Patients who received a reverse triple pelvic osteotomy for treatment of pincer/combined type FAI at the Orthopedic Clinic Bulovka in Prague between 2011 and 2020 were recruited for this study. A total of 18 patients completed our middle follow-u (1–9 years) The average age of the patients was 37.3 (28.0–45.0) years. All specifications of patients are disclosed in Table 1.
Table 1
Patients before surgical intervention. Average age is mentioned in the text. More women were included (73%). Pain during activities included movements to abductions, and flexions (ice skating, horse riding). X-ray retroversion was measured according to Siebenrock et al. [11]. MRI scans were measured at the most retroverted side of the acetabulum.
Patient no. | Sex | Pain VAS during movement | ROM | X-ray retroversion | MRI retroversion |
Sagittal | Rotational | Functional |
1 | M | 5 | 0-0-120 | 10-0-10 | 30-0-20 | x | 5.5° |
2 | F | 6 | 0-0-120 | 10-0-0 | 30-0-10 | x | 6.9° |
3 | F | 5 | 0-0-120 | 10-0-10 | 30-0-20 | x | 7.0° |
4 | F | 5 | 0-0-120 | 10-0-10 | 30-0-20 | x | 6.5° |
5 | M | 7 | 0-0-110 | 10-0-0 | 30-0-10 | x | 5.2° |
6 | F | 8 | 0-0-100 | 10-0-0 | 20-0-10 | x | 6.5° |
7 | F | 5 | 0-0-120 | 10-0-10 | 30-0-20 | x | 5.1° |
8 | F | 5 | 0-0-120 | 10-0-10 | 30-0-20 | x | 4.8° |
9 | F | 6 | 0-0-110 | 10-0-10 | 30-0-10 | | 3.9° |
10 | M | 6 | 0-0-120 | 10-0-10 | 30-0-10 | x | 5.2° |
11 | F | 7 | 0-0-110 | 10-0-0 | 20-0-10 | x | 6.1° |
12 | F | 8 | 0-0-110 | 10-0-0 | 20-0-10 | x | 6.3° |
13 | F | 9 | 0-0-110 | 10-0-0 | 20-0-10 | x | 6.0° |
14 | F | 10 | 0-0-100 | 10-0-0 | 20-0-10 | x | 6.2° |
15 | F | 7 | 0-0-120 | 10-0-10 | 30-0-10 | x | 3.4° |
16 | F | 7 | 0-0-120 | 10-0-10 | 30-0-10 | | 3.2° |
17 | M | 7 | 0-0-120 | 10-0-10 | 30-0-10 | x | 5.0° |
18 | M | 5 | 0-0-120 | 10-0-10 | 30-0-20 | | 3.4° |
Clinically, patients presented with symptomatic anterior femoroacetabular impingement with groin pain and decreased hip flexion and internal rotation. The anterior FAI test usually shows reproducible hip pain. Patients are then first treated non-operatively with modification of sports activities; unfortunately, this usually produces no effect. We recommended to all patients not to make painful astraddle sport movements (horse riding, motorbike riding, etc). Usually, patients with pincer FAI present with limited range of motion of the hip. This period is not limited, and often lasts for longer than a full year before the patients come to our office for their first check-up and before they are indicated for surgery. All of our patients were evaluated by Harris Hip Scores (HHSs) before and after the surgery was performed. X-ray and MRI scans were also carried out to clearly assess the focal retroversion or global retroversion of the acetabulum [7]; otherwise, it would not have been possible to distinguish between a retroverted acetabulum and a prominent anterior rim. Fortunately, we were able to use this procedure as the retroverted pelvic osteotomy. There are different operative treatments when there is a prominent anterior rim found (we do surgical luxation of the hip and abrasion of the prominent rim of the acetabulum, or we do redirective osteotomy of the acetabulum as one segment if there is retroverted acetabulum). We also provided pre- and post-operative X-ray parameters for comparison (Figs. 2, 8, and 9). According to Siebenrock [11], retroverted acetabulum may be diagnosed through the following three key X-ray findings: 1) positive crossover sign (with a retroversion index exceeding 30%); 2) positive posterior wall sign; and 3) positive ischial sign. The results of this study indicate that substantial acetabular retroversion in young (up to the age of 35 years) symptomatic patients is best treated with an anteverting periacetabular osteotomy. We used the same X-rays to visualize pincer FAI. Figure 4 shows the lines of the osteotomy, and Fig. 5 presents the findings of MRI scanning after operation, with anteversion measurement.
We performed MRI scans to determine the status of the cartilage inside the joint before operation, and to identify the exact range of reorientation before operation (Fig. 3).
The operative technique, reverse triple pelvic osteotomy, was performed to change the orientation of the acetabulum. Retroversion of this part of the pelvic bone, which was selected on the MRI scans before the operation, is usually performed to prevent rear FAI clinical signs. This surgery only involves reorientation of the acetabulum, so no bone graft was used (as in another pelvic osteotomies) and there was no lower-leg prolongation. During the operation, extraction of part of the bone was performed from the os ischii (segment of 0.5 cm). Next, an inner rotation of the acetabular segment of approximately 30° (see Table 2 for exact values of each retroversion) with Kirschner wires fixation was performed. It is important to note, here, that no reference points were taken for the degree measurements. When doing osteotomy we don’t have any reference points. No scale, we turn it according to the degree what we see on the MRI.
The indication for this surgery only exists if pincer/combined FAI has developed clinically. We chose to perform this extraarticular procedure in order to safely address intraarticular arthritis. This operation usually takes 90 minutes. After surgery, our patients were instructed to start physiotherapy immediately, to prevent periarticular adhesions. The guidelines for such included recommendations of continuous passive motion, walking with two crutches for at least 8 weeks, and limiting range of flexion motion in the hip to 70° for 3 to 6 months.
When performing the reverse pelvic osteotomy, it was necessary to evaluate the degree of destruction of the cartilage observed on the MRI scans. The Kirschner wires were applied to hold the bones in place. At the 1-year post-surgery follow-up, the hip was still in proper alignment for all patients (Fig. 6, representative case). This means, that there is no movement of the osteotomy.
At the 2-year post-surgery follow-up, the bone healed completely and the Kirschner wires were removed from all patients (Fig. 7A, representative case). At the 3-year post-surgery follow-up, there was no damage to the femoral head or necrosis observed in any of the patients (Fig. 7B, representative case). This verification means, that we didn’t find any necrosis of the femoral head.
At the conclusion of this study, our patients had been followed-up for up to 9 years after the surgery. As such, we performed an analysis of the follow-up data for the patients at their middle-age of life. We evaluated HHS as a clinical result and frontal and dorsal type impingement tests were performed again to evaluate the clinical results of the surgery. X-ray images and MRIs were obtained to determine the success of the surgery. On MRIs, we evaluated only whether the osteotomy had healed and the position of the reverted acetabulum. No classification tests were used. No revisions of osteotomy were performed to address infection or bad healing.