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EXCISION of the FEMORAL HEAD and NECK for ANKYLOSIS and ARTHRITIS of the HIP by J

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EXCISION of the FEMORAL HEAD and NECK for ANKYLOSIS and ARTHRITIS of the HIP by J 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.
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