Triple Innominate Osteotomy for Perthes Disease: Indications and Technique V. Salil Upasani, MD Assistant Clinical Professor Department of Orthopedic Surgery Rady Children’s Hospital San Diego University of California San Diego 6th Annual IPSG Meeting October 6, 2017

Triple Innominate Osteotomy Indications: Open TRC Perthes Untreated DDH Residual DDH

Steel TIO – 1973 (Philadelphia) Salter osteotomy Pubic osteotomy Ischial cut below ischial spine and at ischial tuberosity Less free rotation, increased risk of pseudarthrosis

Tonnis TIO – 1981 (Germany) Salter osteotomy Pubic osteotomy Oblique ischial cut – separate posterior incision (above insertion of both ligaments) Ideal free acetabular rotation

Disadvantages – Tonnis Posterior incision Close to sciatic nerve

Carlioz TIO – 1982 (France) Salter osteotomy Pubic osteotomy Ischial cut below spine closer to acetabulum Sacro-tuberous lig. – not attached Sacro-spinous lig. – attached

Video

Slight modifications Angled cut in Salter osteotomy Pubic and Ischial osteotomy with Misonix Bone Scalpel

Case Example – TIO for Perthes 9 yo F Worsening right hip pain and limp for past 5 months PMH / PSH: none Pex: Hip flexion: 95/95 Hip abduction in ext: 20/40 Hip IR: 0/20 Hip ER: 20/40 Neuro intact

Post-op

4 weeks post-op

16 months post-op

Pre-op Post-op

Matthew Stepanovich, MD Advanced Containment with the Triple Innominate Osteotomy for LCPD: Outcomes According to Age versus Disease Chronology Matthew Stepanovich, MD Vidyadhar V. Upasani, MD James D. Bomar, MPH Dennis R. Wenger, MD JPO 2015 Dec 17

Purpose To evaluate the outcomes of triple innominate osteotomy (TIO) in Perthes disease Based on disease chronology and severity Age Modified Elizabethtown – Joseph et al Catterall Lateral pillar – Herring et al

Methods Retrospective chart and radiographic review 54 patients (56 hips) Inclusion: All patients with LCPD treated with TIO Single institution – 1995-2011 Minimum 2-year follow-up Exclusion: Non LCP AVN / Concomitant femoral osteotomy

Methods – Patient Classification Disease chronology Chronological age Modified Elizabethtown Disease severity Catterall Lateral Pillar

Primary Outcome Measure Stulberg classification Spherical Aspherical

Radiographic Assessment Neck-Shaft Angle Tonnis Angle Center Edge Angle Femoral Head Extrusion Index Articular Trochanteric Distance Cross-over sign Ischial spine sign

Radiographic Assessment Neck-Shaft Angle Tonnis Angle Center Edge Angle Femoral Head Extrusion Index Articular Trochanteric Distance Cross-over sign Ischial spine sign

Radiographic Assessment Neck-Shaft Angle Tonnis Angle Center Edge Angle Femoral Head Extrusion Index Articular Trochanteric Distance Cross-over sign Ischial spine sign

Radiographic Assessment Neck-Shaft Angle Tonnis Angle Center Edge Angle Femoral Head Extrusion Index Articular Trochanteric Distance Cross-over sign Ischial spine sign

Radiographic Assessment Neck-Shaft Angle Tonnis Angle Center Edge Angle Femoral Head Extrusion Index Articular Trochanteric Distance Cross-over sign Ischial spine sign

Radiographic Assessment Neck-Shaft Angle Tonnis Angle Center Edge Angle Femoral Head Extrusion Index Articular Trochanteric Distance Cross-over sign Ischial spine sign

Results – Patient Cohort 51 male / 3 female Mean age at surgery: 8.3 ± 1.8 yrs Mean follow up: 6.4 ± 3.2 yrs Stulberg: I/II: 8/28 (64%) III/IV/V: 14/5/1 (36%)

Results – Radiographic Outcomes Pre-op Post-op p-value NSA 136.9°±5.7° 136.4°±6.4° 0.652 Tonnis Angle 12.6°±5.7° -0.8°±7.1° <0.001 CEA 11.6°±7.5° 33.9°±10.6° FHEI (%) 29.7±9.9 12.9±10.1 ATD (mm) 18.7±4.9 15.1±8.7 0.20

Results – Stulberg by Age 2015-4 POSNA EMR Results – Stulberg by Age Younger children trended to do better but some older children still benefited. TSHR < 8 yrs 68% vs 32% and > 8 yrs 50% vs 50%

Results – Stulberg by Elizabethtown 2015-4 POSNA EMR Results – Stulberg by Elizabethtown Unlike Joseph, we did not find that the effect of surgical intervention was dependent upon intervening prior to the late fragmentation stage

Results – Stulberg by Catterall 2015-4 POSNA EMR Results – Stulberg by Catterall Based on the Catterall classification, less severe patients trended to do better, however, more than half of the most severe cases showed good results

Results – Stulberg by Lateral Pillar 2015-4 POSNA EMR Results – Stulberg by Lateral Pillar Based on the Herring classification, less severe patients trended to do better, however, again nearly half of severe cases showed good results

Results – Stulberg by Lateral Pillar 2014-1 – India – Perthes Results – Stulberg by Lateral Pillar Spherical 4 (25%) 4 (9%) Aspherical 12 (75%) 40 (91%) Stulberg Classification TSRH Results Spherical 8 (47%) NA Aspherical 9 (53%) Stulberg Classification San Diego Results Lat Pillar C Non-Op These results are quite different to the results reported by Dallas in 2004 with surgical containment that lead to their statement that operative containment in severe cases did not improve outcome. This is even more conflicting when you consider that only 9 percent of their severe nonoperative population achieved good results (4/44)

Results – Complications Impingement: 8 (14%) Undercoverage: 2 (4%) Non-union: 1 (2%) Revision surgery: 11 (20%)

Avg yrs before revision 2014-1 – India – Perthes Results – Revisions (n=11) Procedure N Avg yrs before revision Femoral head neck osteochondroplasty 4 8.2 (6.5 to 12.3) Valgus osteotomy 2 1.4 (1.3 to 1.4) Femoral head trap door, osteochondroplasty 1 1.1 Pubic non-union debridement and autograft Osteochondroplasty and varus Shelf 0.9 Shelf, osteochondroplasty and valgus 3.4

Discussion 7yrs post op Pre-op 2015-4 POSNA EMR Discussion Pre-op Elizabethtown classification of disease chronology did not correlate with final head sphericity 7yrs post op Pre-op In some disagreement with Benjamin Joseph’s published advice we found that chronology at time of containment did not correlate with final head shape

2015-4 POSNA EMR Discussion Older and more severely involved children (Catterall and Herring) have less satisfactory results Complete femoral head containment can improve outcomes Our study clarifies that older children tend to have less satisfactory results but good outcomes are still possible even in older patients with severe disease 10yo male 16yo male

Discussion Perthes is a… May not respond to a… 2014-1 – India – Perthes Discussion Perthes is a… May not respond to a… Going back to etiology this a biologic problem and applying a standard mechanical solution through bony reconfiguration will have its limitations

Limitations Retrospective / selection bias Single center No control group Limited follow-up – not to skeletal maturity Lost to follow-up (5/59 = 8%)

Take Home Points Containment should still be considered for older and more severely affected Perthes patients Triple innominate osteotomy – viable technique Primary complication: over-containment (FAI) Future research: not just a mechanical solution

2014-1 – India – Perthes Thank You