[Hip arthroplasty after pelvic and femoral osteotomies]. / Hüftendoprothetik nach Osteotomien des Beckens und des proximalen Femurs.

Pelvic and femoral osteotomies can be a challenge even for experienced orthopedic surgeons. Residual metal may complicate the insertion of the endoprosthesis in some cases. Sometimes, the anatomical modification of the previous osteotomy complicates the total hip replacement. This may require the use of an acetabular revision system for the primary implantation. Femoral deformities can require additional osteotomies of the femur during the implantation. In every case, accurate preoperative planning should be performed. A preoperative CT with 3D reconstruction is a powerful tool for further information beyond conventional imaging.

[Tönnis and Kalchschmidt triple pelvic osteotomy]. / Die 3­fache Beckenosteotomie nach Tönnis u. Kalchschmidt.

BACKGROUND: The Tönnis and Kalchschmidt triple pelvic osteotomy (TPO) has been performed at the Klinikum Dortmund for more than 30 years. In more than 5000 cases the TPO has proven its potential to deal with even severe dysplastic hips. TPO can be easily combined with other hip procedures as intertrochanteric osteotomies and even impingement treatment can easily be done. As an elaborate technique TPO respects the growth plates and can therefore also be used for treating Legg-Calve-Perthes disease. PROCEDURE: In most cases only conventional X­rays are needed for proving the indication. Further imaging like MRI or CT-scans are only needed in certain cases. In addition EOS® is becoming an increasingly useful tool in planning and performing the surgery. For adequate movement of the acetabulum, three clearly defined osteotomies are needed. Current osteosynthesis methods provide an enhanced stability due to a novel technique of screw fixation. This is in line with the general trends towards short hospitalization and early mobilization. THERAPY: A successful treatment requires not only experience in performing the surgical technique, but furthermore an experienced team, including care, physical examination and also pain management. The surgeon should be aware that he is performing highly elective surgery and complications or a poor outcome can significantly reduce the quality of life of the mainly young patients.

[Intertrochanteric femoral osteotomy : Indications, surgical technique, results]. / Die intertrochantäre Femurosteotomie : Indikationen, Operationstechnik, Ergebnisse.

BACKGROUND: Intertrochanteric osteotomies are part of joint-preserving hip surgery. Indications involve not only the mature but also the growing skeleton. After identification of the causative pathologies multidimensional corrections with the aim of a better joint situation and prevention of early osteoarthritis are possible. METHODS: The surgical technique of intertrochanteric osteotomies is presented. Potential indications are discussed on the basis of results in the literature. RESULTS: In the surgical treatment of developmental dysplasia of the hip intertrochanteric osteotomies are used as additional surgery. In Perthes disease the containment is improved while the onset of osteoarthritis in epiphysis capitis femoris can be decelerated. Treatment of torsion pathologies is reliable. Avascular necrosis of the femoral head and beginning osteoarthritis are critical indications. CONCLUSION: For appropriate indications intertrochanteric osteotomies are a valuable element in joint-preserving surgery with very good long-term results.

[Tönnis and Kalchschmidt triple pelvic osteotomy]. / Dreifache Beckenosteotomie nach Tönnis und Kalchschmidt.

OBJECTIVE: With three precise osteotomies it is possible to move the acetabulum to achieve sufficient coverage in dysplastic hips. INDICATIONS: Main indication is a painful dysplastic hip. Other acetabular pathologies, such as retroversion can also be addressed. In recent years young patients with Legg-Calve-Perthes disease CONTRAINDICATIONS: Patients with an arthrosis (Tönnis level 2) and obesity often have poor results. Therefore the combination of these parameters should be seen as a contraindication. SURGICAL TECHNIQUE: The operation starts with the patient in a lateral decubitus position. The first incision is parallel to the sacrotuberal ligament. The gluteus maximus muscle is spread until the ligament itself with its bony connection at the tuber ischiadicum is visible. After putting two special retractors in the foramen obturatorium and one to the spina ischiadica, osteotomy of the os ischium is performed from the incisura ischiadica to the foramen obturatorium. For the next osteotomy the os pubis is approached and it should be performed subperiostally. The vasa and nervus obturatorius and femoralis should be protected. At the os ilium the abdominal muscles are separated from the iliac crest. The third osteotomy has a 90° angle and starts at the linea terminalis and leads just below the spina iliaca anterior superior iliac spine. The acetabulum can now be moved with a Schanz screw. At this point it is necessary to elevate the os pubis while moving the acetabulum laterally. This prevents a lateralization and reduces the distance at the iliac osteotomy. The osteosynthesis is performed with screws at the os ilium and also at the os pubis. POSTOPERATIVE MANAGEMENT: Patients are advised to avoid weight bearing for 12 weeks. In the first 6 weeks they are allowed to perform a maximum flexion of 60°. RESULTS: According to the Harris hip score 80.4 % of the patients showed good and very good results after 11.5 years. In cases with arthrosis and obesity a higher rate of poor results were found.

[Joint preserving surgery of the adult hip: pelvic osteotomies]. / Gelenkerhaltende Hüftchirurgie im Erwachsenenalter: Beckenosteotomien.

Deformity and malposition of the acetabulum can occur during the development of the hip. Developmental hip dysplasia and acetabular retroversion are possible causes of osteoarthritis in the young adult. Surgical management with reorientation of the acetabulum allows causal therapy of the deformity and preservation of the native hip joint. Established techniques are the Bernese periacetabular osteotomy (PAO) and the Tönnis and Kalchschmidt triple osteotomy of the pelvis. Both techniques permit three-dimensional correction of the position of the acetabulum. Advantages and disadvantages of each technique must be considered and are summarized in the present paper. If performed early (osteoarthritis grade Tönnis 0 and 1) with correct indication and proper technique, good results can be expected.

[Complications after hip operations]. / Komplikationen nach Hüftoperationen.

From 1999 to 2008, according to a prospective and sequential compilation of data, the 12,590 hip operations (11,059 in adults and 1,531 in children) performed in our hospital showed a postoperative complication rate of 4.96% (5.2% in adults and 1.96% in children). The most frequent complications were 110 thromboses (0.87%), which were clinically apparent and proven by Doppler ultrasonography or phlebography; 191 superficial and deep disorders of wound healing (1.5%), including 57 (0.45%) infections; 88 peripheral nerve lesions (0.7%); and 53 hematoma revisions (0.42%). Operation-specific statistics for complications (total hip replacements, revisions, femoral and pelvic osteotomies, hardware removals, and operations in children, including acetabuloplasty, femoral osteotomies, and open reductions) are presented here. Those statistics make it possible to judge and compare method-specific and department-specific risks and their development over time. An open and active attitude when dealing with postoperative complications can cost effectively and efficiently improve treatment results.