Chiari Internal Pelvic Osteotomy

Chiari pelvic internal osteotomy is used for the surgical treatment of congenital dislocation of the hip. Pelvic osteotomy is used for acetabular dysplasia and hip dislocation in order to increase the stability of the acetabulum after reduction of the femoral head. Common surgical methods are: 1Salter tibia osteotomy; 2Chiari pelvic internal osteotomy; 3Pemberton joint sac around the humerus osteotomy; 4 pelvic multiple osteotomy. In 1955, Chiari designed a pelvic internal osteotomy. The osteotomy line is between the large ischial incision and the anterior and posterior iliac spine. It is close to the joint capsule and is obliquely cut from the head to the side by 10° to 15°. The distal end of the bone is displaced from the inside to the side by 30% to 50%. The proximal end of the osteotomy is inserted into the joint capsule between the acetabular apex and the femoral head, and the embedded joint capsule can be converted into fibrocartilage. Chiari pelvic internal osteotomy is a remedial procedure. It is not a hip reconstruction. It only provides fibrous cartilage for the acetabulum covering the femoral head, not hyaline cartilage. In the weight-bearing state, fibrocartilage is not as durable as hyaline cartilage, and osteoarthritis is more likely to occur. Secondly, pelvic internal migration can lead to sciatic nerve injury (1%). However, it usually recovers within 6 to 12 weeks after surgery. Secondly, the pelvic internal movement changes the pelvic ring and affects the normal delivery of women, and the possibility of cesarean section increases. Treatment of diseases: congenital dislocation of the hip and acetabular fracture Indication Chiari pelvic internal osteotomy is available for: 1. Those who are over 8 years old. 2. The acetabular height is poorly developed, and the acetabular index is above 45°. 3. The acetabulum is shallow and the femoral head is significantly enlarged. 4. Adolescents with hip pain, unstable joints or flat hips. Contraindications 1. Those who are under 6 years of age at the time of surgery. 2. A hip dislocation with better acetabular and femoral head development. 3. After the posterior dislocation, the femoral head dislocation is more than 3cm above the upper edge of the acetabulum. 4. Patients with severe osteoarthritis, moderately damaged articular cartilage, and loss of joint function need to consider joint replacement or arthrodesis. Preoperative preparation Bone traction for 2 to 3 weeks before surgery, if necessary, first to do soft tissue release. Surgical procedure 1. Incision approach and surgical exposure method with Salter tibia osteotomy. (1) Incision: Along the humerus to the anterior superior iliac spine, 3 cm down, make a diagonal incision, 8 to 10 cm long, and use the anterolateral arc incision when performing the upper extremity osteotomy. (2) revealing the internal and external humerus plate: the iliac crest iliac crest is opened longitudinally, and the subperiosteal peel is attached to the gluteus medius, the gluteus maximus and the anterior superior ligament of the joint capsule, and the rectus femoris and iliac crest are cut off. The lumbar muscles and the former are turned to the distal end, and the joints and venous branches are not ligated to expose the joint capsule. Following the periosteal peeling of the humerus inner plate, the ischial notch was revealed. When the inner and outer plates of the tibia are removed, the vascular bones of the tibia should be ligated, electrocauterized, or filled with bone wax to stop bleeding. When peeling the inner and outer humerus plates, it is only necessary to expose the sciatic notch, and avoid excessive peeling to increase the chance of bleeding. The sciatic notch was inserted with the tibial retractor to reveal the inner and outer humerus plates. 2. Pelvic osteotomy plane In order to accurately select the osteotomy plane, a K-wire should be drilled in the predetermined osteotomy site and an X-ray film should be taken to confirm whether the selected site is correct or not. According to the X-ray film, the correct osteotomy should be between the rectus femoris reclining head and the hip joint capsule attachment point. The osteotomy line should be inclined to the head side from 10 to 15 degrees from the horizontal line of the pelvis. If the plane of the osteotomy is too high, it can hurt the ankle joint. If it is too low, it may hurt the acetabulum. The osteotomy penetrates from the outer plate of the humerus to the inner plate. To prevent the inner plate from fracture, a row of holes is drilled in the osteotomy surface. In order to prevent the distal end from being displaced rearward after osteotomy, the osteotomy surface should be designed to be "shallow curved". After the osteotomy is completed, the distal end is displaced inward by 1 to 2 cm, which is equivalent to about 1/3 of the thickness of the tibia. A new acetabular top is formed at the proximal end, and the joint capsule is sandwiched between the acetabulum top and the femoral head, and fibrocartilage can be formed in the future. During the operation, the lateral extremity abduction was performed when the distal end of the osteotomy was moved inward. The surgeon pushed the femur with the inward trochanter, and the assistant used the periosteal screwdriver to move the proximal end of the osteotomy. Because the pelvic osteotomy is based on the pubic symphysis and the ankle joint as a "hinge", the action to reduce the damage to the two joints should be gentle. 3. Two bone ends are fixed with 2 to 3 threaded needles (length 9cm, 11cm, diameter 3~3.5mm), the threaded needle is inserted in the direction, obliquely inward and downward from the outer upper part of the anterior superior iliac spine, taking care to avoid the threaded needle entering In the hip joint cavity, if necessary, take X-ray examination on the operating table to confirm.

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