The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 92, Issue 18

Scientific Articles | December 15, 2010

Periacetabular Osteotomy for Containment of the Nonarthritic Dysplastic Hip Secondary to Poliomyelitis

Rafael J. Sierra, MD¹; S. Ralf Schoeniger, MD²; Michael Millis, MD³; Reinhold Ganz, MD⁴

¹ Department of Orthopedics, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address: sierra.rafael@mayo.edu
² Department of Orthopedic Surgery, Spitalzentrum Emmental, Oberburg Strasse 43, 3400 Burgdorf, Switzerland
³ Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115
⁴ Orthopedic Department, Inselspital University of Bern, 3010 Bern, Switzerland

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at Inselspital University of Bern, Bern, Switzerland, and Boston Children's Hospital, Boston, Massachusetts

J Bone Joint Surg Am, 2010 Dec 15;92(18):2917-2923. doi: 10.2106/JBJS.I.00753

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Abstract

Background:

Poliomyelitis results in a flaccid paralysis of muscles that can lead to hip instability. The objective of this study was to determine the results of the Bernese periacetabular osteotomy in patients with paralytic hips secondary to poliomyelitis.

Methods:

Nine patients who had a Bernese periacetabular osteotomy were identified as having paralytic hip dysplasia secondary to poliomyelitis. All patients had hip pain and instability at the time of presentation. Clinical records and radiographs were reviewed. One patient did not return for physical examination at last follow-up.

Results:

The mean length of follow-up was 103 months. All patients had a decrease in the severity of pain but less improvement in function, as hip abductor muscle strength was improved in only two of the eight patients examined. The average postoperative Harris hip score was 80.2. All patients had an improvement in the extrusion index, the acetabular index, and the lateral center-edge angle. According to the Tönnis radiographic classification, three patients progressed from Grade 0 to Grade 1 and one patient progressed from Grade 1 to 2.

Conclusions:

The correction obtained with use of the Bernese periacetabular osteotomy provides containment of the hip joint in patients with hip dysplasia secondary to poliomyelitis. The patients had a decrease in the severity of pain and less improvement in function. The results have been long-lasting and may have slowed the progression of osteoarthritis of the hip.

Level of Evidence:

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

The hip is commonly affected in patients with neuromuscular disorders, including poliomyelitis^1-3. In patients with poliomyelitis, the hip dysplasia results from a flaccid paralysis of muscles about the hip. As early as 1932, Elzinga and Key⁴ reported on twenty-six paralytic hip dislocations in patients with poliomyelitis. The paralytic dislocation was found most frequently in hips with strong flexor, adductor, and internal rotator muscles and weak extensor, abductor, and external rotator muscles. More severe dislocation was seen in patients with poorly formed acetabuli and with severe femoral coxa valga.

Treatment of the hip affected by poliomyelitis may require containment of the hip to prevent progressive subluxation or dislocation. Successful containment of the hip may be achieved with various surgical modalities, including soft-tissue releases, muscle transfers, open reduction, and a combination of femoral and/or acetabular osteotomies^5,6. Since 1984, the two senior authors (R.G. and M.M.) have treated nine hips in patients with polio by means of the Bernese periacetabular osteotomy⁷ in an effort to provide containment of the hip joint in these patients with symptomatic hip dysplasia. We reviewed the records and radiographs of these patients to determine whether the correction provided by the osteotomy provided containment of the hip, whether it provided pain relief and good clinical results, and whether it prevented progression of arthritis of the hip.

Materials and Methods

Nine patients who had undergone a Bernese periacetabular osteotomy were identified as having paralytic hip dysplasia secondary to poliomyelitis. The Bernese periacetabular osteotomy in these patients had been performed by one or the other of the senior authors (R.G. and M.M.), whose combined practice included more than 2800 periacetabular osteotomies performed over a twenty-year period. The average age of the patients at the time of surgery was thirty-one years (range, twelve to forty-seven years). The right hip was involved in five patients.

All patients had hip pain, and five also complained of instability. All patients walked and had varying degrees of muscle weakness (Table I). Three of the patients had prior hip surgery, and two had previous foot surgery. Six patients had additional procedures performed at the time of the periacetabular osteotomy: three had an intertrochanteric proximal femoral osteotomy, two had foot procedures, and one patient had an iliotibial band release.

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TABLE I Demographic Data and Examination

Patient	Side	Age at Time of Surgery (yr)	Follow-up (mo)	Chief Complaint	Preoperative Abductor Muscle Strength
1	Right	37	141	Hip instability, pain	3 of 5
2	Right	36	165	Pain, hip instability	2 of 5
3	Left	35	23	Pain	4 of 5
4	Right	24	240	Pain	Not available
5	Left	12	13	Hip instability, pain	2 of 5
6	Right	13.5	135	Hip instability, pain	2 of 5
7	Left	34	143	Hip instability, pain	3 of 5
8	Left	43	23	Pain	3 of 5
9	Right	47	43	Pain	4 of 5

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TABLE I Demographic Data and Examination

Patient	Side	Age at Time of Surgery (yr)	Follow-up (mo)	Chief Complaint	Preoperative Abductor Muscle Strength
1	Right	37	141	Hip instability, pain	3 of 5
2	Right	36	165	Pain, hip instability	2 of 5
3	Left	35	23	Pain	4 of 5
4	Right	24	240	Pain	Not available
5	Left	12	13	Hip instability, pain	2 of 5
6	Right	13.5	135	Hip instability, pain	2 of 5
7	Left	34	143	Hip instability, pain	3 of 5
8	Left	43	23	Pain	3 of 5
9	Right	47	43	Pain	4 of 5

Preoperative clinical notes were reviewed. Eight patients were assessed with physical examination and radiographs at their most recent review. One patient was contacted by telephone and radiographs were made elsewhere and forwarded to us for review. Clinical assessment was performed with use of the Harris hip score⁸. Abductor muscle strength was evaluated with use of a 0-to-5 scale, as described by the Medical Research Council⁹. Anteroposterior and lateral radiographs were evaluated before and after the Bernese osteotomy and were evaluated at the last follow-up. These radiographs were evaluated for the center-edge angle of Wiberg, the acetabular index of Tönnis, and the extrusion index¹⁰. Each radiograph was also assessed for the presence of arthritis on the basis of the classification system described by Tönnis¹¹. According to that system, Grade 1 signifies sclerosis of the femoral head and acetabulum with only a mild decrease in joint space, Grade 2 is a hip with small cysts in the head or acetabulum with a moderate decrease in joint space, and Grade 3 is a hip with formation of large cysts with moderate to complete loss of joint space and possible collapse of the femoral head (Table II).

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TABLE II Preoperative and Postoperative Radiographic Measurements

Patient	Preoperative Lateral Center-Edge Angle	Postoperative Lateral Center-Edge Angle	Preoperative Extrusion Index	Postoperative Extrusion Index	Preoperative Tönnis Acetabular Index	Postoperative Tönnis Acetabular Index	Preoperative Tönnis Grade	Postoperative Tönnis Grade
1	—23°	32°	68.00	10.00	38°	14°	0	1
2	—26°	34°	73.30	11.10	40°	—6°	0	1
3	—32°	33°	75.00	8.69	42°	7°	0	1
4	—4°	30°	50.00	17.85	37°	10°	1	2
5	—7°	28°	51.00	12.5	37°	11°	0	0
6	4°	40°	44.00	0	30°	5°	0	0
7	6°	34°	58.00	20.00	22°	35°	1	1
8	0°	20°	60.00	35.00	27°	10°	2	2
9	8°	40°	27.00	5.00	27°	—3°	1	1

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TABLE II Preoperative and Postoperative Radiographic Measurements

Patient	Preoperative Lateral Center-Edge Angle	Postoperative Lateral Center-Edge Angle	Preoperative Extrusion Index	Postoperative Extrusion Index	Preoperative Tönnis Acetabular Index	Postoperative Tönnis Acetabular Index	Preoperative Tönnis Grade	Postoperative Tönnis Grade
1	—23°	32°	68.00	10.00	38°	14°	0	1
2	—26°	34°	73.30	11.10	40°	—6°	0	1
3	—32°	33°	75.00	8.69	42°	7°	0	1
4	—4°	30°	50.00	17.85	37°	10°	1	2
5	—7°	28°	51.00	12.5	37°	11°	0	0
6	4°	40°	44.00	0	30°	5°	0	0
7	6°	34°	58.00	20.00	22°	35°	1	1
8	0°	20°	60.00	35.00	27°	10°	2	2
9	8°	40°	27.00	5.00	27°	—3°	1	1

Surgical Technique

The technique of the Bernese periacetabular osteotomy was first described in 1988⁷ and has since evolved with minor changes. We used a modified Smith-Petersen approach to the hip, which allows protection of the lateral femoral cutaneous nerve. An osteotomy of the anterior superior iliac spine with the sartorius tendon and inguinal ligament attached was done to reduce tension on the lateral femoral cutaneous nerve. For the two patients operated on before 1993, the origins of the tensor fasciae latae and gluteus medius and minimus muscles were released from the pelvis, but, after 1993, the osteotomy was performed through an abductor-sparing approach, which remains the currently preferred technique¹². Both heads of the rectus femoris muscle were detached from their origins and reflected medially. Fibers of the iliacus muscle, which were attached to the anterior hip capsule, were dissected until the pectineal bursa was visualized and the psoas tendon was exposed. The osteotomies performed in Europe by one of us (R.G.) were done without fluoroscopic guidance, but the anatomic landmarks were well defined. The posterior column of the pelvis was kept intact, and the mobile acetabular fragment was rotated laterally, anteriorly, and medially as necessary to achieve optimal containment of the femoral head. An intraoperative pelvic radiograph was made to verify adequate positioning of the acetabular fragment. The fragment was then fixed with at least three 3.5-mm or 4.5-mm fully threaded screws. In the three patients who required substantial correction and in whom it was believed that screws would not provide adequate bone fixation, 3.5-mm pelvic reconstruction plates were used.

Statistical Analysis

The normality of the distribution of the continuous variables was assessed before any analysis and, if necessary, the data were transformed or nonparametric methods were used. The differences in preoperative and postoperative radiographic parameters, Tönnis grade, and clinical scores were compared with use of either the Student t test or an analysis of variance. A p value of <0.05 was considered significant.

Source of Funding

No funding was received for the study.

Results

The Bernese periacetabular osteotomy improved all radiographic parameters associated with hip dysplasia, with a dramatic improvement in the extrusion index, the acetabular index, and the lateral center-edge angle (Table II). The average preoperative lateral center-edge angle was —8.2° (range, —32° to 8°) and the average postoperative lateral center-edge angle was 32.3° (range, 20° to 40°). The average preoperative extrusion index was 56.25 (range, 27 to 75) and the average postoperative extrusion index was 13.3 (range, 0 to 35). The average preoperative acetabular index was 33.3 (range, 22 to 42), and the average postoperative acetabular index was 9.2 (range, —6° to 35°). The improvements were all significant (p < 0.005).

The improvement in radiographic containment was associated with a decrease in the severity of pain in all patients. As shown in Tables III and IV, all patients had a decrease in the severity of pain, with less improvement in function. The osteotomy did not reliably improve abductor muscle function, as only two of the eight patients in whom the preoperative muscle strength was known had improvement in abductor muscle strength at the time of the last follow-up. Overall good clinical results were obtained, with a significant improvement of the average Harris hip score from 53 preoperatively (range, 43 to 70) to 80 postoperatively (range, 72 to 93; p < 0.001). The lack of improvement in function in some patients was attributed to a combination of persistent muscle weakness about the hip and disability related to other joints. In most cases, walking distance and the use of gait aids was highly dependent on the presence or absence of disability related to other joints.

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TABLE III Preoperative Pain, Function, and Limb Length

Patient	Pain	Distance Patient Can Walk	Limp	Support	Ability to Climb Stairs	Ability to Sit	Limb-Length Inequality
1	Marked	Two blocks	Moderate	None	Normally, with support	Comfortably	1.5 cm
2	Marked	Two blocks	Moderate	None	Normally, with support	Comfortably	3.5 cm
3	Marked	Two blocks	Moderate	None	Normally, with support	Comfortably	2 cm
4
5	Moderate		Moderate	None	Normally, with support	Comfortably	2 cm
6	Moderate	Unlimited	Moderate	None	Normally	Comfortably	1.5 cm
7	Marked	Two blocks	Moderate	None	Normally	Comfortably	2 cm
8	Marked	Two blocks	Moderate	Cane	Normally, with support	Comfortably	2 cm
9	Marked	One block	Moderate	None	Normally, with support	Comfortably	2 cm

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TABLE III Preoperative Pain, Function, and Limb Length

Patient	Pain	Distance Patient Can Walk	Limp	Support	Ability to Climb Stairs	Ability to Sit	Limb-Length Inequality
1	Marked	Two blocks	Moderate	None	Normally, with support	Comfortably	1.5 cm
2	Marked	Two blocks	Moderate	None	Normally, with support	Comfortably	3.5 cm
3	Marked	Two blocks	Moderate	None	Normally, with support	Comfortably	2 cm
4
5	Moderate		Moderate	None	Normally, with support	Comfortably	2 cm
6	Moderate	Unlimited	Moderate	None	Normally	Comfortably	1.5 cm
7	Marked	Two blocks	Moderate	None	Normally	Comfortably	2 cm
8	Marked	Two blocks	Moderate	Cane	Normally, with support	Comfortably	2 cm
9	Marked	One block	Moderate	None	Normally, with support	Comfortably	2 cm

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TABLE IV Postoperative Pain, Function, and Limb Lengths

Patient	Pain Severity	Distance Patient Can Walk	Limp	Support	Ability to Climb Stairs	Ability to Sit	Limb-Length Inequality	Muscle Strength
1	None	Unlimited	Moderate	None	Normally, without support	Comfortably in any chair	1.5 cm	3 of 5
2	None	Six blocks	Moderate	None	Normally, with support	Comfortably in any chair	3.5 cm	2 of 5
3	Slight	Six blocks	Moderate	None	Normally, with support	Comfortably in any chair	2 cm	4 of 5
4	Moderate	Six blocks	Severe	None	With support	High chair only	Short*	-
5	None	Two blocks (limited by other leg)	None	None (contralateral ankle-foot orthosis)	Normal	>1 hour	1 cm (surgically treated leg stronger)	2 of 5
6	None	Two blocks (limited by flail ankles, ankle-foot orthosis)	Not from hip	Ankle-foot orthosis	Railing (due to ankles)	>1 hour	Equal	2 of 5
7	Mild	Two blocks (limited by contralateral triple arthrodesis and contralateral Chiari)	Not from hip	None	Railing (due to other leg)	>1 hour	1.5 cm (surgically treated leg longer)	3 of 5
8	None			Crutches	With support	Comfortably in chair	2.5 cm	2 of 5
9	Mild	One block	Mild	None		Comfortably in chair	1.5 cm	3 of 5

*Actual inequality not known.

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TABLE IV Postoperative Pain, Function, and Limb Lengths

Patient	Pain Severity	Distance Patient Can Walk	Limp	Support	Ability to Climb Stairs	Ability to Sit	Limb-Length Inequality	Muscle Strength
1	None	Unlimited	Moderate	None	Normally, without support	Comfortably in any chair	1.5 cm	3 of 5
2	None	Six blocks	Moderate	None	Normally, with support	Comfortably in any chair	3.5 cm	2 of 5
3	Slight	Six blocks	Moderate	None	Normally, with support	Comfortably in any chair	2 cm	4 of 5
4	Moderate	Six blocks	Severe	None	With support	High chair only	Short*	-
5	None	Two blocks (limited by other leg)	None	None (contralateral ankle-foot orthosis)	Normal	>1 hour	1 cm (surgically treated leg stronger)	2 of 5
6	None	Two blocks (limited by flail ankles, ankle-foot orthosis)	Not from hip	Ankle-foot orthosis	Railing (due to ankles)	>1 hour	Equal	2 of 5
7	Mild	Two blocks (limited by contralateral triple arthrodesis and contralateral Chiari)	Not from hip	None	Railing (due to other leg)	>1 hour	1.5 cm (surgically treated leg longer)	3 of 5
8	None			Crutches	With support	Comfortably in chair	2.5 cm	2 of 5
9	Mild	One block	Mild	None		Comfortably in chair	1.5 cm	3 of 5

*Actual inequality not known.

Correction of the hip dysplasia and containment of the hip appeared to slow the progression of osteoarthritis in the affected hip. Four patients progressed by one Tönnis grade: three patients had progression from Tönnis Grade 0 to Tönnis Grade 1, and one patient had progression from Grade 1 to Grade 2 with resubluxation of the femoral head at a follow-up time of twenty years postoperatively. In five patients, the Tönnis grade remained the same. Figures 1-A, 1-B, and 1-C show a patient with hip dysplasia secondary to childhood polio. Twelve years following periacetabular osteotomy, there has been no progression in Tönnis.

Fig. 1-A

Figs. 1-A, 1-B, and 1-C Thirty-six-year-old male patient with right hip dysplasia secondary to poliomyelitis as a child. Fig. 1-A Preoperative anteroposterior pelvic radiograph.

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Fig. 1-B

Anteroposterior pelvic radiograph made immediately after periacetabular osteotomy. Acetabular version was maintained (note the anterior and posterior acetabular walls).

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Fig. 1-C

Anteroposterior pelvic radiograph, made at the twelve-year follow-up, showing maintenance of correction and preservation of joint space.

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Discussion

Containment of the hip affected by muscle weakness secondary to poliomyelitis should be attempted to prevent progressive subluxation or dislocation and subsequent osteoarthritis. The Bernese periacetabular osteotomy was successful in achieving containment in this selected group of patients and offers several advantages over other pelvic osteotomies for the treatment of hip dysplasia in patients with poliomyelitis. In a report by Betz et al.¹³ on six patients with poliomyelitis who underwent a Chiari osteotomy, four of the six patients were reported to have good results with pain relief. Lau et al.⁵ reported on a series of patients with poliomyelitis in which the hips were treated with a number of operative procedures. They reported an average increase in coverage of approximately 37% and an average improvement in center-edge angle of 18.5°. This correction may not be sufficient to provide containment in some hips affected by poliomyelitis, as a negative lateral center-edge angle with subluxation of the lateral aspect of the femoral head is not uncommonly seen. In our series, the average correction of the lateral center-edge angle was approximately 45°, which is twice as much as that seen with the Chiari osteotomy in the series by Lau et al. The Salter innominate osteotomy positions the acetabulum in retroversion, favoring containment of the femoral head anteriorly. The periacetabular osteotomy, however, provides three-dimensional correction of the acetabular fragment, which favors global containment of the femoral head. The correction obtained with the periacetabular osteotomy also appears to be better than that obtained with the triple osteotomy as reported by Lee et al.¹⁴. Table II illustrates the near normal acetabular index postoperatively in almost all of our patients.

From a clinical perspective, the majority of our patients had a decrease in the severity of pain but less improvement in abductor muscle power after the osteotomy. Lee et al.¹⁴ reported that 30% of their patients had an appreciable improvement in abductor muscle power after the triple osteotomy. In that series, however, several patients underwent additional surgical procedures, including muscle transfers. It has not been our practice to augment the hip abductor muscles with muscle transfers at the time of the Bernese periacetabular osteotomy. The authors believe that improvement in muscle function occurs by optimizing acetabular coverage and medializing the hip joint to improve the length and lever arm of the abductor musculature.

The majority of patients with poliomyelitis have involvement of multiple joints and a limb-length discrepancy, which add to their functional impairment. We were unable to increase limb length with use of the periacetabular osteotomy, but no shortening of the limb occurred. Lee et al.¹⁴ reported relatively good results with the use of transiliac osteotomy for limb-lengthening in patients whose lower extremities had been affected by poliomyelitis, with an average increase in limb length of approximately 1.7 cm. It is our opinion that attempting additional lengthening, as described by Lee et al., is not recommended in these patients because transiliac lengthening usually does not provide optimal acetabular reorientation and resultant correction.

Containment of the femoral head may have slowed the progression of osteoarthritis, but longer follow-up is needed before this determination can be made in the five patients who had no progression in Tönnis grade. Four of our patients had progression by one Tönnis grade of arthritis, but none of these patients have required a total hip arthroplasty as of the time of the last follow-up.

In summary, the Bernese periacetabular osteotomy provided containment of the hip joint in patients with dysplasia and progressive subluxation secondary to poliomyelitis. All patients had a decrease in the severity of pain, with less improvement in function, and the radiographic results were satisfactory at the time of midterm follow-up.

Acknowledgements

Note: The authors thank Dr. B. Isler, Winterthur, Switzerland, for providing follow-up of one patient.

References

Eberle CF. Pelvic obliquity and the unstable hip after poliomyelitis. J Bone Joint Surg Br. 1982;64:300-4.[PubMed]

Jones GB. Paralytic dislocation of the hip. J Bone Joint Surg Br. 1954;36:375-84.

Somerville EW. Paralytic dislocation of the hip. J Bone Joint Surg Br. 1959;41:279-88.[PubMed]

Elzinga ER; Key JA. Paralytic dislocation at the hip in poliomyelitis. J Bone Joint Surg Am. 1932;14:867-81.

Lau JH; Parker JC; Hsu LC; Leong JC. Paralytic hip instability in poliomyelitis. J Bone Joint Surg Br. 1986;68:528-33.[PubMed]

MacDonald SJ; Hersche O; Ganz R. Periacetabular osteotomy in the treatment of neurogenic acetabular dysplasia. J Bone Joint Surg Br. 1999;81:975-8.[PubMed][CrossRef]

Ganz R; Klaue K; Vinh TS; Mast JW. A new periacetabular osteotomy for the treatment of hip dysplasias. Technique and preliminary results. Clin Orthop Relat Res. 1988;232:25-36.

Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51:737-55.[PubMed]

Medical Research Council. Aids to the examination of the peripheral nervous system, memorandum no. 34. London: Her Majesty's Stationery Office; 1981.

Murphy SB; Ganz R; Müller ME. The prognosis in untreated dysplasia of the hip. A study of radiographic factors that predict the outcome. J Bone Joint Surg Am. 1995;77:985-9.[PubMed]

Tönnis D. Eine neue Form der Hüftpfannenschwenkung durch Dreifachosteotomie zur Ermoglichung späterer Hüftprothesenversorgung. Orthopädische Praxis . 1979;15:1003-9.

Siebenrock KA; Leunig M; Ganz R. Periacetabular osteotomy: the Bernese experience. J Bone Joint Surg Am. 2001;83:449-55.

Betz RR; Kumar SJ; Palmer CT; MacEwen GD. Chiari pelvic osteotomy in children and young adults. J Bone Joint Surg Am. 1988;70:182-91.[PubMed]

Lee DY; Choi IH; Chung CY; Ahn JH; Steel HH. Triple innominate osteotomy for hip stabilisation and transiliac leg lengthening after poliomyelitis. J Bone Joint Surg Br. 1993;75:858-64.[PubMed]

Topics

poliomyelitis ; hip region ; hip dislocation, congenital ; hip joint ; pain ; periacetabular osteotomy

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Rafael J. Sierra, S. Ralf Schoeniger, Michael Millis, Reinhold Ganz; Periacetabular Osteotomy for Containment of the Nonarthritic Dysplastic Hip Secondary to Poliomyelitis. The Journal of Bone & Joint Surgery. 2010 Dec;92(18):2917-2923.

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