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The management of hip instability in myelomeningocele patients is controversial. The purpose of this study is to review our long-term results of isolated Chiari osteotomies in the treatment of hip instability in children with myelomeningocele. Between 1975 and 1988, 11 patients underwent 13 Chiari osteotomies for reducible hip subluxation or dislocation and acetabular deficiency. The patients returned for follow-up clinical examinations, interviews, and radiographs. The average age at the time of surgery was 9.4 years (range, 5-18). The average age at follow-up was 18 years (range, 13-23). The average follow-up was 11.4 years (range, 2-18). The mean preoperative center-edge (CE) angle was -38 degrees. The mean immediate postoperative CE angle was 41 degrees. At final follow-up, the mean CE angle was 4.6 degrees. Only three of the 10 hips had a normal CE angle of > or = 25 degrees. The Chiari osteotomy alone did not achieve long-term hip stability in the majority of patients. Several, if not most, of our patients may progress to frank dislocation with longer follow-up.

Hip subluxation and dislocation in patients with cerebral palsy are challenging problems. The Chiari pelvic osteotomy has been commonly recommended as a technique for hip stabilization when acetabular dysplasia is present. We evaluated the results of Chiari osteotomy without concomitant femoral osteotomy in 24 hips in 23 patients with an average follow-up of > 7 years. Evaluation consisted of a pain and function questionnaire, chart review, physical examination, and review of serial radiographs. At final follow-up, 19 of 24 (79%) of the hips were painless, and 21 of 24 hips (88%) permitted unlimited sitting. Seven of 24 (29%) of hips, however, had a migration index of > or = 30%. Painful hips were associated with a greater migration index preoperatively, at 1 year postoperatively, and at final follow-up, and a greater height of the osteotomy above the edge of the acetabulum. Deterioration in the migration index (resubluxation) occurred largely in the first year postoperatively. Alternative acetabular procedures, simultaneous femoral osteotomies, or both may improve on these results. Long-term follow-up studies are necessary to compare the results of different treatments for spastic hip subluxation and dislocation to determine optimal treatment.

A. Why Perform An Osteotomy In Childhood or Adolescence? 1. Progressive deformity for which osteotomy is curative. 2. Cosmesis. 3. To prevent the development of late osteoarthritis (unproven). 4. Progressive ligamentous laxity (rare). 5. Functionally limiting deformities (rare). 6. Development of adaptive joint deformity (rare). B. When To Perform An Osteotomy 1. Immediate correction for progressive deformities or functionally limiting deformities that can not be expected to improve by the natural history of the deformity. 2. Immediate correction if the problems listed under "A" are present such as the development of adaptive joint deformity or progressive ligamentous laxity. 3. If no indication for osteotomy exists except cosmesis, consider delaying correction to avoid the need for repeated osteotomies in disorders for which recurrence is common. C. How To Do The Osteotomies 1. Perform the osteotomy at the level of the deformity when possible. 2. Choose the simplest, safest method that will accomplish specific goals. 3. Complex restoration of perfect mechanical axis and joint alignment may not be necessary. The lesser risks of simpler techniques should be considered. 4. The specific technique chosen will depend on the experience and abilities of the treating physician.

Osteotomy for deformity of the legs is a commonly performed operation for which many techniques have been described. Indications for osteotomy, however, are lacking. To assess the amount of angulation compatible with good long-term function and avoidance of osteoarthritis we followed a group of patients with fractured tibias a mean of 29 years from injury. Clinical and radiographic outcomes were unaffected by the amount of angulation or by whether there was varus or valgus angulation. Our data suggest that angular deformities less than 10-15 degrees are well tolerated long term with respect to development of osteoarthritis.

We reviewed the results of fifty consecutive spike osteotomies that were performed in thirty-five children for the treatment of angular deformity of a long bone. After forty-three of the procedures, the radiographs were adequate to assess the stability of the fragments. At the time of healing, the average loss of correction from the position that had been accepted at operation was 2 degrees in the anterior-posterior plane and 1.2 degrees in the lateral plane. In four limbs, more than 5 degrees of correction had been lost. No patient lost more than 10 degrees of correction. The rates of complications and of recurrence were similar to those of other reported series. We concluded that the spike osteotomy is safe and effective.