Can An Osteotomy Be Done Instead Of Shaving For Iliac Crest Reduction?

Q: Dr. Eppley, I was wondering if it would be possible (and if so what the main issues would be) to make a low osteotomy on the iliac crest and then rotate it inwards as a mean to achieve a greater hip reduction than it’s currently offered with the iliac crest resection method. In the attached file there’s the visual representation of what I mean. At the right is the unmodified hip and at the left the modified hip where I show two versions of the same idea, one (left) where the osteotomy goes above the ASIS process and the other (right) where the osteotomy does not go through the ASIS but below it and above the AIIS. The right one is probably the better option as it would allow for a bigger reduction and it would not mess with the process destined to support the TFL, sartorius muscle and the inguinal ligament. I’m also wondering if the gluteus muscles like the gluteus medius and the iliacus muscle on the iliac fossa would be a problem. Also, maybe rehabilitation would be harder because of the stretching of the muscles and ligaments. Thanks for your time.

A:Thank you for your thoughtful inquiry in regards to the iliac crest osteotomy. I would not disagree with you from a conceptual standpoint and clearly the one where the osteotomy line leaves the ASIS intact would be the more effective one in terms of inward movement and it is obviously prudent to leave the inguinal ligament attachment intact. Technically this would be more of a bone cut and tilting the iliac crest inward with the placement of inter-positional grafts (cadaveric bone chips) in the opening wedge that is created. I could see some issues trying to just push the iliac crest inward because of what lies on inner surface of the pelvis. But, quite frankly until you actually do it it’s hard to say which bony movement can actually be done with greater ease. This obviously would require some plate fixation.

I see only two potential issues with this approach really crest reduction. The first is you would have to strip off all of the TFL fascial attachments along the crest to expose the bone for the osteotomy cut. Whether they could be put back by suture suspension to the  crest is unknown, and if not,  what does that mean for postoperative ambulation. Secondly, how much greater benefit comes from moving the bony crest inward as opposed to shaving reduction. Theoretically you would think you would but I would not be so certain.  A fair amount of bone can be shaved off laterally that easily exceeds one cm. On the 3-D model you have to actually simulate both of them and see how much different it really is. In other words is the greater effort involved in the  iliac crest osteotomy  worth the additional improvements that provides over that are shaving. Like all aesthetic procedures the risk to benefit ratio must be very carefully calculated. And in iliac crest shaving reduction there have never been any significant aesthetic or functional issues.

Dr. Barry Eppley

World-Renowned Plastic Surgeon