The incidence and risk factors for stress fracture following periacetabular osteotomy

Bone Joint J. 2022 Sep;104-B(9):1017-1024. doi: 10.1302/0301-620X.104B9.BJJ-2021-1391.R3.


Aims: The aims of this study were to characterize the incidence and risk factors associated with stress fractures following periacetabular osteotomy, and to determine their effect on osteotomy union.

Methods: We retrospectively reviewed all periacetabular osteotomies (PAOs) performed for developmental dysplasia of the hip (DDH) at one institution over a six-year period between 2012 and 2017. Perioperative factors were recorded, and included demographic and surgical data. Postoperatively, patients were followed for a minimum of one year with anteroposterior and false profile radiographs of the pelvis to monitor for evidence of stress fracture and union of osteotomies. We characterized the incidence and locations of stress fractures, and used univariate and multivariable analysis to identify factors predictive of stress fracture and the association of stress fracture on osteotomy union.

Results: A total of 331 patients underwent PAO during the study period with 56 (15.4%) stress fractures: 46 fractures of the retroacetabular posterior column, five cases of ischiopubic stress fracture, and five cases of concurrent ischiopubic and retroacetabular stress fractures. Overall, 86% (48/56) healed without intervention. Univariate analysis revealed that stress fractures occurred more frequently in females (p = 0.040), older patients (mean age 27.6 years (SD 8.4) vs 23.8 (SD 9.0); p = 0.003), and most often with the use of the broad Mast chisel (28.5%; p < 0.001). Multivariable analysis revealed that increasing age (odds ratio (OR) 1.04; 95% CI 1.01 to 1.07; p = 0.028) and use of the broad Mast chisel (OR 5.1 (95% CI 1.3 to 19.0) compared to narrow Ganz chisel; p = 0.038) and surgeon (p = 0.043) were associated with increased risk of stress fracture. Patients with stress fractures were less likely to have healed osteotomies after one-year follow-up (76% vs 96%; p < 0.001).

Conclusion: Stress fracture of the posterior column may be an under-recognized complication following PAO, and the rate may be influenced by surgical technique. Consideration should be given to using a narrow chisel during the ischial cut to reduce the risk of stress propagation through the posterior column.Cite this article: Bone Joint J 2022;104-B(9):1017-1024.

Keywords: Complication; Ischiopubic stress fracture; Osteotomies; Periacetabular osteotomy; Posterior column stress fracture; Radiographs; Stress fracture; Stress fractures; Univariate analysis; developmental dysplasia of the hip (DDH); hips; lateral centre-edge angles (LCEAs); pelvis; periacetabular osteotomies; t-tests.

MeSH terms

  • Acetabulum / surgery
  • Adult
  • Female
  • Fractures, Stress* / diagnostic imaging
  • Fractures, Stress* / epidemiology
  • Fractures, Stress* / etiology
  • Hip Dislocation* / etiology
  • Hip Joint / surgery
  • Humans
  • Incidence
  • Osteotomy / adverse effects
  • Osteotomy / methods
  • Retrospective Studies
  • Risk Factors
  • Treatment Outcome