minimal invasive periacetabular osteotomy (PAO) for adult hip dysplasia surgical tips and tricks

Background: Periacetabular osteotomy (PAO) is an established surgical intervention for symptomatic developmental dysplasia of the hip (DDH) in skeletally mature patients, aimed at optimizing femoral head coverage and delaying secondary osteoarthritis. Traditional techniques involve extensive soft tissue dissection, necessitating modifications to reduce surgical morbidity and accelerate postoperative recovery.

Objective: This article describes a modified minimally invasive PAO technique utilizing a bikini incision and muscle-preserving approaches, detailing the surgical steps, preoperative planning, and clinical indications.

Key Points: Preoperative assessment requires digital 2D planning to target a lateral center-edge angle of 30° and a femoral extrusion index ≤ 25%. The modified technique employs a short ilioinguinal (bikini) incision and preserves the origins of the sartorius and rectus femoris muscles. Four distinct osteotomies—ischial, pubic, supraacetabular, and retroacetabular—are performed through two surgical windows. Maintaining a 1-cm posterior column bridge is critical for pelvic stability and early mobilization. Intraoperative assessment of the hip range of motion is mandatory; if impingement persists despite optimal acetabular reorientation, a concomitant femoral head-neck osteochondroplasty is performed via a Smith-Petersen interval. Postoperative protocols include 50% weight-bearing for four weeks and pharmacological prophylaxis against heterotopic ossification.

Conclusion: The modified minimally invasive PAO provides effective radiographic correction of DDH while minimizing soft tissue trauma. Success depends on precise preoperative planning, maintenance of posterior column integrity, and intraoperative verification of impingement-free range of motion to ensure favorable clinical outcomes in young adults with mild to no preoperative osteoarthritis.