EXTRA-ARTICULAR AUGMENTATION FOR RESIDUAL

HIP DYSPLASIA
RADIOLOGICAL ASSESSMENT AFTER CHIARI OSTEOTOMIES AND
SHELF PROCEDURES

K. KLAUE, M. SHERMAN, S. M. PERREN, A. WALLIN, C. LOOSER, R. GANZ

From the Inseispital, Bern, Switzerland

The Chiari osteotomy and various shelf procedures are In an adult with hip dysplasia, the extent of articular
used to augment the weight-bearing area in dysplastic cover for the femoral head is the most critical factor for
acetabula. The new articular surface derives by metaplasia the prognosis of secondary degeneration (Pauwels 1976).
from the acetabular rim andjoint capsule, and is therefore This cover is usually evaluated on conventional plain
of poorer quality than congruous hyaline cartilage. radiographs. Many different angles and factors have
We reviewed 32 patients after augmentation proce- been described and measured (T#{246}nnis 1987), but there
dures, using conventional radiographs and three-dimen- has been no assessment of the quantitative relationship
sional reconstruction from CF scans. We showed that between these and the potential risk of degeneration.
Chian osteotomy and shelf procedures generally achieve The operations used to improve a dysplastic aceta-
less than complete cover, especially over the posterolateral bulum can be considered in two groups : those which
quadrant of the femoral head. reorientate the whole acetabulum in relation to the ilium
Our results suggest that alternative methods which (LeCoeur 1965 ; Hopf 1966 ; Salter, Hansson and Thomp-
reonentate the whole of the acetabulum are the treatment son 1984), and those which augment the acetabulum with
of choice. Augmentation procedures remain as a salvage an additional, extra-articular buttress (Lance 1925;

option when reorientation is inappropriate or the original Chiari 1953; Fig. 1).
hyaline cartilage surface is absent, as in subluxed joints The enlargement of the weight-bearing surface
with a secondary acetabulum. Computerised assessment is achieved by augmentation reduces the unit pressure on
recommended before operation to assess existing cover and articular surfaces and the shear forces caused by
the possible extent of provision of new cover. instability. It is believed to prevent or delay degenerative
arthritis (Pawlansky, Slavik and Kubat 1976), but such
JBoneJoint Surg[Br] 1993; 75-B :750-4. bony augmentation, with interposed capsule, cannot be
Received 10 August 1992; Accepted after revision 29 March 1993
fully congruent with the original joint surface. The
capsule is attached to bone only at the rim of the old
acetabulum and is not in continuity with the original

K. Klaue, MD
R. Ganz, MD, Professor of Orthopaedics
Department of Orthopaedic Surgery
C. Looser, MD
Department of Radiology
Inselspital, University ofBern, CH-3010 Bern, Switzerland.

M. Sherman, Research Fellow

A. Wallin, PhD, Research Fellow
Maurice E. Mueller Institute for Biomechanics, University of Bern, Fig. la Fig. lb
CH-3008 Bern, Switzerland.
S. M. Perren, Professor, Head Augmentation procedures. Diagram of anteroposterior
Maurice E. Mueller Institute for Biomechanics, University of Bern, views. Figure 1 a - Chiari osteotomy allows a medial shift
CH-3008 Bern and AO Research Institute, Claradelerstrasse, CH-7260 of the joint, so that the acetabulum becomes effectively
Davos, Switzerland. abducted and the original acetabulum covers less of the
femoral head. Figure lb - A shelf procedure does not
Correspondence should be sent to Dr K. Klaue. shift the joint but augmentation provides support for the
interposed limbus and capsule as in the Chiari osteotomy.
©l993 British Editorial Society of Bone and Joint Surgery
Both procedures inevitably leave a discontinuity between
0301-620X/93/5642 $2.00
the augmented roof and the original acetabulum.

750 THE JOURNAL OF BONE AND JOINT SURGERY

 EXTRA-ARTICULAR AUGMENTATION FOR RESIDUAL HIP DYSPLASIA 71

hyaline cartilage. The limbus is also attached to bone, The operative technique was that of Chiari, but eight
deep to the capsule. This attachment is vulnerable, and hips had an additional anterior roof plasty to provide
prone to the development of intraosseous ganglia (Itoi- optimal correction in the anterior part of the joint
gawa, Azuma and Kako 1980; Klaue, Durnin and Ganz (Fernandez, Isler Muller
and 1984).
1991). Detachment ofthe limbus is probably the first step The 14 shelfprocedures were performed in the same
towards degeneration in the untreated dysplastic aceta- period as the Chiari osteotomies, using the technique of
bulum and has been suggested as one cause of failure Lance (Judet and Judet 1965). The mean age at surgery
after Chiari osteotomy (Nishina et al 1990). After a was 20.8 years (15 to 34) with follow-up of 2 to 1 1 years
Chiari osteotomy there is an obvious incongruency (mean 6.1).
opposite the upper part of the femoral head (Fig. 1). Radiology. Radiological assessment was performed by
Augmentation procedures are extra-articular, and conventional radiography to measure the CE angle
the unknown thickness and structure of the interposed (Wiberg 1939), and by CT scanning. For the latter the
soft tissue make it difficult to assess the efficiency of the patient was supine, with iliac crests level and in a
bony buttress by standard early imaging. In the long transverse plane, knees extended, legs and feet parallel
term, however, functional remodelling can be recognised and together. A series of 4 mm transverse plane cuts was
by increasing density and conformity, and failure by performed through the acetabular roofand thejoint. The
progressive resorption. films were magnified to normal size and evaluated on a

Diagrams to show the CT examination for

assessment of extra-articular augmentation
procedures. Transverse plane cuts are per-
formed from the augmented roof down to the
equator of the femoral head. Figure 2a -
Femoral head cover is defined in four quad-
rants, measured from the centre as seen in
axial projection. Because, in most cases, the
femoral head is not a perfect sphere, its apex
or pole is positioned slightly away from the
geographical centre. Figure 2b - Superimpo-
sition of both groups of curves allows cover to
be expressed in mm2 or as a percentage of the
subtended area of the femoral head.

Fig. 2a Fig. 2b

An alternative method of assessment is to measure digitising tablet (Calcomp 3000 ; Californian Computer
the true articular coverage of the femoral head in three Products mc, Anaheim, California).
dimensions (Klaue, Wallin and Ganz 1988). We have The contours of the acetabular roof and of the
assessed the cover achieved by the Chiari osteotomy and surrounding part of the pelvis were digitised. A second
by a shelf procedure, using CT-based graphical recon- set of contours was digitised for the femoral head, from
structions. its apex to its widest part or equator (Fig. 2). For precise
description, the femoral head was divided into four
quadrants, defined from the geometrical centre of the
PATIENTS AND METHODS
head (Fig. 2a). Data for both sets of curves were stored
We examined 16 patients with 19 Chiari osteotomies, on a VAX 1 1/780 computer (Digital Equipment Corp.
and 13 patients with 14 shelf procedures. The Chiari Maynard, Massachusetts). Examination of the superim-
group had a mean age at surgery of 24.3 years (1 1 to 51), posed groups of contours along the longitudinal axis
with follow-up of 3 to 12 years (mean 6.8). One of the allowed us to create an intersection diagram, from which
patients was operated on by Chiari himself. All the hips the cover of the femoral head could be deduced (Fig. 2b).
had subluxation due to residual dysplasia, and three of Heyman and Herndon (1950) described a comparable
them already had radiological signs ofdegeneration. Five technique, but in two dimensions only, and using
of the patients had had two to four previous operations. anteroposterior radiographs.

VOL. 75-B, No. 5, SEPTEMBER 1993

752 K. KLAUE, M. SHERMAN, S. M. PERREN, A. WALLIN, C. LOOSER, R. GANZ

Table I. Radiological assessment of femoral head cover after augmentation operations for
dysplastic acetabula, compared with normal values (percentage ± sEM)

Quadrant
CE angle
Procedure Total Anterolateral Posterolateral Anteromedial Posteromedial (degrees)

Chiari(n=19) 77±3* 71±4 48±6 93±3 93±2* 48±3

Shelf(n=14) 73±6 69±9 40±9* 92±4 92±4* 48±4

Normal(n=26) 90±1 78±2 84±2 99±0.2 100±0 >25t

* significant difference from normal values (Student’s t-test, p < 0.05); there were no significant
differences between the two operated groups
t from Wiberg (1939), 200 normal hips had a mean value ofabout 32

The computed results gave absolute and relative than in the natural course of the disease (Wainwright
values for surface apposition of the acetabulum against 1976; Love, Stevens and Williams 1980; White and
the femoral head (Fig. 3). To allow comparison with Sherman 1980 ; Le Saout et al 1985). Reports of the
normaljoints, we performed the same examination on 26 outcome after Chiari osteotomy are inconsistent, mainly
because of the varying indications for the procedure
Anterior (Fuhrman 1972 ; Strauss, Kreutzer and Daum 1973;
Schulze and Kramer 1975; Chiari and Schwagerl 1976;
Kerschbaumer and Bauer 1979 ; Le Saout et al 1983;
Kempf and Persoons 1985 ; Reynolds 1986 ; Calvert et al
1987; H#{248}ghand Macnicol 1987; Lack et al 1991;
Windhager et al 1991).
Medial For either augmentation procedure there will be
discrepancies in the results, depending on whether the
assessment is made by conventional radiography or by
CT (Benson and Evans 1976 ; Bl#{227}siusand Wimmer 1984).
Our CT assessments for the Chiari osteotomy agree with
the earlier findings of Bl#{228}siusand Wimmer (1984) , but
in addition we have been able to localise with precision
Posterior
those areas left uncovered. Our computer-evaluated CT
technique also highlights the inherent incongruency
Fig. 3 between the original joint surface and the augmented
area (Fig. 1). Jacquemier, Chrestian and Bouyala (1982)
Femoral head cover in different quadrants of a normal hip
(looking down on a right hip).
reported the first quantitative measurements of femoral
head cover calculated by a comparable method.
hips ofpatients who needed CT scans for non-orthopaedic The planning for correction, by whatever means,
reasons. should include assessment of the posterior cover likely to
be achieved in all planes in any particular case.
Overcorrection may lead to unexpected problems, and it
RESULTS
is interesting that early descriptions of reorientation
These are given in Table I which shows clearly that both procedures included cases of subsequent posterior dislo-
the Chiari osteotomy and the shelf procedure provide cation of the femoral head (Bollini 1980). It is relevant
very deficient cover over the posterolateral quadrant of that in certain activities, such as rising rapidly from a
the femoral head. This insufficiency is not shown up by sitting position, the posterior wall of the acetabulum is
classical radiography and measurement of the CE angle subject to more than twice the force exerted on the apex
(Fig. 4), and is difficult to assess by any other conventional ofthe acetabulum duringjogging (Hodge et al 1989). Our
technique (Figs 5 and 6). method of CT-based reconstruction can predict the
probable femoral head cover before the surgery is
performed. It is possible to predict any deficiency of the
DISCUSSION
important posterior aspect of the hip and take action to
The early stabilisation ofa dysplastic hip by reorientation avoid it (Klaue et al 1986).
of the acetabulum has been shown to achieve a
We thank Dr C. Engel of the MEM Institute of Biomechanics, Bern
satisfactory and lasting clinical outcome (LeCoeur 1965;
for the statistical evaluation of our data and Mr David Reynolds,
Salter et al 1984; Wilkinson 1987). Long-term studies of FRCS, of London who revised the manuscript.
No benefits in any form have been received or will be received
shelf procedures for dysplasia have shown that degener-
from a commercial party related directly or indirectly to the subject of
ative changes are not prevented, but are delayed to later this article.

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 EXTRA-ARTICULAR AUGMENTATION FOR RESIDUAL HIP DYSPLASIA 753

CE (degrees)

80

60

Graphs showing the relationship between CE

Cover Cover angle and total cover for Chiari osteotomy (a)
(per cent) (per cent) and the shelf procedure (b). The horizontal
40 bars represent the normal mean values. Al-
though the values of the CE angles after both
operations are scattered well above normal
Normal (mean for Chiari 48.2#{176};for shelf 47.8#{176}),the
total cover in the majority is below normal
(mean forChiari 76.6%; mean for shelf 72.9%).
20

50

0 0

Fig. 4a Fig. 4b

Fig. Sc

Chiari osteotomy in a 45-year-old woman. Figure Sa - Preoperative radiograph. Figure Sb - Six years postoperatively, a significant step is
seen at the apex of the joint, but the CE angle is greater than normal. On close examination, the posterior wall is seen to be deficient. Figure
Sc - Planimetric cover. There is a deficiency crossing the weight-bearing area, which corresponds to the original soft acetabular rim. The
posterior femoral head lacks cover.

Fig. 6a Fig. 6b Fig. 6c

Shelf procedure on the left hip of a 21-year-old woman. Figure 6a - Preoperative radiograph. Figure 6b - Ten years later, the shelf is
incorporated but the posterior wall of the acetabulum is inadequate. Figure 6c - Planimetric evaluation confirms the lack of posterior cover
(diagram reversed for comparibility with Figures 3 and Sc).

VOL. 75-B, No. 5, SEPTEMBER 1993

754 K. KLAUE, M. SHERMAN, S. M. PERREN, A. WALLIN, C. LOOSER, R. GANZ

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