The gold standard surgical treatment for hip dysplasia in adolescents and adults with preserved joint cartilage. Mr Balakumar trained in this technically demanding procedure at Harvard’s Children’s Hospital Boston.
(03) 9573 9659
Periacetabular osteotomy (PAO) is the gold standard surgical treatment for hip dysplasia in adolescents and adults with preserved joint cartilage. It repositions the acetabulum to correct abnormal coverage of the femoral head, reducing rim overload and protecting the joint from further damage. It is a joint preservation procedure, meaning the goal is to maintain the patient’s own hip for as long as possible rather than replacing it with an artificial one.
Mr Balakumar trained in PAO during his fellowship at Harvard’s Children’s Hospital Boston, one of the world’s leading centres for this procedure. He has performed PAO across a range of patient ages and levels of complexity.
The surgeon makes cuts around the acetabulum to free it from the pelvis, then rotates it into a more stable, horizontal position that provides better coverage of the femoral head. The repositioned acetabulum is held in place with screws while the bone heals. The procedure corrects the primary mechanical problem in dysplasia: the abnormal pressure of the femoral head on the rim of the acetabulum.
Between four and twelve months after surgery, most patients undergo screw removal as a brief outpatient procedure once the osteotomy has fully healed.
PAO is designed for patients whose growth plate around the socket has closed, which typically occurs in mid-adolescence. In younger children with open growth plates, different osteotomies are used.
In children under approximately seven years, a Dega or Pemberton osteotomy reduces the volume of the socket to improve stability. The Salter osteotomy reorients the socket in younger children and has excellent long-term results, though it allows less three-dimensional correction. The Bernese triple osteotomy is used in older children with open growth plates and allows greater correction, but carries more significant risks and should only be performed by surgeons with specific fellowship training in the technique.
The Ganz PAO, which Mr Balakumar performs, is the procedure of choice once the triradiate cartilage has closed. It involves five cuts in the pelvis around the socket, preserves the pelvic ring and allows full three-dimensional correction. It is technically one of the most demanding procedures in hip surgery. Mr Balakumar has been fellowship trained by the world-leading authority in this technique.
The ideal candidate has symptomatic hip dysplasia with preserved or near-preserved joint cartilage, little or no narrowing of the cartilage space on X-ray, and can flex the hip to at least 90 degrees with minimal pain. In borderline cases, Mr Balakumar uses dGEMRIC cartilage mapping to assess the health of the joint cartilage and help determine whether preservation or replacement is the better option.
Patients with significant cartilage loss are unlikely to benefit from PAO and are better served by hip replacement.
Hip preservation is not an inferior second choice to replacement. Recovery is longer, but a well-functioning native hip retains its own cartilage, sensation and mechanical properties in a way that an artificial joint cannot fully replicate. For younger patients with preserved cartilage, PAO offers the prospect of decades of function from their own hip before replacement is required, if it is required at all.
Of more than 800 patients who underwent various types of PAO over 16 years at Harvard’s Children’s Hospital Boston, only approximately 40 required total hip replacement. More than 90 per cent of patients had little or no pain and well-functioning hips at 10 years or more. The patients who required replacement were those who had the most cartilage damage before the PAO.
Hospital stay is typically three to five nights. Weight-bearing is restricted for six to eight weeks while the osteotomy heals, and crutches are used during this period. Full return to activity including sport takes six to twelve months. Physiotherapy is integral from the outset. Unlike hip replacement, there are no positional restrictions after PAO.
PAO is major surgery. Risks include infection, blood clots, nerve injury (particularly to the lateral femoral cutaneous nerve, causing numbness over the outer thigh), non-union of the osteotomy, heterotopic ossification and the possibility that further surgery including hip replacement may be needed in the longer term. Mr Balakumar discusses all risks in detail at the consultation.
(03) 9573 9659
Mr Balakumar is one of a small number of surgeons in Australia with formal training in both paediatric and adult hip surgery. His fellowship at Harvard’s Children’s Hospital in Boston, under some of the world’s leading specialists in hip preservation, gives him a depth of expertise that is difficult to find in a single practice.
His approach is the same whether the patient is 6 months or 65 years old – thorough assessment, honest options, and no pressure toward surgery until the clinical picture clearly supports it.
(03) 9573 9659
A procedure in which the femur is cut and repositioned to correct abnormal alignment around the hip or knee. Used in both paediatric and adult patients as part of joint preservation surgery.
An alternative to total hip replacement in which the femoral head is capped rather than removed. Suitable for a carefully selected group of younger, active patients with end-stage hip arthritis.
An open procedure allowing complete access to all surfaces of the hip joint. Used for complex conditions that cannot be adequately addressed through arthroscopy alone.
Keyhole surgery to treat impingement, labral tears and a range of other hip conditions. Mr Balakumar is fellowship trained in hip arthroscopy and performs labral repair and reconstruction as required.
Melbourne Orthopaedic Group is home to a team of experienced orthopaedic surgeons, providing comprehensive care for sports injuries and orthopaedic conditions. Whether it’s joint replacement or sports injuries, our specialists provide comprehensive orthopaedic care.
