Pemberton Osteotomy

Pemberton OsteotomyThis pericapsular osteotomy was described by Pemberton in 1965. It has become more widely used with time for correction of dysplasia due to developmental hip dysplasia and neuromuscular disorders.

Indications

This osteotomy is indicated for correcting persisting acetabular dysplasia in the child less than 6–7 years of age with DDH and about 10–12 years of age with neurodysplasia. The procedure changes the shape of the acetabulum, as the osteotomy hinges at the triradiate cartilage.

Pemberton and Salter osteotomies have similar indications. The advantages of the Pemberton procedure are the feasibility to perform bilateral procedures in one operative session, the lack of need for pin fixation, and a greater capacity for correction. The disadvantage is the alteration in the shape of the acetabulum, which requires the procedure to be performed early in childhood to allow sufficient time for remodeling to create congruity with the femoral head.

Preoperative Planning

Make available curve osteotomes. Special Pemberton osteotomes with a 90° curve are available for the final portion of the osteotomy but are not essential. Determine in advance the need for an open reduction by abduction internal rotation radiographs and/or a preliminary arthrogram.

Technique of Pemberton Osteotomy

Prep and drape the leg free with the pelvis slightly elevated. Make a bikini incision parallel to and slightly below the iliac crest. Expose the inner and outer pelvis through a standard approach. Place a retractor in the sciatic notch. Perform a psoas release and an open reduction if indicated. Perform a curved osteotomy that starts just above the insertion of the rectus and curves paralleling the acetabulum and into the triradiate cartilage just lateral to the sciatic notch. If uncertain about the osteotomy, monitor with imaging. From the ilium, remove a triangular wedge of bone with the base about 2–3 cm. Open the osteotomy with a lamina spreader and place the graft in under compression. Create an acetabular index of about 10°, but avoid overcorrection. Trim graft. The graft should be solidly impacted in the osteotomy and secure without fixation. Close the wound and apply a spica cast with the hip in about 30° flexion, 30° abduction, and neutral rotation. Remove the cast in the clinic in 6 weeks. Hip stiffness may occur but will resolve spontaneously over a period of a few weeks or months.

Clinical Examples

Unilateral dysplasia A 12-month-old infant with DDH following closed reduction is shown. Persisting dysplasia was noted at 24 months. A Pemberton osteotomy was performed at 28 months.
Bilateral dysplasia A 30-month-old infant with DDH has persisting dysplasia corrected by concurrent bilateral Pemberton osteotomies.

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