U.S. patent application number 09/764173 was filed with the patent office on 2002-07-18 for innominate osteotomy.
Invention is credited to Yoon, Taek-Rim.
Application Number | 20020092532 09/764173 |
Document ID | / |
Family ID | 25069885 |
Filed Date | 2002-07-18 |
United States Patent
Application |
20020092532 |
Kind Code |
A1 |
Yoon, Taek-Rim |
July 18, 2002 |
INNOMINATE OSTEOTOMY
Abstract
This invention provides a surgical method to treat hip diseases,
including Legg-Calve-Perthes disease or developmental hip
dysplasia. This method includes several surgical techniques: a
transverse osteotomy of the posterior portion of supraacetabular
portion, an oblique and inclined osteotomy of the anterior portion
of the supraacetabulum, detachment of a bone block from iliac
crest, anterolateral displacement of the distal fragment, and
insertion of the bone block into the distracted space of the
osteotomy site.
Inventors: |
Yoon, Taek-Rim; (Kwangju,
KR) |
Correspondence
Address: |
Merchant & Gould P.C.
P.O. Box 2903
Minneapolis
MN
55402-0903
US
|
Family ID: |
25069885 |
Appl. No.: |
09/764173 |
Filed: |
January 17, 2001 |
Current U.S.
Class: |
128/898 |
Current CPC
Class: |
A61B 2017/564 20130101;
A61B 17/58 20130101 |
Class at
Publication: |
128/898 |
International
Class: |
A61B 019/00 |
Claims
What is claimed is:
1. A method of treating a disease of a hip, said hip comprising an
ilium having a proximal section and a distal section, an iliac
crest, and a subpraacetabular ilium having a medial and a lateral
surface, comprising: surgically accessing the hip; making a
transverse cut that extends from a first location at the medial
surface of the supraacetabular ilium to a second location up to
halfway between the medial surface and the lateral surface the
supraacetabular ilium; making an oblique cut extending from the
transverse cut towards the iliac crest, such that the oblique cut
and the transverse cut define an opening between the proximal
section and the distal section; rotating the distal section of the
hip anteriorly, laterally and inferiorly; obtaining a bone graft;
enlarging the opening defined by the transverse cut and the oblique
cut; inserting the bone graft into the opening defined by the
transverse cut and the oblique cut; and surgically closing access
to the hip.
2. The method of claim 1, wherein the step of obtaining the bone
graft comprises surgically detaching a bone graft from the proximal
section of the ilium.
3. The method of claim 1, wherein the hip diseases is selected from
the group consisting of Legg-Calve-Perthes disease, developmental
hip dysplasia, and hip dislocation.
4. The method of claim 1, further comprising a step of securing the
bone graft to the proximal and distal section of the ilium with at
least one fastening member.
5. The method of claim 4, wherein the fastening member is
biodegradable.
6. The method of claim 4, wherein the fastening member is selected
from the group consisting of a screw, pin, staple and wire.
7. The method of claim 1, wherein the oblique cut extends in an
oblique direction on a coronal plane with an inclined direction
posterioinferiorly on a saggital plane.
8. The method of claim 1, wherein the oblique cut extends from the
second location between the medial surface and the lateral surface
the supraacetabular ilium.
9. The method of claim 1, wherein the step of making a transverse
cut comprises making a cut with a Gigli saw or a reciprocal
saw.
10. The method of claim 1, wherein the step of making an oblique
cut comprises making a cut with a Gigli saw or a reciprocal
saw.
11. The method of claim 1, wherein the bone graft is surgically
detached from the iliac crest.
12. The method of claim 1, wherein the bone graft is substantially
shaped like a wedge or a truncated wedge.
13. The method of claim 12, wherein the bone graft is triangular or
trapezoidal in shape.
Description
BACKGROUND OF THE INVENTION
[0001] A. Field of the Invention
[0002] The invention relates to a surgical method of treating hip
diseases. More specifically, the invention provides an innominate
osteomy for treating diseases such as Legg-Calve-Perthes Disease,
developmental hip dysplasia, or hip dislocation.
[0003] B. Description of the Prior Art
[0004] Legg-Calve-Perthes disease is a self-limiting hip disorder
caused by a varying degree of ischemia and subsequent necrosis of
the femoral head. Signs of the disorder include avascular necrosis
of the proximal femoral epiphysis nucleus, abnormal growth of the
physis, and eventual remodeling of regenerated bone. Typically,
avascular necrosis of the femoral epiphysis results in delayed
occific nucleus. Articular cartilage is nourished by synovial fluid
and continues to grow. Consequently, cartilage columns become
distorted with some loss of cellular components and do not undergo
normal ossification. This results in an excess of calcified
cartilage in the primary trabecular bone. Symptoms occur with
subchondral collapse and fracture.
[0005] The incidence of Legg-Calve-Perthes disease is generally
greater in males than females with a male to female ratio is 4-5 to
1. Generally, Legg-Calve-Perthes disease is found in young boys (4
to 8 years old) with delayed skeletal maturity. The age at which
treatment is initiated appears to be the key to a good prognosis.
If detected and treated after 8 years of age, the prognosis tends
to be poor.
[0006] Developmental hip dysplasia involves displacement of the
femoral head from the acetabulum, which disrupts the normal
development of the hip joint. Developmental hip dysplasia is
estimated to occur in 1-1.5 cases per 1000 live births and includes
a wide spectrum of abnormalities ranging from simple hip
instability with capsular laxity to complete displacement of the
femoral head from an anomalous acetabular socket. Thus, the term
dysplasia includes a developmental abnormality of the hip joint in
which the capsule, the proximal femur, and/or the acetabulum are
defective.
[0007] Innominate osteotomy has been used to treat
Legg-Calve-Perthes disease and developmental dysplasia of the hip.
A widely used procedure was developed in 1961 by Robert Salter and
is called a Salter osteotomy or Salter's innominate osteotomy. The
objective of Salters innominate osteotomy is to derotate the
maldirected acetabulum and correct excessive acetabular
antetorsion. Stability is thus improved by providing anatomic
coverage of the femoral head by anterior and superolateral portions
of the acetabulum in the weight bearing position.
[0008] Although successful in many cases, the Salter technique has
many complications, such as loss of fixation with displacement of
the distal fragment, stiffness, and loss of hip flexion. Also the
patient generally requires two operations, one to perform the
osteotomy and a second to remove the metal pins or screws.
SUMMARY OF THE INVENTION
[0009] The present invention provides a surgical method of treating
hip diseases, including Legg-Calve-Perthes Disease, developmental
hip dysplasia, and/or hip dislocation. The method includes a series
of surgical procedures including a transverse osteotomy of the
posterior portion of supraacetabular portion, an oblique and
inclined osteotomy of the anterior portion of the supraacetabulum,
detachment of a bone graft from iliac crest, anterolateral
displacement of a distal section of the ilium, and insertion of the
bone graft into the exposed opening of the osteotomy site.
[0010] The procedure rotates the distal section of the osteotomy
site laterally and anteriorly, increasing coverage of the
acetabulum over the femoral head. The procedure also establishes
better concentric reduction in hips with dysplasia or dislocation.
It also increases coverage of the acetabulum over the femoral head
in hips with Legg-Calve-Perthes diseases to achieve better
stability and remodeling of the femoral head. Additionally, the
technique reduces complications by providing stability without the
use of metal pins or screws. Furthermore, a patient can undergo
rehabilitation earlier than with a Salter osteotomy, in part
because a secondary operation is not necessary.
BRIEF DESCRIPTION OF THE FIGURES
[0011] FIG. 1 is a schematic diagram of an anterior view of a
pelvis.
[0012] FIG. 2 is a schematic of a medial aspect of a right hip
bone.
[0013] FIG. 3 is a schematic diagram illustrating a line of
osteotomy in the conventional method of innominate osteotomy, drawn
in relation to a whole pelvis.
[0014] FIG. 4 is a schematic diagram illustrating a conventional
innominate osteotomy in which a triangular bone fragment is
inserted and fixed with two K-wires.
[0015] FIG. 5 is a schematic diagram illustrating the change in
pelvic shape after conventional innominate osteotomy.
[0016] FIG. 6 is a schematic diagram illustrating the line of
osteotomy in the method of the invention, drawn in relation with a
whole pelvis.
[0017] FIG. 7 is a schematic diagram illustrating the final shape
of the pelvis after the method of the invention in which a
triangular bone fragment is inserted and stabilized without
fixation using K-wires.
[0018] FIG. 8 is a schematic diagram illustrating the change of the
shape of the pelvis after the method of the invention.
DETAILED DESCRIPTION OF THE INVENTION
[0019] The invention provides a surgical method of treating a hip
disease, including Legg-Calve-Perthes Disease, developmental hip
dysplasia, and/or hip dislocation. This method includes a series of
surgical procedures including a transverse osteotomy of the
posterior portion of supraacetabular portion, an oblique and
inclined osteotomy of the anterior portion of the supraacetabulum,
detachment of a bone graft from iliac crest, anterolateral
displacement of the distal fragment, and insertion of the bone
graft into the opening defined by the osteotomy site.
[0020] A. The Pelvis
[0021] To provide a better understanding of the method of the
invention, a brief overview of the anatomy of the pelvis and the
lower limb will be provided.
[0022] FIG. 1 shows an anterior view of a pelvis 1. The pelvis is
formed anteriorly and laterally by a right 2 and left 3 hip bone.
The right 2 and left 3 hip bones are essentially symmetrical and
will not be discussed separately. The hip bones 2, 3 have three
main parts: the ilium 4, ischium 5 and pubis 6. These three parts
meet at the acetabulum 7, the cup shaped cavity in the lateral
surface of the hip bone into which the head 8 of the femur 9 fits
(See FIG. 5).
[0023] As used herein, the term "proximal section 13" of the hip
bone 2, 3 refers to the section of the hip bone 2, 3 that includes
the ilium 4, iliac crest 16, anterior superior iliac spine 15,
posterior superior iliac spine 17, and the anterior inferior iliac
spine 12, among others. The term "distal section 14" of the hip
bone 2, 3 refers to the section of the hip bone 2, 3 that includes
the acetabulum 7 and the ischium 5, among others.
[0024] B. Conventional Osteotomy
[0025] Again, to provide a better understanding of the method of
the invention, a brief overview of Salters innominate osteotomy
will be provided. As shown in FIG. 3, Salters osteotomy is
performed by making a transverse linear cut 10 at a location above
the acetabulum 7, at the level of the greater sciatic notch 11 and
the anterior inferior iliac spine 12. After the transverse linear
cut 10 is made, the distal section 14, including the acetabulum 7,
is tilted inferiorly, anteriorly and laterally by rotating the
distal section 14 around a pivot point at the flexible pubic
symphysis 29. The rotated position of the distal section 14 is
maintained by inserting a bone graft fragment 18 (typically
triangular in shape), taken from the anterosuperior portion of
ilium 13 (near the iliac crest 16 and/or the anterior superior
iliac spine 28), into the opening 24 defined by the transverse
linear cut 10.
[0026] The bone graft 18 is typically secured to the proximal 13
and distal 14 sections by two Kirshner wires 27 that traverse the
proximal 13 section, the graft 18, and the distal section 14.
[0027] The femoral head 8 is thus covered by the hip 2, 3 in normal
weight-bearing positions due to the rotation and redirection of the
acetabulum 7.
[0028] C. The Method of the Invention
[0029] According to the method of the invention, a transverse cut
20 is made starting at a medial surface 30 of the supraacetabular
ilium 19, extending towards the lateral surface 31 of the
supraacetabular ilium 19. Importantly, the transverse cut 20 does
not extend all the way to the lateral surface 31 of the
supraacetabular ilium 19 (i.e., the transverse cut extends only
through a "posterior section" 21 of the supraacetabular ilium 19).
As used herein, the term "medial surface" 30 refers to the surface
of the ilium 4 that is proximal to the superior pelvic aperture 32.
The term "lateral surface" 31 refers to the surface of the ilium 4
that is distal to the superior pelvic aperture 32. "The
supraacetabular ilium 19" refers to the hip bone 2, 3 at a location
superior to the acetabulum 7, and at or inferior to the greater
sciatic notch 11 and/or the anterior inferior iliac spine 12.
According to the invention, the transverse cut 20 preferably
extends from a first location 25 at medial aspect 30 of the
supraacetabular ilium 19 and terminates at a second location 26
between the medial 30 and lateral 31 surface of the ilium 4.
Preferably, the transverse cut 20 terminates prior to reaching the
midpoint between the medial 30 and lateral 31 surface (i.e., the
transverse cut extends up to half way between the medial 30 and
lateral 31 surfaces of the supraacetabular ilium 19). The
transverse cut 20 can be made using any known method, for example,
using a Gigli saw or a reciprocal saw.
[0030] According to the invention, an oblique cut 23 is then made
that extends from the transverse cut 20 towards the anterior
superior iliac spine 28. Generally, the oblique cut 23 extends at
an oblique angle on the coronal plane from a location near or at
the second location 26 (i.e., the termination point of the
transverse cut 20) with an inclined direction posteroinferiorly on
the sagittal plane as shown in FIGS. 6, 7, and 8. The oblique cut
23 can be made using any known method, for example, using a Gigli
saw or a reciprocal saw.
[0031] The opening 24 defined by the transverse cut 20 and the
oblique cut 23 is then enlarged, for example, using a distractor
and stout towel forceps. A bone graft 18, againtaken from the
proximal section 13 (typically the iliac crest 16 and/or the
anterior superior iliac spine 28) of the ilium 4, is inserted into
the opening 24. Preferably, the bone graft 18 is substantially in
the shape of a wedge or a truncated wedge having one end (the major
end 33) that is generally larger than the other end (the minor end
34). For example, the bone graft 18 may be substantially triangular
or trapezoidal in shape. The bone graft 18 is inserted into the
opening 24 defined by the transverse cut 20 and the oblique cut 23
such that the major end 33 is positioned proximal the lateral
surface 31 of the ilium 4 and the minor end 34 is positioned
proximal the medial surface 30 of the ilium 4 (see FIGS. 7 and
8).
[0032] At least one additional fastening member, such as wires,
pins, screws, staples, etc. can be used to secure the bone graft 18
in place. Preferably a biodegradable fastening member, for example,
a biodegradable screw, is used. However, such fastening members are
typically not necessary. The bone graft 18 is generally stable,
without the use of additional fastening members. In this new
technique, the site and direction of the osteotomy is different
than in prior methods. By changing the direction of the osteotomy
(i.e., the transverse and oblique cuts), the method of the
invention provides increased stability, even without fixation with
pins, wires, screws or staples because the oblique cut 23 supports
the bone graft 18 (as shown in FIG. 6).
[0033] The procedure of the invention rotates the distal section 14
of the hip bone 2, 3 laterally and anteriorly, thus increasing
coverage of the acetabulum 7 over the femoral head 8. The procedure
thus establishes better concentric reduction in hips with dysplasia
or dislocation. The procedure also establishes increased coverage
of the acetabulum 7 over the femoral head 8 in patients with
Legg-Calve-Perthes diseases, thus achieving increased stability and
remodeling of the femoral head 8. Additionally, the technique of
the invention reduces complications because metal pins or screws
are not necessary. Furthermore, the patient can undergo
rehabilitation earlier, in part because a secondary operation (to
remove wires, pins, or screws) is not necessary.
[0034] The present method also reduces the incidence of
complications, such as loss of fixation with displacement of the
distal fragment, stiffness, and loss of hip flexion, typically seen
in conventional procedures. Patients do not have to be immobilized
with hip spica cast, as in conventional procedures, to prevent loss
of fixation and displacement of the distal fragment. Additionally,
the present technique is easy to perform and generally requires
less operation time.
EXAMPLE
[0035] A patient is placed on an operating table in a semilateral
decubitus position or supine position. The patient's lower limb is
prepared and draped to allow free motion of the hip during
operation. Prior to the osteotomy, an adductor tenotomy may be
performed if the tendon is tight. Generally, an incision is made
starting from the middle of the iliac crest, extending anteriorly
along the iliac crest, and finishing around midpoint of the
inguinal ligament. The subcutaneous tissue is divided in line with
the skin incision. The fascia lata is incised along the medial
border of the tensor fascia lata. The cartilaginous iliac apophysis
under the incised skin is split in the middle down to the bone. The
periosteum is elevated in both sides of the ilium to expose the
sciatic notch. The iliopsoas tenotomy is performed.
[0036] A transverse cut is made through the posterior section of
the supraacetabular ilium using a Gigli saw. An oblique cut is then
made using a reciprocal saw. The opening defined by the transverse
cut and the oblique cut is then enlarged using a distractor and
stout towel forceps. Distraction may be easily performed if the leg
is extended and externally rotated with traction of the leg by an
assistant. A triangular bone graft taken from the iliac crest is
inserted into the opening.
[0037] The two halves of the cartilaginous iliac apophysis are
sutured together over the iliac crest. The wound is closed using
routine techniques.
[0038] Postoperatively, a double splint (anterior and posterior)
extending from above pelvis to distal thigh is applied. During
postoperative hospitalization the surgical wound is treated with
temporary removal of the splint and intermittent active and
assisted mobilization of the hip joint. The double splint is kept
in place for 6 weeks. After 6 weeks, the patient is allowed to walk
with using crutches (partial weight bearing) until radiographic
bony union is observed. Then tolerable weight bearing is permitted
depending on the patients condition.
* * * * *