Outcomes of Periacetabular Osteotomy for Borderline Acetabular Dysplasia

Abstract

Background:The optimal surgical treatment (hip arthroscopy compared with periacetabular osteotomy [PAO]) for borderline acetabular dysplasia (lateral center-edge angle [LCEA], 18° to 25°) remains a topic of debate. To date, the literature has focused primarily on arthroscopy outcomes, with only a few small reports on PAO outcomes. The purpose of this study was to define PAO outcomes in a large cohort of borderline hips. In a secondary analysis, we assessed the effect of prior failed arthroscopy, concurrent hip arthroscopy, and concurrent femoral osteoplasty on PAO outcomes in this cohort.Methods:A prospective database was retrospectively reviewed for patients who underwent PAO for symptomatic instability in the setting of borderline dysplasia (LCEA, 18° to 25°). Of the 232 identified hips, 186 (80.2%) were assessed at a mean follow-up of 3.3 ± 2.0 years postoperatively. The mean patient age was 25.2 ± 8.5 years (range, 14 to 45 years), and 88.2% were female. Thirty hips (16.1%) had undergone a failed prior arthroscopy. Arthroscopy was performed concurrently with the PAO in 130 hips (69.9%), and femoral osteoplasty was performed concurrently in 120 hips (64.5%). The modified Harris hip score (mHHS) was assessed relative to the minimal clinically important difference (MCID) of 8 and patient acceptable symptom state (PASS) of 74. Clinical failure was defined as a reoperation for persistent symptoms or a failure to achieve either the mHHS MCID or PASS.Results:Of the 156 hips undergoing a primary surgical procedure, clinical success was achieved in 148 hips (94.9% [95% confidence interval (CI), 90.2% to 97.4%]). Two hips (1.3% [95% CI, 0.4% to 4.6%]) underwent reoperation (hip arthroscopy) for persistent symptoms and an additional 6 hips (3.8% [95% CI, 1.8% to 8.1%]) failed to achieve the mHHS MCID or PASS, for a clinical failure rate of 5.1% (95% CI, 2.6% to 9.8%); 8.8% reported dissatisfaction with the surgical procedure. Clinical failure was more frequent among the 30 hips (23.3% [95% CI, 11.8% to 40.9%]; p = 0.001) that had undergone a prior failed arthroscopy. There were no outcome differences between hips that had or had not undergone concurrent hip arthroscopy or femoral osteoplasty.Conclusions:This study demonstrates excellent early outcomes of PAO for borderline acetabular dysplasia, with significant clinical improvement in 94.9% of patients undergoing a primary surgical procedure; 91.2% were satisfied with the surgical procedure.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Team Approach: Hip Preservation Surgery

“…Although currently ongoing, there are no published trials comparing PAO with or without hip arthroscopy to address concomitant intra-articular pathology 84 . For patients with borderline hip dysplasia, at 3 years, clinical success was achieved in 94.9% of patients with PAO, without any noted differences between those who had undergone concurrent hip arthroscopy or femoral osteoplasty 57 . In patients with significant proximal femoral deformity in the setting of AD, PAO combined with PFO has demonstrated good short- and long-term results as well, with long-term survival reported to be 90.0% and 61.8% at 15 and 20 years, respectively 85,86 .…”

“…Improving outcomes of hip arthroscopy in the future hinges on optimal patient selection and determining the limits of hip arthroscopy alone. For instance, in the setting of borderline AD, a substantial portion of patients treated with isolated hip arthroscopy continue to have persistent symptoms 56 , whereas periacetabular osteotomy (PAO) (often with hip arthroscopy) has demonstrated excellent outcomes in selected patients 57 . Similarly, in the setting of significant acetabular retroversion (which may be combined with borderline dysplasia), long-term studies have demonstrated inferior outcomes of acetabular rim trimming (which can be performed with arthroscopy), compared with reorientation of the acetabulum with an anteverting PAO 58 .…”

Arthroscopy Confers Favorable Clinical Outcomes in Asian Patients with Borderline Developmental Dysplasia of the Hip

“…BDDH is commonly defined as a lateral LCEA between 18° and 25° 4 and has been associated with symptoms. BDDH is an increasingly acknowledged factor that predisposes individuals to microinstability and hip labral tears 5 . Hip arthroscopy is increasingly used as a treatment option for patients with FAIS and BDDH 6,7 .…”

Outcomes and Return-to-Sports Rates in Patients With Borderline Hip Dysplasia After Periacetabular Osteotomy: A Case Series With 5-Year Follow-up

“…Even though labral abnormalities and coexisting femoroacetabular impingement can be addressed arthroscopically, addressing instability due to acetabular undercoverage requires acetabular reorientation through PAO. 15,21 At the time of indication, regardless of the surgical approach chosen, patients are usually young and active with high functional demands. Those who participate in sports want to resume and maintain sports activities after surgery, 2,6,13,18,[23][24][25] and the ability to do so plays an important role in the choice of a treatment method.…”

“…4,20,22 Improved patient-reported outcomes and hip function have been reported after both hip arthroscopic surgery and PAO in patients with BHD. 4,7,10,[20][21][22]26 However, with isolated hip arthroscopic surgery, as many as 40% of patients experience suboptimal outcomes. 8,9,21 These high rates of treatment failure likely stem from the difficulty in differentiating between the underlying primary problem of hip symptoms in patients with BHD.…”