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Ganz Osteotomy for DDH

- See: DDH

- Discussion:
    - indicated for residual dysplasias in adolescents and young adults;
    - allows both anterior and lateral rotation as well as medialization of the hip;
    - can expect good improvement in the center edge angle (avg correction of 31 deg);
    - does not change the diameter of the true pelvis (allows for subsequent child birth);
    - posterior column of the hemipelvis is not violated, which allows minimal internal fixation and early mobilization;
    - vascular supply via inferior gluteal artery is maintained;

- Technical Considerations:
    - exposure:
           - ilioinguinal approach or smith peterson approach is typically used;
           - lateral exposure:
                  - abductor musculature should not be violated but tensor fascia lata is elevated from its attachment;
                  - compartment of the tensor fasciae latae is entered and the muscle bluntly dissected off the septum along with the sartorius muscle
                  - superior joint capsule is well exposed and posterior joint and notch is palpated;
                  - subperiosteal dissection of the inner table of the ilium is performed;
                  - protect the lateral femoral cutaneous nerve;
           - medial exposure:
                  - iliacus and sartorius are elevated off their attachments to ASIS and iliac wing;
                  - sartorius may be detached with a thin wafer of bone that will be repaired with suture at the end of the procedure
                  - rectus insertion to the AIIS is elevated and reflected attachment to the capsule is divided;
                  - direct head of the rectus femoris and the underlying capsular portion of the iliacus are elevated as a unit and reflected distally and medially from the underlying joint capsule;
                  - dissection is complete when psoas tendon, pubis, and iliopectoneal line are exposed;
                  - iliacus, sartorius, and abdominal contents are then reflected medially;
                  - sheath of the psoas may be opened longitudinally and its muscle and tendon retracted medially
                  - define gap between the psoas and the joint capsule;
    - osteotomy cuts:
           - partial (incomplete) osteotomy of the ischium;
                  - exposure:
                        - procedes through the space between the psoas tendon and the distal joint capsule;
                        - infracotyloid groove (posterior inferior rim of the acetabulum) is palpated
                        - cautions: obturator artery is medial and medial femoral circumflex artery is postero-lateral;
                  - flouro is used to direct chisel placement;
                  - angled chisel is inserted through space between psoas tendon and distal joint capsule, and then chisel  is applied against infracotyloid groove;
                  - chisel is hammered 5-10 mm without attempts to complete the osteotomy;
           - complete osteotomy of the pubis;
                  - assurance is made that soft tissues (including obturator nerve) are protected;
                  - osteotomy is made just in front of the acetabulum;
           - biplanar roof shaped osteotomy of the ilium;
                  - consists of an anterior and posterior limb which form an agle of 110-120 deg (appex superior);
                  - inner and outer borders of the ilium are scored with an osteotome;
                  - be aware of the potential for a large intra-osseous artery which may require hemostasis with bone wax;
                  - anterior limb:
                        - osteotmy procedes superior to the AIIS
                        - extends to the posterior margin of the capsule;
                  - posterior limb:
                        - is directed toward to the ischial spine (do not enter into the joint or sciatic notch);
                        - outline the osteotomy along the inner and outer iliac tables;
                        - only the first 15 mm needs to be fully osteotomized;
    - correction of deformity:
           - half pin is inserted anteriorly through the supra-acetabular fragment without entering into the joint;
           - completion of triple osteotomy;
                  - quadrilateral surface is exposed down to obturator foramen;
                  - osteotome is inserted approx 4 cm below the pelvic brim and is impacted until fracture is completed through the infra-cotyloid groove;
           - acetabular fragment is rotated anterior and laterally (maintaining anteversion) and is then medialized;
           - acetabular fragment is secured with three long cortical 4.5-mm screws;
    - closure:
           - AIIS is removed and can be used as bone graft into the anterior gap of the transverse osteotomy;
           - repair the sartorius and rectus femoris muscle origins;

  - Complications:
    - intra-articular fracture
    - femoral nerve palsy
    - nonunion
    - ectopic bone formation

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