Osteoarthrosis of the hip is frequently caused by mechanical abnormalities — for
example, residual deformity from developmental hip disease such
as acetabular dysplasia1. Untreated
acetabular dysplasia is the most common cause of secondary osteoarthrosis2,3 arising from pathological joint-loading
forces4. It has been reported
to cause secondary osteoarthrosis by the age of fifty years in 25
to 50 percent of patients5,6.
In order to improve the prognosis for the hip in this relatively young
cohort of patients, pelvic osteotomies have recently been introduced
to improve the abnormal anatomical conditions and reduce the load
across the hip joint7.
In acetabular dysplasia, intrinsically normal intra-articular
soft-tissue structures are exposed to loading forces that physically exceed
their tolerance level, resulting in anatomical deformities and damage
to the hip joint. For example, deficient acetabular coverage of
the femoral head has been related to osteoarthrosis8,9, whereas the orientation of the femoral
head plays a less important role10.
The resulting instability and anterolateral migration of the femoral
head leads to chronic shear stresses at the acetabular margin. The
acetabular labrum initially hypertrophies in order to maintain the
femoral head within the joint. If the chronic shear stresses persist,
the labral "soft-tissue compensation" fails, and
the labrum is torn off the acetabular rim, sometimes with an osseous
fragment11. Histomorphologically,
the labrum shows myxoid degeneration of its fibrocartilage structure and
adjacent ganglion formation within the bone or soft tissues11. In addition to increased femoral head
instability resulting from secondary labral lesions, the joint-sealing
function, which is required for sufficient cartilage lubrication
and distribution of joint pressures12,13,
is lost14. Labral alterations
are known to represent an early precursor of osteoarthrosis of the
hip8,11,15. In this mechanically
compromised situation, elevation of joint contact pressures at the
acetabular rim is directly related to the onset of cartilage degeneration4. As a consequence, an adaptive increase
in the anterolateral subchondral bone density occurs in these insufficiently
contained hips9.
Although prosthetic replacement of the hip has a predictably good
functional outcome in the elderly, the longevity of prosthetic replacement
in young patients has been notably inconsistent16,17.
Artificial prosthetic surfaces with the mechanical properties and
durability of articular cartilage have yet to be found7. Prosthetic replacement therefore
remains the treatment of choice for most patients with inflammatory
disease and for patients who are not expected to outlive their implant.
However, its use in the younger, more physically active patient
remains controversial, especially if the cause of the osteoarthrosis
is mechanically correctable18,19.
Since arthrodesis is not indicated for bilateral hip disease and
this procedure is frequently unacceptable to the patient, alternative
methods with which to prevent the hip from failing have been pursued20. There is an increasing body of evidence
that the prognosis for the hip can be substantially improved by
joint-preserving osteotomiesin
which the emphasis has shifted from the proximal part of the femur
to the pelvis21-23.
The goal of pelvic osteotomy is to change the pathological mechanical
environment that leads to secondary osteoarthrosis. In patients
with acetabular dysplasia, this might be achieved by improving
coverage or congruity, or both, through either of two basic mechanisms.
Either the pelvic osteotomy increases femoral head coverage
by augmentation of the acetabular roof or it changes the spatial
orientation of the acetabulum (Table I).
Augmentation Procedures
Procedures such as the Chiari osteotomy24 and the shelf procedure25,26 reduce joint-loading forces by augmenting
the main weight-bearing area of the joint. With both methods, osseous
coverage can be reproducibly improved, and the superior aspect of
the capsule undergoes metaplastic transformation to fibrocartilage. However,
the labrum remains within the main weight-bearing area and is subjected
to chronic shear stresses. Nishina et al.27 reported
a 50 percent rate of failure of the Chiari osteotomy in patients
with acetabular dysplasia when the preoperative arthrogram showed
evidence of a labral lesion. Moreover, compared with hyaline cartilage, fibrocartilage
has inferior mechanical characteristics for withstanding
axial loading. Also, optimal coverage, particularly in the posterolateral
quadrant of the acetabulum, is not achieved28.
While augmentation procedures can provide reliable pain relief for
some years, they should be regarded as salvage procedures29.
Reorientation Procedures
These procedures change the orientation of the acetabular articular
surface, thereby correcting the anterolateral deficiency. In the
vast majority of hips with acetabular dysplasia, there is sufficient
articular surface in the posteroinferior quadrant to allow reorientation
procedures. These provide greater surface area for load-bearing
while maintaining stability of the joint. In reorientation
procedures, coverage is achieved with hyaline cartilage supported
by subchondral bone, which has optimal mechanical qualities
for weight-bearing. Reorientation procedures include single, double,
and triple osteotomies as well as spherical and periacetabular osteotomies.
The Bernese periacetabular osteotomy redirects the acetabulum into
a mechanically more appropriate position, thereby decreasing shear
forces and load at the acetabular rim. This paper focuses on the
Bernese periacetabular osteotomy for reorientation of the acetabulum
with an emphasis on the rationale for its development.
Mechanics
The dysplastic acetabulum can be reoriented by a single innominate
osteotomy such as that described by Salter30.
While this may be beneficial in children, the degree of correction that
is possible in adolescents and adults is limited by the age-related
increase in the stiffness of the symphysis pubis. Moreover, this
osteotomy retroverts and lateralizes the joint because of a hinged
angulation of the acetabulum around a fixed axis. The dysplastic
hip joint is usually relatively lateralized. Additional lateralization
and distalization is undesirable, as it further increases adverse
joint reactive forces. As a result, a variety of double and triple osteotomies
and periacetabular osteotomies have been developed in an attempt
to improve the degree and accuracy of correction.
LeCoeur31 was the first to
perform a technique for triple osteotomy of the pelvis. His method,
and the one described later by Steel32,
divides the ilium, pubis, and ischium distant to the joint. Improvements
in coverage with this osteotomy are limited by the size of the fragment
and by the muscular and ligamentous attachments, especially the strong
sacropelvic ligaments. The double osteotomy technique of Sutherland
and Greenfield33 consists of an
anterior pelvic osteotomy in addition to an innominate osteotomy
close to the symphysis pubis. Hopf34 recommended
a double osteotomy variant through the floor of the true acetabulum
in hips with higher subluxation.
Acetabular reorientation has been substantially increased by the
juxta-articular triple osteotomy of Tönnis et
al.35,36. This technique avoids
the sacropelvic ligaments, which usually limit the mobility of the osteotomized fragment.
A similar technique was proposed by Carlioz et al.37. These osteotomies may result in
a defect between the osteotomized fragment and the ischium if major
corrections are performed. They may often require special efforts
for stabilization, such as use of a spica cast. Nishio38, Eppright39,
Wagner40, and Ninomiya and Tagawa41 described the so-called
dial, or spherical, osteotomy in the periacetabular region. The
osteotomy described by Eppright is barrel-shaped along the anterior-posterior
axis, allowing for excellent lateral coverage but only a limited
amount of anterior coverage. Kuznenko and Adiev42 described
a translocation osteotomy in which the acetabulum is cut into the
shape of a funnel, with the apex situated inside the pelvis. The
more spherical osteotomies provide good lateral and anterior coverage
but are limited with regard to the correction of version and mediolateral displacement.
On the basis of mechanical as well as biological considerations, and
in light of the limitations of previous techniques, a new pelvic
osteotomy, the Bernese periacetabular osteotomy43,
was developed in 1983. The polygonally shaped juxta-articular osteotomy
respects the vascular blood supply to the acetabular fragment. It
facilitates extensive acetabular reorientation, including correction
of version and mediolateral displacement, and it can be combined
with a femoral osteotomy. The posterior column remains mechanically
intact, which protects the sciatic nerve and enables minimal internal
fixation as well as early mobilization. The dimensions of the true pelvis
remain unchanged, permitting unimpaired vaginal delivery44, an important aspect that is less favorable
with all other nonspherical osteotomies. All steps of the acetabular
osteotomy are performed with use of the modified Smith-Petersen
approach45. An anterior joint
capsulotomy provides information about and treatment options for
lesions of the acetabular rim and, more importantly, allows control
of an impingement-free range of motion.
In contrast to distant pelvic osteotomies, the Bernese periacetabular
osteotomy and the spherical osteotomies cross the posterior line
of the triradiate cartilage. Therefore, these osteotomies
are not indicated if growth potential remains within this physis,
since growth abnormalities could result from its premature closure46.
Biological Characteristics
There are some concerns regarding the vascularity of the acetabular
fragment with juxta-articular (spherical) osteotomies. Although
vascular compromise has not been described, as it was after Hopf’s
double osteotomy34, there is the
potential of separating the acetabular fragment from the acetabular
artery. Since, after spherical osteotomies, the acetabular fragment
relies on the blood supply provided through the acetabular artery
and the capsule, a simultaneous capsulotomy should not be performed. The
conception of the Bernese periacetabular osteotomy ensured
the preservation of the blood supply to the acetabular fragment46,47.
Establishing the diagnosis is straightforward in cases of clinical
and radiographic end-stage disease, whereas it is much
more difficult to assess incipient disease. However, patients with incipient
disease are the ones who benefit the most from a joint-preserving
procedure, especially when there are no radiographic signs of secondary osteoarthrosis.
History
The majority of patients presenting with symptoms related to
an underlying lesion of the acetabular rim11 are
young adults in their second, third, or fourth decade of life. The
primary symptom is a sharp, knife-like pain in the groin
that subsides as acutely as it presents. Prolonged sitting or walking
can exacerbate the pain. Symptoms of acetabular dysplasia range from
early fatigue to clear weakness of the abductors, with irritation
over the greater trochanter. The pain can be reproduced by activities
that involve forced hip flexion, adduction, and internal rotation,
including rapid descent of stairs (particularly on a circular staircase),
breaststroke swimming, entering or exiting a motor vehicle, tennis,
and soccer. The catching phenomenon appears to be similar to that
caused by meniscal disease of the knee and occasionally requires
manipulation of the lower limb, usually in the form of a "shaking-free" movement.
As the symptoms increase in frequency, residual pain may result
in a slight limp.
Physical Examination
A complete physical examination includes assessment of gait, limb
length, muscle power, and range of motion as well as special tests.
An antalgic gait will be evident immediately after an acute episode
of locking. A positive Trendelenburg gait and sign indicate
underlying abductor weakness. A full (or even increased) range of
motion is normal in early hip dysplasia and will begin to decrease
with the onset of secondary osteoarthrosis. There is a clunk in
some dysplastic hips with deficient anterior coverage. As the extremity
is externally rotated, the active iliopsoas tendon snaps over the
prominent femoral head, producing a normally pain-free snapping
or clunking sensation. This is eliminated by placing the limb in
neutral or internal rotation.
There are specific clinical tests that are used to examine underlying
hip disease and abnormalities of the surrounding osseous and soft-tissue
structures. A suspicion of a lesion of the acetabular rim11,48 is best confirmed by the impingement
test (Fig. 1-A).
With the patient supine, the hip is internally rotated as it is
passively flexed to about 90 degrees and adducted. Flexion and adduction
leads to the approximation of the femoral neck and the acetabular
rim. Additional internal rotation induces shearing forces at the
labrum, which is similar to the knee meniscus, causing stimulation
of the nerve-endings. This will elicit sharp groin pain
if the labrum is torn or degenerated. Less frequently, patients
may have a positive apprehension test for symptomatic anterior instability
(Fig. 1-B).
With this test, the patient lies supine and the hip is extended, abducted,
and externally rotated. Discomfort and a sense of instability are
produced secondary to deficient anterior acetabular coverage of
the femoral head. In a very thin patient, this external rotation
in extension can produce a mass in the inguinal region, referred
to as the lump sign15, which represents
the femoral head pushing against the anterior aspect of the hip
capsule. Patients may also reveal trochanteric irritation on the
bicycle test (in the lateral position), reflecting abductor muscle
insufficiency (Fig. 1-C). This test is performed by placing
the patient in the lateral position, with the affected hip up; a bicycle-pedaling
maneuver is then performed as the lateral and posterior margins
of the trochanter are palpated. Increasing the load on the pedaling
foot may exacerbate the pain. Tenderness is most commonly palpated along
the posterior border of the gluteus medius muscle. With direct palpation
over the trochanteric bursa, the examiner may feel crepitus,
which the patient may have previously described as a sensation of "sand in
the joint."
Conventional Radiography
An orthograde standing anteroposterior radiograph and a false-profile radiograph
of the pelvis are made for each patient, to assess hip joint biomechanics49,50 and to check for the presence
of osteoarthrosis51. The anteroposterior
radiograph allows visualization of the three innominate bones, the
caudad part of the lumbar spine, the sacrum, the coccyx, and the proximal
one-fourth of both femora (Fig. 2-A). The false-profile radiograph permits
evaluation of the anterior portion of the acetabular roof and the
amount of anterior coverage of the femoral head (Fig. 2-B). For this
projection, the patient stands with the affected hip against the
radiographic cassette and the pelvis rotated 65 degrees from the
plane of the radiographic film, maintaining the ipsilateral foot
parallel. The beam is then centered on the femoral head, perpendicular
to the cassette. Finally, anteroposterior abduction radiographs
are used to assess the joint congruency achievable with reorientation
of the acetabulum and the potential need for a concomitant femoral
intertrochanteric osteotomy (Fig. 2-C).
Magnetic Resonance Arthrography
Magnetic resonance arthrography is a widely accepted method for
imaging of the hip joint. It has a high sensitivity and specificity
for the detection of various processes such as avascular necrosis
of the femoral head, transient bone-marrow edema, occult trauma,
neoplasm, and infection. Expanding applications and the development
of new techniques have allowed improved visualization of intra-articular
and periarticular joint structures, especially the acetabular labrum
and the cartilage surface of the hip. These techniques include
high-field-strength magnetic resonance imaging and use of surface
coils. The development of new imaging protocols and the use of intra-articular
gadolinium-diethylenetriamine pentaacetic acid (DTPA) as
a contrast agent have improved intra-articular soft-tissue
contrast. In addition to standard T1 and T2-weighted sagittal
oblique and coronal oblique images, magnetic resonance arthrography
includes proton-weighted radial sequencing of the acetabulum52, which allows the imaging to be initiated
at the center of the femoral head and to continue in a plane that
proceeds radially. The acetabular and femoral articular cartilage,
as well as the labrum, are visualized orthogonal to the radius of
curvature.
With these modifications, magnetic resonance arthrography has been
shown to be extremely helpful in detecting labral lesions (Figs. 2-D and 2-E), including tears,
degenerative changes, and cyst and ganglion formation53-57, with the latter frequently predating
any degenerative changes11. Moreover,
this technique enables a better assessment of the cartilage damage,
which is always more extensive than it appears on conventional radiographs58.
The most frequent indication for the Bernese periacetabular osteotomy
is symptomatic acetabular dysplasia in an adolescent or adult. The
lower age-limit is determined by whether the patient has open triradiate cartilage
of the acetabulum. The upper age-limit is determined by the degree
of secondary osteoarthrosis and whether the morbidity, risk, and
individual prognosis associated with the procedure are worse than
those associated with a total hip arthroplasty. Contraindications
include high subluxation with the femoral head articulating with
a secondary acetabulum, complete dislocation, end-stage (grade-3)
osteoarthrosis50, and a radius
of the acetabulum that is smaller than that of the femoral head
with the possibility of worsening of the congruity after the reorientation.
The latter can be assessed on a preoperative anteroposterior abduction
radiograph. It is important also to be aware of functional incongruities such
as impingement between the femoral head-neck junction and
the acetabular rim, as is seen when the anterior head-neck
offset is insufficient. These situations might be encountered in
a Perthes-like hip with resulting secondary acetabular dysplasia. General
aspects such as the patient’s chronological and biological
age, the status of adjacent joints (the knee and spine), the body
habitus, the level of activity, and the functional goals also have
to be considered in the decision regarding the performance of an
osteotomy.
For the Bernese periacetabular osteotomy, the ilioinguinal, direct
anterior, combined anterior-posterior, and modified Smith-Petersen
approaches have been described43,59-61.
Since 1993, we have used the modified Smith-Petersen approach,
which does not necessitate stripping of the abductors45,60,61. The incision is curved, starting at
the anterior third of the os ilium, crossing the anterior superior
iliac spine, and running fifteen centimeters distally, crossing
the tensor fasciae latae muscle (Fig. 3-A). The anterior superior iliac spine
is osteotomized, with preservation of the attachment of
the sartorius muscle and the inguinal ligament to protect the lateral cutaneous
femoral nerve. The osteotomized fragment, including the iliacus
muscle, is mobilized medially (Fig. 3-B). This is performed by placing the
hip in 45 degrees of flexion to release muscular tension. Between
the tensor fasciae latae and the rectus femoris, both heads of the
rectus femoris are identified. The indirect head is tenotomized,
and the direct head is separated from the anterior inferior iliac
spine. Together with the iliocapsularis muscle, this flap is mobilized
medially62. Distally, the iliopectineal
bursa is opened to identify the iliopectineal eminence (Fig. 3-C). Lateral
to this, the gap between the capsule and the psoas tendon anteriorly,
and that between the capsule and the obturator externus muscle more
posteriorly, are identified. This allows access to the ischium.
The abductor muscles are elevated from the iliac wing only at the
level of the horizontal part of the superior acetabular osteotomy.
A blunt retractor protecting the soft tissues is inserted through
this tunnel, in a posterior direction, into the greater sciatic
notch. Medially, the strong periosteum over the quadrilateral surface
is elevated by a blunt retractor, which is placed on the base of
the ischial spine, thus protecting the medially located obturator
and external iliac neurovascular bundles.
The individual correction remains the most difficult part of this
procedure45. Therefore, current
attention is focused on the narrow range between undercorrection
and overcorrection, with the latter possibly causing impingement between
the femoral neck and the acetabular rim. When overcorrection is
extensive, the acetabular notch becomes part of the loaded area.
To prevent malcorrection, computed tomography-based preoperative
planning and computer-guided intraoperative navigation
have been shown to be promising, with the latter still under clinical
evaluation63,64.
After identification of the pubis, ischium, and ilium, the five
steps of the Bernese periacetabular osteotomy can be performed (Figs. 4-A and 4-B). The first step
is the incomplete osteotomy of the ischium. With the hip in flexion
and after palpation to determine the ischial location and size,
a specially angled chisel is inserted distal to the acetabulum,
between the capsule and the tendon of the psoas and the obturator
externus muscle. The osteotomy starts at the infracotyloid groove
with a depth of fifteen to twenty-five millimeters, incompletely
separating the ischial bone. Care must be taken not to injure the
sciatic nerve, and fluoroscopy may be used to monitor this step.
The second step is the complete osteotomy of the pubic bone, with
maintenance of slight flexion and adduction of the hip to prevent
damage to the neurovascular structures of the thigh. After subperiosteal
preparation of the pubic bone, two blunt retractors are placed around
the anterior ramus to protect the obturator nerve and vessels. The centrally
inclined oblique osteotomy is performed medial to the iliopectineal
eminence.
The third step is the chevron-shaped supra-acetabular osteotomy,
which is performed with the hip joint kept in slight flexion and
adduction. At present, this osteotomy, consisting of two parts,
is performed more proximally than it was in the first description
of this procedure43. An oscillating
saw is used to begin the cut at the inferior border of the osteotomized
anterior superior iliac spine and directed transversely, ending
approximately one centimeter proximal to the iliopectineal line.
The second, posterior part is performed with a chisel and is directed
inferiorly toward the ischial spine at an angle of 110 to 120 degrees
to the anterior osteotomy. A one-centimeter bone bridge
is kept between the inferior border and the greater sciatic notch.
A five-millimeter Schanz screw is inserted into the anterior inferior iliac
spine parallel to the supra-acetabular osteotomy in the
acetabular fragment; this provides a good lever for mobilization
of the fragment. Care must be taken not to perforate the joint.
With distal traction and tilt on the Schanz screw, the supra-acetabular
osteotomy gap is opened and a lamina spreader is inserted into the
posterior part of the gap. Opening the spreader leads to a fracture
propagation of the posterior osteotomy toward the ischial spine.
Sometimes, additional gentle blows on an osteotome directed toward
the ischial spine are required to promote this propagation.
The fourth step is the retroacetabular osteotomy. This is performed
after subperiosteal preparation of the quadrilateral surface four
centimeters beneath the iliopectineal line, at an angle of approximately
30 degrees toward the quadrilateral surface. For this cut, a special
chisel is used while steady traction is applied with use of the
Schanz screw and the lamina spreader within the supra-acetabular osteotomy
site. By maintaining tension, this step produces the fifth step
of the osteotomy, a controlled fracture of the incompletely osteotomized
ischium (the first cut).
Performance of the osteotomies as described above avoids compromise
of the vascularity to the periacetabular fragment. The blood flow
to the periacetabular fragment is supplied by three main
sources entering the bone on the external surface of the pelvis.
The acetabular branch of the obturator artery supplies the acetabular
notch, the entire subchondral bone, the anterior wall, and the labrum.
The inferior branch of the superior gluteal artery penetrates the
gluteus minimus, following the course of the piriformis muscle,
and supplies the roof of the acetabulum and the posterior wall as
well as parts of the capsule and the labrum. Terminal branches of
the inferior gluteal artery and the internal pudendal artery supply the
ischial bone and the posterior wall. In order not to endanger the branches
of the superior gluteal artery running within the gluteus minimus,
the surgeon dissects this muscle from the external iliac wing only
in an area big enough to facilitate the supra-acetabular osteotomy.
The osteotomy of the ischium may separate the fragment from the blood
supply coming from the inferior gluteal artery and the internal
pudendal artery; however, anastomoses with the obturator system
and the medial femoral circumflex artery remain intact and usually
provide adequate perfusion65.
The acetabular fragment is completely mobilized, and the necessary
correction is performed. After provisional fixation of the fragment
with Kirschner wires, an orthograde anteroposterior pelvic radiograph
is made to evaluate the correction. Image-intensifier or radiographic assessment
of the treated side alone is insufficient. For judgment of the correction,
radiographic landmarks such as the orientation of the acetabular roof,
the position of the head relative to the ilioischial line, the position
of the radiographic teardrop, the anterior and posterior aspects
of the acetabular rim, and the Shenton line are evaluated. While
radiographs are made and processed, an anterior capsulotomy is performed.
The joint is inspected for intra-articular lesions (labral,
cartilaginous, and osseous) and, if necessary, these lesions are
addressed.
Labral tears can range in size from a very small microdetachment
to one involving 50 percent of the circumferential attachment55. The lesion is ususally located
in the anterosuperior quadrant of the acetabular rim and can resemble
a bucket-handle tear of a knee meniscus. The next most common lesion
is an intrasubstance degeneration with an intact outer surface but
an undersurface rupture into a degenerative focus. Less commonly,
the labrum will be attached to a free osseous fragment from the
acetabular rim. An unstable labrum (intrasubstance lesion) might
be resected or, if an osseous fragment of sufficient size is attached to
it, it can be refixed. Small and stable tears are left untreated. Cartilage
damage observed in these hips ranges from superficial erosions through
cartilage flakes to full-thickness defects, which are treated by
resection and sometimes drilling of the subchondral bone.
If current limitations are overcome, cartilage transplantation might
be a promising future adjunctive approach in the reconstruction
of these lesions.
Cyst or ganglion formation is frequently found in these hips. Soft-tissue
ganglia are removed, and cysts within bone are curetted and filled
with cancellous bone. Even more important is an assessment of the
range of motion after correction, which has to be of sufficient
amplitude for flexion and internal rotation to be free of impingement. Often,
the anterior head-neck contour in dysplastic hips is flat and
therefore may lead to impingement with the acetabular rim
after correction. If necessary, the superomedial offset
of the femoral neck should be optimized by the creation of a substantial
step-off at the head-neck junction.
After the correct reorientation is seen on the intraoperative radiograph,
definitive fixation of the fragment to the ilium is performed with
three 3.5-millimeter screws placed in the supra-acetabular area
in a triangular configuration. The polygonal shape of the osteotomy
with the posterior column left intact and the avoidance of soft-tissue
stripping of the abductors enhance stabilization of the reoriented fragment;
thus, early mobilization and rehabilitation are facilitated.
Preoperatively, two to three units of autologous blood is obtained. Intraoperatively,
a cell-saver system is used. The operation is performed under spinal,
peridural, or general anesthesia, with the patient supine on a radiolucent table
and the side of the operation draped free.
During the first forty-eight hours postoperatively, the patient remains
in bed with the leg in a positioning device for pain relief. After
the drains are removed, the patient is allowed to walk using two
crutches. For the first eight weeks, the maximum allowed load on
the hip joint is restricted to five to ten kilograms. Active flexion
of the hip joint is prohibited for six weeks to protect the reattached
sartorius and rectus femoris muscles. Prophylaxis against deep venous
thrombosis is achieved with use of low-molecular-weight heparin. Because
of the careful dissection technique with use of a scalpel only,
prophylaxis against heterotopic ossification is not necessary. Eight
weeks postoperatively, the patient is assessed clinically and radiographically.
By then, healing is usually sufficient for full weight-bearing,
and full muscular strengthening can be started.
The Bernese periacetabular osteotomy is a joint-preserving procedure
used after growth-plate closure to correct acetabular coverage and
stabilize the femoral head. The polygonal, juxta-articular
osteotomy respects the vascular blood supply to the acetabular fragment and
facilitates an extensive acetabular reorientation. It achieves improvement
of the insufficient coverage of the femoral head, reduction of mediolateral displacement,
and correction of the version of the fragment. All osteotomies
are performed through the modified Smith-Petersen approach,
which also allows for an anterior capsulotomy. Joint inspection
not only provides information on lesions of the rim but also facilitates
the control of an impingement-free range of motion after
the correction. The posterior column remains partially intact, allowing minimal
internal fixation of the acetabular fragment and early mobilization
similar to that after an intertrochanteric osteotomy. Because the
majority of our patient population consists of young women, it is
important to note that the dimensions of the true pelvis and thus
the potential for future vaginal delivery are preserved.
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