Periacetabular Osteotomy In Patients Research Articles

Hip Morphology in Periacetabular Osteotomy (PAO) Patients Treated for Developmental Dysplasia of the Hip (DDH) as Infants Compared With Those Without Infant Treatment.

A subset of patients successfully treated for developmental dysplasia of the hip (DDH) as infants have symptomatic acetabular dysplasia at skeletal maturity leading to periacetabular osteotomy (PAO). The purpose of this study was to compare femoral and acetabular morphology in PAO patients with late acetabular dysplasia after previous treatment for DDH with PAO patients who do not have a history of DDH treatment. A single surgeon's patients who underwent PAO between 2011 and 2021 were retrospectively reviewed. Patients previously treated for infantile DDH with a Pavlik harness, abduction brace, closed reduction and spica casting, or open reduction and spica casting were included. Patients with previous bony hip surgery were excluded. Preoperative radiographic measurements of each hip were recorded including lateral center edge angle, anterior center edge angle, and Femoro-Epiphyseal Acetabular Roof index. Computed tomography measurements included the coronal center edge angle, sagittal center edge angle, Tönnis angle, acetabular anteversion at 1, 2, and 3 o'clock, femoral neck-shaft angle, femoral version, and alpha angle. Control PAO cases without a history of DDH diagnosis or treatment were matched with the infantile DDH treatment group in a 2:1 ratio based on coronal center edge angle, age, and sex. There were 21 hips in 18 patients previously treated for infantile DDH (13 patients Pavlik harness, 3 abduction brace, 1 closed reduction, and 1 open reduction). The control PAO cohort was 42 hips in 42 patients who did not have previous DDH treatment. There was no statistically significant difference in any of the recorded measurements between patients previously treated for DDH and those without previous treatment including femoral version (P=0.494), anteversion at 1 o'clock (P=0.820), anteversion at 2 o'clock (P=0.584), anteversion at 3 o'clock (P=0.137), neck-shaft angle (P=0.612), lateral center edge angle (P=0.433), Femoro-Epiphyseal Acetabular Roof index (P=0.144), and alpha angle (P=0.156). Femoral and acetabular morphology is similar between PAO patients with persistent symptomatic acetabular dysplasia following DDH treatment and patients presenting after skeletal maturity with acetabular dysplasia and no previous history of DDH treatment. Level III-case-control, prognostic study.

Pain and quality of life are impaired in adults with hip dysplasia undergoing periacetabular osteotomy (PAO): A systematic review and meta-analysis

Introduction: Little is known about the pain, sport and recreation, and quality of life (QOL) in adults with hip dysplasia undergoing periacetabular osteotomy (PAO). This systematic review aims to (i) evaluate pre to post- operative changes in pain, sport and recreation and QOL following PAO; and (ii) evaluate differences in pain, sport and recreation, and QOL in those undertaking PAO versus healthy controls. Methods: The search was performed in five databases on 05/01/2021. Included studies used a hip-specific patient-reported outcome measure and reported ≥Level IV evidence. Participants/intervention: Aged >15 years with hip dysplasia undertaking PAO surgery. Comparator: Between-group and pre- to post- intervention comparisons will be made where appropriate. Outcomes: Pain, sport and recreation, and QOL. Results: The search yielded 5,017 titles and abstracts for screening, with 62 studies included in the final analyses. Meta-analysis found low-level evidence that patients experienced clinical improvements across all subgroups one year after PAO, compared to pre-surgery, and this was maintained at the two-year timepoint. Pain improved from pre-surgery to one-year (SMC (95% CI): 1.35; 1.02 to 1.67) and two-years post-operatively (1.35; 1.16 to 1.54). Similarly, sport & recreation (one-year (1.29; 1.01 to 1.57) and two-years (1.24; 0.92 to 1.57)); and QOL (one-year (1.36; 1.22 to 1.5) two-years (1.3; 1.1 to 1.5)) all improved. Meta-analysis comparing PAO patients and healthy participants found low-level evidence that PAO patients have significantly worse outcomes across all subgroups. This occurs both pre-operatively and postoperatively at 6, 12 and 32 months. This was found for pain (SMD (95% CI): -4.05; -4.78 to -3.32), sport & recreation (-3.47; -3.79 to -3.16), and quality of life (-4.10; -4.43 to -3.77). Discussion: Before undergoing PAO surgery, adults with hip dysplasia have worse levels of pain, sport and recreation and QOL compared to healthy participants. These levels improve over two years following PAO, but do not reach the same level as their asymptomatic peers. When compared to healthy controls, PAO patients experience significantly worse outcomes when compared to healthy controls, both pre-operatively and post-operatively until 32 months. Conflict of interest statement: My co-authors and I acknowledge that we have no conflict of interest of relevance to the submission of this abstract.

Tönnis Grade 1 dysplastic hips have improved patient-reported outcome scores when intraarticular pathology is treated during periacetabular osteotomy.

ABSTRACTIt is unclear whether treatment of intraarticular pathology should be performed during periacetabular osteotomy (PAO) to improve outcomes. Therefore, we asked: (i) What are the clinical results of PAO in patients with and without intraarticular intervention? (ii) Is there a difference in reoperations with and without intraarticular intervention? and (iii) Is there a difference in clinical results and reoperations depending on preoperative Tönnis Grade if intraarticular intervention is performed? Prospective evaluation of 161 PAO in 146 patients was performed. The cohort was 84.5% female, mean age was 26.7 ± 7.9 years and mean follow-up was 2.4 years; 112 hips had Grade 0 changes and 49 hips had Grade 1 changes. Patients were classified into three groups based on treatments during PAO: major (labral repair, femoral head–neck osteochondroplasty), minor (labral debridement, femoral/acetabular chondroplasty) or no intervention. A subset of eight patient-reported outcome measures (PROMs) was analyzed to determine whether the minimal clinically important difference (MCID) was achieved. Major, minor and no intervention groups exceeded the MCID in 5, 8 and 8, of 8 PROMs (P ≥ 0.20), respectively; intraarticular interventions did not influence reoperation-free survival (P ≥ 0.35). By Tönnis Grade, PROMs exceeding MCID decreased in Grade 1 versus 0 receiving no intervention (P < 0.001) but did not decrease for either intervention (P ≥ 0.14); intraarticular interventions did not influence reoperation-free survival (P ≥ 0.38). Overall, intraarticular intervention was associated with excellent PROMs and reoperation-free survival. Although Grade 1 patients had fewer PROM which achieved MCID, intraarticular interventions attenuated this decrease, suggesting a therapeutic advantage of intraarticular procedures for more advanced pathology.

Pain and quality of life are impaired in adults with hip dysplasia undergoing periacetabular osteotomy: a systematic review and meta-analysis

Purpose: In adults with hip dysplasia (i) evaluate pre to post- operative changes in pain, function and quality of life following Periacetabular Osteotomy (PAO); (ii) evaluate differences in pain, function and quality of life in those undertaking PAO and healthy controls; and (iii) evaluate differences in pain, function and quality of life in those with mild versus severe dysplasia, as defined by the Lateral Centre Edge Angle (LCEA) LCEA. Methods: A comprehensive, reproducible search strategy was performed on the following databases MEDLINE CINAHL, EMBASE, Sports Discuss, and PsychINFO from inception until 11th July 2019. Studies were eligible for inclusion if they used a hip-specific patient-reported outcome measure (PROM) and reported Level IV evidence or above. Participants: People aged 15 years and older with hip dysplasia undertaking PAO. Intervention: Studies utilising PAO surgery as primary intervention for Hip Dysplasia. The terms “Bernese Osteotomy” and “Ganz Osteotomy” were considered interchangeable with ‘Periacetabular Osteotomy’. Studies were ineligible if the PAO was reported to be a ‘rotational’ or ‘”curved” procedure. Comparator: Studies using sham treatment, no treatment or other treatment as the comparator/control treatment were included. We also included studies where no control group was present. Outcomes: Primary outcomes of interest were pain, function and quality of life. The hip-specific PROMs included: Hip Dysfunction and Osteoarthritis Outcome Score (HOOS), Western Ontario and McMaster universities osteoarthritis Index (WOMAC), the International Hip Outcome Tool (iHOT), the Copenhagen Hip and Groin Outcome Score (HAGOS), NAHS (Non-arthritic Hip Score), and the Oxford Hip Score (OHS). A modified version of the Downs and Black checklist was used to assess the quality of included studies. Quality Evaluation and Data Extraction was performed by two independent reviewers with any disagreements discussed in a consensus meeting and an independent arbitrator was employed when consensus could not be met. A hierarchy of PROMs was decided on between authors to prioritise data extraction where more than one had been used. The order of the hierarchy was based on the established level of validity and reliability of the PROM for young people with hip pain, and applicability to people with hip dysplasia undergoing PAO. In order of selection the hierarchy was HOOS, WOMAC, IHOT, HAGOS, NAHS, OHS. Results: The search yielded 4065 titles and abstracts for screening, with 51 studies included in the final analyses. The methodological quality scores ranged from 50% to 94%, with an overall mean (SD) rating of 71% (11.6%). Sample sizes of the PAO groups ranged from 16 patients to 391 patients. The ages for patients in the included studies ranged from 20 years to 45 years. All included studies used a PROM. Seventeen studies used the HOOS, 34 studies used the WOMAC, five studies used the iHOT, 4 studies used the HAGOS and 3 studies used the NAHS.Two studies, one prospective cohort study and a retrospective cohort study, compared subscale scores (pain, symptoms, activities of daily living (ADL), sport & recreation, and quality of life) pre-operatively versus post-operatively. For the pain subscale (Fig. 1) a significant improvement was found between pre-surgery and the one-year timepoint (SMC (95% CI): 1.50; 1.33 to 1.67) and this improvement was maintained at the two-year timepoint (1.43; 1.16 to 1.70). This also occurred in the symptoms subscale at one-year (1.21; 1.06 to 1.36) and two-years (1.08; 0.82 to 1.34); ADL at one-year (1.21; 1.06 to 1.36) and two-years (1.11; 0.98 to 1.23); sport & recreation at one-year (1.41; 1.25 to 1.57) and two-years (1.32; 0.88 to 1.75); and quality of life at one-year (1.38; 1.22 to 1.54) and two-years (1.31; 1.04 to 1.57). These results provide low-level evidence that patients experience clinical improvements across all subgroups at one year after PAO, compared to pre-surgery, and this is maintained at the two-year timepoint. Two studies compared outcomes between PAO patients and healthy participants, one high-quality prospective cohort study and one high quality cross-sectional study. Meta-analysis of the pre-operative time point showed significantly worse outcomes in the PAO group with large effect sizes across all subgroups. This included pain (Fig. 2) (SMD (95% CI): -3.84; -4.73 to -2.95), symptoms (-3.84; -4.36 to -3.29), ADL (-2.81, -3.89 to -1.74), sport & recreation (-3.47; -3.79 to -3.16), and quality of life (-4.10; -4.43 to -3.77). This result provides low-level evidence that PAO patients have significantly worse outcomes across all subgroups when compared to healthy participants. This occurs both pre-operatively and postoperatively and 6, 12 and 32 months. Conclusions: Before undergoing PAO surgery, adults with hip dysplasia have worse levels of pain, symptoms, ADL, sport and recreation and quality of life compared to healthy participants. These levels improve over two years following PAO, but do not reach the same level as their asymptomatic peersView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Periacetabular Pelvic Osteotomy in Treatment of Patients with Developmental Dysplasia of the Hip

Background. Pelvic osteotomies are widely used for treatment of young active patients with developmental dysplasia of the hip (DDH) Type I according to the Crowe or type A according to Hartofilakidis classifications and the absence of severe degenerative cartilage lesions. Nowadays, Ganz periacetabular osteotomy (PAO) is the most common choice of surgeons around the world in treatment of such patients.The aim of the study was to evaluate the radiological and functional results of Ganz periacetabular osteotomy in patients with DDH.Material and Methods. A single-center retrospective analysis of 49 Ganz PAO was performed in 43 patients aged 36±9 years. The radiological evaluation criteria were Wiberg (AW), Lequesne (AL), Tonnis (AT) angles, and joint medialization. The results of treatment were evaluated using the Harris scale, iHOT-12, and VAS before treatment and 1 year after, the presence of complications was also monitored.Results. The average follow-up period was 35±15 months (from 1.0 to 6.9 years). Radiological parameters improved after surgery compared to preoperative ones: AW +19.9° (17.1° vs. 37.0°), AT -11.5° (19.9° vs. 8.4°), AL +14.1° (25.1° vs. 39.2°), joint medialization -5.5 mm (14.3 mm vs. 8.8 mm) (p0.001). Functional results and quality of life of patients also improved: the Harris scale +35.6 points (47 vs 83 points), iHOT-12 +40.9 points (44 vs 85 points), pain level -2.8 points (5 vs 2 points) (p0.001). Various complications developed in 20 out of 49 cases (40.8%). Neurological complications were resolved conservatively (22.4%). A direct correlation was evaluated between the surgical treatment of DDH in childhood and the development of neurological complications after PAO (R = 0.76; p0.001). In 9 cases out of 49 (18.4%), revision surgery was required: in 3 — total hip replacement, in 2 — reorientation of the acetabulum, in 4 — arthroscopic fixation of the anterior articular lip. In 93.9% of cases native hip joint surfaces were preserved.Conclusion. Ganz PAO has good reconstructive capabilities and sufficient efficiency. The operation allows to restore the coverage of the femoral head with the acetabulum, delays total hip replacement and provides improved functional results.

A New Rectus and Sartorius Sparing Approach for Periacetabular Osteotomy in Patients with Developmental Dysplasia of the Hip

Background: periacetabular osteotomy (PAO) is known as the gold standard surgical treatment in young adults with symptomatic hip dysplasia. With the aim of reducing soft tissue trauma, we developed a new rectus and sartorius sparing (RASS) approach. We hypothesized that this new PAO technique was equal regarding acetabular reorientation, complication rate, and short-term clinical outcome parameters, compared to our conventional, rectus sparing (RS) approach. Patients and Methods: we retrospectively assessed all PAO procedures performed by a single surgeon between 2016 and 2019 (n = 239 hips in 217 patients). The cases in which the new RASS technique were used (n = 48) were compared to the RS cases for acetabular orientation parameters, surgical time, perioperative reduction of hemoglobin level, and length of hospital stay (LOHS). Inclusion criteria were a lateral center-edge angle (LCEA) <25° and osteoarthritis Tönnis grade ≤1. Patients with acetabular retroversion or additional femoral osteotomy were excluded. Results: the mean patient age at the time of surgery was 29 years (14 to 50, SD ± 8.5). Females accounted for 79.5% in this series. The mean preoperative LCEA were 16° (7 to 24°, SD ± 4.4) and 15° (0 to 23°, SD ± 6) in the RASS and the RS group, respectively (p = 0.96). The mean preoperative acetabular index (AI) angles were 14° (2 to 25°, SD ± 4) and 14° (7 to 29°, SD ± 4.3), respectively (p = 0.67). The mean postoperative LCEA were significantly improved to 31° (25 to 37°, SD ± 3.5, p < 0.001) and 30.2° (20 to 38°, SD ± 4, p < 0.001), respectively. The mean postoperative AI angles improved to 2.8° (−3 to 13°, SD ± 3.3, p < 0.001) and 3° (−2 to 15°, SD ± 3.3, p < 0.001), respectively. There were no significant differences between the RASS and the RS group for surgical time, perioperative reduction in hemoglobin level, and LOHS. No blood transfusions were necessary perioperatively in either group. No major perioperative complication occurred in either group. We observed one surgical site infection (SSI) requiring superficial debridement in the RS group. Conclusion: the RASS approach for PAO showed to be a safe procedure with equivalent acetabular reorientation and equivalent clinical outcome parameters compared to the RS approach. Additionally, patients have fewer postoperative restrictions in mobilization with the RASS approach.

Transversus abdominis Plane Block for Improved Early Postoperative Pain Management after Periacetabular Osteotomy: A Randomized Clinical Trial.

Background: Patients undergoing periacetabular osteotomy (PAO) may experience significant postoperative pain due to the extensive approach and multiple osteotomies. The aim of this study was to assess the efficacy of the transversus abdominis plane (TAP) block on reducing opioid consumption and improving clinical outcome in PAO patients. Patients and Methods: We conducted a two-group randomized-controlled trial in 42 consecutive patients undergoing a PAO for symptomatic developmental dysplasia of the hip (DDH). The study group received an ultrasound-guided TAP block with 20 mL of 0.75% ropivacaine prior to surgery. The control group did not receive a TAP block. All patients received a multimodal analgesia with nonsteroidal anti-inflammatory drugs (NSAID) (etoricoxib and metamizole) and an intravenous patient-controlled analgesia (PCA) with piritramide (1.5 mg bolus, 10 min lockout-time). The primary endpoint was opioid consumption within 48 h after surgery. Secondary endpoints were pain scores, assessment of postoperative nausea and vomiting (PONV), measurement of the quality of recovery using patient-reported outcome measure and length of hospital stay. Forty-one patients (n = 21 TAP block group, n = 20 control group) completed the study, per protocol. One patient was lost to follow-up. Thirty-three were women (88.5%) and eight men (19.5%). The mean age at the time of surgery was 28 years (18–43, SD ± 7.4). All TAP blocks were performed by an experienced senior anaesthesiologist and all operations were performed by a single, high volume surgeon. Results: The opioid consumption in the TAP block group was significantly lower compared to the control group at 6 (3 mg ± 2.8 vs. 10.8 mg ± 5.6, p < 0.0001), 24 (18.4 ± 16.2 vs. 30.8 ± 16.4, p = 0.01) and 48 h (29.1 mg ± 30.7 vs. 54.7 ± 29.6, p = 0.04) after surgery. Pain scores were significantly reduced in the TAP block group at 24 h after surgery. There were no other differences in secondary outcome parameters. No perioperative complication occurred in either group. Conclusion: Ultrasound-guided TAP block significantly reduces the perioperative opioid consumption in patients undergoing PAO.

Periacetabular Osteotomy as a Salvage Procedure: Early Outcomes in Patients Treated for Iatrogenic Hip Instability.

A periacetabular osteotomy (PAO) can reduce pain and improve quality of life in patients with hip dysplasia. While its utility for patients without traditional radiographic parameters for hip dysplasia has not been previously established, the PAO may help treat patients with hip instability that does not improve following single or multiple hip arthroscopic procedures, or when such procedures lead to hip instability. A single-surgeon registry of patients at a single institution was queried to identify patients with a lateral center-edge angle (LCEA) of ≥24° and a Tönnis angle of <10° who underwent PAO because of hip pain and/or instability that failed treatment with hip arthroscopy. Descriptive summary statistics were reported on patient demographics, mean change in LCEA, and patient-reported outcome measures, including the modified Harris hip score (mHHS) and the International Hip Outcome Tool-33 (iHOT-33), at a minimum of 6 months of follow-up. Among 25 patients (mean age, 27.3 ± 6.9 years; 100% women), the mean LCEA increased from 27.2° (range, 24° to 37°) preoperatively to 39.0° ± 5.1° postoperatively (net increase, 11.8° ± 4.5°). Overall, the mean improvement in the mHHS was 11.5 ± 16.9 (preoperative, 59.4 ± 11.6; postoperative, 70.9 ± 20.6) and the mean improvement in the iHOT-33 was 23.8 ± 23.6 (preoperative, 32.2 ± 17.2; postoperative, 56.0 ± 30.0). Eighteen patients (72%) achieved a minimal clinically important improvement in mHHS (mean improvement, 17.4 ± 12.9) and iHOT-33 (mean improvement, 32.4 ± 19.1) scores. In comparison with 7 patients who did not show improvement, the 18 patients who showed improvement had significantly greater mean baseline patient-reported outcome scores. To our knowledge, these findings provide the first report on outcomes of PAO in patients with hip pain following arthroscopy who do not meet the traditional criteria for acetabular dysplasia. Early benefits in clinical outcomes suggest a novel surgical indication for PAO as a potential salvage option for selected patients; however, longer-term studies are needed. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Rectus-sparing approach to the periacetabular osteotomy in adolescents preserves hip flexion strength.

PurposeThe classic periacetabular osteotomy (PAO) approach can result in hip flexor weakness in adolescents. The rectus-sparing approach (PAO-RS) preserves the origin of the rectus femoris tendon which may prevent hip flexor weakness and improve functional outcome.MethodsThis is a prospective analysis of adolescents treated with a PAO or PAO-RS. The PAO group included 24 hips/21 patients (18 female, meanage 16 years (sd 4)); the PAO-RS group included ten hips (eight female, mean age 16 years (sd 1)). Preoperatively, the PAO group had decreased hip flexion strength compared with the PAO-RS group (83 Nm/kg versus 102 Nm/kg). A subset of PAO patients (n = 13 hips/12 patients, nine female, mean age 15 years (sd 3)) were matched for preoperative flexion strength to the PAO-RS group. Radiographic parameters, modified Harris hip score (mHHS), isokinetic hip strength and instrumented motion analysis preoperatively, six months and one-year postoperatively were compared.ResultsThere were no differences in preoperative deformity, postoperative correction or degree of correction between groups. Hip flexor strength decreased significantly at six months in the PAO group compared with the PAO-RS group (-35 Nm/kg versus -7 Nm/kg; p = 0.012), as did hip flexion pull-off power (1.33 W/kg PAO versus 1.76 W/kg PAO-RS; p = 0.010). Hip flexion strength improved from six months to one year in the PAO group, with no significant differences in strength at one year between groups (80 Nm/kg versus 90 Nm/kg). There were no differences between groups in mHHS any time point; both groups improved significantly postoperatively.ConclusionPreserving the rectus femoris may lead to improved short-term hip flexor strength and pull-off power. Further assessment at long-term follow-up is needed to determine if this strength leads to improved functional outcomes.Level of EvidenceII

Dynamic hip kinematics before and after periacetabular osteotomy in patients with dysplasia

BackgroundWe prospectively analyzed the hip kinematics in patients with developmental dysplasia of the hip (DDH) before and after periacetabular osteotomy (PAO) and in healthy subjects while squatting to determine the influence of coverage of the femoral head on hip kinematics. Methods14 hips in 14 patients with DDH and 10 hips in 10 volunteers were included. Continuous radiographs while squatting and computed tomography images were obtained to assess the in vivo kinematics of the hip and the rim-neck distance using density-based 3D-to-2D model-to-image registration techniques. ResultsThe maximum hip flexion angles were 100.4° and 94.9° before and after PAO (p = 0.0863), respectively. The maximum hip flexion angles after PAO did not significantly differ from those of normal hips (102.2°; p = 0.2552). The hip abduction angles at maximum hip flexion were 31.7° and 26.2° before and after PAO (p = 0.1256), respectively. The rim-neck distance decreased from averaged 12.2 mm–8.9 mm (p = 0.0044) after PAO. The lateral center edge angle (LCEA) and anterior center edge angle (ACEA) significantly improved 14.7°–42.4° and 50.4°–54.0° after PAO (p < 0.0001, p = 0.0347), respectively; in particular, the ACEA after PAO did not significantly differ from that in the normal hips (p = 0.1917). The ACEA was not correlated with hip flexion, or the rim-neck distance (p = 0.9601, 0.8764). The LCEA was also not correlated with hip abduction (p = 0.1683). ConclusionPatients after PAO showed no significant difference in maximum hip flexion while squatting compared to before PAO and normal hips. Horizontalized weight-bearing acetabulum with normalized ACEA could be adequate correction of the acetabular fragment to restore hip RoM without coxalgia that induce the inability to perform squats after PAO.

Multi-Centered Comparison of Outcomes After Hip Arthroscopy Versus Combined Hip Arthroscopy Alone and Peri-acetabular Osteotomy in Patients with Acetabular Dysplasia

Multi-Centered Comparison of Outcomes After Hip Arthroscopy Versus Combined Hip Arthroscopy Alone and Peri-acetabular Osteotomy in Patients with Acetabular Dysplasia

Are Complications After the Bernese Periacetabular Osteotomy Associated With Subsequent Outcomes Scores?

The Bernese periacetabular osteotomy (PAO) continues to be a commonly performed nonarthroplasty option to treat acetabular dysplasia, but only a few short-term studies have evaluated complications rigorously after PAO. (1) What complications are observed at 10-year mean followup of the Bernese PAO in patients with symptomatic acetabular dysplasia? (2) What factors are associated with these complications? (3) Do these complications affect clinical outcome scores? We reviewed 238 hips in 206 patients treated with PAO from July 1994 to August 2008. Only PAOs performed for symptomatic acetabular dysplasia and those that had at a minimum 4-year followup were included. Patients who went on to THA before 4 years were included in the study. Patients with hip pain who presented with a clinical presentation of symptomatic acetabular dysplasia, radiographic evidence of femoral head uncovering, and a lateral center-edge angle < 25° were considered for PAO and no other juxtaacetabular osteotomy was offered other than PAO. Sixty-two hips had diagnoses other than acetabular dysplasia and 22 were lost to followup. The remaining 154 hips (129 patients) were evaluated by chart review at a mean of 10 years (range, 1.7-20.5 years) using the UCLA Activity Score, modified Harris hip score (mHHS), WOMAC, and radiographic analysis. The mean age at PAO was 26 years (range, 10-60 years) and consisted of 113 female patients (132 hips [86%]) and 16 male patients (22 hips [14%]). Complications were graded using the validated Clavien-Dindo system. Complications were assessed for each hip and the highest complication grade was assigned to the hip if multiple complications occurred. We divided complication grades into three groups for analysis: no complications, Grade 1 complications, and complications that deviated from the standard postoperative course (Grades 2, 3, and 4). There were no Grade 5 complications. Variables with significant (p < 0.05) univariable associations with complications were considered for inclusion in a multivariable model. Outcome variables (mHHS and WOMAC) at the most recent followup visit were analyzed using a generalized estimating equation approach. Analysis of variance was used to compare UCLA at the most recent followup among the complication classes. Major complications defined as Clavien-Dindo Grade 3/4 occurred in 14 hips (9%). After controlling for potential confounding variables, we found that increasing body mass index (BMI) (odds ratio [OR], 1.16; 95% confidence interval, 1.05-1.25; p = 0.004) was associated with increased risk of complication. In contrast, greater surgeon experience was associated with a decreased risk (OR, 0.3; p = 0.002). Complications were associated with postoperative pain and activity, WOMAC (mean ± SD: 0 complications = 1.5 ± 15.1, 1 complication = 4.3 ± 4.1, 2-3 complications = 3.8 ± 4.6; p = 0.020) and UCLA scores (mean ± SD: 0 complications = 7.8 ± 2, 1 complication = 6.7 ± 2.1, 2-3 complications = 6.5 ± 2; p = 0.003). Most hips undergoing PAO have few complications. The most common major surgical complication is nonunion. Increasing BMI was a predictor of having a complication, and surgeon experience decreased complication risk. Having a complication adversely affected long-term pain and activity. To minimize complications and maximize outcomes, a patient's BMI should be assessed preoperatively and those with excessive BMI should be counseled on the increased risk of complications. In an experienced surgeon's hands, PAO has few complications at mean 10-year followup and a low risk of permanent disability. Level III, therapeutic study.

Minimum 10-Year Clinical Outcomes After Periacetabular Osteotomy for Advanced Osteoarthritis Due to Hip Dysplasia.

The purpose of this study was to examine the minimum 10-year clinical outcomes, including patient-reported and functional outcomes, of periacetabular osteotomy in patients with advanced osteoarthritis. A total of 46 hips in 44 patients with advanced osteoarthritis who underwent periacetabular osteotomy between 1992 and 2006 were retrospectively reviewed. Mean age at surgery was 47.5 years, and mean follow-up was 16.9±4.7 years. Survivorship was determined using the Kaplan-Meier method, and the associated risk factors for the endpoint-conversion to total hip arthroplasty less than 15 years after surgery-were evaluated. The Oxford Hip Score and the University of California, Los Angeles activity score were evaluated at final follow-up. The survival rates at 15 and 20 years after surgery were 80% and 59%, respectively. Multivariate analysis indicated that body mass index greater than 24 kg/m2 (P=.034; odds ratio, 1.72) was significantly associated with the endpoint as an independent risk factor. For 32 hips of 31 patients with preserved native joints at final follow-up, the Oxford Hip Score and the University of California, Los Angeles score averaged 41±5 and 5.2±1.8, respectively, equivalent (P=.28 and P=.215, respectively) to the scores of 14 hips of 13 patients with conversion to total hip arthroplasty (38±8.7 and 5.8±1.4, respectively). The results of this mid-term study may be useful for surgical decision-making among patients with advanced osteoarthritis who want to preserve native hip joints. [Orthopedics. 2018; 41(5):300-305.].

Successful Outcomes at Midterm Follow-up of Periacetabular Osteotomy Done for Mild Hip Dysplasia

AbstractYoung hip surgeons are often faced with the decision to either perform arthroscopic surgery or a periacetabular osteotomy (PAO) in patients with symptomatic mild hip dysplasia (MHD). There is, however, a paucity of data on the results of PAO in this group. The aim of this paper is to report the results of PAOs in patients with MHD and compare those to hips with more severe forms of hip dysplasia (SHD). This data can then be used to compare emerging data reporting the results of hip arthroscopy for MHD. From January, 1996 to May, 2009, 299 hips in 268 patients were identified that underwent PAO at one institution. After removing those with &lt;2 years of follow-up, 182 hips were followed up. The average age of the cohort was 31 years, and 85% were female. Nineteen hips with lateral center edge (LCE) angle from 18 to 25° and a Tönnis angle (TA) between 10 and 15° were considered to have MHD. This group was compared with the rest of the cohort (SHD). The mean clinical follow-up for the MHD group was 121 months. There was no significant difference in demographic variables between the groups. There were no complications in the MHD cohort. Surgical correction resulted in significant improvements in all radiographic measurements consistent with hip dysplasia in both groups. The Harris Hip Score (HHS) improved significantly in both groups ([MHD: 52–92] [SHD: 66–89]). Two hips (10.5%) in the MHD group and 15 hips (9.2%) in the SHD group underwent future THA (p = 0.69). The survivorship free from THA was 100%, 100%, and 86% at 3, 5, and 10 years, respectively, in the MHD group. The corresponding rates for hips in the control group at 3, 5, and 10 years, respectively, were 99%, 95%, and 81%. PAO in patients with MHD provides predictable improvements in pain, function, and results that are durable and comparable to hips with SHD. This data should be used to compare the early and midterm results of arthroscopic surgery performed in mildly dysplastic hips.

Sports Participation in Patients After Total Hip Arthroplasty vs Periacetabular Osteotomy: A Propensity Score-Matched Asian Cohort Study

BackgroundNo studies have compared sports participation between total hip arthroplasty (THA) and periacetabular osteotomy (PAO) in matched Asian cohorts. We investigated sports participation and activity levels in Asian THA cohort, and compared them between THA and PAO cohorts. MethodsMultivariate analyses were applied to determine which factors were associated with postoperative sports participation and University of California-Los Angeles (UCLA) activity score in (1) 524 THA patients and (2) 487 acetabular dysplasia patients (295 THA patients and 192 PAO patients). In addition, postoperative sports participation and UCLA score were compared between 62 THA and 62 PAO patients after adjusting for baseline characteristics with propensity score matching. ResultsSports participation and UCLA score significantly increased after THA (P < .001 in both analyses). Preoperative sports participation was the factor most associated with both postoperative sports participation and UCLA score in both 524 THA patients and 487 acetabular dysplasia patients (P < .001 in all analyses). Multivariate analysis in 487 acetabular dysplasia patients demonstrated that THA, compared with PAO, was negatively associated with postoperative sports participation (P < .001), but not postoperative UCLA score (P = .22). THA patients showed significantly lower rate of postoperative sports participation (32.3% and 51.6%, respectively, P = .046), but not postoperative UCLA score (5.0 ± 1.6 and 5.2 ± 1.9, respectively, P = .47) compared with matched PAO patients. ConclusionTHA significantly increased both sports participation and activity levels. Both multivariate and propensity score-matched analyses showed that postoperative activity levels were comparable between THA and PAO cohorts.

Multi-centered Comparison of Patient Reported Outcomes After Hip Arthroscopy versus Combined Hip Arthroscopy Alone and Peri-acetabular Osteotomy in Patients with Acetabular Dysplasia

Objectives:The purpose of this study was to compare prospectively collected patient reported outcomes (PRO) data in patients undergoing Hip Arthroscopy alone versus combined Hip Arthroscopy and Peri-acetubular Osteotomy (HA/PAO).Methods:Prospectively collected PRO data was reviewed in patients enrolled in IRB approved studies at two high volume hip preservation centers who underwent either Hip Arthroscopy alone or combined HA/PAO. Patients were included who had a lateral center edge angle <25 degrees, completed pre-operative and a minimum of 1 year post-operative PRO data. Questionnaires were administered to patients at intervals including pre-operative, 3 months, 1 year and 2 years post-operative. Questionnaires were composed of validated PRO scores: modified Harris Hip Score (mHHS), Hip Outcome Score (HOS) Activities of Daily Living (ADL) and Sports subscales, Non-arthritic Hip Score (NAHS) and Pain Visual Analog Scale (VAS).Results:Prospectively collected data was reviewed for 91 patients who underwent Hip Arthroscopy and 34 patients who underwent HA/PAO. Average age at the time of surgery was 32 years old (range 14-62) for arthroscopy and 31 years old (range 15-51) for combined surgery. Hip Arthroscopy patients were 35% male and 65% female. HA/PAO patients were 15% male and 85% female. PRO data for Hip Arthroscopy, reported as averages with 95% confidence intervals in parentheses at pre-operative, 3 months, 1 year and 2 years post-operatively. mHHS: 66.3 (3.1), 83.8 (3.5), 84.3 (4.1), 84.4 (3.4). HOS ADL: 70.1 (4.0), 85.3 (3.2), 87.1 (4.2), 87.4 (4.0). HOS Sports: 47.3 (4.6), 64.7 (6.6), 73.7 (8.1), 75.2 (5.9). NAHS: 65.5 (3.7), 80.1 (3.3), 83.8 (4.5), 83.8 (3.9). Pain VAS: 5.4 (0.5), 2.6 (0.5), 2.5 (0.6), 2.6 (0.6). PRO data for HA/PAO, reported as averages with 95% confidence intervals in parentheses at pre-operative, 3 months, 1 year and 2 years post-operatively. mHHS: 51.1 (4.6), 58.7 (7.9), 71.7 (7.3), 74.7 (13.1). HOS ADL: 58.3 (6.5), 65.7 (9.0), 83.6 (9.8), 85.1 (18.7). HOS Sports: 41.7 (7.2), 38.0 (11.7), 72.5 (11.5), 79.3 (11.9). NAHS: 56.7 (5.2), 71.6 (5.3), 80.2 (7.7), 83.4 (11.8). Pain VAS: 5.3 (0.9), 1.9 (0.8), 2.2 (1.0), 1.0 (0.9).Conclusion:Both cohorts had significant improvement in all PRO measures at 1 and 2 years when compared to pre-operative PRO measures. HA/PAO patients had significantly lower mHHS and HOS ADL pre-operatively; NAHS approached significance. HOS Sports and Pain VAS had no significant pre-operative differences between groups. At 3 months, the HA/PAO patients had significantly lower mHHS, HOS ADL and HOS Sports, while again NAHS approached significance. There was no significant difference in Pain VAS at 3 months. Only the mHHS remained significantly lower for the HA/PAO patients at 1 year. At 2 years, only Pain VAS showed significantly better pain scores for HA/PAO patients, although lacking clinical significance. All other PRO measures showed no significant difference at 2 years. Patients who underwent HA/PAO had significantly lower pre-operative and early post-operative PRO measures. HA/PAO patients, however, reached similar values for PRO measures by 1 year; only the mHHS remained lower. At 2 years, neither group showed statistical or clinical difference in PRO measures.

Hip Arthroscopy Failure in the Setting of Acetabular Dysplasia: A Concerning Trend?

Objectives:Despite the success of hip arthroscopy, evidence suggests that arthroscopy alone is inadequate for treatment of conditions such as acetabular dysplasia (AD) due to its failure to correct structural deformity. Our objective was to define the incidence of failed hip arthroscopy in patients with symptomatic AD requiring periacetabular osteotomy (PAO). We secondarily analyzed the patient and structural characteristics of the failed arthroscopy cases.Methods:Utilizing a prospective, multicenter joint preservation database, we identified a cohort of primary AD patients from 2009-2014 who underwent PAO after a single prior ipsilateral hip arthroscopy. A comparison cohort of PAO patients without prior arthroscopy was isolated. Patients with hip disease attributable to cerebral palsy, Perthes, etc. were excluded. Demographic and radiographic data were summarized for each category. We compared the proportion of PAO after failed hip arthroscopy between the beginning and end of the study period by 2-tailed z-test with P<0.05 regarded as statistically significant.Results:Ninety-nine patients (99 hips) had received arthroscopic surgery prior to PAO, while 1053 patients (1103 hips) underwent PAO without prior hip arthroscopy. The proportion of PAO procedures after previous ipsilateral hip surgery stayed constant (13-19%); however, the incidence of PAO after previous hip arthroscopy increased from 2.5% in 2009 to 9.8% in 2014 (P=0.004). Over the 6 year period, the rate of all PAO procedures increased 12% per year, whereas rates of PAO after hip arthroscopy grew an average 54% per year. Female sex, increased average LCEA and ACEA, and decreased acetabular inclination were associated with failed hip arthroscopy (P<0.01).Conclusion:Over the last six years, we have seen clear increases in the rate of PAO after previous hip arthroscopy. Though the rate of PAO following previous ipsilateral surgery remains constant, hip arthroscopies now constitute almost 60% of those previous surgery attempts. Additionally, we have identified mild dysplastic features and female sex as characteristics that are associated with failure of hip arthroscopy. These results are consistent with prior literature suggesting that inadequately corrected structural deformity is the most common indication for revision surgery. These findings raise concern that isolated hip arthroscopy is being increasingly utilized in patients with acetabular dysplasia and highlight the need for refined surgical indications for hip arthroscopy and further investigation into its impact on subsequent surgeries.Figure 1Rate of ipsilateral periacetabular osteotomy (PAO) procedures petformed after any previous surgery and after hip arthroscopy (HS)

Periacetabular Osteotomy Redirects the Acetabulum and Improves Pain in Charcot-Marie-Tooth Hip Dysplasia With Higher Complications Compared With Developmental Dysplasia of the Hip.

The Bernese periacetabular osteotomy (PAO) is a well-accepted reorientation pelvic osteotomy used to treat symptomatic acetabular dysplasia secondary to developmental dysplasia of the hip (DDH). However, there are limited data regarding PAO in patients with symptomatic hip dysplasia secondary to Charcot-Marie-Tooth disease. We compared patients who underwent PAO for the treatment of Charcot-Marie-Tooth disease hip dysplasia (CMTHD group) with patients who underwent PAO for treatment of hip dysplasia secondary to DDH in terms of (1) modified Harris Hip scores; (2) radiographic correction of acetabular dysplasia; and (3) the rate of complications. Twenty-seven subjects with Charcot-Marie-Tooth disease who underwent a PAO between January 1991 and December 2010 were matched to 54 subjects with DDH on the basis of sex, age, date of surgery, and body mass index. Preoperative and postoperative hip functional scores and radiographic data were collected with a minimum 2-year follow-up. The modified Harris Hip Scores (mHHS) assessed functional hip outcomes. Radiographic variables included lateral (LCEA) and anterior (ACEA) center-edge angles, Tönnis angle and Tönnis grade of arthritis. Postoperative complications were classified according to a modified Dindo-Clavien system. At latest follow-up mHHS improved in the CMTHD group (preoperative median 63; (interquartile range [IQR]=54-70 to postoperative median 88; IQR=74-91); P=0.004) and in the DDH groups (preoperative median 71; IQR=58-83 to postoperative median 86; IQR=73-96; P=0.002) with no difference between the 2 groups (P=0.631). Radiographic improvement (LCEA: mean difference, 36 degrees, 95% confidence interval [CI], 30-41 degrees, P<0.001; ACEA: mean difference, 27 degrees, 95% CI, 20-33 degrees, P<0.001; Tönnis angles: mean difference, 21 degrees, 95% CI, 15-26 degrees, P<0.001) was achieved in the CMTHD group. Similarly, radiographic improvements in LCEA (mean difference, 33 degrees, 95% CI, 29-37 degrees, P<0.001), ACEA (mean difference, 18 degrees, 95% CI, 13-23 degrees, P<0.001) and Tönnis angles (mean difference, 13 degrees, 95% CI, 9-17 degrees, P<0.001) were also achieved in the DDH group. After PAO, 33% of the patients in the CMTHD group and 13% in the DDH group developed a complication that required treatment (odds ratio, 3.4; 95% CI, 1.1-10.4; P=0.035). The Bernese PAO is capable of comprehensively achieving improvement in patient-reported outcome scores and redirecting the acetabulum in symptomatic acetabular dysplasia secondary to CMTHD. However, patients with CMTHD have a higher risk for developing complications. Level III-therapeutic study.

Complications after periacetabular osteotomy

Aim. To study the frequency and structure of complications after periacetabular osteotomy in patients with hip dysplasia.Methods. Complications that arose after the Ganz periacetabular osteotomy, based on observation of 71 patients (83 operated joints): 58 women and 13 men, were analyzed. The average follow-up duration was 8 years, the mean age - 23 years (range 13 to 44 years). Complications after surgery were divided into two groups: minor and major. Functional state of the hip joint was evaluated by the Harris Hip Score (HHS) before and after surgery.Results. In 5 patients dysesthesia of external femoral nerve, in 1 - of sciatic nerve, was revealed, ossification grade 1-2 (according to Brucker) was found in 5 patients, grade 3-4 - in 2, ischial bone pseudarthrosis was determined in 2 patients, the ilium fracture - in 3, superficial abscess - in 2, screw penetration into the joint - in 2, femoral head subluxation - in 1, symptomatic screws - in 5 patients. In 71 adult patients (83 joints) with hip dysplasia and arthrosis after Ganz osteotomy, in 17 (20.4%) cases minor complications, in 11 (13.25%) - major complications were registered. In 66 patients out of 71 the joint preservation was achieved.Conclusion. Ganz osteotomy performed according to indications is effective and allows joint preservation in the majority of cases, however, the surgical complexity and the relatively high rate of complications require sufficient qualification and experience of the physician.

What Are the Results of Surgical Treatment of Hip Dysplasia With Concomitant Cam Deformity?

Periacetabular osteotomy (PAO) is a reliable procedure to correct the deficient acetabular coverage in hips with developmental dysplasia. It is unclear how the presence of additional femoral cam-type deformity might influence the clinical and radiographic treatment results of PAO. (1) Are there differences in clinical scores (WOMAC, EQ-5D) and examination findings (impingement sign) or radiographic measures of acetabular orientation and head sphericity after PAO for isolated acetabular dysplasia when compared with the combined pathology of dysplasia and additional femoral cam deformity? (2) Are these clinical and radiographic findings after combined surgical therapy for additional cam deformity influenced by different pathology-adjusted surgical techniques? From July 2005 to December 2010, 86 patients (106 hips) underwent PAO for hip dysplasia. Surgical and outcome data were prospectively collected and retrospectively reviewed in a comparative observational study. Indications for surgery were a lateral center-edge angle less than 25° and hip pain for at least 6 months. The contraindications for surgery were advanced radiographic osteoarthritis (Kellgren-Lawrence Grade 3), incongruency of joint space, and patient age > 50 years. Depending on preoperative hip ROM, impingement test, and presence of a radiographically visible cam deformity, treatment allocation was performed: Group I: isolated PAO in patients without symptomatic asphericity, Group IIa: PAO with subsequent osteochondroplasty through arthrotomy for patients with symptomatic cam deformity and no labrochondral pathology, and Group IIb: arthroscopically assisted osteochondroplasty and additional labrochondral repair with subsequent PAO when patients had labrochondral lesions in addition to a symptomatic cam deformity. Clinical outcome (impingement test, EQ-5D, WOMAC) as well as radiographic parameters (lateral center-edge angle, crossover sign, alpha angle, osteoarthritis grade) were obtained after a mean followup of 63 ± 18 months (range, 31-102 months) and compared with the baseline data. Eleven patients (13%) were lost to followup. With the numbers available, our study had 80% power to detect a difference between Groups I and II of 10 points on the WOMAC scores. There was no difference in the increase of WOMAC scores in patients with PAO alone (Group I; preoperative score 74 ± 17 versus postoperative 91 ± 15, p = 0.033) when compared with PAO and concurrent osteochondroplasty (Groups II A and B preoperative 73 ± 19 versus postoperative 90 ± 13 p < 0.001). The mean postoperative alpha angles in Group II (38° ± 6°) improved when compared with preoperative values (56° ± 15°; p < 0.001) and were even lower than native offset alpha angles in Group I (47° ± 11°). Clinical scores as well as postoperative radiographic parameters were not different between patients with conventional osteochondroplasty alone (Group IIA) and patients with arthroscopically assisted cam resection and intraarticular labrochondral repair (Group IIB). With the numbers available, we detected no differences in outcome scores and radiographic results between patients who had been treated with PAO alone and patients who underwent combined PAO and offset correction for cam deformity. Although arthroscopically assisted treatment of advanced labrochondral lesions together with osteochondroplasty is possible during PAO and the results were not different in this small study when compared with patients with PAO and osteochondroplasty alone, the type and extent of damage that would indicate additional cartilage surgery over cam resection alone remain unclear. Level III, therapeutic study.