UNASSIGNED: Previous studies have sought to determine the effect of inpatient ketamine therapy on postoperative pain in a variety of surgical specialties.
UNASSIGNED: To determine the effects of postoperative ketamine analgesia after periacetabular osteotomy (PAO) and/or derotational femoral osteotomy (DFO) on opioid requirements, pain, and discharge time.
UNASSIGNED: Cohort study; Level of evidence, 3.
UNASSIGNED: Prospective data were collected on 145 patients who underwent PAO and/or DFO by the senior author between January 2021 and December 2022. Hip arthroscopy was performed 3 to 10 days before addressing any intra-articular pathology. In 2021, patients (n = 91 procedures; control group) received a traditional postoperative multimodal pain regimen. In 2022, postoperative low-dose ketamine (0.1-1 mg/kg/h) was added to the multimodal analgesic approach until 24 hours before discharge (n = 81 procedures; ketamine group). The ketamine and control groups were matched based on procedure type. Total opioid consumption was collected using milligram morphine equivalents (MMEs) for both groups. Postoperative pain was measured using the Defense and Veterans Pain Rating Scale (DVPRS), which was analyzed as the mean score per day. Data on the mean MME and DVPRS were analyzed for up to 7 days postoperatively. Linear mixed statistical analysis was performed to determine the significance of low-dose postoperative ketamine on postoperative pain and opioid utilization.
UNASSIGNED: Patients who did not receive ketamine after PAO and/or DFO utilized a mean of 181 ± 335 MMEs and had a mean DVPRS score of 4.18 ± 1.63. Patients who received postoperative ketamine required a mean of 119 ± 291 MMEs and had a mean DVPRS score of 4.34 ± 1.61. The ketamine group was found to consume a significantly lower total MME dose per day (P < .001). No significant difference was found in the mean DVPRS score between the ketamine and control groups (P = .42). Also, no significant difference was found on the day of discharge (P = .79).
UNASSIGNED: Patients who received postoperative ketamine after PAO and/or DFO had a significant decrease in MME dose when compared with a control group of patients who did not receive ketamine. Surgeons should consider adding ketamine to their postoperative multimodal pain control protocol to decrease opioid consumption while adequately addressing postoperative pain.

BACKGROUND: Individuals with acetabular dysplasia often report hip joint instability, pain, and poor hip-related function. Periacetabular osteotomy (PAO) is a surgical procedure that aims to reposition the acetabulum to improve joint congruency and improve pain and function. We aimed to examine the influence of presurgery clinical measures on functional recovery following PAO and the associations among clinical outcomes after PAO.
METHODS: We screened 49 potential participants, 28 were enrolled, and 23 completed both study visits (pre-PAO and 6 months post-PAO). We evaluated dynamometer-measured hip and thigh strength, loading patterns during a squat and countermovement jump (CMJ), pain intensity, and device-measured physical activity (PA) levels (light, moderate-to-vigorous PA [MVPA], and daily steps). We used linear regression models to examine the influence of muscle strength (peak torque; limb symmetry index [LSI]) and loading patterns before PAO on pain intensity and PA levels in individuals 6 months following PAO. Additionally, we used Pearson correlation coefficient to examine cross-sectional associations among all variables 6 months following PAO.
RESULTS: Lower extremity muscle strength and loading patterns during the squat and CMJ before PAO did not predict pain intensity or device-measured PA levels in individuals 6 months following PAO (p > 0.05). Six months following PAO, higher knee extensor LSI was associated with higher time spent in MVPA (r = 0.56; p = 0.016), higher hip abductor LSI was associated with both lower pain (r = 0.50; p = 0.036) and higher involved limb loading during the squat task (r = 0.59; p = 0.010). Lastly, higher hip flexor LSI was associated with higher CMJ takeoff involved limb loading (r = 0.52; p = 0.021) and higher involved hip extensor strength was associated with higher CMJ landing involved limb loading (r = 0.56; p = 0.012).
CONCLUSIONS: Six months after PAO, higher hip and thigh muscle strength and strength symmetry were associated with lower pain, higher PA levels, and greater normalized limb loading during dynamic movement tasks.

Periacetabular osteotomy (PAO) is an effective approach for the surgical treatment of developmental dysplasia of the hip (DDH). However, due to the complex anatomical structure around the hip joint and the limited field of view (FoV) during the surgery, it is challenging for surgeons to perform a PAO surgery. To solve this challenge, we propose a robot-assisted, augmented reality (AR)-guided surgical navigation system for PAO. The system mainly consists of a robot arm, an optical tracker, and a Microsoft HoloLens 2 headset, which is a state-of-the-art (SOTA) optical see-through (OST) head-mounted display (HMD). For AR guidance, we propose an optical marker-based AR registration method to estimate a transformation from the optical tracker coordinate system (COS) to the virtual space COS such that the virtual models can be superimposed on the corresponding physical counterparts. Furthermore, to guide the osteotomy, the developed system automatically aligns a bone saw with osteotomy planes planned in preoperative images. Then, it provides surgeons with not only virtual constraints to restrict movement of the bone saw but also AR guidance for visual feedback without sight diversion, leading to higher surgical accuracy and improved surgical safety. Comprehensive experiments were conducted to evaluate both the AR registration accuracy and osteotomy accuracy of the developed navigation system. The proposed AR registration method achieved an average mean absolute distance error (mADE) of 1.96 ± 0.43 mm. The robotic system achieved an average center translation error of 0.96 ± 0.23 mm, an average maximum distance of 1.31 ± 0.20 mm, and an average angular deviation of 3.77 ± 0.85°. Experimental results demonstrated both the AR registration accuracy and the osteotomy accuracy of the developed system.

Periacetabular osteotomy (PAO) is a common treatment for prearthritic hip dysplasia. The goal of this investigation was to determine if computationally assessed hip contact mechanics are associated with joint failure at minimum 10-year follow-up. One hundred patients with hip dysplasia (125 hips) completed patient-reported outcomes an average of 13.8 years (range 10.0-18.0 years) after PAO. 63/125 hips were classified as having failed: 26 converted to total hip arthroplasty (THA) and 37 with significant disability indicated by modified Harris Hip Score (mHHS) ≤ 70. Differences in discrete element analysis-computed contact mechanics were compared between (1) preserved and failed hips, (2) preserved hips and hips that failed by THA, and (3) preserved hips and hips that failed by mHHS ≤ 70. Failed hips had significantly higher preoperative contact stress and exposure metrics (p < 0.001-0.009) than preserved hips. Failed hips also had significantly higher postoperative peak contact stress (p = 0.018), higher mean contact stress (p < 0.001), and smaller contact area (p = 0.044). When assessed based on type of failure, hips that failed by THA had significantly higher postoperative contact stress and exposure metrics than preserved hips (p < 0.001-0.020). In hips that failed by mHHS ≤ 70, mean postoperative contact stress exposure was significantly higher compared to preserved hips (p = 0.043). Despite improved radiographic measures of dysplasia after PAO, pathologic joint contact mechanics can persist and predict treatment failure at minimum 10 years after surgery. Operative and nonoperative techniques specifically intended to reduce harmful contact mechanics in dysplastic hips may have the potential to further improve clinical outcomes after PAO.

BACKGROUND: The treatment option for borderline hip dysplasia (BHD) includes hip arthroscopy and periacetabular osteotomy (PAO). To the present day the controversial discussion remains, which intervention to prefer. Literature reports supporting an educated choice are scare, based on small patient cohorts and do not address the variability of acetabular morphology. Consequently, we intended to report PAO outcomes, from patients diagnosed with BHD, dependent on acetabular morphology, in a large patient cohort and aimed to define risk factors for poor clinical results and patient satisfaction.
METHODS: A prospective monocentre study was conducted. Patients enrolled underwent PAO for symptomatic BHD (LCEA, 18°-25°). A total of 107 hips were included with 94 complete data sets were available for evaluation with a minimum follow-up of 1 year and a mean follow-up of 2.3 years. The mean age was 31 ± 8.2 years, and 81.3% were female. As the primary outcome measure, we utilized the modified Harris hip score (mHHS) with minimal clinically important change (MCID) of eight to define clinical failure. Results were compared after a comprehensive radiographic assessment distinguishing between lateral deficient vs. anterior/posterolateral deficient acetabular and stable vs. unstable hip joints.
RESULTS: Overall, clinical success was achieved in 91.5% of patients and the mHHS improved significantly (52 vs. 84.7, p < 0.001). Eight hips failed to achieve the MCID and four had radiographic signs of overcorrection. Comparing variable joint morphologies, the rate of clinical success was higher in patients with an anterior/posterolateral deficient acetabular covarage compared to lateral deficient acetabular (95.2% vs. 90.4%). tThe highest rate of clinical failure was recorded in unstable hip joints (85.7% vs. 92.5% in stable hips).
CONCLUSIONS: This study demonstrates that PAO is an effective means to treat symptomatic BHD with variable acetabular morphologies, achieving a clinical success in 91.5% of all patients. To maintain a high level of safety and patient satisfaction technical accuracy appears crucial.

UNASSIGNED: Hip dysplasia is a leading cause of hip osteoarthritis. While periacetabular osteotomy (PAO) is effective for relieving pain and dysfunction caused by hip dysplasia in adolescents and young adults, there is concern that patients over 40 years of age will have an increased risk of persistent dysfunction and need for total hip arthroplasty. Current available evidence for PAO in older adults is limited and there is no systematic review in the literature focusing on this topic. The current systematic review offers insight into the demographics, patient-reported outcome measure (PROM) scores, and hip survivorship from total hip arthroplasty in patients over 40 years older treated for hip dysplasia with PAO.
UNASSIGNED: The review was conducted under the guidelines for the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Databases that were searched included PubMed, OVID Medline, SCOPUS, Embase, Cochrane Library, and clinicaltrials.gov. Studies were screened based on predetermined inclusion and exclusion criteria.
UNASSIGNED: Five studies were included in this systematic review. Enrollment years were 1990-2013. In total, there were 335 hips with mean ages between 43.5-47.2 years. Mean follow up was 4-10.8 years. Most patients that underwent hip preservation had Tonnis osteoarthritis grade 0-1. There was contradicting evidence whether patients >40 years did better or worse compared to <40 years; although, most patients in the >40 years group had good outcomes after PAO. PAO survivorship ranged from 67-100% depending on the study. Complications ranged from 2-36% of cases depending on the study; although, none of these complications had lasting effects.
UNASSIGNED: Patients over 40 years old appear to have positive outcomes when treated for hip dysplasia with PAO, though these patients were likely selected for no to minimal osteoarthritis, high functional status, and good health. PAO should be considered for patients with hip dysplasia over 40 years old without hip arthritis, though we recommend very selective indications. Level of Evidence: II.

UNASSIGNED: Periacetabular osteotomy (PAO) is a well-established surgical treatment for hip dysplasia, but very few studies report the impact of peri-operative management strategies on early pain and function. The purpose of this study is to describe peri-operative management variability among a group of experienced surgeons and review the literature supporting these practice patterns.
UNASSIGNED: We surveyed 16 surgeons that perform PAO to document various aspects of peri-operative management at four stages: pre-operative, intra-operative, post-operative in the hospital, and at discharge. Our goal was to report current surgical pain management strategies, adjunct medications, type of anesthesia, deep venous thrombosis and heterotopic ossification prophylaxis strategies, initiation of physical therapy, and use of continuous passive motion (CPM). We reviewed current literature to identify studies supporting these perioperative strategies and identify knowledge gaps that would benefit from further investigation.
UNASSIGNED: Of the 16 surgeons surveyed, 75% had been in practice greater than 10 years and most had not altered their post-operative protocol for more than 3 years. 15/16 surgeons felt that length of stay could be reduced at their institution with improved peri-operative pain management. 6/16 were considering or had already implemented outpatient PAO as a part of their practice. We found significant variability in the pain medications provided at all peri-operative stages. 14/16 utilized general anesthesia, and many utilized epidural or peripheral nerve blocks. 6/16 surgeons utilized surgical field block (also referred to as periarticular block). These surgeons advocated that surgical field block was an effective intervention with no/minimal complication risk. There is very little literature critically evaluating efficacy of these perioperative management strategies for PAO.
UNASSIGNED: There is significant practice variability in peri-operative management of PAO surgery. We report various strategies utilized by a group of experienced surgeons and review supporting literature. There are significant knowledge gaps in best surgical pain management strategies, adjunct medications, surgical field blocks, and use of CPM that need further investigation. Level of Evidence: IV.

UNASSIGNED: Determination of need for osteochondroplasty (OCP) during periacetabular osteotomy (PAO) commonly relies on intraoperative assessment of internal rotation at 90° flexion (IRF). Performing an OCP helps decrease the risk of iatrogenic femoroacetabular impingement from PAO reduction. Avoiding impingement helps decrease risks of accelerated secondary osteoarthritis. The literature is limited for factors that predict need for OCPs during PAOs. The purpose of this study was to (1) define the characteristics of patients needing concurrent OCP and provide OCP rate based on IRF and femoral version and (2) identify predictive factors (clinical, radiographic) associated with need for OCP during PAO. As some surgeons determine need for OCP pre-operatively, predictive factors would aid decision making.
UNASSIGNED: This was a prospective cohort of 224 hips (207 patients) who underwent PAO for symptomatic acetabular dysplasia, of which 154 hips (69%) underwent OCP between years 2013 and 2017. Patients underwent OCP if they had restrictions in motion or impingement intra-operatively. Pre-operative factors such as age, sex, BMI, and CT findings were recorded that underwent univariate and multivariable analyses. Multivariable analysis found predictors that were described using odds ratios and 95% confidence intervals. IRF>30° and femoral version 10°-25° were used as the reference groups during categorical analysis. P-values ≤0.05 were considered significant.
UNASSIGNED: Alpha angles >55° (OR= 2.20, CI: 1.08-4.52, p= 0.03), IRF≤20° (OR: 9.52, CI: 3.87-23.40, p<0.001), IRF >20°-30° (OR: 2.68, CI: 1.08-6.62, p=0.03), and femoral version <10° (OR: 5.26, CI: 1.09-25.30, p=0.04) were associated with increased odds of OCP. On continuous modeling, decreasing femoral version (OR: 1.07, CI: 1.02-1.12, p=0.002) and IRF (OR: 1.06, CI: 1.03-1.09, p<0.001) were associated with increased chance of OCP. For 5° changes, the chance of OCP increased by 40% (OR: 1.40, CI: 1.13-1.73, p=0.002) and 35% (OR: 1.35, IC: 1.16-1.57, p<0.001), respectively.
UNASSIGNED: Awareness of need for OCP may be valuable in peri-operative planning for these patients especially since some surgeons perform this technique arthroscopically before PAO. Factors associated with increased chances of OCP were alpha angles >55°, decreased IRF, and decreased femoral version. More studies in the future would help determine how OCP affects patient outcomes. Level of Evidence: III.

UNASSIGNED: Bernese periacetabular osteotomy (PAO) improves symptoms and delays degenerative changes in patients with acetabular dysplasia. Yet, eventual total hip arthroplasty (THA) is needed in many of these patients. The impact of PAO on subsequent THA outcomes is not well defined.
UNASSIGNED: 1) clinical outcomes, 2) post-operative complications and 3) implant survivorship for patients undergoing THA after prior ipsilateral PAO.
UNASSIGNED: A retrospective review was conducted at three institutions to identify individuals undergoing THA after ipsilateral PAO surgery with minimum 1 year follow up. Patient reported outcome measures (PROMs) were collected preoperatively and at final follow-up. Surgical details, radiographic and clinical outcomes, and major complications according to the modified Dindo-Clavien classification system were identified through review of the medical record. Regression analysis and student\'s t-test were used to compare pre- and post-operative outcome scores. Kaplan-Meier analysis was performed to estimate reoperation-free survivorship.
UNASSIGNED: A total of 113 THA in 112 patients were identified with initial review. 103 hips had a minimum of 1-year follow-up and an average follow of 5 ± 4 years (range, 1 to 20). 10 hips (9%) were lost to follow-up leaving 103 (91%) hips available for review with a minimum of 1-year follow-up (mean = 5 years). Mean interval from PAO to THA was 7.7 years (range, 2-15). The average post-operative mHHS improved 37 points (50 to 87, P < 0.001) when compared to pre-operative scores. Eight patients (7.1%) experienced a major grades III-V) surgical complication. These included 2 cases of instability, 2 cases of acetabular loosening, and one case each of periprosthetic fracture, wound dehiscence, periprosthetic infection, acetabular loosening and pneumonia. Failures occurred early at average 3.2 years and survivorship analysis for all-cause revision demonstrated 96% survivorship at both 5 and 10 years.
UNASSIGNED: THA after PAO achieves significant clinical improvement and satisfactory survivorship (96%) at mid-term follow-up, with a major complication rate of 7.1%. Level of Evidence: III.

UNASSIGNED: Early post-operative pain control is essential to facilitate rapid recovery after orthopaedic surgery. Despite periacetabular osteotomy (PAO) being the gold standard treatment of prearthritic hip dysplasia, there is limited evidence assessing efficacy of early post-operative pain management strategies. Recent literature has focused on non-opioid supplemental treatments such as nerve blocks or local wound infiltration. The purpose of this systematic review was to assess efficacy of these interventions to reduce pain, facilitate mobilization, reduce length of stay after PAO surgery.
UNASSIGNED: A systematic review was created under the guidance of PRISMA from databases that included PubMed, OVID Medline, Embase, SCOPUS, Cochrane Central Register of Clinical Trials, and clinicaltrials.gov from their creation dates to 12/21/23. These studies were screen based on predetermined inclusion and exclusion criteria.
UNASSIGNED: A total of six studies were included in this analysis from independent institutions. Three investigated nerve blocks (fascia iliaca, pericapsular, transversus abdominis), one investigated local wound infiltration with ropivacaine, one investigated high-dose dexamethasone, and the last investigated removal of the epidural catheter on postoperative (POD) 1 compared to POD 2. There were heterogeneous outcomes that were measured from these studies. In general, nerve blocks decreased opioid use, pain, and length of hospital stay. The local wound infiltration decreased pain on POD 3 and 4. Removing the epidural catheter on POD1 compared to POD 2 decreased pain and length of stay. High-dose dexamethasone use decreased opioid use on POD 1, otherwise, there was no difference in pain.
UNASSIGNED: In summary, supplemental pain management strategies peri-operatively for PAO surgery can decrease pain, opioid use, and length of hospital stay, though there are few studies assessing these interventions. Limiting opioid use after surgery reduces known negative consequences of the medication and facilitates rapid recovery. Clinical trials are needed that assess efficacy of supplemental pain management strategies after PAO surgery. Level of Evidence: II.