Hip Arthroscopy in Patients with Recurrent Pain following Bernese Periacetabular Osteotomy for Acetabular Dysplasia: Operative Findings and Clinical Outcomes

Background: Previous studies on periacetabular osteotomy (PAO) reported complication and reoperation rates of 5.9% and 10%, respectively. Hip arthroscopy is increasingly utilized as an adjunct procedure to PAO to precisely treat associated intra-articular pathology. The addition of this procedure has the potential of further increasing complication rates. Purpose: To determine the rates of complication and reoperation of combined hip arthroscopy and PAO for the treatment of acetabular deformities and associated intra-articular lesions. Study Design: Case series; Level of evidence, 4. Methods: Using a prospective database, the authors retrospectively reviewed 248 hips (240 patients) that underwent combined hip arthroscopy and PAO between 2007 and 2016. Data were collected at scheduled follow-up visits at approximately 1 month, 3 to 4 months, and 1 and 2 years after surgery. Mean follow-up from surgery was 3 years (range, 1-8 years). A total of 220 PAOs were done for symptomatic acetabular dysplasia, 18 for symptomatic acetabular retroversion, and 10 for combined acetabular dysplasia and acetabular retroversion. Central compartment arthroscopy was performed for treatment of intra-articular chondrolabral pathology in all cases. Select cases underwent femoral head-neck junction osteochondroplasty either arthroscopically before the PAO or through an open approach after it. Complications were graded according to the modified Dindo-Clavien complication scheme, which was validated for hip preservation procedures. Reoperations (excluding hardware removal) were recorded. Results: Grade III complications occurred among 7 patients (3%) while there were no grade IV complications. Grade III complications included deep infection (n = 3), wound dehiscence (n = 1), hematoma requiring exploration (n = 1), symptomatic heterotopic ossification requiring excision (n = 1), and deep venous thrombosis (n = 1). There were 13 reoperations (5%), and 3 were repeat hip arthroscopy. Univariate Cox hazard models were used to estimate the relative risk factors for complication and reoperation. Increased age (per decade) showed over twice the increased likelihood for complications (hazard ratio, 2.5; 95% CI, 1.67-3.74). Also, preoperative diagnosis of acetabular retroversion, not acetabular dysplasia, showed >3 times the increased risk of reoperation (hazard ratio, 3.05; 95% CI, 1.41-6.61). Conclusion: The rate of complications reported is comparable (3%) with previously published complication rates of PAO without hip arthroscopy. In this cohort, increasing age and diagnosis of acetabular retroversion were associated with higher complication and reoperation rates.

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Outcomes of periacetabular osteotomy for borderline hip dysplasia in adolescent patients

Journal of Hip Preservation Surgery ◽

10.1093/jhps/hnaa012 ◽

2020 ◽

Vol 7 (2) ◽

pp. 249-255

Author(s):

Ishaan Swarup ◽

Ira Zaltz ◽

Stacy Robustelli ◽

Ernest Sink

Keyword(s):

Hip Arthroscopy ◽

Acetabular Dysplasia ◽

Periacetabular Osteotomy ◽

Hip Pain ◽

Center Edge ◽

Outcome Scores ◽

Adolescent Patients ◽

History Of ◽

Outcome Tool

Abstract Treatment of borderline acetabular dysplasia (lateral center edge angle ≥18°) remains controversial, and there is a paucity of literature focusing on outcomes in adolescent patients. The purpose of this study was to evaluate the outcomes of a periacetabular osteotomy (PAO) as surgical management of borderline acetabular dysplasia in adolescent patients. We performed a retrospective review of prospectively collected data and included patients ≤ 21 years of age that underwent PAO for borderline acetabular dysplasia. All patients had a minimum of 1-year follow-up. Outcomes were assessed using modified Harris Hip Scores (mHHS), Hip Outcome Scores (HOS) and international Hip Outcome Tool (iHOT-33). Descriptive and univariate statistical analyses were performed. This study included 33 adolescent patients (35 hips) with symptomatic, borderline acetabular dysplasia. The majority of patients was female (32 patients, 97%); half of all patients reported a history of hip pain for over 1 year; and seven patients had previous hip arthroscopy. In addition to PAO, seven hips (20%) underwent a concurrent hip arthroscopy at the time of surgery. There were significant improvements in mean mHHS, HOS-activities of daily living (ADL), HOS-Sport and iHOT-33 scores after surgery (P < 0.01). Minimal clinically important difference in outcome scores was achieved for over 90% of patients at a minimum of 1-year follow-up. Borderline acetabular dysplasia is a major cause of hip pain in adolescent patients. Patients with symptomatic borderline acetabular dysplasia report a significant benefit after a PAO to correct structural hip instability.

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OUTCOME OF SURGICAL TREATMENT IN PATIENTS WITH BORDERLINE ACETABULAR DYSPLASIA: A COMPARATIVE ANALYSIS OF HIP ARTHROSCOPY AND PERIACETABULAR OSTEOTOMY

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120s00209 ◽

2020 ◽

Vol 8 (4_suppl3) ◽

pp. 2325967120S0020

Author(s):

Jeffrey J Nepple ◽

Maria Schwabe ◽

Elizabeth Graesser ◽

Cecilia Pascual-Garrido ◽

John C Clohisy

Keyword(s):

Surgical Outcomes ◽

Hip Arthroscopy ◽

Hip Dysplasia ◽

Acetabular Dysplasia ◽

Periacetabular Osteotomy ◽

Treatment Decision ◽

Patient Characteristics ◽

Diagnosis And Treatment ◽

Radiographic Measurements ◽

Significant Difference

Background: Optimal treatments of patients with borderline hip dysplasia, defined as LCEA 20°-25°, is controversial. These patients can have symptomatic impingement and/or instability. The optimal treatment of either hip arthroscopy (HA) alone or periacetabular osteotomy (PAO) (with/without hip arthroscopy) has not been established. Purpose: The purpose of this study was to evaluate surgical outcomes of patients with borderline hip dysplasia at a minimum of 2-year follow-up. Methods: A longitudinal cohort was utilized to identify patients with borderline acetabular dysplasia defined via prospective radiographic measurements. Demographics and radiographic measurements were recorded. Patient evaluation, diagnosis and treatment decisions (PAO v HA) were made by one treating surgeon. Outcome were assessed at baseline and a minimum 2 years postoperative. Descriptive and comparative statistics were performed. Failure was defined as reoperation, or failure to reach mHHS MCID (8 points) or PASS (mHHS <74). Results: Total of 113 hips were included at 4.7 years postoperatively (range 2.0-11.2 years). Overall, 76% were female and 42% of hips had PAO (65% combined with hip arthroscopy), while 58% had isolated hip arthroscopy (HA). For PAO group, mHHS improved from 57.9 to 82.8 postoperatively, compared to 62.6 to 84.0 for the HA group. Similarly, HOOS pain (PAO 48.2 to 79.1, HA 61.2 to 82.0) and HOOS Sports (PAO 36.5 to 73.0, HA 47.8 to 74.4) demonstrated similar improvements. Comparing the PAO and HA groups, the change in PRO was significantly greater for the PAO group for HOOS Pain (10.5 ±23.2, p=0.02) and HOOS ADL (9.4 ±20.5, p=0.04) which was primarily due to a lower baseline score (similar final score). No significant difference was detected for other PROs. Reoperations in the PAO group were 2% (1 hip arthroscopy) and 6% for hip arthroscopy group (3 hip arthroscopies, 1 PAO). The failure rate was 17% for PAO and 15% for HA (p=0.86). Discussion: Surgical outcomes at minimum of 2 years in patients with borderline hip dysplasia in selected patients undergoing PAO or hip arthroscopy were good. Significant differences in patient characteristics and radiographic parameters were present between hips indicated for PAO vs. HA emphasizing the need for careful diagnosis and treatment decision-making.

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Periacetabular Osteotomy After Failed Hip Arthroscopy for Labral Tears in Patients with Acetabular Dysplasia

The Journal of Bone and Joint Surgery (American) ◽

10.2106/jbjs.j.01770 ◽

2011 ◽

Vol 93 (Suppl 2) ◽

pp. 57-61 ◽

Cited By ~ 54

Author(s):

Michael SH Kain ◽

Eduardo N Novais ◽

Clarisa Vallim ◽

Michael B Millis ◽

Young-Jo Kim

Keyword(s):

Hip Arthroscopy ◽

Acetabular Dysplasia ◽

Periacetabular Osteotomy ◽

Labral Tears

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Hip Arthroscopy in Patients Less than 25 Years of Age in the Treatment of Labral Tears: Aetiology and Clinical Outcomes

Hip International ◽

10.5301/hipint.5000493 ◽

2017 ◽

Vol 27 (5) ◽

pp. 436-442 ◽

Cited By ~ 4

Author(s):

Gillian Bayley ◽

Stephane Poitras ◽

Gillian Parker ◽

Paul E. Beaulé

Keyword(s):

Quality Of Life ◽

Clinical Outcomes ◽

Hip Arthroscopy ◽

Periacetabular Osteotomy ◽

Cartilage Damage ◽

Alpha Angle ◽

Young Patients ◽

Labral Repair ◽

Labral Tears

Background Hip arthroscopy has evolved into a well-established and rapidly growing field of orthopedic surgery for the management of labral tears. The purpose of this study was to review clinical outcomes of patients less than 25 years of age undergoing hip arthroscopy for treatment of a labral tear. Methods From 2005 to 2013, 82 hips in 76 patients with mean age of 20.4 (16-25 range) underwent hip arthroscopy for treatment of labral-chondral damage. The Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) and hip disability and osteoarthritis outcome score (HOOS) were recorded at latest follow-up. Results 36 of 86 hips (42%) had isolated labral pathology with no associated bony pathology (normal alpha and centre-edge angle; no retroversion). Beck score (intraoperative cartilage damage) of 3 or more was significantly associated with an alpha angle of more than 55 degrees (odds ratio [OR], 3.6; confidence interval [CI], 1.2-11.0) and presence of femeroacetabular impingement (OR, 4.5; CI, 1.3-15.2). HOOS pain, sports/recreation, and quality of life significantly improved from preoperative to one year after surgery (p<0.05). 8 patients had re-operations for persistent pain; 5 underwent arthroscopic labral repair; 2 underwent arthroscopy with subsequent periacetabular osteotomy (PAO); 1 had only a periacetabular osteotomy (PAO). Complications included 2 lateral femoral cutaneous nerve deficits and 1 deep vein thrombosis. Conclusions Labral tears in patients less than 25 years of age occurs commonly without bony deformities, with those with normal head/neck contour demonstrating significantly less early cartilage damage than those with bony pathology. Hip arthroscopy in young patients can improve function and quality of life with minimal morbidity.

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A Contemporary Look at the Evaluation and Treatment of Adult Borderline and Frank Hip Dysplasia

The American Journal of Sports Medicine ◽

10.1177/0363546519881411 ◽

2019 ◽

Vol 48 (9) ◽

pp. 2314-2323 ◽

Cited By ~ 1

Author(s):

Matthew J. Kraeutler ◽

Marc R. Safran ◽

Anthony J. Scillia ◽

Olufemi R. Ayeni ◽

Tigran Garabekyan ◽

...

Keyword(s):

Clinical Outcomes ◽

Hip Arthroscopy ◽

Hip Dysplasia ◽

Wide Spectrum ◽

Meta Analysis ◽

Periacetabular Osteotomy ◽

Narrative Review ◽

Level Of Evidence ◽

Center Edge ◽

Hip Morphology

Background: Adult hip dysplasia is often diagnosed according to the lateral center-edge angle (LCEA). Patients with frank hip dysplasia (LCEA <20°) traditionally require treatment with bony realignment through a periacetabular osteotomy (PAO) and/or derotational femoral osteotomy, while patients with borderline hip dysplasia (BHD) present a challenging treatment dilemma, as it remains unknown when they should be treated with hip arthroscopy and/or a PAO. Purpose: To perform a narrative review to report the differences in hip morphology and clinical outcomes between adult patients with frank hip dysplasia and BHD. Study Design: Narrative review. Methods: A systematic search of the literature was conducted through the Medline, EMBASE, and Cochrane databases with the search phrase borderline hip dysplasia. Results: The search identified 305 articles, of which 48 were considered relevant to this study after screening of titles and abstracts. Four articles discussed new radiographic means of evaluating adult hip dysplasia, 16 articles analyzed morphology of dysplastic hips, and 28 articles described the clinical outcomes of patients with frank hip dysplasia or BHD treated with hip arthroscopy and/or PAO. Because the level of evidence obtained from this search was not adequate for systematic review or meta-analysis, a current concepts review on the diagnosis, hip morphology, and clinical outcomes of patients with frank hip dysplasia or BHD is presented. Conclusion: Adult hip dysplasia is most commonly diagnosed based on the LCEA; however, the LCEA is an unreliable sole marker for dysplasia, and additional radiographic parameters should be utilized. Furthermore, specific pathology identified on imaging and/or during hip arthroscopy can provide clues to a surgeon when the diagnosis is inconclusive according to history and physical examination alone. While the data support that patients with frank dysplasia are best treated with PAO, there is no such preferred treatment for patients with BHD, who have a wide spectrum of instability. Selective use of arthroscopic labral and capsular treatment alone may provide good results in carefully chosen patients with BHD, while some may end up requiring a bony realignment procedure.

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Operative findings and complications associated with adjunctive hip arthroscopy in 95 hips undergoing periacetabular osteotomy

Hip International ◽

10.5301/hipint.5000564 ◽

2017 ◽

Vol 28 (3) ◽

pp. 278-283

Author(s):

Gregory Maxwell Gosey ◽

Michael P Muldoon ◽

Robert M Healey ◽

Richard F Santore

Keyword(s):

Hip Arthroscopy ◽

Periacetabular Osteotomy ◽

Ligamentum Teres ◽

Fluid Extravasation ◽

Surgical Dislocation ◽

Articular Damage ◽

Labral Pathology ◽

Operative Findings ◽

Articular Pathology

Purpose: to report our initial experience with adjunctive hip arthroscopy and periacetabular osteotomy (PAO). Methods: Retrospective review of patients who underwent PAO and ipsilateral hip arthroscopy between 2003 and 2013. Indications for arthroscopy were mechanical symptoms and/or positive magnetic resonance imaging to suggest intra-articular pathology including chondrolabral lesions, ligamentum teres tears and hypertrophy, and synovitis. Preoperative Tönnis arthritis grades, age, sex, operative findings and treatment, complications, and, if available, hip survival were recorded. Results: Of 78 patients (95 hips) included, 64 (82%) were female and 14 (18%) male, average age was 30.6 (14-63) years. Tönnis grades were 0 in 40 hips (42%), 1 in 45 hips (47%), and 2 in 10 hips (11%). No Tönnis 3 hips were included. 84% of hips demonstrated labral pathology. 92% had chondromalacia, which was severe enough in 4 patients to warrant cancellation of PAO; all 4 have subsequently required total hip replacement at short-term follow-up. Labral debridement was performed in 73 hips and refixation in 7. 5 postoperative complications occurred – none major, including 1 fluid extravasation, 1 case of heterotopic ossification, and 3 transient neuropraxias. Conclusions: Intraarticular pathology is highly prevalent in patients undergoing PAO with mechanical symptoms, and can be safely managed by adjunctive arthroscopy. Complications were minimal in our series and are comparable to reports of PAO without arthroscopy. Arthroscopy can treat pathology that is inaccessible during standalone PAO and permits avoidance of routine arthrotomy, surgical dislocation, rectus release, and futile PAO in cases with severe articular damage.

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BORDERLINE ACETABULAR DYSPLASIA: THREE-DIMENSIONAL DEFORMITY PREDICTORS OF THE DIAGNOSIS OF SYMPTOMATIC INSTABILITY TREATED WITH PERIACETABULAR OSTEOTOMY

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967121s00160 ◽

2021 ◽

Vol 9 (7_suppl3) ◽

pp. 2325967121S0016

Author(s):

Elizabeth Graesser ◽

Maria Schwabe ◽

Cecilia Pascual Garrido ◽

John C. Clohisy ◽

Jeffrey J. Nepple

Keyword(s):

Low Dose ◽

Acetabular Dysplasia ◽

Periacetabular Osteotomy ◽

Alpha Angle ◽

Three Dimensional ◽

Acetabular Coverage ◽

Low Dose Ct ◽

Femoral Version ◽

Center Edge ◽

Hip Morphology

Introduction: Borderline acetabular dysplasia is classically defined as a lateral center edge angle (LCEA) of 20-25 degrees. The optimal treatment strategy in this patient group remains controversial, with some patients having primarily hip instability-based symptoms, while others have primarily impingement-based symptoms (non-instability). The purpose of the current study was to define the 3D characteristics on low-dose CT that differentiate patients with instability symptoms from those without instability in the setting of borderline acetabular dysplasia. Methods: Seventy consecutive hips with borderline acetabular dysplasia undergoing surgical treatment were included in the current study. All patients underwent low-dose pelvic CT with femoral version assessment for preoperative planning. CT measurements included alpha angle and radial acetabular coverage (RAC) at standardized clockface positions (9:00-posterior to 3:00-anterior), central and cranial acetabular version. RAC was assessed in three sectors (anterior, superior, and posterior) and defined (relative to published normative data) as normal (-1 SD, +1 SD), undercoverage (<-1 SD), or overcoverage (>+1 SD). Statistical analysis was performed to compare the CT characteristics of the symptomatic instability and non-instability groups. Results: Of the 70 hips, 62.9% had the diagnosis of symptomatic instability, while 37.1% had no instability symptoms. Hips with instability (compared to non-instability) had significantly lower alpha angle (maximal difference at 1:00 - 47.0° vs. 59.4°), increased femoral version (22.3° vs. 15.3°), and decreased radial acetabular coverage (maximal difference at 1:00 – 59.9% vs. 62.2%) (all p<0.001). Multivariate analysis identified femoral version (OR 1.1, p=0.02), alpha angle at 1:00 (OR 0.91, p=0.02), and RAC at 1:00 (OR 0.46, p=0.003) as independent predictors of the presence of instability. The model combining these three factors had excellent predictive probability with a c-statistic 0.92. Conclusion: We found significant differences in the 3D hip morphology of the symptomatic instability and non-instability subgroups within the borderline dysplasia cohort. In the setting of borderline dysplasia, three-dimensional deformity characterization with low-dose CT allowed for differentiation of patients diagnosed with underlying instability vs. non-instability. Femoral version, alpha angle at 1:00, and radial acetabular coverage at 1:00 were identified as independent predictors of diagnosis in borderline acetabular dysplasia. Summary: This study attempts to define 3D CT characteristics to help distinguish between patients with impingement-based vs instability-based symptoms of borderline acetabular dysplasia.

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