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Smith SR, Terhune EB, Williams JC, Mayo KA. Step-cut osteotomy of the anterior superior iliac spine for increased visualisation in the Levine approach for Bernese periacetabular osteotomy surgery. Hip Int 2024; 34:248-251. [PMID: 37909542 DOI: 10.1177/11207000231209665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
BACKGROUND Hip dysplasia can lead to pain and dysfunction in the young adult. Acetabular undercoverage leads to abnormal joint loading and results in joint degeneration, accelerating need for arthroplasty in this patient population. Conceptually, treatment focuses on increasing acetabular coverage in the form of periacetabular osteotomy. The procedure can be performed through the iliofemoral approach, and performing an anterior superior iliac spine (ASIS) osteotomy can enhance the visualisation in this approach. Several techniques have been described for ASIS osteotomy. AIM The purpose this study was to report on step-cut technique for ASIS osteotomy during the Bernese periacetabular osteotomy procedure to enhance visualisation when utilising the iliofemoral approach. SURGICAL TECHNIQUE This step-cut technique enhances stability at the osteotomy site, and minimises soft tissue dissection to reduce pain and assists with maintaining a stable fixation construct postoperatively. RESULTS There were no nonunions and minimal morbidity to the lateral femoral cutaneous nerve injury in cohort of 86 patients while utilising this technique. CONCLUSIONS We recommend using this step-cut ostetomy of the ASIS during Bernese periactetabular osteotomy for benefit of increasing exposure while maintaining a low complication profile.
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Affiliation(s)
- Shelby R Smith
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - E Bailey Terhune
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Joel C Williams
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Keith A Mayo
- Department of Orthopaedic Surgery, Swedish Medical Center, Seattle, WA, USA
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Lara J, Garín A, Abara S, del Río J, Besomi J, Herrera C, Cancino J, Villegas D, Tobar C. Prevention of motor ascending branch of the rectus femoris injuries in Bernese periacetabular osteotomy: a cadaveric study. J Hip Preserv Surg 2024; 11:51-58. [PMID: 38606330 PMCID: PMC11005754 DOI: 10.1093/jhps/hnad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/08/2023] [Accepted: 09/24/2023] [Indexed: 04/13/2024] Open
Abstract
The Bernese periacetabular osteotomy (PAO) is a surgical procedure used to treat hip dysplasia in young adults, but it carries the risk of neurological complications, including injury to the motor ascending branch of the rectus femoris (MABRF). This study aimed to describe anatomical considerations to prevent MABRF injuries during PAO. A cadaveric study was conducted on seven specimens. The original and modified PAO approaches were used, with and without disinsertion of the rectus femoris muscle origin. The femoral nerve was dissected in all specimens from the endopelvic position to the MABRF origin (T-point). The average distance from the anterosuperior iliac spine to the T-point was 10.2 ± 0.4 cm. To protect the MABRF, a safety zone was identified for the osteotome placement during the ischial cut. The osteotome was slid over the joint capsule, deflecting the iliocapsularis muscle medially and distally. This manoeuvre shields the MABRF with the iliocapsularis muscle, reducing the risk of neurological injury. Both the original and modified PAO approaches were considered safe techniques with low risk to the rectus femoris innervation. These findings offer valuable insights for surgeons performing PAO, emphasizing the significance of understanding anatomical relationships and implementing protective measures to enhance patient outcomes and minimize complications. In conclusion, implementing these anatomical considerations can help prevent MABRF injuries during PAO, contributing to safer and more successful surgical interventions for hip dysplasia in young adults.
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Affiliation(s)
- Joaquín Lara
- Clínica MEDS, Hip Unit, Avenida José Alcalde Délano 10581, Santiago 7691236, Chile
| | - Alan Garín
- Intituto Traumatológico, Hip Unit, San Martín 771, Santiago 8340220, Chile
- Clínica RedSalud Santiago, Hip Unit, Avenida Libertador Bernardo O’Higgins 4850, Santiago 9190015, Chile
| | - Selim Abara
- Hospital DIPRECA, Hip Unit, Avenida Vital Apoquindo 1200, Santiago 7601003, Chile
| | - Javier del Río
- Clínica MEDS, Hip Unit, Avenida José Alcalde Délano 10581, Santiago 7691236, Chile
- Hospital Clínico Mutual de Seguridad, Hip Unit, Avenida Libertador Bernardo O’Higgins 4848, Santiago 9190015, Chile
| | - Javier Besomi
- Clínica Alemana de Santiago, Hip Unit, Avenida Vitacura 5951, Santiago 7650568, Chile
- Hospital Clínico San Borja Arriarán, Hip Unit, Avenida Santa Rosa 1234, Santiago 8360160, Chile
| | - Cristhián Herrera
- Clínica Alemana de Santiago, Hip Unit, Avenida Vitacura 5951, Santiago 7650568, Chile
- Hospital Clínico San Borja Arriarán, Hip Unit, Avenida Santa Rosa 1234, Santiago 8360160, Chile
| | - Jaime Cancino
- Hospital Clínico Mutual de Seguridad, Hip Unit, Avenida Libertador Bernardo O’Higgins 4848, Santiago 9190015, Chile
| | - Diego Villegas
- Clínica RedSalud Providencia, Hip Unit, Avenida Salvador 100, Santiago 7500995, Chile
| | - Carlos Tobar
- Clínica RedSalud Providencia, Hip Unit, Avenida Salvador 100, Santiago 7500995, Chile
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Löchel J, Wassilew GI, Krämer M, Kohler C, Zahn RK, Leopold VJ. Transversus Abdominis Plane Block Reduces Intraoperative Opioid Consumption in Patients Undergoing Periacetabular Osteotomy. J Clin Med 2022; 11:jcm11174961. [PMID: 36078890 PMCID: PMC9456368 DOI: 10.3390/jcm11174961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/08/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Administering intraoperative analgesia in patients undergoing periacetabular osteotomy (PAO) is challenging due to both the relevant surgical approach and osteotomies, which are associated with pain. The aim of this study was to assess the effect of the transversus abdominis plane block (TAPb) on intraoperative opioid consumption and circulation parameters in PAO patients. Patients and Methods: We conducted a two-group randomized-controlled trial involving 42 consecutive patients undergoing PAO for symptomatic developmental dysplasia of the hip (DDH) in our department. Patients assigned to the study group received an ultrasound-guided TAPb with 0.75% ropivacaine before the beginning of the surgery and after general anesthesia induction. Patients assigned to the control group did not receive a TAPb. General anesthesia was conducted according to a defined study protocol. The primary endpoint of the study was the intraoperative opioid consumption, measured in morphine equivalent dose (MED). Secondary endpoints were the assessment of intraoperative heart rate, mean arterial pressure (MAP), need for hypotension treatment, and length of hospital stay (LOHS). A total of 41 patients (n = 21 TAPb group, n = 20 control group) completed the study; of these, 33 were women (88.5%) and 8 were men (19.5%). The mean age at the time of surgery was 28 years (18–43, SD ± 7.4). All operations were performed by a single high-volume surgeon and all TAPb procedures were performed by a single experienced senior anesthesiologist. Results: We observed a significantly lower intraoperative opioid consumption in the TAPb group compared to the control group (930 vs. 1186 MED per kg bodyweight; p = 0.016). No significant differences were observed in the secondary outcome parameters. We observed no perioperative complications. Conclusion: Ultrasound-guided TAPb significantly reduces intraoperative opioid consumption in patients undergoing PAO.
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Affiliation(s)
- Jannis Löchel
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery Augustenburger Platz 1, D–13353 Berlin, Germany
- Correspondence:
| | - Georgi I. Wassilew
- Department for Orthopaedic Surgery, University of Greifswald, Ferdinand-Sauerbruch-Straße, D–17475 Greifswald, Germany
| | - Michael Krämer
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Clinic for Anesthesiology and Intensive Care, Charitéplatz 1, D–10117 Berlin, Germany
| | - Christopher Kohler
- Orthopädisches Versorgungszentrum Zehlendorf, Clayallee 225A, D–14195 Berlin, Germany
| | - Robert Karl Zahn
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery Augustenburger Platz 1, D–13353 Berlin, Germany
| | - Vincent Justus Leopold
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery Augustenburger Platz 1, D–13353 Berlin, Germany
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Siddiqi A, Alden KJ, Yerasimides JG, Kamath AF. Direct Anterior Approach for Revision Total Hip Arthroplasty: Anatomy and Surgical Technique. J Am Acad Orthop Surg 2021; 29:e217-e231. [PMID: 33351524 DOI: 10.5435/jaaos-d-20-00334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/10/2020] [Indexed: 02/01/2023] Open
Abstract
There has been increased interest and literature on the efficacy of direct anterior approach (DAA) for total hip arthroplasty (THA). Developments in surgical technique and instrumentation, along with exposure earlier in orthopaedic residency training, may augment the adoption of this approach among practicing orthopaedic surgeons. With the increasing number of primary THA performed through the DAA, understanding the indications and techniques associated with revision THA via the DAA has proved increasingly important. Patient positioning, understanding surgical anatomy and extensile maneuvers, and applying key reconstructive methods are essential for obtaining adequate exposure and fixation. Acetabular exposure can be facilitated through capsular and soft-tissue release, along with extensile approaches to the pelvis and acetabulum. Extensile distal extension can be performed for safe access to the femur, including extended femoral osteotomies. The purpose of this review is to describe indications, surgical anatomy, intraoperative tips, clinical outcomes, and complications after DAA for revision THA.
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Affiliation(s)
- Ahmed Siddiqi
- From the Department of Orthopedics, Cleveland Clinic Foundation, Cleveland, OH (Kamath and Siddiqi), the Hinsdale Orthopaedics, Hinsdale, IL (Alden), and the Norton Orthopedic Institute, Louisville, KY (Yerasimides)
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A New Rectus and Sartorius Sparing Approach for Periacetabular Osteotomy in Patients with Developmental Dysplasia of the Hip. J Clin Med 2021; 10:jcm10040601. [PMID: 33562732 PMCID: PMC7915261 DOI: 10.3390/jcm10040601] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 12/12/2022] Open
Abstract
Background: periacetabular osteotomy (PAO) is known as the gold standard surgical treatment in young adults with symptomatic hip dysplasia. With the aim of reducing soft tissue trauma, we developed a new rectus and sartorius sparing (RASS) approach. We hypothesized that this new PAO technique was equal regarding acetabular reorientation, complication rate, and short-term clinical outcome parameters, compared to our conventional, rectus sparing (RS) approach. Patients and Methods: we retrospectively assessed all PAO procedures performed by a single surgeon between 2016 and 2019 (n = 239 hips in 217 patients). The cases in which the new RASS technique were used (n = 48) were compared to the RS cases for acetabular orientation parameters, surgical time, perioperative reduction of hemoglobin level, and length of hospital stay (LOHS). Inclusion criteria were a lateral center-edge angle (LCEA) <25° and osteoarthritis Tönnis grade ≤1. Patients with acetabular retroversion or additional femoral osteotomy were excluded. Results: the mean patient age at the time of surgery was 29 years (14 to 50, SD ± 8.5). Females accounted for 79.5% in this series. The mean preoperative LCEA were 16° (7 to 24°, SD ± 4.4) and 15° (0 to 23°, SD ± 6) in the RASS and the RS group, respectively (p = 0.96). The mean preoperative acetabular index (AI) angles were 14° (2 to 25°, SD ± 4) and 14° (7 to 29°, SD ± 4.3), respectively (p = 0.67). The mean postoperative LCEA were significantly improved to 31° (25 to 37°, SD ± 3.5, p < 0.001) and 30.2° (20 to 38°, SD ± 4, p < 0.001), respectively. The mean postoperative AI angles improved to 2.8° (−3 to 13°, SD ± 3.3, p < 0.001) and 3° (−2 to 15°, SD ± 3.3, p < 0.001), respectively. There were no significant differences between the RASS and the RS group for surgical time, perioperative reduction in hemoglobin level, and LOHS. No blood transfusions were necessary perioperatively in either group. No major perioperative complication occurred in either group. We observed one surgical site infection (SSI) requiring superficial debridement in the RS group. Conclusion: the RASS approach for PAO showed to be a safe procedure with equivalent acetabular reorientation and equivalent clinical outcome parameters compared to the RS approach. Additionally, patients have fewer postoperative restrictions in mobilization with the RASS approach.
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