Hip Clinical Pearls: #12 The PAO: Periacetabular Osteotomy |
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Clinical Pearl #12: The PAO: Periacetabular Osteotomy
When people cannot remember the name of the procedure, I refer to it as “the big hip procedure” beyond a hip scope. The PAO is quite different than a total hip arthroplasty (THA). Anyone who sees you on crutches after surgery may compare this procedure to a THA since a THA is more common. Try not to get too frustrated by this. A PAO is far more involved technically than a THA, and thus the healing process is much longer to feel "recovered".
HISTORY:
The original procedure developed years ago was called the Ganz Osteotomy, named after Professor Ganz in Switzerland. The procedure cuts the pelvis to realign the hip socket to help provide better bony coverage for the dysplastic hip for more inherent stability. The procedure has become more frequently performed in the last decade, and the training for surgeons is very specific. Over time, the Bernese Periacetabular Osteotomy has been more commonly adapted. This keeps the load bearing column intact through the posterior, or back, portion of the pelvis. This influences weight bearing precautions through the recovery stages. This approach is more commonly known as the PAO today.
GENERAL INFORMATION:
The PAO commonly accompanies a hip arthroscopy. This can be within the same day, a week or a month, or more, depending on your surgeon(s). While the idea of having both procedures done on the same day is understandable as this allows for one event of anesthesia. On the other hand, having the procedures performed on separate days allows the hip to start flushing the fluids associated with surgery via early mobility after the hip scope via the bike and ADLs. This is beneficial in the recovery of the hip joint related to the hip arthroscopy since mobility will be quite limited in early days and weeks after the PAO.
It is common that the surgeon who performs your hip arthroscopy is different than the one performing your PAO. There are surgeons who perform both procedures for the patient, and this is less common. If you decide to undergo surgery with two surgeons completing the process, I recommend discussing the process of follow up care and visits. Should you have any questions, issues, or concerns, who is it that you contact? Being able to consult with a surgeon who does both procedures could lessen the potential confusion for follow up care as a patient.
Many times, the procedure involves a large incision on the front of the hip, from approximately 4-7”, depending on the surgical approach of your surgeon. I have had the experience of seeing a smaller anterior incision by a local surgeon and accompanied by a small posterior incision based on his specific approach. I personally favor this approach for a couple of reasons. One, it provides better visualization of the Sciatic Nerve while doing the posterior cut, minimizing potential nerve irritation or damage to the Sciatic Nerve. Second, the extent of soft tissue "damage" related to the procedure is less and this potentially contributes to less post operative pain. I will not go into the absolute specifics of the procedure since I am not a surgeon and there are variations amongst surgeons. However, here are commonalities we will discuss.
PROCEDURAL COMMONALITIES:
In order to get to the ability to realign the pelvis, a few things need to happen. A small section of the abdominals needs to be removed from the insertion on the pelvis where the incision is performed in order to gain access to the pelvic bone. The iliacus muscle, a hip flexor muscle, is retracted off the inside of the pelvis to gain access to the flare of the pelvis. The Sartorius and Rectus Femoris (both assist hip flexion) muscles need to be removed from the attachments at the pelvis for access to the anterior pubic ramus, the front side of the public bone, for the innermost cut for the procedure. All of these are sutured back according to how your surgeon performs the procedure. At a minimum, 3 muscles are cut and put back in place by sutures, and a fourth is effected by it's relationship with it's insertion on the bone during the procedure.
The appropriate amount of angular change of the socket will depend on a multitude of factors and measurements your surgeon will be assessing preoperatively via your scans. Due to the nature of cutting bone, there is bleeding which accompanies this procedure. This will affect healing of structures including bone, nerve and soft tissue. Therefore, it is normal to have a variety of symptoms following surgery, and every one of them will be valid and acceptable in your healing process. Whenever questions in recovery arise, I always advise patients to consult with their surgeon(s) about specific questions.
REHABILITATION AFTER PAO:
As introduced in the beginning of this section, many others will compare this procedure to a THA. Treating this procedure as though it is a THA in rehab is not appropriate and is more accelerated than typical timelines related to PAO recovery. Surgeons are increasingly teaming with physical therapists to create protocols which can be viewed prior to surgery. This helps patients identify common timelines and types of physical activities appropriate after surgery.
Timelines for weight bearing, crutch use, physical activities and progressions will vary according to the surgeon and his or her specific techniques related to the procedure. Working with a physical therapist who understands this procedure and can help you work through the rehabilitation process is important, not only through the initial stages of rehab, but through the entire process to help you reach your goals safely. While many patients are feeling quite "functional" by 6 months post operatively, it is not uncommon for return to "full function" or "full sport participation" to take more than 12 months to achieve.
POST OPERATIVE TOOLS FOR HOME AFTER PAO:
Whether or not your surgeon's office provides you a list of helpful tools at home for post operative care, please visit a blog by a former patient, Carey Martin, at https://careymartin.com/ultimate-pao-supplies-list/ . Her blog is very extensive, and not only presents her surgical journey, but her journey of personal growth in parallel to her numerous surgeries. It is quite inspirational and reflective, and not only for someone having hip issues or undergoing a PAO.
When people cannot remember the name of the procedure, I refer to it as “the big hip procedure” beyond a hip scope. The PAO is quite different than a total hip arthroplasty (THA). Anyone who sees you on crutches after surgery may compare this procedure to a THA since a THA is more common. Try not to get too frustrated by this. A PAO is far more involved technically than a THA, and thus the healing process is much longer to feel "recovered".
HISTORY:
The original procedure developed years ago was called the Ganz Osteotomy, named after Professor Ganz in Switzerland. The procedure cuts the pelvis to realign the hip socket to help provide better bony coverage for the dysplastic hip for more inherent stability. The procedure has become more frequently performed in the last decade, and the training for surgeons is very specific. Over time, the Bernese Periacetabular Osteotomy has been more commonly adapted. This keeps the load bearing column intact through the posterior, or back, portion of the pelvis. This influences weight bearing precautions through the recovery stages. This approach is more commonly known as the PAO today.
GENERAL INFORMATION:
The PAO commonly accompanies a hip arthroscopy. This can be within the same day, a week or a month, or more, depending on your surgeon(s). While the idea of having both procedures done on the same day is understandable as this allows for one event of anesthesia. On the other hand, having the procedures performed on separate days allows the hip to start flushing the fluids associated with surgery via early mobility after the hip scope via the bike and ADLs. This is beneficial in the recovery of the hip joint related to the hip arthroscopy since mobility will be quite limited in early days and weeks after the PAO.
It is common that the surgeon who performs your hip arthroscopy is different than the one performing your PAO. There are surgeons who perform both procedures for the patient, and this is less common. If you decide to undergo surgery with two surgeons completing the process, I recommend discussing the process of follow up care and visits. Should you have any questions, issues, or concerns, who is it that you contact? Being able to consult with a surgeon who does both procedures could lessen the potential confusion for follow up care as a patient.
Many times, the procedure involves a large incision on the front of the hip, from approximately 4-7”, depending on the surgical approach of your surgeon. I have had the experience of seeing a smaller anterior incision by a local surgeon and accompanied by a small posterior incision based on his specific approach. I personally favor this approach for a couple of reasons. One, it provides better visualization of the Sciatic Nerve while doing the posterior cut, minimizing potential nerve irritation or damage to the Sciatic Nerve. Second, the extent of soft tissue "damage" related to the procedure is less and this potentially contributes to less post operative pain. I will not go into the absolute specifics of the procedure since I am not a surgeon and there are variations amongst surgeons. However, here are commonalities we will discuss.
PROCEDURAL COMMONALITIES:
In order to get to the ability to realign the pelvis, a few things need to happen. A small section of the abdominals needs to be removed from the insertion on the pelvis where the incision is performed in order to gain access to the pelvic bone. The iliacus muscle, a hip flexor muscle, is retracted off the inside of the pelvis to gain access to the flare of the pelvis. The Sartorius and Rectus Femoris (both assist hip flexion) muscles need to be removed from the attachments at the pelvis for access to the anterior pubic ramus, the front side of the public bone, for the innermost cut for the procedure. All of these are sutured back according to how your surgeon performs the procedure. At a minimum, 3 muscles are cut and put back in place by sutures, and a fourth is effected by it's relationship with it's insertion on the bone during the procedure.
The appropriate amount of angular change of the socket will depend on a multitude of factors and measurements your surgeon will be assessing preoperatively via your scans. Due to the nature of cutting bone, there is bleeding which accompanies this procedure. This will affect healing of structures including bone, nerve and soft tissue. Therefore, it is normal to have a variety of symptoms following surgery, and every one of them will be valid and acceptable in your healing process. Whenever questions in recovery arise, I always advise patients to consult with their surgeon(s) about specific questions.
REHABILITATION AFTER PAO:
As introduced in the beginning of this section, many others will compare this procedure to a THA. Treating this procedure as though it is a THA in rehab is not appropriate and is more accelerated than typical timelines related to PAO recovery. Surgeons are increasingly teaming with physical therapists to create protocols which can be viewed prior to surgery. This helps patients identify common timelines and types of physical activities appropriate after surgery.
Timelines for weight bearing, crutch use, physical activities and progressions will vary according to the surgeon and his or her specific techniques related to the procedure. Working with a physical therapist who understands this procedure and can help you work through the rehabilitation process is important, not only through the initial stages of rehab, but through the entire process to help you reach your goals safely. While many patients are feeling quite "functional" by 6 months post operatively, it is not uncommon for return to "full function" or "full sport participation" to take more than 12 months to achieve.
POST OPERATIVE TOOLS FOR HOME AFTER PAO:
Whether or not your surgeon's office provides you a list of helpful tools at home for post operative care, please visit a blog by a former patient, Carey Martin, at https://careymartin.com/ultimate-pao-supplies-list/ . Her blog is very extensive, and not only presents her surgical journey, but her journey of personal growth in parallel to her numerous surgeries. It is quite inspirational and reflective, and not only for someone having hip issues or undergoing a PAO.