One-stage Combined Hip Arthroscopy and Periacetabular Osteotomy

Abstract

Intra-articular hip pathology is common in young patients with hip dysplasia. One-stage combined hip arthroscopy and periacetabular osteotomy (PAO) allows for thorough treatment of both intra-articular pathology (labral tear and cartilage defects) and a dysplastic acetabulum in a single surgical setting. We describe our method for efficiently and effectively accomplishing both procedures in pediatric and adolescent patients, with emphasis on a streamlined set-up and transition.

Key concepts: (1)One-stage combined hip arthroscopy and periacetabular osteotomy (PAO) addresses all relevant hip pathologies in a single, same-day surgery and facilitates patient recovery through one postoperative rehabilitation program.(2)A specialized surgical table attachment system and a dedicated, experienced surgical team optimize efficiency during the transition between the two procedures and minimize the need to move the patient to a second operating room (OR) table.(3)Hip arthroscopy may be performed using limited arthrotomy, and the capsule may not need to be closed. To enhance efficiency, hip joint capsule management can be deferred to the PAO portion, either for plication of the capsule or, in rare cases, for additional work on femoroplasty after correcting acetabular coverage.(4)Before concluding the PAO procedure, it can be helpful to use a "checklist" to confirm that the acetabulum has been appropriately corrected.

Keywords: Hip arthroscopy; Hip dysplasia; Hip impingement; Labral tear; Periacetabular osteotomy; Sports medicine.

Figure 1

Lumbar plexus catheter placement and padding. (A) The catheter is secured with a Tegaderm dressing and reinforced with 1-inch tape around the edges. (B) The catheter tubing is placed on foam tape to protect the skin and (C) is secured in place with an overlying 1-inch tape; (D) pieces of foam are positioned over the catheter before the patient is flipped supine, and a sacral Mepilex® dressing is applied caudally to prevent pressure sores. (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD).

Figure 2

Room setup for one-stage hip arthroscopy followed by PAO: (A) The Stryker Pivot Guardian® distraction system is attached to the bed before opening the sterile instruments and rolling the patient back. (B) There are two monitors near the head of the bed to allow for simultaneous visualization of both fluoroscopic and arthroscopic images. (C) All instrument trays for both the arthroscopy and PAO are opened and covered with sterile drapes; the C-arm is positioned from the nonoperative side and tilted to match the Trendelenburg angle of the bed such that the trajectory of the X-ray beam is perpendicular to the coronal plane of the patient's body. (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD). PAO, periacetabular osteotomy.

Figure 3

Stryker Pivot Guardian Hip Distraction System® and patient positioning: #1 = greater trochanter (blue skin mark); #2 = high-friction foam pad; #3 = Trendelenburg angle guide (red circle); #4 = system for controlling leg position and traction. The greater trochanter (#1) should be positioned distally to the angle guide (#3) to facilitate intraoperative fluoroscopy. Crank handles: the handle at the top of the picture marked by a white arrow near the yellow circles controls fine traction, while the lower handle (lower white arrow) manages gross traction. Yellow circles indicate the traction force gauge. (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD).

Figure 4

Interportal capsulotomy: (A) The cutting knife is introduced through the MAP and (B) cuts toward the viewing anterolateral entry portal. (C) After switching the viewing portal to the MAP, the knife is now introduced and cuts from the anterolateral portal toward the MAP. (D) Following capsulotomy, the arthroscopic shaver is used to debride the soft tissue around the portals for clear visualization. (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD). MAP, mid-anterior portal.

Figure 5

Hip arthroscopy and labral repair: (A) a labral tear is identified by probing the chondrolabral junction and the surrounding erythema, compared to (B), an intact labrum; the acetabular rim is prepared using (C) the arthroscopic shaver and (D) a 50-degree radiofrequency (RF) device, until the bone bed is clearly visualized for (E and F) suture-anchor placement for labral repair. (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD).

Figure 6

Femoral osteochondroplasty: (A) Recessing the joint capsule and marking out the area to work on using the RF device, followed by (B) using an arthroscopic burr to complete the osteochondroplasty. (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD). RF, radiofrequency.

Figure 7

(A) The long peg of the Stryker radiolucent extension block is slid into place and locked onto the undersurface of the bed, as shown in (B and C). (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD).

Figure 8

(A) The radiolucent extension block is connected, and the patient's legs are placed on the block while closing the arthroscopy portals. (B) Before preparing for the PAO portion, the C-arm is used to ensure adequate visualization of the pelvis for the PAO; a sequential compression device is positioned on the nonsurgical lower extremity. (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD).

Figure 9

(A) Draping the operated hip on the same Stryker table now connected to the radiolucent extension block and (B) marking the incision while the two arthroscopic portal incisions are covered. (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD).

Figure 11

A sharp Hohman retractor is positioned into the superior pubic ramus, medial to the planned osteotomy site (A and B). The root of the superior ramus is safeguarded with retractors on both the superior and inferior aspects to minimize the risk of injury to the obturator nerve and vessels during the osteotomy (C and D). (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD).

Figure 12

The iliac and posterior column cut junction is marked with a ball spike pusher or drill bit (A and B). The iliac osteotomy starts just below the anterior superior iliac spine (ASIS) osteotomy and is directed toward the hole made with the ball spike pusher (C and D). (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD).

Figure 13

(A and B) The posterior column cut is made using the angled Ganz osteotome. The osteotome should be visible in profile on the posterior column view and must align with the posterior column, bisecting it between the femoral head and the greater sciatic notch. (C and D) illustrate the direction of the osteotome in the AP view. (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD).

Figure 10

The distal dissection beyond the capsule is facilitated by the large inferior flap and the distal extension of the Smith-Petersen interval. A pair of long scissors is used to identify the ischium and create a pathway for the osteotome (A and B). The osteotomy starts in the infracotyloid groove (C and D), with the osteotome directed toward the base of the ischial spine on the broad iliac view (E and F). In this view, the osteotomy should extend to the midpoint of the posterior column between the acetabulum and the greater sciatic notch (E). (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD).

Figure 14

Use of a Schanz pin and bone-holding clamp to mobilize the acetabular fragment and obtain correction. (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD).

Figure 15

Check for impingement after provisional fixation of the acetabular fragment with K-wires (A) and confirm under fluoroscopy on the false profile (65° oblique) view (B). (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD).

Figure 16

Transosseous sutures used for repair of the ASIS osteotomy. (Image courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD). ASIS, anterior superior iliac spine.

Figure 17

After adequate padding of the hip, an ice machine is used. Also note the scars from the scope and PAO on the opposite hip. (Image courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD). PAO, periacetabular osteotomy.

Figure 18

A figure displaying the preoperative (A) and postoperative AP (B) views of the pelvis following the correction of the right hip in the past. (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD).

Figure 19

Figures illustrating corrections on the AP (A) and false-profile views (B). The solid black arrow highlights the elevation of the teardrop and medialization of the hip. The solid white arrows demonstrate that the posterior wall is now near the center of the femoral head. The white arrows with black borders illustrate a horizontal sourcil in the AP view with a center edge (CE) angle of 30.4° and no crossover sign, while the sourcil is slightly downturned in the false-profile view (B) with a CE angle of 31.4°. (Images courtesy of Mihir M. Thacker, MD and Alvin Su, MD, PhD).