Rehabilitation

Guidelines after

Periacetabular

Osteotomy

(PAO)

March 2017

Bobby Jean Lee, PT, DPT, SCS, CSOMT, CSCS, USAW

Texas Health Sports Medicine

Fort Worth, TX

To discuss the patient criteria for selection for a PAO procedure

Describe the surgical procedures utilized for PAO

Discuss the rehabilitation guidelines implemented after PAO

Objectives

HIP

PRESERVATION

Classifying Hip Pain

Classifying hip pain:

Non-hip disorders with referred pain

Extra-articular hip disorders

Intra-articular disorders without

structural abnormality

Structural abnormalities

Advance intra-articular disorders

Clohisy et al, 2005

Indications for Hip Preservation

Surgery

Age < 40 yo

Epiphyseal plates closed

Acetabular dysplasia present

Hip flexion ROM > 100°

OA

Mild to moderate OA in those with well preserved hip ROM and joint

congruency

Clohisy et al, 2005; Pogliacomi et al, 2005

Contraindications for Hip

Preservation Surgery

Lack of congruency between

acetabulum and femoral head

Open physes

Complete dislocation

Advanced OA

Advanced age at which time a THA

would give good results

Imaging Indications

A/P and Lateral Rx Views:

Pelvis

Increased acetabular

retroversion (cross over sign)

Normal = 15°-20° of

anteversion

Acetabular protrusion

Measurements:

Tonnis angle (AI):

Normal < 10°

Abnormal ≥ 15°

Center edge angle of Wiberg:

Normal > 25°

Dysplasia < 15°

Nunley et al. 2011

Mechlenburg et al. 2007

Steppacher et al, 2014

Labral Involvement

Almost 50% prevalence of labral tear in those with mild to moderate

dysplasia

Majority anterior tears

Few posterior or lateral tears

No isolated posterior or lateral tears

McCarthy et al, 2001; Peelle et al, 2005

Arthroscopic labral debridement:

Short term relief

Not recommended alone

Anterolateral cartilage damage

Kain et al, 2011

PAO

What is PAO?

Augmentation and reorientation of the acetabulum to improve femoral

head coverage

Most commonly used is Bernese PAO, 1983

Polygon-shaped Acetabular Osteotomy

Encompasses ischium, pubis, and iliac portions of the pelvis

Freed osteotomized acetabulum is reoriented in desired position and

fixated with cortical screws.

Restores lateral and anterior center edge angles

Pogliacomi et al, 2005

Purpose of PAO Procedure

Normalize osseous

anatomy

Improve hip biomechanics

Decrease articular surface

overload

Relieve impingement

Decrease risk of premature

secondary OA

Clohisy et al, 2005

Additional Procedures &

Complications

In addition to the PAO, patients may also undergo:

Cam resection

Proximal femoral osteotomy

Labral repair or debridement

Complications

Transitory lateral femoral cutaneous nerve palsy

Malpositioning

Nonunion

Sciatic nerve lesion

Necrosis of acetabular fragment

HO

Benefits of PAO

Abductor, hip flexor & ER sparing

Preserves the posterior column

Enables multiplanar corrections

Preserves acetabular blood supply

Reliable healing

Preserves true pelvis

Accelerated rehabilitation

Delays need for THA

Clohisy et al, 2005; Pogliacomi et al,

2005

60% of hips survived avg of 20

years

Steppacher et al, 2008

PROTOCOLS

General Guidelines

NO:

Significant AROM hip flexion – 8 weeks

SLR – 8 weeks

Simultaneous hip extension and knee flexion –

8 weeks

Driving until FWB

No pool until 3 weeks

Raise toilet seat

Avoid excessive extension and ER (legs

crossed, etc.)

Do NOT push flexion – 12 weeks

PHASE I (0-6 weeks) Home Health or HEP

Precautions:

FFWB for 20# x 6-8 weeks

PROM/AROM: 3 weeks

Flexion: ≤ 90°

CPM to 60° for ≥ 4-6 hrs/day

for 2-4 weeks

Extension: 0-5°

IR/ER: 0-20°

Abduction: 0-45°

Ice:

Day: 0-7 – All day

7+ – 2-3x/day

PHASE I (0-6 weeks) Cont. Home Health or HEP

Exercises:

Quad and glute sets

Isometrics

Ankle pumps

LAQ

Standing HS curl

Heel slides to 90°

AROM all directions*

Upright bike (3 weeks)

Standing hip abduction (4

weeks)

Stretches:

Non-operative knee to chest

stretch

Long sit HS

Prone knee flexion

Progressive “belly” time

Manual: Grade I to II

mobilizations

AP glide

Long axis distraction

Phase I: Criteria for Progression

to Phase II

Low to no pain with ADL’s (≤4/10)

Pain/pinch free ROM:

PROM flexion: > 100°

PROM abd: > 40°

AROM extension: > 5°

Quadruped rock: > 110°

Muscle strength: Pain free up to 60 reps

Prone extension

LAQ

Standing knee flexion

Posterior pelvic tilt

Prone glute set

PHASE II (6-8 weeks)

Physical Therapy

Precautions:

PROM/AROM:

Within comfort level

No IR in flexion

WBAT

Avoid twisting

PHASE II (6-8 weeks) Cont.

Exercises:

Standing hip abduction +

resistance (8 weeks)

Quadruped rocking

Bent knee fall out

Plank progression

Clams/Sidelying abd

Child’s pose

Cat/camel

Core strengthening

Short lever extension

Prone IR/ER isometrics

Stretching:

All LE flexibility exercises

Manual:

+ Scar

massage/desensitization

Phase II: Criteria for

Progression to Phase III Low to no pain with ADL’s (≤3/10)

Pain/pinch free ROM:

PROM flexion: > 115°

PROM abd: > 45°

WFL:

ER, extension, quadruped rock

Muscle strength: Pain free

Prone extension

Prone IR/ER

LAQ

Standing knee flexion

Standing march to 90°

Sidelying abd

Functional tasks:

SL balance for 60”

Ellip x 5’

Bike x 20’

PHASE III (8-12 weeks)

Precautions:

ROM:

Avoid extremes of ROM in all

directions

No forced rotation

WB:

Progress off crutches as

tolerated

PHASE III (8-12 weeks) Cont.

Exercises:

Hip rotation

Stand/sit resisted ER

Stool

Backwards and side stepping

Prone IR/ER

Bridge progression

Core roll outs

Squats/leg press to 45°

¼ Lunges

Step ups

Heel taps

Standing trunk rotation

Standing trunk rotation

Proprioception training

Advanced bridging

Cable column hip strengthening

Stretching:

Knee to chest stretch

Prone quad stretch

Manual: Grade III mobilizations

Inferior, lateral distraction, long axis

traction, AP

STM: TFL, Psoas

PHASE IV (12-20 weeks)

Precautions: Avoid forceful ROM, not too deep with TherEx

Exercises:

Dynamic balance drills

Hip strengthening is main focus

Lunge matrix

Tri-planar movements

Agility drills

Sport specific drills/plyos

Gradual hip flexor strengthening

Manual: Higher grade mobilizations

Cont. STM

PHASE V (>20 weeks) Criteria: Return to Sport/Running

Full pain free ROM

Strength testing > 90% of uninvolved side

Cardio respiratory fitness at pre-injury

level

Completion of sport specific loading and

functional training program

Progress:

Bilateral unilateral multiplanar

Acceleration/deceleration

Sagittal frontal

Tippet, 2006

+

THANK YOU!

+ QUESTIONS??

References

Clohisy JC, Keeney JA, Schoenecker PL. Preliminary assessment and treatment

guidelines for hip disorders in young adults. Clinical Orthopaedics and Related

Research. 2005;444:168-179.

Kain MSH, Novais EN, Vallim C, Millis MB, Kim YJ. Periacetabular osteotomy after

failed hip arthroscopy for labral tears in patients with acetabular dysplasia. J Bone

Joint Surg Am. 2011;93(2):57-61.

McCarthy JC, Noble PC, Schuck MR, Wright J, Lee J. The role of labral lesions to

development of early degenerative hip disease. Clinical Orthopaedics and Related

Research. 2001;393:25-37.

Mansour A, Juneau C. Hip PAO protocol phase I handout. 2018;1-12.

Mansour A, Juneau C. Hip PAO protocol phase II handout. 2018;1-5.

Mechlenburg I, Kold S, Rømer L, Søballe K. Safe fixation with two acetabular screws

after Ganz periacetabular osteotomy. Acta orthopaedica.2007;78:344-9.

Nunley RM, Prather H, Hunt D, Schoenecker PL, Clohisy JC. Clinical presentation of

symptomatic acetabular dysplasia in skeletally mature patients. J Bone joint Surg Am.

2011;93(2):17-21.

Peelle MW, Della Roca GJ, Maloney WJ, Curry MC, Clohisy JC. Acetabular and

femoral radiographic abnormalities associated with labral tears. Clinical

Orthopaedics and Related Research. 2005;444:327-333.

References

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2005;76(1):67-74.

Steppacher SD, Lerch TD, Gharanizadeh K, Liechti EF, Werlen SF, Puls M, Tannast M,

Siebenrock KA. Size and shape of the lunate surface in different types of pincer

impingement: theoretical implications for surgical therapy. Osteoarthritis and

Cartilage. 2014;22(7):951-958.

Steppacher SD, Tannast M, Ganz R, Siebenrock KA. Mean 20-year followup of Bernese

periacetabular osteotomy. Clin Orthop Rela Res. 2008;466:1633-1644.

Sucato DJ, Tulchin K, Shrader MW, DeLaRocha A, Gist T, Sheu G. Gait, hip strength and

functional outcomes after a Ganz periacetabular osteotomy for adolescent hip

dysplasia. J Pediatr Orthop. 2010;30(4):344-350.

Tippet SR. Returning to sports after periacetabular osteotomy for developmental

dysplasia of the hip. North American Journal of Sports Physical Therapy. 2006;1(1):32-

39.

Wells JE. Periacetabular osteotomy protocol handout. 2018;1-3.

Wenger DE, Kendell KR, Miner MR, Trousdale RT. Acetabular labral tears rarely occur

in absence of bony abnormalities. Clinical Orthopaedics and Related Research.

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