An Osteotomy is an operation where a bone is cut, usually realigned in some way, and then re-fixed to heal in its new configuration. This is usually done to improve its orientation and reduce the risk of the adjacent joint tiring out or wearing out prematurely.
Interlocking Triple Pelvic Osteotomy is a major operation to realign the hip socket to correct mis-alignment of the socket, usually due to diseases of the hip that have developed during childhood and manifest themselves as tiring out of the hip joint in early adult life.
Over the last 20 years, two surgeons in Germany, Professor Tonnis and Professor Wagner, have performed several hundred operations of this type and have reported excellent results.
Professor Tonnis has followed up over 270 patients whose operations were done between 15 and 17 years ago. Approximately 85% of his patients have remained symptom free. 3% of his patients have had total hip replacements carried out. The remainder of his patients remain significantly improved but are not entirely symptom free. Professor Heinz Wagner reported a series of 200 patients, 100 of whose operations were more than 20 years old. Only one hip replacement had been necessary in this group, although he did have to realign the femur (or thighbone) afterwards in a proportion of his patients, as their symptoms were not completely relieved by realigning the hip socket alone.
Over the last 12 years I have performed more than 700 interlocking triple pelvic osteotomies of my own design. By careful planning of the bone cuts, the osteotomy is intrinsically very stable. In the last 3 or 4 years I have developed a form of internal fixation, which is solid enough to allow nearly full weight bearing virtually immediately.
So far there has been a 6% re-exploration rate – this is where the osteotomies have moved, have healed in the wrong position or have failed to heal. This rate reflects the whole period of my experience and has been declining in recent times. I investigated this 6% re-exploration rate and discovered that smoking was a major factor here. Whilst 25% of the general population smoke, 80% of the patients who had their pelvic osteotomies re-explored were smokers. Smoking is known to impair the growth and development of small healing vessels and therefore interferes with bone healing.
Out of this whole cohort of patients, two men, one of whom had a simple triple osteotomy and the other of whom had it combined with a valgus osteotomy of the femur with lengthening, have had sciatic nerve permanent partial sciatic nerve palsies. As a result of this they have very good function in the region of the affected hip joint but have numbness in the ankle and extensive numbness below the knee.
The second patient mentioned, also bled a great deal during the course of the operation and it is possible that damage was caused to one of the nerve cables whilst trying to stop the bleeding.
There have been 7 patients who have had transient sciatic nerve irritation – temporary numbness or weakness, which recovered fully. There has been one patient where, following a combination of a valgus osteotomy and a triple osteotomy, the leg, being restored to its full length, stretched the sciatic nerve that the patient had sciatic nerve pain and weakness. A week later it was necessary to re-explore the operation and shorten the leg a centimetre in order to restore sciatic nerve function. As might be anticipated, her leg is one centimetre short (previously it was four). She requires a small heel insert and has otherwise excellent function.
In recent years, since 1995, when I have performed perhaps 100 cases or more each year, I have had a short-term failure rate of approximately 0.5% – one patient every year who requires a resurfacing. Such operations are not compromised in any way by having had a previous triple osteotomy – and indeed the socket is more stable so the fixation of the resurfacing is usually better than it would otherwise be.
his is a relatively recent use of this operation. I have been using it for approximately eight years. There are surgeons in Austria, South Africa and San Diego California, who also have recent experience of this operation in the treatment of Perthes’ disease. None of us has experience of more than about nine years.
The operation aims to regain the cover of the hip socket for the thighbone (femoral head) – a characteristic problem in this condition.
I have 25 patients whose operations have been done more than five years ago. The results are such that none of these patients has regretted having this operation performed, and in no case have I regretted operating.
Whilst vastly improving the appearance of the x-rays, the patients have, with one exception, experienced a vast improvement in their pain, an improved range of movement (although slightly less than normal) and have generally been able to enjoy life a great deal more afterwards.
In the longer-term I do not know what the outcome of this operation will be, but given that we know achievement of a round head on the thighbone is a key to success in the longer-term and this has been the usual outcome in our small number of patients, I am optimistic about the future.
Before carrying out this operation, it is usual to have a manipulation of the hip under anaesthetic and put on thigh broomstick plasters – short plaster cuffs on the thighs attached to one another by a broomstick, so as to keep the thighs apart. These are worn for about 2 weeks and though a source of some inconvenience.
After your initial consultation and the decision being been made as to the type of surgery required, you are usually investigated carefully with various scans and x-rays in order to plan as accurately as possible the direction and degree of required correction of the hip socket.
Wherever possible I encourage you to meet or make contact with other patients who have had similar operations performed (or, indeed, to read their stories on this site), so that you can find out what to expect.
Prior to the operation some people have a course of physiotherapy in order to improve their range of movements. Some patients need a brief examination of the hip movements under anaesthetic. Some patients benefit from an injection into the hip under anaesthetic, both to clarify the diagnosis and give an idea of the likely benefit from treatment and to ease pain. This injection cannot be expected to be curative, but it gives the patient an idea of the improvement that could be expected after surgery.
In readiness for the operation it will be necessary for you to have some routine blood tests. A small sample of your blood is taken so that units of blood matched to your own are available should they be necessary during surgery. You will also be checked to make sure you are not anaemic and that other risk factors are kept to a minimum. Having your blood sample taken is a very simple procedure and only takes a few minutes.
You may also need to have an ECG (heart tracing) performed and a chest x-ray, but this will depend on your age and general level of fitness. Some younger people do not need these tests taken. If you are a National Health Service patient, you will be admitted to hospital the day before your operation and these tests will be performed at that time.
So the dreaded day dawns and yes, I know you will be nervous and dreading the prospect of the operation. This is why I always try and admit my private patients to hospital on the day of their surgery. I ask you not to eat anything for six hours beforehand and not to drink anything for three to four hours prior to surgery. If you are a National Health patient you will be admitted the day before your surgery, so that all the necessary pre-operative tests can be performed.
In the private sector you will come into hospital a few hours before your operation. You will then be required to fill out various forms. Once this has been done you will be shown to your own room, with an en-suite bathroom. You are then asked to shower or bathe and will be given a theatre gown. You will also be given an elasticated stocking to wear, which is to prevent the risk of deep venous thrombosis (DVT) and needs to be worn for at least four weeks. Deep vein thrombosis is a serious risk factor but is routinely treated with daily injections of Clexane, which minimises the risk. Very rarely if a deep venous thrombosis develops, it is possible to develop a pulmonary embolism (clot in the lungs). This is a very rare but life threatening condition but can be treated successfully with drugs to thin your blood. You will also be asked if you are allergic to anything, including drugs, food and metal. If you are allergic to anything this will be marked on an armband and will need to be worn so that anyone who is caring for you will know of your allergies or sensitivities.
My Consultant Anaesthetist colleague and I will see you before the operation. If you are taking any drugs, please bring them with you and show them to the Consultant Anaesthetist. The operation itself is performed under general anaesthetic, often with additional epidural pain relief used. It takes approximately 2 hours, but you are likely to be away from the ward for 4 or 5 hours normally. Some patients stay overnight in the High Dependency Unit and are away from their room/ward for an extra 24 hours.
The operation itself is done through two wounds. There is a small wound on the buttock, in the flesh part, approximately 6.5-7.5cm (2.5-3″) long. There is a second wound in the groin, in the crease of the skin where you bend your leg, approximately 12.5cm (5″) long. Both wounds are sewn up with invisible stitches that self-dissolve and do not need removal. As a result, the wounds do not have any cross-hatching afterwards.
The wound in the groin involves the handling of a nerve to the skin in the outer part of the thigh, where you would feel if you put your hand in your pocket. It is very common for this area to be numb afterwards and this numbness does not always recover perfectly. Whilst the numbness is recovering some patients get shooting pains in the area that was previously numb. This can be an irritation and a little unnerving, but is of no adverse effect.
When you start to come round from the anaesthetic you will be aware of an oxygen mask around your nose and mouth, elasticated stockings on both legs to help to prevent a deep vein thrombosis developing, a drip going into your vein to replace fluids, a cuff on your arm to measure your blood pressure, a sensor on your fingertip to record your pulse and oxygen level. The bottom of your bed may be raised. You will have a pain-controlling device attached to your wrist, which you can operate yourself, but is controlled so that you cannot give yourself too much analgesia.
After you have woken up completely you will be taken back to your room/ward where nurses will look after you. There is always a qualified doctor on call 24 hours a day, should it be necessary for you to have medical attention, which is a fairly rare occurrence. The anaesthetist will call in and make sure your pain control is adequate. I will call in and see you on a regular basis to ensure your progress is satisfactory.
For approximately 24 hours after your operation you will have a period of rest, pain relief and general support from the nurses. The operation is usually structurally sound and will bear at least some of the weight of the body on the leg. Thereafter, it is possible to become mobile quite quickly. Many patients, on the afternoon after their operation, are able to get up out of bed and take a few steps, perhaps going to the toilet. Thereafter, the Physiotherapist begins a programme of exercises and activities to restore the function of the hip. Some younger and more active patients have managed to go home on the 4th or 5th day after their operation, but a week after surgery is more usual: 5 ½ days is the average.
Unlike a hip replacement, with this type of operation there is no need whatsoever to be worried that the hip is unstable and might come out of joint. In fact, the hip is more stable, and apart from considerations of comfort, you can do as much as you wish, as soon as you are able, without risk.
One patient has fallen down on a slippery floor – did the splits – and loosened the screws, causing a serious loss of position. As a result of this risk, if you do not have somebody else at home it is advisable, before coming in to hospital, to arrange various facilities in your kitchen in such a way as to minimise the demands on your hip bending in the first few weeks.
It may be useful to have your bed moved to a downstairs room if you feel you will have difficulty going up and down stairs. Likewise, if you make provision of some microwavable meals, certainly for the first week or so, these could be particularly useful.
Whilst after a total hip replacement it is virtually obligatory to sit on a raised toilet seat and use a high chair (due to the risk of dislocation), following an Interlocking Triple Pelvic Osteotomy, the only requirement is that you sit on a chair you can easily get up out of without assistance, and possibly to have some handles on the wall next to your toilet to ease getting up an down.
Gradually, over the first 6-8 weeks after the operation, having a comprehensive course of physiotherapy and/or hydrotherapy, you will gradually become more independent and more confident. Most patients need to use both crutches for the first 5 or 6 weeks, but thereafter many patients discard one crutch and often just use one stick. I try to persuade patients that by six weeks after their operation they should be getting rid of one crutch and a further four or five weeks after that they should be getting rid of the second crutch. Patients who have had associated angular corrections of the thigh will take longer to rehabilitate – up to 50% longer than those who have had an interlocking triple pelvic osteotomy alone.
In the first six weeks after the operation it is ideal for you to have hydrotherapy, involving a complete programme of range of movement exercises in all directions – again we do not need to be particularly concerned that any particular movement would put the hip at risk under these circumstances – the hip is always more stable post-operatively than pre-operatively.
I advise you following this operation – and indeed beforehand – not to take anti-inflammatories because they are known to impair bony union. They also slow down periarticular ossification, (conversion of cartilage etc into bone around the joint), but I have never seen periarticular ossification following interlocking triple pelvic osteotomies in the way I perform it. I usually advise patients to take Co-proxamol, Co-dydramol or Tylex.
You are seen six weeks after your operation, a further six weeks later (i.e. three months) and at six and twelve months post-operatively. An x-ray will be taken on each occasion. Please bring all your x-rays (plus the pre-operative x-rays and scans) with you to each consultation. If you live abroad I will ask you to have x-rays taken locally at all of these stages and send them to me, so that I may check on your progress this way. By the first anniversary of your operation I will discharge you from my care.
Generally speaking, it takes at least a year to fully appreciate the benefits of the operation in terms of relief of symptoms and significant improvement in mobility and independence.
Q Why should I have the operation performed now?
A Hip dysplasia is not a benign or harmless condition. It is known that, from studies of patients who have presented with hip dysplasia over the years, once the joint is symptomatic it is most unusual for symptoms to get better while maintaining activities, although some people will get relief of symptoms by restricting activities. It is possible to defer operation by reducing activities. Unfortunately, many such people come to the clinic 10 years later than is ideal and they have often put on weight because of their chronic mild physical disability. The operation itself then becomes harder to do. The joint is at greater risk of having deteriorated to a level that the operation no longer works. The rehabilitation is a great deal slower because the person has lost fitness before the operation.
Q Why should I have a triple pelvic osteotomy, rather than a hip resurfacing or hip replacement?
A A modern triple pelvic osteotomy, for people whose hips are suitable, is a much better bet in the long-term than any form of operation that replaces the joint surfaces. Once you have lost your joint surfaces and replaced them, you can never have them back. A well-performed osteotomy, if carried out in time, can be expected to have a 75-80% survival over a 20-year period: this is better than the survival yet achieved for any hip replacement or resurfacing. A triple pelvic osteotomy therefore offers a very good chance of buying a significant amount of time before replacement is, if ever, required.
Q How long will I be in hospital?
A Approximately 7 nights. If you live locally I ask you to pop along to have a blood sample taken for cross-matching purposes, so that if I need to give you a blood transfusion I have blood perfectly compatible with your own available. However, if you live out of the area, I admit you the day before so the blood sample may be taken and cross-matched. You are then admitted on the day of your operation. I don’t believe in admitting you the day before, as no matter how nice a hospital is nobody wants to stay there longer than absolutely necessary and apart from having to do the paperwork and maybe some minor tests, such as an x-ray or ECG (but only on much older patients), there is nothing to be done and people tend to just worry about their forthcoming surgery unnecessarily.
Q What sort of anaesthetic will I have?
A The operation is performed under a general anaesthetic, which is administered by a Consultant Anaesthetist, who is fully conversant with hip surgery and who will be happy to talk to you when you are admitted to hospital if you have any particular fears, concerns, or worries.
Q What about the post-operative treatment?
A After discharge from hospital, for the first 6-12 weeks, there will be a fairly busy period when you will be seen by the Physiotherapist several times each week. During the first six weeks you will not be encouraged to put full weight on the joint, but partial weightbearing is encouraged. All forms of exercises, including hydrotherapy, are carried out during that time. When not going to physiotherapy and hydrotherapy, the hip will benefit from being “walked” into shape.
Q How long will I be attending the clinic?
A The vast majority of people who have a successful triple osteotomy carried out are discharged from the clinic soon after their metalwork is removed at about a year afterwards. People, of course, are free to come back to be seen if any problems occur later on.
Q What about removing the metalwork?
A The metalwork needs to be removed through the same wound through which it was inserted, but it doesn’t usually need the whole wound to be reopened. It is not necessary to relearn how to walk and use the muscles afterwards because there is only a very short period of discomfort afterwards – usually solved by perhaps a week or two of the use of Paracetamol. You will only be in hospital for one night when this procedure is carried out.
Q Why do I need to have the metal work removed?
A It is usually worth taking the metalwork out because it isn’t really meant to be there. It is stiffer than the bone and if you really want to have a spring in your step, dance the night away or indulge in contact sports, you almost certainly need it removed. If you think it isn’t important in the short-term to have it removed, if it’s left in for much more than a year, it becomes rather difficult to remove.