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Incisional Hernia after Periacetabular Osteotomy

Burmeister, H; Kaiser, B; Siebenrock, K, A; Ganz, R

Clinical Orthopaedics and Related Research: August 2004 - Volume 425 - Issue - p 177-179
doi: 10.1097/01.blo.0000130203.28818.da

The incidence of incisional abdominal hernias, an unreported complication after a Bernese periacetabular osteotomy, was evaluated. Two cases of an incisional hernia above the iliac crest were detected in a series of 950 cases since 1984. Although the incidence has been small, risk factors may be obesity, weak abdominal muscle strength, or increased abdominal pressure attributable to chronic coughing or obstipation. The surgeon should recognize the importance of restoring continuity of the abdominal fascia in patients with such factors.

From the Department of Orthopedic Surgery, University of Bern, Inselspital, Bern, Switzerland.

Received: August 18, 2003

Revised: January 20, 2004

Accepted: February 23, 2004

Each author certifies that he has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

Each author certifies that his institution has approved the reporting of this case report, that all investigations were conducted in conformity with ethical principles of research.

Correspondence to: H. Burmeister, MD, Orthopedic Department, University of Berne, Inselspital 3010 Berne Switzerland. Phone: 41-31-6322111; Fax: 41-31-6323600; E-mail:

The Bernese periacetabular osteotomy first was described in 1988.3 The procedure has been done at our institution for treatment of residual dysplasia of the acetabulum since 1984. From April 1984 to March 2003, the procedure was done in 950 patients. Well-recognized postoperative complications include: loss of correction, subsequent femoral head resubluxation, heterotopic ossification with limitation of flexion, nonunion of an osteotomy, and sciatic nerve lesions.7,8,10 We recently recognized two cases of incisional hernia over the iliac crest. We describe this rare but important complication, which has not been reported previously in association with periacetabular osteotomies. We also address the risk factors for development of an incisional hernia, and what must be done to avoid this complication.

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Surgical Technique

In all cases, a modified Smith-Petersen approach was used as described by Leunig et al.6 After osteotomy of the anterior superior iliac spine, the abdominal muscles were elevated off the iliac crest. Subperiosteal dissection of the iliac muscle then was completed to expose the inner aspect of the pelvis. After the procedure, the abdominal muscles were reattached over the iliac crest to the gluteus medius fascia with a running 2.0 Ethicon Vicryl suture (Johnson & Johnson, Belgium).

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Case 1

A 45-year-old man with residual acetabular dysplasia had a periacetabular osteotomy in February 1992. He was obese, with a body mass index of 32.9. He was a smoker with chronic obstructive pulmonary disease and a persistent cough.

Three months after surgery he had swelling at the scar over the iliac crest and increasing local pain without interference in bowel function. An incisional hernia of the lateral abdominal wall was diagnosed, and in August 1992 the hernia repair was done. Intraoperatively, the oblique abdominal muscles were detached at their insertion over the iliac crest. In addition to dehiscence in the oblique abdominal muscles, a 4- to 5-cm defect was seen in the transverse abdominal muscle with herniation of preperitoneal fat. The transverse and the oblique abdominal muscles were reattached to the iliac crest with 0 Ethicon Vicryl sutures (Johnson & Johnson), and a Vicryl mesh (Johnson & Johnson) was used for augmentation. A preexisting asymptomatic umbilical hernia was left untreated. Four months after surgery, a palpable defect in the abdominal musculature developed over the iliac crest without evidence of a recurrent hernia. The patient was last seen in June 1994. He had a persisting abdominal musculature dehiscence without palpable herniation and tenderness over the incision. He declined to return for additional followup.

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Case 2

A 41-year-old obese woman with a body mass index of 32.7 and with symptomatic residual acetabular dysplasia on the left side was treated with a periacetabular osteotomy in January 2000. In February 2002, the patient had swelling above the left iliac crest with abdominal pain and cramping. The patient reported that she had some symptoms for more than a year. A CT scan showed a large defect of the abdominal wall directly anterior to the iliac crest, with herniation of the descending colon (Fig 1). In April 2002, the hernia repair was done. Intraoperatively, a 3 × 5-cm abdominal wall defect was seen. The defect was closed using Prolene mesh (Ethicon, Johnson & Johnson, Somerville, NJ). At the final followup in October 2002, the patient reported a similar swelling in the same area only while coughing, but had no pain and had normal bowel function. On physical examination, a defect could be felt but a herniation was not found. It was decided to observe her clinical course.

Fig 1.

Fig 1.

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To our knowledge there are no reports describing herniation after pelvic osteotomies done to improve coverage of the deficient acetabulum. In 950 patients with residual acetabular dysplasia treated with a periacetabular osteotomy using a Smith-Petersen approach, two patients had an incisional hernia develop over the iliac crest, representing an incidence of 0.2%. Both patients were obese, each with a body mass index of approximately 32, and one patient had chronic obstructive pulmonary disease with persistent cough. The first symptoms developed after 3 months in one patient and after 1 year in the other patient. Both patients had swelling develop over the iliac crest and increasing pain. The second patient also had abdominal cramping. Both patients had repair of the abdominal fascia using mesh augmentation. Both patients also had incomplete healing of their hernia repair, which is consistent with the high recurrence rate seen with incisional hernias.2,5

Stephen et al9 reported 13 cases of incisional hernias diagnosed 5 months to 11 years after obtaining full-thickness graft of the iliac crest. Bosworth1 reported that taking a full-thickness bone graft from the middle of the iliac crest makes it impossible to reattach the abdominal fascia along the edge of the superior aspect of the ilium. He recommended taking the graft from the anterior or posterior third of the iliac crest. Hamad and Majeed4 described three cases of incisional hernias after full-thickness grafts. All of their patients were obese and had weak abdominal muscles. Activities that increased intraabdominal pressure, such as coughing or obstipation, were mentioned as additional risk factors for development of a hernia, and this was observed in one of our patients. There are no case reports of incisional hernias after surgery for pelvic or acetabular fractures. At our institution, a patient with an incisional hernia over the iliac crest recently was observed after an ilioinguinal approach was used for treatment of an acetabular fracture.

Posttraumatic abdominal wall hernias associated with pelvic fractures, especially iliac wing fractures, have been described but apparently are rare.11,12

Incisional hernia, however, is a frequent complication after surgery for intraabdominal disorders. Khaira et al5 reported incisional hernias in 11% of surgical abdominal wounds, with 44% recurrent herniation after repair. Franz and Kuhn2 reported the incidence of hernias to be 20%, with a recurrence rate of 54% after repair.

Patients with obesity, chronic obstructive pulmonary disease, or obstipation having a periacetabular osteotomy must be informed about the risk of an incisional hernia. The surgeon must understand the risk factors, including obesity, weak abdominal muscles, and increased intraabdominal pressure. Most importantly for the operation, the surgeon must restore the continuity of the abdominal fascia while detaching it from the iliac crest. We suspect the critical issue is maintaining an intact tendinous sleeve at the lower border of the abdominal wall muscles during the surgical approach. For its reattachment over the iliac crest to the gluteus medius fascia, a tight running suture with absorbable material seems to be adequate because the suture only has to keep the abdominal fascia in place and does not act as an abdominal wall closure.

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