Sunday, January 31, 2010

Triple Innominate Osteotomy for DDH video

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Triple Innominate Osteotomy for DDH

 http://orthopedicsvideos.blogspot.com/2010/01/triple-innominate-osteotomy-for-ddh.html

Salter's osteotomy of the innominate bone redirects the entire acetabulum so that its roof “covers” the femoral head anteriorly and superiorly.

Advantages:

- anterolateral coverage of the femoral head, 

- lengthening of the extremity (possibly shortened by the avascular process), and 

- avoidance of a second operation for plate removal. 

Disadvantages:

- inability to obtain proper containment of the femoral head, especially in older children

-  increase in acetabular and hip joint pressure that may cause further avascular changes in the femoral head; and 

- an increase in leg length on the operated side compared with the normal side that may cause a relative adduction of the hip and uncover the femoral head.

Remove a full-thickness graft from the anterior part of the iliac crest, and trim it to the shape of a wedge. Make the base of the wedge about as wide as the distance between the anterior superior and anterior inferior iliac spines











The following are prerequisites for the success of this operation:

   1.    The femoral head must be positioned opposite the level of the acetabulum. This may require a period of traction before surgery or primary femoral shortening.
   2.    Contractures of the iliopsoas and adductor muscles must be released. This is indicated in subluxations and dislocations. Open reduction is performed for hip dislocation, but usually is unnecessary for hip subluxation.
   3.    The femoral head must be reduced into the depth of the true acetabulum completely and concentrically. This generally requires careful open reduction and excision of any soft tissue, exclusive of the labrum, from the acetabulum.
   4.    The joint must be reasonably congruous.
   5.    The range of motion of the hip must be good, especially in abduction, internal rotation, and flexion.
In a cadaver study, Birnbaum et al. identified several structures that are at risk of injury during a Salter innominate osteotomy, as follows:

   1.    The lateral femoral cutaneous nerve may be injured during an anterior approach. Ensuring that the skin including the lateral femoral cutaneous nerve is pulled anteriorly avoids this.
   2.    The nutrient vessels to the tensor fasciae latae muscle can be injured if retraction is too prolonged.
   3.    The sciatic nerve can be crushed or irritated by an inadequate subperiosteal approach during the pull on the Hohmann retractor.
   4.    An inadequate subperiosteal application of the medial Hohmann retractor can damage the obturator nerve.
   5.    Too prolonged retraction of the iliopsoas muscle can cause compression of the femoral nerve.