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PELVIC OBLIQUITY. Mohahad osman, MD Assist. prof. Zagazig University. Definition of Pelvic Obliquity ( PO).

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PELVIC OBLIQUITY

Mohahad osman, MD

Assist. prof. Zagazig University

slide3

Definition of Pelvic Obliquity ( PO)

A- PO is failure of the pelvis to lie in a perfectly horizontal position in the frontal plane; ie; interspinous line is not perpendicular to midline of body provided that legs are parallel to midline of body.

B- 3-D definition : any fixed malalignment bet. Spine & pelvis, in frontal, sagittal, horizontal or all these 3 planes.

slide4

CLASSIFICATIONS of PO.

I- Mayer (1936) :

1- Functional / non-structural PO :

- present only when pt. stands with knees straight & no lift under foot & disappear on sitting & on recumbency w legs parallel to midline of body

- due to LLD.

2- Structural / fixed PO :

-persists in all positions & cannot be passively corrected.

-Aetiology: a- infrapelvic (hips) b- pelvic

c-suprapelvic ( spine) d- combined

slide5

Classifications of PO. ( cont.)

II- Dubousset ( 1991) :

1- Regular PO : spine & pelvis in same directions of deformity.

2- Opposite PO : in opposite directions.

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INFRA-PELVIC FIXED PO.

A- Congenital hip contracture:

1- cong. Abductor contracture

2- cong. Adduction contracture

B- neuromuscular hip contractures :

abd, add or both.

SUPRA-PELVIC FIXED PO.:

- in cong. or neuromuscular scoliosis

- not in idiopathic scoliosis ( curve not extend to pelvis )

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DISABILITY & SEQUILAE of PO.

A- locomotor:

Interferes w sitting, standing balance & walking.

B- 2ry. Deformities :

* spinal : L. scoliosis( cause / result) . Increased L. lordosis.

* hip : Abd / add contractures .

* knee : hyperextension on long side

* apparent LLD.

C- decubitus ulceration: ischial / G. trochanter on lower side.

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DIAGNOSIS & ASSESSMENT OF PO.

HISTORY

GENERAL EXAM.:

* CARDIOPULMONARY FUNCTION

* Gait :

- short leg limp ( dipping gait)

- Trendlenburg gait

EXAM OF DEFORMITY :

* inspection

* palpation

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EXAM for FIXED DEFORMITY:

a- Pelvic obliquity:

* Oblique pelvis : interspinous line is not perpendicular to midline of body provided that legs are parallel to midline of body

* functional PO.; present only when pt. stands with knees straight & no lift under foot & disappear on sitting & on recumbency w legs parallel to midline of body

* fixed PO. : persists in all positions & cannot be passively corrected

1- infra-pelvic; overcomed by swining legs to one side or other while recumbent.

2- supra-pelvic; never.

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EXAM for FIXED DEFORMITY ( cont):

B- Scoliosis:

* trunk alignment : plumb line

* type of curve

* flexibility / rigidity of curve

* rotation

* neurologic exam.

* clinical photographs.

C- Fixed hip def. : abd, add, flexion ,rotation

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ROM : hip. Spine . Knee. Ankle.

NEUROLOGIC EXAM:

- Power - specific muscles ( hip / trunk) -sensation

MEASUREMENTS :

- PO. - LLD ( app / true) - circumference.

SPECIAL TESTS :

- iliotibial band

- hip instability.

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RADIOLOGIC ASSESSMENT

A- Pelvic obliquity :

* diagnosis of PO. :

- in frontal plane - 3-D

* Angle of PO: Osebold , 1982

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B- Scoliosis:

A- Angle ( Cobb )

B- rotation ( pedicles displac.)

C- c rigidity : - side bending - traction - suspension

D- Torso decompensation: Osebold

E- Pt. maturation : Risser sign

LORDOSIS

SPINA BIFIDA

2ry changes in hips

CT

MRI

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A- side-bending XR

B- suspension XR

B

A

C- traction XR

C

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C- MEASUREMENT of LEG LENGTH

  • Plain X- ray: scanogram
  • CT

OTHER INVESTIGATIONS:

* cardiopulmonary

* Biochemical ; ms dystrophy

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TREATMENT

TTT of PO is directed to the specific cause

Ttt of functional PO:

- by leg length balancing

- up to 3 cm LLD ; shoe lift

- > 20 cm LLD; orthosis

- 3-20 cm LLD; shortening, lengthening or both.

* correct bony def. or jt. Contracture 1st.

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TTT of infra-pelvic type:

A- cong hip contractures:

- early ; stretching / traction and spica casting

- neglected ; surgical release & splinting.

B- Paralytic hip contractures ; surgical

- abd contracture by ;

1- soft tissue release ( prox & distal).

2- STR+ erector spinae transplant or

3- STR+ intertroch. femoral osteotomy ; > 3 y old, severe, 3-D

- add contracture ;

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TTT of supra-pelvic type

A- Abdominal fascial plastic operations

B- Muscle- tendon transplant operations

C- Spinal surgery.

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Spinal surgery :

Objective: correction of def. to the point at which pelvis is level & then fusion of spine & pelvis in that corrected position.

Methods :

A- Post. Surgery only; if pelvis can be levelled by passive bending / traction

* Harrington sacral bar * Luque * recent segmental instrumentations

B- Combined ant. & post . Surgery ; if pelvis can not be levelled by passive bending / traction or deficient post. elements

* ant correction& fusion without instrumentation

* ant correction& fusion with instrumentation ( Dwyer system).

slide30

TTT of combined type

A- correct hip & knee def. 1st then spinal fusion, otherwise spinal def will recur [ Barr, 1950 & Turek, 1984]

B- Beaty [1992]; when PO is moderate & L. scoliosis is fixed , correct scoliosis w instrumentation 1st.

slide31

TTT of PO that cannot be corrected by hip / spinal surgery

INDIC.:

1- 2ry osseouship changes or 2ry arthritic changes in L spine rendering full correction impossible.

2- residual significant fixed PO [ 18 deg]

METHODS:

1- LL realigning to trunk by femoral osteotomy

2- post iliac osteotomy [ Lindseth,1978]; compensating pelvic def. placing isch tuberosities & acetabla in planes perpendicular to long axis of body

3- ischium excision; partial / complete

ad