Introduction. We perform PAO via a modified Smith-Petersen approach. The purpose of this study was to investigate the result of PAO via a modified Smith-Petersen approach at a minimum 10-years' follow-up. Methods. We retrospectively reviewed 209 hips in 179 patients with acetabular dysplasia who underwent PAO with a modified Smith-Petersen approach from August 1995 to April 2010. Exclusion criteria were as follows: under 10 year follow-up, incomplete clinical or radiographic data. Harris hip score (HHS) was investigated preoperatively, at the time of most improvement and at the final follow-up for clinical evaluation. Tönnis classification was investigated preoperatively and at the final follow-up for evaluation of osteoarthritis. Center edge (CE) angle and acetabular roof obliquity (ARO) were investigated preoperatively, postoperatively and at the final-follow up for radiographic evaluation. Tönnis classification and radiographic parameters were investigated on anterior-posterior radiographs. Patients of conversion of PAO to total hip arthroplasty (THA) were investigated for preparing Kaplan Myer survival analysis. The Wilcoxon signed-rank test was used to compare changes in HHS and radiographic parameters between the preoperative and the postoperative values. Statistical significance was defined a priori as p < 0.05. Results. Eighty-seven hips in 79 patients (44.1%) were included in this study. 100 patients were excluded from this study. The average age of the patients at the time of surgery was 39 years (rang, 15 to 65 years) and the mean follow-up period was 12 years and 2 months (range, 10 years to 18 years and 3 months). The mean HHS improved from 74 points (range, 38 to 98 points) preoperatively to 95 points (range, 62 to 100 points) at the time of most improvement (p < 0.01) and decrease slightly to 89 points (range, 32 to 100 points) at final follow-up. Tönnis classification was as follows: grade 0 was 4 hips preoperatively and 2 hips at the final follow-up, grade 1 was 55 hips preoperatively and 50 hips at the final follow-up, grade 2 was 25 hips preoperatively and 24 hips at the final follow-up, grade 3 was 3 hips preoperatively and 11 hips at the final follow-up. The mean CE angle improved from 5° (range, −19 to 24°) preoperatively to 30° (range, 2 to 56°) postoperatively (p < 0.01) and increased 38° (range, 12 to 68°) at final follow-up. The mean ARO improved from 24° (range, 6° to 45°) preoperatively to 6° (range, −14° to 48°) postoperatively (p < 0.01) and increased to 12° (range, −24 to 45°) at final follow-up. THA was performed on 5 hips in 5 patients (5.7%) after PAO. The mean duration between PAO and THA was 9 years and 6 months (range, 1 year and 4 months to 15 years 4 months). Ten-year survival rate was 97 % with conversion THA as the end point. Discussion & Conclusion. Clinical data and radiographic parameter were improved in patients who underwent PAO satisfactory. PAO was instrumental as time-saving surgical treatment of symptomatic acetabular dysplasia or slightly osteoarthritis because of 97% survival rate at 10 years

Background

The increasing desire to protect the periarticular structures led the need of a Tissue Sparing Surgery. The accesses most widely used are the direct-lateral approach and the postero-lateral one, both with patient in lateral decubitus. Aim: This accesses require however an incision of tendons and muscles even in their minimally invasive technique, so we looked for an approach that would wholly protect the periarticular structures and allow us not to revise our experience in patient positioning, preparation of the operating field and surgeon's position during surgery. Our intent was to leave the acquired knowledge unchanged and to preserve unaltered the anatomical landmarks that we had previously identified and consolidated for the correct positioning of the components.

The Bernese periacetabular osteotomy (PAO) is a well-established procedure in the management of symptomatic hip dysplasia. The associated Smith-Petersen exposure offers excellent visualization of the acetabulum and control of acetabular osteotomy and mobilization. The traditional exposure of the true pelvis involves osteotomy of the iliac wing in order to mobilize the sartorial and inguinal ligament insertion. However, full osteotomy of the iliac spine may necessitate screw fixation if a relatively large segment of bone is included. A known complication with screw fixation of the iliac wing osteotomy involves failure of fixation and screw back out. Moreover, the screw may be irritative to the patient even in the setting of adequate fixation. A larger osteotomy may also injure the lateral femoral cutaneous nerve as it travels near the anterior superior spine. To minimize the risk of these potential complications, a wafer osteotomy may be used to develop a sleeve of tissue involving the sartorial insertion. Markings may be made so that the curvilinear incision is centered about the anterior-superior iliac spine (ASIS). The sartorial sleeve also mobilizes the entirety of the lateral femoral cutaneous nerve medially as it runs and branches to varying degrees in a fatty tissue layer in the tensor-sartorius interval directly beneath the subcutaneous layer, thereby affording protection throughout the procedure. When the ASIS is first osteotomized as a several millimeter-thick mobile fragment and reflected, the sartorius attachment to the mobile fragment of the wafer osteotomy may be preserved. Furthermore, the wafer osteotomy may be re-fixed to the stable pelvis during closure with simple heavy suture fixation alone, avoiding screw insertion or associated removal. Because only a wafer or bone is taken during the spine osteotomy, more bone is available at the ASIS for fixation of the mobile fragment after repositioning. In this technical note, we describe the wafer osteotomy technique in further detail. For any figures or tables, please contact authors directly

Direct anterior approach (DAA) is one of the best way to the hip joint for prevention of post-operative dislocation. We have applied this method as minimum invasive surgery (MIS) to more than two hundred developmental dysplastic hip of Japanese patients in total hip arthroplasty (THA) and there is no post-operative dislocation within three years of last observation carried forward (LOCF). The reason of this benefit is derived from the accuracy of cup positioning and keeping good muscle balance. But the learning curve is very important and some technical pitfalls are there in this approach. We have chosen thirty four patients that the duration of operating time more than one and half hours and loss of blood more than five hundred gram in hour series. The most important factors of the difficulties are the combinations of shortening of femoral neck, especially Perthes like deformity of developmental deformities of the hip joint (DDH) and widening of pelvic bone for the reason of insufficiency working spaces and the difficulties of broaching insertion (8/34). The second factor is the contracture of hip and knee joints combinations for the difficulties of lift up the proximal femur as broaching stem (3/34). The obesity, Body Mass Index (BMI) above thirty is not the reason of difficulties of women in our series. DAA can be extended to Smith-Petersen approach and very useful technique for primary THA in Japanese dysplastic hip patients

Introduction. The anterior approach to primary total hip arthroplasty is an unfamiliar approach to most surgeons that is considered to be minimally invasive based on the premise that there is less soft tissue damage and quicker post-operative recovery time. We present our experience of using the anterior approach exclusively by a single surgeon at multiple surgical centers for a period of 3.5 years. Method. 709 consecutive patients undergoing primary hip arthroplasties from 8/2007 to 12/2010 through a direct anterior approach were performed by single surgeon with extensive training in the approach. The procedure was performed with the patient supine on a fracture table (Trumph arch table extension) through an anterior approach as described by Dr. Joel Matta through a Smith-Peterson interval. Intra-operative data and complications were collected prospectively and to avoid missing any complications, electronic medical records (Alteer) were retrospectively reviewed. Results. The demographic characteristics of patients are listed in Table 1 and intra-operative data collected presented in Table 2. The overall major complication rate was 2.81% (19/709). Overall revision rate due to any cause was 1.83% (13/709). Wound related complications were 6.67% which included any type of drainage noted during post op clinic visits, wound dehiscence, stitch abscesses, or superficial infections requiring irrigation and debridement. Discussion. The anterior approach through a modified Smith-Petersen approach provides preservation of the major hip muscles to facilitate recovery. However, the lack of familiarity with the approach has prevented widespread adoption of the method. Our overall major complication rate was in the lower end of the range of published complication rates (range, 1.36%-15.79%). Although the high incidence of wound complications is of concern, it can be explained by the location of the incision being in an area where large skin folds or moist skin make healing difficult. We have since implemented a preoperative protocol to sterilize the area near the inguinal area and included silver impregnated dressing to help decrease our wound related complications