Hip dysplasia in skeletally immature hips in which other pelvic osteotomies are ineffective, incomplete, or counterproductive. The use of this osteotomy is described in complex hip dysplasia secondary to neuromuscular and teratologic conditions.

 Plain anteroposterior (AP) radiographs of the pelvis and abduction/flexion/internal rotation view of the hips should be obtained. The surgeon should note the presence of triradiate cartilage and evaluate coverage of the femoral heads by measuring acetabular indices, lateral center edge angle of Wiberg, femoral head migration according to Reimer, Shenton’s line, and the presence of a congruent joint.

 Computed tomography of the pelvis with both proximal femurs and a single slice through the distal femoral condyles can be used to assess version of the femoral neck (Kim and Wenger, 1997). Three-dimensional reconstructions help localize acetabular deficiency and allow for more specific planning concerning the degree of correction in each plane using a mobilized acetabular socket (Lee et al., 1991).

 Smith-Petersen interval—superficial internervous plane between the sartorius (femoral nerve) and tensor fasciae latae (superior gluteal nerve) and deep internervous plane between the rectus femoris (femoral nerve) and gluteus medius (superior gluteal nerve).

 The lateral femoral cutaneous nerve should be preserved by incising the fascia of the tensor fasciae latae (TFL) from proximal to distal in an oblique fashion, remaining lateral to the anterior superior iliac spine (ASIS). Staying within the fascial sheath of the TFL will protect the lateral femoral cutaneous nerve because the nerve runs over the fascia of the sartorius. Cutting it can lead to a painful neuroma and diminished sensation on the lateral aspect of thigh.

 The large ascending branch of the lateral femoral circumflex artery crosses the operative field between the sartorius and TFL just below the ASIS and must be coagulated.

 Muscles either take origin from or insert into the iliac crest but do not cross it. Therefore, the crest offers a truly internervous plane. A part of the external oblique muscle attachment must be sharply incised to expose the underlying iliac apophysis for proximal extension of the approach. After sharply incising the iliac apophysis parallel to the crest, muscles attached to the crest may be stripped off the inner and outer wall of the ilium, always following the contour of the bone. Connecting this arm of the dissection to the Smith-Petersen interval provides excellent exposure.

 Contents of the greater sciatic foramen and lesser sciatic foramen—superior gluteal artery and nerve, inferior gluteal artery and nerve, pudendal nerve, internal pudendal vessels, nerve to the obturator internus, sciatic nerve, posterior femoral cutaneous nerve, nerve to the quadratus femoris. The internal pudendal vessels and nerve run in the lesser sciatic foramen along with the tendon of the obturator internus and nerve to the obturator internus. These structures passing through both foramens are at risk during the iliac and ischial osteotomy.

 Medial approach for ischial osteotomy—The anterior division of the obturator nerve passes through the obturator foramen between the adductor longus and brevis muscles. Tracing the nerve proximally will help locate the ischium, which borders the obturator foramen laterally.

 Pubic ramus osteotomy—While performing the pubic ramus osteotomy, the contents of the obturator foramen, which include the obturator nerve and vessels, have to be protected.

 The patient is positioned supine on a radiolucent table with a small padding under both hips and shoulder to elevate the torso.

 First incision to obtain exposure for ischial osteotomy

• The medial skin incision extends approximately 8 cm longitudinally along the posterior aspect of the adductor longus muscle.

• First the fascia is incised in a line parallel to the skin incision and blunt dissection is used to elaborate the plane between the adductor longus and the brevis. This will expose the anterior division of the obturator nerve, which overlies the adductor brevis.

• The nerve is traced proximally to the point at which it exits the obturator foramen, and a finger is then placed laterally in the foramen to identify the ischium.

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