Rotational acetabular osteotomy through an ollier lateral u approach

Changes in muscle strength of the hip after rotational acetabular osteotomy: a retrospective study

AIMS

Rotational acetabular osteotomy (RAO) is an effective joint-preserving surgical treatment for acetabular dysplasia. The purpose of this study was to investigate changes in muscle strength, gait speed, and clinical outcome in the operated hip after RAO over a one-year period using a standard protocol for rehabilitation.

PATIENTS AND METHODS

A total of 57 patients underwent RAO for acetabular dysplasia. Changes in muscle strength of the operated hip, 10 m gait speed, Japanese Orthopaedic Association (JOA) hip score, and factors correlated with hip muscle strength after RAO were retrospectively analyzed.

RESULTS

Three months postoperatively, the strength of the operated hip in flexion and abduction and gait speed had decreased from their preoperative levels. After six months, the strength of flexion and abduction had recovered to their preoperative level, as had gait speed. At one-year follow-up, significant improvements were seen in the strength of hip abduction and gait speed, but muscle strength in hip flexion remained at the preoperative level. The mean JOA score for hip function was 91.4 (51 to 100)) at one-year follow-up. Body mass index (BMI) showed a negative correlation with both strength of hip flexion (r = -0.4203) and abduction (r = -0.4589) one year after RAO. Although weak negative correlations were detected between strength of hip flexion one year after surgery and age (r = -0.2755) and centre-edge (CE) angle (r = -0.2989), no correlation was found between the strength of abduction and age and radiological evaluations of CE angle and acetabular roof obliquity (ARO).

CONCLUSION

Hip muscle strength and gait speed had recovered to their preoperative levels six months after RAO. The clinical outcome at one year was excellent, although the strength of hip flexion did not improve to the same degree as that of hip abduction and gait speed. A higher BMI may result in poorer recovery of hip muscle strength after RAO. Radiologically, acetabular coverage did not affect the recovery of hip muscle strength at one year's follow-up. A more intensive rehabilitation programme may improve this. Cite this article: Bone Joint J 2019;101-B:1459-1463.

Curved periacetabular osteotomy via a novel intermuscular approach between the sartorius and iliac muscles

INTRODUCTION

Herein, we describe and evaluate a curved periacetabular osteotomy (CPO) via an intermuscular approach (IM-CPO) between the sartorius and iliac muscles.

METHODS

Between January 2009 and January 2016, IM-CPO was performed in 17 joints (16 patients), and a traditional CPO was performed in 17 joints. The length of incision at wound closure, operative time, intraoperative blood loss, serum creatinine kinase (CK) level the day after surgery, correctional angle, walking ability assessed using the gait items of the Harris Hip Score (at 3 and 6 months after surgery), and perioperative complications were evaluated. Group differences were assessed using t-tests.

RESULTS

The IM-CPO and CPO groups did not differ in the mean operative time (130 minutes and 124 minutes, respectively), mean serum CK the day after surgery (349 IU/L and 425 IU/L, respectively), or mean correctional angle (24.9° and 24.6°, respectively). The mean incision length was significantly shorter in the IM-CPO group (8.3 cm) compared to that in the CPO group (9.5 cm). The mean walking ability was significantly higher in the IM-CPO group (24.2 points) compared to that in the CPO group (20.9 points) at 3 months after surgery, but not at 6 months after surgery (26.4 points and 24.9 points, respectively). No serious complications were observed in either group.

CONCLUSION

In addition to demonstrating a similarly satisfactory correctional angle, IM-CPO is anticipated to enable early weight-bearing and recovery of walking ability. Thus, IM-CPO is considered a superior surgical technique.

Minimum 10-Year Clinical Outcomes After Periacetabular Osteotomy for Advanced Osteoarthritis Due to Hip Dysplasia

The purpose of this study was to examine the minimum 10-year clinical outcomes, including patient-reported and functional outcomes, of periacetabular osteotomy in patients with advanced osteoarthritis. A total of 46 hips in 44 patients with advanced osteoarthritis who underwent periacetabular osteotomy between 1992 and 2006 were retrospectively reviewed. Mean age at surgery was 47.5 years, and mean follow-up was 16.9±4.7 years. Survivorship was determined using the Kaplan-Meier method, and the associated risk factors for the endpoint-conversion to total hip arthroplasty less than 15 years after surgery-were evaluated. The Oxford Hip Score and the University of California, Los Angeles activity score were evaluated at final follow-up. The survival rates at 15 and 20 years after surgery were 80% and 59%, respectively. Multivariate analysis indicated that body mass index greater than 24 kg/m² (P=.034; odds ratio, 1.72) was significantly associated with the endpoint as an independent risk factor. For 32 hips of 31 patients with preserved native joints at final follow-up, the Oxford Hip Score and the University of California, Los Angeles score averaged 41±5 and 5.2±1.8, respectively, equivalent (P=.28 and P=.215, respectively) to the scores of 14 hips of 13 patients with conversion to total hip arthroplasty (38±8.7 and 5.8±1.4, respectively). The results of this mid-term study may be useful for surgical decision-making among patients with advanced osteoarthritis who want to preserve native hip joints. [Orthopedics. 2018; 41(5):300-305.].

Incidence of Venous Thromboembolism in Patients Undergoing Major Hip Surgeries at a Single Institution: A Prospective Study

BACKGROUND

Venous thoromboembolism (VTE) is one of the most significant complications after hip surgeries. Many studies have been reported about the incidence of VTE after THA, but a small number of reports were found concerning Periacetabular osteotomy, Revision THA and Surgery for hip fracture postoperatively. Furthermore, there exists no comparative study of the incidence of VTE among major hip surgeries at a single institution. We reported the incidence of VTE among hip surgeries performed at a single institution.

METHODS

A total of 820 Hip surgeries were performed at same institution. The procedures included 420 hips that underwent primary total hip arthroplasties (THA), 91 revision or removal of total hip arthroplasties (Revision THA), 144 periacetabular osteotomy (PAO) and 165 surgery for hip fracture (SHF) between 2006 and 2012. VTE was detected by Multidetector computed tomography (MDCT) that scanned 768 cases and by ultrasound that scanned 52cases postoperative 10-14 days.

RESULTS

The overall incidence of VTE was 12.2% (100 of 820). The incidence of VTE after THA was 13.1% (55 of 420), Revision THA was 13.2% (12 of 91), PAO was 2.1% (3 of 144) and SHF was 18.1% (30 of 165). The incidence of VTE was significantly higher in SHF than in PAO.

CONCLUSION

This data indicates that the incidence of VTE after PAO is significantly lower than SHF and relatively lower than THA and Revision THA. A younger age and non-invasion of the bone marrow of the femur may have affected the result. Prophylaxis therapy was effective especially on SHF.

Gender difference does not affect the outcomes of eccentric rotational acetabular osteotomy used in hip dysplasia

INTRODUCTION

Various types of periacetabular osteotomies have been proposed to treat acetabular dysplasia for young and active patients. Acetabular dysplasia is prevalent in women and rare in men, therefore few reports exist concerning periacetabular osteotomy of male patients. The purpose of this study is to clarify the gender differences in surgical techniques, radiographic and clinical outcomes.

MATERIALS AND METHODS

Between 1989 and 2007, we performed 530 eccentric rotational acetabular osteotomies and followed them annually for more than five years. Thirty-six male patients were investigated. As a control group, 72 female patients were matched for age and preoperative stage of osteoarthritis at the time of surgery. We evaluated operative time and blood loss, radiographic parameters, Harris Hip Score (HHS) and survival rate. We investigated the clinical and radiographic differences between men and women.

RESULTS

The mean operative time was 148 min in males and 135 min in females. The bleeding during surgery was 445 g in males and 351 g in females. HHS improved 94.1 points in males and 93.5 points in women postoperatively. The mean CE angle improved 31.7° in males and 35.1° in females. The mean AHI was 90.8% in males and 94.1% in females postoperatively. The survival rate of male patients were 92.8% and that of female patients were 98.1%.

CONCLUSIONS

The mean operative time and the blood loss were not significantly different between male and female patients. Postoperative CE angle tended to be smaller in male than female patients. The survival rate was not significantly different between males and females. Gender difference did not affect the clinical outcomes of ERAO in patients with hip dysplasia.

Early weight-bearing after periacetabular osteotomy leads to a high incidence of postoperative pelvic fractures

BACKGROUND

It has not been shown whether accelerated rehabilitation following periacetabular osteotomy (PAO) is effective for early recovery. The purpose of this retrospective study was to compare complication rates in patients with standard and accelerated rehabilitation protocols who underwent PAO.

METHODS

Between January 2002 and August 2011, patients with a lateral center-edge (CE) angle of < 20°, showing good joint congruency with the hip in abduction, pre- or early stage of osteoarthritis, and age younger than 60 years were included in this study. We evaluated 156 hips in 138 patients, with a mean age at the time of surgery of 30 years. Full weight-bearing with two crutches started 2 months postoperatively in 73 patients (80 hips) with the standard rehabilitation protocol. In 65 patients (76 hips) with the accelerated rehabilitation protocol, postoperative strengthening of the hip, thigh and core musculature was begun on the day of surgery as tolerated. The exercise program included active hip range of motion, and gentle isometric hamstring and quadriceps muscle sets; these exercises were performed for 30 minutes in the morning and 30 minutes in the afternoon with a physical therapist every weekday for 6 weeks. Full weight-bearing with two axillary crutches started on the day of surgery as tolerated. Complications were evaluated for 2 years.

RESULTS

The clinical results at the time of follow-up were similar in the two groups. The average periods between the osteotomy and full-weight-bearing walking without support were 4.2 months and 6.9 months in patients with the accelerated and standard rehabilitation protocols (P < 0.001), indicating that the accelerated rehabilitation protocol could achieve earlier recovery of patients. However, postoperative fractures of the ischial ramus and posterior column of the pelvis were more frequently found in patients with the accelerated rehabilitation protocol (8/76) than in those with the standard rehabilitation protocol (1/80) (P = 0.013).

CONCLUSION

The accelerated rehabilitation protocol seems to have advantages for early muscle recovery in patients undergoing PAO; however, postoperative pelvic fracture rates were unacceptably high in patients with this protocol.

Ischio-pubic stress fracture after peri-acetabular osteotomy in patients with hip dysplasia

PURPOSE

Ischio-pubic stress fracture is one of the potential complications after peri-acetabular osteotomy (PAO) in patients with hip dysplasia. The purpose of this study was to examine the prevalence of and risk factors for ischio-pubic fractures following PAO.

METHODS

A total of 296 hips in 275 patients who underwent transposition osteotomy of the acetabulum between 2001 and 2012 were retrospectively reviewed. Patient characteristics and radiographic parameters were compared between patients with and without fracture.

RESULTS

Fourteen ipsilateral hips (4.7%) in 14 female patients had fracture of the inferior pubic ramus (11 hips) or the ischial ramus (three hips) on the same side as the surgery at an average of 4.6 weeks after PAO. Multivariate analysis indicated that younger age at operation (odds ratio of 1.43 per five years, p = 0.0169) and greater degree of correction (odds ratio of 1.98 per five degrees, p = 0.0005) were significantly associated with ischio-pubic fracture as independent risk factors. All fractures healed conservatively with partial weight-bearing.

CONCLUSIONS

Younger female patients and greater deformity corrections increased the risk of ischio-pubic stress fracture after PAO.

Developing a novel custom cutting guide for curved peri-acetabular osteotomy

PURPOSE

Curved peri-acetabular osteotomy (CPO) produces excellent clinical results, but the surgical procedure is technically demanding, and severe complications related to the osteotomy have been reported. To provide a safe, accurate surgical procedure, we have developed a novel method for setting the cutting line and direction. We have designed and made a custom cutting guide for individual patients. The purpose of the study was to evaluate the efficacy of this new method and cutting guide.

METHODS

The cutting line was designed on a full-scale three-dimensional plaster model made from computed tomography (CT) data for each case. The surface of each plaster model was colour-coded according to the distance from the centre of the femoral head. A custom cutting guide was designed based on this cutting line on the workstation. A titanium custom cutting guide was fabricated using rapid prototyping technology. The cutting guide directed the cutting direction of the osteotome. We evaluated the outcomes for seven consecutive hips in seven patients who underwent CPO using the system between April and December 2011. All peri-operative complications were recorded. The accuracy of the cutting line was evaluated using CT data obtained two weeks after the operation.

RESULTS

There were no major complications related to the osteotomy such as posterior column fracture or intra-articular osteotomy. The actual cutting line corresponded almost exactly to the planned cutting line in all cases.

CONCLUSIONS

The colour-coded plaster model and the custom cutting guide were effective for avoiding severe complications associated with a CPO.

Blood perfusion and bone formation before and after minimally invasive periacetabular osteotomy analysed by Positron Emission Tomography combined with Computed Tomography

PURPOSE

Sufficient blood perfusion is essential for successful bone healing after periacetabular osteotomy (PAO). The purpose of this study was to quantify blood perfusion and bone formation before and after PAO analysed by positron emission tomography (PET) combined with computed tomography (CT).

METHODS

Twelve dysplastic patients (nine women) were included consecutively in the study and all were operated upon by the senior author (KS). Median age was 33 (23-55) years. Initially, two patients were PET scanned in a pilot study to test our models for calculation of the physiological parameters. The following ten patients had their hip joints PET/CT scanned immediately before PAO and three to four weeks after. Oxygen-15-water was used to quantify blood perfusion and Flourine-18-fluoride was used to produce quantitative images interpreted as new bone formation in the acetabular fragment.

RESULTS

The blood perfusion of the operated acetabulum before surgery was 0.07 ± 0.02 ml/min/ml, and after surgery 0.19 ± 0.03 ml/min/ml (p = 0.0003). Blood perfusion of the non-operated acetabulum was 0.07 ± 0.02 ml/min/ml before PAO and 0.07 ± 0.02 ml/min/ml after surgery (p = 0.47). The fluoride-clearance per volume bone of the operated acetabulum was 0.02 ± 0.01 ml/min/ml preoperatively, and 0.06 ± 0.01 ml/min/ml postoperatively (p = 0.0005). Fluoride-clearance of the non-operated acetabulum was 0.01 ± 0.01 ml/min/ml before PAO and 0.02 ± 0.01 ml/min/ml after PAO (p = 0.49).

CONCLUSION

Blood perfusion and new bone formation increased significantly in the acetabular fragment. Thus, the results of this study do not support the concern about surgically damaged vascularity after PAO.

Rotational acetabular osteotomy through an Ollier lateral U approach for early-stage osteoarthritis secondary to acetabular dysplasia

OBJECTIVE

To explore the surgical technique and mid-term results of rotational acetabular osteotomy for early -stage osteoarthritis secondary to acetabular dysplasia.

METHODS

Rotational acetabular osteotomies were performed on 14 hips of 12 patients from May 2000 to May 2006 and the patients followed up. All patients were female and their average age was 28.9 years (range, 13-46 years) at the time of surgery. The mean duration of clinical and roentgenographic follow-up was 6.0 years (range, 3.1-9.1 years). The lateral center-edge (CE) angle, acetabular roof angle and head lateralization index were measured on radiographs taken preoperatively, postoperatively and at the time of final follow-up. Clinical follow-up included use of the Harris hip score. The acetabular osteotomies were performed through an Ollier lateral U transtrochanteric approach and postoperative traction and cast immobilization were not used.

RESULTS

All patients had satisfactory pain relief. The mean preoperative Harris score was 72 points; this had improved to a mean of 91 points at the time of last follow-up (P < 0.05). The mean CE angle improved from 0.9° preoperatively to 27° postoperatively (P < 0.05), the mean acetabular roof angle from 29° to 5° (P < 0.05) and the mean head lateralization index from 0.68 to 0.65. Solid bone-to-bone healing of the osteotomy sites and great trochanters occurred in all patients.

CONCLUSIONS

Rotational acetabular osteotomy through an Ollier lateral U approach, which provides wide exposure and technical ease, for early-stage osteoarthritis secondary to acetabular dysplasia can relieve pain and delay the appearance or reduce the severity of osteoarthritis. Satisfactory mid-term results can be obtained.

Patient selection criteria for periacetabular osteotomy or rotational acetabular osteotomy

BACKGROUND

Hip dysplasia is the most common cause of secondary osteoarthritis (OA). Periacetabular osteotomy (PAO) or rotational acetabular osteotomy (RAO) has been used as a joint-preserving procedure. However, the patient selection criteria are not clearly defined.

QUESTIONS/PURPOSES

Based on a systematic review, we identified reported patient selection criteria for PAO or RAO.

METHODS

We performed a systematic review of RAO and 18 studies met our inclusion criteria. For the PAO, the systemic review performed by Clohisy et al. was used. WHERE ARE WE NOW?: For patients with symptomatic hip dysplasia, lateral center-edge angle less than 10° to 30°, radiographic pre- or early OA, mean age at the time of surgery of 18 to 45 years, and improvement in joint congruency on AP radiograph with hip abduction, radiographic deformity correction consistently improved hip function in all studies. Radiographic OA progression was noted in 5% to 33% at 3.2 to 20 years postoperatively. Clinical score and prevention of radiographic OA progression of patients 50 years or older or with advanced stage were worse in younger patients or those with early stage. WHERE DO WE NEED TO GO?: The key challenges are (1) preoperative evaluation of articular cartilage; (2) indication for older patients; (3) prevention of secondary femoroacetabular impingement; and (4) intraarticular treatment combined with PAO or RAO. HOW DO WE GET THERE?: Future prospective, longitudinal cohort studies need to determine optimal patient selection criteria, risk factors for clinical failure, optimal deformity correction parameters, and the role of adjunctive surgical procedures.

Intermediate to long-term results of periacetabular osteotomy in patients younger and older than forty years of age

BACKGROUND

The treatment of middle-aged patients with periacetabular osteotomy remains controversial. The goal of the present retrospective study was to analyze the intermediate to long-term functional and radiographic results of periacetabular osteotomy in patients below and above the age of forty years.

METHODS

Between February 1990 and December 2004, 166 periacetabular osteotomies were performed in 146 patients. We evaluated 158 hips in 139 patients who had a mean age of thirty-two years at the time of surgery. The mean duration of follow-up was eleven years (range, five to twenty years). We compared thirty-six patients (forty-one hips) who were forty years of age or older with 103 patients (117 hips) who were younger than forty years of age at the time of surgery.

RESULTS

The average Harris hip score increased from 70 points preoperatively to 90 points postoperatively. The mean Harris hip scores at the time of the five-year follow-up were similar in the older and younger groups (p = 0.57), although the latest follow-up scores were significantly higher in the younger group than in the older group (91 compared with 88 points; p = 0.02). The average modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score (with 0 representing the worst score and 100 representing the best score) was higher for the younger group than for the older group (92 compared with 90 points; p = 0.03). Kaplan-Meier analysis with progression of the Tönnis grade of osteoarthritis as the end point showed a ten-year survival rate of 90.8% (95% confidence interval, 88.3% to 93.3%) and a fifteen-year survival rate of 83.0% (95% confidence interval, 78.5% to 87.5%); the ten-year survival rates in the younger and older groups were 94.4% and 81.3%, respectively, and the fifteen-year survival rates were 86.9% and 71.2%, respectively (p = 0.025).

CONCLUSIONS

Periacetabular osteotomy yielded similar results for the two groups at the time of the five-year follow-up, although the results for the older group deteriorated thereafter. Decrease in physical function due to aging and increased susceptibility to the progression of osteoarthritis may be responsible for the poorer results over time in the older group.

A periacetabular osteotomy for the treatment of severe dysplastic hips

BACKGROUND

We believe a curved periacetabular osteotomy is indicated for treatment of severe dysplastic hips with center-edge angles less than 0°, classified as Severin Group IV-b. However, the lower limit of the center-edge angle in hips classified as Severin Group IV-b is not clearly defined to determine which patients should receive periacetabular osteotomy alone.

QUESTIONS/PURPOSES

We retrospectively compared the results of curved periacetabular osteotomies performed for the treatment of severe (Severin Group IV-b: center-edge angle < 0°) and moderate (Severin Groups III and IV-a: center-edge angle ≥ 0°) dysplastic hips. We investigated the lower limit of the center-edge angle, which was corrected by a curved periacetabular osteotomy alone in Severin Group IV-b hips.

PATIENTS AND METHODS

We divided 191 hips in 163 patients into moderate (147 hips) and severe (44 hips) dysplastic hip groups. Minimum followup was 2 years (mean, 70.9 and 70.6 months, respectively). Clinical evaluations were performed using the Harris hip score. Radiographic measurements included the center-edge angle, acetabular head index, acetabular roof obliquity, and head lateralization index. Complications were compared between the two groups.

RESULTS

All clinical and radiographic postoperative parameters showed satisfactory improvement over the preoperative parameters in both groups. The postoperative acetabular roof obliquity and head lateralization index were equivalent between the two groups. Eleven hips deteriorated to end-stage osteoarthritis. No complications were specifically associated with the severe dysplastic hips.

CONCLUSIONS

Curved periacetabular osteotomy alone for treatment of severe dysplastic hips with preoperative center-edge angles as low as -20° and classified as Severin Group IV-b restored weightbearing area and medialization.

Joint congruency as an indication for rotational acetabular osteotomy

Long-term results of periacetabular osteotomy for advanced-stage osteoarthritis secondary to developmental dysplasia of the hip are reportedly unsatisfactory compared with results for early-stage osteoarthritis. Other preoperative information that can be used to determine indications for periacetabular osteotomy is therefore important to avoid performing osteotomy in young patients with advanced-stage osteoarthritis who would not likely achieve substantial benefit. We retrospectively reviewed 47 patients (49 hips) with advanced-stage osteoarthritis who underwent rotational acetabular osteotomy (RAO) using preoperative congruency in abduction. The minimum postoperative followup was 8 years (mean, 12.3 years; range, 8-20 years) and mean age at surgery was 43.1 years (range, 30-59 years). At followup, osteoarthritic stage was improved in 12 hips, unchanged in 24 hips, and had progressed in 13 hips. Preoperative joint congruency in abduction was good in 13 hips, poor in 32 hips, and narrowed in four hips. Patients with better congruency in abduction had better results. We believe osteoarthritis with good congruency in abduction preoperatively remains a good indication for RAO even in advanced stages of disease.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.