Transiliac Osteotomy Research Articles

Long-term outcomes of reconstructive treatment for painful dislocations in patients with cerebral palsy.

This report presents the long-term results of the hip joint reconstruction in patients with spastic hip disease through open reduction, proximal femur varus derotation osteotomy, and Dega transiliac osteotomy. We analyzed retrospectively patients diagnosed with a spastic form of bilateral cerebral palsy with painful hip subluxation or dislocation. All patients underwent the same surgical procedure. The minimum follow-up time was 15 years. The study group comprised 15 patients (22 hips), classified with the Gross Motor Function Classification System as levels IV and V. The hip joint range of motion and anteroposterior X-ray examination at the final follow-up visit were compared with pre-operative data. The pain level was evaluated using the Visual Analogue Scale (VAS), and the femoral head shape was assessed using the Rutz classification. The patients' caregivers answered questions regarding pain during sitting, personal hygiene activities, and at rest. The caregivers' satisfaction with the treatment was also assessed with the Caregiver Priorities and Child Health Index of Life with Disabilities questionnaire. We observed a significant reduction of the hip joint pain and improvement in both radiological hip stability parameters and range of motion at the final follow-up visit. Based on the Rutz classification, one hip remained type B, while the other joints became type A. Reduced pain was reported in all three positions, with the most pronounced improvement during sitting and personal hygiene activities. Interestingly, patients with unilateral hip reconstruction were more prone to pain after reconstruction than those operated bilaterally. Primary reconstruction of the painful hip joint neurogenic dislocation results in a stable joint reduction, pain decrease, and improved quality of life in patients with cerebral palsy. IV case series.

Léčení dislokované kyčle u DMO extraartikulární intervencí

PURPOSE OF THE STUDY Hip dislocation is one of the major causes of disability in children with cerebral palsy (CP). Surgical treatment can be achieved using different techniques including proximal femoral varus derotation osteotomy (FVDRO), pelvic osteotomies, and open hip reduction (OHR). However, we claim that pathologies originating from extraarticular structures in the dislocated hip in CP can be reconstructed by extraarticular methods and OHR may not always be necessary. Therefore, this study aims to discuss the results of hip reconstruction with extraarticular intervention in patients with CP. MATERIAL AND METHODS In total, 141 hips (95 patients) were included in the study. All patients underwent FVDRO, either with or without a Dega osteotomy. Changes in the Acetabular Index (AI), Migration Index (MI), neck-shaft angle (NSA), and center-edge angle (CEA) were assessed on the preoperative, postoperative, and final follow-up anterior-posterior radiographs of the pelvis. RESULTS Median age was 8 years (range between 4-18 years). The average follow-up duration was 5 years (range between 2-9 years). Changes in AI, MI, NSA and CEA values were statistically significant for postop and follow-up periods when compared to preoperative values. Of the 141 operated hips, 8 (5.6%) hips required revision surgery due to redislocation/resubluxation detected at the follow-ups, and unilateral operation can be accepted as a risk factor for redislocation. CONCLUSIONS Our results demonstrate that reconstructive treatment consisting of FVDRO, medial capsulotomy (in the case of reduction difficulty) and transiliac osteotomy (in the case of acetabular dysplasia) provides satisfactory outcomes in hip dislocation in CP. Key words: hip displacement, cerebral palsy, hip reduction.

Classics. Transiliac osteotomy in the treatment of congenital dysplasia of the hip

The author is presenting his experience in surgical reconstruction of the dysplastic acetabular roof. The reconstruction is combined with a simultaneous reduction of the subluxed hip. This method was under the author’s elaboration since 1927 and it was named by him as transiliac osteotomy in 1958. Detailed surgical technique is described.

Operative treatment of paralytic hip dislocation in myelomeningocele by Dega transiliac osteotomy combined with iliopsoas transfer: technique and historical case series.

The technique of one stage procedure - open reduction, Dega transiliac with or without femoral subtrochanteric osteotomy combined with iliopsoas transfer according to Mustard - has been described for the treatment of paralytic dislocation of the hip in myelomeningocele patients. Historical series of 16 children (26 hips) operated on between 1987 and 2003 were analyzed retrospectively. There were nine boys and seven girls with upper and lower lumbar level lesions (15 with Sharrard groups 3 and 4 and one with Sharrard 2) and 20 dislocated and six subluxated hips. The mean age at operation was 5.1 years (3-12.3). Ten children were operated bilaterally. Follow-up ranged from 1 to 17 years (mean 10). Concentric reduction was achieved in 23 hips, subluxation in 1 and redislocation in 2. In one hip, acute avascular necrosis of the femoral head was visible early after operation. Immediately after the operation, most of the patients improved ambulation. After operation, 15 patients out of 16 became community ambulators. At the final follow-up, none of the patients worsened their ambulation due to operation. Open reduction and Dega transiliac osteotomy with or without subtrochanteric derotation/varus shortening osteotomy combined with iliopsoas transfer seem to be safe and valuable procedure for operative treatment of dislocated hip in myelomeningocele patients. Levels of evidence: level IV - case series.

The significance of the Dega osteotomy.

Wiktor Dega has significantly impacted contemporary pediatric orthopedics by developing transiliac osteotomy - Dega's pelvic osteotomy. The global implementation of the surgery technique gained dynamism in the 2000s after being published by Ward and Grudziak. Since then, derivative operative techniques called Dega, Dega-like or Dega family osteotomies have been developed. We analyzed the original articles published by Dega between 1929 and 1974 concerning transiliac osteotomy technique development and articles about its derivatives. The epidemiological significance of developmental hip dysplasia focused Wiktor Dega's attention in the 1920s. At that time, he treated patients according to König's idea of acetabular roof plastic surgery. The osteotomy depth gradually increased, which allowed deeper graft placement to perform what we nowadays call acetabuloplasty. In 1958, Dega coined the name 'supraacetabular semicircular osteotomy'. It differed from the final concept of the transiliac osteotomy by not assuming the cut of the inner cortex of the iliac bone. The hinge for the acetabular rotation was located at the inner cortex's whole length, disallowing the excessive redirection. The final concept of osteotomy allows for simultaneous acetabuloplasty and redirection to change the shape, location and acetabular volume. Dega derivatives are Mubarak (San Diego) and high Dega osteotomies. Dega osteotomy and its derivates are routinely implemented to treat developmental hip dysplasia and spastic hip disorders. It might be considered an option in Legg-Calve-Perthes disease, congenital deficiencies, and flaccid hip displacement in neurological conditions.

More than 20 years of experience with Dega transiliac osteotomy in the treatment of dislocated hip joints in children with cerebral palsy.

Cerebral palsy in children, which is the result of a nonprogressing damage to the central nervous system, causes motor and posture disorders that change with age. The level of child activity correlates with the hip dislocation risk. It most often affects nonwalking patients and those with tetraparesis or oblique pelvis. The aim of the study was to assess the effectiveness and clinical value of Dega pelvic osteotomy with accompanying directional femoral bone osteotomy after minimum of 20 years from surgery of patients with cerebral palsy. The conducted research was retrospective and concerned the children operated at our Hospital. The assessment was carried out in 346 children with spastic hip during the years 1993-2000. The inclusion criteria were applied: unilateral dislocation of the hip, the observation period of at least 20 years, pelvic osteotomy by Dega method and combined with varus derotation femur osteotomy. The analysis involved fifteen patients. The follow-up period was minimum 20 years (20-27 years). The average migration percentage decreased from 88% down to 25%, and an improved range of mobility was observed in the operated joint after surgery. However, the range of mobility was again significantly reduced during the last control examination after a minimum of 20 years. In all hips, the degenerative joint disease was present. Pelvic transiliac osteotomy, according to Dega, with VDRO, ensures very effective correction of the deficit in femoral head coverage by the acetabulum in the upper, lateral and posterior parts. However, it does not prevent the development of the early degenerative disease of the joint.

Dega Transiliac Pelvic Osteotomy: the History of Surgical Technique Development

Wiktor Dega originally described the surgical technique of transiliac osteotomy in 1969 in the Polish Orthopaedics and Trauma Surgery Journal. Its worldwide popularity spread just after it was presented in English by Grudziak and Ward in 2001 [1]. This paper aims to describe the development of the technique by Wiktor Dega's team. An analysis of original papers published by Dega between 1929-1974 was performed to clarify the chronology of development of the technique. Dega's interest in developmental dysplasia of the hip (DDH) had begun as early as 1929, when he presented in Vilnius a paper about the aetiology and pathogenesis of the disease. The concept of transiliac osteotomy had been initially based on König's idea of shelf procedure. Dega called this procedure plastic surgery of the acetabular roof and performed it between 1927 and 1930. In 1964, Dega published a paper that described the basic concept of DDH treatment with a pelvic osteotomy termed supraacetabular semi-circular osteotomy. This procedure differed from transiliac osteotomy because it did not involve cutting the inner cortex of the ilium. In 1968 the first 'technically proper' transiliac osteotomy was performed and then described in 1969. In 1974, Dega emphasized that both the outer and inner iliac walls should be osteotomized in the transiliac osteotomy. The political situation of the 1950s and the 1960s made it difficult to freely exchange views and clinical experiences between the Western and Eastern political camps. Despite this, Wiktor Dega became a precursor of effective surgical treatment in DDH worldwide.

Surgical reconstruction of hip subluxation and dislocation in children with cerebral palsy.

This study aims to review the efficacy of femoral varus derotation osteotomy (VDRO) and Dega transiliac osteotomy in the treatment of hip subluxation and dislocation of cerebral palsy (CP) patients. This retrospective study included 25 hips of 22 CP patients (9 males, 13 females; mean age 8.7 years; range 4 to 18 years) who were operated due to hip subluxation and dislocation between July 2010 and December 2015. The mean follow-up period was 36.1±10.4 months (range, 20 to 65.6 months). Femoral VDRO and Dega transiliac osteotomy were performed in all cases. None of the patients were administered cast immobilization postoperatively. Patients were evaluated clinically with gross motor function classification system preoperatively and at the follow-up period. Acetabular index (AI), migration percentage (MP), and neck-shaft angle (NSA) were measured and documented by pelvic radiographs taken pre- and postoperatively and at the follow-up period. Intra- and postoperative complications were recorded. Gross motor function classification system scores improved in 16 patients. Mean AI was 33.2° preoperatively and 20.4° postoperatively. In preoperative period, MP and NSA were 72.7% and 160°, respectively, which improved to 24.3% and 130°, respectively, postoperatively. The postoperative improvement in AI, NSA and MP were statistically significant (p<0.001). We performed revision surgery due to implant failure in two patients and detected hip subluxation due to increased pelvic obliquity in one patient who had thoracolumbar scoliosis. In CP patients, reconstruction of hip subluxation and dislocation with femoral VDRO and Dega transiliac osteotomy establish femoroacetabular congruency. Without any cast immobilization, early physical therapy is encouraged for immediate recovery.

Anterior stabilization of sacroiliac disruption through transiliac osteotomy

Background Sacroiliac joint diastases from high-energy trauma are always complicated by pain and disability. Open reduction and anterior stabilization with a plate are biomechanically advanced because of direct reduction and stabilization. We report our experience of managing 15 patients with sacroiliac disruption by anterior double plates. The purpose of this study was to evaluate the effectiveness of anterior pelvic plating for these complicated fractures. Patients and methods This study included 15 patients who sustained sacroiliac disruption from January 2008 to March 2012 at Menoufia University Hospital. All patients were treated by anterior double plates through an anterolateral approach with transiliac osteotomy. All patients were males. Results The average age was 34 years with a range of 20–49 years. The mean follow-up period was 20 months with a range of 12–36 months. The average healing period was 16 weeks. The clinical results according to the Coles pelvic score revealed 12 cases of satisfactory (five of excellent and seven of good) and three cases of unsatisfactory results (two fair and one poor). Conclusion Posterior injuries, especially sacroiliac disruptions, affect the long-term outcome significantly; therefore, an anterior approach would allow adequate exploration and the reduction can be confirmed. Double plates allow rigid fixation. Bone-to-bone healing of osteotomy revealed decreased risk of wound complications.

Transiliac Osteotomy in Surgical Management of Pelvic Post-Traumatic Malunions: A Retrospective Study.

While uncommon, post-traumatic pelvic malunions present reconstructive challenges and are associated with significant disability and financial burden. A transiliac osteotomy is a surgical technique useful to correct certain types of pelvic fracture malunions, and is only used when the correction of a limb-length discrepancy is the primary goal. This study aims to present our experience with this technique in the treatment of post-traumatic pelvic malunions.Eight patients who underwent transiliac osteotomies for post-traumatic pelvic malunions at our department from 2006 to 2011 were included in this study. We reviewed the clinical and radiographic results of these patients.By the time of their last follow-up, all osteotomy sites and iliac bone graft had healed with no evidence of internal fixation failure. Of the 3 patients who complained of preoperative posterior pain, 2 reported an improvement. All 8 patients noted the resolution of their lower back pain. At the time of their final follow-up, 4 patients could walk normally, 2 had a slight limp without a cane, 1 patient used a cane to help with standing and walking, and the final felt limited during ambulation with a cane. Limb-lengthening relative to preoperative measurements was 2.86 cm (2.2–3.0 cm) at the time of the last follow-up. Two patients were able to return to their previous jobs, 4 patients changed their jobs or engaged in light manual labor while the final 2 were able to perform activities of daily living but were unable to participate in work or labor. Three patients reported being “extremely satisfied” with their outcomes, 3 were “satisfied,” and 2 were “unsatisfied.”A transiliac osteotomy can be used to manage selected cases of post-traumatic pelvic malunions that are unable to be corrected with a traditional release and osteotomy. However, in these cases the correction of limb-length discrepancies should be the primary reconstructive goal.

Malunion of pelvic fracture: reconstruction with transiliac osteotomy

Objective To evaluate transiliac osteotomy for treatment of malunion of pelvic fracture. Methods From January 2005 to December 2012, 9 patients with malunion of pelvic fracture were treated in our department. They were 5 men and 4 women, 22 to 35 years of age (average, 27.0 years). According to the Tile classification, 3 cases were C1.1, 4 C1.2, and 2 C2. The mean leg length discrepancy in all patients was 4.3 cm shorter (from 3.5 to 5.2 cm). All patients complained about hip pain, limited motion and lameness more or less. The mean time from injury to surgery was 6.2 months (from 3.5 to 11.0 months). They were treated with transiliac osteotomy, bone grafting and double steel plating. Visual analogue scale (VAS) and Majeed evaluation system were used to assess functional recovery. Complications were recorded at the follow-up. Results All cases were followed up for an average duration of 29 months (from 11 to 40 months). Last follow-ups showed that the Majeed scores increased from 45.7 points (from 42 to 56 points) preoperatively to 85.3 points (from 78 to 91 points) postoperatively. The preoperative VAS scores of 6.1 points (from 4 to 8 points) decreased to 1.6 points (from 0 to 3 points) at last follow-ups. According to the pelvic X-ray films, the limbs were lengthened by an average of 3.6 cm (from 3.3 cm to 4.0 cm). Postoperative complications included deep venous thrombosis in one case and cystic mass at the affected thigh in another. No infection, fixation failure, iatrogenic nerve or vessel injury was recorded. Conclusion Transiliac osteotomy can be an effective surgical strategy to treat malunion of pelvic fracture, because it can correct pelvic deformity, lengthen the limb and rebuild stability of the pelvic ring, leading to fine functional recovery and good clinical results. Key words: Pelvis; Fractures, bone; Fractures fixation, internal; Osteotomy; Malunion

Incomplete Transiliac Osteotomy in Skeletally Mature Adolescents with Cerebral Palsy

Incomplete transiliac osteotomy is commonly used in the surgical treatment of spastic hip disease in children with cerebral palsy. The osteotomy hinges through an intact sciatic notch and an open triradiate cartilage. We asked whether incomplete transiliac osteotomy, combined with varus osteotomy of the femur and soft tissue reconstruction, performed after skeletal maturity could improve hip coverage and acetabular shape and provide pain relief in patients with spastic hip disease. We retrospectively evaluated 27 consecutive adolescent patients (33 hips) with cerebral palsy in whom an incomplete transiliac osteotomy was performed after closure of the triradiate cartilage. The mean age at surgery was 15 years. Five hips were dislocated and 28 hips were subluxated preoperatively. The minimum followup was 2 years (mean, 3.3 years; range, 2 years-7.5 years). The subluxated hips had a minimum Reimers' migration index of 23% (mean, 52%; range, 23-95%), which was reduced to 0% (mean, 7%; range, 0-39%) at followup. The minimum preoperative Sharp's angle was 34 degrees (mean, 52 degrees ; range, 34 degrees -70 degrees ), which was reduced to 20 degrees (mean, 35 degrees ; range, 20 degrees -50 degrees ) at followup. A painless hip was achieved in 26 of 33 hips at followup. An incomplete transiliac osteotomy can be performed after skeletal maturity, resulting in a painless and stable hip in the majority of patients.

Simultaneous Open Reduction and Dega Transiliac Osteotomy for Developmental Dislocation of the Hip in Children Under 24 Months of Age

The authors studied retrospectively 33 hips in 26 children at an average of 9 years 5 months after simultaneous open reduction and Dega transiliac osteotomy for developmental dislocation of the hip (DDH). All children were younger than 2 years of life at surgery. At the latest follow-up 89% of the clinical results and 72% of the radiographic results were rated excellent or good, despite a 45% rate of avascular necrosis observed before surgery. The authors attempted to identify factors influencing the final result. Given the low complication rate (3%) and low reoperation rate (3%), the authors conclude that the reviewed surgical protocol is safe and efficient in the treatment of DDH in young children.

Long-term results after open reduction of developmental hip dislocation by an anterior approach lateral and medial of the iliopsoas muscle

The technique of and especially the approach to open reduction of developmental dislocation of the hip are still a matter of discussion. The anterior approach, first lateral and then medial to the iliopsoas muscle, was described by Tonnis in 1978. A follow-up investigation to adulthood has now been performed. Eighty-seven children (118 hips) out of 105 children (83%) who underwent open reduction of developmental dislocation of the hip before the age of 4 years were reinvestigated 10-21 years after the operation. An anterior approach first lateral, then medial to the iliopsoas muscle was chosen, because this offers the best access to the joint. Additional operations including transiliac osteotomy for acetabuloplasty, shortening osteotomy, and femoral osteotomies were performed as necessary. In 92 (78%) of the 118 hips studied the CE angle exceeded 25 degrees and in 98 hips (83%) the VCA angle exceeded 25 degrees. Critical CE angles between 20 and 25 degrees were found in 14% of the hips, and critical VCA angles in 4%. Residual dysplasia (<20 degrees) was found in 8 and 13% of the hips, respectively. Avascular necrosis according to Hirohashi was observed after operation in grade 1 in 5.9% and grade 2 in 1.7%. No necrosis was found following shortening osteotomy of the proximal femur. The anterior approach, first lateral, then medial to the iliopsoas muscle, offers an optimal access to the medial parts of the joint with control of reduction, protects the vasculature of the femoral neck, and allows simultaneous postero-lateral capsulorrhaphy and pelvic osteotomies.

Dega osteotomy for the treatment of congenital dysplasia of the hip.

In 1969 Dega described a transiliac osteotomy to treat residual acetabular dysplasia secondary to congenital hip dysplasia or dislocation. We were unable to find a thorough description of the technique in the English-language orthopaedic literature, and the number of clinical follow-up series is small. Twenty-two children (twenty-four hips) with an average age of five years and ten months and varying degrees of congenital hip dysplasia, subluxation, or dislocation were treated with a Dega osteotomy. Twenty hips (83%) had a concomitant femoral osteotomy and thirteen (54%) had an anterior open reduction of the hip in addition to the Dega osteotomy. To be included in the study group, each patient had to have complete clinical documentation of the range of motion, presence or absence of a limp, limb-length discrepancy, hip pain, and limitation of activity. Radiographs were reviewed to determine the acetabular index, the center-edge angle, whether the Shenton line was intact or broken, and any change in the projection of the obturator foramen. At an average of fifty-five months postoperatively, all patients demonstrated unlimited physical activity and no limp. The average acetabular index changed from 33 degrees preoperatively to 12 degrees at the time of follow-up. The center-edge angle ranged from less than -30 degrees to 18 degrees preoperatively and from 18 degrees to 40 degrees (average, 31 degrees) at the time of follow-up. A change in the obturator foramen was observed in fourteen hips (58%). The Shenton line was broken in seventeen hips preoperatively but in none postoperatively. One Dega osteotomy was revised immediately after the index operation, and three hips underwent late repeat correction of the proximal part of the femur; one of the repeat corrections was performed together with a repeat Dega osteotomy. Our initial experience with the Dega osteotomy demonstrated it to be a valuable surgical treatment of congenital dysplasia of the hip in a child of walking age. Our experience is comparable with that of many European authors, including those reporting studies from Dega's own institution.

Dega's transiliac osteotomy in the treatment of spastic hip subluxation and dislocation in cerebral palsy.

The study presents the long-term results of operative treatment of spastic subluxation and dislocation of hip joints in cerebral palsy children with open reduction and pelvic transiliac osteotomy by Dega. The subjects were 25 patients (30 hips) and the follow-up lasted from 3 to 25 years (average 12 years). Final examinations were carried out after the end of body growth. Detailed analysis covered a patient's function, occurrence and intensity of pain in the hip joint, value of radiological parameters such as angle of centre-edge of the roof after Wiberg (CE), acetabular index (AI), neck-shaft angle (NS) and migration percentage (MP). The final evaluation of radiological results was carried out in accordance with Severin's classification. The clinical and radiological results obtained showed gradual deteriorations in comparison with the early postoperative results (dating from 12 months after surgery). In the final examination, in one patient a recurrent dislocation of the hip joint was diagnosed and subluxation was diagnosed in six patients (23%). Only the values of the CE angle went up (from -16 degrees in the early postoperative examination to 20 degrees in the final assessment), which we consider to be due to the change of sphericity of the head of femur. The remaining radiological parameters did not change significantly: AI from 22 degrees to 23 degrees, MP from 11% to 23%, NS from 133 degrees to 140 degrees. The surgical method presented is currently applied in a modified form, with a wider release within the soft tissues, more radical varusderotation osteotomy and greater shortening of the femur.

„Anteposition des Femurkopfes” nach Chirurgie der angeborenen Hüftgelenkluxation

A new term called "femoral head anteposition" to describe the clinical appearance of a hip operated on because of CDH and suspected of anterior dislocation, has been introduced. CT scans of both the horizontal and sagittal planes of 22 hips suspected of iatrogenic anterior dislocation were made from 22 children. These had been operated on because of CDH by the open reduction method with derotation varus osteotomy of the femur and transiliac osteotomy by Dega. An evaluation of the CT scans combined with clinical examination allowed the differentiation of the homogeneous clinical appearance from the "anteposition". It was then possible to establish one or several coexisting reasons to the situation. These were: anterior dislocation of the hip, coxa magna after avascular necrosis, gluteal muscle fibrosis or periarticular ossifications.