Imperial College Healthcare NHS Trust, London, UK.
Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK.
Hip Int. 2020 Nov;30(6):787-792. doi: 10.1177/1120700020922202. Epub 2020 May 11.
Periacetabular osteotomy (PAO) is an established treatment for symptomatic acetabular dysplasia in skeletally mature individuals without arthritis. Pelvic nonunion and associated stress fractures are under-reported. Nonunited stress fractures can cause continued buttock pain and pelvic instability. The aim of this study is to report on our experience managing patients with ongoing pain following nonunion of PAO.
8 patients presented to a tertiary referral pelvic service with symptomatic PAO nonunion between 2015-2018. All patients underwent open reduction internal fixation of the superior pubic ramus nonunion, with ipsilateral iliac autograft, at an average of 48.1 (15-82) months following initial osteotomy. Demographic and perioperative data were recorded. Follow-up was on average to 9.9 months, once union was confirmed radiographically.
All patients were female and average age was 31.8 (18-41) years. In 7/8 (87.5%) patients a modified Stoppa approach was successfully utilised. 1 patient required an ilioinguinal approach due to the amount of rotational correction. All patients went on to union at the superior pubic ramus and reported improvement in mechanical symptoms. 5/8 (62.5%) patients were noted to develop union of the posterior column or inferior pubic ramus stress fracture indirectly. 2/8 (25%) patients developed progression of intra-articular pain, despite restoration of pelvic stability. 1 patient required intraoperative transfusion due to femoral vein injury. There were no other complications seen in this series.
To our knowledge, this is the largest case series of surgically managed PAO nonunion. Pelvic instability resulting from nonunion and stress fracture can be satisfactorily addressed by mobilising, grafting and plating the nonunion at the superior pubic ramus. The modified Stoppa approach is suitable in most cases, allowing excellent exposure whilst minimising the insult to soft tissues. The altered anatomy of the pelvis following PAO should be anticipated to reduce the risk to nearby neurovascular structures.
髋臼周围截骨术（PAO）是一种成熟的治疗方法，适用于无关节炎的髋臼发育不良的骨骼成熟个体。骨盆不愈合和相关的应力性骨折报告较少。未愈合的应力性骨折可导致持续的臀部疼痛和骨盆不稳定。本研究旨在报告我们治疗 PAO 不愈合后持续疼痛患者的经验。
2015 年至 2018 年间，8 名患者因 PAO 不愈合出现症状来到三级转诊骨盆服务处就诊。所有患者均在初次截骨术后平均 48.1（15-82）个月接受了同侧髂骨自体移植物的切开复位内固定治疗。记录了人口统计学和围手术期数据。在影像学确认愈合后，平均随访 9.9 个月。
所有患者均为女性，平均年龄为 31.8（18-41）岁。在 8 例（87.5%）患者中，成功使用改良 Stoppa 入路。由于旋转矫正量较大，1 例患者需要采用髂腹股沟入路。所有患者均在耻骨联合上支愈合，并报告机械症状改善。8 例（62.5%）患者中有 5 例间接发现后柱或耻骨下支应力性骨折愈合。尽管恢复了骨盆稳定性，但仍有 2 例（25%）患者出现关节内疼痛进展。1 例患者因股静脉损伤需要术中输血。本系列无其他并发症。
据我们所知，这是最大的手术治疗 PAO 不愈合的病例系列。由于不愈合和应力性骨折导致的骨盆不稳定，可以通过移动、移植和固定耻骨联合上支的不愈合来满意地解决。改良 Stoppa 入路适用于大多数情况，既能提供良好的暴露，又能最大限度地减少对软组织的损伤。PAO 后骨盆的解剖结构改变应加以预期，以降低对附近神经血管结构的风险。
