The Addition of Hip Arthroscopy to Periacetabular Osteotomy Does Not Increase Complication Rates: A Prospective Case Series

Abstract

Background: Previous studies on periacetabular osteotomy (PAO) reported complication and reoperation rates of 5.9% and 10%, respectively. Hip arthroscopy is increasingly utilized as an adjunct procedure to PAO to precisely treat associated intra-articular pathology. The addition of this procedure has the potential of further increasing complication rates. Purpose: To determine the rates of complication and reoperation of combined hip arthroscopy and PAO for the treatment of acetabular deformities and associated intra-articular lesions. Study Design: Case series; Level of evidence, 4. Methods: Using a prospective database, the authors retrospectively reviewed 248 hips (240 patients) that underwent combined hip arthroscopy and PAO between 2007 and 2016. Data were collected at scheduled follow-up visits at approximately 1 month, 3 to 4 months, and 1 and 2 years after surgery. Mean follow-up from surgery was 3 years (range, 1-8 years). A total of 220 PAOs were done for symptomatic acetabular dysplasia, 18 for symptomatic acetabular retroversion, and 10 for combined acetabular dysplasia and acetabular retroversion. Central compartment arthroscopy was performed for treatment of intra-articular chondrolabral pathology in all cases. Select cases underwent femoral head-neck junction osteochondroplasty either arthroscopically before the PAO or through an open approach after it. Complications were graded according to the modified Dindo-Clavien complication scheme, which was validated for hip preservation procedures. Reoperations (excluding hardware removal) were recorded. Results: Grade III complications occurred among 7 patients (3%) while there were no grade IV complications. Grade III complications included deep infection (n = 3), wound dehiscence (n = 1), hematoma requiring exploration (n = 1), symptomatic heterotopic ossification requiring excision (n = 1), and deep venous thrombosis (n = 1). There were 13 reoperations (5%), and 3 were repeat hip arthroscopy. Univariate Cox hazard models were used to estimate the relative risk factors for complication and reoperation. Increased age (per decade) showed over twice the increased likelihood for complications (hazard ratio, 2.5; 95% CI, 1.67-3.74). Also, preoperative diagnosis of acetabular retroversion, not acetabular dysplasia, showed >3 times the increased risk of reoperation (hazard ratio, 3.05; 95% CI, 1.41-6.61). Conclusion: The rate of complications reported is comparable (3%) with previously published complication rates of PAO without hip arthroscopy. In this cohort, increasing age and diagnosis of acetabular retroversion were associated with higher complication and reoperation rates.

Incidence of Heterotopic Ossification with NSAID Prophylaxis Is Low After Open and Arthroscopic Hip Preservation Surgery

“…Four cases were Brooker grade I incidental radiographic findings, which has previously been considered not a true complication after hip arthroscopy. 12 , 13 , 14 The low incidence of HO in our study is comparable to others reported in the current literature. 1 , 2 , 5 , 6 In their series, Bedi et al.…”

“…While there are multiple reports of the incidence of HO with and without NSAID prophylaxis after hip arthroscopy, 6 , 9 it is still unknown whether these concurrent procedures increase the rate of clinically relevant HO after hip arthroscopy. 12 , 13 , 14 Two patients in our series developed grade I HO after PAO and AIIS decompression, but both did not require additional treatment. There was also a sizable difference in the number of patients who received AIIS decompression or an open osteotomy procedure versus arthroscopic procedures alone, but the rate of HO observed in patients who underwent an osteotomy was not increased in comparison hip arthroscopy alone.…”

Is a periacetabular osteotomy as efficacious in retroversion as it is in dysplasia?

“…The role of hip arthroscopy in the context of PAO surgery for both dysplasia and retroversion remains controversial and is the subject of ongoing studies. 27 - 29 We did not have sufficient data from this study to be able to determine what proportion of patients who underwent hip arthroscopy with retroversion features did not then subsequently require a PAO.…”

Single Table Concomitant Post-Less Hip Arthroscopy Combined with Periacetabular Osteotomy for Hip Dysplasia

“…Any new technique involving the combination of multiple complex, difficult procedures and new equipment can carry potential disadvantages and risks (Table 2). When performed by an experienced surgeon, however, the addition of arthroscopy before PAO can be done safely and does not increase the complication rate 12 Table 2Technical Pitfalls, Disadvantages, and RisksPitfallsDisadvantagesRisksPatient’s perineum must be placed near the distal portion of the pad, approximately 4 to 6 cm from the hole for the post; too distal and they may tilt toward the contralateral side; too proximal and the spars will obstruct the fluoroscopy view during the PAOHip arthroscopy and PAO are very different skill sets with steep learning curvesUse of a pad could potentially result in the epidural backing out and care must be taken during gross traction and large patient shifts; anesthesia should also be aware and safely secure the epiduralAlcohol will degrade the pad and therefore care must be taken during skin prep to not get alcohol on the padWould often require 2 surgeons unless a single surgeon is skilled in both arthroscopy and PAOPatient falling or severely tilting on narrow bedBoots must be secured within the holder on the spar or the patient is at risk for having their extremity fall out of the holderLeg can be “floppy” or unstable without the use of the perineal post and require someone to hold the knee to keep the hip from over-externally rotating during the peripheral compartment arthroscopy and PAOLack of experience with new technique, table or equipment can lead to potential incorrect use by operative staffBoots must be “unclicked” or gently loosened once central compartment work is complete or patient could suffer undue prolonged compression of the foot soft-tissue structuresIt remains to be seen what the impact of additional arthroscopic treatment is of central and peripheral compartment hip disease on mid- and long-term outcomes of PAOUnknown potential complications of new techniquePAO, periacetabular osteotomy.…”