autologous bone grafting and osteosynthesis with screws ... J Bone Joint Surg [Br] 2003;85-B:953-5. ... THE JOURNAL OF BONE AND JOINT SURGERY. Fig. 1.
Painful nonunion after triple pelvic osteotomy REPORT OF FIVE CASES C. Tschauner, A. Sylkin, S. Hofmann, R. Graf From Orthopädische Abteilung, Stolzalpe, Austria
önnis triple pelvic osteotomy is an accepted technique to correct acetabular dysplasia and degenerative labral pathology. A series of 409 consecutive patients who underwent a triple pelvic osteotomy between 1987 and 1999 were followed for a mean of 7.1 years (2 to 15). Five patients (1.2%), all women, developed a double nonunion and required revision, which involved excision of the pseudarthrosis, autologous bone grafting and osteosynthesis with screws or reconstruction plates. Bony healing was achieved in all after a mean of 7.8 months.
T
J Bone Joint Surg [Br] 2003;85-B:953-5. Received 16 January 2003; Accepted 9 May 2003
The triple pelvic osteotomy (TPO) as described by Tönnis et al1 is an accepted procedure to treat acetabular dysplasia and degenerative labral pathology in young adults.2 The whole of the acetabulum is mobilised by osteotomies through the ischium, pubis and ilium and reorientated in three dimensions.3 Although this creates temporary pelvic discontinuity with a potentially unstable hemi-pelvis and a pseudarthrosis may develop at one or more osteotomy sites, there are no reports of the incidence of nonunion after TPO or its management.
Patients and Methods A total of 409 consecutive TPOs were undertaken between 1987 and 1999. There were 341 women and 68 men with a mean age of 25.7 years (10 to 51). There were 209 left and 200 right hips; 73 had previously undergone an
C. Tschauner, MD, Associate Professor A. Sylkin, MD, Resident S. Hofmann, MD, Associate Professor R. Graf, MD, Professor and Chairman Allgemeines und orthopädisches Landeskrankenhaus Stolzalpe, Orthopädische Abteilung, A-8852 Stolzalpe, Austria. Correspondence should be sent to Dr C. Tschauner. ©2003 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.85B7.14173 $2.00 VOL. 85-B, No. 7, SEPTEMBER 2003
intertrochanteric osteotomy and 49 underwent combined osteotomies of the femur and acetabulum. The mean followup was 7.1 years (2 to 15). No patient was lost to follow-up. The number of patients who smoked was not recorded. TPO was carried out as described by Tönnis et al.1,3 This involved three separate skin incisions, ischial osteotomy from a posterior approach in the lateral position and pubic and iliac osteotomies from an anterior approach in the supine position, with iliac osteosynthesis using between three and five AO stainless steel screws. The pubic and ischial osteotomies were not fixed. Routine postoperative mobilisation, without bracing or casting, included non-weight-bearing for eight weeks, and partial to full weight-bearing during a further eight weeks. The screws were routinely removed after remodelling of the osteotomy at about one year after operation. An isolated pseudarthrosis of the pubis was seen in eight patients (2%). All were asymptomatic and required no further surgical treatment. Five, all women (1.2%), developed a double pseudarthrosis with nonunion of the pubis and ischium. All were painful and required stabilisation at a mean of 19.4 months (9 to 30) after TPO (Table I). All TPOs had been fixed with standard AO stainless steel screws. Three of these patients (cases 1, 4 and 5) were heavy smokers, smoking more than 30 cigarettes per day. Clinical evaluation before revision surgery included a record of the Harris hip score (HHS).4 The main symptom of nonunion was pain on walking. The pain was characteristically diffuse, affecting the pelvic and gluteal regions, and different from the groin pain, which they had experienced before the primary surgery. None had pain at rest. Radiological assessment before revision surgery included standard anteroposterior (AP) and false profile views. Dysplasia was graded according to Lequesne and Seze5 and Tönnis.6 The five patients with symptomatic double nonunions presented with persistent iliac and pubic nonunion either with (case 1), or without (cases 3, 4 and 5; Fig. 1), a secondary stress fracture of the inferior pubic ramus or with delayed union of the osteotomies and a stress fracture of the pubic ramus which did not unite spontaneously (case 2). Additional CT scans assisted with the planning of the revision surgery. The final decision about proceeding to revision surgery was always made after extensive evaluation, informing the 953
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C. TSCHAUNER, A. SYLKIN, S. HOFMANN, R. GRAF
Table I. Pre- and post-revision data for the five women who underwent revision surgery for painful nonunions after TPO
Case
Age at primary surgery (yrs)
1 2 3 4 5 Mean
20 25 31 24 36 27.2
Loss of bony contact Partial pubis No Total pubis Partial pubis No
a
Interval between primary surgery and revision (mths) 20 30 24 9 14 19.4
Grade of dysplasia
Grade of osteoarthritis
HHS
Before primary Postsurgery revision
Before primary Postsurgery revision
Prerevision
3 4 2 4 3 3.2
1 1 1 1 2 1.2
39 58 34 44 53 45.6
1 1 1 1 2 1.2
1 1 1 1 3 1.4
Postrevision
Time to bony healing (mths)
Follow-up (mths)
88 95 83 88 59 82.6
12 6 6 9 6 7.8
41 30 24 37 26 31.6
b
c
d Fig. 1
Radiographs of a 31-year-old woman (case 3). a) Preoperatively, showing lost bony contact at the pubic osteotomy. Postoperatively with b) the AP view and c) the false profile showing osteosynthesis of the pubic and ischial osteotomies and a screw at the site of iliac bone harvest. d) Radiograph showing healing of the osteotomies. THE JOURNAL OF BONE AND JOINT SURGERY
PAINFUL NONUNION AFTER TRIPLE PELVIC OSTEOTOMY
patient about possible neurovascular complications and obtaining carefully informed consent. Revision surgery and postoperative treatment. The nonunions were exposed through the original incisions. Care was taken to avoid traction to nerves and vessels. The pseudarthrosis was excised and an autologous block of iliac bone graft interposed. The ischium was fixed with a long cannulated lag screw and the pubis with a reconstruction plate and screws (cases 1, 2, 4 and 5) or a long axial screw (case 3), depending on the individual case (Fig. 1). Patients remained on bed rest until the wounds healed. They were then mobilised non-weight-bearing for eight weeks. Weight-bearing was then gradually increased to full by six months postoperatively, when there was radiological evidence of bony union. Radiographs were routinely taken at eight, 16 and 24 weeks postoperatively.
Results Clinical and radiological outcome. The clinical and radiological results after a mean of 31.6 months (24 to 41) are summarised in Table I. All nonunions healed and there was radiological evidence of healing at a mean of 7.8 months (6 to 12) after operation. The HHS at follow-up was excellent or good in four patients, but, despite bony healing, poor in one (case 5). The patient with a poor outcome has secondary osteoarthritis and will require total hip replacement.
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There is some evidence that smoking might be a factor for delayed union, as reported by Kalchschmidt (personal communication, 2001). Moller et al9 have recently described the importance of smoking as a risk factor for the development of complications after elective orthopaedic surgery. Based on our study of 409 TPOs, five (1.2%) of which developed double nonunion and required revision, we would make the following recommendations. First, adequate bony contact should be ensured at all three osteotomy sites even when extensive rotational corrections are undertaken. Secondly, two or three cannulated titanium screws should be used to stabilise the iliac osteotomy. Thirdly, a long mediolateral screw should be used to stabilise the pubic osteotomy until bony union, particularly when there is poor bony contact. Finally, patients should not sit on the ipsilateral ischial tuberosity for six weeks postoperatively, and they should be informed that smoking is a risk factor and might compromise bony healing. In our view, TPO is a reliable procedure with a low revision rate. We should like to thank Thomas P. Sculco (New York, USA) and John O’Hara (Birmingham, UK) for reading and revising the manuscript. And we are very grateful to Dietrich Tönnis and Klaus Kalchschmidt (Dortmund, Germany) for their friendship and for giving us strong support in learning and carrying out their continuously developing ‘state-of-the-art’ technique of triple pelvic osteotomy. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
References Discussion There is little information about the incidence of symptomatic nonunion after Tönnis TPO. There is functional anatomical evidence to suggest that load is vertically transferred in a sitting person from the ischial tuberosity to the sacroiliac joint and that the vertical compressive forces from the ischial tuberosity act as shear forces at the oblique ischial osteotomy, which in TPO is not routinely fixed.7 Additionally, during the postoperative period, the forces which are transmitted across the symphysis deform the inferior pubic ramus. This combination of a shearing force at the ischial osteotomy and a deforming force at the inferior pubic ramus increases micromovement at the sites of the ischial and pubic osteotomies which may lead to nonunion or stress fractures. This mechanism of increased movement as a potential cause of double nonunion could, theoretically, be avoided by leaving the posterior column intact, such as in the Bernese periacetabular osteotomy.8
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1. Tönnis D, Arning A, Bloch M, Heinecke A, Kalchschmidt K. Triple pelvic osteotomy. J Pediatr Orthop 1994;3:54-67. 2. Tschauner CH, Hofmann S, Graf R, Engel A. Labral lesions in acetabular dysplasia. Hip Intern 1998;8:233-8. 3. Tönnis D, Behrens K, Tscharani F. A modified technique of the triple pelvic osteotomy: early results. J Pediatr Orthop 1981;1:241-9. 4. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty: an end result study using a new method of result evaluation. J Bone Joint Surg [Am] 1969;51A:737-55. 5. Lequesne M, de Seze S. Le faux profil du bassin: nouvelle incidence radiographique pour l’étude de la hanche. Rev Rhum Mal Osteoartic 1961;28:643-52. 6. Tönnis D. Die angeborene hüftdysplasie und hüftluxation im Kindesund erwachsenenalter. Berlin: Springer-Verlag, 1984:5171-7. 7. Pauwels F. Beitrag zur Klärung der Beanspruchung des Beckens. S. 186, Abb.5. In: Pauwels F, ed. Gesammelte Abhandlungen zur funktionellen Anatomie des Bewegungsapparates. Berlin: Springer-Verlag, 1965. 8. Siebenrock KA, Leunig M, Ganz R. Periacetabular osteotomy: the Bernese experience. J Bone Joint Surg [Am] 2001; 83-A:449-55. 9. Moller AM, Pedersen T, Villebro N, Munksgaard A. Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg [Br] 2003;85-B:178-81.
