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Periacetabular Osteotomy: Intra-articular Work
Department of Orthopaedic surgery, University of Toronto, Toronto, Ontario, Canada,
Hip and Pelvis Clinic , Chonbuk University Hospi-tal , Jeonju, Korea .E-mail: [email protected]
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Background• Periacetabular Osteotomy
- Goal : Improvement of hip biomechanics by reorienting the acetabulum
→ postpone degenerative progression
Desire of im-provement
Potential for overcorrection
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Background
Complications of PAO Prevalence % AuthorsAcetabular cartilage delamination
28 of 64 hips 44% CLP
Labral injury 22% Siebenrock et alLabral tearing+/-de-generation
63 of 73 hips 86.3% Ross et al
Hypertrophied labrum
46 of 73 hips 63%
Acetabular retrover-sion
25 of 95 os-teotomies
26% Dora et al
Overcoverage of femoral head
→ iatrogenic FAI
Overlooked chondrolabral injury
(dysplasia, FAI)
Overlooked intra-articular hip inspec-tion
(early experience)
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Intra-articular WorkLabral pathology
Dysplastic hip pathomorphology
FAI-pincer type FAI-cam type
Labral tissue hypertro-phy with myxoid degen-eration and/or detach-ment from the osseous acetabular rim
Undersurface labral tear-ing without hypertrophy
Labral tearing -extends perpendicular to the labral surface
Labral tearing- at the transition(fibrous cartiliginous labrum/ar-ticular hyaline cartilage) zone perpendicular to the articular surface
Labral injury alone could generate sufficient pain to re-quire intervention
The positive outcome- pain relief after debridement and/or fixation of labral tears,
The acetabular labrum - a triangular structure with a basilar attachment to the osseous acetabular rim - a capsular insertion along the external surface - a free intra articular apical margin
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Intra-articular WorkLabral pathology
1. Anterior hip arthrotomy
Modified Smith-Petersen approach used for Bernese PAO 2. Indirect head of rectus femoris is tagged and mobilized for
improved view3. Capsular incision along the long axis of the femoral neck →
AP direction at the level of acetabular rim 4. Simple debridement5. Labral repair using suture anchor technique is used for
labral detachment at the extra-articular osseous inser-tion
6. Labral detachment → Preservation of the blood supply
Labral repair with suture anchor : TOC for unstable hypertrophied labrum
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Intra-articular WorkLabral pathology
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Intra-articular WorkLabral pathology
Labral refixation with suture an-
chors fixed to new acetabular rim
Labral takedown and Rim resection
Correction achieved
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Intra-articular WorkChondral pathology
• Chondral lesion - Location : anterior and superolateral aspect of acetabulum - Size : 171.7 mm2
• Chondral lesion– Chondromalacic, cleavage, or debonding injury
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Intra-articular WorkChondral pathology
• The natural history of these lesion and whether chondral le-sions are independent source of pain have not been deter-mined.
• Nascent chondral lesions identified at the time of PAO rep-resent an opportunity to alter the degenerative cas-cade.
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Intra-articular WorkChondral pathology
In contrast with labral pathology, preOP diagnosis of chondral injury has implications for preOP planning
- Hip MR Arthrography : mainstay of soft-tissue hip diag-nostic imaging
(Specificity ↑, Sensitivity ↓)
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Intra-articular WorkChondral pathology
1. Inspection : Patient’s specific hip pathophysiology
Diagnostic imaging
2. Rim resectionAmount of rim resection to properly address the
chondral lesion
Staged surgical dislocation → PAOObtain consent for a possible simultaneous
PAO
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Intra-articular WorkChondral pathology
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Femoral head-neck offset• More than 90% of patients treated with PAO require some
degree of femoral head-neck offset correction → Intraoperative C-arm fluoroscopy (False profile view, Dynamic impingement view)
Intended ac-etabular correc-
tionFemoral head-
neck offsetPotential exac-erbation of FAI
Assess
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Femoral head-neck offset
Cam lesion on femoral head-neck
junction
burr allows ade-quate restoration
of the femoral head-neck offset
Adequate offset achieved