Arch Orthop Trauma Surg (1999) 119 : 253257

Springer-Verlag 1999

O R I G I N A L A RT I C L E

Y. Yasunaga H. Iwamori Y. Ikuta S. Yamamoto A. Harada

Rotational acetabular osteotomy for advanced osteoarthrosis secondary to dysplasia of the hip
Results at 611 years postoperatively*
Received: 16 July 1998

Abstract Clinical and radiological studies were done on the results of rotational acetabular osteotomy for advanced osteoarthrosis secondary to dysplasia of 29 adult hips followed up for 6 to 11 years postoperatively (mean 8 years). Clinical evaluation by Merle dAubigne and Postels system showed improvement from a preoperative mean of 12.8 to a follow-up mean of 14.8, with aggravation being observed in 8 joints. Radiologically, this procedure produced adequated improvement regarding femoral head coverage, but improvement in joint congruency could not necessarily be obtained due to joint deformity and progression of arthrosis, with aggravation of joint congruency being observed in 6 joints. The most important factor influencing the postoperative results of this procedure was postoperative joint congruency. If the postoperative joint congruency is satisfactory, with the joint congruent index being more than 6.0, progression of arthrosis can be prevented in the long term by this procedure, even in advanced cases.

Introduction
For osteoarthrosis secondary to dysplasia of the hip, periacetabular osteotomies to transfer the position of the acetabula en bloc, such as Steels triple osteotomy [12, 13], Wagners spherical acetabular osteotomy [15], Epprights dial osteotomy [3] and Tagawas rotational acetabular osteotomy (RAO) [11], are theoretically superior to the conventional acetabuloplasties and pelvic osteotomy such as Chiaris osteotomy [2] from the standpoint that the femoral head can be covered with articular cartilage. Satisfactory results of this procedure have been reported for early stage osteoarthrosis secondary to dysplasia of the hip, and the usefulness of this procedure has also been shown in long-term results [5, 14]. However, only a few detailed reports have been made on the results of this procedure for advanced cases, and the long-term results have been obscure [5, 17]. In the present study, RAO was performed for advanced cases, and 29 joints were reviewed 611 years postoperatively (mean 8 years and 1 month), including the indications for advanced cases.

Patients and methods

* No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Y. Yasunaga () Y. Ikuta Department of Orthopaedic Surgery, Hiroshima University School of Medicine, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan Tel.: (+81)82-257-5233, Fax: (+81)82-257-5234 H. Iwamori Department of Orthopaedic Surgery, Chuden Hospital, Hiroshima, Japan S. Yamamoto Department of Orthopaedic Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan A. Harada Department of Orthopaedic Surgery, Yoshida General Hospital, Hiroshima-ken, Japan The 29 patients of this study suffer from advanced osteoarthrosis secondary to dysplasia of the hip and underwent RAO between 1986 and 1991. Osteoarthrosis of the hip was staged from prearthrosis to end stage arthrosis according to the radiological appearance. Prearthrosis presented no osteoarthrotic change from acetabular dysplasia, early stage arthrosis was characterised by slight narrowing of the joint space associated with sclerosis of the subchondral bone, advanced stage arthrosis by marked narrowing of the joint space with some cystic lucencies and small osteophytes in the femoral head and acetabulum, and end-stage arthrosis by disappearance of the joint space with marked osteophytes. All patients were women except for one. Their age at the time of operation ranged from 21 to 56 years, with a mean of 39 years and 6 months. The postoperative follow-up period ranged from 6 years to 11 years, with a mean of 8 years and 1 month. According to Charnleys category classification [1], there were 12 unilateral cases (A) and 17 bilateral cases (B). The stages of the non-operated side of patients belonging to category B were prearthrosis in 4 joints, early stage arthrosis in 9 joints, and advanced stage

254 Fig. 1 Radiological indices of the hip: = CE angle, = acetabular roof obliquity, head A lateralisation index = 1/2 T Fig. 2 Joint congruent index = (b a) d + 5 (a radius of curvature in femoral head, b radius of curvature in acetabulum, d deviation of femoral head centre and acetabulum centre)

arthrosis in 4 joints. As an additional procedure, valgus osteotomy was performed on 2 joints. Cases showing improvement in femoral head coverage and joint congruency in abduction on anteroposterior view of plain X-ray and arthrography were as a rule considered indications for the operative procedure. For the clinical assessment, we used the system of Merle dAubigne and Postel [8] graded from 0 to 6 relief of pain, restoration of mobility and improvement in walking. Radiological indices included CE angle [16], acetabular roof obliquity [7] and head lateralisation index [4], which was calculated from two lengths, from the centre of the femoral head to the tip of the teardrop and between bilateral teardrops (Fig. 1). The difference in the radius of curvature between the femoral head and acetabulum was regarded as the joint space (mm). From this value we subtracted the deviation (mm) of the femoral head centre and acetabulum centre, and 5 was added to obtain the joint congruent index [6]. This index was employed in evaluating joint congruency (Fig. 2). Operative technique RAO procedure [11] reported by Ninomiya and Tagawa was employed, but for immobilization of the rotated acetabulum following osteotomy, a sapphier screw (Kyocera, Kyoto, Japan) was used instead of Kirschner wire. None of the patients underwent limbus resection or osteophyte resection. Range of motion (ROM) exercises of the hip joint commenced 7 days postoperatively, followed from the 6th postoperative week by partial weight-bearing. Full weightbearing was initiated 56 months postoperatively.

Table 1 Clinical score of 29 patients before and after rotational acetabular osteotomy (RAO, THA total hip arthroplasty) Score Excellent (18) Good (1517) (Fair 1214) Poor (< 12 or THA) Preoperative 0 6 18 5 Follow-up 5 14 6 4

Table 2 Radiological evaluation in 29 patients before and 3 months after RAO Preoperative Centre-edge angle (range) Acetabular roof obliquity (range) Head lateralisation index (range) 4.2 9.0 (22 to 10) 31 8.8 (12 to 47) 0.70 0.08 (0.59 to 0.91) Postoperative 33 9.0** (20 to 50) 5.4 10* (6 to 30) 0.67 0.11 (0.51 to 0.89)

* P < 0.01, ** P < 0.001, preoperative vs postoperative value, Wilcoxon signed-rank test

Results
Clinical evaluation showed a significant improvement from the preoperative mean of 12.8 1.4, with pain 3.0 0.7, mobility 5.0 0.5, and walking 4.8 0.5 to follow-up mean of 14.8 2.6, with pain 5.2 1.3, mobility 4.8 1.0, and walking 4.8 1.0 (Wilcoxon signed-rank test: P < 0.001). Improvement in pain grade was good, but that of mobility decreased. In 19 joints, functional grading showed a score of 15 or more at the time of follow-up to account for 66% of the total (Table 1). Aggravation compared with the preoperative score was observed in 8 joints, and in one joint total hip arthroplasty (THA) was performed in the 5th postoperative year. Category comparison of the clinical score did not demonstrate any significant difference; the aggravation cases concerned 3 joints in group A and 5 joints in group B. Radiologically, the CE angle showed significant improvement from a preoperative mean of 4.2 to a postoperative mean of 33, and the acetabular roof obliquity from a preoperative mean of 31 to a postoperative mean

of 5.4, with no case of aggravation. The head lateralization index improved from a preoperative mean of 0.70 to a postoperative mean of 0.67, but the difference was not significant (Table 2). Joint congruent index changed from a mean preoperative value of 3.7 to mean 3-month value of 5.5 and to mean follow-up value of 5.3. The follow-up joint congruent index was aggravated compared with the preoperative value in 6 joints. Narrowing of the lateral joint space was the cause of the decrease in joint congruent index with progression of osteoarthrosis and aggravation of the clinical score compared with the preoperative score. In the patients showing improvement, no change or aggravation in joint congruent index at the time of follow-up compared with the preoperative stage, significant differences in joint congruent index were observed 3 months postoperatively and at follow-up. Of 23 joints in the non-aggravation group, 11 with a joint congruent index of more than 6.0 observed 3 months postoperatively either maintained this value or showed improvement (Table 3). The factors found to be correlated to the clinical evaluation at the time of follow-up were joint congruent index

255 Table 3 Joint congruent index values Total (29 joints) Joints showing improvement or no change at follow-up compared with preoperative index (n = 23) Preoperative 3.7 1.4 3.7 1.6 3 months postoperative 5.5 1.5 5.7 1.6 > 6.0 (11 joints) 7.0 0.9 < 5.9 (12 joints) ** 4.4 0.9 4.5 0.6 * 4.7 0.8 2.4 0.4 Follow-up 5.3 2.0 6.0 1.5 7.5 0.4 ** **

* P < 0.05, ** P < 0.001, MannWhitney U-test Fig. 3 ac A 50-year-old woman belonging to category B. Clinical score improved from preoperative 11 (pain: 2, mobility: 5, walking: 4) to follow-up of 17 (pain: 6, mobility: 6, walking: 5) at 9 years and 1 month postoperatively. Joint congruent index was 5 preoperatively (a), 6.5 at 3 months postoperatively (b), and 7 at follow-up (c). No change in the non-operated side was observed at the early stage Fig. 4 ac A 21-year-old woman belonging to category B. At the age of 13 years, she underwent varus osteotomy. RAO was performed together with valgus osteotomy of the femur. Clinical score improved from preoperative 14 (pain: 4, mobility: 5, walking: 5) to follow-up of 16 (pain: 6, mobility: 5, walking: 5) at 8 years postoperatively. Joint congruent index improved from 5 preoperatively (a) to 6.5 postoperatively (b), and to 7.5 following remodeling (c). No change in the non-operated side was observed at prearthrosis Fig. 5 ac A 31-year-old woman belonging to category B. Clinical score aggravated from preoperative 13 (pain: 3, mobility: 5, walking: 5) to follow-up of 10 (pain: 4, mobility: 2, walking: 4) at 9 years and 6 months postoperatively. Joint congruent index improved from preoperative 3.0 (a) to postoperative 4.5 (b), but decreased to 2.0 at follow-up (c)

Joints showing aggravation at follow-up compared with preoperative index (n = 6)

4.0 1.1

3a

4a

5a

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at the time of follow-up (R = 0.740, P < 0.0001), postoperative follow-up period (R = 0.597, P < 0.001) and joint congruent index 3 months postoperatively (R = 0.497, P < 0.01), but age at time of surgery (R = 0.230), head lateralisation index 3 months postoperatively (R = 0.140), preoperative joint congruent index (R = 0.126), CE angle 3 months postoperatively (R = 0.063) and acetabular roof obliquity 3 months postoperatively (R = 0.056) were not found to be correlated (Figs. 35). Surgical complications No major complications were observed such as penetration of the chisel into articular cartilage, deep infection, damage to intrapelvic structures, non-union and osteonecrosis of the acetabulum. One complication seen was transient irritation of the lateral femoral cutaneous nerve in 2 patients.

Discussion
Trousdale et al. [14] in their study of 42 joints of patients (mean age at operation 37 years, mean postoperative course 4 years) reported that of the 33 joints belonging to grades 1 and 2 of Tnniss classification, the results were excellent or good in 32, and of the 9 joints belonging to grade 3, that is, advanced stage, the results were fair or poor in 8 joints. Kleuver et al. [5] evaluated 48 joints (mean age at operation 28 years, mean postoperative course 10 years) and observed progression of osteoarthrosis in 10 joints (21%) when compared with preoperative osteoarthrosis, indicating that the presence or absence of osteoarthrosis influences the postoperative results. Yano et al. [17] in their report on the results of RAO performed on 50 joints with advanced osteoarthrosis of middle-aged patients who were studied for a mean postoperative course of 3 years and 3 months noted that the results were satisfactory in 82%, but collapse of the femoral head developed in 4 joints within 1 year postoperatively. Also, use of a cane was necessary to allow the hip joint to adjust to the new postoperative biomechanical environment. In these reports, it was found radiologically that there was adequate coverage of the femoral head postoperatively, but no reference has been made whatsoever to the correlation of the postoperative joint congruency to the clinical results. In our study of RAO for advanced arthrosis, improvement of femoral head coverage and femoral head position was almost possible, but adequate improvement of joint congruency was not necessarily possible. If a joint congruent index of more than 6.0 can be obtained postoperatively, it is possible to maintain a satisfactory clinical score for a mean postoperative period of 8 years and to prevent progression of radiological osteoarthrosis. Thus, joint congruency is the most important factor in the postoperative results. The joint congruent index proposed by Konishi et al. [6] was computed by multiple regression analysis of a

combination of congruent indices, showing the highest correlation with the mean values based on a 10-point congruency evaluation done by 6 hip joint specialists on 10 joints with osteoarthrosis, with each specialist using his own arbitrary criterion. At present, the decision for the operative indication of RAO is based on joint congruency observed on preoperative anteroposterior view of X-ray of the hip in abduction. This must be considered a non-quantitative evaluation. We feel that the congruent index proposed by Konishi et al. is one which should be employed in future when deciding on operative indications. According to Millis [9], reconstructive surgery including periacetabular osteotomy is possible only if the articular cartilage retains enough biological plasticity to adjust to the reorientation imposed by the operation. Our experimental study on RAO [18] also indicated that remodelling of the articular cartilage develops in the early postoperative stage in response to load stress. Synthetic clones of chondrocytes [10] have been observed in the medial acetabulum which moved from a secondary load site to the primary load site, and these histological changes gradually stabilize. Unless such favorable cartilage remodelling occurs, progression of osteoarthrosis cannot be avoided. Therefore, in order to prevent postoperative progression of osteoarthrosis, activity of articular cartilage that can adjust to changes in load stress is important. Degeneration of articular cartilage in advanced cases in particular is relatively severe, and the plasticity and activity of the cartilage tissue cannot be very high. Thus, indications should be restricted to patients in whom improvement of joint congruency can be obtained postoperatively to some extent. The long-term results of RAO (more than 10 years) have been satisfactory for prearthrosis and early stage osteoarthrosis secondary to dysplasia of the hip, but it is undeniable that the long-term results of advanced cases are inferior. RAO for advanced stage arthrosis is not a procedure to replace THA, but THA should be put off for as long as possible in young patients. If it can be predicted even in advanced cases that the postoperative joint congruent index would be 6.0 or more, satisfactory long-term results can be expected by RAO.

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