Factors influencing the outcome of Chiari
pelvic osteotomy: a long-term follow-up
Hirotsugu Ohashi, Kenji Hirohashi, Yoshiki Yamano
From Osaka City University Medical School and Osaka University of Health and
Sports Sciences, Japan
e have reviewed 103 of 126 Chiari osteotomies
W carried out in our department between 1956 and
1987. The cases were graded radiologically, using the
Japanese Orthopaedic Association (JOA) system, into
a pre/early osteoarthritis (OA) group and an advanced
OA group. In the pre/early group there were 86 hips.
The mean follow-up was for 17.1 years (4 to 37).
Preoperatively, 51 hips had an average JOA clinical
score of 78.6 8.4 points and the final mean JOA
clinical score was 89.4 12.5 points. Advanced
degenerative change developed in 33.7% and one hip
required a total replacement arthroplasty (TRA).
Chiari osteotomy alone, without accompanying
intertrochanteric osteotomy, was performed on 62
hips. For these the median survival time was 26.0
2.5 years, using as the endpoint progression to
advanced OA. Differences in survivorship curves
related significantly to the severity of the preoperative
OA, the shape of the femoral head and the level of
osteotomy. In the advanced OA group, we followed up
17 hips for a mean of 16.2 years (1 to 27). Before
operation, the mean JOA clinical score in 13 hips was
63.2 7.9 points and the final score 84.0 12.0 points.
TRA was eventually carried out on four hips.
Our findings suggest that the Chiari osteotomy
remains radiologically effective for about 25 years.
The procedure is best suited to subluxated hips with
round or flat femoral heads and early or no
degenerative change. Intra-articular osteotomy can
lead to osteonecrosis, and should be avoided. In hips
with advanced OA, the Chiari procedure creates an
acetabulum which facilitates later TRA, and may
delay the need for this procedure in younger patients.
J Bone Joint Surg [Br] 2000;82-B:517-25.
Received 22 October 1998; Accepted after revision 24 June 1999
H. Ohashi, MD, Orthopaedic Surgeon
Y. Yamano, MD, Professor
Department of Orthopaedic Surgery, Osaka City University Medical
School, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan.
K. Hirohashi, MD, Professor
Division of Sports Medicine, Osaka University of Health and Sports
Sciences, Osaka 590-0451, Japan.
Correspondence should be sent to Dr H. Ohashi.
2000 British Editorial Society of Bone and Joint Surgery
0301-620X/00/49583 $2.00
VOL. 82-B, NO. 4, MAY 2000
It is well known that acetabular dysplasia, with or without
subluxation of the femoral head, leads to osteoarthritis
1
(OA), and the primary aims of treatment are to relieve
2
pain and retard the progression of the disease. Chiari
reported good short-term results after five years for the
treatment of subluxation of the hip by medial displacement
pelvic osteotomy. Since 1956, we have used this procedure,
which provides additional superior bony cover for the
femoral head and alters the biomechanics around the hip
joint.
Since medial displacement pelvic osteotomy is carried
out mainly on adolescents and young adults, the long-term
3-7
results are especially important. Recent studies have
shown that while the procedure relieves pain, it does little
to retard the progression of OA. Although many factors,
including the extent of the preoperative degenerative
change, the age of the patient, the level of osteotomy and
the degree of medial displacement are thought to have a
3,6-12
role, which of these influence outcome is still not
clear. We have reviewed the long-term clinical and radio-
logical results of Chiari osteotomy, using survivorship anal-
ysis to examine some of the preoperative and operative
factors which affect outcome.
Patients and Methods
Between 1956 and 1987, we performed 126 Chiari pelvic
osteotomies on 113 patients with subluxation of the hip and
OA. We were able to follow up 91 of these patients (103
osteotomies, 81%).
The system of the Japanese Orthopaedic Association
13
(JOA) for the radiological grading of hips with OA is
listed in Table I and illustrated in Figure 1. We divided our
patients into two groups, one in which the hips had pre-
osteoarthritic or early OA changes and the other in which
there was advanced OA.
Pre/early OA group. For this group, we defined our aim as
the identification of factors which retard progression of
OA. Progression to advanced OA was the endpoint in
survivorship analysis. Radiologically visible obliteration of
the joint space, cysts or formation of osteophytes were
considered indications of progressive OA.
Of a total of 86 hips in 78 patients (12 men and 66
women), 51 were preosteoarthritic and 35 had early OA.
517
518 H. OHASHI, K. HIROHASHI, Y. YAMANO

The mean age at operation was 18.2 years (6 to 48). The
mean follow-up was for 17.1 years (4 to 37).
Chiari osteotomy alone had been performed on 62 hips
and in addition an intertrochanteric osteotomy on the other
24. Combined femoral and Chiari osteotomies were carried
out on 12 hips. Of these, eight subsequently had a varus
Fig. 1a Fig. 1b
Fig. 1c Fig. 1d
The JOA system for radiological grading of osteoarthritic hips, showing a)
a preosteoarthritic hip one year after Chiari osteotomy, b) early OA 17
years later, c) advanced OA after 27 years and d) terminal OA 31 years
after operation.
osteotomy and one a valgus osteotomy, while three had
previously undergone varus osteotomy.
Advanced OA group. For this group, we defined our aim
as the identification of factors which led to relief of pain.
Conversion to total hip replacement (THR) was the
endpoint.
There was advanced OA in 17 hips (15 patients). At the
time of surgery, the mean age of the 14 women and one
man was 36.8 years (11 to 54). The mean follow-up was
16.2 years (1 to 27). Chiari osteotomy alone was carried out
on 12 hips, and an additional varus osteotomy on the other
five.
Method of assessment. We used the clinical scoring sys-
13
tem of the JOA, which carries a maximum score of 100,
to evaluate pain (0 to 40 points), range of movement (0 to
20 points), walking ability (0 to 20 points) and activities of
daily living (0 to 20 points). For radiological evaluation, we
used preoperative and postoperative anteroposterior (AP)
and lateral films.
We measured the shape of the femoral head and the
centre-edge (CE) angle of Wiberg on the preoperative
radiographs, classifying hips by severity of dysplasia. Type
A had dysplasia alone (Fig. 2a), type B dysplasia with
subluxation (Fig. 2b) and type C dysplasia and a partial
false acetabulum (Fig. 2c). Type-B hips were further sub-
divided into type B1 in which the break in Shentons line
was improved by abduction (Fig. 2d), and type B2 in which
it was not (Figs 2e and 2f). Using AP radiographs of both
hips in the neutral position, we further assessed the severity
of dysplasia by measuring the break in Shentons line and
the lateral subluxation of the femoral head (Figs 3a and 3b)
and related these to the radiological measurement using
one-way factorial ANOVA and multiple-comparison tests
(Table II). We used Moses rings to determine the diameter
of the femoral head. We described the head as spherical
when the difference between the AP and lateral diameters
was less than 2 mm (Figs 4a and 4b), as ovoid when the
difference was 2 to 6 mm (Figs 4c and 4d), and as angular
14
when it was greater than 6 mm (Figs 4e and 4f).
We measured the CE angles and medial displacement
radiologically, immediately after surgery. Osteotomies were
described as high when carried out more than 5 mm from
the acetabular edge, as proper if between 0 and 5 mm from
the edge, and as low when intra-articular.

Table I. Radiological grading of OA of the hip according Table II. Position of the femoral head in the acetabulum
13
to the JOA system related to the radiological classification
Stage Criteria Break in Shenton's line Lateral subluxation
Type (mm) (mm)
PreOA Acetabular dysplasia
No other abnormal findings A 2.5 3.5 8.0 2.8
Early Slight narrowing of the joint space B1 9.9 8.1 11.4 3.7
Abnormal subchondral sclerosis B2 12.7 7.3* 16.8 3.6
Advanced Marked narrowing of the joint space, with C 20.1 7.8 22.6 4.2
or without cysts or sclerosis
* p < 0.05 v type A
Terminal Widespread obliteration of the joint space p < 0.05 v type A, B1
with cysts and formation of osteophytes p < 0.05 v type A, B1, B2

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 FACTORS INFLUENCING OUTCOME OF CHIARI PELVIC OSTEOTOMY: LONG-TERM FOLLOW-UP 519

Fig. 2a Fig. 2b Fig. 2c Fig. 2d

Radiographs of the stages of hip dysplasia showing a) a type-A hip, with

dysplasia but no OA b) a type-B hip with dysplasia and subluxation, c) a
type-C hip, with dysplasia and a partial false acetabulum, d) a type-B1 hip
(the same hip as in b) in which, with abduction, there is an improvement
in the break in Shentons line, e) a type-B2 hip in the neutral position and
f) the same hip in abduction; Shentons line remains broken with subluxa-
tion of the femoral head.

Fig. 2e Fig. 2f

Fig. 3a Fig. 3b Fig. 3c

Figure 3a The break in Shentons line was measured by projecting the inferior surface of the femoral neck in relation to the obturator foramen. Figure
3b Lateral subluxation of the femoral head was measured as the distance between a line joining the medial margin of the head and the lowest point
of the tear drop. Figure 3c Medial displacement was defined as the extent of the medial shift of the distal fragment as a percentage of the width of
the innominate bone at the level of osteotomy (b/a
100).

VOL. 82-B, NO. 4, MAY 2000

520 H. OHASHI, K. HIROHASHI, Y. YAMANO

Fig. 4a Fig. 4b Fig. 4c Fig. 4d

AP and lateral views of a,b) spherical, c,d) ovoid and e,f) angular femoral
heads

Fig. 4e Fig. 4f

Table III. Mean ( SD) preoperative radiological and clinical findings in the pre/early OA group
OA stage Femoral head
Total Pre Spherical Mean
number (number (number CE angle
of hips of hips) Early OA of hips) Ovoid Angular (degrees)
Chiari 62 38 24 20 29 13 -2.0 10.7
Chiari combined with varus osteotomy 12 9 3 2 7 3 -12.8 11.2*
Chiari followed by varus osteotomy 8 2 6 4 3 1 -7.1 11.7
Chiari followed by valgus osteotomy 1 1 0 0 1 0 -12.0
Varus osteotomy followed by Chiari 3 1 2 1 2 0 -10.8 4.9
86 51 35 27 42 17 -4.4 11.4
* p < 0.01 v Chiari by Student t-test

13
Using the JOA method listed in Table I, we assessed the
progression of degenerative change on serial radiographs
taken during follow-up. In the pre/early OA group, out-
comes were regarded as successful if the hips remained
preosteoarthritic or had only early OA at the last follow-up.
A postoperative increase in the break in Shentons line or
lateral subluxation of the femoral head was considered the
evidence of migration of the femoral head (Figs 3a to 3c).
We used Kaplan-Meier survivorship curves to estimate
long-term survival and the log-rank test to compare sur-
vivorship curves.
Results
Pre/early OA group. Table III shows the preoperative
radiological findings, grouped by surgical procedure. The
mean preoperative CE angle was -4.4 11.4. The CE
angle was significantly smaller in hips treated by com-
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 FACTORS INFLUENCING OUTCOME OF CHIARI PELVIC OSTEOTOMY: LONG-TERM FOLLOW-UP 521

Fig. 5a Fig. 5b Fig. 5c

Radiographs a) of the preosteoarthritic left hip of a 32-year-old man with an angular femoral head (type C),
b) one month after a classical Chiari osteotomy, and c) after 27 years showing maintenance of the joint
space. The JOA clinical score was 92 points.

Table IV. Mean ( SD) postoperative radiological and clinical results in the pre/early OA group
Mean Mean medial Number of Number with Mean Mean
Total CE angle displacement successful progression JOA score follow-up
number (degrees) (%) cases of OA (points) (yr)
Chiari 62 31.4 12.2* 42 15 43 19 90.1 12.3 17.3 8.6
Chiari combined with varus osteotomy 12 21.2 16.1* 33 13 8 4 91.1 8.2 12.8 6.1
Chiari followed by varus osteotomy 8 26. 9 22.5* 43 10 5 3 84.3 8.8 21.9 11.3
Chiari followed by valgus osteotomy 1 16.0 27 0 1 95.0 3.0
Varus osteotomy followed by Chiari 3 32.0 7.8 45 6 1 2 79.0 33.0 14.7 9.1
86 29.4 14.1 41 14 57 29 89.4 12.5 17.1 8.7
* p < 0.01 v preoperative CE angle for each operative procedure in Table II (paired Student t-test)
p < 0.05 v preoperative CE angle for each operative procedure in Table II (paired Student t-test)

Table V. Mean ( SD) postoperative superior and lateral migration

(mm) of the femoral head during progression to OA and at final
follow-up
Number
of hips Advanced OA At final follow-up
Progression 29
Superior 10.2 8.9* 12.4 11.3*
Lateral 4.5 4.9* 5.4 5.8*
Success 57
Superior 0.7 4.6
Lateral 1.2 3.4
* p < 0.05 v successful outcome

bined varus and Chiari osteotomy than in those treated by

Chiari osteotomy alone (p < 0.01). The postoperative
radiological and clinical results show an improvement in
the CE angle (mean 29.4 14.1) (Table IV). The pre-
operative JOA clinical scores were available for 51 hips:
the mean score was 78.6 8.4. At final follow-up, the
mean JOA clinical score was 89.4 12.5 and overall
clinical results were satisfactory. Figures 5a to 5c illustrate
a good result. The five different combinations of surgical
procedures produced no difference in final JOA clinical
scores (one-way factorial ANOVA and multiple-compar-
ison tests). Table V shows that migration of the femoral
head was significantly less in successful hips than in those
VOL. 82-B, NO. 4, MAY 2000
Fig. 6
Kaplan-Meier survivorship curves for Chiari osteotomy carried out alone
and in combination with varus osteotomy on the 84 hips in the pre/early
OA group. When progression to advanced OA was considered as the
endpoint, additional varus osteotomy had no effect on survival rates.
with progressive OA (one-way factorial ANOVA and mul-
tiple-comparison tests). When progression to advanced
OA was considered as the endpoint, additional varus
osteotomy had no effect on the rates of survival (Fig. 6).
One hip, treated by Chiari osteotomy alone, required total
hip replacement (THR) 26 years later (Figs 7a to 7d). The
522 H. OHASHI, K. HIROHASHI, Y. YAMANO
Fig. 7a Fig. 7b
Radiographs a) of the preosteoarthritic left hip of a 12-year-old girl with an ovoid femoral head (type C) b) one month after a high Chiari osteotomy,
c) eight months later showing that the femoral head has a partial defect and superolateral dislocation, and d) 25 years later with gradual progression of
degenerative change; 26 years after the osteotomy, THR was performed.
Fig. 8
JOA clinical scores at the last follow-up for 62 hips treated by Chiari
osteotomy (
, hips with progressive OA;  successful outcomes; *
required THR).
survival rate for hips treated by Chiari osteotomy alone
was 84.4 4.8% after ten years and 68.6 7.1% after 20
years, and for the combined group it was 81.5 11.9% and
43.5 21.2%, respectively. The median survival time was
26.0 2.5 (SEM) years.
Within the pre/early OA group, we further analysed the
results of patients treated by Chiari osteotomy alone. Fig-
ure 8 shows the relationship between final JOA clinical
scores and follow-up times. In successful cases the mean
JOA clinical score was 93.7 7.7 points, while in those
with progressive OA it was 81.9 16.6 points (Mann-
Whitney U test, p = 0.02). We used the log-rank test to
analyse relationships between progressive OA and various
factors (Table VI). In some instances the sample size was
too small to allow comparisons. We found that the stage of
OA, the shape of the femoral head and the level of
Fig. 7c Fig. 7d
osteotomy significantly affected the radiological results. In
preosteoarthritic hips, the long-term results were better
when the femoral heads were spherical or angular. In more
than half of the hips with ovoid femoral heads there was no
progression of degenerative change. Partial osteonecrosis
of the femoral head was present in five of nine hips whose
osteotomy was at a low level (Figs 9a to 9c). In general,
neither the severity of dysplasia nor the preoperative CE
angle adversely affected the postoperative radiological
results. The percentage of patients with progressive OA
was lower when preoperative radiographs showed little
dysplasia or a positive CE angle. We noted that the per-
centage was lower when the postoperative radiographs
showed a CE angle of 30 to 60 or medial displacement of
40% to 60%. Figure 10 shows survivorship curves for the
pre/early OA group.
Advanced OA group. Table VII gives the preoperative and
postoperative radiological findings and the clinical results.
After a mean follow-up of 16.2 years, the mean JOA
clinical score was 84.0 12.0 points. The mean JOA score
for 13 hips before operation was 63.2 7.9 points. Acet-
abular bone cysts diminished or disappeared in three hips
(Fig. 11). One hip required THR after one year, one after
eight years, and two after 16 years. With the endpoint
defined as conversion to THR, the survival rate was 88.2
7.8% (SEM) at ten years and 72.2 12.1% (SEM) at 20 years
(Fig. 12).
Complications. Superficial wound infection developed in
one patient. Another suffered injury to the external iliac
artery during surgery. Vascular anastomosis was undertaken
immediately. The patient went on to develop nonunion,
which required a bone-graft nine months later.
Obstetric implications. During the follow-up period, 14
women gave birth normally. Another four had caesarean
deliveries for non-orthopaedic reasons.
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 FACTORS INFLUENCING OUTCOME OF CHIARI PELVIC OSTEOTOMY: LONG-TERM FOLLOW-UP 523

Table VI. Relationship between various factors and progression of degenerative change in 62 pre/early hips treated
by Chiari osteotomy
Number of Mean
Number successful Number with follow-up p value
of hips cases progression (yr) (log-rank test)
Age (years)
15 29 20 9 18.9 9.2
>15 33 23 10 15.9 8.0 NS*
Stage of OA
PreOA 38 30 8 18.0 8.7
Early 24 12 12 16.2 8.5 0.014 v pre-OA
Severity of dysplasia
Type A 2 2 0 9.0 5.7
B1 7 6 1 12.0 6.9
B2 38 27 11 16.6 7.6
C 15 7 8 22.6 9.7 NS
Shape of femoral head
Spherical 20 15 5 15.6 8.4
Ovoid 29 16 13 18.5 8.9
Angular 13 11 2 17.2 8.3 0.027 v ovoid
Preoperative CE angle (degrees)
-20 3 1 2 32.0 5.6
-19 to -10 13 9 4 17.3 6.1
-9 to 0 20 13 7 18.6 9.7
1 to 10 22 15 7 14.5 7.9
11 to 20 4 4 0 15.3 4.3 NS
Postoperative CE angle (degrees)
0 1 0 1 26.0
1 to 10 1 0 1 32.0
11 to 20 9 7 2 14.6 5.9
21 to 30 19 10 9 19.1 9.7
31 to 40 20 17 3 15.3 8.6
41 to 50 9 6 3 16.3 7.7
51 to 60 3 2 1 22.3 6.5 NS
Medial displacement (%)
20 to 29 12 9 3 18.3 9.0
30 to 39 18 10 8 17.5 7.0
40 to 49 17 14 3 14.6 7.6
50 to 59 8 6 2 19.3 11.5
60 to 69 2 1 1 32.5 0.7
70 to 79 3 2 1 17.7 8.1
80 to 89 1 0 1 13.0
90 to 99 1 0 1 5.0 NS
Osteotomy level
High 5 3 2 18.4 8.6
Proper 48 37 11 16.5 8.0
Low 9 2 7 20.7 11.7 0.009 v proper
* not significant

Fig. 9a Fig. 9b Fig. 9c

Radiographs a) of the left hip of a 13-year-old boy with early OA and an ovoid femoral head (type B2) b)
two months after a low Chiari osteotomy and c) nine months after surgery, showing the development of
osteonecrosis in the superior portion of the femoral head.

VOL. 82-B, NO. 4, MAY 2000

524 H. OHASHI, K. HIROHASHI, Y. YAMANO

Table VII. Preoperative and postoper- Discussion

ative radiological findings and clinical
results for the advanced OA group after Besides Chiari osteotomy, double and triple innominate
a mean follow-up of 16.2 years 15-18 19,20
osteotomy and periacetabular osteotomy are used
Preoperative to treat dysplasia of the hip. Since the evaluation of the
Shape of femoral head
Spherical 4 results is not standardised, direct comparison is impossible.
17
Ovoid 7 De Kleuver et al reported good or excellent clinical
Angular 6 results with triple osteotomy in 60% of cases and over a
CE angle (degrees) -0.5 7.2
ten-year period the degree of OA progressed in only 21%.
Postoperative 20
CE angle (degrees) 30.5 10.8*
In a follow-up study of two to eight years, Trousdale et al
Osteotomy level reported that the severity of OA was reduced in 52% of
High 2 patients who had undergone periacetabular osteotomy. Our
Proper 10
Low 5
results, with 33.7% of patients developing degenerative
JOA point score 84.0 12.0
change during follow-up, are similar to those of other
3-7
authors. In our study, clinical results at the last follow-up
* p < 0.01 v preoperative CE angle
(paired Student t-test) examination were satisfactory, with JOA scores above 80
points.
In our pre/early OA group, there was a correlation
between the clinical and radiological results. We have
14
previously reported that postoperative superolateral
migration of the femoral head precedes osteoarthritic
change (Fig. 7). In this study, we measured migration on
AP radiographs of both hips in the neutral position. Migra-
tion was greater in hips with superior and lateral progres-
sion of OA. On radiographs, the median survival time was
26.0 2.5 years, suggesting that Chiari osteotomy is
probably radiologically effective for about 25 years. This is
longer than that reported after other periacetabular
osteotomies.
Other long-term studies confirm that the prognosis is
3,7-9
poor when there is preoperative OA. The point of
contact between the acetabular roof and the femoral head
Fig. 10 remains unchanged after Chiari osteotomy. When we
Kaplan-Meier survivorship curves for the 62 hips in the pre/early OA defined the endpoint as progression to advanced OA, the
group treated by Chiari osteotomy. Progression of degenerative change rate of survival of hips graded as preosteoarthritic was
was significantly related to the extent of preoperative OA (log-rank test,
p = 0.014). higher than those with early OA. This is presumably related
to the narrowing of the joint space evident on preoperative

Fig. 11a Fig. 11b Fig. 11c

Radiographs a) of the right hip of a 54-year-old woman with advanced OA, b) one month after Chiari
osteotomy, and c) 14 years after surgery showing that cysts in the innominate bone have disappeared and
those in the femoral head have diminished. The patients JOA clinical score was 86 points.

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 FACTORS INFLUENCING OUTCOME OF CHIARI PELVIC OSTEOTOMY: LONG-TERM FOLLOW-UP
Fig. 12
Kaplan-Meier survivorship curves for 17 hips in the advanced OA group.
The endpoint was defined as conversion to THR.
11
radiographs. Reynolds reported that the Chiari osteotomy
was suited to round or flat femoral heads. Our results were
best with spherical or angular femoral heads, but over half
the results achieved with ovoid femoral heads were also
satisfactory. We found that the percentage of cases with
progressive OA tended to decrease when the preoperative
radiographs showed little dysplasia or a positive CE angle,
but not to any significant extent. It has been reported that
the results are better in young people with a CE angle
10
greater than -9 and that coxa valga is associated with a
5,9
poor outcome.
Classical and high osteotomies have been reported to
6,10,11
yield good results. In five of the hips on which we
performed a low osteotomy, there was partial osteonecrosis
of the femoral head, possibly owing to high focal pressure
in the area of the newly formed acetabular roof. Chiari and
others have considered the degree of medial displacement
2,6,11
to be important. We achieved medial displacement of
20% to 50% in most cases, but were unable to determine an
ideal degree. We observed a reduction in the percentage of
cases with progressive change when the postoperative CE
angle was 30 to 60 or the medial displacement 40% to
60%, but this was not statistically significant. Scher and
12
Jakim found it advantageous to combine intertrochanteric
varus and Chiari osteotomy, but there are no long-term
7
radiological or clinical differences. We did not find that
additional varus osteotomy affected the rate of degenerative
change.
In the advanced OA group, the limited number of hips
precluded analysis of prognostic factors. Although the over-
all clinical results in this group were satisfactory, outcomes
were poor compared with those of the pre/early OA group.
The Chiari procedure does, however, create an acetabulum
which facilitates later THR, and may delay the need for
THR in younger patients.
We did not establish any correlation between outcome
VOL. 82-B, NO. 4, MAY 2000
525
and patient age, severity of dysplasia or degree of medial
6,8-11
displacement. Our findings showed that preoperative
degenerative change, the shape of the femoral head and,
most importantly, the level of osteotomy all affect long-
term outcome. The Chiari osteotomy appears to be best
suited to a dysplastic hip in which OA has not yet devel-
oped, even if the femoral head is deformed.
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this
article.
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