Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Michael B. Millis, MD*,
Children's Hospital, Boston, Massachusetts
The adult patient with dysplasia often presents with
symptoms long before joint replacement can be considered as a lifetime solution1,2. Fortunately, surgical realignment of the congruous
dysplastic acetabulum can improve symptoms for years in a majority of
appropriately selected patients, even in those with some degree of preoperative
arthrosis3-5. Pelvic reorientation osteotomy was first devised by
Salter6,7 in the 1950s, before the advent
of total hip replacement. Salter's innominate osteotomy was novel in concept
but limited in both amount and direction of correction. The subsequent five
decades have seen major advances in the surgical techniques of acetabular
realignment, beginning in the 1960s with the independent innovation of
rotational acetabular osteotomy by Ninomiya and Tagawa in Japan8 and
Wagner9,10 in Germany. In 1988, Ganz et al.11 described a new periacetabular osteotomy
that offered improved fixation, easier medialization of the acetabular
fragment, and the possibility of abductor-sparing surgical approaches. Salter et al.3 and subsequent authors12-14 observed
that achievement and/or maintenance of femoroacetabular congruity is essential
to good long-term outcome following acetabular realignment.
The real and perceived technical challenges represented by
acetabular realignment osteotomies may be a factor that limits their
application. Therefore, reports of the learning curve associated with
periacetabular osteotomy are pertinent15,16.
Peters et al. offer an honest report of their first eighty-three periacetabular
osteotomies, which were performed between 1997 and 2003. They have carefully
documented the education and the preparation undertaken by the senior surgeon
before he began performing the procedure.
Eleven of the twelve reported complications occurred within
the time span of the first thirty procedures. Only one complication, a transient femoral nerve palsy, occurred within the time
span of the last fifty-three operations. A high proportion of the patients achieved
greatly improved function at the time of follow-up, as reflected by improvement
in the mean Harris Hip Score from 54 preoperatively to 87 at the time of
follow-up. Failure occurred in four hips, three of which were converted to a
total hip replacement because of progressive arthrosis and one of which
underwent revision periacetabular osteotomy as treatment for femoroacetabular
incongruity. All four of these failed hips were in the first group of thirty
hips that underwent the procedure, perhaps again reflecting a learning curve in
terms of both operative technique and/or patient selection.
Peters et al. clearly and frankly describe the evolution of
their surgical treatment program for the skeletally mature patient with symptomatic
acetabular dysplasia. They describe their current techniques of preoperative
evaluation (including complex imaging) and intraoperative techniques (including
attention to intraarticular pathology, assessment of acetabular version, and
potential femoroacetabular impingement), which represent the state of the art
in this field as it is practiced in North America in 2006. Though Dr. Peters
did not, as he frankly admits, train directly in Berne, he is clearly a worthy
disciple of the Bernese principles of joint preservation procedures in treating
acetabular dysplasia. His paper offers a useful roadmap for the surgeon wishing
to undertake the practice of joint-preserving surgery for hip dysplasia, and it
may serve to diminish the learning curve for future surgeons.
In a most interesting article, Yasunaga et al. report their
extremely positive experience in the use of rotational acetabular osteotomy in forty-three
hips at an advanced stage of osteoarthritis, analogous to Tönnis grade II17.
The mean age of the patients at the time of surgery was 43.8 years, and the
mean duration of follow-up for these forty-three hips was 8.5 years.
Clinical results as assessed with use of the Merle d'Aubigné
score improved from a mean of 13.3 preoperatively to 15.4 points at the time of
follow-up, with a mean improvement of 2.4 points in the pain score, a slight
decrease in mean mobility of 0.1 point, and no change in the score for walking
ability. Postoperatively, the clinical score was <14 points in nine hips,
with five of these hips having end-stage arthritis radiographically and two of
them having been converted to total hip arthroplasty.
Radiographic results showed disappearance of preexisting
cysts in six hips, appearance of new cysts in four previously noncystic hips at
follow-up, and no change in the cystic appearance in the rest of the
twenty-three cystic hips.
Radiographic factors associated with radiographic signs of
progression after revision acetabular osteotomy included fair rather than good
preoperative congruence, preoperative joint space of <2.2 mm, and
postoperative joint space of <2.5 mm.
The Kaplan-Meier survivorship analysis predicted a ten-year
survival rate of 72.2%.
This report by Yasunaga et al. is remarkable and important
for several reasons. First, in many parts of the world, patients with this
degree of arthrosis, even with demonstrated congruity in abduction, have only
infrequently been considered as candidates for joint-preserving acetabular
redirection osteotomy. Second, this is a report of a reasonably large number of
patients, followed for a reasonably long period of time. The results are quite
good at three and ten years following revision acetabular osteotomy, with only
two hips having been converted to arthroplasty.
Should surgeons in other parts of the world attempt to apply
this positive experience of Yasunaga et al. to their own practices, they should
be aware that differences in patient population, surgical technique, and
postoperative treatment may lead to dramatically different results. For
example, it may be more important to correct intraarticular pathology in the
non-Japanese dysplastic hip. The relatively prolonged and
gradual resumption of weight-bearing, which is not usually practiced in North
American and European centers, may or may not be critically important in this
particular patient group with established arthrosis.
In summary, Yasunaga et al. have set a high standard for
joint-preserving surgery in this group of patients with dysplasia and congruous
moderate arthrosis. While many surgeons may prefer to manage these patients with
total hip arthroplasty, joint replacement clearly should not be the only
surgical option considered.
*The author did not receive grants or outside funding in
support of his research for or preparation of this manuscript. He did not
receive payments or other benefits or a commitment or agreement to provide such
benefits from a commercial entity. No commercial entity paid or directed, or
agreed to pay or direct, any benefits to any research fund, foundation,
educational institution, or other charitable or nonprofit organization with
which the author is affiliated or associated.
References
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3. Salter RB, Hansson G, Thompson GH. Innominate osteotomy in the management of residual congenital subluxation of the hip in young adults. Clin Orthop Relat Res. 1984;182:53-68.
4. Trousdale RT, Ekkernkamp A, Ganz R, Wallrichs SL. Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips. J Bone Joint Surg Am. 1995;77:73-85.
5. Siebenrock KA, Leunig M, Ganz R. Periacetabular osteotomy: the Bernese experience. Instr Course Lect. 2001;50:239-45.
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