Modified Smith-Petersen Approach Research Articles

Modified Smith–Petersen approach with rectus-sparing reduces severe avascular necrosis for developmental dysplasia of the hip at walking age: minimum 5-year follow-up

BackgroundDevelopmental dysplasia of the hip (DDH) is one of the most common orthopedic malformations in children. Open reduction for DDH at walking age remains a major concern. The goal of this study is to evaluate the mid-term effect of a modified Smith–Petersen approach which preserves the rectus femoris on DDH at walking age, in particular avascular necrosis (AVN).MethodsA retrospective review of DDH patients aged between 12 and 24 months was carried out between January 2010 and June 2016. Open reduction through the Smith–Petersen approach (Group A) and modified Smith–Petersen approach, which preserves the rectus femoris (Group B), were both used. Measurement of hip geometry included acetabular index, the International Hip Dysplasia Institute classification, and AVN degree. Clinical records included operation time, bleeding volume, and abduction angle.ResultsThere were 101 children (119 hips) with DDH who met the inclusion criteria. There were 66 hips in Group A and 53 in Group B. The mean surgical age at open reduction was 17.0 ± 2.4 months, with a mean 104.9 ± 19.5 months at last follow-up. There was no statistical difference in surgical age between the two groups (17.2 vs. 16.4 months). There was no significant difference in the incidence of all types of clinically significant AVN between group A and group B (27.3 vs. 18.9%), but the incidence of severe AVN was lower in group B (19.7 vs. 5.7%, P = 0.026). In addition, the lower the age at the time of open reduction, the lower the severity of AVN (P = 0.002).ConclusionsThese mid-term data suggest that the modified Smith–Petersen approach with rectus-sparing could reduce severe AVN more than the classical Smith–Peterson approach in open reduction in DDH at walking age. In addition, early open reduction can reduce the postoperative degree of AVN.

Early open reduction of dislocated hips using a modified Smith-Petersen approach in arthrogyposis multiplex congenita

BackgroundArthrogryposis multiplex congenita (AMC) is a rare syndrome with multiple joint contractures. Within the medical community, there is controversy surrounding AMC in terms of the ideal surgical approach and age for performing a reduction of dislocated hips. The purpose of this retrospective study was to evaluate the clinical outcomes of early open reduction of infant hip dislocation with arthrogryposis multiplex congenita following a modified Smith-Petersen approach that preserves the rectus femoris.MethodsFrom 2010 to 2017, we performed this procedure on 28 dislocated hips in 20 infants under 12 months of age with AMC. The clinical and radiology data were reviewed retrospectively. The mean age at surgery was 6.9 ± 5.1 months, with a mean follow-up of 42.4 ± 41.1 months.ResultsAfter open reduction, the average hip acetabular index (AI), the international hip dysplasia institute classification (IHDI), and the hip range of motion significantly improved (all P < 0.001). After the surgery, 16 patients were community walkers, and four patients were home walkers. Three hips in two patients required secondary revision surgery for residual acetabular dysplasia with combined pelvic osteotomy and femoral osteotomy. Seven of the hips that had been operated on showed signs of avascular necrosis (AVN). Among them, four were degree II, two were degree III, and one was degree IV. Multiple linear regression analysis demonstrated that greater age (in months) heightened the risk for secondary revision surgery (P = 0.032).ConclusionsThe modified Smith-Petersen approach preserving the rectus femoris is an encouraging and safe option for treating hip dislocation in young AMC patients (before 12 months). If surgery takes place at less than 12 months of age for patients with AMC, this earlier open reduction for hip dislocation may reduce the chances of secondary revision surgery.Level of evidenceIV, retrospective non-randomized study.

CORR Insights®: Does the Watson-Jones or Modified Smith-Petersen Approach Provide Superior Exposure for Femoral Neck Fracture Fixation?

CORR Insights®: Does the Watson-Jones or Modified Smith-Petersen Approach Provide Superior Exposure for Femoral Neck Fracture Fixation?

Does the Watson-Jones or Modified Smith-Petersen Approach Provide Superior Exposure for Femoral Neck Fracture Fixation?

A well-reduced femoral neck fracture is more likely to heal than a poorly reduced one, and increasing the quality of the surgical exposure makes it easier to achieve anatomic fracture reduction. Two open approaches are in common use for femoral neck fractures, the modified Smith-Petersen and Watson-Jones; however, to our knowledge, the quality of exposure of the femoral neck exposure provided by each approach has not been investigated. (1) What is the respective area of exposed femoral neck afforded by the Watson-Jones and modified Smith-Petersen approaches? (2) Is there a difference in the ability to visualize and/or palpate important anatomic landmarks provided by the Watson-Jones and modified Smith-Petersen approaches? Ten fresh-frozen human pelvi underwent both modified Smith-Petersen (utilizing the caudal extent of the standard Smith-Petersen interval distal to the anterosuperior iliac spine and parallel to the palpable interval between the tensor fascia lata and the sartorius) and Watson-Jones approaches. Dissections were performed by three fellowship-trained orthopaedic traumatologists with extensive experience in both approaches. Exposure (in cm) was quantified with calibrated digital photographs and specialized software. Modified Smith-Petersen approaches were analyzed before and after rectus femoris tenotomy. The ability to visualize and palpate seven clinically relevant anatomic structures (the labrum, femoral head, subcapital femoral neck, basicervical femoral neck, greater trochanter, lesser trochanter, and medial femoral neck) was also recorded. The quantified area of the exposed proximal femur was utilized to compare which approach afforded the largest field of view of the femoral neck and articular surface for assessment of femoral neck fracture and associated femoral head injury. The ability to visualize and palpate surrounding structures was assessed so that we could better understand which approach afforded the ability to assess structures that are relevant to femoral neck fracture reduction and fixation. After controlling for age, body mass index, height, and sex, we found the modified Smith-Petersen approach provided a mean of 2.36 cm (95% confidence interval [CI], 0.45-4.28 cm; p = 0.015) additional exposure without rectus femoris tenotomy (p = 0.015) and 3.33 cm (95% CI, 1.42-5.24 cm; p = 0.001) additional exposure with a tenotomy compared with the Watson-Jones approach. The labrum, femoral head, subcapital femoral neck, basicervical femoral neck, and greater trochanter were reliably visible and palpable in both approaches. The lesser trochanter was palpable in all of the modified Smith-Petersen and none of the Watson-Jones approaches (p < 0.001). All modified Smith-Petersen approaches (10 of 10) provided visualization and palpation of the medial femoral neck, whereas visualization of the medial femoral neck was only possible in one of 10 Watson-Jones approaches (p < 0.001) and palpation was possible in eight of 10 Watson-Jones versus all 10 modified Smith-Petersen approaches (p = 0.470). In the hands of surgeons experienced with both surgical approaches to the femoral neck, the modified Smith-Petersen approach, with or without rectus femoris tenotomy, provides superior exposure of the femoral neck and articular surface as well as visualization and palpation of clinically relevant proximal femoral anatomic landmarks compared with the Watson-Jones approach. Open reduction and internal fixation of a femoral neck fracture is typically performed in a young patient (< 60 years old) with the objective of obtaining anatomic reduction that would not be possible by closed manipulation, thus enhancing healing potential. In the hands of surgeons experienced in both approaches, the modified Smith-Petersen approach offers improved direct access for reduction and fixation. Higher quality reductions and fixation are expected to translate to improved healing potential and outcomes. Although our experimental results are promising, further clinical studies are needed to verify if this larger exposure area imparts increased quality of reduction, healing, and improved outcomes compared with other approaches. The learning curve for the exposure is unclear, but the approach has broad applications and is frequently used in other subspecialties such as for direct anterior THA and pediatric septic hip drainage. Surgeons treating femoral neck fractures with open reduction and fixation should familiarize themselves with the modified Smith-Petersen approach.

Benign Aggressive Lesions of Femoral Head and Neck: Is Salvage Possible?

Background:Benign aggressive bone lesions of the femoral head and neck are mostly seen in young adults and warrant treatment for pain, impending fracture or established fracture, and disease clearance. It becomes challenging to treat them effectively while attempting salvage of the femoral head and yet achieving long term disease control with minimum complications. We describe our technique and experience in dealing with these lesions which can achieve the above-mentioned goals and can be easily replicated.Materials and Methods:We analyzed 15 cases of surgically treated, biopsy-proven benign, locally aggressive lesions affecting the femoral head and neck in skeletally mature individuals. All cases were treated with extended curettage through anterolateral modified Smith–Petersen approach along with tricortical iliac crest bone graft (combined with fibular graft in some cases) reconstruction with or without suitable internal fixation.Results:All, except one, patients were available for follow up. The age ranged from 18 to 43 years and the follow up ranged between 24 and 124 months (average 78 months). These included aneurysmal bone cysts (9), giant cell tumors (4), and fibrous dysplasia (2). The indication was pain (8), with impending (2) or established pathological neck femur fracture (5). In all cases, there was satisfactory healing of lesion and timely rehabilitation. Nonunion, avascular necrosis or local recurrences were not seen. The MSTS functional score was good or excellent in all (range 26–29, average 28).Conclusion:Benign aggressive lesions affecting femoral head and neck in young and middle-aged adults pose a treatment challenge. A sturdy, lasting reconstruct with acceptable functional outcome and minimal recurrence rate can be achieved by salvaging the femoral head and neck using curettage and reconstruction, obviating the need for replacement at such an early age.

Minimally invasive periacetabular osteotomy using a modified Smith-Petersen approach: technique and early outcomes.

Periacetabular osteotomy is an effective way of treating symptomatic hip dysplasia. We describe a new minimally invasive technique using a modification of the Smith-Peterson approach. We performed a prospective, longitudinal cohort study to assess for any compromise in acetabular correction when using this approach, and to see if the procedure would have a higher complication rate than that quoted in the literature for other approaches. We also assessed for any improvement in functional outcome. From 168 consecutive patients (189 hips) who underwent acetabular correction between March 2010 and March 2013 we excluded those who had undergone previous pelvic surgery for DDH and those being treated for acetabular retroversion. The remaining 151 patients (15men, 136 women) (166 hips) had a mean age of 32 years (15 to 56) and the mean duration of follow-up was 2.8 years (1.2 to 4.5). In all 90% of cases were Tönnis grade 0 or 1. Functional outcomes were assessed using the Non Arthritic Hip Score (NAHS), University of California, Los Angeles (UCLA) and Tegner activity scores. The mean pre-operative lateral centre-edge angle was 14.2° (-5° to 30°) and the mean acetabular index was 18.4° (4° to 40°). Post-operatively these were 31° (18° to 46°) and 3° (-7° to 29°), respectively, a significant improvement in both (p < 0.001). Allogenic blood transfusion was required in two patients (1.2%). There were no major nerve or vascular complications, and no wound infections. At the time of last follow-up, we noted a significant improvement in functional outcome scores: UCLA improved by 2.31 points, Tegner improved by 1.08 points, and the NAHS improved by 25.4 points (p < 0.001 for each). Hypermobility and longer duration of surgery were significant negative predictors for a good post-operative UCLA score, while residual retroversion was a positive predictor of post-operative UCLA score. We have found this approach to be safe and effective, facilitating early recovery from surgery. Cite this article: Bone Joint J 2017;99-B:22-8.

Bernese periacetabular osteotomy for hip dysplasia: Surgical technique and indications.

For young, active patients with healthy hip cartilage, pelvic osteotomy is a surgical option in to address hip pain and to improve mechanical loading conditions related to dysplasia. Hip dysplasia may lead to arthrosis at an early age due to poor coverage of the femoral head and abnormal loading of the joint articulation. In patients with symptomatic dysplasia and closed triradiate cartilage (generally over age 10), including adolescents and young adults (generally up to around age 40), the Bernese periacetabular osteotomy (PAO) is a durable technique for addressing underlying structural deformity. The PAO involves a modified Smith-Petersen approach. Advantages of the Bernese osteotomy include preservation of the weight-bearing posterior column of the hemi-pelvis, preservation of the acetabular blood supply, maintenance of the hip abductor musculature, and the ability to effect powerful deformity correction about an ideal center of rotation. There is an increasing body of evidence that preservation of the native hip can be improved through pelvic osteotomy. In contrast to hip osteotomy and joint preservation, the role of total hip arthroplasty in young, active patients with correctable hip deformity remains controversial. Moreover, the durability of hip replacement in young patients is inherently limited. Pelvic osteotomy should be considered the preferred method to address correctable structural deformity of the hip in the young, active patient with developmental dysplasia. The Bernese PAO is technically demanding, yet offers reproducible results with good long-term survivorship in carefully selected patients with preserved cartilage and the ability to meet the demands of rehabilitation.

Bilateral simultaneous heterotopic ossification of the reflected head of rectus femoris muscle: a case report and review of the literature.

Lamellar bone formation in an abnormal location is defined as heterotopic ossification. It commonly occurs around the hip joint and most often involves the abductor muscles. It is a benign condition; however, its etiology remains largely unknown. Most previously reported cases have been due to trauma or intramuscular hemorrhage. In this paper, we present a case of bilateral heterotopic ossification of the reflected head of rectus femoris muscle without antecedent trauma or any other known cause, as the first and unique case in the literature. She was treated by excision of the right symptomatic bony mass via a modified Smith-Petersen approach. Postoperatively, she received 75 mg indomethacin daily for six weeks. She was pain-free and obtained full range of motion 3 weeks after the first intervention.

Mid-term results in relation to age and analysis of predictive factors after fixation of acetabular fractures using the modified Stoppa approach

Data concerning outcome after management of acetabular fractures by anterior approaches with focus on age and fractures associated with roof impaction, central dislocation and/or quadrilateral plate displacement are rare. Between October 2005 and April 2009 a series of 59 patients (mean age 57 years, range 13-91) with fractures involving the anterior column was treated using the modified Stoppa approach alone or for reduction of displaced iliac wing or low anterior column fractures in combination with the 1st window of the ilioinguinal approach or the modified Smith-Petersen approach, respectively. Surgical data, accuracy of reduction, clinical and radiographic outcome at mid-term and the need for endoprosthetic replacement in the postoperative course (defined as failure) were assessed; uni- and multivariate regression analysis were performed to identify independent predictive factors (e.g. age, nonanatomical reduction, acetabular roof impaction, central dislocation, quadrilateral plate displacement) for a failure. Outcome was assessed for all patients in general and in accordance to age in particular; patients were subdivided into two groups according to their age (group "<60yrs", group "≥60yrs"). Forty-three of 59 patients (mean age 54yrs, 13-89) were available for evaluation. Of these, anatomic reduction was achieved in 72% of cases. Nonanatomical reduction was identified as being the only multivariate predictor for subsequent total hip replacement (Adjusted Hazard Ratio 23.5; p<0.01). A statistically significant higher rate of nonanatomical reduction was observed in the presence of acetabular roof impaction (p=0.01). In 16% of all patients, total hip replacement was performed and in 69% of patients with preserved hips the clinical results were excellent or good at a mean follow up of 35±10 months (range: 24-55). No statistical significant differences were observed between both groups. Nonanatomical reconstruction of the articular surfaces is at risk for failure of joint-preserving management of acetabular fractures through an isolated or combined modified Stoppa approach resulting in total joint replacement at mid-term. In the elderly, joint-preserving surgery is worth considering as promising clinical and radiographic results might be obtained at mid-term.

Does the Choice of Approach for Hip Hemiarthroplasty in Geriatric Patients Significantly Influence Early Postoperative Outcomes? A Randomized-Controlled Trial Comparing the Modified Smith-Petersen and Hardinge Approaches

Minimally invasive surgical approaches for total hip replacement, such as the modified Smith-Petersen approach, have been reported to be advantageous over alternative techniques because of reduced soft tissue damage and improved immediate postoperative rehabilitation. This study compares the advantages of the Smith-Petersen approach against the lateral Hardinge approach for femoral neck fractures in geriatric patients. In a randomized-controlled trial, 48 patients were treated by a hemiarthroplasty of the hip using either a modified Smith-Petersen or a Hardinge approach. Age, American Society of Anesthesiologists score, body mass index, blood loss, pain, and postoperative mobilization were compared between groups to detect statistically significant differences. The same outcome measures were analyzed for significant differences between patients with or without complications in each group. The Smith-Petersen approach yielded a statistically significant increase in postoperative pain within the first 4 days and an increase in operation time. Complications were also associated with a significantly higher intraoperative time in the same group. However, 6 months postoperatively, there were no significant differences in the Harris Hip score between groups. Despite early postoperative differences, postoperative mobility does not seem to be greatly influenced by the choice of either an anterior modified Smith-Petersen or a lateral Hardinge approach for hip hemiarthroplasty. Operative time was significantly linked to postoperative complications. In this respect, it can be concluded that it is not be the approach itself that determines the early postoperative result, but the routine the individual surgeon has with it.

RETRACTED ARTICLE: Outcomes of length-stable fixation of femoral neck fractures

The most common implants for treating unstable femoral neck fractures are sliding constructs, which allow postoperative collapse. Successful healing, typically, is a malunion with a shortened femoral neck. Functional sequelae resulting from altered femoral neck biomechanics have been increasingly reported. Re-operation rate due to nonunion, avascular necrosis, hardware cut-out and prominence is high with this treatment modality. We evaluated the outcomes of patients with femoral neck fractures treated with stable calcar pivot reduction, intraoperative compression across the fracture, and stabilization with length-stable implants. Fifty-four patients with femoral neck fractures underwent open reduction and internal fixation. Average follow up duration was 23.6 months (range: 15-36 months). There were 23 Garden I, 2 Garden II, 14 Garden III and 15 Garden IV fractures. Reduction was achieved through a modified Smith-Petersen approach. Fractures were compressed initially, and subsequently stabilized with a length-stable device. Post-operative radiographs were assessed for change in fracture alignment. Variation in the femoral neck offset and abductor lever arm measurements was performed using the contralateral hip as control. Functional outcome was assessed using SF-36, Harris Hip Score (HHS) and a gait analysis device. The average patient age was 78 years. Fifty-one (94%) healed without complications. Surgical fixation failed in two patients and one patient developed avascular necrosis. The average femoral neck shortening was 1.7 mm. The average difference in femoral neck offset and the abductor lever arm measurement at the latest follow up was 3.5 and 1.5 mm respectively. The average score on physical, mental components of SF-36 and HHS was 42 and 47 and 87 respectively. By 6 months, patients on average recovered 94% of the single limb stance time, 98% of cadence, 90% of cycle duration, 96% in stride length compared to the uninjured side. Reduction with a stable calcar pivot, intraoperative compression and length-stable fixation can achieve high union rates with minimal femoral neck shortening and improved functional outcomes. IV, retrospective with historical controls.

Treatment of developmental dysplasia of the hip with periacetabular osteotomy.

Objective To report the preliminary results of treatment of developmental dysplasia of the hip (DDH) with periacetabular osteotomy. Methods From February 2002 to February 2008, 53 patients (55 hips) with DDH were treated with periacetabular osteotomy. 51 patients were females, 2 were males, with the average age of 25.5 years (ranged, 13 to 51 years). The hip pain period before surgery varied from 1 month to 6 years (mean 16 months). 6 patients had the history of hip surgery. The mean Wiberg CE angle was 3°(range, -20°to 15°). According to Tonnis osteoarthritis classification, there were 16 cases in grade Ⅰ, 1 in grade Ⅱ. 25 patients had Shenton's line broken. The ilioinguinal approach was used in former 13 cases. The modified Smith-Petersen approach was used in later 40 cases. Intertrachanteric varus osteotomy was done simultaneously in 6 cases. Results The mean follow-up period was 28 months (ranged, 12 to 60 months). Bone union was achieved in 3 months after surgery. The pain relieved in most of patients. The Har-ris hip score increased from 77.4 points (ranged, 68 to 87 points) preoperatively to 94.6 points (ranged, 70 to 100 points) post-operatively. The range of motion of the hip decreased 20°-60° after surgery. The mean CE angle increased to 29°(ranged, 20° to 50°) postoperatively. 5 patients had limp after surgery, mostly due to dysfunction of gluteus medius, and recovered after 6 months of exercises. 18 patients got lateral femoral cu-taneous nerve injury. Two patients suffered pelvic ring broken and healed without affecting on hip function.No complication such as infection, vascular injury, sciatic neve injury happened in this series. Conclusion Satisfactory results can be obtained through periacetabular osteotomy in young patients with DDH. Periac-etabular osteotomy can correct the acetabular deformity in multiplanar. No vascular impair in acetabular fragment. The stability of the pelvic can be reserved. Early rehabilitation is allowed after surgery. Key words: Hip dislocation; congenital; Osteotomy; Acetabulum

A modification of periacetabular osteotomy using a two-incision approach.

In residual hip dysplasia periacetabular osteotomy (PAO) can improve insufficient coverage of the femoral head. It requires a broad dissection of the pelvic bones and detachment of muscle insertions, however. We have developed a modification of the Bernese periacetabular osteotomy with reduced soft tissue exposure. It uses two small skin incisions and offers therefore the perspective of nicer scars but also increases the risk of technical complications due to impaired vision. To be able to draft these risks, the clinical and radiographic results of 23 patients with PAO through the modified Smith-Petersen approach of Ganz (group A) and 24 patients with our two-incision modification (group B) have been reviewed retrospectively with an average follow-up of 19 (group A) and 12 (group B) months postoperatively.Functional improvement (Harris Hip Score) and center-edge-angle normalization did not differ significantly in both groups. Scars of patients in group B were significantly shorter. However, the overall patient satisfaction (as measured with a visual analogous scale) was the same in both groups. 4 patients in group A and one patient in group B developed superficial or deep wound infections.In conclusion, the experience with our cohort study showed that approach-related morbidity can be reduced without increasing the risk for the individual patient. This observation clearly holds a promise for further minimal invasive approaches as well as for further morbidity reduction of PAO.Level of Evidence: Retrospective comparative study (Level III).

MicroHip: A minimally invasive procedure for total hip replacement surgery A modified Smith-Petersen approach

In this article we present the surgical technique of our anterior minimally invasive approach to the hip joint. This is aligned along an interneural plane and makes the approach truly minimally invasive. This technique is performed in a lateral decubitus position on a normal operating table; there is no need for a specific orthopaedic or fracture table. As leg traction is not necessary, this enables the approach to be used routinely. Most of the instruments used for this procedure are standard instruments; only the acetabular reamers and positioners are angulated and specifically designed. The angled instruments (MI minimally invasive) are especially useful when performing hip replacement in obese patients. An excellent view of both the acetabulum and the proximal femur can be obtained through an incision of only 6-8cm, using this MI approach. The approach follows the interval between the tensor fascia lata muscle and the rectus muscle using a section of the anterior iliofemoral approach described by Smith-Petersen. No tendon or muscle is cut or detached. The joint capsule is split and left in place. The hip joint is not dislocated and we perform the osteotomy of the femoral neck in situ. To date we have performed over 500 MicroHip operations. We have not observed any nerve lesions or fractures of the trochanter. Our experience to date shows that the method we have de-veloped allows us to operate reliably on virtually any patient. Preliminary results also show that important factors like length of stay, pain, blood loss and return to work can be reduced significantly. The MicroHip technique is being used by more and more different clinics all over the world and can be applied with success after suitable training.

MicroHip: A Minimally Invasive Procedure for Total Hip Replacement Surgery: A modified Smith-Petersen approach

In this article we present the surgical technique of our anterior minimally invasive approach to the hip joint. This is aligned along an interneural plane and makes the approach truly minimally invasive. This technique is performed in a lateral decubitus position on a normal operating table; there is no need for a specific orthopaedic or fracture table. As leg traction is not necessary, this enables the approach to be used routinely. Most of the instruments used for this procedure are standard instruments; only the acetabular reamers and positioners are angulated and specifically designed. The angled instruments (MI minimally invasive) are especially useful when performing hip replacement in obese patients. An excellent view of both the acetabulum and the proximal femur can be obtained through an incision of only 6-8cm, using this MI approach. The approach follows the interval between the tensor fascia lata muscle and the rectus muscle using a section of the anterior iliofemoral approach described by Smith-Petersen. No tendon or muscle is cut or detached. The joint capsule is split and left in place. The hip joint is not dislocated and we perform the osteotomy of the femoral neck in situ. To date we have performed over 500 MicroHip operations. We have not observed any nerve lesions or fractures of the trochanter. Our experience to date shows that the method we have de-veloped allows us to operate reliably on virtually any patient. Preliminary results also show that important factors like length of stay, pain, blood loss and return to work can be reduced significantly. The MicroHip technique is being used by more and more different clinics all over the world and can be applied with success after suitable training.

Extra-Articular Resection of the Hip with a Posterior Column-Preserving Technique for Treatment of an Intra-Articular Malignant Lesion

A malignant lesion extending into the hip may necessitate en bloc resection of the joint, which may result in substantial loss of pelvic bone stock and compromise pelvic stability. Few reports have dealt specifically with the technical aspects of extra-articular resection of the hip1-4. In this report, we present a technique that allows en bloc resection of the hip with use of a periacetabular osteotomy, reconstruction of the acetabulum with an acetabular allograft, and total hip arthroplasty through a combined ilioinguinal and iliofemoral approach. Fig. 1 The utilitarian incision described by Enneking is used. This incision is well suited for a combination of a modified Smith-Petersen approach, representing the standard approach for the Bernese periacetabular osteotomy, and the ilioinguinal approach described by Judet et al., allowing plate application along the anterior column of the pelvis. We present the cases of two patients in whom we performed an extra-articular resection of the hip for the treatment of intra-articular extension of a proximal femoral malignant lesion. By employing the principles of the Bernese periacetabular osteotomy, we preserved the posterior acetabular column and maintained the continuity and stability of the pelvic ring5. Both patients were informed that data concerning the cases would be submitted for publication. Fig. 2 En bloc resection of the hip was performed with use of a periacetabular osteotomy, as described by Ganz et al., leaving the posterior column intact. The osteotomies were performed in the following order: ischial (a), pubic (b), anterior aspect of the ilium (c), and posterior aspect of the ilium (d). Fig. 3 An acetabular allograft (hatched area) is used for reconstruction of the acetabular bone stock. The graft is fixed with screws (not shown in the diagram but can be seen in Figures 4-B and 5-C) augmented with an anterior reconstruction plate. Fig. 4-A Figs. 4-A and …

Surgical dislocation and periacetabular osteotomy through a posterolateral approach: a cadaveric feasibility study and initial clinical experience

Since its introduction, Bernese periacetabular osteotomy with a modified Smith-Petersen approach has become a successful strategy for the treatment of insufficient femoral head coverage in developmental dysplasia of the hip. Additionally, femoro-acetabular impingement secondary to acetabular retroversion has been effectively treated by this technique. Although the vascularity of the osteotomized acetabular fragement has not been a problem with the modified Smith-Petersen approach for the Bernese periacetabular osteotomy, little information is available on the vascularity of the periacetabular bone after an osteotomy through a posterolateral approach. Such an approach would allow for improved treatment of certain intraarticular pathologies while simultaneously providing the option of performing an acetabular osteotomy. This study was designed to determine the vascularity of the external periacetabular bone with a colored latex injection technique into the common iliac artery in 16 fresh cadavers. Additionally, in 7 injected cadavers, a periacetabular osteotomy was performed with a posterolateral approach. Our dissections demonstrated the technical feasibility of a juxta-acetabular osteotomy performed through a posterolateral approach. These dissections further demonstrated the importance of identifying and protecting the constant acetabular branch of the superior gluteal artery (present in 23 of 23 cases), which is necessary for preservation of the superior acetabular blood supply. The integrity of both the superior gluteal branch and the acetabular branch of the obturator artery were maintained in all 7 osteotomy cases. Thus, in indicated cases, a juxta-acetabular osteotomy can be safely executed and combined with a capsulotomy, femoral head dislocation, and femoral head/neck shaping procedure through a posterolateral approach.

The Anterior Approach to Hip and Pelvis

Objective Exposure of the anterior pelvic column and the anterior hip in the internervous plane between the femoral nerve (sartorius and rectus muscle) and the superior gluteal nerve (tensor fasciae latae, gluteus medius, and gluteus minimus muscle) as well as between the blood supply of the external (medial) and internal iliac artery (lateral). Indications All pelvic osteotomies. Shelf procedures. Anterior labral lesions. Fractures of the femoral head, anterior column, anterior acetabular wall, and high transverse acetabular fractures. Contraindications None. Surgical Technique Incision along the iliac crest, over the anterosuperior iliac spine to the lateral aspect of the proximal thigh. Separation of sartorius and tensor fasciae latae. Osteotomy and medial reflection of the anterosuperior iliac spine. Subperiosteal detachment of the abdominal muscles and the iliacus muscle. Division of both origins of the rectus. Elevation of the iliocapsular muscle and the psoas tendon. Incision and medial retraction of the periosteum at the anterior surface of the anterior acetabular wall to exposure the acetabular floor. Detachment of the tensor fasciae latae, gluteus medius, and gluteus minimus muscles to expose the outer ilium. Results To date, this modified Smith-Petersen approach has been used in approximately 700 periacetabular osteotomies. Complications: transient femoral (n = 1), sciatic (n = 5), and lateral femorocutaneous (30%) nerve deficits. Distal aspect of the scar always large, revision rare (n = 3). No vascular injuries. Resection of heterotopic ossification in five of six patients. Very low rates of infection, hematoma, deep thrombophlebitis, and embolism.

Hip arthroscopy using the mini-openapproach

Abstract Hip arthroscopy is a technically difficult procedure to perform. Nonetheless, several indications exist for the procedure. We describe a “mini-open” approach to the hip joint, using a modified Smith-Petersen approach through a 4-cm incision in the groin skin crease. The interval between the sartorius and tensor fascia lata is developed while protecting the lateral femoral cutaneous nerve. The rectus femoris muscle and iliopsoas tendon are retracted medially, exposing the hip capsule. Standard arthroscopy is then performed through the open incision, utilizing either manual or a formal traction setup. We believe this technique decreases the risk of neurovascular or iatrogenic injury to the articular cartilage or labrum during instrument placement. Because the soft tissues are dissected down to the capsule, there is increased maneuverability of instruments, and less traction is necessary to provide joint distraction. There is tremendous versatility in this procedure; for example, a purely percutaneous hip arthroscopy can be performed supine on a fracture table, and if this fails to gain hip joint access or adequate visualization, the mini-open approach can be performed without the need to reposition or redrape the patient. If needed, this mini-open approach can also be easily converted to an open arthrotomy. We believe our hip arthroscopy technique utilizing a limited anterior approach combines the benefits of an arthroscopic and open procedure, while minimizing operative risk. This technique allows the arthroscopic surgeon an alternative method for performing this very technically challenging procedure.

The Bernese Periacetabular Osteotomy

A dysplastic acetabulum inadequately covering the femoral head is freed from the bony pelvis through several osteotomy cuts close to the joint, properly positioned and fixed with three screws. Symptomatic acetabular dysplasia with closed physes. Osteoarthritis Tonnis stage ≤2. Improved coverage on abduction view. Dislocation. Neoacetabulum. Worsening of congruence in abduction. Osteoarthritis Tonnis stage 3. Modified Smith-Petersen approach. Incomplete osteotomy of the ischial ramus. Complete osteotomy of the pubic ramus. Supra- and retroacetabular osteotomies: perpendicular osteotomy directly below the anterosuperior iliac spine ending short of the linea terminalis, continuing in direction of the ischial spine. Osteotomy 4 cm below the linea terminalis, connecting to the ischial osteotomy. Mobilization and reorientation. Radiographic control. Anterior capsulotomy: check for labral and chondral pathology, and impingement. Fixation with three 3.5-mm cortical screws. Reconstruction of the detached structures. No cast or orthosis. Touch weight bearing for 8 weeks, then abductor strengthening. Of the first 63 patients, 60 (71 hips) were followed for 10–14 years. 58 hip joints were still preserved (82%), and function was excellent to good in 52 (73%). Negative prognostic factors were advanced age, osteoarthritis, and insufficient correction.