Osteotomy

The term Osteotomy, in practice, refers to reshaping a bone. When the pelvic side of
the socket is repaired, it is called pelvic osteotomy. There are several different
types of pelvic osteotomy and the choice depends on the shape of the socket and the
surgeons experience. When the upper end of the thigh bone is re-shaped, this is
called femoral osteotomy.
Each of these procedures may be done alone, in combination, or together with a
reduction. Children older than 2 years almost always need all three procedures to
make the hip stable and return it to a more normal shape.
An arthrogram (x-ray dye injected into the hip joint) at the beginning of the surgery
can help the surgeon decide exactly what needs to be corrected. Whether one or all
three procedures are performed, the recovery time is about the same.
The child is usually in the hospital for 2 or 3 nights and in a body cast for 6-8 weeks.
That is generally followed by bracing full-time or part-time for another 6-12 weeks.
For some osteotomy procedures, pins and plates are used. They are removed after
the bone is healed. That may range from eight weeks for the pelvis to one year for
the femur. Typically, they can be removed after a few months, but up to three years
after surgery.

Pelvic Osteotomy
Some examples of pelvic osteotomy surgeries used to treat hip dysplasia in young
children are the Dega osteotomy and Salter (Innominate) osteotomy.

Dega Osteotomy

The Dega osteotomy hinges the acetabulum (the socket) down over the head of the
femur (thigh bone). This is done when the socket is too wide and too shallow. The
socket sometimes gets worn down on the edge of the socket when the head of the
femur rubs on the edge of the socket from being partly out of the joint. This
osteotomy can help restore that worn down area of shallow socket. A similar
procedure to the Dega osteotomy is the Pemberton osteotomy, which has a slightly
different final orientation of the socket.

Salter (Innominate) Osteotomy

The Salter osteotomy is often performed when the socket doesnt sit on top of the
ball at the top of the thigh bone (femoral head). The pelvic bone is cut and the entire
socket is rotated into a better position on top of the femoral head after the hip is
reduced into the socket.
Bones in young children can bend for this to happen and then they remodel after the
socket is stable. This does not interfere with the size of the pelvis later in life. In these
cases, the socket is round and may even be smaller than the femoral head, but the
socket hasnt developed properly and needs to be shifted so it can support the hip
better.
This type of abnormal shape of the socket may be more common when the hip has
never been in the socket and hasnt rubbed on the edge of the socket.

Femoral Osteotomy
Femoral osteotomy is done when the upper end of the thigh bone needs to be tipped
so the ball points deeper into the socket. This is sometimes called a Varus Derotational Osteotomy (VDO or VDRO). The thigh bone often needs to be shortened
when the hip is dislocated high above the socket. This allows the ball to be lowered
down to the level of the socket without stretching the entire leg and all the soft
tissues like muscles and nerves.
When there is a high dislocation and this isnt done, then there may be increased risk
of redislocation and increased risk of damage to the growth of the hip. Surprisingly,
shortening the bone actually stimulates growth of the leg so the shortening is almost
always temporary as long as the hip stays in the joint and does not develop growth
disturbance from AVN.

Varus osteotomy of the femur

This osteotomy tips the hip into the socket and redirects the forces toward the middle
of the socket instead of toward the outer edge of the socket. The before and after
illustrations show how the forces on the hip joint are redirected by the osteotomy

Combined Osteotomy
This is a more common procedure in children older than 18 months. One advantage
of the bigger procedure is that all the elements of hip dysplasia are corrected
surgically so that the time in the cast is actually less than waiting for natural growth
to help restore the joint to normal. However, the bigger procedure itself should not be
the first choice when less invasive methods might work as well in the long run.

Open Reduction, Pelvic Osteotomy, Femoral Shortening and Varus

Osteotomy