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Periacetabular Osteotomy : Intra-articular Work Department of Orthopaedic surgery, University of Toronto, Toronto, Ontario, Canada, . Hip and Pelvis Clinic , C honbuk University Hospital , Jeonju, Korea . E-mail : hugo999@naver.com. Background. Periacetabular Osteotomy

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Periacetabular Osteotomy: Intra-articular WorkDepartment of Orthopaedic surgery, University of Toronto, Toronto, Ontario, Canada,

Hip and Pelvis Clinic , Chonbuk University Hospital , Jeonju, Korea .

E-mail: hugo999@naver.com

background
Background
  • Periacetabular Osteotomy

- Goal : Improvement of hip biomechanics by reorienting the acetabulum

→ postpone degenerative progression

Desire of improvement

Potential for overcorrection

background1
Background

Overlooked intra-articular hip inspection

(early experience)

Overcoverage of femoral head

→ iatrogenic FAI

Overlooked chondrolabral injury

(dysplasia, FAI)

intra articular work labral pathology
Intra-articular WorkLabral pathology

The acetabular labrum

- a triangular structure with a basilar attachment to the osseous

acetabular rim

- a capsular insertion along the external surface

- a free intra articular apical margin

  • Labral injury alone could generate sufficient pain to require intervention
  • The positive outcome- pain relief after debridement and/or fixation of labral tears,
intra articular work labral pathology1
Intra-articular WorkLabral pathology

Labral repair with suture anchor

: TOC for unstable hypertrophied labrum

Anterior hip arthrotomy

Modified Smith-Petersen approach used for Bernese PAO

Indirect head of rectus femoris is tagged and mobilized for improved view

Capsular incision along the long axis of the femoral neck → AP direction at the level of acetabular rim

Simple debridement

Labral repair using suture anchor technique is used for labral detachment at the extra-articular osseous insertion

Labral detachment → Preservation of the blood supply

intra articular work labral pathology3
Intra-articular WorkLabral pathology

Labral takedown and Rim resection

Labral refixation with suture anchors fixed to new acetabular rim

Correction achieved

intra articular work chondral pathology
Intra-articular WorkChondral pathology
  • Chondral lesion

- Location : anterior and superolateral aspect of acetabulum

- Size : 171.7 mm2

  • Chondral lesion
    • Chondromalacic, cleavage, or debonding injury
intra articular work chondral pathology1
Intra-articular WorkChondral pathology
  • The natural history of these lesion and whether chondral lesions are independent source of pain have not been determined.
  • Nascent chondral lesions identified at the time of PAO represent an opportunity to alter the degenerative cascade.
intra articular work chondral pathology2
Intra-articular WorkChondral pathology
  • In contrast with labral pathology, preOP diagnosis of chondral injury has implications for preOP planning

- Hip MR Arthrography : mainstay of soft-tissue hip diagnostic imaging

(Specificity ↑, Sensitivity ↓)

intra articular work chondral pathology3
Intra-articular WorkChondral pathology

Inspection

: Patient’s specific hip pathophysiology

Diagnostic imaging

2. Rim resection

Amount of rim resection to properly address the chondral lesion

Staged surgical dislocation → PAO

Obtain consent for a possible simultaneous PAO

femoral head neck offset
Femoral head-neck offset
  • More than 90% of patients treated with PAO require some degree of femoral head-neck offset correction

→ Intraoperative C-arm fluoroscopy

(False profile view, Dynamic impingement view)

Assess

Intended acetabular correction

Femoral head-neck offset

Potential exacerbation of FAI

femoral head neck offset1
Femoral head-neck offset

Cam lesion on femoral head-neck junction

burr allows adequate restoration of the femoral head-neck offset

Adequate offset achieved