Ganzosteotomy Description and indications Dr. Jaak Roos - A.Z. Turnhout
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Turnhout Flanders Cultural Capital 2012 Turnhout: Stad van m n hert
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
o 55 y. untreated hip dysplasia
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
Hip Dysplasia Goal of surgery: alter the natural course Goal of pelvic osteotomy : increase the weigth bearing surface transform shearing forces into compressive forces
Pelvic Osteotomy Coverage of the femoral head can be increased by: Augmentation of the acetabular roof Changing the spatial orientation
Augmentation Procedures Reduction of the joint-loading forces by augmenting the weigth-bearing area. Chiari-Osteotomy Shelf Procedure
Chiari Osteotomy
Shelf Procedure
Augmentation Procedures Can provide pain relief for some years Should be regarded as salvage procedures
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
Single Pelvic Osteotomy: Salter osteotomy Children Limited correction in adults Retroversion Lateralisation
Double, Triple Pelvic Osteotomies Sutherland, Carlioz, Steel, Tönnis... Limited range of displacement Narrow the pelvic concavity Create a pelvic discontinuity Substantial internal fixation
Spheric Acetabular Osteotomy Good lateral and anterior correction Medialization is difficult Osteotomy runs intraarticular Vascularity No simultaneous Capsulotomy
Spheric Acetabular Osteotomy Good lateral and anterior correction Medialization is difficult Osteotomy runs intraarticular Vascularity No simultaneous Capsulotomy
Spheric Acetabular Osteotomy Good lateral and anterior correction Medialization is difficult Osteotomy runs intraarticular Vascularity No simultaneous Capsulotomy
Ganz Periacetabular Osteotomy Based on: Mechanical considerations Biological considerations Limitations of the previous techniques
Ganz Periacetabular Osteotomy Single incision Juxta-articular/Polygonal Posterior column intact
Ganz Periacetabular Osteotomy Extensive reorientation version mediolateral Unchanged dimension of the true pelvis Anterior capsulotomy
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: 361 367
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: 361 367 4
Indications can be a difficult subject in the practical clinical situation ideal case is easy marginal cases sometimes difficult
Typical case Female about 30 years old No knowledge of childhood problems Gradual pain increase Recent acute pain increase locking or hip going out
Acetabular Rim Fracture
Basic Indications Acetabular dysplasia Triradiate cartilage closure Presence of joint space Mobile hip Pain
Acetabular Dysplasia
Lateral center edge angle
Acetabular Dysplasia
Acetabular Dysplasia
Basic Indications Acetabular dysplasia Triradiate cartilage closure Presence of joint space Mobile hip Pain
The patient should derive at least 10 years of benefit
Osteoarthritis?
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
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
Most important arthritic sign is cartilage space narrowing
A Lot of PAO candidates have some evidence of OA
Ideal Candidate Normal joint space Minimal arthritic changes Congruent joint Spherical femoral head Good congruence on the abduction view
Abduction View
Probable Candidate Joint slightly narrowed Congruence and joint space good on the abduction view
Possible Candidate Joint narrowed Improved congruence and joint space on the abduction view
Indication varies with age Under 30: Push the indication Over 45: more hesitant
Indication varies with the patient
Indication varies with the patient
Other indications Retroversion secondary dysplasia: e.g. perthes disease... selected cases of protrusio acetabuli after acetabulumfracture to fix the bone...
to fix the bone
Contraindications Open triradiate cartilage Marked Cephalad dislocation Secondary acetabulum with fibrocartilage (OA with a Tönnis grade > 1)
How urgent is the surgery? Typically a 2-year window of opportunity Recommendation: surgery within 6 months Varies with individual cases
Bilateral PAO?
Bilateral PAO? No indication for bilateral PAO Danger of separating the anterior pelvic ring from the posterior pelvic ring in case of a fracture.
Conclusion beautiful surgery effective surgery difficult surgery steep learning curve
Many thanks! to my mentor, my friend Minne Heeg
Dr. Eric Vanlommel: Dus...niet elke ganz is een vogel!
Thank You