Combined Periacetabular Osteotomy and Hip Arthroscopy Results in High Return to Sport Rates in Contact and Noncontact Athletes With Hip Dysplasia
Orthopaedic journal of sports medicine · 2026
Combined PAO plus arthroscopy gave 89% return-to-sport in this uncontrolled case series, in line with prior single-procedure data, not proof it's better.
The paper
Retrospective case series, n=103 hips in 84 athletic patients with hip dysplasia treated with combined periacetabular osteotomy and hip arthroscopy.
What they found
89.3% of hips returned to sport at a mean of 297.5 days; contact athletes had 82.5% RTS versus 93.7% for noncontact athletes, with no significant association between RTS and demographics, diagnosis, degree of dysplasia, or mHHS.
Study design
Single-institution retrospective case series (Level of evidence 4), 103 hips/84 patients, 2016-2023, with a minimum 6-month follow-up requirement and mean follow-up of about 17 months.
Methodology
There is no comparison group, so the 89.3% figure cannot be attributed to the combined procedure versus arthroscopy or PAO alone, it is simply compared against historical ranges from other studies. Retrospective design brings selection bias (single tertiary referral centre, likely a younger and more motivated athletic cohort), no blinding is possible for a surgical case series, follow-up length varies hugely (SD of 326 days on a mean of 515), and RTS is self-reported with no stated definition of what counts as 'returning'. The contact versus noncontact split (82.5% vs 93.7%) is a subgroup comparison on what is likely a small subgroup n, and the abstract does not report a formal statistical test or confidence interval for that specific comparison, only that other associations were 'not significant'; a clinician should ask for the actual subgroup sizes and CIs before trusting that gap is real.
The appraisal
An 89.3% RTS rate sounds impressive but sits within the range already reported for arthroscopy alone, PAO alone, and combined procedures in prior literature, so this is confirmatory rather than new evidence that combined surgery is superior. Without a control arm or randomisation, the study cannot support a causal or comparative claim, it can only describe what happened in one surgeon's/institution's cohort, and the non-significant subgroup findings need much larger numbers before ruling out real differences by dysplasia severity or contact status. Two more things temper the headline number: RTS wasn't defined against a standardised return-to-preinjury-level criterion, so it's unclear what 'returned' actually means for each athlete, and follow-up ranged hugely (mean 514.9 ± 326.5 days, minimum 6 months), so some athletes labelled as not-yet-returned may simply not have had enough time. The abstract's own framing that contact athletes and those with severe dysplasia had 'high' RTS 'specifically' also overstates the finding, contact athletes actually returned less often than noncontact (82.5% vs 93.7%), and neither association reached significance, so this reads more like reassurance dressed up as a subgroup win.
The gap
A prospective comparative study (or at minimum a well-matched cohort comparing combined surgery to arthroscopy-alone or PAO-alone in similar dysplasia severity) with a standardised RTS definition and adequate power for the contact-sport subgroup is needed before drawing conclusions about who benefits most.
Landmark context
This builds on the existing body of PAO and hip arthroscopy outcome literature cited in the introduction (arthroscopy-alone, PAO-alone, and prior combined-procedure series reporting 70-92% RTS), rather than overturning or extending a single landmark trial; there is no foundational RCT in this space to compare against.
What to do Monday
This does not change Monday's practice. It gives a reasonable ballpark (roughly 90% overall, lower for contact sport at around 82%) to quote when counselling athletic patients with dysplasia about RTS chances after combined PAO and arthroscopy, but don't present it as proof the combined procedure beats arthroscopy or PAO alone, and don't reassure contact-sport athletes that their odds match noncontact athletes, the numbers here point the other way even though it wasn't formally significant.
In practice
This applies to young athletic patients (mean age ~20) with symptomatic hip dysplasia (LCEA <25°) going through combined PAO and arthroscopy who want to get back to sport, contact or not. In clinic, use the roughly 10-month (297-day) mean RTS timeline to set expectations and pace rehab progressions (hip abductor and external rotator strength, single-leg control, impact tolerance) rather than clearing on a fixed calendar date, and be upfront with contact-sport athletes that this cohort's RTS rate was numerically lower, so don't promise them the headline 89% figure. On the S&C floor, treat these athletes as a distinct long-timeline return-to-performance population, coordinate directly with the surgical and physio team on when to introduce loaded, cutting, and contact work rather than assuming standard post-arthroscopy hip timelines apply, and use an objective strength gate such as the Single Leg Hip Thrust or Cable Hip Abduction test, given PAO surgical approaches commonly affect abductor function, to individualise clearance for contact drills instead of relying on time since surgery alone.
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