Surgical Techniques

Pelvic Osteotomies in the Child and

Young Adult Hip: Indications and
Surgical Technique

Abstract
Courtney M. Selberg, MD Pelvic osteotomies are used for hip preservation in children and young
Berrien Chidsey, MSMI, CMI adults to improve femoral head coverage and stabilize the hip joint.
Redirectional osteotomies aim to reduce the overall volume and
Anne Skelton, BS
redirect the acetabulum. These include Salter, Pemberton, Dega, and
Stephanie Mayer, MD San Diego osteotomies. Reorientation osteotomies aim to reorient the
acetabulum and include periacetabular and triple osteotomies.
Salvage osteotomies aim to enlarge the acetabulum and medialize the
hip center. These include shelf and Chiari osteotomies. The standard
anterior approach and surgical technique for the eight pelvic
osteotomies used by hip preservation surgeons are described along
with each osteotomy’s history, indications, and outcomes.

• Reorientation: These are com-

Take-Home Points plete osteotomies which aim to
From the Department of Orthopedic reorient the entire acetabulum
Surgery, University of Colorado
including periacetabular and tri-
School of Medicine (Dr. Selberg and • Pelvic osteotomies are used for
Dr. Mayer), the Department of ple osteotomies.
hip preservation in children and
Orthopedic Surgery, Children’s • Salvage: These are osteotomies
young adults.
Hospital Colorado (Dr. Selberg, which aim to enlarge the ace-
Ms. Skelton, and Dr. Mayer), and • Redirectional osteotomies aim
tabulum and/or improve femoral
Surgeon-in-Chief Administration, to reduce the overall volume and
University of Colorado School of head coverage by medializing
redirect the acetabulum.
Medicine, Aurora, CO (Mr. Chidsey). the hip center, most often in an
• Reorientation osteotomies aim
incongruent or arthritic hip joint
None of the following authors or any to reorient the acetabulum.
immediate family member has that is not an appropriate can-
• Salvage osteotomies aim to en-
received anything of value from or has didate for a reorientation oste-
stock or stock options held in a large the acetabulum and me-
otomy. These include shelf and
commercial company or institution dialize the hip center.
Chiari osteotomies.
related directly or indirectly to the In children and young adults, pelvic
subject of this article: Dr. Selberg, osteotomies are used for hip preserva-
Mr. Chidsey, Ms. Skelton, and
Dr. Mayer. tion including femoral head coverage Standard Anterior
improvement and hip joint stabilization. Approach
Supplemental digital content is
available for this article. Direct URL
There are three main categories used by
citation appears in the printed text and hip preservation surgeons as follows: A standard anterior approach ac-
is provided in the HTML and PDF • Redirectional: These are incom- cesses the pelvis and performs the
versions of this article on the journal’s plete osteotomies which aim following pelvic osteotomies. A
Web site (www.jaaos.org).
to reduce the overall volume and bikini-type incision exposes the Smith-
J Am Acad Orthop Surg 2019;00:1-8 redirect the acetabulum by a hinge Petersen interval as an internervous
DOI: 10.5435/JAAOS-D-19-00223 located at the triradiate cartilage plane between the sartorius and ten-
and/or pubic symphysis. These sor muscles. A more contemporary
Copyright 2019 by the American
Academy of Orthopaedic Surgeons. include Salter, Pemberton, Dega, approach uses a fascial incision lateral
and San Diego osteotomies. to this interval over the tensor muscle

Month 2019, Vol 00, No 00 1

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Pelvic Osteotomies in the Child Hip

to avoid injury to the lateral femoral tractors are placed subperiosteally threaded screws can also be used in
cutaneous nerve and to enter the deep around the sciatic notch from medial older patients. Kirschner wire or
interval laterally. Proximally, the to lateral and lateral to medial. Mal- screw placement should be confirmed
external oblique muscles are elevated leable retractors can be used to pro- to be within the proximal fragment,
from the iliac crest, and the iliac tect the contents of the sciatic notch. bone graft, and distal fragment medial
apophysis is split sharply to expose Injury to the superior gluteal and and posterior to the joint. Finally, the
both the inner and outer tables of the sciatic nerves as they exit the sciatic hip joint should be confirmed to have
iliac wing as necessary. Distally, the notch can be prevented by careful concentric reduction before wound
direct head of the rectus femoris ten- exposure and subperiosteal place- closure and cast placement. The
don is detached from the anterior ment of retractors, as well as careful patient is immobilized in a hip spica
inferior iliac spine (AIIS), and tagged placement of the Gigli saw. cast for 6 weeks. Kirschner wires are
for later repair, to expose the hip A right angle forceps is passed from typically removed after osteotomy
capsule if open reduction is necessary medial to lateral between the re- healing (3 to 6 months).
as a concomitant procedure. tractors and the bone of the sciatic
notch, and a Gigli saw is pulled
around the notch from lateral to Pemberton Osteotomy
Salter Osteotomy medial. The Gigli saw passage can also
be facilitated by a nylon suture. Skin Pemberton5 originally described his
Salter and Dubos described their margins are retracted widely, and the pericapsular osteotomy in 1965. He
experience with the innominate oste- Gigli saw is used to create a straight found that forward and lateral
otomy for congenital hip dislocation posterior to anterior cut in the ilium rotation of the acetabulum would
in 1974.1 The Salter osteotomy is from the sciatic notch to a point just reposition the articular surface to
typically indicated for children older above the AIIS on the interspinous provide correction of a defective
than 18 months. Before this age, ridge, distal to the anterior superior anterolateral acetabulum.5,6 Rota-
closed reduction and casting or iliac spine (ASIS) (Figure 1). If no tion would also allow the superior
bracing treatment may yield satis- femoral shortening is being per- acetabulum to wrap around the
factory results, and the remodeling formed, a triangular wedge of bone is femoral head, correcting the struc-
potential of the acetabulum is high cut from the iliac crest to the exit tural size deficit often seen in per-
without pelvic osteotomy.1–3 In point of the osteotomy. Alternatively, sistently subluxating hips.5 Patients
addition, the pelvis is small before this a piece of allograft iliac crest can be indicated for the procedure include
age, and the iliac wing may not be used to preserve the native anatomy those with congenital hip subluxa-
strong enough to support the oste- of the patient’s iliac crest. The distal tion or dislocation between 1 and 14
otomy force.1 Salter described the acetabular fragment is manipulated years of age. The youngest age is
upper age limit as 6 years because of by a pointed reduction clamp in the limited by bone texture, whereas the
joint incongruity, poor remodeling supra-acetabular bone to hinge on the oldest age is limited by triradiate
potential of the acetabulum, and pubic symphysis and provide anterior cartilage plasticity and remodeling
muscle contractures limiting concen- and/or lateral translation. The use potential, which are necessary to
tric reduction in older children.1,3 of a laminar spreader to open the permit acetabular displacement and
Children older than 6 years are con- osteotomy or excessive upward force correct incongruity caused by the
sidered candidates if they are con- on the proximal fragment will create procedure.5–7
centrically reducible with good range simple distraction and failure to open The standard anterior approach
of motion while reduced.4 the osteotomy in a wedge shape as is exposes the outer table in a subperi-
The innominate osteotomy is a needed for the appropriate rotational osteal fashion, and a retractor is
complete redirectional osteotomy, as redirection. The bone graft is sized placed in the sciatic notch for pro-
the entire acetabulum is reoriented appropriate to the amount of cover- tection against the osteotome. The
without changing the shape of the age needed in a triangular shape and inner table is also exposed in a
joint surface itself. The osteotomy placed into the osteotomy site. subperiosteal fashion, but no retrac-
hinges on the pliable pubic symphysis Two- or three-threaded Kirschner tor is placed at the level of the sciatic
and is not stable without fixation. wires, typically 2.0 mm, are placed notch; rather, the blunt retractor is
The standard anterior approach through the superior fragment at the kept superficial at the level of the
accesses the iliac wing in a subperi- iliac crest, through the graft, and into pelvic brim.
osteal fashion. The outer and inner the acetabular fragment posterior and In the Pemberton acetabuloplasty,
tables are exposed, and blunt re- medial to the joint. 3.5-mm fully the osteotomy line is incomplete

2 Journal of the American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Courtney M. Selberg, MD, et al

(Figure, Supplemental Digital Con- Figure 1

tent 1, http://links.lww.com/JAAOS/
A424). It begins anteriorly on the
interspinous ridge between the ASIS
and AIIS and ends posteriorly above
the triradiate cartilage. An AP fluo-
roscopic view is taken to choose an
appropriate starting point on the
outer table, heading toward the tri-
radiate cartilage. A special curved
1/4- or 1/2-inch osteotome is used
for a curvilinear cut starting from the
outer table using fluoroscopic guid-
ance, heading toward the posterior
branch of the triradiate cartilage.
The osteotomy is widened in this
same path anteriorly and posteriorly
around the acetabular roof, heading
to but not through the triradiate
cartilage. The osteotomy is bicortical
anteriorly at the interspinous ridge.
When the osteotomy is sufficiently
free, a laminar spreader or osteo-
tome opens the osteotomy to provide
anterior and lateral coverage, hing-
ing on the triradiate cartilage. This
opening is maintained by a bicortical
graft harvested from the iliac wing
or a sufficiently sized allograft. The
graft is positioned for necessary
coverage, providing lateral coverage
and variable amounts of anterior or
posterior coverage depending on the
placement. Because the osteotomy is
an incomplete cut, forces will keep
the graft stable in its position.
However, threaded Kirschner wires Illustrations of the Salter osteotomy. Arrow 1: triangular-shaped bicortical graft
may be used if the graft is not stable. harvested from the iliac wing. Arrow 2: osteotomy is hinged on the symphysis
pubis to provide anterior and lateral coverage.
Postoperatively, the patient is main-
tained in a hip spica cast for a min-
imum of 6 weeks.
hip by creating an acetabulum with limit for patients is typically between
more anterolateral coverage.9,10 This 13 and 16 years. The lower age limit
Dega Osteotomy osteotomy maintains a hinge ante- is around 4 years because other os-
rior to the sciatic notch; however, the teotomies may be more effective
The Dega osteotomy is another re- exact location can be variable. The before this age. Degeneration of the
shaping, incomplete osteotomy simi- triradiate cartilage is the most com- femoral head as determined radio-
lar to that of Pemberton used to treat mon location for hinging, especially graphically or during open reduction
acetabular dysplasia, often as a result when it remains open, but the pro- is another contraindication, as it can
of developmental disorders such as cedure has also been performed with prevent proper coverage by the
spastic cerebral palsy.8 It was origi- hinging closer to the symphysis acetabulum. 8,12
nally developed by Dega et al to treat pubis.11 Full skeletal maturity is not The approach for the Dega oste-
developmental dislocations of the recommended; thus, the upper age otomy uses a similar approach to

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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Pelvic Osteotomies in the Child Hip

Pemberton. The inner and outer ta- of neuromuscular abnormalities, erage. Because the osteotomy is an
bles are exposed in a subperiosteal this osteotomy combines muscle- incomplete cut, existing forces in the
fashion, and the Dega osteotomy line tendon lengthening, open reduction pelvic ring keep the graft stable in its
is also incomplete (Figure, Supple- with capsulorrhaphy, and peri- position. However, threaded Kirsch-
mental Digital Content 2, http://links. capsular acetabuloplasty to create ner wires can be used if the graft is not
lww.com/JAAOS/A425). It begins greater posterior acetabular cover- stable. The patient is maintained in
anteriorly on the interspinous ridge age.13 Patients should have open a hip spica cast for a minimum of
between the ASIS and AIIS and ends triradiate cartilage; thus, the upper 6 weeks.
posteriorly above the greater sciatic age limit is in the mid-teens, whereas
notch. An AP fluoroscopic view is the lower age limit is 4 years. The
taken to choose an appropriate femoral head may also have some Bernese Periacetabular
starting point on the outer table. degree of incongruity, and the pro- Osteotomy
A special curved 1/4- or 1/2-inch cedure can still be successful.13,14
osteotome makes the curvilinear cut The San Diego osteotomy also Skeletally mature adolescent or adult
starting from the outer table using uses a similar approach as the previ- patients with symptomatic acetabu-
fluoroscopic guidance, heading ously described techniques, exposing lar dysplasia can be surgically treated
toward the sciatic notch. The oste- inner and outer tables in a subperi- with a periacetabular osteotomy
otomy is widened in this same path osteal fashion. It is bicortical both (PAO).15 As a type of reorientation
anteriorly and posteriorly around anteriorly at the interspinous ridge osteotomy that combines ischial,
the acetabular roof, heading to but and posteriorly at the sciatic notch pubic, and iliac cuts, the PAO permits
not through the sciatic notch. The and requires complete safe exposure considerable correction of version,
osteotomy is bicortical anteriorly at of the sciatic notch in a subperiosteal lateral coverage, and anterior cover-
the interspinous ridge. When the fashion (Figure, Supplemental Digital age. The ischial osteotomy is incom-
osteotomy is sufficiently free, a Content 3, http://links.lww.com/ plete, which preserves the continuity of
laminar spreader or osteotome opens JAAOS/A426). The inner table re- the posterior column and allows for
the osteotomy and provides anterior mains intact at all points, except for weight bearing up to 20% body weight
and lateral coverage, hinging on the at the anterior-most and posterior- after surgery with three or four 3.5- or
triradiate cartilage. This opening at most aspects of the osteotomy. An 4.5-mm screws.15 Further indications
the osteotomy site is maintained by a AP fluoroscopic view is taken to include osteoarthritis of the hip that
bicortical graft harvested from the choose an appropriate starting point does not exceed Tönnis grade 2; oste-
iliac wing or a sufficiently sized on the outer table. A special curved otomy success becomes more difficult,
allograft. The graft is positioned 1/4- or 1/2-inch osteotome is used and patient outcomes are poorer with
where coverage is necessary, pro- for a curvilinear cut starting from the increased osteoarthritis severity.16–20
viding lateral coverage and a vari- outer table using fluoroscopic guid- Incongruence of the hip on functional
able amount of anterior or posterior ance, heading toward the sciatic radiographs (abduction and internal
coverage. Because the osteotomy is notch, taking care to leave the inner rotation images; flexion false-profile
an incomplete cut, existing forces in table intact. The osteotomy is wid- images) can also predict poorer out-
the pelvic ring will keep the graft ened in this same path anteriorly and comes in patients with aspherical
stable in its position. However, posteriorly around the acetabular femoral heads.21 A higher failure rate
threaded Kirschner wires can be used roof. When the osteotomy is suffi- after PAO has also been reported in
if necessary. Postoperatively, the ciently free, a laminar spreader or hips with a lower delayed Gadolinium-
patient is maintained in a hip spica osteotome opens the osteotomy and enhanced magnetic resonance image
cast for a minimum of 6 weeks. provides posterior and lateral cov- of cartilage (dGEMRIC) index on
erage, hinging on the triradiate car- preoperative MRI, indicating damage
tilage. This osteotomy site opening is to the articular cartilage has already
San Diego Osteotomy maintained by a bicortical graft occurred.19 PAO success rates have
harvested from the iliac wing, or a been reported approximately 90% at
The San Diego osteotomy is similar sufficiently sized allograft, posi- 10-year, 75% at 18-year, and 29% at
to the Dega in that it treats sub- tioned where coverage is necessary. 30-year follow-up.22–24
luxated hips in children with open Historically, the San Diego oste- The surgical technique has been
triradiate cartilage. Developed by otomy has been used for postero- slightly modified over time but re-
McNerney and associates specifi- lateral acetabular deficiency and can mains quite similar to the original
cally for hip subluxations as a result preferentially provide posterior cov- technique described in 1988 by Ganz

4 Journal of the American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Courtney M. Selberg, MD, et al

et al.15 The patient is placed supine and remain extra-articular. The teochondroplasty for offset correc-
on a radiolucent table. The initial supra-acetabular osteotomy is per- tion is necessary.21,26
incision curves proximally over the formed with an oscillating saw after
iliac crest to the gluteal tubercle and blunt retractors are placed into the
extends proximally into the Smith- greater sciatic notch. Recent modi- Triple Osteotomy
Peterson interval and laterally to the fication of the original technique
ASIS.15,21,25,26 Some surgeons use has been described using minimal The triple is a complete reorientation
a bikini-type incision, but this has disruption of the abductor attach- osteotomy described to improve on
the potential to limit distal expo- ment to the outer table; a narrow the drawbacks of the Salter innomi-
sure, especially for the ischial oste- Hohmann retractor is tunneled be- nate osteotomy in skeletally immature
otomy.21,26 A wafer osteotomy of neath the abductors only at the hips by addressing the restricted
the ASIS is completed to develop the level of the osteotomy.15,21,25,26 The movement of the fragment and the
tensor-sartorius interval. Originally, supra-acetabular cut is performed to lateralization of the hip joint.28–30
the technique involved division of a point 1 centimeter off the pelvic This osteotomy has been reported to
the direct and indirect heads of the brim, in line with the planned ret- successfully treat complex hip dys-
rectus tendon to allow for expo- roacetabular osteotomy down the plasia associated with congenital,
sure of the hip capsule. Owing to posterior column. The retro- neuromuscular, and teratologic con-
reported hip flexor weakness after acetabular osteotomy is performed ditions.28,30 Unlike Salter or Pem-
PAO, more recent techniques leave with a straight chisel, and a chisel berton’s methods, three combined
the indirect and direct heads of the angled 120 degrees away from the cuts allow for complete freedom of
rectus intact and retract them later- the acetabular fragment.28–31 Patients
supra-acetabular cut and directed
ally.21,27 The interval between the who are too mature for Salter or
toward the proximal portion of the
capsule and iliopsoas tendon is Pemberton osteotomies have a sym-
ischial cut. Care is taken to split the
developed to access the ischium. The physis that will not bend easily; thus,
posterior column halfway between
ischial osteotomy is performed with the mobility obtained through triple
the greater sciatic notch and the
a curved or angled chisel using osteotomy allows for more effective
acetabulum; this cut is also guided
fluoroscopic guidance; this oste- lateral and anterior acetabular cov-
by the false-profile fluoroscopic
otomy begins just inferior to the in- erage.28 Le Coeur originally
view.15,21,25,26
fracotyloid notch and extends described his osteotomy using cuts of
When all the cuts have been com-
toward the base of the ischial spine the pubis and ischium to allow for
pleted and the acetabular fragment is
for approximately 15 to 20 mm increased mobilization of the ace-
(Figure, Supplemental Digital Con- completely free, a Schanz pin is used tabular fragment.28,31,32 The main
tent 4, http://links.lww.com/JAAOS/ to manipulate the fragment into its limitation of this original triple oste-
A427).15,21,25,26 Care must be taken final position. The fragment is mobi- otomy is the sacrospinous ligament,
to stop short of the ischial spine, lized to include ideal lateral and which remains intact and can retro-
leaving the posterior column in anterior coverage as well as ideal vert the acetabular fragment, result-
continuity. Care must also be taken version of the acetabulum.15,21,25,26 ing in notable pelvic asymmetry.28 In
to remain extra-articular; as such, Fluoroscopy or a plain AP pelvic 1973, Steel28 modified Le Coeur’s
this osteotomy is typically performed radiograph is used to judge correc- triple osteotomy to divide the ischium
using the false-profile fluoroscopic tion intraoperatively; the osteotomy and pubis through an incision in the
view.15,21,25,26 The superior ramus is is fixed with three to four 3.5- or 4.5- buttocks.
exposed subperiosteally, and a mm fully threaded cortical screws Tönnis later further modified
pointed Hohmann retractor is used after preliminary correction has been Steel’s osteotomy and described a
for visualization medial to the oste- made and the surgeon is satis- juxta-articular triple osteotomy
otomy for retraction of a tight ilio- fied.15,21,25,26 Once the acetabular which conducts the ischial oste-
psoas tendon. Blunt retractors are correction has been obtained and otomy proximal to the ischial spine
placed subperiosteally around the fixation is stable, potential sources to avoid the connection to the sac-
superior ramus to protect the obtu- of femoroacetabular impingement rotuberous and sacrospinous liga-
rator neurovascular bundle. The are addressed by taking the hip ments, increasing the mobility of the
osteotomy is completed just medial through a full range of motion. The acetabular fragment and avoiding
to the iliopectineal eminence; care hip capsule can be exposed and the technical difficulty of retrover-
must be taken to remain perpendic- anterior capsulotomy performed at sion.33 However, this modification
ular to the bony surface of the ramus this point if femoral head-neck os- can create pelvic discontinuity and

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Pelvic Osteotomies in the Child Hip

destabilize both the pelvic ring and The superior ramus is exposed combined with reorientation osteot-
acetabular fragment. The triple extraperiosteally to protect the con- omies, especially if more efficient
osteotomy surgical technique con- tents of the obturator foramen and is correction is achieved than any sin-
tinues to evolve in the modern era; cut in an oblique fashion from the gle procedure alone.38,39
the most commonly performed pro- iliopectineal eminence into the most The shelf acetabuloplasty gains
cedure now follows a Bernese-type lateral aspect of the foramen using access to the outer table of the ilium.
approach through a single incision, either an osteotome or Gigli saw Rectangular strips of bone are har-
similar to a PAO without the pos- (Figure, Supplemental Digital Con- vested superior to the acetabular rim
terior column cut.30 A recent 15-year tent 5, http://links.lww.com/JAAOS/ (Figure, Supplemental Digital Con-
follow-up of Legg-Calvé-Perthes A428).29,30,34 tent 6, http://links.lww.com/JAAOS/
(LCP) patients treated with a triple The iliac osteotomy is performed A429). A groove is created at the
osteotomy reported an 85% success through the proximal aspect of this superior margin of the acetabulum,
rate based on radiographs and incision, angled down into the sciatic curving posteriorly. The harvested
functional outcome scores.34 Ho- notch using reverse Hohmann re- rectangular strips of bone are bev-
salkar et al also reported good results tractors to protect the contents of the eled at their tips and placed into the
in patients with open triradiate car- notch.29,30 A Schanz pin placed into groove. When the labrum is in a
tilage with femoral head deformity the acetabular fragment directs it normal position over the femoral
and acetabular dysplasia as a con- into the desired position where it head, it is left intact with the shelf
sequence of LCP; they note that the is then fixed in place with three to acetabuloplasty reinforcing it and
hip joint remodeling potential exists four 3.5-mm screws. Final position extending out laterally past the edge
even in patients older than 8 years of the acetabular fragment is con- of the native labrum. The patient is
who initially present with LCP and firmed with intraoperative AP and maintained in a hip spica cast for
in patients with complete femoral false-profile imaging. As the triple a minimum of 6 weeks. The shelf is
head involvement. Hosalkar re- osteotomy violates the posterior a salvage-type procedure that pro-
ported the triple can be an effective column and creates pelvic disconti- vides bone stock sufficient for a
reorientation osteotomy performed nuity, the acetabular fragment and future total hip arthroplasty. Tem-
for containment purposes in patients pelvic ring are unstable, typically porary preoperative and postopera-
with early extrusion of the femoral requiring rigid fixation and long- tive traction has been described in
head as a consequence of LCP.29 term postoperative immobilization the perioperative period to assist with
In the most contemporary tech- in a single-leg spica cast for a min- femoral head reduction at the time of
nique of a Bernese-type triple oste- imum of 6 weeks.28,30,34 shelf acetabuloplasty. The shelf can
otomy, the patient is placed supine be performed in a hip that has
on a radiolucent table, and the oste- arthritic changes present, in contrast
otomy is completed using a single Shelf Osteotomy to reorientation osteotomies.
anterior approach similar to a PAO
incision.28–30 The skin incision may Shelf osteotomies were the main sur-
need to extend further distally than gical treatment for acetabular dys- Chiari Osteotomy
the standard PAO incision, as the plasia until reorientation osteotomies
ischial cut needs to be directed became more popular and proved Another type of salvage osteotomy was
proximally to exit above the ischial more effective.35 Staheli’s shelf oste- developed by Chiari40 in 1974, which
spine and avoid tethering the oste- otomy creates an acetabular shelf to uses medial displacement of the can-
otomy into retroversion by the sac- restore femoral head coverage and cellous bone of the ilium to better
rospinous ligament. The ischial cut increase hip stability through the distribute the load of the hip joint. The
extends from the infracotyloid notch creation of a slot in the ilium for a major indication is a dysplastic hip
to a point proximal to the ischial bone graft.36 This osteotomy is a joint, especially in adolescents or
spine and is performed medial to the salvage procedure as bone is used to adults in whom a reorientation oste-
hip capsule and lateral to the ilio- increase coverage versus articular otomy is not possible.41 Most often,
psoas tendon with a curved mast cartilage.37 Hips with an acetabular patients undergo this procedure if
chisel, taking care to exit above the abnormality or aspherical congruity conservative treatment leaves residual
ischial spine. Retroversion can be are most indicative of this procedure, dysplasia or untreated congenital
avoided by a proximal trajectory of as reorientation osteotomies cannot dysplasia is maintained until adult-
the ischial cut to avoid leaving the appropriately correct the morphol- hood. This procedure has also been
ischiospinous ligament intact.28–30 ogy.36 This procedure can often be applied to hips that have developed

6 Journal of the American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Courtney M. Selberg, MD, et al

some degree of osteoarthritis, 3. Gillingham BL, Sanchez AA, Wenger DR: 16. Millis MB, Kain M, Sierra R, et al:
Pelvic osteotomies for the treatment of hip Periacetabular osteotomy for acetabular
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achievement of a concentric reduction Salter osteotomy and Tonnis lateral Wallrichs SL: Periacetabular and
acetabuloplasty with simultaneous open intertrochanteric osteotomy for the
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Midterm results. J Pediatr Orthop B 2016;
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Bone Joint Surg Am 1965;47:65-86. 19. Cunningham T, Jessel R, Zurakowski D,
sciatic notch at the inner and outer Millis MB, Kim YJ: Delayed gadolinium-
tables and an osteotomy of the iliac 6. Pemberton PA: Pericapsular osteotomy of enhanced magnetic resonance imaging of
wing are performed with a Gigli saw or the ilium for the treatment of congenitally cartilage to predict early failure of Bernese
dislocated hips. Clin Orthop Relat Res periacetabular osteotomy for hip dysplasia.
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7. Baki ME, Baki C, Aydin H, Ari B, Özcan 20. Sharifi E, Sharifi H, Morshed S, Bozic K,
with a complete cut in the sciatic notch M: Single-stage medial open reduction and Diab M: Cost-effectiveness analysis of
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