[Acetabuloplasty - The Dega and Pemberton technique]

Bernese periacetabular osteotomy (PAO): from its local inception to its worldwide adoption

The development of the Bernese periacetabular osteotomy (PAO) is based on a structured approach starting with an analysis of the preexisting procedures to improve the coverage of the femoral head and was followed by a list of additional goals and improvements. Cadaveric dissections with a detailed description of the vascular supply of acetabulum and periacetabular bone set the stage for an intrapelvic approach, which offered the largest acetabular correction possible combined with safe intracapsular access. The final composition of osteotomies required the development of several instruments and cutting devices before the feasibility could be tested on a series of cadaveric hips.While the sequence of the osteotomies remained largely unchanged over time (except for the pubic and ischial osteotomies), several propositions for an easier/less invasive approach have been discussed; some made it into standard practice. Efforts were undertaken to optimize the learning curve and minimize failures using video-clips, hands-on courses, fellowships, publications, and ongoing mentoring programs. In retrospect, with almost 40 years of experience, such efforts have promoted a worldwide adoption of the Bernese periacetabular osteotomy.

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.

Mid- and long-term outcome of Salter's, Pemberton's and Dega's osteotomy for treatment of developmental dysplasia of the hip: a systematic review and meta-analysis

INTRODUCTION

Early diagnosis and early treatment have become the gold standard for management of developmental dysplasia of the hip. Surgery is required in case of failed initial treatment. Innominate pelvic osteotomy of Salter (SIO), Pemberton's pericapsular osteotomy (PPO) and Dega's acetabuloplasty (DA) are among the most used procedures.We performed a systematic review and meta-analysis of the past 57 years in order to assess the mid- and long-term outcome of these techniques.

METHODS

Studies met inclusion criteria if they: (1) reported at least 5 cases treated by 1 of the abovementioned surgical techniques; (2) included children aged between 1 and 8 years; (3) surgical indication was late detected DDH or a failed initial treatment; (4) presented a minimal follow-up of 24 months; (5) reported the radiological score of Severin and/or the clinical score of McKay.Clinical and radiological outcomes were dichotomised into favourable and unfavourable outcome and weighted summary rates were determined using meta-analysis models.

RESULTS

From a total of 7391 articles, 48 level of evidence grade IV articles were included in our review. A total of 2143 cases with a mean follow up of 112.4 months were included.Pooled Severin score indicated a statistically better outcome for PPO and DA compared to SIO (p = 0.0003 and p = 0.002, respectively). By dichotomising the results in favourable and unfavourable outcome, PPO showed the best results (p = 0.0002 vs. SIO, p = 0.01 vs. DA).Pooled McKay score showed a statistically better outcome for PPO and DA compared to SIO (p < 0.0001 and p = 0.03, respectively) as well as better outcomes for PPO compared to DA (p = 0.01). By dichotomising the results in favourable and unfavourable, PPO showed the best results.

CONCLUSIONS

Even if our review demonstrates slightly better radiological and clinical results with the PPO, the currently available and limited data do not allow for clear recommendation towards one of these techniques.

MRI-based assessment of acetabular version and coverage after previous Pemberton osteotomy in skeletally mature patients

PURPOSE

In hip dysplasia the Pemberton osteotomy can modify the shape of the acetabulum and is indicated for children aged between two and 12 when the triradiate cartilage is still open. However, there have been concerns about acetabular retroversion following this type of osteotomy. The studies, however, have been based on plain radiographs. The aim of our investigation was to assess the 3D acetabular orientation in patients with previous Pemberton osteotomy after skeletal maturation.

METHODS

Ten patients with 12 operated hips were included who received Pemberton osteotomy for hip dysplasia between January 3, 2005 and March 25, 2011. Mean age at surgery and at follow-up were 7.2 years (sd 3.7) and 19.2 years (sd 3.7), respectively. MRIs were conducted with 1.5 T. Besides the measurement of acetabular version, the analysis included alpha angles, acetabular sector angles (ASAs) as well as modified ASAs (cartilage covered area angles). Furthermore, the presence of osteoarthritis (OA) as well as acetabular retroversion was determined on plain radiographs. Patient-related outcome measures included the international Hip Outcome Tool (iHOT) and EuroQol-5-Dimensions (EQ5D) scores.

RESULTS

In comparison with the contralateral native and healthy hips the operated hips showed similar version (19.5° (sd 4.6°) versus 18.6° (sd 7.0°); p = 0.974). Also, there were no differences in terms of femoral head sphericity (alpha angles) and acetabular coverage (ASA angles). Five of 12 Pemberton hips showed signs of beginning OA (Kellgren-Lawrence classification I or II) while none of the non-operated hips did. Patients who received surgery before the age of six years had similar functional and radiological results when compared with patients who were older than six years at surgery. Among all patients, iHOT was 91.9 (sd 10.0) and EQ5D was 90.3 (sd 7.3)).

CONCLUSION

The Pemberton osteotomy provides good long-term radiographic and functional results without compromising acetabular version or coverage.

LEVEL OF EVIDENCE

Level III: retrospective comparative study.

[Hip dysplasia-new and proven methods]

BACKGROUND

Hip dysplasia is one of the most common disorders in paediatric orthopedics. With the development of ultrasound techniques treatment has changed, and earlier diagnosis and treatment is possible. So, for more than 20 years diagnosis and treatment has been focused on ultrasound. Many papers reporting new diagnostic techniques like MRI have been published. Arthroscopic reduction is a new surgical procedure. However, established surgical procedures continue to play an important role in the treatment.

CURRENT TREATMENT

This paper presents new and established diagnostic techniques, conservative and surgical treatment options. Unfortunately, due to the great number of publications, not all aspects could be taken into account. In particular, we describe the diagnostic and treatment standards in German-speaking countries based on ultrasound hip screening. However, also international aspects of diagnostic and treatment options have been included.