Arthroscopy and arthrotomy to address intra-articular pathology during PAO for hip dysplasia demonstrates similar short-term outcomes

Abstract

Periacetabular osteotomy (PAO) remains the gold standard procedure for joint preservation in symptomatic developmental dysplasia of the hip (DDH). Hip arthroscopy (HA) and open arthrotomy have been used to correct intra-articular pathology at the time of PAO, but there is limited data regarding differences in outcomes between these techniques when performed at the time of PAO. The aim of this study was to determine if short-term clinical outcomes differed between patients managed with HA versus arthrotomy to evaluate and treat intra-articular pathology at the time of PAO to discern if one technique is associated with better pain and functional results. Data were retrospectively reviewed from two surgeons at one institution managing DDH patients from September 2013 to December 2015. One surgeon treated patients with PAO and arthrotomy (N = 32), while the other performed PAO and HA (N = 39). There were 87% women, median age was 28 years and mean BMI was 25. Seventy-five percent of all patients received an intra-articular intervention. Patients completed 13 PROs at the pre-operative and 1-year post-operative clinical visits. Pre-operatively, there were no differences in any of the 13 PROs between patients treated with HA versus arthrotomy (P ≥ 0.076). Patients treated with PAO and arthrotomy experienced greater mean improvement in two out of the 13 PROs; the other 11 showed no differences. No treatment effect was observed for any of the 13 PROs using multivariable modelling that accounted for severity of dysplasia and degree of arthritis. Few differences were shown in short-term clinical outcomes between HA and arthrotomy at the time of PAO. This work highlights the need for a high quality randomized clinical trial to provide definitive guidance on whether hip preservation surgeons should address intra-articular pathology at the time of PAO for DDH and which technique best serves this purpose.

Is the Femoral-Epiphyseal Acetabular Roof (FEAR) index associated with hip pain in patients with hip dysplasia?

“…In addition, the HOOS has been found to be the most appropriate patient-reported outcome measure in patients undergoing PAO compared to the Western Ontario and Osteoarthritis Outcome Score (WOMAC) and the modified Harris Hip Score (25). The improvements found in all five subscales of HOOS in our study are similar to previously reported data on patients with hip dysplasia in other databases with prospective data collection (25,32,33), although previous studies compared patient-reported outcomes preoperatively to 12 months postoperatively. Another strength is the use of the same two blinded raters performing all radiographic measurements and investigating their inter-rater reliability.…”

Addressing intraarticular pathology at the time of anteverting periacetabular osteotomy for acetabular retroversion is associated with better short-term patient-reported outcomes

“…With regard to the technique used to visualize the joint, the findings of the present cohort demonstrate parity between arthrotomy and arthroscopic techniques in joint examination. This has previously been reported for patients undergoing PAO for classic hip dysplasia [ 28 ]. Arthroscopy is increasingly done today at the time of PAO to examine and treat the labrum and to perform a femoral head–neck junction osteochondroplasty, although some surgeons still perform an arthrotomy after acetabular correction to assess impingement and perform the osteochondroplasty.…”

“…Supporting the treatment of labral pathology at the time of surgery, the presence of labral lesions [ 29 ] or a detached labrum [ 30 ] has been associated with inferior outcomes or a risk of repeat hip arthroscopy, respectively, after PAO, suggesting that intraarticular procedures may positively influence labral health in excess of the mechanical offloading achieved through PAO alone. However, previous reports of 1 year PROM in patients receiving PAO with intraarticular procedures did not detect a differential effect of major versus minor interventions [ 28 ]. Longer follow-ups of 4.5 years in patients receiving PAO report that postoperative pain is not influenced by labral repair, excision or no treatment [ 8 ].…”

Tönnis Grade 1 dysplastic hips have improved patient-reported outcome scores when intraarticular pathology is treated during periacetabular osteotomy

“…Third, this study did not account for other factors that may influence PROM or natural history following PAO, namely the accuracy and degree of acetabular correction. Recent data have shown that patients with more severe baseline DDH experience greater improvements in PROM [ 25 ], and the natural history of the native hip is improved with the restoration of ‘normal’ radiographic parameters of the acetabular fragment [ 26 ].…”