Postgrad Med J: first published as 10.1136/pgmj.24.271.241 on 1 May 1948. Downloaded from 241

EXCISION OF THE FEMORAL HEAD AND NECK FOR ANKYLOSIS AND ARTHRITIS OF THE HIP By J. S. BATCHELOR, F.R.C.S. Honorary Orthopaedic Surgeon, Guy's Hospital and St. Vincent's Orthopaedic Hospital

For many years the tendency has been to regard of the hip muscles. I have now performed this arthrodesis as the treatment of choice for a stiff operation in 34 patients and have found that a free and painful hipjoint, forwhen sound bony ankylosis range of painless movement is practically assured. occurs the patient is assured of a strong, stable This procedure has however one serious dis- and painless hip. There are, however, certain dis- advantage-the potential instability of the pseud- advantages associated with this procedure. The arthrosis. This instability, which varies in degree operation itself may be formidable and the period in different hip conditions and depends to a large of immobilization in plaster for three to four extent on the amount of fibrosis present around the months which often follows is not well tolerated joint before operation, can be overcome to a certain by elderly patients. Unless the lumbar spine is extent by the use of a calliper for some months supple the fixed hip makes it difficult, if not im- after the operation, or more effectively by a low possible, for the patient to sit comfortably on an sub-trochanteric osteotomy of the Schanz type. upright chair and to put on shoes and stockings. I have therefore supplemented the excision with At a recent orthopaedic meeting a demonstration an osteotomy in a large number of cases and have of devices to enable the patient to dress himself found that it provides excellent stability. Plating by copyright. portrayed graphically the difficulties that patients of the osteotomy followed by Hamilton-Russell with fixed hips may encounter. Arthrodesis is traction avoids plaster spicas and allows early contra-indicated when both hips are affected or movement at the new joint. when the lumbar spine is stiff and arthritic. To produce a new hip joint which is mobile, Clinical Material painless and stable has proved a difficult problem. Excision, with or without osteotomy, has been Formal arthroplasty by remodelling of the femoral employed in the following conditions: head and the insertion of a fascial flap has proved Number unsuccessful, for although a limited range of move- ofcases http://pmj.bmj.com/ ment may be obtained for a short time, the joint i. Ankylosing spondylitis and rheuma- soon stiffens, and becomes painful. During recent toid arthritis ...... 7 years, however, Smith-Petersen has achieved 2. Traumatic and degenerative osteo- considerable success with his vitallium cup arthritis ...... I2 arthroplasty. 3. (a) Fracture-dislocation of hip* .. 3 The operation of pseudarthrosis of the hip has (b) Ununited fracture of femoral neck 4

made little appeal to the orthopaedic surgeon. The 4. Bilateral ankylosis following suppura- on September 26, 2021 by guest. Protected method advocated by Sir Robert Jones, which tive arthritis ...... 4 consists essentially of the excision of a large wedge 5. Chronic suppurative arthritis .. 4 of bone from the trochanteric region and the attachment of the gluteal insertion to the stump of Indications for Osteotomy the femoral neck, is followed by considerable in- Osteotomy should be performed in patients with stability and loss of power, for the action of many unilateral degenerative and traumatic osteo- of the hip muscles, particularly the glutei, is lost. arthritis, in ankylosing spondylitis and in patients At a meeting ofthe British Orthopaedic Associa- with ununited fracture of the femoral neck and tion at the Wingfield-Morris Orthopaedic Hospital fracture-dislocation ofthe hip. In these conditions in 1938, Professor Girdlestone demonstrated the peri-articular fibrosis is minimal and the prolonged good results that can be obtained in osteo-arthritis use of a calliper cannot be relied upon to give good ofthe hip by excision ofthe femoral head and neck. stability. Osteotomy is particularly indicated when This is a simple procedure, well borne by the the patient is young and active, for it greatly im- elderly, which effectively relieves pain and restores proves the quality of the end result. movement and leaves undisturbed the attachment Considerable peri-articular fibrosis is usually Postgrad Med J: first published as 10.1136/pgmj.24.271.241 on 1 May 1948. Downloaded from 242 POST GRADUATE MEDICAL JOURNAL May I948 present when there has been a suppurative or hip joint is now exposed. A longitudinal incision infective arthritis and here the use of a calliper for along the neck of the femur, commencing at the four to six months gives good stability. Occasion- acetabular margin and extending to the inter- ally a calliper can be dispensed with altogether in trochanteric line, is made through the joint capsule. these cases, particularly when the patient is light A rougine is thrust into the cleft and the capsule in weight. levered off the superior surface of the femoral Osteotomy is contra-indicated in elderly patients neck; a large Lane's bone lever, the curved with bilateral degenerative osteo-arthritis. tongue of which passes behind the neck, is then inserted. The lower border of the femoral neck Excision of the Femoral Head and Neck neck is exposed in the same way with the aid of a second bone lever. With a The excision a few touches of the is performed through Smith- knife the remaining attachments of the capsule to Petersen approach. The patient is placed on the the anterior margin of the acetabulum are sepa- operating table in the semi-lateral position with rated and the is sandbags beneath the buttock and shoulder. The joint freely exposed. chief landmark for the incision is the anterior Dislocation of the femoral head from the aceta- superior iliac spine. From this point the incision bulum should precede section of the neck. The is carried posteriorly over the iliac crest for three anterior superior margin of the acetabulum is re- to four inches and distally down the antero-lateral moved together with any osteophytes which are surface of the thigh for five to six inches. The present, or, when the joint is fused, the ankylosis interval between the Sartorius and the Tensor between the femoral head and acetabulum is Fascia Femoris Muscles is defined at a point divided with a gouge. The head is then levered about one inch below the anterior superior spine out of the acetabulum bv adduction and external and with the aid of retractors the incision is rotation of the leg. deepened between the Rectus Femoris medially The femoral neck is now divided. The line of and the Glutei laterally. Care at this stage, parti- osteotomy commences at its inferior border as cularly in identifying and retracting the deepest low down as possible and passes upwards andby copyright. gluteal fibres, facilitates the later stages of the outwards so as to divide the neck close to the great operation. trochanter. If all the neck is not excised with the The surgeon now turns to the anterior three or head, the remainder is removed with an osteotome, four inches of the iliac crest and reflects the care being taken to leave a smooth surface. The periosteum from the lateral half of its subcutaneous acetabulum is inspected and any osteophytes surface. The gluteal attachment to the over- remaining round its margin are removed. hanging lateral margin of the crest is separated After re-attaching the reflected head of the with the scalpel and then reflected sub-periosteally Rectus Femoris, the wound is closed by suturing from the outer face of the ilium. Firm packing in back the lateral muscle flap to the iliac crest andhttp://pmj.bmj.com/ the space between the muscles and the ilium con- anterior superior spine. A few interrupted sutures trols the brisk oozing which occurs at this stage and are required between the fascia overlying the holds the gluteal flap aside for the next stage. The Sartorius and Tensor Fascia Femoris Muscles. tendinous origin of the Tensor Fascia Femoris No drainage is required. A firm spica bandage Muscle from the anterior superior spine is applied over wool compresses the wound and by divided and the few remaining attachments of the diminishing the dead space assists healing. gluteal muscles separated from the ilium. on September 26, 2021 by guest. Protected The distal portion of the incision in the thigh Osteotomy is now deepened throughout its length by dividing The osteotomy can be carried out as a primary the fascial attachments between the Rectus procedure at the time of the excision but preferably Femoris medially and the Tensor Fascia Femoris as a secondary procedure three to five weeks later and Vastus Lateralis laterally. At this stage the when the first incision has soundly healed. ascending branches of the external circumflex When osteotomy is doneprimarily the distal part of artery and vein should be located and divided be- the incision is extended for an inch orso, the Rectus tween artery forceps where they emerge from Femoris mobilized and retracted well medially beneath the lateral margin of the Rectus Femoris and the Vastus Lateralis reflected sub-periosteally Muscle about two to three inches below the from the femoral shaft. With the aid of bone anterior superior spine. levers two to three inches of the upper part of the The reflected head of the Rectus Femoris is shaft are easily exposed. The osteotomy, which :arefully defined, separated from its bony attach- should be cuneiform in type in order to allow ment and stripped downwards for two to three rotation of the fragments on each other without inches. The anterior surface of the capsule of the displacement, is performed just below the lesser Postgrad Med J: first published as 10.1136/pgmj.24.271.241 on 1 May 1948. Downloaded from May 1948 BATCHELOR: Excision of the Femoral Heald and Neck

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FIG. i -Bilateral excision for ankylosing spondylitis. http://pmj.bmj.com/ on September 26, 2021 by guest. Protected

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FIG. 3.-Monarticular osteo-arthritis treated by excision and osteotomy. http://pmj.bmj.com/

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FIG. 4.-Irreducible fracture-dislocation of the hip treated by excision and osteotomy. Postgrad Med J: first published as 10.1136/pgmj.24.271.241 on 1 May 1948. Downloaded from May 1948 lATCIELOR: Pxcision of the Pemoral Head and Neck 24S

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Fig. 6.-guppurative arthritis with pathological dislocation treated by excision and osteotomy. Postgrad Med J: first published as 10.1136/pgmj.24.271.241 on 1 May 1948. Downloaded from 246 POST GRADUATE MEDICAL JOURNAL May 1948

Diag. I Diag. II Diag. III trochanter, using small sharp osteotomes. In Lane plate which may be bent to the required order to abduct the lower fragment sufficiently it angle before operation. The upper fragment is often necessary to separate a small triangular tends to flex after the osteotomv has been com- piece of bone from the lateral surface of the upper pleted; if the patient is prone, this angulation can fragment (Fig. 4). The osteotomy is now fixed be reduced by' breaking' the table a few degrees. with a special plate angled in the coronal plane It is also important to guard against the tendency for which is applied to the anterior surfaces of the the leg to fall into internal rotation while the plate is great trochanter and femoral shaft (Diag. I). being applied. I have found that six screws give a

When the osteotomy is done as a secondary perfectly adequate grip, allowing the plate to by copyright. be procedure it can be performed through either a angled between the middle two holes which are- lateral or a postero-lateral approach. The use of not used. The screws in the proximal fragment a lateral incision entails splitting the Vastus should not penetrate the medial (weight-bearing) Laterglis and with the leg abducted after the bone surface of the bone and the upper two should has been divided, the depth of the wound makes it therefore not exceed one inch in length; in the difficult to fix the plate in position. Technically, distal fragment the screws should engage the the osteotomv is much easier to perform through a cortical bone medially and should be approximately postcro-lateral approach with the patient in the one and a half inches in length. prone position. An incision is made over the http://pmj.bmj.com/ postero-lateral surface of the hip, commencing Angle of the Osteotomy over the great trochanter and extending distally for five to six inches. The fascia lata is divided The condition of the opposite hip and lumbar lateral to the insertion of the Gluteus Maximus, spine must be considered when estimating the thus exposing the posterior aspect of the trochanter correct angle of osteotomy. For unilateral osteo- and upper shaft. The Vastus Lateralis is reflected arthritis with a sound contralateral hip and supple anteriorly fiom its attachment to the linea aspera

lumbar spine, the distal fragment may be abducted on September 26, 2021 by guest. Protected and the upper part of the shaft and sub-tro- 400 on the proximal fragment. This produces chanteric region are exposed. a certain armount of fixed abduction with tilting of The bone is divided just below the lesser tro- the pelvis and apparent lengthening of the limb. chanter, a locking type of osteotomy with a tongue In bilateral ankylosis of the hips with a supple of bone on the lateral aspect of the distal fragment lumbar spine, osteotomy may be performed after being used in order to ensure good stability of the excision of one hip when the contralateral hip is fragments. The tongue should be cut out first ankylosed by bone in adduction; the angle of the and then the bone divided around its circumference osteotomy is then adjusted to the position of the at the base of the tongue, again using small, sharp fixed hip. Osteotomy is contra-indicated when the osteotomes (Diag. II). Before the distal fragment ankylosis of the'opposite hip is fibrous or when it is abducted the tongue may have to be slightly is fixed in abduction. When both hips are shortened with bone-cutting forceps so that with ankylosed and the lumbar spine is rigid, as in the aid of a fine osteotome used as a shoe-horn it ankylosing spondylitis, an angle of osteotomy can be impacted well into the proximal fragment greater than 250 may render adduction of the leg (Diag. III). to the neutral position impossible and should he The osteotomy is now fixed with an eight-hole avoided. Postgrad Med J: first published as 10.1136/pgmj.24.271.241 on 1 May 1948. Downloaded from May 1948 BATCHELOR: Excision of Femoral Head and Neck After-treatment for Excision and for Of the seven cases treated, excision of the head Osteotomy and neck of both hips has been performed in six, After the operation a Steinmann's pin is inserted followed in four cases by osteotomy. My first through the upper end of the tibia and traction case in this group, a man aged thirty-five whose applied by Hamilton-Russell extension with a treatment was commenced in I938, was one of the weight of 7 lb. The chief advantage of the tibial two in whom bilateral excision only was performed. pin is that it controls rotation and prevents There was an interval of about seven months be- eversion of the limb, which can be troublesome tween the two operations and after each operation after this operation. It is important that shorten- the patient used a weight-relieving calliper for six ing should be prevented and that the great tro- months. The result has been most satisfactory, for chanter should lie below the level of the aceta- he now has a pair of relatively painless and stable bulum. The position of the hip should be checked hips with a range of flexion of 800 (Fig. i). He by X-ray examination the day after operation. can walk moderate distances using sticks and drives Shortening with upward displacement of the great a car. The second patient in whom bilateral ex- trochanter on to the dorsum ilii will of course lead cision was performed walks with the aid of elbow to troublesome instability. crutches but the functional result is marred by After fourteen days movements for the hip and ankylosis of btoth knees. knee and exercises for the thigh and hip muscles Of the four cases in which excision followed by are commenced. Joint movements are at first osteotomy was performed on both hips, good performed through a limited range with the ex- stability has been secured without the use of tension apparatus in place. After four weeks the callipers (Fig. 2). These four patients have a weight is removed during treatment so that a free good range of movement at the hips and can walk range of movement at the hip and knee can be with the aid of sticks or elbow crutches. The obtained, patient in whom the excision of only one hip was In a straightforward case of excision without performed, when last examined, could walk osteotomy, traction is continued for eight weeks. reasonably well. It was intended to proceed with by copyright. The patient then commences walking with the aid excision of the other hip but the war interrupted of crutches or a walking-machine and with a his treatment and he has been lost sight of. weight-relieving calliper, the measurements for which were taken during the period of traction. 2. Traumatic and Degenerative Osteo-Arthritis The calliper is worn for four to eight months and In six patients with bilateral degenerative osteo- when clinical tests indicate that the hip is stable arthritis of the hips, excision of the head and neck is gradually dispensed with. has been performed on the more painful hip. Osteo- When osteotomy has been performed traction is tomy is not indicated in these cases, for the tilting of the which it would maintained for ten to twelve weeks. Weight bear- pelvis produces throw an ad- http://pmj.bmj.com/ ing without a calliper is commenced when X-ray duction strain on the contra-lateral hip. The examination shows that the osteotomy has united. results in this group of patients have been dis- appointing. Although the operation has relieved Discussion and Results pain and restored a free range of movement in one hip, function is poor, for the gait in the i. Ankylosing Spondylitis majority of these patients is slow and halting. In Here a free range of movement at both hips is bilateral osteo-arthritis of the hips, therefore, essential; otherwise the fixed spine makes it im- excision of one hip is indicated only when pain is on September 26, 2021 by guest. Protected possible for the patient to sit in comfort. In severe; a good functional recovery cannot be assessing the results the severe degree of crippling expected. frequently found in many of these patients must be Excision followed by osteotomy has been carried appreciated; some of them have been bedridden out in six patients with unilateral osteo-arthritis. for years with ankylosis of the hips, knees and The need for osteotomy in this group was indicated spine. The prospect of a good functional result by the progress made by my first patient with a is brighter when the knees are unaffected, for unilateral osteo-arthritis after he had been treated ankylosis of these joints makes sitting difficult even by this method (Fig. 3). After excision of the when the hips move freely. After the surgical femoral head and neck in I94i a weight-relieving treatment has been completed a prolonged and calliper was worn for eight months. When the laborious course of training extending over two calliper was discarded the hip felt unstable and years or more is essential to achieve the optimal ached after use. These symptoms were completely degree of functional recovery. This necessitates relieved by a sub-trochanteric osteotomy (Fig. 4). considerable co-operation on the part of the In five patients in this group the results are very patient. satisfactory. The range of flexion varies from 750 Postgrad Med J: first published as 10.1136/pgmj.24.271.241 on 1 May 1948. Downloaded from 248 POST GRADUATE MEDICAL JOURNAL May 1948 to goo, the hips are painless and stable and the gait 5. Chronic Suppurative Arthritis is good with only a slight limp. One elderly patient refused to co-operate in carrying out after- In this group there are four patients, in three of treatment and did not learn to walk. whom long-standing infection with multiple sinuses had persisted despite numerous operations 3. (a) Fracture-dislocation of the Hip for drainage and sequestrectomy. Here the in- Excision of the femoral head and neck followed fection appears to linger in the relatively avascular by osteotomy has been performed in three cases cancellous bone of the femoral head and it may of irreducible fracture-dislocation of the hip prove impossible to obtain sound healing until the (Fig- 4). femoral head has been removed. In all of these (b) Ununited Fracture of the Femoral Neck cases excision of the femoral head and neck re- In this condition there is a tendency to advise moved the main site of infection and allowed the some form of osteotomy almost as a routine. sinuses to heal (Fig. 5). A good result may be expected if the osteotomy In the three cases with long-standing infection, is followed by union of the fracture but unfor- adequate stability was provided by periarticular tunately, owing to degenerative changes in the fibrosis; in the fourth case, a child of nine with a femoral head and absorption of the neck, the recent infection and pathological dislocation, an fracture fails to unite in a high proportion of cases. osteotomy was performed (Fig. 6). The results The patient is then left with a stiff, painful and obtained in this group have been very satisfactory. often unstable hip. I have therefore excised the Although the range of flexion is somewhat limited, femoral head and remainder of the neck in four the hips are stable and painless. patients with ununited fracture of the femoral neck. In three cases the excision was followed by Summary an osteotomy. In these two groups the results, like those in i. In unilateral traumatic and degenerative patients with degenerative and traumatic osteo- osteo-arthritis, ununited fracture of the femoral

neck and fracture-dislocation of the hip, excisionby copyright. arthritis, are with one exception most satisfactory. of Of the seven patients, six have a good range of the femoral head and neck followed by osteo- movement, are free of pain and walk well. In the tomy can be relied upon to give a painless and one case of ununited fracture of the femoral neck stable joint with an average range of flexion of in which excision of the head was not followed by 750 to 900. osteotomy, the result has been unsatisfactory 2. In ankylosing spondylitis and rheumatoid owing to shortening and adduction deformity. arthritis, excision of both hips followed by osteo- 4. Bilateral Ankylosisfrom Suppurative Arthritis tomy has restored to limited activity patients who Four such cases have been treated. In were previously bedridden. two good http://pmj.bmj.com/ results were obtained by excision without osteo- 3. In bilateral ankylosis of the hips following in- tomy, for excellent stability was provided by fection, excision of one hip followed by the use of fibrosis around the joint. In one case the excision a calliper has produced a stable joint with an aver- was followed by an osteotomy and here the result age range of flexion of 60W. was only fair owing to limitation of flexion (400). 4. In four patients with chronic suppurative In the fourth patient, on whom arthroplasty had arthritis, three of whom had discharging sinuses, been attempted elsewhere, a range of flexion of excision of the femoral head and neck was followed only 300 has been obtained after excision of the by healing of the sinuses and restoration of a on September 26, 2021 by guest. Protected head and neck. limited range of painless movement.