1/15/ year old male. Hip Preservation Surgery for Acetabular Dysplasia in Adolescents and Young Adults PATHOMECHANICS OF ACETABULAR DYSPLASIA

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1 29 year old male Hip Preservation Surgery for Acetabular Dysplasia in Adolescents and Young Adults Eduardo Novais, MD Assistant Professor of Orthopedic Surgery PATHOMECHANICS OF ACETABULAR DYSPLASIA Static overload Dynamic instability Stress concentration Shear forces Klaue et al. JBJS B 1991 ACETABULAR DYSPLASIA AND OSTEOARTHRITIS CLINICAL PRESENTATION Major cause of hip osteoarthritis in <40 yo Aronson 1986 Increased risk of OA (OR 3.3) in females with LCEA <30 o Nancy Arthritis Rheum 2000 Increased risk of OA (OR 5.40) for LCEA and ACEA <25 o Agricola Osteoarthritis Cartilage2013 No hips with LCEA <16 o survives past age 65 years Groin pain Abductor fatigue Activity related Murphy JBJS

2 PHYSICAL EXAMINATION RADIOGRAPHIC EVALUATION FADIR Apprehension Bicycle test LATERAL CENTER EDGE ANGLE (WIBERG) LATERAL CENTER EDGE ANGLE (WIBERG) Acetabular dysplasia < 20 o Normal > 25 o Wiberg, G. Acta Chirurgica Scandinavica 58S:5-135, Wiberg, G. Acta Chirurgica Scandinavica 58S:5-135, ACETABULAR ROOF INCLINATION ANGLE (TONNIS) Break in Shenton s line (>5 mm) Acetabular dysplasia > 10 o Normal 0-10 o Tönnis, D. Congenital Dysplasia and Dislocation of the Hip in Children and Adults. Springer, NY

3 FALSE PROFILE VIEW LEQUESNE LATERAL CENTER EDGE ANGLE (LEQUESNE) Most sensitive to detect hip dysplasia Jessel JBJS 2009 Acetabular dysplasia < 20 o Normal 25 o - 40 o ABDUCTION INTERNAL ROTATION (VON ROSEN) ALPHA ANGLE Dunn 45 o Cross table Meyer, et al. CORR 2006 Domayer, et al. E Radiology D Computed Tomography MRI 3

4 Byrd Arthroscopy 2009 Fukui Arthroscopy 2015 Fukui Bone Joint J 2015 Domb Am J Sports Med 2013 Parvizi J Arthoplasty /15/2016 DGEMRIC INDEX TREATMENT GOALS Stability Congruency Impingement Cunninghan et al, JBJS AM vol. 88-A, 2006 Dynamic instability Shear forces ARTHROSCOPY TREATMENT IN HYP DYSPLASIA? 48 patients 80% patients improved more than 10 mhhs points 100 hips (35 ys) LCEA deg. 5% conversion to THA 7% revision arthroscopy 28 hips (34 ys) LCEA deg. 32% revision surgeries 5 THA (18%) 2 PAO (7%) 2 revision scope (7%) 22 hips (20 ys) LCEA deg. 9% (2/22) revision scope 34 hips 70% failure (24/34) 58% acelerated arthritic changes (14/34) Condral and labral damage are common during PAO Redmond Arthroscopy 2014 Domb CORR 2014 Peters CORR 2012 No long term follow-up studies High revision rate ARTHROSCOPY TREATMENT IN HYP DYSPLASIA? Bernese (Ganz) Periacetabular Osteotomy Supine Standing Post PAO Ganz et al CORR 1988 Stepacher CORR

5 # 1 Incomplete Ischial cut #2 Superior pubic ramus # 3 Supra acetabular # 4 Posterior Column Ganz et al CORR 1988 Stepacher CORR 2008 How to deal with the Rectus Femoris? How to deal with the Rectus Femoris? Release Preserve Release Preserve Preserving the rectus if no intra-articular pathology and >20 of internal rotation allows for similar radiographic and functional improvement Novais CORR 2015 Improvement in hospital rehabilitation with similar radiographic reorientation Peters CORR 2015 Fragment provisional fixation true AP pelvis Fragment provisional fixation Horizontal Sourcil LCEA >25 Neutral version Medialization 5

6 Range of motion: > 90 o flexion > 20 o IR Trim AIIS + Osteochondroplasty Impingement AIIS Femoral Head-Neck offset PAO IS A BIOMECHANICAL SURGERY 37 PAO 26 years mean age No arthritis DGEMRIC Preoperative 1, 2 years Bernese (Ganz) Periacetabular Osteotomy Outcomes Cartilage responds to normalized mechanical load after PAO PAO AND PHYSICAL ACTIVITY Novais CORR YEAR FOLLOWUP Matheney JBJS % at 5 years 84% at 10 years 135 PAO 27 years mean age Physical activity level improves after PAO at 1 and 2 years Predictors of failure Poor / Fair joint congruency Age >35 years 6

7 INTRA-ARTICULAR SURGERY AT TIME OF PAO 20 YEAR FOLLOWUP Steppacher CORR 2008 Correct head asphericity Neutral acetabular version 20 ys Mean follow-up 75 PAO 29 ys Mean age Preoperative osteoarthritis predicts failure Grade 2-3 = 13% Avoid impingement Impingement adversely affect 10-year PAO survivorship Albers CORR 2013 Grade 0-1 = 75% >30 years Low MD scores Impingement test Limp Extrusion index >20 o HOW DOES PAO COMPARE TO THA? DOES PAO COMPROMISE THA? PAO N= 100 THA N = 55 PAO N= 100 THA N = 55 Patients between yo Mean follow-up of 6 years (2-13) Similar outcomes improvement (mhhs) Low complication rate Similar outcomes for THA with and without prior PAO Amanatullah CORR 2015 Similar clinical results and survivorship Increased operative time and blood loss Duncan J Arthroplasty 2015 Gray Bone B Joint J yo female bilateral hip pain (gymnast) 1 year after bilateral PAO 7

8 13 yo female (arthrogryposis ) 13 yo female right hip pain (arthrogryposis ) Missing ilium 14 yo male Osteonecrosis deformity 14 yo male Osteonecrosis deformity Adduction Abduction SHD: Relative neck lengthening + osteoplasty Valgus/derotatinal ITO 2 years after surgery: pain free, residual limp Abduction 8

9 THANK YOU Eduardo Novais, MD Assistant Professor of Orthopedic Surgery 9