Chiari pelvic osteotomy for advanced osteoarthritis in patients with hip dysplasia

BACKGROUND: It is not clear whether a Chiari pelvic osteotomy performed for the treatment of advanced osteoarthritis can delay the need for total hip arthroplasty. We present the mid-term results of the Chiari pelvic osteotomy performed for the treatment of T?nnis grade-3 osteoarthritis (large cysts, severe narrowing of the joint space, or severe deformity or necrosis of the head with extensive osteophyte formation), with a particular focus on whether this procedure can delay the need for total hip arthroplasty. METHODS: We followed thirty-two hips in thirty-one patients with T?nnis grade-3 osteoarthritis who had refused total hip arthroplasty and had been treated with a Chiari pelvic osteotomy. The mean age at the time of surgery was 35.2 years. The mean duration of follow-up was 11.2 years, at which time clinical evaluation with the Harris hip score and radiographic evaluation were performed. RESULTS: The average Harris hip score improved from 52 points preoperatively to 77 points at the time of follow-up; the average pain score improved from 20 to 31 points. Three hips with a hip score of <70 points required total hip arthroplasty. With a hip score of <70 points as the end point, the cumulative rate of survival at ten years was 72%. The clinical outcome was significantly influenced by the preoperative center-edge angle (p = 0.004), the preoperative acetabular head index (p = 0.039), achievement of the appropriate osteotomy level (p = 0.011), and superior migration (p = 0.009) and lateral migration (p = 0.026) of the femoral head. CONCLUSIONS: Although the clinical results were inferior to those of total hip arthroplasty, Chiari pelvic osteotomy may be an option for young patients with advanced osteoarthritis who prefer a joint-conserving procedure to total hip arthroplasty and accept a clinical outcome that is predicted to be less optimal than that of total hip arthroplasty. Moderate dysplasia and moderate subluxation without complete obliteration of the joint space and a preoperative center-edge angle of at least -10 degrees are desirable selection criteria.     

Valgus-extension osteotomy for osteoarthritis of the hip. Indications and long-term results

We reviewed the results of 277 intertrochanteric valgus-extension osteotomies performed between 1973 and 1975 for primary or secondary osteoarthritis. The average age of the patients was 51 years and follow-up varied from 11 to 15 years. At the latest evaluation 67% of the hips were good or excellent on the Merle D'Aubigné scale. Better results were obtained in patients under 40 years of age with unilateral involvement and a mechanical (secondary) aetiology. An elliptical femoral head, minimal subluxation and an adequate pre-operative range of motion were also favourable. There was radiographic evidence of regression of the arthritic changes in 39% of the hips at final review. Valgus-extension osteotomy is effective for secondary osteoarthritis of the hip in selected younger patients, but not for those with primary hip disease or a poor range of movement.     

The Chiari pelvic osteotomy—Indications and results

Summary Chiaris pelvic osteotomy with or without intertrochanteric osteotomy was performed in more than 100 cases during the past ten years. An evaluation of 97 operations showed good results in younger patients (age groups from 5–17 years). In adults with evident signs of arthrosis a higher rate of failures was obvious and therefore the indication for the pelvic osteotomy in this group of patients should be restricted.

---

Zusammenfassung Aufgrund einer Nachuntersuchung von 97 Operationsergebnissen nach Chiari-Beckenosteotomie mit und ohne intertrochantere Osteotomie, zeigt sich, daß gute Resultate bei Patienten vom 5. bis zum 17. Lebensjahr zu erwarten sind. Die besten Ergebnisse wurden bei Patienten vom 5. bis 7. Lebensjahr erreicht. Erwachsene Patienten mit deutlichen Arthrosezeichen wiesen die höchste Rate an schlechten Ergebnissen auf.

     

Triple pelvic osteotomy as treatment for osteoarthritis secondary to developmental dysplasia of the hip

Joint-preserving osteotomies are an established treatment for adult hip pain secondary to developmental dysplasia of the hip. However, their value for advanced osteoarthritis is unclear. Therefore this study addresses the question of long-term results of triple pelvic osteotomy in patients with second grade osteoarthritis. Thirty-two patients with second grade osteoarthritis secondary to developmental dysplasia of the hip before triple pelvic osteotomy were clinically and radiographically assessed 11.5 years postoperatively. Five patients required conversion to total hip replacement. Kaplan-Meier survivorship analysis predicted a survival rate of 85.3%. The mean Harris hip score increased significantly with more than 56% good or very good results. A preoperative BMI > 25 and Harris hip score < 70 resulted in worse outcome or early conversion into total hip arthroplasty. The results indicate that developmental dysplasia of the hip even in second grade osteoarthritis can be treated with triple pelvic osteotomy.     

Long-term results of Chiari pelvic osteotomy in patients with developmental dysplasia of the hip: indications for Chiari pelvic osteotomy according to disease stage and femoral head shape

Background We evaluated the long-term results of Chiari pelvic osteotomy for developmental dysplasia of the hip (DDH) after follow-up of 10 years or more. The indications for Chiari osteotomy were assessed based on the results. Methods We evaluated 74 hips in 69 patients treated for DDH with Chiari osteotomy. The average postoperative follow-up period was 13 years. The mean age at the time of surgery was 32 years (range 6–64 years). The disease was classified into two stages based on joint space measurements on radiographs: an early stage (36 hips) in which the mean age at surgery was 21 years (range 6–48 years) and an advanced stage (38 hips) in which the mean age at surgery was 41 years (range 18–64 years). Femoral head shape was classified into two types based on measurements of the sphericity of the femoral head: spherical (33 hips) or flat (41 hips). Clinical manifestations were evaluated according to Japanese Orthopaedic Association (JOA) hip scores. The joint space was measured on radiographs as an index of the progression of osteoarthritis. We attempted to identify factors that affected the long-term results of Chiari osteotomy, especially in regard to disease stage and femoral head shape. Results The mean total JOA score was 72 preoperatively and 87 at final follow-up. It had improved in 66 hips and was worse in 7 hips. All of the worse cases were at the advanced stage at the time of surgery, and in 6 of the worse cases the femoral head was spherical. Hips with advanced DDH and a spherical femoral head had poor outcomes and exhibited joint space narrowing postoperatively. Conclusions Early DDH is considered a good indication for Chiari pelvic osteotomy because of the good results at 10 years or more. Even with advanced DDH, a flat femoral head predicts a good surgical outcome, but patients with a spherical femoral head may experience early progression to osteoarthritis.     

Rotational acetabular osteotomy for advanced osteoarthritis secondary to dysplasia of the hip

BACKGROUND: Satisfactory intermediate and long-term results of rotational acetabular osteotomy for the treatment of early osteoarthritis secondary to developmental dysplasia of the hip have been reported. The purpose of this study was to examine the results of rotational acetabular osteotomy in patients with advanced osteoarthritis secondary to developmental dysplasia of the hip. METHODS: We performed a retrospective review of the results of rotational acetabular osteotomy in forty-three patients (forty-three hips). All of the patients had radiographic evidence of advanced-stage osteoarthritis, defined as narrowing of the joint space with cystic radiolucencies and small osteophytes according to the staging system of the Japanese Orthopaedic Association. Forty-one patients were female, and two were male. The mean age was 43.8 years at the time of surgery, and the mean duration of follow-up was 8.5 years. Clinical follow-up was performed with use of the system of Merle d'Aubigné and Postel. The center-edge angle, acetabular roof angle, head lateralization index, and minimum width of the joint space were measured on radiographs made preoperatively, postoperatively, and at the time of final follow-up. Postoperative joint congruency was classified into four grades. RESULTS: The mean preoperative Merle d'Aubigné clinical score was 13.3 points, which improved to a mean of 15.4 points at the time of the latest follow-up (p < 0.0001). The mean center-edge angle improved from 0.7 degrees preoperatively to 29 degrees at three months postoperatively (p < 0.0001), the mean acetabular roof angle improved from 30 degrees to 11 degrees (p < 0.0001), the mean head lateralization index improved from 0.69 to 0.65 (p < 0.01), and the mean minimum width of the joint space improved from 2.2 to 2.5 mm (p < 0.0003). Ten hips had radiographic evidence of progression of osteoarthritis. Kaplan-Meier survivorship analysis, with radiographic signs of progression of osteoarthritis as the end point, predicted a ten-year survival rate of 72.2%. CONCLUSIONS: Rotational acetabular osteotomy for advanced osteoarthritis secondary to dysplasia of the hip in properly selected patients can improve clinical scores and is associated with a lack of radiographic signs of progression of osteoarthritis in most patients. LEVEL OF EVIDENCE: Therapeutic Level IV.     

The Chiari pelvic osteotomy. A review of the long-term results

We report the clinical and radiographic results of the Chiari pelvic osteotomy in 49 hips (45 patients) at an average of 14 years after operation. Of these hips, over half had minimal or no pain, had good or excellent results as assessed by the Harris hip score, and could walk at least three miles; three-quarters, however, had a positive Trendelenburg sign. A younger age at operation and a painless hip with no radiographic evidence of degeneration before operation were associated with a higher hip score at review. The percentage of hips without degenerative changes fell from 68% before operation to 15% at final review. There were no major complications and it was found that a Chiari osteotomy need not interfere with normal childbirth.     

Chiari pelvic osteotomy in the treatment of hip dysplasia in adults]

INTRODUCTION: [corrected] The aim of the study is early results evaluation of Chiari pelvic osteotomy. MATERIALS AND METHODS: In the years 1997-2003 36 patients (26 women and 10 men) in the age from 16 to 50 years old were operated on because of hip joint dysplasia. The indications for operative treatment were: pain, age less than 50 years, insufficient femoral head coverage without evidence of arthritic changes on X-ray. RESULTS: There were no intraoperative and postoperative complications. Harris Hip Score improved from 85 points before operation (from 82 to 90 pts.) to 95 points (from 92 to 100 pts.) after operative treatment. There was pain relief in most of the patients after osteotomy. Osteotomy healing was seen on X-ray examination usually after 6-12 weeks in 33 patients. Delayed osteotomy union till 6th postoperative month without influence on clinical hip improvement was seen in 3 patients. The increase in Wiberg CE angle from average 17.2 degrees (from 3 to 33 degrees) before operation to 44.9 degrees (from 19 to 78 degrees) after operation was statistically significant p< 0.00045. There was no loss in osteotomy correction. CONCLUSION: Supraacetabular osteotomy decreases pain, and increases hip function. Improvement in hip biomechanics and increase in femoral head coverage may lead to decrease in development of hip joint arthritic changes and time preserve before total hip arthroplasty.     

Rotational acetabular osteotomy for advanced osteoarthritis secondary to developmental dysplasia of the hip

We evaluated the results of rotational acetabular osteotomy in 44 hips (42 patients) with advanced osteoarthritis secondary to developmental dysplasia. The mean age of the patients at surgery was 43.4 years (30 to 59) and the mean follow-up was 12.1 years (8 to 19). The mean Merle d'Aubigné clinical score improved from 10.8 points (8 to 15) pre-operatively to 13.5 points (6 to 18) at follow-up. Radiologically, this procedure produced adequate improvement regarding cover of the femoral head. At follow-up, the osteoarthritic stage assessed using the Japanese Orthopaedic Association grading, was improved in 11 hips (25%), unchanged in 22 (50%) and had progressed in 11 (25%). The mean pre-operative roundness index of the femoral head was significantly different in the 33 hips which had improved or maintained their osteoarthritic stage compared with the 11 which had progressed (53.7% vs 63.7%; p < 0.001). Osteoarthritis with a round femoral head is considered to be an indication for rotational acetabular osteotomy, even in advanced stages of the disease.     

The Chiari pelvic osteotomy. A long-term review of clinical and radiographic results

We have reviewed a series of 94 Chiari pelvic osteotomies carried out from 1966 to 1982. In 83 hips the indication for surgery had been pain, and of these patients 73 (88%) had appreciable relief within one year of operation. The other 11 hips were all in children and were painless; in them the osteotomy had successfully stabilised progressive subluxation of the hip. At review after a mean follow-up of 10 years (range, 2 to 18 years) 68 previously painful hips were reassessed. Although function of the hips had deteriorated slowly with time, four of the seven cases with 18 years' follow-up had good function and only minor symptoms. A detailed analysis of the radiographic changes produced by the Chiari osteotomy was made, using computerised analysis of variance. The beneficial effects of the osteotomy resulted from complex changes, among which the provision of a stable fulcrum for the hip seemed to be the most important.     

Combined intertrochanteric and Chiari pelvic osteotomies for hip dysplasia

Thirty-two dysplastic hips with secondary osteoarthritis, in 28 patients aged 18 to 42 years, were treated by combined intertrochanteric and Chiari osteotomy. They were followed up for 2.5 to 10 years. Pain was the main presenting symptom in all the patients. The indication for surgery was based on the severity of disease with respect to congruency, secondary degenerative change and degree of dysplasia. The average pre-operative Harris hip score was 47.7 and the majority had severe dysplasia with degenerative changes. On final review the average score was 88. The radiographic appearances of degenerative arthritis regressed in 72% of hips and dysplasia was improved in all cases. The results of this conservative form of surgery are better in hips with less severe dysplasia and mild secondary degenerative change.     

Endoscopic pelvic osteotomy for the treatment of hip dysplasia.

Adolescent and adult hip dysplasia can be surgically treated by rotating the acetabulum into a better weight-supporting position; however, open pelvic osteotomies are among the most invasive of all pediatric orthopaedic procedures. Endoscopic pelvic osteotomy offers the theoretical advantages of magnified visualization of the bone cuts, minimized surgical dissection, and rapid postoperative recovery. The technique of endoscopically assisted triple innominate osteotomy requires the combination of endoscopic skills and facility with more standard surgical approaches.     

Transtrochanteric valgus osteotomy for the treatment of osteoarthritis of the hip secondary to acetabular dysplasia

Our study describes the mid-term clinical results of the use of transtrochanteric valgus osteotomy (TVO) for the treatment of osteoarthritis of the hip secondary to acetabular dysplasia. The operation included valgus displacement at the level of the lesser trochanter, and lateral displacement of the greater trochanter by inserting a wedge of bone. We reviewed 70 hips. The mean age of the patients at operation was 44 years (14 to 59). Most (90%) had advanced osteoarthritis. The scores for pain and gait had improved significantly at a mean follow-up of 9.4 years. The rate of survival until an endpoint of a further operation during a follow-up of ten years was 82%. The survival rate was 95% in patients with unilateral involvement who were less than 50 years of age at operation. TVO is a useful form of treatment for advanced osteoarthritis of the hip, particularly in young patients with unilateral disease.     

Modified Chiari pelvic osteotomy: a long-term follow-up study.

In a series of 100 modified Chiari pelvic osteotomies in ninety-six patients, who were followed for an average of nine years and three months (range, six years to fourteen years and eight months), an excellent or good clinical result was obtained in seventy-eight hips. The level of the osteotomy line on postoperative radiographs was compared with the clinical result. The average clinical result was good in seventy-four (84 per cent) of the eighty-eight patients in whom the osteotomy was at the I-I, I-II, or II-II level, according to the classification of levels by Azuma et al., but was good in only four of the twelve patients in whom the osteotomy was at another level (p = 0.0003). We found that smooth anterior and lateral coverage can be obtained by the use of a dome-shaped osteotomy line.     

髋臼旋转截骨术治疗早中期髋关节发育不良

目的探讨髋臼旋转截骨术治疗早中期髋关节发育不良的手术技术要点及中期疗效。方法2000年5月至2006年5月对12例（14髋）早、中期髋关节发育不良患者进行了髋臼旋转截骨术,所有患者均为女性,手术时年龄13—46岁,平均28．9岁。随访时间3．1—9．1年,平均6．0年。术前、术后及随访时X线片上测量CE角,髋臼顶角及头外移指数。Harris评分判断髋关节功能。手术采用Oilier外侧“U”形入路,股骨大转子截骨显露。术后未行外固定。结果患者疼痛症状得到明显改善,Harris评分术前72分,术后91分（P〈0．001）。CE角术前0．9°,术后27°（P〈0．001）;髋臼顶角术前为29°,术后5°;头外移指数术前为0．68,术后0．65。所有病例截骨块及股骨大转子截骨处愈合良好。结论Oilier外侧“U”形入路行髋臼旋转截骨术髋臼缘显露充分;治疗早中期髋关节发育不良可以缓解疼痛,延缓骨关节炎的进展速度,中期随访疗效满意。     

Total hip arthroplasty of dysplastic hip after previous Chiari pelvic osteotomy

Introduction: Many reports have suggested that Chiari pelvic osteotomy would improve the results of acetabular component placement and fixation in subsequent total hip arthroplasty. However, little is known concerning the biomechanical, radiological, and clinical effects of Chiari pelvic osteotomy on subsequent total hip arthroplasty. Materials and methods: Ten total hip arthroplasties for developmental dysplasia of the hip after previous Chiari pelvic osteotomy (Chiari group) were compared with 20 total hip arthroplasties for developmental dysplasia of the hip without previous surgery (control group). Preoperative patient demographic data and operative technique were well matched between the groups. The mean duration of follow-up was 3.0 years. Biomechanical, radiological, and clinical evaluations were performed. Results: No acetabular or femoral components exhibited loosening. All patients had good or excellent clinical score according to the Merle d’Aubigne-Postel rating system at the most recent follow-up. Abductor force and joint force were smaller in the Chiari group, although long operative time, more blood loss, and verticalization of joint force were noted in this group. Conclusion: This limited study suggested that Chiari pelvic osteotomy changed the biomechanical features of the hip joint, and that this alteration might have compromised subsequent total hip arthroplasty.     

Biomechanical analysis of hip function after Chiari pelvic osteotomy

Summary The reasons are discussed for differences in functional results of the pelvic osteotomy after Chiari, regardless of the fact that the CE and AC angles were equal in all patients. When lateralization and distal displacement of the greater trochanter were performed in addition to the pelvic osteotomy, the functional results proved to be better. Biomechanical analysis of the relationship between gluteal force and body weight revealed that these relations change; in all examined cases where lateralization and distal displacement of the greater trochanter were performed, the relationship proved postoperatively to be considerably more favorable. In the same group of patients, the relationship between the force of reaction and body weight was also changed after surgery. Therefore, lateralization and distal displacement of the greater trochanter are important factors for the undisturbed functioning of a hip; in all examined patients the functional results were better when lateralization and distal displacement of the greater trochanter were performed.

---

Zusammenfassung In der Arbeit werden die Gründe erörtert, aus welchen es nach der durchgeführten Beckenosteotomic nach Chiari bei gleichen CE- und AC-Winkelwerten bei einigen Patienten zu besseren und bei anderen zu schlechteren Funktionsergebnissen kommt. Das Funktionsergebnis war bei jenen Patienten besser, bei denen neben der Beckenosteotomie auch die Lateralisation und die Distalisation des großen Trochanters durchgeführt wurden. Aufgrund der biomechanischen Analyse der relativen Verhältnisse des Gesäßmuskels zum Körpergewicht hat man festgestellt, daß sich diese ändern und daß sie nach der Operation in allen geprüften Fällen, wo Lateralisation und Distalisation durchgeführt wurden, wesentlich günstiger sind. Die Verhältnisse der Reaktionskräfte in Bezug aufs Körpergewicht ändern sich nach der Operation bei der gleichen Patientengruppe genauso. Es ist offensichtlich, daß Lateralisation und Distalisation des großen Trochanters einen wichtigen Faktor für eine regelrechte Funktion des Gelenkes darstellen, daß er bei allen unseren geprüften Fällen ein besseres Funktionsergebnis bewirkt hat im Vergleich zu Patienten, bei denen die Lateralisation und Distalisation des großsen Trochanters nicht durchgeführt wurden.

     

Day-case pelvic osteotomy for developmental dysplasia of the hip

Purpose:In this article we report the results of a pilot study analysing the implications of performing pelvic osteotomies for developmental dysplasia of the hip (DDH) as a day case. We assess the advantages of performing paediatric pelvic osteotomies as day-case procedures from a financial perspective and from an in-patient bed resource point of view.Methods:This was a prospective cohort study analysing Salter and Pemberton pelvic osteotomies performed for DDH over a three-year period from 1st January 2017 to 30th September 2019. All patients residing within 50 km of the hospital were eligible for day-case procedures. All other cases were performed as in-patients. A detailed financial costing analysis was performed and the in-patient resources utilized were documented and compared between the two models of care.Results:In total, 84 Salter and Pemberton osteotomies were performed between 1st January 2017 to 30th September 2019. Of these cases, 35 were performed as day-case procedures. A total reduction in 70 in-patient bed days was reported. Total costs for a single in-patient requiring two nights of admission amounted to €5,752, whereas the discharge cost of a day case was reported at €2,670. The savings made by our institution amounted to €3,082 per day case. A total saving of €102,696 was made over three years. In all, seven day-case patients re-attended due to inadequate pain control. They required overnight admission and were discharged uneventfully the following day.Conclusion:Day-case pelvic osteotomies significantly reduce the number of in-patient bed days used in an elective paediatric orthopaedic setting. Significant financial savings in excess of €3,000 per case are possible. The introduction of day-case pelvic osteotomy procedures can significantly improve the cost-effectiveness of managing DDH provided there are clear protocols in place with close clinical follow-up.Level of evidence:IV