Surg Radiol Anat 22: 225-233 © Springer-Verlag France 2000
Anatomic bases of medical, radiologicaland surgical techniques
Complications of Chiari and Salter osteotomies a cadaver study K. Birnbaum1, A. Pastor1, A. Prescher2 and K.-D. Heller1 1 2
Orthopedic Department, University Hospital, Technical University Aachen, Germany Anatomical Institute, Technical University Aachen, Pauwelsstraße 30, D-52074 Aachen, Germany
Received December 15, 1999 / Accepted in final form July 23, 2000
Key words: Chiari - Nerve injury - Osteotomy - Operative risk - Salter - Vascular injury Correspondence to: K. Birnbaum
Abstract Previous investigations of the Chiari and Salter osteotomies showed that intraoperative vessel and nerve injuries are described repeatedly in the case of both pelvic osteotomies. The aim of our investigations was the exposure of each operation step in anatomic specimens to show the anatomic landmarks and potential risks. We performed nine Chiari osteotomies and five Salter osteotomies on formalin-fixed cadavers. The operation steps were made consecutively to assess the risks to the vessels and nerves as well as the determination of anatomically important reference points. In both procedures an injury of the lateral femoral cutaneous nerve at the anterior access route is feasible. By ensuring that the skin including the lateral femoral cutaneous nerve is pulled medially, injury can be avoided. Additionally, too long retraction of the tensor fasciae latae muscle injures its nutrient vessels. An inadequate subperiosteal approach during the pull on the Hohmann´s retractor leads to crushing and irritation of the sciatic nerve. Moreover, there is a risk that the superior gluteal nerve as well as the superior gluteal artery may be injured. An inadequate subperiosteal application of the medial Hohmann´s retractor can endanger the obturator nerve. In the Chiari osteotomy there is a risk of injury to the articular branch of the superior gluteal nerve, which supplies parts of the ventral hip joint capsule. By inserting the K-wire too far medially the internal oblique muscle is endangered. Too prolonged retraction of the iliopsoas muscle in a Salter osteotomy can lead to compression of the femoral nerve. The form of the osteotomy has an influence on the stability of the hip joint in the course of exposure of the hip joint. On account of the narrow spatial connection between the anatomic pathways and the osteotomy area, strict subperiosteal dissection and careful use of the retractor are essential to avoid nerve and vessel injuries.
Most cases of hip dysplasia present an insufficient roof of the anterolateral and superolateral portions of the acetabulum [35]. Therefore, the aim of surgery is to obtain better femoral head coverage by innominate osteotomy. Two types of osteotomy are proposed reorientation osteotomies (Salter, triple osteotomy), which have both a mechanical and biological effect, and widening osteotomies (Chiari), which are in fact extracapsular arthroplasties [29]. All the techniques of
reorientation osteotomy are very similar and achieve a reorientation of the acetabulum on the femoral head by varization, retroversion and, when possible, medialization. Chiari developed his innominate osteotomy [4] in 1955 as a reconstructive measure for hip dysplasia. The Salter osteotomy (SO) was introduced in 1961 [30]. On the other hand, the triple osteotomy of the innominate bone is obtained by circum-acetabular osteotomies through the ilium, ischium and pubis. This method achieves coverage of a dislocated or subluxated femoral head where other iliac osteotomies are ineffective or incomplete [37]. The innominate osteotomy is able to diminish the excessive antetorsion of the acetabulum by rotating the distal fragment outwards [26]. With large anterior defects, and in cases of bilateral hip dysplasia, a triple pelvic osteotomy will be preferred to Salter´s osteotomy [26]. Principle and aim of the Chiarís osteotomy The aim of Chiarís osteotomy (CO) is the construction of a congruent roof over the intact hip joint without bony transplantation and correction of the pathologic position of the femoral head in development . Often an intertrochanteric varus osteotomy is added since the Chiari osteotomy alone could not adequately influence the pathological position of the femoral head. It includes a transverse osteotomy of the ilium at the upper capsular insertion [34, 11, 36, 38, 43] (Fig. 1a, b). Then follows a medial shifting of the distal segment with the rotation point through the symphysis, [28, 41] (Fig. 1). The articular capsule is interposed as a functional tissue. Some authors found a transformation of this capsular tissue to a synovial-like tissue [5, 42, 43]. The joint capsule is then pressed against the spongiosa of the new-formed acetabulum [11]. The acetabular labrum is shaped as a meniscus and interposed between the capsule and the femoral head as a cushion [1]. For a sufficient long-term result, a high osteotomy and adequate medialisation are necessary [6]. In contrast to intertrochanteric osteotomy, it has the advantage of facilitating the implantation of an acetabular prosthesis if an arthroplasty becomes necessary at a later stage. The postoperative limp so often seen can at times be caused by hip abductor insufficiency, the muscles being too weak to counteract the torque from body weight during single-leg stance [22]. Simulated procedures by Delp with high angulation and marked medial displacement reduce gluteus medius abductor torque by up to 65 % [10]. In the biomechanical model of Delp high angulation reduces the length of the gluteus medius and is the primary cause of reduced abductor strength. Simulated horizontal osteotomies (0˚ to 10˚) were found to best conserve both muscle strength and abductor torque. Concerning the best age for operation, Migaud found that the functional outcome was best when surgery was performed before the age of 40, and in hips with the greatest degree of dysplasia [27].
Figs. 1a, b X-ray of a 12-year-old girl with hip dysplasia (a) before and (b) after a Chiari pelvic osteotomy (CO). The CO was combined with a varus osteotomy. The osteotomy was fastened fixed with a Kirschner wire Principle of the Salter osteotomy The principle of the Salter osteotomy consists of a transection of the ilium at the innominate line and a subsequent tilting movement of the distal pelvic part, formed by the acetabulum, pubis and ischium, in a ventral/caudal/lateral direction [14, 17, 28, 40] (Fig. 2a, b). The rotation point is located in the pubic symphysis [17, 28, 40]. A bony wedge is inserted in the osteotomy [20, 25, 31, 36]. The acetabulum gets a caudal position after being opened laterally. The weight-bearing cartilage is extended and the pressure is alleged [33]. Triple and Salter osteotomies with adductor release seem to be useful procedures to restore good hip morphology at the end of growth [31, 32].
Figs. 2a, b X-ray of a 10-year-old girl with hip dysplasia (a) before and (b) after a Salter pelvic osteotomy (SO). The SO was combined with a varus osteotomy. The inserted bony wedge was fixed with a Kirschner wire Aim of the study In follow-up studies of patients who underwent a CO or SO, there were often reported nerve and vessel lesions. The reason for these injuries could not be evaluated in most cases. Therefore, the aim of our study was to define anatomic location points of the operation and to analyze the complications of CO and SO with the related vessel and nerve lesions. Material and Methods During the period from May 1997 until February 1999 fourteen formalin-fixed human cadavers (6 female, 8 male average age at the time of death 78 years) without dysplastic, osteoarthritic or subluxated hip joints were evaluated in the Anatomical Institute of the Technical University of Aachen. Medical histories of the individuals were not available. In nine cases a CO and in five cases a SO was done. We performed the CO step-by-step in accordance with the operation descriptions of Windhager and Bauer [2, 42]. During the incision we paid attention to the course of the lateral femoral cutaneous n. (Fig. 3). Afterwards blunt dissection between the tensor fasciae latae and sartorius mm. was done. We isolated the tensor fasciae latae m. from its origin at the anterior superior iliac spine for a better view of the reflected head of the rectus femoris m. Furthermore, we removed the glutaeus minimus m. for a better exposure of the hip joint capsule. Then we put a curved aluminium retractor from a laterodorsal approach around the femoral head and reached the greater sciatic notch with the tip of
the retractor. For the medial insertion of another retractor in the greater sciatic notch, we removed subperiosteally the anterior part of the iliacus m. Both retractors came into contact in the greater sciatic notch. For the osteotomy we used a Gigli saw in seven cases, in spite of the fact that its use is accompanied by more complications in the operative intervention. In two cases we used a Gigli saw from the medial aspect and from the lateral part an oscillating saw guided by a K-wire. In the sagittal plane we achieved an arched form of the osteotomy towards the acetabular edge. After the medial shifting of the distal part of the pelvis we monitored the position of the endangered nerves and vessels.
Fig. 3 Right hip joint, right-sided view. Possible lesion of the lateral femoral cutaneous n. by the skcin incision (anatomic orientation left/proximal, right/caudal, top/medial, bottom/lateral). 1, femoral v. 2, femoral a. 3, femoral n. 4, inguinal lig. 5, iliopsoas m. 6, sartorius m. 7, tensor fasciae latae m. 8, greater trochanter, arrow, lateral femoral cutaneous n. Salter´s operation technique We carried out the SO according to the operation description of Küsswetter [21]. After the skin incision, we began by longitudinally splitting the common origin of the sartorius and tensor fasciae latae mm. at the anterior superior iliac spine. Subsequent subperiosteal dissection of the musculature at the inner side of the iliac bone was done. To prevent a lesion of the soft tissue a subperiosteal dissection is imperative. After dissection of the anterior head of the rectus femoris m., we separated its origin at the anterior inferior iliac spine. The Gigli saw for the osteotomy was placed in the lesser sciatic notch by using curved clamps. The osteotomy was performed from the lesser sciatic notch towards the anterior inferior iliac spine. The autologous bone wedge was removed from the anterior superior iliac spine. The distal pelvic part was pulled distally, ventrally and laterally. Then the bone wedge was inserted and fixed by K-wires. Results Pelvic osteotomy The sole application of the oscillating saw hardly allows an arcuate form of the CO. We achieved the best results by using a combination of a Gigli and an oscillating saw. Nevertheless, the use of the Gigli saw is accompanied by a higher risk of nerve and vessel injuries in comparison to the use of an oscillating saw guided by a K-wire. The SO was carried out solely by the use of the oscillating saw guided by a K-wire, because we did not have to take into consideration an arcuate form of the osteotomy. In the case of two COs it was difficult to find the correct height for the osteotomy. In one case the posterior head of the rectus femoris m. was very broad. In another case the rectus femoris m.
inserted in the hip joint capsule, so that the line for the osteotomy could not be determined exactly. Concerning the osteotomy, we did not recognize an increased risk of a vessel or nerve injury related to the horizontal or ascending osteotomy line. Rather, the ascending osteotomy line had an influence on the better medial translation of the inferior block containing the hip joint. While inserting the Kirschner wires, it should be ensured that the skin including the lateral femoral cutaneous n. is pulled sufficiently medially to avoid injury. By fixing the bone wedge with Kirschner wires it could happen that these wires go too far medially, so that they could injure the internal obturator m., the obturator m. and the accompanying vessels. While the pelvic plane of inlet is slightly changed by the CO, we recognized a greater change by the SO. Furthermore, there was compression of the sacrotuberous and sacrospinous ligg. by the SO. In osteotomy of the inner cortical bone we have to pay attention to the external iliac a. and v., which lie in direct neighbourhood of the terminal line of the pelvis. Such a risk was identified several times in our investigations. In connection with the Chiari osteotomy the cut with the oscillating saw can lead to a disruption of the greater sciatic notch. Furthermore, the medial translation may lead by the same process to a posterior displacement of the inferior block. Nerve Lesions Lateral Femoral Cutaneous Nerve The lateral femoral cutaneous n. passes along the anterior superior iliac spine in a caudal direction. For this reason the skin at the level of the iliac spine should always be retracted medially to avoid nerve injury. Sciatic nerve On positioning the lateral retractor, especially Hohmann's retractor, in the greater sciatic notch, in eleven of fourteen cases it was immediately adjacent to the sciatic n. (Figs. 4, 5). In three specimens the nerve ran more medially and the retractor did not come so close to the sciatic n. In four COs we found an insignificant stretching of the sciatic n. when the distal pelvic segment was shifted medially. In one case the nerve was pulled over the edge of the osteotomy. The surgeon must ensure that the medial shifting is not excessive.
Fig. 4 Right hip joint, medial view from the lesser pelvis to the greater sciatic notch. Medial point of view to the greater sciatic notch. Possible iatrogenic injury or irritation of the sciatic n. by using the
lateral retractor (arrow) inserted in the greater sciatic notch (anatomic orientation left/caudal, right/proximal, top/ventral, bottom/dorsal). 1, internal iliac a. 2, obturator n. 3, obturator a. 4, superior gluteal a. 5, internal iliac v. 6, internal oblique m. 7, internal pudendal a. 8, inferior gluteal a. 9, sciatic n. nerve roots L5/S1/S21 marked in the figure arrow, lateral position of the retractor
Fig. 5 Right hip joint, medial view from the lesser pelvis to the greater sciatic notch. Possible iatrogenic injury or irritation of the sciatic n. by using the medial retractor (arrow) inserted in the greater sciatic notch. There is the further possibility of an injury of the obturator n. if the surgeon does not approach subperiosteally (anatomical orientation left/caudal, right/proximal, top/ventral, bottom/dorsal). 1, internal iliac a. 2, obturator n. 3, obturator a. 4, superior gluteal a. 5, internal iliac v. 6, internal oblique m. 7, internal pudendal a. 8, inferior gluteal a. 9, sciatic n. nerve roots L5/S1/S21 marked in the figure arrow, lateral position of the retractor Superior gluteal nerve In eight cases we recognized endangering of the superior gluteal n. by the lateral retractor. In one case the sensory branch of the superior gluteal n., which innervates parts of the hip joint capsule, was damaged by the CO (Fig. 6). Furthermore, there is the possibility of endangering the nerve in the course of a SO (Fig. 7). How far an injury of the superior gluteal n. affects the long-term results after osteotomy has to be discussed.
Fig. 6 Left hip joint, medial view from the lesser pelvis to the greater sciatic notch. Risk of injury of the articular branch of the superior gluteal n. by the CO (anatomic orientation left/proximal, right/caudal, top/ventral, bottom/dorsal). 1, sciatic n. 2, superior gluteal a. 3, superior gluteal v. 4,
superior gluteal n. arrow, osteotomy line
Fig. 7 Left hip joint, medial view from the lesser pelvis to the greater sciatic notch. Risk of injury of the articular nerve branch and the gluteal vessels during the SO. This injury can happen during the osteotomy or the insertion of the bony wedge. Also possible pressure lesion of the sciatic n. by the iliac retractors or lesion by a hematoma (anatomical orientation left/dorsal, right/ventral, top/proximal, bottom/caudal). 1, sciatic n. 2, articular branch of the superior gluteal n. 3, superior gluteal n. 4, superior gluteal v. 5, superior gluteal a. 6, superficial branch of superior gluteal v. 7, superficial branch of superior gluteal a. arrow, Salter osteotomy line Obturator nerve In one CO, which was carried out by using the oscillating saw, the obturator n. was damaged at the lateral boundaries of the inferior pelvic area shortly before it entered the obturator canal (Fig. 5). Femoral nerve During dissection of the iliopsoas m. in the course of a SO an endangering of the femoral n. is feasible (Fig. 8). To avoid such damage, the iliopsoas m. should not be retracted too strongly or for too long during the operation.
Fig. 8 Right hip joint, medial view from the inner side of the upper thigh to the inguinal canal. Temporary iatrogenic pressure injury of the femoral n. by using the retractor (anatomic orientation
left/caudal, right/proximal, top/lateral, bottom/medial part of the upper thigh). 1, femoral v. 2, femoral a. 3, femoral n. 4, iliopsoas m. 5, inguinal lig. 6, sartorius m. arrow, pressure on the iliopsoas m. by using the retractor and consequent temporary lesion of the femoral n. Vascular lesions Superior Gluteal Artery In ten cases the lateral retractor endangered the superior gluteal a. We recognized different courses of the artery. In one case we exposed the deep branch of the artery on its way to the dorsal hip joint capsule, which was endangered during the SO (Fig. 9).
Fig. 9 Right hip joint, medial view from the lesser pelvis to the lesser sciatic notch. Lateral retractor placed into the lesser sciatic notch for a Salter osteotomy greater sciatic notch (dorsal view) and after removing the piriformis m. Possible lesion to the superior gluteal vessels during the SO (anatomic orientation left/caudal, right/proximal, top/ventral, bottom/dorsal). 1, sciatic n. 2, articular branch of the superior gluteal n. 3, superior gluteal n. 4, deep branch of superior gluteal v. 5, deep branch of superior gluteal a. 6, superficial branch of superior gluteal v. 7, superficial branch of superior gluteal a. arrow, Hohmann's retractor placed into the greater sciatic notch Inferior gluteal artery In none of the operations was an injury to the inferior gluteal a. detected. We noted different courses of the artery In two cases the rami of the superior gluteal a. traversed the sciatic n. and ran afterwards in a dorsal direction, In one case the ramus passed over the sciatic n. and afterwards in a dorsal direction, In another case the inferior gluteal a. passed together with the superior gluteal a. through the suprapiriform foramen. Discussion Chiarís Osteotomy Pelvic Osteotomy
Our investigations showed that a sufficient medial shift is more difficult with a descending osteotomy [4]. Too low an osteotomy can lead to an injury of the hip joint capsule [5, 6, 11, 15, 38, 43]. Furthermore the cartilage of the femoral head can be impaired [7, 11, 16]. If the osteotomy is done too high, it can lead to a sloping shape and subsequent reluxation, to an injury of the caudal end of the sacroiliac joint, and to problems within the scope of the medial shifting [5, 11, 38, 41, 42, 43]. In accordance with Chiari, the osteotomy should start 0.5 to 1.0 cm above the acetabulum between the origin of the posterior head of the rectus femoris m. and the hip joint capsule [6]. Furthermore, it should be ascending 6˚ to 10˚ or pass horizontally towards the inside of the pelvis. In osteotomy of the inner cortical bone we have to pay attention to the external iliac a. and v., which are lying in the direct neighbourhood of the terminal line of the pelvis. A risk was evident several times in our investigations. It is difficult to determine the degree of medial shift. Concerning the instruments, the Gigli saw is preferred by some authors [3, 8, 15, 44]. Others prefer the oscillating saw [8]. To obtain an arcuate osteotomy within the scope of a CO the Gigli saw is the better choice. On the other hand we demonstrated the higher risk of a nervous or vascular lesion by using the Gigli saw in comparison to the use of the oscillating saw guided by a K-wire. Good preoperative planning is essential for minimizing the peroperative risks of vessel or nerve injuries and for the exact placement of the osteotomy. More recent imaging studies and reports of operative correction of hip dysplasia recommend three-dimensional (3D) analysis, and some have mentioned but not emphasized the importance of transverse-plane acetabular osteotomy (anteversion/ retroversion). For example, analysis of the 3D CT studies after triple osteotomy showed a change in the position of the acetabular fragment osteotomy into greater adduction, anterior rotation (extension) and external rotation, improving femoral head coverage [13]. We suggest similar planning for the Chiari and Salter osteotomies. Nerve Lesions To protect the lateral cutaneous n. the tension on the retractor should not be too great. Furthermore, the dissection should not be too medial [42]. During a CO the surgeon has to pay attention to the posterior arch of the greater sciatic notch because the nerves and vessels are lying in the direct neighbourhood of the notch. Nevertheless, with the right positioning of Hohmann's retractors in the greater sciatic notch, the risk of a vessel or nerve injury can be minimized. By possibly endangering the sensory innervation of the posterior parts of the hip joint capsule by injury to the articular branches of the superior gluteal n. it is quite conceivable that there is an a modification in the proprioception of the hip joint. Nevertheless, this indirect partial denervation effect could relieve the pain for the patient. How far this partial denervation effect has any long-term influence on the progress of the osteoarthritis of the hip joint was not examined. We may postulate that the decrease of proprioceptive sense leads to overload of the hip joint with progression of the Xray signs of osteoarthritis but we cannot prove it. Kaplan found no X-ray changes after partial denervation of the hip joint in a period of observation over 1.5 years [20]. Tavernier found an amelioration of the osteoarthritic signs in the X-rays after denervation of the hip joint after a period of observation of 2.5 years [39]. After regional anesthesia of the hip joint capsule, Kang found a progression of the osteoarthritic signs over a period of 9 to 49 months [19]. In all cases an amelioration of hip joint pain was described. These divergent results show that a conclusive answer concerning the consequences of partial impairment of the sensory innervation of the hip joint capsule cannot be given. Lesions of the peroneal n. were found with peroneal paralysis. Chiari mentioned as a cause bleeding from the periosteal vessels of the ilium [5]. Jaster described for both operation techniques a
compression injury by a resulting hematoma [18]. An injury of the sciatic n. by the chisel is possible, when the medial and lateral Hohmann's retractors do not have direct contact within the greater sciatic notch, so that the chisel may slip and damage the sciatic n. Vascular Lesions To avoid bleeding from the endangered gluteal vessels and the external iliac a. and v. at the level of the terminal line of the pelvis, bowed retractors were constructed to replace Hohmann's retractors. They conformed better to the shape of the pelvis and could be inserted more easily into the greater sciatic notch. The retractor contains an aperture, where the Gigli saw can be introduced [12]. The surgeon has also to respect the specific blood-supply at different ages of the patient. Damsin found by an anatomic study of the vascularization of the acetabulum of the fetus a periacetabular vascular circle, formed by the superior gluteal, inferior gluteal, internal pudendal and obturator aa. [9]. The abundant vascularity of the acetabulum makes massive necrosis improbable in the child. However, there is a zone of precarious anastomosis at its anterior portion. This is valid for the Salter osteotomy as well. Salter Osteotomy Pelvic Osteotomy Exact exposure of the relevant anatomic structures is important, especially of the greater sciatic notch [32, 33]. The hip joint capsule should be displaced caudally to place the osteotomy at the right level [24]. Moreover, the periosteum around the greater sciatic notch should be sufficiently removed to ensure that a sufficient tilting movement of the distal part of the pelvis is possible [24]. The insertion of the saw should be done with direct contact to the bone and ventral to the Hohmann's retractor [17]. Several authors use a guide-wire to ensure a correct course of the osteotomy, making an ascending osteotomy from the lateral to medial direction [8,15]. We found also that marking of the planned osteotomy is useful. After the osteotomy it is important that the distal fragment does not dislocate in a posterior or medial direction [24]. Our investigations showed that the oscillating saw, with the use of Hohmann's retractors which have contact in the greater sciatic notch, represents the best modality for the SO. It is recommended by Küsswetter to chisel a notch in the proximal osteotomy surface, to avoid disintegration of the distal pelvic fragment when spreading after the SO [21]. The Kirschner wire should therefore be inserted from a proximal to distal direction, to reduce the risk, of the wire penetrating in an intra- or retroperitoneal direction [32]. An alternative to these osteotomies (Salter/Chiari) is the juxta-acetabular osteotomy, mentioned by Lazennec, which avoids major disorganization of the pelvic framework and allow easier reorientation of the acetabulum [23]. According to Lazennec this osteotomy is easier to perform, because of a single positioning associating two simultaneous approaches [23]. Another valuable aspect of this double approach consists of very easy correction of « automatic » unwanted retroversion due to the lowering of the acetabular roof. This unintended displacement is often only perceptible in 3-dimensional CT-scan reconstructions for pre- and peroperative evaluation. Nerve Lesions There is the possibility of an injury of the lateral femoral cutaneous n. and the sciatic n. [21, 24, 25]. The assumed reason is a compression injury by a hematoma [14]. Several authors describe a possible injury of the femoral n. in the SO [21, 24, 31]. We noted a possibility of femoral n. compression when dissecting the tendon of the iliopsoas m. Furthermore, we have to mention the possible nervous stretching during Salter´s osteotomy due to
the acetabular lowering. This could not be proved in our investigations because they were made on formalin-fixed cadavers, so that stretching could not be measured accurately. Vascular Lesions Mau described a possible lesion of the superior gluteal a. at the level of the great sciatic notch, i.e. at the suprapiriform foramen [24]. Such a risk was recognized in our investigations. In some cases of SO a lesion of the femoral vessels was described [21]. A lesion of the femoral vessels was not registered in our investigations. The lesion seems improbable, because the instruments do not usually come near to the femoral vessels. Clinical Relevance In our opinion an exact dissection of the anatomical landmarks mentioned during each operating stage is decisive. Subperiosteal dissection during the osteotomy and careful use of the retractors guarantee an uncomplicated procedure. As already mentioned, preoperative planning by a 3D-CTmodel is recommended to minimize the possible intraoperative complications. References 1. Bauer R, Kerschbaumer F (1975) Results of the Chiarís osteotomy. Arch Orthop Unfallchir 81 301-314 2. Bauer R, Kerschbaumer F, Poisel S (1994) Chiarís osteotomy. In Orthopädische Operationslehre. Thieme, Stuttgart-New York, pp 105-109 3. Betz RR, Kumar SJ, Palmer CT, McEwen GD (1988) Chiari pelvic osteotomy in children and young adults. J Bone Joint Surg 70-A 182-191 4. Chiari K (1955) Ergebnisse mit der Beckenosteotomie als Pfannendachplastik. Z Orthop 87 14-26 5. Chiari K (1974) Medial displacement osteotomy of the pelvis. Clin Orthop 98 55-71 6. Chiari K, Schwagerl X (1976) Pelvic osteotomy indications and results. Rev Chir Orthop 62 560568 7. Chiari K, Endler M, Hackel H (1978) Indication et résultats de l´ostéotomie du bassin selon Chiari dans l´arthrose avancée. Acta Orthop Belg 44 176-191 8. Colton CL (1972) Chiari osteotomy for acetabular dysplasia in young subjects. J Bone Joint Surg 54-B 578-589 9. Damsin JP, Lazennec JY, Gonzales M, Guérin-Surville H, Hannoun L (1992) Arterial supply of the acetabulum in the fetus application to periacetabular surgery in the childhood. Surg Radiol Anat 14 215-221 10. Delp SL, Bleck EE, Zajac FE, Bollini G (1990) Biomechanical analysis of the Chiari pelvic osteotomy. Preserving hip abductor strength. Clin Orthop 254 189-198 11. Ebach G (1966) Current experiences with Chiarís osteotomy. Z Orthop 102 250-262 12. Franz R (1974) Protective elevator for Chiarís osteotomy of the pelvis. Beitr Orthop Traumatol 21 116-118
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32. Salter RB (1972) Specific guidelines in the application of the principle of innominate osteotomy. Orthop Clin North Am 3 149-156 33. Salter RB, Hansson G, Thompson GH (1984) Innominate osteotomy in the management of residual congenital subluxation of the hip in young adults. Clin Orthop 182 53-68 34. Salvati EA, Wilson PD (1974) Treatment of irreducible hip subluxation by Chiarís iliac osteotomy. A report of results in 19 cases. Clin Orthop 98 151-161 35. Schneider PG, Schlüter M (1991) Chiari osteotomy combined with intertrochanteric osteotomy within the treatment of the hip dysplasia in the adulthood. In Hackenbroch MH, Rütt J The treatment of hip dysplasia by pelvic osteotomy. Thieme, Stuttgart-New York, pp 65-73 36. Seyfarth H (1967) Remarks over indications and technique of the pelvic osteotomy. Arch Orthop Unfallchir 61 1-18 37. Steel HH (1977) Triple osteotomy of the innominate bone. A procedure to accomplish coverage of the dislocated or subluxated femoral head in the older patient. Clin Orthop 122 116-127 38. Strauss HJ (1978) Chiarís osteotomy for hip dysplasia in patients below the age of twenty. In Progress in orthopedic surgery, Acetabular dysplasia. Skeletal dysplasia in childhood. Springer, Berlin-Heidelberg-New York, pp 121-129 39. Tavernier L, Truchet P (1942) La section des branches articulaires du nerf obturateur dans le traitement de l´arthrite chronique de la hanche. Rev Orthop 18 62-68 40. Utterback JD, McEwen GD (1974) Comparison of pelvic osteotomies for the surgical correction of the congenital hip. Clin Orthop 98 104-110 41. Waigand D (1965) Indication and technique of the Chiarís osteotomy. In Chapchal G Pelvic osteotomy, acetabular arthroplasty. Thieme, Stuttgart, pp 94-96 42. Windhager R, Kotz R (1992) The Chiarís osteotomy. Op Orthop Traumatol 4 225-236 43. Ziegert D (1974) Early results of pelvic osteotomy using Chiarís method. Beitr Orthop Traumatol 21 731-739 44. Zlatic M, Radojevic R, Lazovic C, Lupulovic I (1988) Late results of Chiarís pelvic osteotomy. A follow-up of 171 adult hips. Int Orthop 12 149-154 Back to the SRA-EE Home Page Last change: March 28, 2001
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