Ganzosteotomy Description and indications. Dr. Jaak Roos - A.Z. Turnhout

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1 Ganzosteotomy Description and indications Dr. Jaak Roos - A.Z. Turnhout

2 Welcome

3 Turnhout Flanders Cultural Capital 2012 Turnhout: Stad van m n hert

4 Hip Dysplasia Natural history of HD without subluxation: 40-50% OA before 50 y. 50% THA before 60 y. LCE-angle < 16 Acetabular index > 15 End-stage 0A Natural history of HD with subluxation: ALL develop OA during 2-3 decade of life

5 o 55 y. untreated hip dysplasia

6 Hip Dysplasia Insufficient coverage of the femoral head by a too small acetabulum High loads at the acetabular roof Maloriented steep acetabular roof instability and migration of the femoral head increase of load and shear stress at the acetabular rim Labral hypertrophy to maintain stability failure labral soft tissue compensation: Tear

7 Hip Dysplasia Goal of surgery: alter the natural course Goal of pelvic osteotomy : increase the weigth bearing surface transform shearing forces into compressive forces

8 Pelvic Osteotomy Coverage of the femoral head can be increased by: Augmentation of the acetabular roof Changing the spatial orientation

9 Augmentation Procedures Reduction of the joint-loading forces by augmenting the weigth-bearing area. Chiari-Osteotomy Shelf Procedure

10 Chiari Osteotomy

11 Shelf Procedure

12 Augmentation Procedures Can provide pain relief for some years Should be regarded as salvage procedures

13 Reorienting Procedures Change the orientation of the acetabular articular surface Correct the area of deficiency Provide a greater surface area for load transmission reestablish or maintain joint stability Procedures: single, double, triple, spheric and periacetabular osteotomies

14 Single Pelvic Osteotomy: Salter osteotomy Children Limited correction in adults Retroversion Lateralisation

15 Double, Triple Pelvic Osteotomies Sutherland, Carlioz, Steel, Tönnis... Limited range of displacement Narrow the pelvic concavity Create a pelvic discontinuity Substantial internal fixation

16 Spheric Acetabular Osteotomy Good lateral and anterior correction Medialization is difficult Osteotomy runs intraarticular Vascularity No simultaneous Capsulotomy

17 Spheric Acetabular Osteotomy Good lateral and anterior correction Medialization is difficult Osteotomy runs intraarticular Vascularity No simultaneous Capsulotomy

18 Spheric Acetabular Osteotomy Good lateral and anterior correction Medialization is difficult Osteotomy runs intraarticular Vascularity No simultaneous Capsulotomy

19 Ganz Periacetabular Osteotomy Based on: Mechanical considerations Biological considerations Limitations of the previous techniques

20 Ganz Periacetabular Osteotomy Single incision Juxta-articular/Polygonal Posterior column intact

21 Ganz Periacetabular Osteotomy Extensive reorientation version mediolateral Unchanged dimension of the true pelvis Anterior capsulotomy

22 Blood Supply Acetabulum The acetabular bllood supply: implications for periacetabular osteotomies. M. Beck, M. Leunig, T. Ellis, J.B. Sledge, R. Ganz Surg Radiol Anat (2003) 25:

23 Blood Supply Acetabular Fragment The acetabular bllood supply: implications for periacetabular osteotomies. M. Beck, M. Leunig, T. Ellis, J.B. Sledge, R. Ganz Surg Radiol Anat (2003) 25:

24 Indications can be a difficult subject in the practical clinical situation ideal case is easy marginal cases sometimes difficult

25 Typical case Female about 30 years old No knowledge of childhood problems Gradual pain increase Recent acute pain increase locking or hip going out

26 Acetabular Rim Fracture

27 Basic Indications Acetabular dysplasia Triradiate cartilage closure Presence of joint space Mobile hip Pain

28 Acetabular Dysplasia

29 Lateral center edge angle

30 Acetabular Dysplasia

31 Acetabular Dysplasia

32 Basic Indications Acetabular dysplasia Triradiate cartilage closure Presence of joint space Mobile hip Pain

33 The patient should derive at least 10 years of benefit

34 Osteoarthritis?

35 Osteoarthritis? Tönnis Classification grade 0: grade 1: Grade 2: Grade 3: No signs of OA increased sclerosis, slight J.S. narrowing, no or slight loss of head sfericity small cysts, moderate J.S. narrowing, moderate loss of head sphericity Large cysts, severe J.S. narrowing, severe deformity of the head

36 Osteoarthritis? Tönnis Classification grade 0: grade 1: Grade 2: Grade 3: No signs of OA increased sclerosis, slight J.S. narrowing, no or slight loss of head sfericity small cysts, moderate J.S. narrowing, moderate loss of head sphericity Large cysts, severe J.S. narrowing, severe deformity of the head

37 Most important arthritic sign is cartilage space narrowing

38 A Lot of PAO candidates have some evidence of OA

39 Ideal Candidate Normal joint space Minimal arthritic changes Congruent joint Spherical femoral head Good congruence on the abduction view

40 Abduction View

41 Probable Candidate Joint slightly narrowed Congruence and joint space good on the abduction view

42 Possible Candidate Joint narrowed Improved congruence and joint space on the abduction view

43 Indication varies with age Under 30: Push the indication Over 45: more hesitant

44 Indication varies with the patient

45 Indication varies with the patient

46 Other indications Retroversion secondary dysplasia: e.g. perthes disease... selected cases of protrusio acetabuli after acetabulumfracture to fix the bone...

47 to fix the bone

48 Contraindications Open triradiate cartilage Marked Cephalad dislocation Secondary acetabulum with fibrocartilage (OA with a Tönnis grade > 1)

49 How urgent is the surgery? Typically a 2-year window of opportunity Recommendation: surgery within 6 months Varies with individual cases

50 Bilateral PAO?

51 Bilateral PAO? No indication for bilateral PAO Danger of separating the anterior pelvic ring from the posterior pelvic ring in case of a fracture.

52 Conclusion beautiful surgery effective surgery difficult surgery steep learning curve

53 Many thanks! to my mentor, my friend Minne Heeg

54 Dr. Eric Vanlommel: Dus...niet elke ganz is een vogel!

55 Thank You

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