Intraoperative Fluoroscopy for Minimally Invasive Periacetabular Osteotomy: A Standardized Step-By-Step Operative Technique.

BACKGROUND: Periacetabular osteotomy (PAO) is an established joint-preserving procedure for symptomatic acetabular dysplasia and other forms of acetabular malalignment. Although minimally invasive techniques have reduced surgical morbidity while maintaining correctional accuracy, the procedure remains technically demanding and relies heavily on intraoperative fluoroscopic guidance. Existing descriptions of minimally invasive PAO provide limited detail regarding the systematic use of fluoroscopy throughout the osteotomy sequence. This article describes a standardized fluoroscopy-guided technique for minimally invasive PAO. OPERATIVE TECHNIQUE: The procedure is performed through an 8-10 cm inguinal incision with preservation of key soft-tissue structures. A sequential series of fluoroscopically guided osteotomies of the superior pubic ramus, ischium, supra-acetabular region, and posterior column are performed using defined radiographic landmarks and checkpoints. Biplanar fluoroscopy is integrated throughout the procedure to confirm osteotome trajectory, osteotomy depth, fragment mobility, and final acetabular correction. Intraoperative assessment includes restoration of acetabular coverage, version, and inclination, with confirmation of lateral center-edge angle, Tönnis angle, anterior wall index, and posterior wall index. Technical pearls, pitfalls, and strategies to minimize neurovascular injury are highlighted. CONCLUSION: This standardized fluoroscopic protocol provides a reproducible framework for minimally invasive PAO. By integrating step-specific radiographic guidance with key anatomical landmarks, the technique aims to improve osteotomy control, optimize acetabular correction, and enhance procedural safety, particularly during the learning phase of this complex hip-preserving procedure.