412 - postgraduate medical journal · 412 i the judet arthroplasty of the hip via gibson's...

412

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THE JUDET ARTHROPLASTY OF THE HIPVIA GIBSON'S LATERAL APPROACH

BY K. I. NISSEN, F.R.C.S.From the Royal National Orthopaedic Hospital and the Institute of Orthopaedics

The method of arthroplasty of the hip intro-duced by Drs. Robert and Jean Judet of Parisover five years ago, primarily for the treatment ofpainful osteoarthritis of the hip, is being employedwith growing frequency by many orthopaedicsurgeons in this country. It is a method whichwould have fascinated that great pioneer in thefield of arthroplasty, the late Ernest Hey-Grovesof Bristol, because he had worked on similar lineswith natural materials such as ivory and the toothof the walrus. Hundreds of surgeons from all overthe world have been able to see the Judet brothersdemonstrate their technique in their private clinicat No. 3 Square Desaix, in Paris. Others haveread first the description of the technique andlater the results in 400 cases over a year old givenby the Judets in the Journal of Bone and JointSurgery. No one- who proposes to practice thisoperation should fail to consult these two readilyavailable articles. The sober finding that in osteo-arthritis roughly one-third of the results aregraded as poor or bad should curb any over-enthusiasm for the method.The Judet brothers continue to use the short

anterior vertical incision of Hueter. Those whohave visited their clinic appreciate that forwarddislocation of the head of the femur is greatly aidedby their type of orthopaedic table, with a transversebar under the fold of the buttock and with a prac-tised theatre assistant manipulating the limb inexternal rotation and in considerable hyperexten-sion below the plane of the operating table.

In our earliest cases we also used the short ver-tical incision, but after one patient had sustained afracture of the shaft of the femur during the procesof dislocation, we employed wider access by ex-tending the incision for about 2 in. along the iliaccrest and reflecting both the tensor fasciae femorismuscle and the rectus femoris. With care tomobilize the lateral margin of ilio-psoas and soallow its medial retraction, this approach gives ex-

Dr. Robert Judet and Dr. Jean Judet.

cellent access for everything except perhaps re-modelling of the acetabulum in a difficult case.Closure of the wound is very simple and theabductor muscles of the hip are not interfered with;on the other hand the lateral cutaneous nerve ofthe thigh may be damaged.Many surgeons now employ the lateral approach

recently described by Dr. Alexander Gibson ofWinnipeg. This approach gives superb lateralaccess to the acetabulum, though at the cost ofsome interference with the abductor mechanism.Gibson's approach to the hip is certain to enjoy atremendous vogue and will no doubt be em-ployed in whole or in part for other major pro-cedures, such as Brittain's ischiofemoral arthro-desis of the hip under direct vision with backwardretraction of the sciatic nerve, and one-stage arthro-desis of the hip with internal fixation by a longSmith-Petersen pin as employed by Watson-Jones.In the case of arthrodesis the fate of the abductorsis a matter for little concern; in the case of arthro-plasty, on the other hand, it is bf the greatest im-portance. Already some surgeons with experienceof both ways of access are beginning to feel, as theJudet brothers certainly do, that the anteriorapproach leaves the hip more stable, with lesstendency to a Tredelenburg type of limp and with

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J7ulY 1952 NISSEN: The Judet Arthroplasty of the Hip via Gibson's Lateral Approach

FIG. 2.-From left to right, the standard Judet prosthesis and three modifications, namely, the headcontaining four wire X-ray markers to detect any rotation of the prosthesis; the head contain-ing Mr. St. John Buxton's umbrella X-ray marker; and the head armoured with a stainlesssteel cap in order to avoid wear of the acrylic resin over the area of weight-bearing. (DownBros. and Mayer & Phelps.)

FIG. 3.-The special instruments used in the operation described in the text. From left to right,outside and inside calipers, a finger saw, two sharp-pointed solid drills of 8 and 13 mm. diameterwith corresponding acrylic templates, a I in. Smith-Petersen osteotome, the Judet auger andcircular cutter, a curved osteotome and a wooden punch. (Most instruments by Down Bros.)

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414 POSTGRADUATE MEDICAL JOURNAL July 1952

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FIG. 4.-Radiographs of the left hip before and after operation. The right hip was arthritic to a lesser degree. Thepost-operative film shows the cylindrical shape of the remainder of the femoral head, and four X-ray markers, twolong and two short, in the prosthesis. The inferior rim of osteophytes could have been more freely removed.The translucent end of the stem is just perforating the lateral cortex of the femur.

greater power of abduction of the leg againstgravity. It may prove that the lateral approach forarthroplasty will come to be reserved for difficultcases where,--remodelling of the acetabulum isessential. Some surgeons may also prefer to cutoff the great trochanter and re-attach it with oneor more screws, Postel (I95 I).The operation illustrated in this article was per-

formed as a demonstration for Sir GordonGordon-Taylor. The patient was of spare mus-cular build and the opportunity was taken tosecure a series of photographs for teaching pur-poses. These demonstrate various points in thetechnique of insertion of the Judet prosthesis usingthe Gibson approach. The captions have beenexpanded into a running commentary.

Fig. 5The patient is lying on his right side facing

towards the reader's left. The longer verticalpart of the incision is running downwards fromthe anterior margin of the left great trochanterfor about 8 in. The superior oblique part of theincision, about 4 in. long, follows the anteriorborder of the gluteus maximus muscle. The longincision is necessary in order to permit wideretraction of the fascia of the thigh.A few superficial vessels are slowly oozing

blood. Hexamethonium bromide has reduced the

blood pressure from I35 to 70 mm. The positionof the patient is ideal for the low blood pressuretechnique because the field of operation is upper-most. In this particular case no vessels wereligatured and only half a dozen small swabs wereused. Such a small amount of blood loss is therule rather than the exception. The duration ofthe operation and the presence of large musclemasses in the wound no doubt favour the spon-taneous arrest of haemorrhage and make thisoperation one of the most suitable for the lowblood pressure technique. On the other hand,Mr. Osmond Clarke has found that infiltration ofthe operative field with adrenalin i :I50,000,mixed with hyalase (333i Benger units in 4 oz.) inorder to spread the vasoconstrictor action, is alsomost effective, though there may be rather morerisk of post-operative oozing.

Fig. 6.Skin towels have been applied, though mastisol

and stockinette applied earlier would have beenpreferable. The incision has been deepenedthrough the fascia lata, exposing the vastus lateraliswhich has been nicked in two places. The constantbursa over the great trochanter has been found andthe point of a pair of curved Mayo scissors intro-duced. If the surgeon's conscience permits, hemay insert his index finger deeply through the



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July 1952 NISSEN: The yudet Arthroplasty of the Hip via Gibson's Lateral Approach 415

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bursa and palpate the thick anterior border ofgluteus maximus. In either case the line ofdivision of the deep fascia is continued upwardsand backwards along the anterior margin of themuscle. It is important to have no muscle fibresin the anterior flap of fascia because they seriouslyobscure the view of the acetabulum at a laterstage. A quantity of loose areolar tissue in theregion of the great trochanter, together with thebursa, is next removed so that gluteus medius isclearly displayed.

Fig. 7A broad retractor is now holding back the

anterior border of gluteus maximus. The gluteusmedius muscle has been divided about I in. fromits line of insertion into the anterior and superior

borders of the great trochanter. In this figure thelinear insertion and the cut margin of the muscleare being displayed, each with two pairs offorceps. Progressive segments of the flat tendonhave been elevated in turn so as to allow divisionclose to the bone, but with a sufficient stump forsound resuture. In this way enough fibrous tissueis reflected with the muscle fibres to avoid cuttingout of the important mattress sutures duringclosure. Not infrequently some deep fibres ofgluteus medius escape elevation and may be mis-taken at first for gluteus minimus.

Fig. 8A second broad retractor is holding gluteus

medius out of sight over to the left. The pinnatefibres of gluteus minimus have in turn been



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4i6 POSTGRADUATE MEDICAL JOURNAL JUIy 395Z

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cleared of areolar tissue. The horizontal anteriormargin of the muscle is being elevated from thegreat trochanter over a pair of curved Mayoscissors. A small vessel in this region frequentlyrequires ligature. The gluteus minimus muscle isdisinserted as far back as the stout tendon of piri-formis, from the anterior margin of which it hasto be separated in order to permit inward re-traction. The process of separate reflection ofgluteus medius and minimus is often difficult whenthe disorganization of the hip joint is advanced,because both these muscles and the capsule itselfmay be very adherent. The anterior and superiorcapsule of the joint is next defined by firm gauzedissection towards the rim of the acetabulum,where the reflected head of rectus femoris maycome into view.

Fig. 9The antero-superior capsule has now been freely

excised and the junction of the head and neck isseen to be covered with a mass of nodular osteo-phytes. The point of the Mayo scissors lies alongthe under surface of the neck, a region which mustbe clearly seen as it is a most important guide.This free resection of capsule greatly aids disloca-tion of the joint but also makes for post-operativeinstability, particularly in external rotation. It is,of course, probable that resection of the capsulecontributes to the relief of pain. Some surgeonsincise and repair the capsule, whereas othersresect it completely; we have been satisfiedwith the middle course shown here.The leg is next flexed to a right angle, and with

gentle external rotation strain in some adduction,



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)Uly 1952 NISSEN: The _udet Arthroplasty of the Flip via Gibson's Lateral Approach 417

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the head of the femur is dislocated. The ease ofdislocation, even in the presence of gross osteo-phytes, contrasts with the amount of force re-quired when a limited anterior approach is used.The average maximum diameter of the head ofthe femur is now measured with a pair of outsidecalipers. The diameter of the head of the selectedprosthesis will be 2 to 4 mm. less than this. As theJudets have repeatedly stressed, it is important tohave the prosthesis fitting the acetabulum asexactly as possible. A large femoral head may be55 mm. in diameter; this shows the need foracrylic heads of a diameter exceeding the usualmaximum of 45 mm.

Fig. IoNote the change of direction of the fibres of

vastus lateralis from the previous figures. Thesurgeon is now standing to the left of the picturewith the patient's knee pressed against hisepigastrium and foot gripped between his thighs;the shaft of the femur is horizontal and the tibiavertical. The exposed upper end of the femur istherefore aligned just as if the bare bone were lyingon a flat table. In this position the degree ofanteversion and the line of axis of the neck can bejudged with considerable accuracy.

With the superior, anterior and inferior marginsof the neck in full view, rather less than half ofthe head is being removed so as to leave a planesurface of cancellous bone exactly at right anglesto the axis of the femoral neck. The first half ofthis flat surface has already been made with abroad osteotome. The posterior half is now being



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418 POSTGRADUATE MEDICAL J0URNAL Yuly i952

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made with a finger-saw, the use of which avoidsall risk of a large fragment of brittle bone breakingaway posteriorly, as may happen when the osteo-tome and hammer are used alone. Note thecomparatively small amount of head which has.been removed. Removal of too much head isprobably a common error; removal of the whole ofthe head leaves the surgeon with a state of affairsalmost as bad as a fresh sub-capital fracture.This part of our technique slightly differs from

that of the Judet brothers, who simply cut off asmall segment of head and insert their large augerdown the neck with a skill and rapidity born oflong practice. Having seen in England mistakessuch as anteversion of the head of the prosthesisleading to recurrent dislocation, and the stem

either too horizontal or too vertical, we prefer towork, from the plane surface carefully defined inthis way.

Fig. IIA perspex template is applied to the flat can-

cellous surface. The diameter of the base of thetemplate corresponds with the inside measurementof the circular cutter and of the acrylic prosthesis.The template is placed over the optimum area forthe seating of the head; it is important not to bemisled by overhanging osteophytes, particularly theposterior ones which are more or less out of sight.All round the margin of the template the cancellousbone should be at least a centimetre in depth so asto allow complete seating of the head of the pros-



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Yuly 1952 NISSEN: The Judet Arthroplasty of the flip via Gibson's Lateral Approach 419

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thesis. A solid drill with a diameter of 8 mm.and with a long sharp point (Fig. 3) is being used tomake a channel through the first few centimetresof cancellous bone, exactly at right angles to thecut surface. This starting drill is specially usefulunder two circumstances: firstly when it is diffi-cult to direct the large Judet auger, for example,when the track of a Smith-Petersen pin is stillpresent; and again when the cancellous bone isvery soft. With soft bone a larger template and adrill 13 mm. in diameter is next used; in this wayno bone chips are removed in the preparation ofthe channel, and the post-operative radiographshows a cylinder of compressed bone round thestem.

Fig. I2The stout Judet auger is next inserted down the

narrow track already made. The cancellous bonechips are all removed in the deep trough in theshaft of the auger.

Fig. 13Here the length of the track down to the lateral

cortex of the femur is being estimated with a longi-in. Smith-Petersen osteotome. Tapping theosteotome against the cortical bone gives a charac-teristic sound. The length of stem of the chosenprosthesis should be about i cm. in excess of thismeasurement. A hole for the squared end of thestem is next made with the osteotome; theSmith-Petersen pattern has a flat head which per-mits it to be tapped out again should the endbecome impacted in the cortical bone. The Judetbrothers use their large calibrated auger both tomeasure the distance down to the cortex and to



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420 POSTGRADUATE MEDICAL JOURNAL July 1952

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perforate it, but we have found it difficult so tojudge the moment of contact and hence the correctlength of stem. In a tall patient with a long femoralneck the measurement down to the cortex mayapproach 8 cm., which is the usual maximumlength of stem. In such a case either the track ofthe stem has been made too vertical or more can-cellous bone should be removed from the re-mainder of the head.The two measurements necessary for the choice

of a prosthesis have now been obtained, namely,the diameter of the head in millimetres and thetotal length of the stem in centimetres. Thecorrect prosthesis is now boiled and in this wayrepeated sterilization of a number of prostheses isavoided.

Fig. I4The Judet circular cutter for the femoral head

is now in position, with the prolongation of itsthick shaft fitting in the first few centimetres of thetrack already made. The cutter is turned until itenters the cancellous bone to its full depth, atwhich stage particles of cancellous bone start beingremoved by the three radial blades in its baseplate. Professor Merle d'Aubigne has designed amore complicated cutter with a series of verticalblades, but we have had no personal experience ofthis instrument.

Fig. ISThe excess cancellous bone of the head and

all the remaining osteophytic outgrowths have



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uly I9-52 NISSEN: The3udet Arthroplasty of the Hip via Gibson's Lateral Approach 421

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been removed with a curved osteotome and areseen in the receiver. Any residual ledge of cor-tical bone just below the reach of the circularcutter, where it might lever off a segment of thenarrow rim of the acrylic prosthesis at the time offinal impaction of the head, has been removed.In this picture the whitish cancellous bone is allpart of the head; the statement sometimes madethat the under surface of the prosthesis is meantto fit over the neck of the femur is quite mis-leading.

Fig. I6Attention is now turned to the acetabulum.

Most of this photograph is deliberately out offocus. The blurred upper end of the femur is overto the right, allowing a direct lateral view of the

acetabulum and the remains of the round liga-ment. The lateral approach of Gibson obviouslygives excellent access for any reaming process.

In this patient haemorrhage during the opera-tion was so slight that the blood clot which hadaccumulated in the acetabulum was removed onone side of a small swab. The marginal osteo-phytes were unusually extensive and were freelyreduced (Fig. 4). The acetabulum, being of goodcontour, did not require remodelling.

Fig. 17The prosthesis is now being driven home by

a mallet and wooden punch. Counter-pressureis provided by an assistant's fist against the upperthigh. The punch is home-made out of soft woodand, being well boiled, there is no risk of abrasion



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POSTGRADUATE MEDICAL JOURNAL

of the polished head of the prosthesis. In thiscase the head of the prosthesis contains an X-raymarker in each quadrant; one of the longer paircan be seen opposite the superior margin of theneck (see also Fig. 4). The prepared cylinder ofcancellous bone, slightly blanched under thepressure of impaction, is everywhere in firm con-tact with the under surface of the head of theprosthesis.The new femoral head is next reduced without

difficulty by moderate traction on the limb in ex-tension and internal rotation; no skids or leversare required. The new joint may creak and maycontinue to do so more or less indefinitely; this isof no significance. The joint is naturally veryunstable in any degree of external rotation, whichmust nowv be avoided at all costs.

Fig. I8The incision is being closed. Gluteus minimus

has already been carefully repaired with parallelmattress sutures and gluteus medius is now beingtreated in the same way. The reinsertion of thesetwo muscles is greatly facilitated by supporting thelower leg, bent to a right angle at the knee, on aninstrument table which straddles the operatingtable; a sandbag is placed under the ankle so thatthe limb is held in some I5° of abduction, internalrotation and flexion. The main criticism ofGibson's lateral approach is the possible damagedone to gluteus medius and minimus. For thisreason great care is given to their repair and unduestrain on the lines of suture is avoided by the use ofcrutches up to six weeks from the time of operation.The deep fascia is now sutured. In the presence

of fixed adduction the fascia may be difficult toapproximate over the prominent great trochanter;this is one reason why any adduction contractureshould, if possible, be overcome by subcutaneousadductor tenotomy at the very start of theoperation. The wound is closed without drainage.By this time the blood pressure has been restoredto within 25 mm. of normal by the use of vaso-pressor drugs.

Post-Operative RoutineOne of the greatest post-operative risks, no

doubt, is dislocation from failure to guard againstexternal rotation. A well-known London ortho-paedic surgeon found three dislocations after hisfirst four Judet operations; we suspect this wasthe reason. We have had only one case of dis-location out of 6o operations; it probably occurredin transit from the theatre and was easily reducedby appropriate traction and slings. We thereforecontinue to follow a post-operative routine whichmay seem at times to be over-cautious.

FIG. I9.-The wavy stype of stirrup, used with a Stein-mann pin and vertical suspension in order to controlwith certainty any post-operative tendency to ex-temal rotation. The wire part of the stirrup slipseasily on to the large bushes. The thumb-screwsare of large gauge and do not loosen spontaneously.The end-protectors are an improvement uponcorks. (Medical Supply Association)

After the application of dressings the patient isturned on his back and a long Steinmann pin isinserted through the upper end of the tibia readyfor the application of the routine extension appara-tus (wavy stirrup, Tulloch Brown U-loop withspecial foot-piece, domette slings to the calf, end-protectors for the Steinmann pin; see Figs. I9 and20. One person is made responsible to seethat the patella and foot are kept pointing forwardsuntil the patient is safely back in the ward with4 to 8 lb. of longitudinal traction on the U-loop,5 to I0 lb. of vertical suspension through a cordattached to the wavy stirrup, low blocks under thefoot of the bed and the leg in slight abduction.The patella is kept pointing forwards by placingthe suspension cord, as a rule, in the loop justlateral to the central one. A post-operative radio-graph is taken as soon as convenient.

Early movements are encouraged in all direc-tions except rotation. In order to avoid flexioncontracture of the hip joint, the patient lies com*pletely flat for 12 hours out of the 24, but for theother 12 hours he may sit up just as much as he

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Yuly 1952 NISSEN: rhe Judet Arthroplast, of the lip via Gibson's Lateral Approach 423

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FIG. 20.-To show the traction apparatus in use with an overhead beam. For afull description, see Proc. Roy. Soc. Med. (Sect. of Orth.), xliii, 308. (TullochBrown U-loop with special foot-piece and wavy type of stirrup, made byMedical Supply Association. Overhead beam by Messrs. Hoskins & Sewell).

likes. 'The type of extension apparatus used avoidsall constriction and allows exercise of the calfmuscles, particularly during the first fortnightafter operation while the risk of thrombosis andpulmonary embolism is greatest.The tibial pin is removed at two weeks and the

pin holes close rapidly. If the patient is fit, hespends the third week up in a chair each day;sometimes, however, the third week is spent inbed with light skin traction and a bandage roundthe knee to control external rotation. Weight-bearing with crutches is encouraged after the thirdor fourth week, and with the Gibson incision thecrutches are maintained till six weeks have elapsedin order to give gluteus medius and minimus everyopportunity to unite soundly. The return of

a ctive movement of the hip joint is so rapid thatt he majority of patients are fit for discharge to out-patient supervision between six and eight weeksfrom the time of operation.

AcknowledgmentThe photographic work has been kindly carried

out by Mr. R. J. Whitley, of the Institute ofOrthopaedics.

BIBLIOGRAPHYJUDET, J., and JUDET, R. (Ig5o), 'The Use of an Artificial

Femoral Head for Arthroplasty of the Hip Joint,' J. Bone &.joint Surg., 32b, I66.

JUDET, J., and JUDET, R. (1952), 'Technique and Results withlthe Acrylic Femoral Prosthesis,' Ibid., 34b, 173.

POSTEL, M. (I95I), Arthroplasties de la Hanche, Paris, Encyclo-pddie Mddico-Chirurgicale.



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