We present the results of Chiari pelvic osteotomy in the treatment of adolescent hip incongruence, with special interest in identifying possibilities, limitations and complications.

In a series of 86 patients treated by Chiari pelvic osteotomy (13 operated bilateraly) at the Institute for Orthopaedic Surgery “Banjica” with a follow-up period more than 48 months, we analyzed the relation of Chiari-specific parameters collected from postoperative radiograms (osteotomy angle and heigth, and displacement index) to various preoperative and postoperative parameters (Sharp acetabular angle, Wiberg CE angle, Heyman and Herndon femoral head extrusion index (FHEI), Acetabular depth ratio (ADR), Shenton-Menard arch integrity, limb length discrepancy, gait quality) and functional result according to HHS and McKay scoring systems.

We found highly significant improvements of Sharp angle (from 47.2±6.1° preoperatively to 38.6±7.8° finally, p<0.01), Wiberg CE angle (from 10.2±16.8° to 38.9±14.6°, p<0.01) and FHEI (from from 53.4±21% to 1.9±70.7%, p<0.01). In adition, HHS was also improved from 76±15.1 to final 87.9±9.4, p<0.01). We also assessed the satisfaction of both patients (index 4.2 out of 5) and surgeons (index 3.7 out of 5).

Chiari pelvic osteotomy is useful surgical procedure in the selected cases of adolescent hip incongruence with disturbance of hip centering and coverage.

Introduction: Insufficient femoral head coverage is found in a variety of diseases, with acetabular dysplasia as the most frequent disorder and the triple pelvic osteotomy as the most recently introduced surgical treatment.

Objective: The study analyses pre- and postoperative pathoanatomical characteristics of triple in comparison to Salter and Chiari osteotomies, with a logistic regression analysis of outcome predictor and effect explanator factors in relation to the chosen type of operation.

Methods: The study involved 136 adolescents, treated with Salter and Chiari osteotomies or a triple pelvic osteotomy. The patients were between 10–20 years old at the time of operation. The following data from all the patients were analysed: illness history, operative parameters, preoperative and postoperative pathoanatomic data. The data was statistically processed using the statistical software SPSS, defining standard descriptive values, and by using the appropriate tests of analytic statistics.

Results: The average CE angle after triple pelvic osteotomy was 43.5 degrees, more improved than after the Salter osteotomy (33.0 degrees) and Chiari osteotomy (31.4 degrees). Postoperative spherical congruence was also more frequent after the triple osteotomy than after the other two types of operations. Preoperative painful discomfor was found to be a valid predictor of indications for the triple osteotomy over both Chiari and Salter osteotomies. The valid explanators of the effect of the triple osteotomy are: postoperative joint congruence (compared to the Chiari osteotomy) and increase in joint coverage (compared to Salter osteotomy).

Conclusion: Triple pelvic osteotomy is the method of choice in the management of acetabular dysplasia and other disturbances of hip joint containment in adolescent age.

We have been following all modern trends in the treatment of Legg-Calve-Perthes disease during several decades (from nonoperative treatment, revascularization procedures, varization femoral osteotomies to various pelvic osteotomies). Last few years we have started to use triple pelvic osteotomy in patients older than seven years, in order to shorten treatment period, establish solid containment and subsequent remodelation of femoral head, and achieve final spheric hip congruence.

In the period from 1996 to 2004 we had 28 such surgical interventions.

Patient age at surgery was between 7 and 10 years. All hips were uncontained preoperatively, and in fragmentation stage. Twelve hips were classified as Catterall group III and sixteen hips as Catterall group IV.

Triple pelvic osteotomy according to Tonnis (modified by Vladimirov) was performed in all cases.

Average follow-up period was 40 (28–96) months.

Treatment result was good in all patients, with full functional recovery.

Spheric joint congruence was achieved in 24, and aspheric congruence in other 4 cases.

Average period for union of osteotomies was 10 weeks, followed by introduction of full weight bearing, considerably earlier than in patients with similar age and disease stage, treated by combination of Salter pelvic osteotomy and femoral shortening.

When surgical treatment of dysplastic hip and hip joint incongruence in adolescence is necessary, triple pelvic osteotomy is preferable to other types of pelvic osteotomies (even when they are associated with femoral ones). We evaluated our ten years long experience with the mentioned method.

We treated 78 hips (67 patients) with Tonnis-Vladimirov triple pelvic osteotomy between 1996 and 2005. Average age of our patients was 15 years and 6 months. The patients were followed for mean 39 (17–133) months. In 2 hips triple pelvic osteotomy was associated with femoral corective osteotomy, in one hip with femoral corective osteotomy and open reduction, and in 7 with the translocation of the greater trochanter.

Treatment results were evaluated, both anatomically and functionally. Anatomic improvement was detected by measuring CE angle of Wiberg. It improved from an average of 16,1 – to 43,1 degrees – the difference has proven to be statistically highly significant. Functional improvement (absence of waddling gate or limp; as well as better range of motion) was noticed in almost all the cases. The improvement was accompanied by spatial reorientation and correction. Major complications included asymptomatic pubic and/or ischial osteotomy nonunions in seven patients.

We found good radiographic correction of deformities and improvement of hip function with an acceptable complication rate. With appropriate patient selection, this procedure is the most physiological treatment of acetabular dysplasia and hip joint incongruence in patients older than 8–10 years. It may prevent and postpone the development of secondary osteoarthrosis.

Aims: Purpose of the study was comparison of the results of different pelvic osteotomies (Chiari, Salter, triple osteotomy) in the treatment of consequences of DDH in adolescents. Methods: Analysis included 124 patients treated operatively for consequences of DDH in adolescence. The average age of patients was 13.6. All patients were divided into four groups according to the operative technique used (isolated Salter pelvic osteotomy, Salter osteotomy and corrective femoral osteotomy, Chiari pelvic osteotomy and triple pelvic osteotomy). Preoperative and postoperative values of CE angle of Wiberg, acetabulum-head ratio of Heyman-Herndon and Harris hip score were analysed. Congruency was assessed according to Stulberg classiþcation before and after operative treatment. Results: Signiþcant improvement was achieved in all groups. The greatest improvement was noticed in the group of triple pelvic osteotomies. Comparison between groups has shown that signiþcantly better results were achieved with triple pelvic osteotomy. Conclusions: In dysplastic hips without signs of damage of the femoral head and neck we suggest triple pelvic osteotomy in patients older than 10. If deformity of femoral head exists, additional radiographic examination should be made to assess the possibility of achieving spherical congruency of the hip operatively. If this can be done we suggest performing triple or Salter osteotomy with corrective osteotomy of femur. Chiari pelvic osteotomy should be reserved for patients older than 10 in whom spherical congruency can not be achieved or if degenerative changes of the hip already exist

Treatment of residual acetabular dysplasia is still controversial regarding the timing of Surgery, and the type of surgical procedur

Material and Methods: We analyzed 70 patients (83 hips) operated between 1980–1988 year, in which Salter innominate osteotomy was performed in the treatment of residual acetabular dysplasia in DDH. Patients were divided in two different age groups: from 2–4 (53 hips) and 4–6 (30 hips) years. The average follow up was 7 years (from 2 to 10 years). Acetabular remodeling was radiographically assessed by measuring of the Acetabular Index (AI) at the beginning and after the 5 years of age subsequently by measuring the CE angle of Wiberg. All preoperative hips were dysplastic according to Tonnis (+2SD) criteria. Results were statistically analyzed by using the Student’s T test, and One Way Repeated Measures ANOVA, with the correction for the different age groups.

Results: We found that there were no statistically significant differences in AI and CE angle between these two age groups and between these groups and normal values.

Conclusion: We recommend Salter innominate osteotomy as a procedure of choice in the treatment of acetabular dysplasia in DDH, provided the patient is younger than 6 years of age.

We compared the clinical and radiological effects of the Salter and the Chiari pelvic osteotomy on congruent dysplastic adolescent hips with mild symptoms and free of degenerative changes.

The Salter innominate osteotomy has a significant role in the surgery of paediatric hips with significant elasticity of triradiate cartilage, while the Chiari procedure is reserved for incongruent dysplasia with mild or moderate arthrosis in adolescents or young adults. Neither of these operative procedures is an ideal indication for congruent dysplastic adolescent hips free of arthrosis. Hypothetically, the residual remodelling potentials of immature congruent dysplastic adolescent hips can be sufficient to overcome the disadvantages of the Salter and the Chiari osteotomy and give good, long-lasting results. The effects of these quite different procedures in two homologous groups were compared.

There were 30 hips treated with Chiari and 25 hips corrected by Salter osteotomy. All hips were congruently dysplastic according to the distance between the centres of the femoral head and the acetabulum (Klaue et al., classification). Groups were homologous considering mean age (14.5 years), follow-up period (8.5 years), presence of preoperative pain, Trendelenburg sign, and degenerative changes. Assessment for pain and Trendelenburg sign was made at follow-up. Radiological measurement was made of the central-edge angle of Wiberg (CE), acetabular angle of Sharp (AAS), and the femoral head coverage index of Heyman and Herndon (FHC). Progression of degenerative changes was analysed according to the criteria of Kellgren and Lawrence.

At follow-up in the Chiari group, presence of pain was reduced from 54% to 6.6%, and from 35% to 12% in the Salter group. The presence of Trendelenburg sign was reduced 3% in the Chiari group and remained the same in the Salter group. At control, mean values of radiological parameters were normal in both groups (Salter: CE-27.8°, AIS-36.8°, ING-82.8%; Chiari: CE-36.8°; AIS-39.7°; ING-90.8%). Individual analysis showed 16% of dysplastic hips in the Salter group, and none in the Chiari group. Only one hip (4%) had grade 1 arthrosis after Salter osteotomy. There were five grade 1 hips (17%) in the Chiari group and one (3%) grade 2 arthrotic hip.

At follow-up (mean 8.5 years) greater reduction of pain was found in the Chiari group than in the Salter group, but the presence of Trendelenburg sign remained almost unchanged in both groups. There was normalisation of the mean values of radiological parameters in both groups, but the Salter osteotomy was unable to correct dysplasia in 16% of the adolescent hips. Progression of degenerative changes was more rapid in the Chiari group.