads to arthritis of the hip.7,17,19,20The treatment of acetabular dysplasia and hip subluxation remain challeng-ing because the normal biomechanical relationships in the

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hip have been altered.If after conservative treatment there continues to be residual symptomatic subluxation and/or acetabular dysplasia,surgical treatments must be considered.The goals of surgery are to reorient the bio-mechanical relationships such that the development of de-generative hip disease is delayed or prevented.To achieve these goals various pelvic osteotomies have been used. Reshaping osteotomies,such as the Pemberton and Dega osteotomies,reshape the acetabulum in order to restore the normal biomechanical relationship between the femoral head and acetabulum in children with open triradiate car-tilage.1,10,11The problems with the reshaping osteotomies are that they primarily are indicated for the capacious ac-etabulum(Pemberton)and they only provide lateral or posterior acetabular coverage when doing the osteotomies (Dega).1,3,10,11

Redirectional osteotomies,including the single innomi-nate Salter osteotomy and the triple innominate Steel os-teotomy,shift the position of acetabulum to a position that gives improved coverage of the femoral head with out changing the shape of the acetabulum.The Salter osteotomy is a single innominate osteotomy used to treat deficiencies of the acetabulum that cause failure of cov-erage of the anterolateral femoral head.A triangular wedge of bone from the iliac crest is placed and fixed in the osteotomy site(Fig1).This procedure has best results when done in children up to4years old13,14and shouldn’t be done after age7because of the pubic symphysis closure that limits mobility of the fragment.Therefore,the Salter osteotomy is limited in that its best results are seen in children younger than4years with anterolateral acetabular deficiencies.

Level of Evidence:Diagnostic study,Level IV(case-control

study—no control or historical control group).See the

From the*Department of Orthopaedic Surgery,Drexel University College of Medicine,Philadelphia,PA and the†Alfred I.duPont Hospital for Children, Wilmington,DE.

Each author certifies that his institution has approved the human protocol for this investigation,that all investigations were conducted in conformity with ethical principles of research,and that informed consent was obtained.

No funding or other financial support has been received by either of the authors or by the institution.Each author certifies that he has no commercial associations that might pose a conflict of interest in connection with the

submitted article.

Correspondence to:J.Richard Bowen,MD,Department of Orthopaedics, The Alfred I.duPont Hospital for Children,P.O.Box269,Wilmington, DE19899.Phone:302-651-5723;Fax:302-651-5951;E-mail:jrbowen@

The Steel osteotomy is a triple osteotomy of the in-nominate bone which consists of a Salter osteotomy with additional osteotomies of the ischium and the pubis(Fig 2).Although this osteotomy allows for great ability to

DOI:10.1097/01.blo.0000163484.93211.94

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