Pelvic osteotomies for acetabular dysplasia: Are there outcomes, survivorship and complication differences between different osteotomy techniques?

The purpose of this study was to evaluate the safety and efficacy of Periacetabular osteotomy (PAO), rotational acetabular osteotomy (RAO), and eccentric rotational acetabular osteotomy (ERAO) for treating hip dysplasia by comparing complication rates, survivorship, and functional outcomes after treatment. A systematic review in the MEDLINE and CINAHL databases was performed, and studies reporting outcomes after pelvic osteotomy for hip dysplasia with a minimum of 1-year follow-up or reported postoperative complications was included. Patient demographics, radiographic measurements, patient reported outcomes including the modified Harris hip score (mHHS), complications using the modified Clavien-Dindo classification, and reoperations were extracted from each study. A meta-analysis of outcome scores, complications, change in acetabular coverage, and revision rates for the 3 pelvic osteotomies was performed. A total of 47 articles detailing outcomes of 6,107 patients undergoing pelvic osteotomies were included in the final analysis. When stratified by procedure, RAO had a statistically greater change in LCEA when compared to PAO (33.9° vs 18.0°; P <0.001). The average pooled mHHS improvement was 15.6 (95% CI: 8.3–22.8, I2= 99.4%). Although ERAO had higher mean score improvements when compared to RAO and PAO, the difference was not statistically significant (P >0.05). Lastly, patients undergoing PAO had a statistically greater complication rate than those undergoing ERAO and RAO (P <0.001 for both), while revision rate was not statistically different between the 3 techniques. In summary, there are many more publications on PAO surgery with a wide range of reported complications. Complications after ERAO and RAO surgery are lower than PAO surgery in the literature, but it is unclear whether this represents an actual difference or a reporting bias. Lastly, there are no significant differences between revisions, or postoperative reported outcomes between the 3 techniques.

Augmented Reality Based Surgical Navigation of Complex Pelvic Osteotomies—A Feasibility Study on Cadavers

Augmented reality (AR)-based surgical navigation may offer new possibilities for safe and accurate surgical execution of complex osteotomies. In this study we investigated the feasibility of navigating the periacetabular osteotomy of Ganz (PAO), known as one of the most complex orthopedic interventions, on two cadaveric pelves under realistic operating room conditions. Preoperative planning was conducted on computed tomography (CT)-reconstructed 3D models using an in-house developed software, which allowed creating cutting plane objects for planning of the osteotomies and reorientation of the acetabular fragment. An AR application was developed comprising point-based registration, motion compensation and guidance for osteotomies as well as fragment reorientation. Navigation accuracy was evaluated on CT-reconstructed 3D models, resulting in an error of 10.8 mm for osteotomy starting points and 5.4° for osteotomy directions. The reorientation errors were 6.7°, 7.0° and 0.9° for the x-, y- and z-axis, respectively. Average postoperative error of LCE angle was 4.5°. Our study demonstrated that the AR-based execution of complex osteotomies is feasible. Fragment realignment navigation needs further improvement, although it is more accurate than the state of the art in PAO surgery.

Three-Dimensional Digital Surgical Planning and Rapid Prototyped Surgical Guides in Bernese Periacetabular Osteotomy

Bernese periacetabular osteotomy (PAO) developed by Ganz is currently the treatment of choice for skeletally mature symptomatic patients with developmental dysplasia of the hip (DDH) without osteoarthritis. However, the steep learning curve and considerable number of severe complications lead surgeons to seek for alternatives to promote greater reproducibility and safety of this procedure. This is a report of a DDH case surgically treated with the aid of a digital three-dimensional (3D) planning and rapidly prototyped sterile ABS plastic osteotomy guide, developed in Brazil. We present details regarding the planning, guide production, and surgical technique and report the early results of this treatment approach in a single patient. Digital 3D planning and rapidly prototyped surgical guides are applicable and helpful in PAO surgery as shown in this case. We noted no safety issues, good accuracy, and low production costs with this approach.

Periacetabular Osteotomy Performed with Imageless Computer-Assisted Navigation: Case Report

Periacetabular osteotomy (PAO) is an effective surgical treatment for developmental hip dysplasia. The goal of PAO is to reorient the acetabulum to increase acetabular coverage of the femoral head, as well as to reduce contact pressures within the hip joint. The primary challenge of PAO is to accurately achieve the desired acetabular fragment orientation, while maximizing containment and congruency. As key parts of the procedure are performed out of direct field of view of the surgeon, combined with this challenge of precise spatial orientation, there is a potential role for technologies such as surgical navigation. Adjunctive technology may provide information on the orientation of repositioned acetabulum and may offer a useful assist in performing PAO. Here, we present a case of developmental dysplasia of the hip treated via PAO with the addition of an imageless computer navigation device. Surgery was successful, and, at 3 months after procedure, the patient was progressing well. To our best knowledge, this is the first case using imageless computer-assisted navigation in PAO surgery.

Periacetabular osteotomy to treat residual dysplasia in adolescents and young adults: indications, complications, results

Purpose Discuss current indications, techniques, complications and results of periacetabular osteotomy (PAO) to treat the adolescent and young adult with symptomatic acetabular dysplasia or the rare minimally symptomatic patient with dysplasia with a guarded prognosis without PAO surgery. Methods Review of clinical experience with PAO at our and other high-volume centres. Results At a mean follow-up of 18 years after PAO, more than 75% of hips are preserved. At 30-year follow-up, longest term reported series notes survival of one-third of hips. Conclusion Both middle- and long-term results suggest efficacy of PAO in improving function and prognosis in most symptomatic adolescent and young adult patients with spherically congruous pre-arthritic dysplastic hips.

What is The Impact of PAO Surgery on Patient Function and Activity Levels?

Objectives: The Bernese periacetabular osteotomy (PAO) is becoming a widely utilized procedure. Patients are younger, highly active, and may desire to return to sport activity. Counseling and managing expectations in these patients is challenging as there is limited information regarding activity level after PAO. The purpose of this study was to analyze physical activity levels after PAO in a large, prospective multicenter cohort. Methods: Assessment of prospectively collected data from a multicenter group included 456 hips treated by PAO for hip dysplasia. After exclusions, 359 hips (80 male, 279 female) remained with a mean age of 25.9 years and mean BMI of 25. Demographics, radiographic measures, and clinical outcomes were evaluated preoperatively, at 1 year follow-up, and at minimum 2 years postoperatively (mean 44.9 months). Activity level was assessed with the University of California-Los Angeles (UCLA) activity score, patients were stratified into low, moderate, and high activity groups based on preoperative function. Descriptive statistics and linear regressions were performed for the primary outcome of change in UCLA. Results: UCLA scores were improved on average 0.6 points at final follow up (p = 0.001). When stratified, the low activity and moderate activity groups had significant improvement in UCLA scores (p<.0001 and p=0007) while the high activity group saw a decrease in UCLA scores (p<.0001). mHHS, HOOS Pain, and HOOS Sports and Recreation scores were significantly improved across all activity levels. Univariable linear regression analysis identified prior ipsilateral surgery, arthroscopy at time of PAO, and preoperative ACEA to be predictors of the change in UCLA score (p<0.05). With the multivariable model, the effect of prior ispilateral surgery was maintained (p = 0.002). Conclusion: The data suggests that improvements in activity level and function can be expected following PAO surgery, with greater gains experienced by patients with lower preoperative level of activity. [Figure: see text][Figure: see text]