Indications:
1. Developmental dysplasia of the hip (DDH)
2. Acetabular retroversion
3. Femoroacetabular impingement (FAI) with acetabular undercoverage
4. Legg-Calvé-Perthes disease sequelae
5. Certain cases of hip instability
Preoperative Evaluation: – Comprehensive history and physical examination – Radiographic assessment:
• AP pelvis
• False profile view
Cross-table lateral view – Advanced imaging:
• MRI or MR arthrography to assess labral and cartilage status
• CT scan for detailed 3D reconstruction and surgical planning
1. Patient positioning: Supine or lateral decubitus
2. Surgical approach: Modified Smith-Petersen or ilioinguinal
3. Osteotomy steps:
• Incomplete osteotomy of the ischium
• Complete osteotomy of the pubis
• Osteotomy of the ilium
• Posterior column cut
4. Acetabular fragment mobilization
5. Reorientation of the acetabulum
6. Fixation with screws
Intraoperative Considerations:
– Fluoroscopic guidance for osteotomy cuts and fragment positioning
– Assessment of hip range of motion and impingement
– Consideration of concomitant procedures (e.g., femoral osteotomy, labral repair)
Postoperative Management:
– Limited weight-bearing for 6-8 weeks
– Progressive physical therapy focusing on:
• Gait training
• Range of motion exercises
• Hip and core strengthening
– Gradual return to activities over 4-6 months – Full recovery and return to sports: 6-12 months
1. Pain relief:
• Significant improvement in hip pain scores (VAS, WOMAC)
• Reduction in analgesic use
2. Functional improvement:
• Enhanced hip function (Harris Hip Score, HOOS)
• Improved gait mechanics and hip stability
3. Radiographic correction:
• Normalization of acetabular coverage (lateral center-edge angle, anterior center-edge angle)
• Improved femoral head containment
4. Joint preservation:
• Slowed progression of osteoarthritis
• Delayed need for total hip arthroplasty
5. Return to sports:
• High rates of return to recreational and competitive sports
• Improved performance in hip-intensive activities
Long-term studies have shown:
– 10-year survivorship (no conversion to THA): 80-90% – 20-year survivorship: 60-70%
Factors associated with better outcomes:
– Younger age at surgery (<30 years) – Minimal preoperative osteoarthritis (Tönnis grade 0-1) – Adequate correction of acetabular coverage
– Absence of femoral head deformity
Complications: While generally successful, PAO is a complex procedure with potential complications:
1. Neurovascular injury (sciatic, femoral, or obturator nerve)
2. Intra-articular penetration
3. Nonunion or malunion of osteotomy sites
4. Heterotopic ossification
5. Venous thromboembolism 6. Femoral head avascular necrosis (rare)
Reported complication rates range from 5-20%, with major complications occurring in 2-5% of cases.
Considerations for Sports Medicine Specialists:
1. Patient education:
• Importance of early intervention in symptomatic hip dysplasia
• Realistic expectations regarding return to sports
2. Preoperative optimization:
• Core and hip muscle strengthening
• Addressing any biomechanical issues (e.g., lower extremity alignment)
3. Collaboration with hip preservation surgeons:
• Timely referral of appropriate candidates
• Shared decision-making regarding surgical vs. conservative management
4. Postoperative rehabilitation:
• Tailored physical therapy protocols
• Gradual progression of activities
• Sport-specific training and return-to-play assessment
5. Long-term follow-up:
• Regular clinical and radiographic evaluation
• Monitoring for signs of osteoarthritis progression
Future Directions:
1. Improved patient selection:
• Advanced imaging techniques (e.g., dGEMRIC, T1rho mapping) to assess cartilage health
• Predictive models for outcomes based on preoperative factors
2. Surgical technique refinements:
• Minimally invasive approaches
• Computer-assisted navigation for improved accuracy
3. Biologics and joint preservation:
• Incorporation of cartilage restoration techniques
• Use of growth factors or stem cells to enhance healing
4. Long-term outcome studies: • Continued follow-up of PAO cohorts to assess durability beyond 20 years
• Comparison with alternative treatments (e.g., hip arthroscopy, THA)
