Periacetabular osteotomy for acetabular retroversion: A systematic review and meta-analysis

Finite element analyses, 3D-printed guides and navigation system optimizes fragment reorientation for periacetabular osteotomy

PURPOSE

Periacetabular osteotomy (PAO) is an effective treatment to correct developmental dysplasia of the hip (DDH). Traditionally, the goal of correction during PAO is based on parameters measured on 2-dimensional images. The aim of the study is to introduce an optimized workflow of PAO in DDH patients by means of personalized correction goal and accuracy of execution.

METHODS

Five patients with DDH were prospectively enrolled. Preoperative computed tomography was performed. Surgical planning was done by the treating surgeon and engineers. The planned correction involved reorienting the osteotomized fragment to achieve a target lateral center-edge angle (LCEA) of 25°-40°.The pelvic model with the preoperative and planned correction was analyzed by finite element analysis, which simulated single-leg stance condition. Average and maximal acetabular stresses in different anatomical areas were calculated and are presented as a dashboard at ± 3° increments to help the surgeon determine the ideal correction. To ensure accuracy of the osteotomy and correction as planned, 3D-printed cutting and reorientation guides were used.

RESULTS

Average operation time (101 ± 23 min) and blood loss (651 ± 176 ml) were comparable to previous reports. Radiographic parameters improved significantly, including LCEA (20.0° ± 6.4° vs. 30.2° ± 3.1°, p = 0.037) and AI (12.5° ± 3.1° vs. 0.8° ± 1.6°, p = 0.001). The planned correction was similar to the final correction (LCEA planned 31.1° ± 2.0° vs. final 30.2° ± 3.1°, p = 0.268; AI planned 1.8° ± 1.5° vs. final 0.8° ± 1.6°, p = 0.349). During an average follow-up period of 1.2 years, all osteotomies healed and these patients reported a significant reduction in mean global pain scale from 70 preoperatively to 23 postoperatively (p = 0.016).

CONCLUSION

The workflow with FEA simulations to optimize mechanical stress and 3D-printed cutting guides to achieve accurate execution was an effective and safe approach to optimize DDH treatment. Further refinements and further evaluation of navigation systems aimed at obtaining planned correction is necessary.

Radiological predictors of outcomes in hip arthroscopy for femoroacetabular impingement

Aims

Hip arthroscopy has gained prominence as a primary surgical intervention for symptomatic femoroacetabular impingement (FAI). This study aimed to identify radiological features, and their combinations, that predict the outcome of hip arthroscopy for FAI.

Methods

A prognostic cross-sectional cohort study was conducted involving patients from a single centre who underwent hip arthroscopy between January 2013 and April 2021. Radiological metrics measured on conventional radiographs and magnetic resonance arthrography were systematically assessed. The study analyzed the relationship between these metrics and complication rates, revision rates, and patient-reported outcomes.

Results

Out of 810 identified hip arthroscopies, 359 hips were included in the study. Radiological risk factors associated with unsatisfactory outcomes after cam resection included a dysplastic posterior wall, Tönnis grade 2 or higher, and over-correction of the α angle. The presence of acetabular retroversion and dysplasia were also significant predictors for worse surgical outcomes. Notably, over-correction of both cam and pincer deformities resulted in poorer outcomes than under-correction.

Conclusion

We recommend caution in performing hip arthroscopy in patients who have three positive acetabular retroversion signs. Acetabular dysplasia with a lateral centre-edge angle of less than 20° should not be treated with isolated hip arthroscopy. Acetabular rim-trimming should be avoided in patients with borderline dysplasia, and care should be taken to avoid over-correction of a cam deformity and/or pincer deformity.

The Use of Combined Hip Arthroscopy and Periacetabular Osteotomy for Hip Dysplasia Is Increasing and Has Low Complication Rates

Purpose

To analyze the annual use of hip arthroscopy (HA) and Bernese periacetabular osteotomy (PAO) for the treatment of hip dysplasia (HD), as well as postoperative outcomes, including ipsilateral reoperations.

Methods

International Classification of Diseases, Ninth and Tenth Revision, codes were used to query the PearlDiver Mariner database from January 2010 through January 2022 to identify patients aged 10 to 59 years who had a presenting diagnosis of HD and subsequently underwent (1) HA; (2) PAO; or (3) combined HA and PAO (HA-PAO, defined as PAO on the same day or within 28 days after HA). We analyzed annual rates for each treatment, as well as rates of postoperative emergency visits, readmissions, and 5-year ipsilateral secondary operations (determined via Kaplan-Meier analysis).

Results

There were 32,068 patients who underwent surgical treatment of HD. For HA, PAO, and HA-PAO, there were 29,700, 2,083, and 285 patients, respectively. All operations had the greatest percent-increase from 2015 to 2016. HA and HA-PAO peaked in 2021, whereas PAO peaked in 2019. For HA, PAO, and HA-PAO, most cases were performed in female patients and patients aged 30 to 49 years, 10 to 19 years, and 10 to 29 years, respectively. The 5-year incidence of ipsilateral secondary operations, which include revision HA, PAO, or conversion to total hip arthroplasty, was 9.2% (95% confidence interval 8.6%-9.8%) in the HA group and 6.5% (95% confidence interval 4.1%-8.8%) in the PAO group. Combining HA with PAO resulted in so few secondary operations that Kaplan-Meier analysis was infeasible. The PAO cohort had the greatest 30-day emergency visit and 90-day readmission rates, with infection as the most common cause for readmission.

Conclusions

HA is more frequently performed than PAO for hip dysplasia. HA-PAO is increasing at the greatest rate, demonstrating fewer complications and reoperations.

Level of Evidence

Level III, retrospective comparative trial.

Comparison of Two Surgical Approaches for Periacetabular Osteotomy: A Retrospective Study of Patients with Developmental Dysplasia of the Hip

OBJECTIVE

Given the intricate challenges and potential complications associated with periacetabular osteotomy (PAO) for developmental dysplasia of the hip (DDH). Our study aimed to compare the clinical and imaging benefits and drawbacks of two surgical approaches, the modified Stoppa combined iliac spine approach and the modified Smith-Peterson approach, for treating PAO and to provide guidance for selecting clinical approaches.

METHODS

A retrospective analysis of 56 patients with 62 DDHs was conducted from June 2018 to January 2022. The experimental group underwent surgery via the modified Stoppa combined iliac spine approach, while the control group underwent surgery via the modified Smith-Peterson approach for periacetabular osteotomy and internal fixation. Basic statistical parameters, including age, sex, BMI, and preoperative imaging data, were analyzed. Differences in surgical time, intraoperative blood loss, and postoperative imaging data were compared, as were differences in preoperative and postoperative imaging data between the two groups.

RESULTS

There were 28 hips in the experimental group and 34 in the control group. Moreover, there was no significant difference in the basic parameters between the experimental and control groups. Before and after the operation, for the LCE angle, ACE angle, and Tonnis angle, there was no significant difference in acetabular coverage (p > 0.05). However, there were significant differences between the two groups in terms of the above four indicators before and after the operation (p < 0.05). After the operation, the experimental group exhibited significant increases in both lateral and anterior acetabular coverage of the femoral head. However, the experimental group had longer operation times and greater bleeding volumes than did the control group. Despite this, the experimental group demonstrated significant advantages in protecting the lateral femoral cutaneous nerve compared to the control group.

CONCLUSION

The modified Stoppa combined iliac spine approach can be considered a practical approach for PAO and is more suitable for patients with DDH who plan to be treated by one operation than the classic modified Smith-Peterson approach for PAO.

Effects of different pelvic osteotomies on acetabular morphology in developmental dysplasia of hip in children

Developmental dysplasia of hip seriously affects the health of children, and pelvic osteotomy is an important part of surgical treatment. Improving the shape of the acetabulum, preventing or delaying the progression of osteoarthritis is the ultimate goal of pelvic osteotomies. Re-directional osteotomies, reshaping osteotomies and salvage osteotomies are the three most common types of pelvic osteotomy. The influence of different pelvic osteotomy on acetabular morphology is different, and the acetabular morphology after osteotomy is closely related to the prognosis of the patients. But there lacks comparison of acetabular morphology between different pelvic osteotomies, on the basis of retrospective analysis and measurable imaging indicators, this study predicted the acetabular shape after developmental dysplasia of the hip pelvic osteotomy in order to help clinicians make reasonable and correct decisions and improve the planning and performance of pelvic osteotomy.

[Fixation techniques in periacetabular osteotomy : Stability and clinical aspects of established and new fixation techniques]

Periacetabular osteotomy according to Ganz (PAO) is an established technique for the surgical treatment of hip dysplasia with the aim of biomechanically optimizing the dysplastic hip joint. Through multidimensional reorientation, the deficient coverage of the femoral head can be improved and physiological values can be achieved. Until bony consolidation is reached, adequate fixation of the acetabulum in the corrected position achieved is necessary. Various fixation techniques are available for this purpose. Alternatively to screws, Kirschner wires can also be used for fixation. The different fixation techniques show comparable stability. Differences exist in the occurrence of implant-associated complications. However, there is no difference in patient satisfaction and joint-specific function.

The Scientific Evolution of Periacetabular Osteotomy: A Global Review

It is well-known that hip disorders are frequently of bony origin related to an underlying pathomorphology. A fundamental understanding of morphology and biomechanics is therefore of essential importance for a targeted approach in defining treatment plans. Treatment is frequently based on altering bony morphology, for which a set of effective techniques have been proposed. Periacetabular osteotomy (PAO) allows for reorientation of the acetabulum and powerful correction of acetabular coverage. The revolutionary aspect of PAO compared to prior osteotomies lies in maintenance of the integrity of the posterior column. This allows for a substantial increase in primary stability, a larger bony surface for healing, and simple reorientation of the acetabular fragment that is free of posterior ligamentous restraints. The results for dysplasia are very promising. Indications have been refined by studies revealing that the presence of degenerative changes and age > 40 years at the time of surgery represent prognostic factors of poorer outcome. Indications have also been broadened to include acetabular retroversion (with posterolateral dysplasia) and borderline hip dysplasia. A glimpse at the future would reflect major advances related to individual planning, surgical training, and precise surgical conduction. In the era of digitalization, augmented reality may assist in performing bony cuts and act as an aid for some of the blind ischial and retro-acetabular cuts. Innovations in perioperative management will enhance recovery after the procedure and allow for early recovery programs with optimized protocols of pain management. Considering that the success of PAO in the young is comparable to the success of hip arthroplasty in the old, PAO should be considered one of the pillars of modern orthopedic surgery.