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Haertlé M, Becker N, Windhagen H, Ahmad SS. Unveiling the learning curve of periacetabular osteotomy. Bone Joint J 2024; 106-B:336-343. [PMID: 38555935 DOI: 10.1302/0301-620x.106b4.bjj-2023-0830.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Aims Periacetabular osteotomy (PAO) is widely recognized as a demanding surgical procedure for acetabular reorientation. Reports about the learning curve have primarily focused on complication rates during the initial learning phase. Therefore, our aim was to assess the PAO learning curve from an analytical perspective by determining the number of PAOs required for the duration of surgery to plateau and the accuracy to improve. Methods The study included 118 consecutive PAOs in 106 patients. Of these, 28 were male (23.7%) and 90 were female (76.3%). The primary endpoint was surgical time. Secondary outcome measures included radiological parameters. Cumulative summation analysis was used to determine changes in surgical duration. A multivariate linear regression model was used to identify independent factors influencing surgical time. Results The learning curve in this series was 26 PAOs in a period of six months. After 26 PAO procedures, a significant drop in surgical time was observed and a plateau was also achieved. The mean duration of surgery during the learning curve was 103.8 minutes (SD 33.2), and 69.7 minutes (SD 18.6) thereafter (p < 0.001). Radiological correction of acetabular retroversion showed a significant improvement after having performed a total of 93 PAOs, including anteverting PAOs on 35 hips with a retroverted acetabular morphology (p = 0.005). Several factors were identified as independent variables influencing duration of surgery, including patient weight (β = 0.5 (95% confidence interval (CI) 0.2 to 0.7); p < 0.001), learning curve procedure phase of 26 procedures (β = 34.0 (95% CI 24.3 to 43.8); p < 0.001), and the degree of lateral correction expressed as the change in the lateral centre-edge angle (β = 0.7 (95% CI 0.001 to 1.3); p = 0.048). Conclusion The learning curve for PAO surgery requires extensive surgical training at a high-volume centre, with a minimum of 50 PAOs per surgeon per year. This study defined a cut-off value of 26 PAO procedures, after which a significant drop in surgical duration occurred. Furthermore, it was observed that a retroverted morphology of the acetabulum required a greater number of procedures to acquire proficiency in consistently eliminating the crossover sign. These findings are relevant for fellows and fellowship programme directors in establishing the extent of training required to impart competence in PAO.
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Affiliation(s)
- Marco Haertlé
- Department of Orthopaedic Surgery, Annastift Hospital, Hanover Medical School, Hanover, Germany
| | - Nils Becker
- Department of Orthopaedic Surgery, Annastift Hospital, Hanover Medical School, Hanover, Germany
| | - Henning Windhagen
- Department of Orthopaedic Surgery, Annastift Hospital, Hanover Medical School, Hanover, Germany
| | - Sufian S Ahmad
- Department of Orthopaedic Surgery, Annastift Hospital, Hanover Medical School, Hanover, Germany
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Hapa O, Hevesi M, Lee SH, Trousdale RT, Sierra RJ. Making the cut: a technical note and literature review of Bernese periacetabular osteotomy techniques with special attention to ischial osteotomy initiation and completion with an inside to anterior curved osteotomy. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1691-1697. [PMID: 38055056 DOI: 10.1007/s00590-023-03787-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 11/15/2023] [Indexed: 12/07/2023]
Abstract
Periacetabular osteotomy includes a fluoroscopy-guided ischial cut without direct visualization. Previously described techniques include a mediolateral ischial cortex cut, which is associated with the risk of injuring nearby nerves. Another drawback of that technique is the difficulty connecting an ischial cortex cut with a retroacetabular cut due to orthogonal nature of the osteotomy. In general, an additional cut from medial to lateral is required. The present study aimed to describe a technique that eliminates those problems due to use of only a central cut of the ischium and the curved nature of the osteotomy.
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Affiliation(s)
- Onur Hapa
- Department of Orthopedic Surgery, Dokuz Eylül University, İzmir, Turkey.
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Mario Hevesi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sheng-Hsun Lee
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Rafael J Sierra
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Dhaliwal AS, Akhtar M, Razick DI, Afzali A, Wilson E, Nedopil AJ. Current Surgical Techniques in the Treatment of Adult Developmental Dysplasia of the Hip. J Pers Med 2023; 13:942. [PMID: 37373931 DOI: 10.3390/jpm13060942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/28/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
The surgical protocols currently used for the treatment of developmental dysplasia of the hip (DDH) are varied, with sufficient differences in clinical outcomes that warrant a review of the role of practicing orthopedic surgeons. This paper aims to summarize the current novel techniques within the realm of surgical treatment for adult DDH, thus serving as a guide to surgeons looking to quickly familiarize themselves with available techniques. We performed computer systematic literature searches of the Embase and PubMed databases from 2010 to 2 April 2022. Study parameters as well as their respective patient reported outcomes (PROMs) were described in detail and compiled into diagrams. Two novel techniques were identified for the treatment of borderline or low-grade DDH. Six techniques which included modifications to the Bernese periacetabular osteotomy (PAO) were identified for the treatment of symptomatic DDH. Three techniques which include combinations of arthroscopy and osteotomy were identified for the treatment of DDH with concomitant hip pathologies such as cam deformities. Finally, six techniques, all of which are modifications to total hip arthroplasty (THA), were identified for the treatment of high-grade DDH. The techniques detailed in this review therefore equip surgeons with the necessary knowledge to improve outcomes in patients with varying degrees of DDH.
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Affiliation(s)
- Anand S Dhaliwal
- College of Medicine, Californa Northstate University, Elk Grove, CA 95757, USA
| | - Muzammil Akhtar
- College of Medicine, Californa Northstate University, Elk Grove, CA 95757, USA
| | - Daniel I Razick
- College of Medicine, Californa Northstate University, Elk Grove, CA 95757, USA
| | - Arya Afzali
- College of Medicine, Californa Northstate University, Elk Grove, CA 95757, USA
| | - Ethan Wilson
- College of Medicine, Californa Northstate University, Elk Grove, CA 95757, USA
| | - Alexander J Nedopil
- College of Medicine, Californa Northstate University, Elk Grove, CA 95757, USA
- Orthopädische Klinik König-Ludwig-Haus, Lehrstuhl für Orthopädie der Universität Würzburg, 97074 Würzburg, Germany
- Department of Biomedical Engineering, University of California, Davis, CA 95616, USA
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Vuillemin N, Meier MK, Moosmann AM, Siebenrock KA, Steppacher SD. Retrotilt of the Pelvis During Periacetabular Osteotomy: How to Avoid a Systematic Error Resulting in Acetabular Retroversion and Possible Femoroacetabular Impingement. Am J Sports Med 2023; 51:1224-1233. [PMID: 36876866 DOI: 10.1177/03635465231155201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND Pelvic tilt directly influences acetabular version on radiographs. Changes of pelvic tilt potentially affect acetabular reorientation after periacetabular osteotomy (PAO). PURPOSE (1) To compare the ratio of the pubic symphysis height to the sacroiliac width (PS-SI) between hips with dysplasia and acetabular retroversion, uni- and bilateral PAO, and male and female patients. (2) To evaluate pelvic tilt (quantified using the PS-SI ratio) in patients after PAO by tracking it from preoperative to intra- and postoperative and short- and middle-term follow-up. STUDY DESIGN Case series; Level of evidence, 4. METHODS A retrospective and radiographic study was conducted evaluating pelvic tilt in 124 patients (139 hips) with dysplasia and 46 patients (57 hips) with acetabular retroversion who were undergoing PAO (January 2005-December 2019). Patients were excluded if they had insufficient radiographic data, previous or concomitant hip surgery, posttraumatic or pediatric deformities, or combined dysplasia and retroversion (90 patients, 95 hips). Dysplasia was defined as a lateral center-edge angle <23°; retroversion was defined by simultaneous appearance of a retroversion index 30% and positive ischial spine and posterior wall signs. Anteroposterior pelvic radiographs were taken in the supine position preoperatively, during PAO, postoperatively, and at short- and middle-term follow-up (mean ± SD [range]; 9 ± 3 weeks [5-23 weeks] and 21 ± 21 weeks [6-125 months]). The PS-SI ratio was calculated at 5 observation periods (preoperatively to middle-term follow-up) for different subgroups (dysplasia vs retroversion, uni- vs bilateral surgery, male vs female) and validated with intra- and interobserver agreement (intraclass correlation coefficients, 0.984 (95%CI, 0.976-0.989) and 0.991 (95% CI, 0.987-0.994), respectively). RESULTS The PS-SI ratio differed between dysplasia and retroversion at all observation periods (P = .041 to P < .001). Male dysplastic hips had a lower PS-SI ratio when compared with female dysplastic hips at all observation periods (P < .001 to P = .005). In hips with acetabular retroversion, the PS-SI ratio was lower in men than women at short- and middle-term follow-up (P = .024 and .003). No difference was found between uni- and bilateral surgery (P = .306 to P = .905) except for short-term follow-up in dysplasia (P = .040). The PS-SI ratio decreased in all subgroups preoperatively to intra- or postoperatively (P < .001 to P = .031). At short- and middle-term follow-up, the PS-SI ratio increased as compared with intraoperatively (P < .001 to P = .044) and did not differ from preoperatively in all subgroups (P = .370 to P = .795). CONCLUSION A lower PS-SI ratio was found for male or dysplastic hips. In all subgroups, the PS-SI ratio decreased during surgery, indicating retrotilt of the pelvis. Correct pelvic orientation during surgery is crucial for accurate acetabular reorientation. Retrotilt during surgery results in underestimation of acetabular version and iatrogenic retroversion of the acetabulum at follow-up, with the pelvis in the correct and more forward-tilted orientation. Not taking into account retrotilt during PAO potentially results in femoroacetabular impingement. Therefore, we changed our intraoperative setting with adjustment of the central beam to compensate for retrotilt of the pelvis.
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Affiliation(s)
- Nicolas Vuillemin
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Malin Kristin Meier
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Angela Maria Moosmann
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Klaus Arno Siebenrock
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon Damian Steppacher
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Ahmad SS, Haertlé M, Konrads C, Derksen A, Windhagen H, Wirries N. The Scientific Evolution of Periacetabular Osteotomy: A Global Review. J Clin Med 2022; 11:jcm11206099. [PMID: 36294420 PMCID: PMC9604972 DOI: 10.3390/jcm11206099] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/27/2022] [Accepted: 10/10/2022] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Sufian S. Ahmad
- Department of Orthopaedic Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Marco Haertlé
- Department of Orthopaedic Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Christian Konrads
- Department of Orthopaedic Surgery, University of Tübingen, 72076 Tübingen, Germany
- Correspondence:
| | - Alexander Derksen
- Department of Orthopaedic Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Henning Windhagen
- Department of Orthopaedic Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Nils Wirries
- Department of Orthopaedic Surgery, Hannover Medical School, 30625 Hannover, Germany
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6
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Kriechling P, Leoty L, Fürnstahl P, Rahbani D, Zingg PO, Vlachopoulos L. A Statistical Shape Model-Based Analysis of Periacetabular Osteotomies: Technical Considerations to Achieve the Targeted Correction. J Bone Joint Surg Am 2022; 104:1107-1115. [PMID: 35363641 DOI: 10.2106/jbjs.21.00454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Classic and reverse Bernese periacetabular osteotomy (PAO) have been shown to be effective for the treatment of developmental dysplasia of the hip (by classic PAO), severe acetabular retroversion (by reverse PAO), and some protrusio acetabuli (by reverse PAO). Especially in severe cases with higher degrees of correction, a relevant overlap between the osteotomized fragment and the pelvis might occur, leading to necessary fragment translation. The aim of the present study was to analyze the necessary translation as a function of the degree of correction using a statistical mean model of the pelvis according to the technique (classic PAO or reverse PAO). METHODS A mean statistical shape model of the pelvis and 2 extreme models were used to simulate rotation of the osteotomized fragment during a classic or reverse PAO and to calculate rotations from -20° to 20° in the frontal, sagittal, and transverse planes and a combination thereof. The depth and volume of the intersection between the mobilized fragment and the pelvis were calculated, and the minimum translation of the fragment necessary to avoid segment overlap was determined. RESULTS The maximum intersection distances between the pelvis and the 20° rotated fragment were 6.7 and 15.3 mm for adduction and abduction (frontal plane), 6.4 and 4.5 mm for internal and external rotation (transverse plane), and 27.8 and 9.2 mm for extension and flexion (sagittal plane). The necessary translations for 20° of fragment rotation were 7.0 and 12.8 mm for adduction and abduction (frontal plane), 4.8 and 5.0 mm for internal and external rotation (transverse plane), and 18.5 mm and 8.8 mm for extension and flexion (sagittal plane). CONCLUSIONS Acetabular reorientation with the classic or reverse PAO results in translation of the fragment and in a consequent change in the rotational center. This finding is more pronounced with higher degrees of fragment reorientation in abduction and extension; it becomes especially pronounced in reverse PAO for acetabular retroversion or protrusio acetabuli, and might limit the ability to achieve the intended improvement in overall hip biomechanics.
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Affiliation(s)
- Philipp Kriechling
- Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
| | - Laura Leoty
- Research in Orthopaedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Philipp Fürnstahl
- Research in Orthopaedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Dana Rahbani
- Graphics and Vision Research Group (GraVis), University of Basel, Basel, Switzerland
| | - Patrick O Zingg
- Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
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7
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Vuillemin N, Steppacher SD, Meier MK, Büchler L. [Treatment strategies for the combination of hip dysplasia, femoroacetabular impingement and malrotation of the proximal femur : How much should be corrected?]. ORTHOPADIE (HEIDELBERG, GERMANY) 2022; 51:438-449. [PMID: 35925372 DOI: 10.1007/s00132-022-04252-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Hip dysplasia, FAI and femoral malrotation often occur together, resulting in mixed symptoms and severe biomechanical limitations of the hip. OBJECTIVES To report on the current recommendations for the best possible diagnosis and treatment strategies of combination pathologies in hip-preserving surgery. METHODS Review and discussion of the relevant literature with consideration of own experience in the treatment of complex combined pathomorphologies of the hip. RESULTS Patient history and a thorough clinical examination are key for determining the predominant pathomorphologies causing the symptoms. Standardized conventional ap pelvic and axial images of the hip are the basis for the radiological assessment of the hip, supplemented with MRI, CT and animations of the hip, depending on the case. As the pathologies influence each other functionally, a stepwise approach to treatment is recommended. The functionally most relevant pathology is treated first, followed by further corrections as needed. The primary goal is to achieve a stable hip with normal acetabular coverage, followed by an impingement-free range of motion and normalized musculoskeletal function. Care must be taken in the choice of surgical method to ensure that all pathologies can be adequately treated. CONCLUSION Complex, combined pathologies of the hip can be treated sufficiently with hip-preserving surgery. A thorough diagnosis is important in order to recognize the functional interaction of the different pathologies. The goal of the surgical therapy is a correctly covered, stable hip with a normal range of motion.
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Affiliation(s)
- Nicolas Vuillemin
- Department für Orthopädie und Traumatologie, Inselspital, Universitätsklinik Bern, Bern, Schweiz
| | - Simon D Steppacher
- Department für Orthopädie und Traumatologie, Inselspital, Universitätsklinik Bern, Bern, Schweiz
| | - Malin K Meier
- Department für Orthopädie und Traumatologie, Inselspital, Universitätsklinik Bern, Bern, Schweiz
| | - Lorenz Büchler
- Department für Orthopädie und Traumatologie, Inselspital, Universitätsklinik Bern, Bern, Schweiz.
- Klinik für Orthopädie und Traumatologie, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Schweiz.
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Breckling A, Katrikh AZ, Jones MW, Ferrigno C. Iliocapsularis: An Exploration of the Muscle and Its Omission in Education. J Morphol 2022; 283:899-907. [DOI: 10.1002/jmor.21468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/07/2022] [Accepted: 03/19/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Abbey Breckling
- Department of Anatomy and Cell Biology UIC College of Medicine Chicago USA
| | | | - Michael W. Jones
- Department of Biological Sciences California Polytechnic State University San Luis Obispo USA
| | - Christopher Ferrigno
- Department of Anatomy and Cell Biology Rush University Medical Center Chicago USA
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Brumat P, Mihalič R, Benulič Č, Kristan A, Trebše R. Patient-specific template and electromagnetic navigation assisted bilateral periacetabular osteotomy for staged correction of bilateral injury-induced hip dysplasia: a case report. J Hip Preserv Surg 2021; 8:192-196. [PMID: 35145717 PMCID: PMC8825680 DOI: 10.1093/jhps/hnab054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/01/2021] [Accepted: 07/19/2021] [Indexed: 11/12/2022] Open
Abstract
ABSTRACT
Periacetabular osteotomy (PAO) for pelvic fracture sequelae presents a challenge in hip preservation surgery due to a combination of complex conditions involving post-traumatic altered anatomy and technically demanding procedure, with high surgical risk involved. To address these challenging conditions and evade potential devastating complications, a combination of patient-specific template (PST) and electromagnetic navigation (EMN) guidance can be used to increase the safety of the procedure and the accuracy of the acetabular reorientation. Herein we report our experience utilizing a combined PST- and EMN-assisted bilateral PAO for staged correction of bilateral severe, injury-induced hip dysplasia. The presented case report describes a unique method of successful surgical treatment of severe, bilateral injury-induced hip dysplasia with combined 3-D printing technology (PST) and intra-operative electromagnetic computer-assisted navigation (EMN) aided technically demanding surgical procedure (PAO), which emphasizes the benefits of PST and EMN use in hip preservation surgery in patients with complex pathoanatomic circumstances.
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Affiliation(s)
- Peter Brumat
- Valdoltra Orthopaedic Hospital, Jadranska cesta 31, Ankaran 6280, Slovenia
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana 1000, Slovenia
| | - Rene Mihalič
- Valdoltra Orthopaedic Hospital, Jadranska cesta 31, Ankaran 6280, Slovenia
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana 1000, Slovenia
| | - Črt Benulič
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana 1000, Slovenia
- Department of Traumatology, Division of Surgery, University Medical Centre Ljubljana, Ljubljana, Zaloška 7, Ljubljana 1000, Slovenia
| | - Anže Kristan
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana 1000, Slovenia
- Department of Traumatology, Division of Surgery, University Medical Centre Ljubljana, Ljubljana, Zaloška 7, Ljubljana 1000, Slovenia
| | - Rihard Trebše
- Valdoltra Orthopaedic Hospital, Jadranska cesta 31, Ankaran 6280, Slovenia
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana 1000, Slovenia
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Pun SY, Hosseinzadeh S, Dastjerdi R, Millis MB. What Are the Early Outcomes of True Reverse Periacetabular Osteotomy for Symptomatic Hip Overcoverage? Clin Orthop Relat Res 2021; 479:1081-1093. [PMID: 33296152 PMCID: PMC8052029 DOI: 10.1097/corr.0000000000001549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 10/06/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acetabular overcoverage is associated with pincer-type femoroacetabular impingement (FAI). A subtype of acetabular overcoverage is caused by a deep acetabulum with a negatively tilted acetabular roof, in which acetabular reorientation may be a preferable alternative to rim trimming to uncover the femoral head. We introduced the true reverse periacetabular osteotomy (PAO) in 2003, which in contrast to an anteverting PAO, also flexes and abducts the acetabulum relative to the intact ilium to decrease anterior and lateral femoral head coverage and correct negative tilt of the acetabular roof. To our knowledge, the clinical results of the true reverse PAO have not been evaluated. QUESTIONS/PURPOSES For a group of patients who underwent reverse PAO, (1) Do patients undergoing reverse PAO demonstrate short-term improvement in pain, function, and hip ROM, and decreased acetabular coverage, as defined by lateral and anterior center-edge angle and Tönnis angle? (2) Are there identifiable factors associated with success or adverse outcomes of reverse PAO as defined by reoperation, conversion to THA, or poor patient-reported outcome scores? (3) Are there identifiable factors associated with early complications? METHODS Between 2003 and 2017, two surgeons carried out 49 reverse PAOs in 37 patients. Twenty-five patients had unilateral reverse PAO and 12 patients had staged, bilateral reverse PAOs. To ensure that each hip was an independent data point for statistical analysis, we chose to include in our series only the first hip in the patients who had bilateral reverse PAOs. During the study period, our general indications for this operation were symptomatic lateral and anterior acetabular overcoverage causing FAI that had failed to respond to previous conservative or surgical treatment. Thirty-seven hips in 37 patients with a median (range) age of 18 years (12 to 41; interquartile range 16 to 21) were included in this retrospective study at a minimum follow-up of 2 years (median 6 years; range 2 to 17). Thirty-four patients completed questionnaires, 24 patients had radiographic evaluation, and 23 patients received hip ROM clinical examination. However, seven patients had not been seen in more than 5 years. The clinical and radiographic parameters of all 37 hips that underwent reverse PAO in 37 patients from a longitudinally maintained institutional database were retrospectively studied preoperatively and postoperatively. Adverse outcomes were considered conversion to THA or a WOMAC pain score greater than 10 at least 2 years postoperatively. Patient-reported outcomes, radiographic measurements, and hip ROM were evaluated preoperatively and at most recent follow-up using a paired t-test or McNemar test, as appropriate. Linear regression analysis was used to assess for identifiable factors associated with clinical outcomes. Logistic regression analysis was used to assess for identifiable factors associated with adverse outcomes and surgical complications. All tests were two-sided, and p values less than 0.05 were considered significant. RESULTS At a minimum of 2 years after reverse PAO, patients experienced improvement in WOMAC pain (-7 [95% CI -9 to -5]; p < 0.001), stiffness (-2 [95% CI -3 to -1]; p < 0.001), and function scores (-18 [95% CI -24 to -12]; p < 0.001) and modified Harris Hip Score (mHHS) (20 [95% CI 13 to 27]; p < 0.001). The mean postoperative hip ROM improved in internal rotation (8° [95% CI 2° to 14°]; p = 0.007). Acetabular coverage, as defined by lateral center-edge angle (LCEA), anterior center-edge angle (ACEA), and Tönnis angle, improved by -8° (95% CI -12° to -5°; p < 0.001) for LCEA, -12° (95% CI -15° to -9°; p < 0.001) for ACEA, and 9° (95% CI 6° to 13°; p < 0.001) for Tönnis angle. The postoperative severity of radiographic arthritis was associated with worse WOMAC function scores such that for each postoperative Tönnis grade, WOMAC function score increased by 12 points (95% CI 2 to 22; p = 0.03). A greater postoperative Tönnis grade was also correlated with worse mHHS, with an average decrease of 12 points (95% CI -20 to -4; p = 0.008) in mHHS for each additional Tönnis grade. Presence of a positive postoperative anterior impingement test was associated with a decrease in mHHS score at follow-up, with an average 23-point decrease in mHHS (95% CI -34 to -12; p = 0.001). Nineteen percent (7 of 37) of hips had surgery-related complications. Four hips experienced adverse outcomes at final follow-up, with two patients undergoing subsequent THA and two with a WOMAC pain score greater than 10. We found no factors associated with complications or adverse outcomes. CONCLUSION The early clinical and radiographic results of true reverse PAO compare favorably to other surgical treatments for pincer FAI, suggesting that reverse PAO is a promising treatment for cases of pincer FAI caused by global acetabular overcoverage. However, it is a technically complex procedure that requires substantial training and preparation by a surgeon who is already familiar with standard PAO, and it must be carefully presented to patients with discussion of the potential risks and benefits. Future studies are needed to further refine the indications and to determine the long-term outcomes of reverse PAO. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Stephanie Y Pun
- S. Y. Pun, Department of Orthopaedic Surgery, The Stanford Child and Adult Hip Preservation Center, Stanford University School of Medicine, Stanford, CA, USA
- S. Hosseinzadeh, R. Dastjerdi, M. B. Millis, Department of Orthopaedic Surgery, The Child and Adult Hip Program, Boston Children's Hospital, Boston, MA, USA
| | - Shayan Hosseinzadeh
- S. Y. Pun, Department of Orthopaedic Surgery, The Stanford Child and Adult Hip Preservation Center, Stanford University School of Medicine, Stanford, CA, USA
- S. Hosseinzadeh, R. Dastjerdi, M. B. Millis, Department of Orthopaedic Surgery, The Child and Adult Hip Program, Boston Children's Hospital, Boston, MA, USA
| | - Roya Dastjerdi
- S. Y. Pun, Department of Orthopaedic Surgery, The Stanford Child and Adult Hip Preservation Center, Stanford University School of Medicine, Stanford, CA, USA
- S. Hosseinzadeh, R. Dastjerdi, M. B. Millis, Department of Orthopaedic Surgery, The Child and Adult Hip Program, Boston Children's Hospital, Boston, MA, USA
| | - Michael B Millis
- S. Y. Pun, Department of Orthopaedic Surgery, The Stanford Child and Adult Hip Preservation Center, Stanford University School of Medicine, Stanford, CA, USA
- S. Hosseinzadeh, R. Dastjerdi, M. B. Millis, Department of Orthopaedic Surgery, The Child and Adult Hip Program, Boston Children's Hospital, Boston, MA, USA
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11
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Mihalič R, Brumat P, Trebše R. Bernese peri-acetabular osteotomy performed with navigation and patient-specific templates is a reproducible and safe procedure. INTERNATIONAL ORTHOPAEDICS 2021; 45:883-889. [PMID: 33427896 DOI: 10.1007/s00264-020-04897-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 12/03/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To present a novel surgical technique for the Bernese peri-acetabular osteotomy (PAO) using electromagnetic navigation (EMN) and patient-specific templates (PST), and to evaluate it against the traditional fluoroscopic technique. METHODS We included 40 dysplastic hips. All PAOs were performed using PST and EMN. We recorded learning-related complications. For the purpose of acetabular fragment correction analysis, patients were divided into two groups. In the study group (EMN group, 30 hips), the acetabular fragment was reoriented with the help of EMN. In the control group (XR group, 10 hips), the acetabular fragment was reoriented using fluoroscopy. We compared the difference between the planned and achieved position of the acetabular fragment and outcomes between both groups. RESULTS Two major complications occurred in four PAOs in the XR group only (first ten PAOs). The average absolute difference in planned and achieved lateral centre -edge angle (LCEA) and acetabular index (AI) was 1.2° ± 1.5° and 1.1° ± 2° for the EMN and 7° ± 6.1° and 6.3° ± 6.3° for the XR group (p = 0.02; p = 0.03). The average surgery duration was 183 ± 32 minutes for the EMN and 203 ± 42 minutes for the XR group (p = 0.19). At the last follow-up, the average Harris Hip Score (HHS) value was 88 ± 12 in the EMN and 86 ± 14 in the XR group (p = 0.84). CONCLUSIONS Our study indicates that PAO performed with EMN and PST seems to be a safe and reproducible procedure with a short learning curve. Additionally, navigated reorientation of the acetabular fragment is significantly more accurate than the fluoroscopic technique.
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Affiliation(s)
- Rene Mihalič
- Valdoltra Orthopaedic Hospital, Jadranska cesta 31, 6280, Ankaran, Slovenia.
| | - Peter Brumat
- Valdoltra Orthopaedic Hospital, Jadranska cesta 31, 6280, Ankaran, Slovenia
| | - Rihard Trebše
- Valdoltra Orthopaedic Hospital, Jadranska cesta 31, 6280, Ankaran, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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12
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Abstract
Classical indications for hip preserving surgery are: femoro-acetabular impingement (FAI) (intra- and extra-articular), hip dysplasia, slipped capital femoral epiphysis, residual deformities after Perthes disease, avascular necrosis of the femoral head. Pre-operative evaluation of the pathomorphology is crucial for surgical planning including radiographs as the basic modality and magnetic resonance imaging (MRI) and/or computed tomography (CT) to evaluate further intra-articular lesions and osseous deformities. Two main mechanisms of intra-articular impingement have been described:
(1) Inclusion type FAI (‘cam type’). (2) Impaction type FAI (‘pincer type’).
Either arthroscopic or open treatment can be performed depending on the severity of deformity. Slipped capital femoral epiphysis often results in a cam-like deformity of the hip. In acute cases a subcapital re-alignment (modified Dunn procedure) of the femoral epiphysis is an effective therapy. Perthes disease can lead to complex femoro-acetabular deformity which predisposes to impingement with/without joint incongruency and requires a comprehensive diagnostic workup for surgical planning. Developmental dysplasia of the hip results in a static overload of the acetabular rim and early osteoarthritis. Surgical correction by means of periacetabular osteotomy offers good long-term results.
Cite this article: EFORT Open Rev 2020;5:630-640. DOI: 10.1302/2058-5241.5.190074
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Affiliation(s)
- Markus S Hanke
- Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Diagnostic, Interventional and Pediatric Radiology, University Hospital of Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Simon D Steppacher
- Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Till D Lerch
- Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Klaus A Siebenrock
- Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern, Bern, Switzerland
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13
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Maldonado DR, Chen JW, Kyin C, Rosinsky PJ, Shapira J, Karom JM, Lall AC, Domb BG. Hips With Acetabular Retroversion Can Be Safely Treated With Advanced Arthroscopic Techniques Without Anteverting Periacetabular Osteotomy: Midterm Outcomes With Propensity-Matched Control Group. Am J Sports Med 2020; 48:1636-1646. [PMID: 32407160 DOI: 10.1177/0363546520916737] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Different options, from reverse (anteverting) periacetabular osteotomy to hip arthroscopy, have been proposed for surgical treatment of femoroacetabular impingement syndrome (FAIS) in the setting of acetabular retroversion. PURPOSE (1) To report and analyze midterm patient-reported outcome scores (PROs) in patients with FAIS and labral tears in the setting of acetabular retroversion after isolated hip arthroscopy and (2) to compare these PROs with those of a propensity-matched control group without acetabular retroversion. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Prospectively collected data were retrospectively reviewed for patients who underwent hip arthroscopy for FAIS and labral tear treatment between June 2008 and March 2014. Inclusion criteria were as follows: acetabular retroversion, pre- and postoperative PROs for modified Harris Hip Score (mHHS), Non-arthritic Hip Score, Hip Outcome Score-Sports Specific Scale (HOS-SSS), and visual analog scale (VAS). Propensity score matching was utilized to identify a control group without acetabular retroversion matched 1:1 with similar age, sex, body mass index, acetabular and femoral head Outerbridge grade, preoperative lateral center-edge angle, and labral treatment. Patient acceptable symptomatic state (PASS) and/or minimal clinically important difference (MCID) for the mHHS, HOS-SSS, International Hip Outcome Tool-12, and VAS was calculated. RESULTS A total of 205 hips with acetabular retroversion were matched to a control group. The groups showed no difference in demographic variables. The retroversion group was composed of 139 female and 66 male hips, with a mean ± SD age of 23.81 ± 7.28 years and follow-up time of 65.24 ± 20.31 months. Intraoperative diagnostic data and procedures performed were similar between groups, except more femoroplasties were performed in the retroversion group. Significant improvements for the mHHS, Non-arthritic Hip Score, HOS-SSS, and VAS were seen for both groups at a mean 5-year follow-up. The proportion of patients who reached the PASS and MCID were similar. CONCLUSION In the setting of FAIS and labral tears, patients with acetabular retroversion can be safely treated with advanced hip arthroscopic techniques without reverse (anteverting) periacetabular osteotomy in a high-volume surgeon's hands. Patients with acetabular retroversion demonstrated favorable PROs at midterm follow-up. Furthermore, the proportion of patients reaching the MCID and PASS for several PROs were comparable with those of a propensity-matched control group without acetabular retroversion.
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Affiliation(s)
| | - Jeffery W Chen
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Cynthia Kyin
- American Hip Institute, Des Plaines, Illinois, USA
| | | | | | | | - Ajay C Lall
- American Hip Institute, Des Plaines, Illinois, USA
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14
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Zurmühle CA, Anwander H, Albers CE, Hanke MS, Steppacher SD, Siebenrock KA, Tannast M. Periacetabular Osteotomy Provides Higher Survivorship Than Rim Trimming for Acetabular Retroversion. Clin Orthop Relat Res 2017; 475:1138-1150. [PMID: 27921206 PMCID: PMC5339145 DOI: 10.1007/s11999-016-5177-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 11/14/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acetabular retroversion can cause impaction-type femoroacetabular impingement leading to hip pain and osteoarthritis. It can be treated by anteverting periacetabular osteotomy (PAO) or acetabular rim trimming with refixation of the labrum. There is increasing evidence that acetabular retroversion is a rotational abnormality of the entire hemipelvis and not a focal overgrowth of the anterior acetabular wall, which favors an anteverting PAO. However, it is unknown if this larger procedure would be beneficial in terms of survivorship and Merle d'Aubigné scores in a midterm followup compared with rim trimming. QUESTIONS/PURPOSES We asked if anteverting PAO results in increased survivorship of the hip compared with rim trimming through a surgical hip dislocation in patients with symptomatic acetabular retroversion. METHODS We performed a retrospective, comparative study evaluating the midterm survivorship of two matched patient groups with symptomatic acetabular retroversion undergoing either anteverting PAO or acetabular rim trimming through a surgical hip dislocation. Acetabular retroversion was defined by a concomitantly present positive crossover, posterior wall, and ischial spine sign. A total of 279 hips underwent a surgical intervention for acetabular retroversion at our center between 1997 and 2012 (166 periacetabular osteotomies, 113 rim trimmings through surgical hip dislocation). A total of 99 patients (60%) were excluded from the PAO group and 56 patients (50%) from the rim trimming group because they had any of several prespecified conditions (eg, dysplasia or pediatric conditions 61 [37%] for the PAO group and two [2%] for the rim trimming group), matching (10 [6%]/10 [9%] hips), deficient records (10 [6%]/13 [12%] hips), or the patient declined or was lost to followup (18 [11%]/31 [27%] hips). This left 67 hips (57 patients) that underwent anteverting PAO and 57 hips (52 patients) that had acetabular rim trimming. The two groups did not differ in terms of age, sex, body mass index, preoperative ROM, preoperative Merle d'Aubigné-Postel score, radiographic morphology of the acetabulum (except total and anterior acetabular coverage), alpha angle, Tönnis grade of osteoarthritis, and labral and chondral lesions on the preoperative MRI. During the period in question, we generally performed PAO from 1997 to 2003. With the availability of surgical hip dislocation and labral refixation, we generally performed rim trimming from 2004 to 2010. With growing knowledge of the underlying pathomorphology, anteverting PAOs became more common again around 2007 to 2008. A minimum followup of 2 years was required for this study. Failures were included at any time. The median followup for the anteverting PAO group was 9.5 years (range, 2-17.4 years) and 6.8 years (range, 2.2-10.5 years) for the rim trimming group (p < 0.001). Kaplan-Meier survivorship analysis was performed using the following endpoints at 5 and 10 years: THA, radiographic progression of osteoarthritis by one Tönnis grade, and/or Merle d'Aubigné-Postel score < 15 points. RESULTS Although the 5-year survivorship of the two groups was not different with the numbers available (86% [95% confidence interval {CI}, 76%-94%] for anteverting PAO versus 86% [95% CI, 76%-96%] for acetabular rim trimming), we found increased survivorship at 10 years in hips undergoing anteverting PAO for acetabular retroversion (79% [95% CI, 68%-90%]) compared with acetabular rim trimming (23% [95% CI, 6%-40%]) at 10 years (p < 0.001). The drop in the survivorship curve for the acetabular rim trimming through surgical hip dislocation group started at Year 6. The main reason for failure was a decreased Merle d'Aubigné score. CONCLUSIONS Anteverting PAO may be the more appropriate treatment for hips with substantial acetabular retroversion. This may be the result of reduction of an already smaller lunate surface of hips with acetabular retroversion through rim trimming. However, rim trimming may still benefit hips with acetabular retroversion in which only one or two of the three signs are positive. Future randomized studies should compare these treatments. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Corinne A. Zurmühle
- grid.5734.50000000107265157Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Helen Anwander
- grid.5734.50000000107265157Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Christoph E. Albers
- grid.5734.50000000107265157Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Markus S. Hanke
- grid.5734.50000000107265157Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Simon D. Steppacher
- grid.5734.50000000107265157Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Klaus A. Siebenrock
- grid.5734.50000000107265157Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Moritz Tannast
- grid.5734.50000000107265157Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
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15
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Abstract
Context: An evolution in conceptual understanding, coupled with technical innovations, has enabled hip preservation surgeons to address complex pathomorphologies about the hip joint to reduce pain, optimize function, and potentially increase the longevity of the native hip joint. Technical aspects of hip preservation surgeries are diverse and range from isolated arthroscopic or open procedures to hybrid procedures that combine the advantages of arthroscopy with open surgical dislocation, pelvic and/or proximal femoral osteotomy, and biologic treatments for cartilage restoration. Evidence Acquisition: PubMed and CINAHL databases were searched to identify relevant scientific and review articles from January 1920 to January 2015 using the search terms hip preservation, labrum, surgical dislocation, femoroacetabular impingement, peri-acetabular osteotomy, and rotational osteotomy. Reference lists of included articles were reviewed to locate additional references of interest. Study Design: Clinical review. Level of Evidence: Level 4. Results: Thoughtful individualized surgical procedures are available to optimize the femoroacetabular joint in the presence of hip dysfunction. Conclusion: A comprehensive understanding of the relationship between femoral and pelvic orientation, morphology, and the development of intra-articular abnormalities is necessary to formulate a patient-specific approach to treatment with potential for a successful long-term result.
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Affiliation(s)
- Kelly L Adler
- Division of Sports Medicine, Hip Preservation Program, Division of Sports Medicine, University of Rochester Medical Center, Rochester, New York
| | - P Christopher Cook
- Division of Sports Medicine, Hip Preservation Program, Division of Sports Medicine, University of Rochester Medical Center, Rochester, New York
| | - Yi-Meng Yen
- Department of Orthopaedic Surgery, Division of Sports Medicine, Children's Hospital Boston, The Adolescent and Young Hip Unit, Boston, Massachusetts
| | - Brian D Giordano
- Division of Sports Medicine, Hip Preservation Program, Division of Sports Medicine, University of Rochester Medical Center, Rochester, New York
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