Periacetabular osteotomy without abductor dissection using direct anterior exposure.

The direct anterior exposure is a new abductor sparing surgical approach to perform periacetabular osteotomy, developed in an effort to eliminate the postoperative abductor morbidity associated with the classic Smith-Petersen approach. The direct anterior exposure also allows anterior arthrotomy of the hip joint, necessary to deal with intraarticular disease of the acetabular rim that is common in adult patients who require periacetabular osteotomy. The direct anterior exposure combines the medial portion of the classic Smith-Petersen iliofemoral exposure with or without the second window of the ilioinguinal exposure. An osteotomy of the anterior superior spine is done routinely to facilitate the approach by relaxing the attached sartorius and inguinal ligament origins. The authors' experience with the direct anterior exposure involves 195 consecutive periacetabular osteotomies done since 1992, with 60 operations done using the full approach through two windows and 135 operations done using the limited approach through one window. There was no difference in functional or radiographic results, with both approaches allowing rapid functional recovery, excellent radiographic corrections, rapid bony healing, and minimal formation of heterotopic bone. No osteonecrosis or vascular injuries were seen. In nearly all patients, abductor function had returned to preoperative levels by 3 months after surgery, in distinct contrast to the authors' previous experience with the Smith-Petersen approach. The authors consider the direct anterior exposure to be the surgical approach of choice for periacetabular osteotomy, with the more limited version proving satisfactory in all patients except the largest and most muscular patients. The full version is useful in large male patients.