1. 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

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

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

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

6. Disadvantages – Tonnis
Posterior incision
Close to sciatic nerve

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

8. Video

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

11. 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

15. Post-op

16. 4 weeks post-op

17. 16 months post-op

18. Pre-op
Post-op

19. 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

20. 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

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

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

23. Primary Outcome Measure
Stulberg classification
Spherical
Aspherical

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

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

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

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

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

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

30. 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%)

31. 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

32. Results – Stulberg by Age
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%

33. Results – Stulberg by Elizabethtown
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

34. Results – Stulberg by Catterall
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

35. Results – Stulberg by Lateral Pillar
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

36. Results – Stulberg by Lateral Pillar
– 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)

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

38. Avg yrs before revision
– 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

39. Discussion 7yrs post op Pre-op
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

40. 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

41. Discussion Perthes is a… May not respond to a…
– 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

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

43. 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

44. – India – Perthes
Thank You