Periasetabuler osteotomilerde medial girişimle uygulanan iskiyal ve pubik osteotomiler: Anatomik bir çalışma

Öz

Amaç: Bu çalışmanın amacı Bernese periasetabuler osteotomisindeki iskiyum ve pubis osteotomilerinin anatomik referans noktalarının saptanması, bu noktaların çevre nörovasküler yapılara mesafelerinin ölçülmesi ve bu osteotomilerin medial girişimle görerek yapılıp yapılamayacağının belirlenmesiydi. Çalışma planı: Çalışmada formaldehit ile tespit edilmiş 10 adet kadavranın 20 hemipelvisi kullanıldı. Kalçaya, medial cerrahi yaklaşımla adduktor longus ve pektineus kasları arasından girilerek obturator arter ve sinir görülerek korundu. Subperiostal olarak ortaya koyulan üst pübik ramusta anterior obturator tüberkülün ön sınırı ve obturator sulkusun tepe noktasının obturator krestteki izdüşümü pübik kemik osteotomisi hattındaki iki nokta olarak belirlendi. İskiyal kemikte posterior obturator tüberkülün alt sınırı ile iskiyadik spinanın tepe noktasını birleştiren çizgi ostetomi hattı olarak tanımlandı. İskiyum osteotomisinin pudendal nörovasküler yapılara olan mesafesini ölçmek amacıyla posterior diseksiyon yapıldı. Tüm ölçümler dijital kompas kullanılarak gerçekleştirildi. Bulgular: Obturator sulkusun obturator sinire uzaklığı ortalama 15.3 (dağılım: 8.1-30.5) mm olarak bulundu. Anterior obturator tüberkülün obturator sinire uzaklığı ortalama 19.5 (dağılım: 27.1-49.5) mm, obturator artere ise 38.5 mm (dağılım: 29.4-51.1) mm idi. İskiyum osteotomisinin pudendal nörovasküler yapılara uzaklığı ise ortalama 13.6 (dağılım: 11.2-17.6) mm bulundu. Çıkarımlar: Pubis ostetomi hattını oluşturan anterior obturator tüberkül ve obturator krest ile posterior obturator tüberkülün alt sınırına (iskiyum osteotomisinin başlangıç noktası) Bernese periasetabuler osteotomisinde medialden yapılan girişimle görerek, güvenli bir şekilde ulaşılabilmektedir.

Anahtar Kelimeler

• İskiyum osteotomisi; medial yaklaşım; periasetabuler osteotomi; pubis osteotomisi.

Ischial and pubic osteotomies performed by medial approach during periacetabular osteotomies: an anatomical study

Öz

Objective: The aim of this study was to identify the anatomic landmarks of ischial and pubic osteotomies performed as part of Bernese periacetabular osteotomy, measure the distances of these landmarks to the main neurovascular structures and determine whether these osteotomies can be performed and visualized using a medial approach.
Methods: The study included 20 hemipelvises of 10 formaldehyde-fixed cadavers. A medial surgical approach between the adductor longus and pectineus muscles was used, while protecting the obturator artery and nerve. The superior pubic ramus was subperiostally exposed to identify the anterior border of the anterior obturator tubercle and the projection point of the highest point of the obturator sulcus on the obturator crest as the two landmarks of pubic bone osteotomy. The line connecting the inferior border of the posterior obturator tubercle and the highest point of the ischial spine on the ischial bone was determined as the osteotomy line. Posterior dissection was carried out to measure the distance from the ischial osteotomy to the pudendal neurovascular structures. All measurements were performed using a digital caliper.
Results: The mean distance from the obturator sulcus to the obturator nerve was 15.3 (range: 8.1 to 30.5) mm. The mean distance from the anterior obturator tubercle to the obturator nerve was 34.3 (range: 27.1 to 49.5) mm and to the obturator artery was 38.5 (range: 29.4 to 51.1) mm. The mean distance from the ischial osteotomy to the pudendal neurovascular structures was 13.6 (range: 11.2 to 17.6) mm.
Conclusion: The ‘pubic osteotomy line’ connecting the anterior obturator tubercle and obturator crest, and the inferior border of the posterior obturator tubercle (the starting point of the ischial osteotomy line) can be approached and visualized safely using a medial incision in Bernese periacetabular osteotomy

Anahtar Kelimeler

• Ischial osteotomy
• medial approach
• periacetabular
• pubic osteotomy

Kaynakça

1. Ganz R, Klaue K. Vinh TS. Mast JW. A new periacetabular osteotomy for the treatment of hip dysplasias. Technique and preliminary results. Clin Orthop Relat Res 1988;(232):26-36.
2. Siebenrock KA, Schöll E, Lottenbach M, Ganz R. Bernese periacetabular osteotomy. Clin Orthop Relat Res 1999;(363):9-20.
3. Trousdale RT, Cabanela ME. Lessons learned after more than 250 periacetabular osteotomies. Acta Orthop Scand 2003; 74:119-26.
4. Biedermann R, Donnan L, Gabriel A, Wachter R, Krismer M, Behensky H. Complications and patient satisfaction after periacetabular pelvic osteotomy. Int Orthop 2008;32:611-7.
5. Thawrani D, Sucato DJ, Podeszwa DA, DeLaRocha A. Complications associated with the Bernese periacetabular osteotomy for hip dysplasia in adolescents. J Bone Joint Surg Am 2010;92:1707-14.
6. Hussell JG, Mast JW, Mayo KA, Howie DW, Ganz R. A comparison of different surgical approaches for the periacetabular osteotomy. Clin Orthop Relat Res 1999;(363):64-72. Peters CL, Erickson JA, Hines JL. Early results of the Bernese periacetabular osteotomy: the learning curve at an academic medical center. J Bone Joint Surg Am 2006;88:1920-6.
7. Davey JP, Santore RF. Complications of periacetabular osteotomy. Clin Orthop Relat Res 1999;(363):33-7.
8. Hussell JG, Rodriguez JA, Ganz R. Technical complications of the Bernese periacetabular osteotomy. Clin Orthop Relat Res 1999;(363):81-92.

9. Kinoshita K, Naito M, Shiramizu K, Shiramizu K, Kamada S. Prevention of obturator artery injury during pubic osteotomy in periacetabular osteotomy. Curr Orthop Pract 2011;22:171
10. Kamada S, Naito M, Shiramizu K, Nakamura Y, Kinoshita K. Is the obturator artery safe when performing ischial osteotomy during periacetabular osteotomy? Int Orthop 2011;35:503-6.
11. Kambe T, NaitoM, Asayama I, Koga K, Fujisawa M, Yamaguchi T, et al. Vascular anatomy for rotational acetabular osteotomy: cadaveric study. J Orthop Sci 2003;8:323-8. de Kleuver M, Kooijman MA, Kauer JM, Kooijman HM, Alferink C. Pelvic osteotomies: anatomic pitfalls at the ischium. A cadaver study. Arch Orthop Trauma Surg 1998;117:376-8.
12. Shiramizu K. Curved periacetabular osteotomy for the dysplastic hip: cadaveric and radiological analyses of safe procedures. J Orthopaed Traumatol 2003;4:55-60.
13. Crockarell J Jr, Trousdale RT, Cabanela ME, Berry DJ. Early experience and results with the periacetabular osteotomy. The Mayo Clinic experience. Clin Orthop Relat Res 1999;(363): 45Wall EJ, Kolata R, Roy DR, Mehlman CT, Crawford AH. Endoscopic pelvic osteotomy for the treatment of hip dysplasia. J Am Acad Orthop Surg 2001;9:150-6.
14. Beck M, Leunig M, Ellis T, Sledge JB, Ganz R. The acetabular blood supply: implications for periacetabular osteotomies. Surg Radiol Anat 2003;25:361-7. de Kleuver M, Kooijman MA, Kauer JM, Veth RP. Pelvic osteotomies: anatomic pitfalls at the pubic bone. A cadaver study. Arch Orthop Trauma Surg 1998;117:270-2.
15. Inan M, Gokce A, Ustunkan F. Endoscopy-assisted periacetabular osteotomy: a preliminary cadaveric study. Clin Orthop Relat Res 2008;466:862-70.
16. Troelsen A, Elmengaard B, Sİballe K. Comparison of the minimally invasive and ilioinguinal approaches for periacetabular osteotomy: 263 single-surgeon procedures in welldefined study groups. Acta Orthop 2008;79:777-84.