What Is The Optimal Timing And Technique For Performing A Periacetabular Osteotomy In A Patient With A Tonnis Grade 2 Hip Dysplasia, And How Can I Minimize The Risk Of Intraoperative Femoral Nerve Injury While Still Achieving Sufficient Acetabular Reorientation To Restore A Normal Acetabular Index And Improve Patient Outcomes?

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Optimal Timing and Technique for Periacetabular Osteotomy (PAO) in Tonnis Grade 2 Hip Dysplasia

Optimal Timing:

  • Early Intervention: Perform PAO when the patient is young, as bone quality and cartilage health are better, leading to improved outcomes.
  • Disease Severity: Optimal in Tonnis grade 2, where joint narrowing is mild, and osteophytes are minimal, to prevent progression to severe osteoarthritis.

Surgical Technique:

  • Procedure Selection: Use the Bernese PAO technique, which involves precise osteotomies to allow acetabular repositioning.
  • Steps:
    1. Imaging and Planning: Utilize 3D CT scans to plan cuts and repositioning accurately.
    2. Surgical Exposure: Use an appropriate incision to balance exposure and minimize nerve risk.
    3. Osteotomies and Mobilization: Make controlled cuts to free the acetabulum, then mobilize and reposition it.
    4. Repositioning: Aim to restore a normal acetabular index (0-10 degrees) through anterior and lateral rotation.
    5. Fixation: Secure the acetabulum with screws to maintain the new position.

Minimizing Femoral Nerve Injury:

  • Nerve Monitoring: Use intraoperative nerve monitoring to reduce injury risk.
  • Surgical Technique: Careful dissection and gentle handling near the femoral nerve.
  • Patient Positioning: Avoid hyperextension and keep the hip flexed to reduce nerve tension.
  • Incision Strategy: Balance minimally invasive approaches with adequate exposure to protect nerves.

Post-Operative Care:

  • Rehabilitation Plan: Implement a structured program to avoid harmful positions and promote healing.
  • Patient Education: Emphasize the importance of adherence to post-operative instructions to protect the hip.

Conclusion: PAO is most effective in young patients with Tonnis grade 2 hip dysplasia. The Bernese technique, with careful planning and execution, can restore acetabular alignment while minimizing complications like femoral nerve injury. Attention to detail in both surgical technique and post-operative care is crucial for optimal outcomes.