The rotational acetabular osteotomy has a long-standing history in Asia and was originally described by Ninomiya and Tagawa74 as a spherical osteotomy providing a large surface area for healing and leaving the pelvic ring intact. Takatori et al.75 reported the long-term results at a minimum of ten years after rotational acetabular osteotomy in thirteen severely dysplastic hips with subluxation in eleven women who were twenty to thirty-five-years old; all patients had minimal or no pain, and twelve of the thirteen hips showed no osteoarthritis.
At ten and twenty years of follow-up, this procedure showed good to excellent results in 73% and 60%, respectively, of the hips78,79. However, if hips with preoperative osteoarthritis were excluded, the results improved to 88% and 75%, respectively78. Factors associated with poor outcome included an older age, the severity of osteoarthritis, and evidence of labral pathology and poor acetabular index postoperatively.
These findings of poor joint congruity and the degree of arthritis as predictors of the short to mid-term outcome after periacetabular osteotomy have been reproduced by other groups64,80-83.
More recent reports on the results of periacetabular osteotomy from independent centers have focused on determining what clinical factors affect not only joint survivorship but also patient function64,79,84-91 (Table III). Independent, poor prognostic factors included an age of more than thirty-five years at the time of the periacetabular osteotomy and poor preoperative joint congruity. Garbuz et al.92 investigated the quality of life in patients more than forty years old who underwent periacetabular osteotomy (twenty-eight subjects) or total hip arthroplasty (thirty-three subjects). Although the results of total hip arthroplasty were superior, the overall success of the periacetabular osteotomy suggests that this procedure still has a role in patients older than forty years. Similarly, Millis et al.93, in a study of the results of periacetabular osteotomy in seventy patients (eighty-seven hips) with an average age of 43.6 years at the time of surgery, found that 24% (twenty-one hips) had undergone total hip arthroplasty within 5.2 years. The risk of total hip arthroplasty at five years after periacetabular osteotomy was 12% in hips with a preoperative Tönnis grade of 0 or 1 and 27% in hips with a Tönnis grade of 2. In a more recent study of the predictors of clinical outcome after periacetabular osteotomy, Beaulé et al.94 found that a higher preoperative alpha angle was significantly associated with a lower functional score postoperatively, potentially indicating more severe articular damage persisting after surgical correction.
We cannot overemphasize that pelvic osteotomies such as the periacetabular osteotomy are demanding procedures with a substantial learning curve and risk of major complications99-101.
Poor short-term outcomes, including persistent pain and iatrogenic instability after labral debridement or capsulotomy, have been demonstrated in several studies in which patients with underlying DDH were treated with hip arthroscopy alone (rather than as an adjunct to open surgery)102-104. Byrd and Jones105 reported on forty-eight dysplastic or borderline dysplastic hips (an LCEA of 20° to 25°) in patients with a mean age of thirty-four years (range, fourteen to sixty-four years) at the time of arthroscopy. Although they had an improvement in functional scores at one year, the scores had decreased at the two-year mark. Additionally, acetabular chondral and labral lesions, mainly located in the anterosuperior region, are common arthroscopic findings in up to 77.8% of hips with dysplasia106,107. Consequently, the role of hip arthroscopy as an adjunct to a pelvic osteotomy108,109 continues to evolve until it will allow concomitant treatment of chondral and/or labral lesions, potentially improving the postoperative clinical function.
A useful classification system for surgical planning is the one described by Hartofilakidis et al.111,112, which encompasses three types of deformity in the adult hip, i.e., dysplasia, low dislocation, and high dislocation (Table IV). Difficulties can arise from anatomical abnormalities and previous operations. In a recent systematic review of the results of total hip replacement for hip dysplasia, Duncan et al.113 found that a comparison of the groups that had or had not had a previous osteotomy failed to demonstrate any significant differences with respect to complications during the perioperative period. The consequence of previous operations on the outcome of a total hip arthroplasty is unclear113. Boos et al.114, in a comparison of the results of seventy-four total hip arthroplasties performed after a previous osteotomy matched by diagnosis to a control group of seventy-four patients who had primary procedures, found no significant difference in the rate of perioperative complications or the rate of revisions. In a recent study, Migaud et al.115 compared the results of total hip arthroplasty in 159 hips that had had conservative surgery for DDH (sixty-four had had pelvic osteotomy; eighty-one, femoral osteotomy; and fourteen, combined pelvic and femoral osteotomies) and in 271 hips that had not had prior operations. The results were comparable between the groups. Preoperative assessment is always important if the patient had a pelvic osteotomy performed because the position of the best available bone stock is altered. One of the most frequent complications of total hip replacement in patients with hip dysplasia is instability (0.9% to 11% in series ranging from twenty-three to 220 total hip arthroplasties)116-120, and the overall rate of complications has been reported to range from approximately 15% to 40%121-125.
The treatment of hip dysplasia in young adults remains a challenge. With the advent of advanced imaging techniques as well as surgical techniques such as the periacetabular osteotomy, the capacity to preserve the hip and its function for a substantial period is now well established (Table V). Continued refinements in diagnostic tools will better define the role of hip arthroscopy, which at this time remains ill-defined with a potential role as an adjunct to the periacetabular osteotomy. Finally, current techniques of total hip replacement remain an excellent option for hips with advanced changes and may be the preferable option in older patients with hip dysplasia.
Investigation performed at the Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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