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The Bernese periacetabular osteotomy is commonly used to treat symptomatic acetabular dysplasia. Although periacetabular osteotomy is becoming a more common surgical intervention to relieve pain and improve function, the strength of clinical evidence to support this procedure for these goals is not well defined in the literature. We therefore performed a systematic review of the literature to define the level of evidence for periacetabular osteotomy, to determine deformity correction, clinical results, and to determine complications associated with the procedure. Thirteen studies met our inclusion criteria. Eleven studies were Level IV, one was Level III, and one was Level II. Radiographic deformity correction was consistent and improvement in hip function was noted in all studies. Most studies did not correlate radiographic and clinic outcomes. Clinical failures were commonly associated with moderate to severe preoperative osteoarthritis and conversion to THA was reported in 0% to 17% of cases. Major complications were noted in 6% to 37% of the procedures. These data indicate periacetabular osteotomy provides pain relief and improved hip function in most patients over short- to midterm followup. The current evidence is primarily Level IV. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Radiographic evaluation provides essential information regarding the diagnosis and treatment of musculoskeletal disorders. We evaluated the ability of hip specialists to reliably identify important radiographic features and to make a diagnosis based on plain radiographs alone. Five hip specialists and one fellow performed a blinded radiographic review of 25 control hips, 25 hips with developmental dysplasia (DDH), and 27 with femoroacetabular impingement (FAI). On two separate occasions, readers assessed acetabular version, inclination and depth, position of the femoral head center, head sphericity, head-neck offset, Tönnis grade, and joint congruency. Observers made a diagnosis categorizing each hip as normal, dysplastic, FAI, or combined DDH and FAI (features of both). Reliability was determined using Cohen’s kappa coefficient. Intraobserver values were highest for acetabular inclination (κ = 0.72) and determination of femoral head center position (κ = 0.77). Interobserver reliability values were highest for acetabular inclination (κ = 0.61) and Tönnis osteoarthritis grade (κ = 0.59). All other measurements, including diagnosis, had kappa values less than 0.55. We concluded many of the standard radiographic parameters used to diagnose DDH and/or FAI are not reproducible. Accordingly, a more clear set of definitions and measurements must be developed to allow for more reliable diagnosis of early hip disease. Level of Evidence: Level III, diagnostic study. See the guidelines for authors for a complete description of the levels of evidence.

Reorientation acetabular osteotomies can correct dysplastic deformities and provide marked improvement in hip function. Deformities of the proximal femur can produce suboptimal articulation or secondary impingement after acetabular reorientation, yet the incidence and characteristics of such deformities have not been well described. To describe the proximal femoral anatomy in patients with symptomatic acetabular dysplasia, we retrospectively analyzed the radiographs of 108 hips treated with periacetabular osteotomy. The radiographic findings were compared with those in 22 control hips. In the dysplastic group, 80 hips were in women and 28 in men, and the average age was 24.8 years. Of the 108 abnormal radiographs, 44% had coxa valga and 4% coxa vara. Seventy-two percent had an aspheric or deformed femoral head and the head-neck offset was insufficient in 75% of the hips. When compared with the control hips, dysplastic hips had differences in parameters of proximal femoral anatomy that we measured. These data demonstrate a high incidence of proximal femoral abnormalities associated with acetabular dysplasia. Identifying and treating these abnormalities may optimize joint congruency and minimize secondary impingement after acetabular reorientation. Level of Evidence: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Abstract Purpose Posteromedial bowing of the tibia is an uncommon but recognized congenital lower extremity deformity in children that can lead to limb length discrepancy (LLD) and residual angulatory deformity. The purpose of this study is to report a series of children at a single institution with posteromedial bowing treated by lengthening. Methods A retrospective review was carried out at our institution identifying 16 patients who were treated with limb lengthening for posteromedial bowing of the tibia and followed to skeletal maturity. Projected LLD was a mean of 7.7 cm (range 5.0 cm to 14.2 cm). Three patients were treated in a staged fashion with lengthening and deformity correction at age three to four years and subsequent definitive tibial lengthening. The remaining 13 patients were treated with limb lengthening approaching adolescence using circular external fixation. Results All patients were pain free and ambulated without a limp at final follow-up. The mean final LLD was 0.3 cm short. In spite of correction of distal tibial shaft valgus in 11 of the 16 patients, eight of the 16 (50%) required later correction of persistent, symptomatic ankle valgus by either hemiepiphyseodesis (seven patients) or osteotomy (one patient). Conclusions Children with posteromedial bowing of the tibial with projected LLD over 5cm can be effectively treated with lengthening. Patients with severe valgus of more than 30° of shaft valgus and difficulty ambulating at age three years can be successfully treated with a two-stage lengthening procedure. Attention should be paid in patients with posteromedial bowing to ankle valgus. Level of Evidence IV

Background Detailed recognition of the three-dimensional (3-D) deformity in acetabular dysplasia is important to help guide correction at the time of reorientation during periacetabular osteotomy (PAO). Common plain radiographic parameters of acetabular dysplasia are limited in their ability to characterize acetabular deficiency precisely. The 3-D characterization of such deficiencies with low-dose CT may allow for more precise characterization. Questions/purposes The purposes of this study were (1) to determine the variability in 3-D acetabular deficiency in acetabular dysplasia; (2) to define subtypes of acetabular dysplasia based on 3-D morphology; (3) to determine the correlation of plain radiographic parameters with 3-D morphology; and (4) to determine the association of acetabular dysplasia subtype with patient clinical characteristics including sex, range of motion, and femoral version. Methods Using our hip preservation database, we identified 153 hips (148 patients) that underwent PAO from October 2013 to July 2015. Among those, we noted 103 hips in 100 patients with acetabular dysplasia (lateral center-edge angle < 20°) and who had a Tönnis grade of 0 or 1. Eighty-six patients (86%) underwent preoperative low-dose pelvic CT scans at our institution as part of the preoperative planning for PAO. It is currently our standard to obtain preoperative low-dose pelvic CT scans (0.75–1.25 mSv, equivalent to three to five AP pelvis radiographs) on all patients before undergoing PAO unless a prior CT scan was performed at an outside institution. Hips with a history of a neuromuscular disorder, prior trauma, prior surgery, radiographic evidence of joint degeneration, ischemic necrosis, or Perthes-like deformities were excluded. Fifty hips in 50 patients met inclusion criteria and had CT scans available for review. These low-dose CT scans of 50 patients with symptomatic acetabular dysplasia undergoing evaluation for surgical planning of PAO were then retrospectively studied. CT scans were analyzed quantitatively for acetabular coverage, relative to established normative data for acetabular coverage, as well as measurement of femoral version. The cohort included 45 females and five males with a mean age of 26 years (range, 13–49 years). Results Lateral acetabular deficiency was present in all patients, whereas anterior deficiency and posterior deficiency were variable. Three patterns of acetabular deficiency were common: anterosuperior deficiency (15 of 50 [30%]), global deficiency (18 of 50 [36%]), and posterosuperior deficiency (17 of 50 [34%]). The presence of a crossover sign or posterior wall sign was poorly predictive of the dysplasia subtype. With the numbers available, males appeared more likely to have a posterosuperior deficiency pattern (four of five [80%]) compared with females (13 of 45 [29%], p = 0.040). Hip internal rotation in flexion was significantly greater in anterosuperior deficiency (23° versus 18°, p = 0.05), whereas external rotation in flexion was significantly greater in posterosuperior deficiency (43° versus 34°, p = 0.018). Acetabular deficiency pattern did not correlate with femoral version, which was variable across all subtypes. Conclusions Three patterns of acetabular deficiency commonly occur among young adult patients with mild, moderate, and severe acetabular dysplasia. These patterns include anterosuperior, global, and posterosuperior deficiency and are variably observed independent of femoral version. Recognition of these distinct morphologic subtypes is important for diagnostic and surgical treatment considerations in patients with acetabular dysplasia to optimize acetabular correction and avoid femoroacetabular impingement.

BackgroundThe optimal treatment of severe acetabular dysplasia with subluxation of the femoral head or the presence of a secondary acetabulum remains controversial. The purpose of this study was to analyze the extent of surgical correction and the early clinical results obtained with the Bernese periacetabular osteotomy for the treatment of severely dysplastic hips in adolescent and young adult patients.MethodsSixteen hips in thirteen patients with an average age of 17.6 years (range, 13.0 to 31.8 years) were classified as having severe acetabular dysplasia (Group IV or V according to the Severin classification). Eight hips were classified as subluxated, and eight had a secondary acetabulum. Preoperatively, all patients had hip pain and sufficient hip joint congruency on radiographs to be considered candidates for the osteotomy. All sixteen hips underwent a Bernese periacetabular osteotomy, and six of them underwent a concomitant proximal femoral osteotomy. Postoperatively, the hips were assessed radiographically to evaluate correction of deformity, healing of the osteotomy site, and progression of osteoarthritis. Clinical results and hip function were measured with the Harris hip score at an average of 4.2 years postoperatively.ResultsComparison of preoperative and follow-up radiographs demonstrated an average improvement of 44.6° (from -20.5° to 24.1°) in the lateral center-edge angle of Wiberg, an average improvement of 51.0° (from -25.4° to 25.6°) in the anterior center-edge angle of Lequesne and de Seze, and an average improvement of 25.9° (from 37.3° to 11.4°) in acetabular roof obliquity. The hip center was translated medially an average of 10 mm (range, 0 to 31 mm). All iliac osteotomy sites healed. The average Harris hip score improved from 73.4 points preoperatively to 91.3 points at the time of the latest follow-up. Eleven of the thirteen patients (fourteen of the sixteen hips) were satisfied with the result of the surgery, and fourteen hips had a good or excellent clinical result. Major complications included loss of acetabular fixation, which required an additional surgical procedure, in one patient and overcorrection of the acetabulum and an associated ischial nonunion in another patient. Both patients had a good clinical result at the time of the latest follow-up. There were no major neurovascular injuries or intra-articular fractures.ConclusionsThe periacetabular osteotomy is an effective technique for surgical correction of a severely dysplastic acetabulum in adolescents and young adults. In this series, the early clinical results were very good at an average of 4.2 years postoperatively; the two major complications did not compromise the good clinical results.Level of EvidenceTherapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Background The goal of periacetabular osteotomy (PAO) is to improve the insufficient coverage of the femoral head and achieve joint stability without creating secondary femoroacetabular impingement. However, the complex tridimensional morphology of the dysplastic acetabulum presents a challenge to restoration of normal radiographic parameters. Accurate acetabular correction is important to achieve long-term function and pain improvement. There are limited data about the proportion of patients who have normal radiographic parameters restored after PAO and the factors associated with under- and overcorrection. Questions/purposes (1) What is the proportion of patients undergoing PAO in which the acetabular correction as assessed by the lateral center-edge angle (LCEA), anterior center-edge angle (ACEA), acetabular inclination (AI), and extrusion index (EI) is within defined target ranges? (2) What patient and preoperative factors are associated with undercorrection of the acetabulum as defined by a LCEA < 22°, a factor that has been reported to be associated with PAO failure at 10-year followup? Methods Between January 2007 and December 2011 we performed 132 PAOs in 116 patients for treatment of symptomatic acetabular dysplasia. One patient with Legg-Calvé-Perthes disease, one with multiple osteochondromatosis, and two with concomitant femoral osteotomy were excluded. A total of 128 hips (112 patients) were included. The hip cohort was 76% (97 of 128) female and the mean age at surgery was 28.5 years (SD 8.7 years). Correction of LCEA between 25° and 40°, ACEA between 18° and 38°, Tönnis angle between 0° and 10°, and EI ≤ 20% were defined as adequate based on normative values. Values lower than the established parameters were considered undercorrection for the LCEA and ACEA and those higher than the established values were considered overcorrection. Because postoperative LCEA < 22 o has been previously associated with PAO failure at a minimum of 10-year followup, in this study we sought to measure whether demographic factors including age, gender, body mass index, and severity of acetabular dysplasia assessed by preoperative LCEA, ACEA, AI, and EI were associated with undercorrection. Postoperative radiographs were obtained at minimum of 1 month after surgery (mean, 7 months; range, 1–44 months) and were measured by a professional research assistant and a hip reconstruction fellow not involved in the clinical care of the patients. No patient was lost to followup. Results Of the 128 hips, the proportion of hips with radiographic parameters within the established range was 78% (100 hips) for the LCEA, 86% (110 hips) for the ACEA, 89% (114 hips) for the AI, and 80% (102 hips) for the EI. For hips with an inadequate correction, the LCEA was more often undercorrected than overcorrected (20% versus 2%; 95% confidence interval [CI], 11%–27%; p < 0.001), whereas the ACEA was more often overcorrected than undercorrected (11% versus 3%; 95% CI, 1%–15%; p = 0.03) After adjusting for age, sex, body mass index, and preoperative radiographic parameters including ACEA, AI, and EI, we found that the preoperative LCEA was the only independent factor associated with a postoperative LCEA < 22° (odds ratio, 0.92; 95% CI, 0.87–0.97; p = 0.003), indicating that hips with lower preoperative LCEA were more likely to have a LCEA < 22°. For each additional degree of preoperative LCEA, the odds of LCEA < 22° were reduced by 15%. Conclusions Acetabular correction after PAO performed by two experienced surgeons was adequate for individual radiographic parameters in most but not all hips. Hips with more severe dysplasia preoperatively are at higher risk for undercorrection as assessed by the LCEA. This intuitive information may help surgeons performing PAO in severely dysplastic hips plan for possible combined procedures including a femoral osteotomy if PAO alone does not allow for adequate correction of femoral head coverage and a congruous concentric hip. Further studies are planned to determine whether the long-term hip function and pain in patients whose hips were corrected within these established parameters will be improved in comparison to those that were under- or overcorrected. Level of Evidence Level III, therapeutic study.

Background Patients with symptomatic residual Perthes-like deformities may present with a combination of structural abnormalities including a large aspheric femoral head, short and wide femoral neck, high greater trochanter, and acetabular dysplasia. Sometimes, the hip is further compromised by concurrent symptomatic femoroacetabular impingement (FAI) (proximal femoral deformities) and structural instability (acetabular dysplasia). Questions/purposes We therefore sought to characterize (1) the intraoperative findings; (2) radiographic correction; and (3) early patient-reported outcomes, complications, and failures of treating complex Perthes-like hip deformities with combined surgical dislocation and periacetabular osteotomy (PAO). Methods We performed 694 hip preservation procedures between November 2006 and August 2010. Of these, 46 had residual Perthes-like hip deformities, defined as proximal deformity consistent with residual Perthes and a history of Perthes disease or treatment of pediatric hip dysplasia. Of these, we report on 16 patients (16 hips) with residual Perthes-like hip deformities and associated acetabular dysplasia (structural instability, defined as radiographic evidence of acetabular dysplasia with intraoperative confirmation of instability). These 16 patients were treated with a combined surgical hip dislocation to comprehensively address intraarticular and extraarticular sources of FAI and PAO to address structural instability and were analyzed at a minimum 24-month followup (median, 40 months; range, 24–78 months). No patients in this series were lost to followup. Ten patients’ hips had previous surgical treatment, including six with previous osteotomy. Operative findings were extracted from standardized prospectively collected intraoperative data collection forms. Radiographic correction was evaluated with established methods (lateral center-edge angle, anterior center-edge angle, acetabular inclination, center-to-trochanter distance) and clinical outcomes were measured with the modified Harris hip score (mHHS) as well as by prospectively recorded data on patient complications and followup. Results Acetabular labrochondral abnormalities included labral hypertrophy in all hips and labral and/or articular cartilage lesions requiring treatment in 13 hips. Radiographic analysis demonstrated consistent radiographic correction. The median preoperative mHHS improved from 64 to 92 at a median followup of 40 months (p < 0.001). Fourteen patients (14 hips) had a good or excellent clinical result. Two patients (two hips) were classified as failures based on mHHS less than 70 (n = 1) or conversion to total hip arthroplasty (n = 1). Conclusions Combined surgical hip dislocation and PAO provides major deformity correction in Perthes-like hip deformities with associated acetabular dysplasia. Early clinical results suggest this technique is safe and effective. Long-term studies are needed to determine if improved long-term outcomes are associated with comprehensive deformity correction. Level of Evidence Level IV, therapeutic study.

Background Many patients who undergo periacetabular osteotomy (PAO) for symptomatic acetabular dysplasia experience decreased pain and improved function, yet some experience inadequate clinical improvement. The etiologies of treatment failure have not been completely defined, and sex-dependent disease characteristics that may be associated with less pain relief are not understood. Question/purposes We sought to determine whether there were clinically important sex-specific differences between male and female patients undergoing PAO for acetabular dysplasia in terms of (1) clinical parameters (anthropomorphic traits and hip scores), (2) radiographic findings, and (3) intraoperative findings at the time of PAO, in particular findings potentially associated with femoroacetabular impingement (FAI) such as chondromalacia at the head-neck junction, impingement trough, or reduced head-neck offset. Methods Between 2007 and 2012 we treated 245 patients (270 hips) with a PAO for symptomatic acetabular dysplasia. Of those, 16 patients (16 hips; 6%) had insufficient documentation for review in the medical record and another 49 patients (51 hips; 19%) met prespecified exclusion criteria, leaving 180 patients (203 hips; 75%) for analysis in this retrospective study. One hundred thirty-nine patients were females and 41 were males. Clinical data including patient demographics, physical examination, patient self-reported outcome scores, radiographic morphologic features, and intraoperative findings were collected prospectively as part of an institutional registry. Statistical analysis was performed with univariate and multivariate analyses. Results Mean age was similar among sexes; however, BMI was greater in males compared with females (26 versus 24 kg/m 2 ; p = 0.002). Males had less hip ROM including internal rotation at 90° flexion (14° ± 13.8° versus 25° ± 16.2°; p = 0.001). Males had higher preoperative UCLA (7 ± 2, versus 6 ± 2; p = 0.02) and Harris hip scores (63 ± 15 versus 58 ± 16; p = 0.04). Radiographically, a crossover sign (88% versus 39%; p < 0.001) and posterior wall sign (92% versus 63%; p < 0.001) were more common in males. Males had greater alpha angles on the frog lateral (63° ± 15.3° versus 58° ± 16°; p = 0.04) and Dunn radiograph views (64° ± 15.5° versus 56° ± 14.8°; p = 0.02). The incidence of femoral head-neck chondromalacia (62% versus 82%; p = 0.03) and an impingement trough observed at surgery was greater in males (35% versus 17%; p = 0.01). Multivariate analysis showed differences between the sexes for reduced internal rotation in flexion, a higher Dunn alpha angle, increased incidence of a crossover sign, and a lower anterior center-edge angle. Conclusions There are sex-dependent, disease characteristic differences in patients with symptomatic acetabular dysplasia. Most notably, male patients have a greater prevalence of clinical, radiographic, and intraarticular findings consistent with concurrent FAI and instability and potentially a heightened risk of secondary FAI after PAO, however postoperative and long-term followup are needed to confirm these findings and it remains unclear which patients need surgical correction of the impingement and instability. Preoperative evaluation of acetabular dysplasia in males should at least include careful attention to factors associated with symptomatic FAI; however, further studies are needed to determine when surgical correction is needed. Level of Evidence Level III, therapeutic study.

Background Tranexamic acid (TXA) has shown safety and efficacy in reducing blood loss associated with various surgical procedures. However, to our knowledge there are no studies evaluating the effect of TXA on blood loss and transfusion requirements associated with periacetabular osteotomy (PAO). Questions/purposes The main purpose of this study is to determine whether TXA reduces blood loss and transfusion use in patients undergoing PAO for symptomatic acetabular dysplasia. Our secondary purpose was to compare the frequency of symptomatic thromboembolic events between patients undergoing surgery with and without TXA. Methods A consecutive series of 100 periacetabular osteotomies performed by one surgeon was reviewed to compare the groups immediately before and after implementation of routine use of tranexamic acid (two retrospective cohorts). TXA dosing followed an established protocol with a standard dose of 1 g infused intravenously during 10 minutes before skin incision and an additional 1 g intravenously at wound closure. Outcome measures include total estimated blood loss perioperatively and transfusion requirements. Total estimated blood loss was calculated using a formula built from the National Surgical Quality Improvement Program data regarding surgical blood loss. Results The mean perioperative total estimated blood loss was less in the patients receiving TXA compared with blood loss in patients who did not receive TXA (706 mL versus 1021 mL; p < 0.001; 95% CI, −495 to −134). Twenty-six (52%) of the 50 patients who did not receive TXA had postoperative blood transfusions compared with 15 (30%) of 50 who received TXA (odds ratio, 0.395; 95% CI, 0.174–0.899; p = 0.0414). No symptomatic deep vein thromboses or symptomatic pulmonary emboli were identified in either group. Conclusions TXA reduces estimated blood loss and the frequency of transfusions in patients undergoing PAO for treatment of symptomatic acetabular dysplasia. Future prospective studies should confirm our findings to determine whether patients undergoing PAO should receive routine perioperative TXA. Level of Evidence Level III, therapeutic study.