Clin Orthop Surg.  2014 Jun;6(2):127-137. 10.4055/cios.2014.6.2.127.

Curved Periacetabular Osteotomy for the Treatment of Dysplastic Hips

• Naito M
• Nakamura Y

• KMID: 1784657
• DOI: http://doi.org/10.4055/cios.2014.6.2.127

Abstract

Curved periacetabular osteotomy (CPO) was developed for the treatment of dysplastic hips in 1995. In CPO, the exposure of osteotomy sites and osteotomy of the ischium are made in the same manner as Bernese periacetabular osteotomy, and iliac and pubic osteotomies are performed in the same manner as rotational acetabular osteotomy. We studied the dynamic instabilities of 25 dysplastic hips before and after CPO using triaxial accelerometry. Overall magnitude of acceleration was significantly decreased from 2.30 +/- 0.57 m/sec2 preoperatively to 1.55 +/- 0.31 m/sec2 postoperatively. Pain relief and improvement of acetabular coverage resulting from acetabular reorientation seem to be related with reduction of dynamic instabilities of dysplastic hips. Isokinetic muscle strengths of 24 hips in 22 patients were measured preoperatively and after CPO. At 12 months postoperatively, the mean muscle strength exceeded the preoperative values. These results seem to be obtained due to no dissection of abductor muscles in CPO. The preoperative presence of acetabular cysts did not influence the results of CPO. An adequate rotation of the acetabular fragment induced cyst remodeling. Satisfactory results were obtained clinically and radiographically after CPO in patients aged 50 years or older. CPO alone for the treatment of severe dysplastic hips classified as subluxated hips of Severin group IV-b with preoperative CE angles of up to -20degrees could restore the acetabular coverage, weight-bearing area and medialization of the hip joint. CPO without any other combined procedure, as a treatment for 17 hips in 16 patients with Perthes-like deformities, produced good mid-term clinical and radiographic results. We have been performing CPO in conjunction with osteochondroplasty for the treatment of acatabular dysplasia associated with femoroacetabular impingement since 2006. The combined procedure has been providing effective correction of both acetabular dysplasia and associated femoral head-neck deformities without any increased complication rate. We have encountered an obturator artery injury in one case and two intraoperative comminuted fractures. Although serious complications such as motor nerve palsy, deep infection, necrosis of the femoral head or acetabulum, and delayed union or nonunion of the ilium were reported, such complications have never occurred in our 700 cases so far.

Keyword

Dysplastic hip; Curved periacetabular osteotomy; Dynamic instability; Abductor muscle; Retroversion

MeSH Terms

Acetabulum/physiopathology/*surgery
Hip Dislocation, Congenital/complications/physiopathology/*surgery
Humans
Osteoarthritis, Hip/etiology/physiopathology/*surgery
Osteotomy/adverse effects/*methods
Recovery of Function

Figure

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  Fig. 1 Radiographs of a 56-year-old female patient with moderate dysplasia of the right hip. (A) Radiograph at presentation showing moderate hip dysplasia with early stage osteoarthritis (OA). (B) Radiograph at 20 months after presentation showing end-stage OA.

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  Fig. 2 Schematic drawing of the skin incision. The skin is incised a few centimeters lateral to the course of the lateral femoral cutaneous nerve. ASIS: anterior superior iliac spine.

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  Fig. 3 Schematic drawing of the osteotomy of the anterior superior iliac spine. The anterior superior iliac spine is osteotomized in a wedge-shaped fashion, with the inguinal ligament and sartorius muscle remaining attached in order to prevent the outer table of the pelvis from dissecting. TFLM: tensor fasciae latae muscle, ASIS: anterior superior iliac spine, IL: ilioinguinal ligament, SM: sartorius muscle.

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  Fig. 4 Photograph of creation of a working space in the quadrilateral space. The blunt tip of a Chiari retractor is fixed in the greater sciatic notch as a landmark. A 3 cm wide retractor is placed in front of the Chiari retractor.

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  Fig. 5 Photograph of C-shaped osteotomy line of curved periacetabular osteotomy. Using a power drill, a C-shaped osteotomy line is started proximal to the anteroinfer

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  Fig. 6 A 50-year-old woman who underwent curved periacetabular osteotomy (CPO) on her right hip. (A) Preoperative radiograph showing advanced osteoarthritis in her right hip. (B) Preoperative false-profile radiograph showing subluxation of the femoral head in her right hip. (C) Postoperative radiograph at 16 years (age 66), showing improvement of the femoral head coverage in her right hip. The Harris hip score of her right hip improved from 46 points preoperatively to 92 points at 16 years after CPO. (D) Sixteen-year postoperative (age 66) false-profile radiograph showing reduction of the femoral head and good congruity in her right hip. The sourcil of her right hip is markedly enlarged, compared to that before CPO (B).

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  Fig. 7 A 35-year-old man who underwent curved periacetabular osteotomy for the treatment of a dysplastic hip with Perthes-like deformities. (A) Preoperative radiograph showing so-called Perthes-like deformities and retroversion of the acetabulum in his right hip. (B) Five-year postoperative radiograph showing improvement of the femoral head coverage and anteversion of the acetabulum in his right hip. The Harris hip score of his right hip improved from 57 points preoperatively to 98 points postoperatively.

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  Fig. 8 A 43-year-old woman who underwent curved periacetabular osteotomy in conjunction with osteochondroplasty on both hips. (A) Preoperative radiograph showing moderate acetabular dysplasia in both hips. (B) Preoperative cross-table radiograph showing a slightly prominent head-neck junction of her right hip. (C) Preoperative cross-table radiograph showing a slightly prominent head-neck junction of her left hip. (D) Radiograph made 2 years postsurgery on her left hip (1 year postsurgery on her right hip) showing improvement of the femoral head coverage in both hips. Signs of impingement also disappeared in both hips. (E) Postoperative cross-table radiograph showing recontouring of the femoral head-neck junction of her right hip. The Harris hip score improved from 83 points preoperatively to 94 points at 1 year postsurgery. (F) Postoperative cross-table radiograph showing recontouring of the femoral head-neck junction of her left hip. The Harris hip score improved from 73 points preoperatively to 96 points at 2 years postsurgery.

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  Fig. 9 A 46-year-old woman who had an intraoperative comminuted fracture of the acetabulum during the iliac osteotomy. (A) Preoperative radiograph showing acetabular dysplasia with advanced osteoarthritis in her left hip. (B) Immediate postoperative radiograph showing the comminuted fracture of the osteotomized acetabulum. (C) Radiograph made 6 years postsurgery showing the increased joint space of her left hip. The Harris hip score improved from 61 points preoperatively to 86 points at 6 years postsurgery.

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  Fig. 10 A 40-year-old-woman who had pubic nonunion after curved periacetabular osteotomy. (A) Preoperative radiograph showing moderate acetabular dysplasia with early stage osteoarthritis in her right hip. (B) Radiograph made 12 years postsurgery showing the pubic nonunion in her right hip. The Harris hip score improved from 96 points preoperatively to 100 points postoperatively.

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