HIP DISORDERS SUPPLEMENT

Recurrent Dislocations and Complete Necrosis: The Role of Pelvic Support Osteotomy
In Ho Choi, MD, Tae-Joon Cho, MD, Won Joon Yoo, MD, and Chang Ho Shin, MD

Abstract: The basic concepts and goals of pelvic support osteotomy (PSO) are to enhance femoro-pelvic stability by proximal femoral valgus osteotomy and to improve hip biomechanics by displacing the center of gravity medially, which results in an improvement in the mechanical eciencies of abductor muscles. However, the clinical application of traditional PSO is limited due to its intrinsic shortcomings. Ilizarov designed a modied PSO, so called Ilizarov hip reconstruction (IHR), which incorporated a second distal femoral osteotomy, to realign the knee joint and to correct limb-length discrepancy and proximal femoral valgus osteotomy for pelvic support. IHR remains as a viable option for the salvage of severely damaged hips in the adolescents and young adults in whom arthrodesis or hip arthroplasty is not suitable. The purpose of this article is to briey review the evolution of PSO and to concentrate on the technical considerations and outcomes of IHR. Key Words: pelvic support osteotomy, Ilizarov hip reconstruction, hip instability (J Pediatr Orthop 2013;33:S45S55)

in posture, gait, and walking tolerance to those adolescents and young adults13 who have unstable hips showing severe dysplastic acetabulum and partial or total absence of the femoral head and neck (Table 1). The purpose of this section of the symposium is to address the roles of PSO and Ilizarov hip reconstruction (IHR), a modied form of PSO, which combines distal femoral (DF) osteotomy for concomitant lengthening and varus angulation, for the management of recurrent dislocations and complete necrosis of the femoral head.1419 We will briey review the histories of PSO and IHR and elaborate on the technical considerations and outcomes of IHR, based upon an extensive review of the literature and personal experience.

BRIEF HISTORY AND RATIONALE OF PSO AND IHR

PSO has long history in orthopaedic surgery. The technique was developed and popularized by Lorenz,2 Von Bayer,3 Schanz,4 Milch,58 and Henderson10 but was rapidly replaced by total hip replacement arthroplasty (THRA). Henry Milch58 expanded the concept and popularized the PSO in the United States during the mid20th century. The basic concepts and goals of PSO are to enhance femoro-pelvic stability by PF valgus osteotomy and to improve hip biomechanics by displacing the center of gravity medially, which results in an improvement in the mechanical eciencies of abductor muscles.57,20 The change of joint biomechanics seems to be more important that the anatomic support to reduce painful instability and to improve hip function.21 Overcorrection of PF valgus osteotomy places the extremity in a xed abduction position relative to the pelvis to eliminate hip adduction and reduces or prevents the Trendelenburg sign because the contralateral pelvis cannot drop.12,20 However, the clinical application of traditional PSO is limited due to its intrinsic shortcomings. In particular, the optimal extent of angulation is dicult to achieve. If the angle is too large, excessive genu valgum, xed pelvic obliquity, and impingement pain on adduction of the lower extremity to the neutral position may ensue. Alternatively, if the angle is too small, the result would be an insucient improvement in hip biomechanics,6,9,20,22,23 and most importantly, the issue of remaining limb-length discrepancy (LLD) cannot be addressed.19 To overcome the shortcomings of traditional PSO, Ilizarov designed a modied PSO, which incorporated a
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he treatment of hip instability in adolescents and young adults is often related to severe dysplastic acetabulum, proximal migration of the femur, and/or the absence of part or all of the femoral head and neck, and presents a surgical challenge. Furthermore, reconstructive procedures for this dicult problem, such as, greater trochanteric arthroplasty, hip arthrodesis, pelvic osteotomy, femoral osteotomy, and Girdlestone operation, are less than satisfactory.1 Dierent methods of proximal femoral (PF) subtrochanteric valgus angulation osteotomy, known as pelvic support osteotomy (PSO),211 have been described to salvage the damaged hips in whom arthrodesis or hip arthroplasty are not appropriate. Support of the pelvis is achieved by means of a valgus osteotomy that places the superior end of the femur against the lateral aspect of the pelvis.12 PSO is a useful surgical procedure that oers a signicant improvement

From the Division of Pediatric Orthopedics, Seoul National University Childrens Hospital, Seoul, Korea. None of the authors received nancial support for this study. The authors declare no conict of interest. Reprints: In Ho Choi, MD, Division of Pediatric Orthopedics, Seoul National University Childrens Hospital, Seoul 110-744, Korea. E-mail: inhoc@snu.ac.kr. Copyright r 2013 by Lippincott Williams & Wilkins

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TABLE 1. Indications of Pelvic Support Osteotomy

Hip instability: severe dysplastic acetabulum DDH: neglected, unsuccessfully treated Traumatic hip dislocation with instability Paralytic or spastic dislocation (postpoliomyelitis, cerebral palsy, muscular dystrophy) Partial or total absence of femoral head and neck Severe sequelae of septic arthritis (Choi type IV) Skeletal dysplasia (SED, Morquio, etc.) Severe AVN Post-Girdlestone resection arthroplasty
AVN indicates avascular necrosis; SED, spondylo-epiphyseal dysplasia.

TECHNICAL CONSIDERATIONS OF IHR

Careful preoperative surgical planning, based on data obtained from clinical and radiographic assessments, is essential to achieve a level pelvis and to restore the mechanical axis of the lower limbs perpendicular to the horizontal line of the pelvis in bipedal stance.1,12,13 Important technical considerations of IHR are summarized as follows.1,1214,19 1. Although some authors have recommended proximal osteotomy, in which the acetabulum rests on the lesser trochanter,3,11 most prefer more distal osteotomy in the anticipation of abductor mechanical benets due to displacement of the center of gravity medially. To determine the optimal level of PF valgus osteotomy, the femoral shaft should be fully adducted against the lateral wall of the pelvis, which is usually situated somewhere between the infracotyloid recess and the ischial tuberosity. This renders longer proximal segment and provides better hip stabilization and an optimal location for soft tissue interposition to produce a weight-bearing surface without direct abutment between the PF osteotomy and the pelvis (Fig. 1). 2. How much valgus angulation is desirable? This issue is highly controversial. In the era of conventional PSO, Henry Milch6,8 emphasized that the postosteotomy angle (b-angle: the obtuse angle formed between a line drawn along the inner aspect of the cortex of the distal fragment and an oblique line drawn from the upper end of the distal fragment tangent to the most medial projection of the proximal fragment, which may be considered as the neck angle of the osteotomized femur) must not be permitted to far exceed the angle of inclination of outer pelvic wall in the level pelvis (aangle: the obtuse angle formed between an oblique line connecting the 2 points of the outer edge of the acetabular roof and the outer edge of the ischial tuberosity and the mechanical axis line, passing through the outer edge of the acetabular roof, perpendicular to the horizontal pelvic reference line). He reported that the mean a-angle was 206.4 4.7 degrees in females and 211.4 5.8 degrees in males. He insisted that postosteotomy angle should be between 210 and 230 degrees, because excessive valgus at the osteotomy site leads to PF abutment against the pelvis, and even pelvic tilt, when the patient tries to bring the involved extremity into a neutral adduction/ abduction position.6,8,13 However, with contemporary IHR, irrespective of the size of the overcorrection of PF valgus angulation, much of the abduction deformity caused by PF valgus angulation can be compensated, if the second DF osteotomy restores the position of knee joint inclination to parallel the horizontal line of the pelvis. The mean PF valgus angulation reported in the literature varied widely between 35 and 60 degrees.12,20,26,29,3237 Paley12,19 (Fig. 1A) recommended overcorrection of 15 to 20 degrees during PF valgus osteotomy to eliminate hip adduction in addition to pelvic drop angle (the angle between the line perpendicular to iliac crest pelvic line
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second DF osteotomy, to realign the knee joint and to correct LLD, and PF valgus osteotomy for pelvic support. Russian literature indicates that Ilizarov and his associates started to use a modied PSO technique in the early or mid-1970s.1517,22,23 Ilizarov emphasized the importance of PF extension to correct the xed exion deformity of the hip and to permit locking of the hip joint by stabilizing the hip in the sagittal plane during single stance.12,14,18,19 IHR is considered a breakthrough in terms of resolving the inherent problems of PSO, as the treatment goals for normal gait are to obtain stability by reconstructing a stable fulcrum, to improve energy eciency by restoring abductor mechanism, and to improve cosmetic appearance by eliminating shortening/joint contracture-related problems.

INDICATIONS OF IHR
IHR is most suitable for skeletally mature adolescents or young adults that present with an unstable hip that is mobile and associated with a Trendelenburg gait (T-gait) and a large LLD. IHR is highly eective at eliminating T-gait, particularly when there is good abductor muscle function before surgery. The 2 most frequent indications are a neglected or an unsuccessfully treated developmental dislocation of the hip2426 and severe septic hip sequelae.1,12,2628 IHR is also indicated for the treatment of hip instability related to paralytic subluxation/dislocation, posttraumatic hip subluxation/dislocation, spondylo-epiphyseal dysplasia,29 osteonecrosis of the femoral head,30 and postexcision arthroplasty31 (Table 2). It seems that IHR is not ideal for young children, because in accordance with Wols law, gradual straightening of the PF tends to occur at the site of valgus angulation and this results in loss of pelvic support. Although IHR is not contraindicated in young children, for example, when hip instability is associated with marked LLD due to multiple lower-limb growth disturbances secondary to neonatal sepsis, one should expect repeat IHR at or near skeletal maturity. Another alternative is to undergo femoral lengthening without a PSO, inserting half pins into the pelvis to prevent proximal migration of the femur, in the younger age, and subsequently perform IHR when the patients are near skeletal maturity.12

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TABLE 2. Summary of the English Literature on Ilizarov Hip Reconstruction

Type of Support (No. Patient)
Subacetab. Subacetab.

Hip Function*

References

Etiology (No. Patient)

Age at Op. (y)

15 20 (12-33)

Preop.
NA 64 (42-72)

Postop.
NA

Postop Trendelenburg Sign (No. Patient)

None

Follow-up
5 mo 68 mo (55-81)

Complications and Comments

NA 3 PTI 3; 1 hypocorrection

Samchukov DDH (1) and Birch20 DDH (11); Kocaoglu PFFD (1); et al32 MMC (1); paralytic dislocat. (1) Septic hip (15) Manzotti et al28

84 (68-92) None (17); P (3)

21.1 (14-36)

Inan et al25 Rozbruch et al12

DDH (17) Septic hip (8)

Acetabular (9); subacetab. (5); pubic ramus (1) 24.8 (17-39) Subacetab. 11.2 (7.8-14.2) Subacetab.

NA

1.94 (W)

None (9); P (6)

108 mo (38-178)

NA 51 (21-67)

NA None (12); P (5) 73 (64-79) None (6); P (2)

36.3 mo (21-65) 5 y (1.9-9.8)

Inan and Bowen33

DDH (12); septic hip (3); traumatic lux. (1) DDH (11) DDH (12); septic hip (5); AVN (5); RP (4) Excision arthroplasty after infected hip arthroplasty (11) Spondyloepiphyseal dysplasia congenita (8 bilat.) DDH (12 unilat., 1 bilat.); septic hip (8) Spina bida (1)

25.3 (17-39)

Subacetab.

50 (32-73) 87.6 (67-98) None (12); P (4)

52.5 mo (26-84)

Inan et al34 El-Mowa24

25.2 (13-39) 22.4 (19-35)

Subacetab. Subacetab.

52 (32-73) 55 (40-78)

92 (77-98) None (6); P (5) 81 (65-90) None (20); P (5)

36 mo (23-59) 4.5 y (2-7)

3 knee sublux.; 2 loss of support; 2 pin substitute; 1 peroneal n. palsy; 1 regenerate fx.; 1 foot ER Many PTI; 2 fx. 3 PTI; 2 knee stiness; 1 knee sublux.; 1 premature consolidation; 1 prox. migration of femur 2 PTI; 2 delayed consolidation; 1 fracture; 1 knee stiness; 1 obturator n. entrapment NA; many PTI 4 of 5 patients with persistent T-sign was RP 7 PTI; 2 knee stiness; 2 residual knee valgus; 3 delayed consolidation 3 PTI; 3 knee stiness; 1 delayed consolidation 15 PTI; 2 prox. fx.; 2 delayed union; 6 knee stiness; 1 depression None; prox.: locking compression plate, distal: Fitbone PTI almost all

Emara31

51.9 (45-61)

Subacetab.

43.5 (31-50) 70.9 (65-80) None (11)

Minimum 2 y

Shetty et al29

16.4 (9-25)

Subacetab.

67.9 (54-85) 79.1 (68-87) None (6 hips); P 25.9 mo (10 hips)

Gursu et al35

22.6 (12-34)

Subacetab.

48.2 (28-79) 80.1 (60-93) None (13 hips); P 33.5 mo (16-45) (8 hips) NA NA Improved 12 mo 59.4 mo (38-86)

Krieg et al36 Marimuthu et al26

14

Subacetab. Subacetab.

Mahran et al27

DDH (1); 23 (13-32) nonunion (NOF) (2); septic hip (6); tuberculois (3) DDH (9); septic 21.5 (14-30) hip (9); RP (2)

44.3 (14-73) 70.8 (60-86) None (9); P (3)

Subacetab.

NA

NA

None (13); P (7)

6 mo

PTI almost all; 2 regenerate fx.; 2 premature consolidation; 4 delayed consolidation; 3 residual LLD > 3 cm

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TABLE 2. (continued) Type of Support (No. Patient)

Subacetab. Subacetab.

Hip Function*

References

Etiology (No. Patient)

Age at Op. (y)

13.5 13.4 (6.4-16)

Preop.
26 12 (W)

Postop.
88 6 (W)

Postop Trendelenburg Sign (No. Patient)

None None (8); P (5) 3y

Follow-up

Complications and Comments

Knee stiness Z quadricepsplasty Repeat IHR in 3 patients; 4 PTI; 4 loss of support; 1 prox. fx.

Sabharwal Osteonecrosis and after leukemia 30 Macleod (1) Choi et al Septic hip (11); (unpublishDDH (2) ed data)

5 y (1-10.2)

*Harris Hip Score or a modied Harris Hip Score.12 AVN indicates avascular necrosis of the femoral head; bilat., bilateral; DDH, developmental dislocation of the hip; dislocat., dislocation; ER, external rotation; fx., fracture; IHR, Ilizarov hip reconstruction; LLD, limb-length discrepancy; lux., luxation; MMC, meningomyelocele; n., nerve; NA, unknown; NOF, nonunion of femur neck fracture; op., operation; P, reduced but persistent T-sign; PFFD, proximal femoral focal deciency; postop., postoperative; preop.; preoperative; prox., proximal; PTI, pin-tract infection; RP, residual poliomyelitis; subacetab., subacetabular; T, Trendelenburg; unilat., unilateral; W, WOMAC score.

and the femoral shaft in single stance or during maximum attempted adduction when supine). On the basis of our experiences, we recommend at least 25 degrees of overcorrection,1 and >30 degrees in preadolescents. Pafilas and Nayagam13 (Fig. 1B) proposed overcorrection of 30 to 40 degrees of extravalgus in addition to the sum of maximum adduction range plus adduction contracture plus another 9 degrees to bring the femur parallel to the vertical axis perpendicular to the pelvic line. The remaining 21 to 31 degrees of abduction will take the femur away from midline. Their 30 to 40 degrees corresponds to 21 to 31 degrees of extravalgus in addition to the pelvic drop angle. Overcorrection is entirely empirical in anticipation of remodeling at the valgus osteotomy and some atrophy of the soft tissue interposed between the femur and lateral pelvic wall. 3. The next important issue is how to determine the level of DF osteotomy. Paley12,19 used the CORA method, which utilizes an imaginary proximal mechanical axis line (Fig. 2A). He stated that proximal mechanical axis line corresponds to a line perpendicular to the horizontal pelvic line, passing through the point of 1/3 to 1/2 the distance lateral to the medial edge of the proximal fragment. In contrast, Kadykalo and Kuftyev22 presented a formula that took into consideration the amount of PF valgus and DF varus angulation (Fig. 2B; Table 3). The mean DF varus angulations reported in the literature varied in the range between 10 and 22 degrees.20,29,30,32 Other important point of consideration when determining the level of distal osteotomy concerns the equalization of distances between the midline of the body axis and the centers of the knee joints of aected and normal contralateral limbs, which was emphasized by Palas and Nayagam13 (Fig. 2C). This suggests that the level of DF osteotomy relies on the level of PF valgus osteotomy, that is, the higher the level of PF valgus angulation, the more proximally located DF osteotomy should be to equalize the distances of knee joints

4.

5.

6.

7.

from the midline of the body axis in bipedal stance. Furthermore, if there is no compensatory DF varus angulation, unequal knee distances from midline may cause secondary pelvic obliquity despite well-performed pelvic support. The amount of extension should be adjusted to correct hip exion contracture and pelvic tilt, and the sacrofemoral angle (the angle formed by the intersection of a line drawn along the top of the sacrum to locate the pelvic inclination and a second line drawn along the shaft of the femur on the standing lateral radiograph). In normal children and adolescents, the sacrofemoral angle measures between 50 and 65 degrees.38 The amount of derotation should also be determined, based on foot progression angle and the amount and direction of rotation during passive maximum adduction. The amount of varization is also controversial. Although Palas and Nayagam13 proposed bringing the femoral shaft parallel to the vertical midline axis, this may cause 9 degree of valgus inclination at the knee. We believe that the knee joint should be realigned to its physiological position even after DF varus angulation. The amount of lengthening should be recalculated after IHR during lengthening using a woodblock or scanogram to obtain a level pelvis. Overlengthening is poorly tolerated in hips that are already in full adduction after IHR. Resection of the femoral head and neck remnant may be indicated, if the hip is painful and sti, regardless of preexisting osteoarthritis. The concept of resection-angulation osteotomy was originally proposed by Milch7 in 1955 for restoring hip mobility and pain relief.

SUMMARY OF THE ENGLISH LITERATURE ON IHR

At the time of writing, only 12 original articles and 3 case reports have been published in the English literature
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FIGURE 1. Determination of valgus angulation of the proximal femur for Ilizarov hip reconstruction. A, Paley12,19 recommended overcorrection of 15 to 20 degrees during valgus osteotomy to eliminate hip adduction and pelvic drop angle, which is an angle between the line perpendicular to iliac crest pelvic line and the femoral shaft in single stance or during maximum attempted adduction in the supine position. On the basis of our experiences, we recommend at least 25 degrees of overcorrection1 and >30 degrees in preadolescents. B, Pafilas and Nayagam13 proposed overcorrection of 30 to 40 degrees of extravalgus in addition to the sum of maximum adduction range plus adduction contracture plus another 9 degrees to bring the femur parallel to the vertical axis perpendicular to the pelvic line. The remaining 21 to 31 degrees of abduction will take the femur away from midline. Their 30 to 40 degrees corresponds to 21 to 31 degrees (b a) of extravalgus in addition to the pelvic drop angle. Overcorrection is entirely empirical in anticipation of remodeling at the valgus osteotomy and some atrophy of the soft tissue interposed between the femur and lateral pelvic wall.

on the merits of IHR (Table 2). Samchukov and Birch20 reported the successful use of IHR to treat a xed, irreducible congenital dislocation of the hip associated with other multiple lower extremity growth disturbances secondary to neonatal multifocal osteomyelitis. Kocaoglu et al32 used IHR for the treatment of hip dislocation in 14 patients in adolescents and young adults (mean age, 20 y)
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with a mean LLD of 4.4 cm. The clinical outcome was satisfactory: pain subsided in all patients, the Trendelenburg sign became negative in all but 3 patients, no patient had LLD, and lower limb alignment was reestablished. Manzotti et al28 reviewed their experience with IHR to treat late sequelae of septic arthritis of the hip in 15 patients (mean age, 21.1 y) with a mean LLD of 6.5 cm. At
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FIGURE 2. Determination of varus angulation of the distal femur for Ilizarov hip reconstruction. A, The CORA method recommended by Paley,12,19 which utilizes an imaginary proximal mechanical axis line. The proximal mechanical axis line corresponds to a line perpendicular to the horizontal pelvic line, passing through the point of 1/3 to 1/2 the distance lateral to the medial edge of the proximal fragment. B, Preoperative simulation of the Ilizarov hip reconstruction, which utilizes a trigonometric equation, recommended by Kadykalo and Kuftyev,22 taking into consideration of proximal femoral (PF) valgus angulation and distal femoral varus angulation and the biomechanical limb axis after reconstruction (Table 3). C, When determining the level of distal osteotomy, the equalization of distances between the midline of the body axis and the centers of the knee joints of affected and normal contralateral limbs should be considered, which was emphasized by Pafilas and Nayagam.13 The level of distal femoral osteotomy relies on the level of PF valgus osteotomy, that is, the higher the level of PF valgus angulation, the more proximally located distal femoral osteotomy should be to equalize the distances of knee joints from the midline of the body axis in bipedal stance.

TABLE 3. K-Value in the Design of the Biomechanical Axis22 (Refer to Fig. 2B, a = K L)
a (Deg.) b (Deg.)
5 10 15 20 25 30 35 40

5
0.50 0.34 0.26 0.21 0.17 0.15 0.14 0.12

10
0.67 0.51 0.41 0.35 0.30 0.27 0.25 0.23

15
0.76 0.61 0.52 0.45 0.40 0.37 0.34 0.31

20
0.81 0.68 0.60 0.53 0.48 0.45 0.42 0.40

25
0.85 0.74 0.66 0.60 0.55 0.51 0.49 0.47

30
0.87 0.78 0.71 0.65 0.61 0.58 0.55 0.53

35
0.89 0.81 0.75 0.71 0.66 0.63 0.61 0.59

40
0.91 0.84 0.78 0.74 0.71 0.68 0.67 0.65

an average follow-up of 108 months after removal of the xator, 10 patients had an excellent or good result, whereas 5 patients had a fair (LLD > 2.5 cm, deformity > 10 degrees, decreased hip and/or knee range of motion between 10 and 20 degrees, a positive Trendelenburg sign, or mild pain) or poor(LLD > 5 cm, deformity > 10 degrees, loss of hip and/or knee range of motion >20 degrees, or continuous pain) result. Rozbruch et al12 similarly reported the results of IHR for the treatment of the late sequelae of infantile hip infection in 8 patients (mean age, 11.2 y) with improvement in pain, gait, LLD, and lower-limb alignment. At a mean followup of 5 years (range, 1.9 to 9.8 y), LLD improved from a
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FIGURE 3. A case of Ilizarov hip reconstruction complicated by refracture at the level of valgus angulation. A, Preoperative radiograph of the pelvis taken in the standing position in a 12-year and 5-month-old boy with complete absence of the femoral head and neck after infantile septic arthritis of the hip. B, A radiograph showing Ilizarov hip reconstruction and 6 cm length gain with use of circular fixator. C, A radiograph showing refracture at the level of valgus angulation at age 15 years. D, A radiograph showing repeat Ilizarov hip reconstruction using a monolateral fixator. Three centimeter length gain was obtained. E, A teleradiogram of the lower extremities taken at age 21 years showing a well-performed pelvic support, in which the acetabulum is rested on the lesser trochanter.

mean of 4.6 (range, 0.6 to 6.4 cm) to 0.8 cm (range, 0 to 1.2 cm). Modied hip score improved from a mean of 51 (range, 21 to 67) to 73 points (range, 64 to 79). Gait analysis data, which was performed in 5 patients, revealed that the mean stance-time asymmetry improved from 16% to 5.4%, and the mean ground-reaction force (second peak) improved from 102% of body weight to 122% of body weight. El-Mowa et al24 reported on the use of IHR in a study of 25 patients (mean, 22.4 y) with unstable hips. At a mean follow-up of 4.5 months, all patients were reported to be pan free with improvement in gait and
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LLD. Four of 5 patients with persistent Trendelenburg sign had residual poliomyelitis. Marimuthu et al26 and Mahran et al27 also reported overall satisfactory results of IHR for chronically dislocated hips or destructed hips due to various causes. Gursu et al35 studied the inuence of etiology of hip instability on the results of IHR. Preceding pathology included neglected congenital dislocation of the hip in 13 hips (12 patients) and septic hip sequelae in 8 hips. At a mean follow-up of 33.5 months, there was no signicant dierence between the nal Harris Hip Scores of the 2 groups. They observed that complications were
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FIGURE 4. The newly reconstructed weight-bearing area is not absolute, nor a true joint or false articulation. A, A radiograph of Ilizarov hip reconstruction in a 15-year and 1-month-old boy. B, When determining the center of rotation during adduction/ abduction motion, the main fulcrum is seemingly located around the lesser trochanter and not around the apex of the valgus angulation adjacent to the ischial tuberosity during passive abduction and adduction. This suggests that the center of rotation seems to vary with the position/direction of motion of the lower limbs and depends on the soft-tissue interpositional weightbearing surface between the PF osteotomy and the pelvis.

more frequent after congenital dislocation of the hip, and patient satisfaction was higher in cases with sequelae of sepsis. Emara31 reported the results of IHR in 11 patients who had undergone excision hip arthroplasty to treat resistant hip infection. Harris Hip Scores improved in all patients: the average score preoperatively was 43.5 (range, 31 to 50), whereas at nal follow-up, the average score was 70.9 (range, 65 to 80). Shetty et al29 reported the ecacy of a modied PSO using hybrid external xator in 8 patients (mean age, 16.4 y) with severe bilateral hip involvement in spondylo-epiphyseal dysplasia congenita. After a mean follow-up of 25.9 months, the mean modied Harris Hip Score had improved from 67.9 to 79.1 points. Waddling gait was absent in 3 patients, reduced in 4 patients, and was the same in 1 at the last follow-up. Mean LLD was >0.5 cm, and the mechanical axis was realigned in all. Sabharwal and Macleod30 reported a case of successful IHR for the management of advanced osteonecrosis of the proximal femur after chemotherapy for acute lymphoblastic leukemia in an adolescent. They performed the 2-level femoral osteotomy with acute valgus-extension angulation at the PF osteotomy site and the DF osteotomy for gradual lengthening and varus angulation using Taylor Spatial Frame (Smith and Nephew, Memphis, TN). Monolateral external xation is usually more comfortable than circular frames for the patient with deformity around the hip and proximal femur, Inan and Bowen33 reported on the use of monolateral external xator (Orthox S.R.L.; Bussolengo, Verona, Italy) for

IHR in 16 patients (mean age, 25.3 y). At a mean followup of 52.5 months, the mean Harris Hip Score increased from 50 points (range, 32 to 73 points) preoperatively to 87.6 points (range, 67 to 98 points). Four patients retained a positive Trendelenburg sign. We have also experienced that monolateral xator that enables multiplanar angular correction and translation (Dyna-ATC; BK Meditech, Seoul, Korea) were suitable for IHR. Recently, Krieg et al36 proposed a new technique of IHR with internal systems exclusively. A locking compression plate is applied to x the PF valgus-extension osteotomy and a motorized retrograde intramedullary lengthening device (Fitbone; Wittenstein, Igersheim, Germany) for the distal, lengthening-varization osteotomy. Although the use of internal implants for IHR is a feasible and patient-friendly alternative to traditional methods, their use, however, may be restricted by geometric preconditions. Reported complications of IHR in the literature (Table 2) included knee stiness, pin-tract infection, delayed consolidation, refracture (Fig. 3), obturator nerve entrapment, straightening of proximal valgus angulation, and persistent T-gait. We think that there is possibility of ischiofemoral impingement if the PF valgus angulation site directly abuts the ischium.

DISCUSSION How to Avoid or Reduce Remodeling of Proximal Valgus Angulation?

IHR is safe to perform at an older age, preferably after peak growth spurt. Rozbruch et al12 observed that
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The Role of Pelvic Support Osteotomy

FIGURE 5. Total hip replacement arthroplasty (THRA) performed in a Mongolian 34-year-old lady who underwent Ilizarov hip reconstruction for treatment of neglected developmental dislocation of the hip at 24 years of age in Russian Federation. She underwent THRA because of diffuse pain around the buttock and hip that had lasted after Ilizarov hip reconstruction. A and B, Preoperative radiographs of the hip. The deformed femoral head is still in close contact with the secondary socket (false acetabulum) of the dislocated hip, which may explain the source of pain. The pelvic support osteotomy without resection of the femoral head might have been contraindicated in this regard. C, Three-dimensional computed tomography of the hip. D and E, Postoperative radiograph of THRA with a straight stem inserted after 4.5 cm of segmental shortening at the subtrochanteric level.

when IHR was performed at a younger age before adolescence, the PF valgus osteotomy site completely remodeled, demonstrating no evidence of the pelvic support within 1 or 2 years after the operation. We also experienced the same phenomenon of remodeling (straightening) of the proximal femur when IHR was performed in the preadolescent age. One should consider adding extravalgus angulation at the PF osteotomy site, when performing IHR to address marked LLD in a younger age. As mentioned previously, one should expect repeat IHR at or near skeletal maturity to obtain a level pelvis and to eliminate residual LLD. Another alternative is to perform simple femoral lengthening with extension of the external xation to the pelvis at a younger age and to reserve PSO for the second lengthening when the patients are near skeletal maturity.12 In our experience, translation of the proximal fragment medially relative to the distal fragment helps facilitate and maintain valgization. Prebent plate xation
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may also be benecial. Most importantly, postoperative strenuous abductor muscle exercise is essential.

Where Is the Weight-bearing Fulcrum?

We agree with others12,13 that the weight-bearing area is not absolute, nor a true joint or false articulation. The center of rotation seems to vary with the position/ direction of motion of the lower limbs and depends on the soft-tissue interpositional weight-bearing surface between the PF osteotomy and the pelvis. To identify the center of rotation during adduction/abduction motion, we used cineradiography in a patient who underwent Shanz-type PSO and managed to gure out that the center of rotation was located around the lesser trochanter and not around the apex of the valgus angulation adjacent to the ischial tuberosity during passive abduction and adduction (Fig. 4).
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Why Does T-Gait Persist After PSO in Some Patients?

The literature suggests that an average of 30.3% (range, 0% to 62.5%) of patients have a persistent positive Trendelenburg sign after IHR, although it is reduced in severity in most patients (Table 2). This persistence may be due to abductor insuciency related to atrophied abductor muscles before surgery or loss of fulcrum during follow-up due to remodeling of PF valgus angulation. Age at the time of PSO may also be an important factor for the retention of hip function.7 Inan et al34 used magnetic resonance imaging to measure alterations in the length and volume of the gluteus medius muscle after IHR in 11 patients with a history of congenital dislocation of the hip. They reported that although the IHR achieved a functional and painless hip in all patients, 5 patients had a persistently positive Trendelenburg sign at a mean follow-up of 3 years after IHR. The muscle volumes were restored to 43% to 89% of the muscle volumes on the normal contralateral side, and the postoperative muscle volume correlated signicantly with the result of the Trendelenburg test. T-gait disappeared with the restoration of gluteus muscle volume. However, there was no correlation between the Trendelenburg test and the change in the length of the gluteus medius muscle. In their series, 4 of 5 patients with a persistently positive T-gait were at least 31 years of age at the time of operation. On the basis of these results, they speculated that atrophied muscle might not be restored by PSO in older patients.

of the external xation to the pelvis at a younger age, and to reserve PSO for the second lengthening. Future studies should be directed toward determining the precise location of the newly reconstructed weight-bearing fulcrum and to develop an eective means of normalizing abductor muscle function. ACKNOWLEDGMENTS The authors thank Yun Su Park, MD, Professor of the Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, for providing us a case of THRA performed in a patient with previous history of IHR. REFERENCES
1. Choi IH, Shin YW, Chung CY, et al. Surgical treatment of the severe sequelae of infantile septic arthritis of the hip. Clin Orthop Relat Res. 2005;434:102109. 2. Lorenz A. On the treatment of irreducible congenital hip dislocation and the femoral neck pseudarthrosis by means of bifurcation osteotomy (Bifurcation of the proximal femur). Wien Klin Wochenschr. 1919;32:997999. 3. Von Baeyer H. Surgical treatment of irreducible congenital hip dislocation. Munster Med Wochenschrift. 1918;165:12161217. 4. Schanz A. On the treatment of old congenital hip dislocation. Munich Med Wochenschr. 1922;69:930931. 5. Milch H. The pelvic support osteotomy. J Bone Joint Surg. 1941;23:581595. 6. Milch H. The post-osteotomy angle. J Bone Joint Surg. 1943;25: 394400. 7. Milch H. The resection-angulation operation for hip-joint disabilities. J Bone Joint Surg Am. 1955;37-A:699717. 8. Milch H. Osteotomy at the Upper End of the Femur. Baltimore: Lippincott Williams & Wilkins; 1965. 9. Peltier LF. The classic. The pelvic support osteotomy. Clin Orthop Relat Res. 1989;249:411. 10. Henderson RS. Osteotomy for unreduced congenital dislocation of the hip in adults. J Bone Joint Surg Br. 1970;52:468473. 11. Hass J. A subtrochanteric osteotomy for pelvic support. J Bone Joint Surg. 1943;25-A:281291. 12. Rozbruch SR, Paley D, Bhave A, et al. Ilizarov hip reconstruction for the late sequelae of infantile hip infection. J Bone Joint Surg Am. 2005;87-A:10071018. 13. Pafilas D, Nayagam S. The pelvic support osteotomy: indications and preoperative planning. Strategies Trauma Limb Reconstr. 2008;3:8392. 14. Catagni MA, Malzev V, Kirienko A. Treatment of disorders of hip joint. In: Maiocchi AB, ed. Advances in Ilizarov Apparatus Assembly. Milan: Il Quadratino; 1994:119134. 15. Ilizarov GA, Kaplunov AG, Tereschenko VA. Modified pelvic support osteotomy for restoration of the pelvic support and simultaneous femoral lengthening. Published in Russian; 1978. 16. Ilizarov GA, Samchukov ML, Kurtov VM. Ilizarov restorative reconstruction surgery in the treatment of hip osteoarthritis, congenital and pathological hip dislocation in children and adults. Materials of Second International Symposium on Experimental, Theoretical, and Clinical Aspects of Transosseous Osteosynthesis. Kurgan, USSR: Kurgan Scientific Research Institute; 1986:100102. 17. Ilizarov GA, Samchukov ML. Ilizarov reconstructive surgery in the treatment of hip osteoarthritis. Ortop Travmatol Protez. 1988:1013. 18. Ilizarov GA. Treatment of disorders of the hip. In: Green SA, ed. Transosseous Osteosynthesis. Berlin: Springer Verlag; 1992:668696. 19. Paley D. Hip joint considerations. Principles of Deformity Correction. Heidelberg: Springer-Verlag; 2002:647694. 20. Samchukov ML, Birch JG. Pelvic support femoral reconstruction using the method of Ilizarov: a case report. Bull Hosp Jt Dis. 1992;52:711.
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Is It Possible to Convert to THRA Later on?

IHR does not burn the bridge in terms of preservation of bone stock around the PF, and thus, THRA after PSO is still possible, although it is a technically demanding procedure due to the PF deformity (Fig. 5). Careful attention to surgical detail is essential for successful THRA, otherwise, the distal end of femoral stem can penetrate the cortex.37 Shiltenwolf et al21 found that THRA could be performed without diculty by straightening the proximal femur by osteotomy and using a long-stem prosthesis.

CONCLUSIONS
IHR eectively improves hip abductor biomechanics by PF valgus osteotomy for pelvic support, and thus eliminates or reduces T-gait and, at the same time, corrects LLD and knee joint malalignment, if any, by DF osteotomy. In this regard, IHR is an excellent option for the treatment of unstable, irreducible hips associated with either severe dysplastic acetabulum or partial or total absence of the femoral head and neck in adolescents and young adults. If IHR is performed at a younger age to correct marked LLD, remodeling of PF valgus angulation is inevitable with resultant loss of pelvic support. In this situation, second IHR should be contemplated near or at skeletal maturity to obtain a level pelvis and to eliminate residual LLD. Another alternative is to perform simple femoral lengthening with extension

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The Role of Pelvic Support Osteotomy

21. Schiltenwolf M, Carstens C, Bernd L, et al. Late results after subtrochanteric angulation osteotomy in young patients. J Pediatr Orthop B. 1996;5:259267. 22. Kadykalo OA, Kuftyev LM. Some biomechanical principles of the hip reconstruction with defect on head and neck of the femur by Ilizarov method. The Value of General Biological Patterns in Regeneration Tissue Opened by G.A. Ilizarov. Scientific Works Collection. 13th ed. The Ministry of Health, The RSFSR (The Russian Soviet Federative Socialist Republic) Kurgan All-Union Scientific Center: Rehabilitation Traumatology and Orthopaedics; 1988:124129. 23. Samchukov ML, Ivanova IV, Dolganov DV. Analysis of PelvoTrochanteric Muscles and Weight-Bearing After Ilizarov Femoral Reconstruction in Patients With Hip Osteoarthritis. USSR: The Congress of Scientific and Technical Advances of the Young Scientists of the Urals; 1986:8687. 24. El-Mowafi H. Outcome of pelvic support osteotomy with the Ilizarov method in the treatment of the unstable hip joint. Acta Orthop Belg.. 2005;71:686691. 25. Inan M, Bomar JD, Kucukkaya M, et al. A comparison between the use of a monolateral external fixator and the Ilizarov technique for pelvic support osteotomies. Acta Orthop Traumatol Turc. 2004;38:252260. 26. Marimuthu K, Joshi N, Sharma CS, et al. Ilizarov hip reconstruction in skeletally mature young patients with chronic unstable hip joints. Arch Orthop Trauma Surg. 2011;131:16311637. 27. Mahran MA, Elgebeily MA, Ghaly NA, et al. Pelvic support osteotomy by Ilizarovs concept: is it a valuable option in managing neglected hip problems in adolescents and young adults? Strategies Trauma Limb Reconstr. 2011;6:1320. 28. Manzotti A, Rovetta L, Pullen C, et al. Treatment of the late sequelae of septic arthritis of the hip. Clin Orthop Relat Res. 2003;410:203212.

29. Shetty GM, Song HR, Lee SH, et al. Bilateral valgus-extension osteotomy of hip using hybrid external fixator in spondyloepiphyseal dysplasia: early results of a salvage procedure. J Pediatr Orthop B. 2008;17:2125. 30. Sabharwal S, Macleod R. Ilizarov hip reconstruction for the management of advanced osteonecrosis in an adolescent with leukemia. J Pediatr Orthop B. 2012;21:252259. 31. Emara KM. Pelvic support osteotomy in the treatment of patients with excision arthroplasty. Clin Orthop Relat Res. 2008;466: 708713. 32. Kocaoglu M, Eralp L, Sen C, et al. The Ilizarov hip reconstruction osteotomy for hip dislocation: outcome after 4-7 years in 14 young patients. Acta Orthop Scand. 2002;73:432438. 33. Inan M, Bowen RJ. A pelvic support osteotomy and femoral lengthening with monolateral fixator. Clin Orthop Relat Res. 2005;440:192198. 34. Inan M, Alkan A, Harma A. Gluteal muscle after pelvic osteotomy to treat congenital dislocation of the hip. J Bone Joint Surg. 2005; 87-A:22462252. 35. Gursu S, Demir B, Yildirim T, et al. The influence of aetiology of hip instability on the results of pelvic support osteotomy. Hip Int. 2010;20:518523. 36. Krieg AH, Lenze U, Hasler CC. Ilizarov hip reconstruction without external fixation: a new technique. J Child Orthop. 2010;4: 259266. 37. Thabet AM, Catagni MA, Guerreschi F. Total hip replacement fifteen years after pelvic support osteotomy (PSO): a case report and review of the literature. Musculoskelet Surg. 2012;96: 141147. 38. Bleck EE. Orthopaedic Management in Cerebral Palsy. London: Mac Keith Press; 1987.

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