of the femoral head and neck ankylosis and arthritis … · 241 excision of the femoral head...

241

EXCISION OF THE FEMORAL HEAD AND NECKFOR 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 regardarthrodesis as the treatment of choice for a stiffand painful hip joint, forwhen sound bony ankylosisoccurs the patient is assured of a strong, stableand painless hip. There are, however, certain dis-advantages associated with this procedure. Theoperation itself may be formidable and the periodof immobilization in plaster for three to fourmonths which often follows is not well toleratedby elderly patients. Unless the lumbar spine issupple the fixed hip makes it difficult, if not im-possible, for the patient to sit comfortably on anupright chair and to put on shoes and stockings.At a recent orthopaedic meeting a demonstrationof devices to enable the patient to dress himselfportrayed graphically the difficulties that patientswith fixed hips may encounter. Arthrodesis iscontra-indicated when both hips are affected orwhen the lumbar spine is stiff and arthritic.To produce a new hip joint which is mobile,

painless and stable has proved a difficult problem.Formal arthroplasty by remodelling of the femoralhead and the insertion of a fascial flap has provedunsuccessful, for although a limited range of move-ment may be obtained for a short time, the jointsoon stiffens, and becomes painful. During recentyears, however, Smith-Petersen has achievedconsiderable success with his vitallium cuparthroplasty.The operation of pseudarthrosis of the hip has

made little appeal to the orthopaedic surgeon. Themethod advocated by Sir Robert Jones, whichconsists essentially of the excision of a large wedgeof bone from the trochanteric region and theattachment of the gluteal insertion to the stump ofthe femoral neck, is followed by considerable in-stability and loss of power, for the action of manyof the hip muscles, particularly the glutei, is lost.At a meeting of the British Orthopaedic Associa-

tion at the Wingfield-Morris Orthopaedic Hospitalin 1938, Professor Girdlestone demonstrated thegood results that can be obtained in osteo-arthritisof the hip by excision of the femoral head and neck.This is a simple procedure, well borne by theelderly, which effectively relieves pain and restoresmovement and leaves undisturbed the attachment

of the hip muscles. I have now performed thisoperation in 34 patients and have found that a freerange of painless movement is practically assured.

This procedure has however one serious dis-advantage-the potential instability of the pseud-arthrosis. This instability, which varies in degreein different hip conditions and depends to a largeextent on the amount of fibrosis present around thejoint before operation, can be overcome to a certainextent by the use of a calliper for some monthsafter the operation, or more effectively by a lowsub-trochanteric osteotomy of the Schanz type.I have therefore supplemented the excision withan osteotomy in a large number of cases and havefound that it provides excellent stability. Platingof the osteotomy followed by Hamilton-Russelltraction avoids plaster spicas and allows earlymovement at the new joint.

Clinical MaterialExcision, with or without osteotomy, has been

employed in the following conditions:Numberof cases

i. Ankylosing spondylitis and rheuma-toid arthritis .. .. .. 7

2. Traumatic and degenerative osteo-arthritis .. .. .. ..I2

3. (a) Fracture-dislocation of hip* .. 3(b) Ununited fracture of femoral neck 4

4. Bilateral ankylosis following suppura-tive arthritis .. .. .. 4

5. Chronic suppurative arthritis .. 4

Indications for OsteotomyOsteotomy should be performed in patients with

unilateral degenerative and traumatic osteo-arthritis, in ankylosing spondylitis and in patientswith ununited fracture of the femoral neck andfracture-dislocation of the hip. In these conditionsperi-articular fibrosis is minimal and the prolongeduse of a calliper cannot be relied upon to give goodstability. Osteotomy is particularly indicated whenthe patient is young and active, for it greatly im-proves the quality of the end result.

Considerable peri-articular fibrosis is usually

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242 POST GRADUATE MEDICAL JOURNAL May I948

present when there has been a suppurative orinfective arthritis and here the use of a calliper forfour to six months gives good stability. Occasion-ally a calliper can be dispensed with altogether inthese cases, particularly when the patient is lightin weight.

Osteotomy is contra-indicated in elderly patientswith bilateral degenerative osteo-arthritis.

Excision of the Femoral Head and NeckThe excision is performed through a Smith-

Petersen approach. The patient is placed on theoperating table in the semi-lateral position withsandbags beneath the buttock and shoulder. Thechief landmark for the incision is the anteriorsuperior iliac spine. From this point the incisionis carried posteriorly over the iliac crest for threeto four inches and distally down the antero-lateralsurface of the thigh for five to six inches. Theinterval between the Sartorius and the TensorFascia Femoris Muscles is defined at a pointabout one inch below the anterior superior spineand with the aid of retractors the incision isdeepened between the Rectus Femoris mediallyand the Glutei laterally. Care at this stage, parti-cularly in identifying and retracting the deepestgluteal fibres, facilitates the later stages of theoperation.The surgeon now turns to the anterior three or

four inches of the iliac crest and reflects theperiosteum from the lateral half of its subcutaneoussurface. The gluteal attachment to the over-hanging lateral margin of the crest is separatedwith the scalpel and then reflected sub-periosteallyfrom the outer face of the ilium. Firm packing inthe space between the muscles and the ilium con-trols the brisk oozing which occurs at this stage andholds the gluteal flap aside for the next stage. Thetendinous origin of the Tensor Fascia FemorisMuscle from the anterior superior spine isdivided and the few remaining attachments of thegluteal muscles separated from the ilium.The distal portion of the incision in the thigh

is now deepened throughout its length by dividingthe fascial attachments between the RectusFemoris medially and the Tensor Fascia Femorisand Vastus Lateralis laterally. At this stage theascending branches of the external circumflexartery and vein should be located and divided be-tween artery forceps where they emerge frombeneath the lateral margin of the Rectus FemorisMuscle about two to three inches below theanterior superior spine.The reflected head of the Rectus Femoris is

:arefully defined, separated from its bony attach-ment and stripped downwards for two to threeinches. The anterior surface of the capsule of the

hip joint is now exposed. A longitudinal incisionalong the neck of the femur, commencing at theacetabular margin and extending to the inter-trochanteric line, is made through the joint capsule.A rougine is thrust into the cleft and the capsulelevered off the superior surface of the femoralneck; a large Lane's bone lever, the curvedtongue of which passes behind the neck, is theninserted. The lower border of the femoral neckneck is exposed in the same way with the aid of asecond bone lever. With a few touches of theknife the remaining attachments of the capsule tothe anterior margin of the acetabulum are sepa-rated and the joint is freely exposed.

Dislocation of the femoral head from the aceta-bulum should precede section of the neck. Theanterior superior margin of the acetabulum is re-moved together with any osteophytes which arepresent, or, when the joint is fused, the ankylosisbetween the femoral head and acetabulum isdivided with a gouge. The head is then leveredout of the acetabulum bv adduction and externalrotation of the leg.The femoral neck is now divided. The line of

osteotomy commences at its inferior border aslow down as possible and passes upwards andoutwards so as to divide the neck close to the greattrochanter. If all the neck is not excised with thehead, the remainder is removed with an osteotome,care being taken to leave a smooth surface. Theacetabulum is inspected and any osteophytesremaining round its margin are removed.

After re-attaching the reflected head of theRectus Femoris, the wound is closed by suturingback the lateral muscle flap to the iliac crest andanterior superior spine. A few interrupted suturesare required between the fascia overlying theSartorius and Tensor Fascia Femoris Muscles.No drainage is required. A firm spica bandageapplied over wool compresses the wound and bydiminishing the dead space assists healing.

OsteotomyThe osteotomy can be carried out as a primary

procedure at the time of the excision but preferablyas a secondary procedure three to five weeks laterwhen the first incision has soundly healed.

When osteotomy is done primarily the distal part ofthe incision is extended for an inch or so, the RectusFemoris mobilized and retracted well mediallyand the Vastus Lateralis reflected sub-periosteallyfrom the femoral shaft. With the aid of bonelevers two to three inches of the upper part of theshaft are easily exposed. The osteotomy, whichshould be cuneiform in type in order to allowrotation of the fragments on each other withoutdisplacement, is performed just below the lesser

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May 1948 BATCHELOR: Excision of the Femoral Heald and Neck

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FIG. i -Bilateral excision for ankylosing spondylitis.

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FIG. 2.-Bilateral excision and osteotomy for ankylosing spondylitis.

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244 POST GRADUATE MEDICAL JOURNAL May 1948

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FIG. 3.-Monarticular osteo-arthritis treated by excision and osteotomy.

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FIG. 4.-Irreducible fracture-dislocation of the hip treated by excision and osteotomy.

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May 1948 lATCIELOR: Pxcision of the Pemoral Head and Neck 24S

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FIG. 5.-Chronic suppurative arthritis treated by excision of the femoral head and neck.

.AVON

:Caterpillar;

Fig. 6.-guppurative arthritis with pathological dislocation treated by excision and osteotomy.

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Diag. I Diag. II Diag. III

trochanter, using small sharp osteotomes. Inorder to abduct the lower fragment sufficiently itis often necessary to separate a small triangularpiece of bone from the lateral surface of the upperfragment (Fig. 4). The osteotomy is now fixedwith a special plate angled in the coronal planewhich is applied to the anterior surfaces of thegreat trochanter and femoral shaft (Diag. I).When the osteotomy is done as a secondary

procedure it can be performed through either alateral or a postero-lateral approach. The use ofa lateral incision entails splitting the VastusLaterglis and with the leg abducted after the bonehas been divided, the depth of the wound makes itdifficult to fix the plate in position. Technically,the osteotomv is much easier to perform through apostcro-lateral approach with the patient in theprone position. An incision is made over thepostero-lateral surface of the hip, commencingover the great trochanter and extending distallyfor five to six inches. The fascia lata is dividedlateral to the insertion of the Gluteus Maximus,thus exposing the posterior aspect of the trochanterand upper shaft. The Vastus Lateralis is reflectedanteriorly fiom its attachment to the linea asperaand the upper part of the shaft and sub-tro-chanteric region are exposed.The bone is divided just below the lesser tro-

chanter, a locking type of osteotomy with a tongueof bone on the lateral aspect of the distal fragmentbeing used in order to ensure good stability of thefragments. The tongue should be cut out firstand then the bone divided around its circumferenceat the base of the tongue, again using small, sharposteotomes (Diag. II). Before the distal fragmentis abducted the tongue may have to be slightlyshortened with bone-cutting forceps so that withthe aid of a fine osteotome used as a shoe-horn itcan be impacted well into the proximal fragment(Diag. III).The osteotomy is now fixed with an eight-hole

Lane plate which may be bent to the requiredangle before operation. The upper fragmenttends to flex after the osteotomv has been com-pleted; if the patient is prone, this angulation canbe reduced by' breaking' the table a few degrees.It is also important to guard against the tendency forthe leg to fall into internal rotation while the plate isbeing applied. I have found that six screws give aperfectly adequate grip, allowing the plate to beangled between the middle two holes which are-not used. The screws in the proximal fragmentshould not penetrate the medial (weight-bearing)surface of the bone and the upper two shouldtherefore not exceed one inch in length; in thedistal fragment the screws should engage thecortical bone medially and should be approximatelyone and a half inches in length.

Angle of the Osteotomy

The condition of the opposite hip and lumbarspine must be considered when estimating thecorrect angle of osteotomy. For unilateral osteo-arthritis with a sound contralateral hip and supplelumbar spine, the distal fragment may be abducted400 on the proximal fragment. This producesa certain armount of fixed abduction with tilting ofthe pelvis and apparent lengthening of the limb.In bilateral ankylosis of the hips with a supplelumbar spine, osteotomy may be performed afterexcision of one hip when the contralateral hip isankylosed by bone in adduction; the angle of theosteotomy is then adjusted to the position of thefixed hip. Osteotomy is contra-indicated when theankylosis of the'opposite hip is fibrous or when itis fixed in abduction. When both hips areankylosed and the lumbar spine is rigid, as inankylosing spondylitis, an angle of osteotomygreater than 250 may render adduction of the legto the neutral position impossible and should heavoided.

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May 1948 BATCHELOR: Excision of Femoral Head and Neck

After-treatment for Excision and forOsteotomy

After the operation a Steinmann's pin is insertedthrough the upper end of the tibia and tractionapplied by Hamilton-Russell extension with aweight of 7 lb. The chief advantage of the tibialpin is that it controls rotation and preventseversion of the limb, which can be troublesomeafter this operation. It is important that shorten-ing should be prevented and that the great tro-chanter should lie below the level of the aceta-bulum. The position of the hip should be checkedby X-ray examination the day after operation.Shortening with upward displacement of the greattrochanter on to the dorsum ilii will of course leadto troublesome instability.

After fourteen days movements for the hip andknee and exercises for the thigh and hip musclesare commenced. Joint movements are at firstperformed through a limited range with the ex-tension apparatus in place. After four weeks theweight is removed during treatment so that a freerange of movement at the hip and knee can beobtained,

In a straightforward case of excision withoutosteotomy, traction is continued for eight weeks.The patient then commences walking with the aidof crutches or a walking-machine and with aweight-relieving calliper, the measurements forwhich were taken during the period of traction.The calliper is worn for four to eight months andwhen clinical tests indicate that the hip is stableis gradually dispensed with.When osteotomy has been performed traction is

maintained for ten to twelve weeks. Weight bear-ing without a calliper is commenced when X-rayexamination shows that the osteotomy has united.

Discussion and Resultsi. Ankylosing SpondylitisHere a free range of movement at both hips is

essential; otherwise the fixed spine makes it im-possible for the patient to sit in comfort. Inassessing the results the severe degree of cripplingfrequently found in many of these patients must beappreciated; some of them have been bedriddenfor years with ankylosis of the hips, knees andspine. The prospect of a good functional resultis brighter when the knees are unaffected, forankylosis of these joints makes sitting difficult evenwhen the hips move freely. After the surgicaltreatment has been completed a prolonged andlaborious course of training extending over twoyears or more is essential to achieve the optimaldegree of functional recovery. This necessitatesconsiderable co-operation on the part of thepatient.

Of the seven cases treated, excision of the headand neck of both hips has been performed in six,followed in four cases by osteotomy. My firstcase in this group, a man aged thirty-five whosetreatment was commenced in I938, was one of thetwo in whom bilateral excision only was performed.There was an interval of about seven months be-tween the two operations and after each operationthe patient used a weight-relieving calliper for sixmonths. The result has been most satisfactory, forhe now has a pair of relatively painless and stablehips with a range of flexion of 800 (Fig. i). Hecan walk moderate distances using sticks and drivesa car. The second patient in whom bilateral ex-cision was performed walks with the aid of elbowcrutches but the functional result is marred byankylosis of btoth knees.Of the four cases in which excision followed by

osteotomy was performed on both hips, goodstability has been secured without the use ofcallipers (Fig. 2). These four patients have agood range of movement at the hips and can walkwith the aid of sticks or elbow crutches. Thepatient in whom the excision of only one hip wasperformed, when last examined, could walkreasonably well. It was intended to proceed withexcision of the other hip but the war interruptedhis treatment and he has been lost sight of.

2. Traumatic and Degenerative Osteo-ArthritisIn six patients with bilateral degenerative osteo-

arthritis of the hips, excision of the head and neckhas been performed on the more painful hip. Osteo-tomy is not indicated in these cases, for the tilting ofthe pelvis which it produces would throw an ad-duction strain on the contra-lateral hip. Theresults in this group of patients have been dis-appointing. Although the operation has relievedpain and restored a free range of movement inone hip, function is poor, for the gait in themajority of these patients is slow and halting. Inbilateral osteo-arthritis of the hips, therefore,excision of one hip is indicated only when pain issevere; a good functional recovery cannot beexpected.

Excision followed by osteotomy has been carriedout in six patients with unilateral osteo-arthritis.The need for osteotomy in this group was indicatedby the progress made by my first patient with aunilateral osteo-arthritis after he had been treatedby this method (Fig. 3). After excision of thefemoral head and neck in I94i a weight-relievingcalliper was worn for eight months. When thecalliper was discarded the hip felt unstable andached after use. These symptoms were completelyrelieved by a sub-trochanteric osteotomy (Fig. 4).

In five patients in this group the results are verysatisfactory. The range of flexion varies from 750

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to goo, the hips are painless and stable and the gaitis good with only a slight limp. One elderlypatient refused to co-operate in carrying out after-treatment and did not learn to walk.3. (a) Fracture-dislocation of the Hip

Excision of the femoral head and neck followedby osteotomy has been performed in three casesof irreducible fracture-dislocation of the hip(Fig- 4).

(b) Ununited Fracture of the Femoral NeckIn this condition there is a tendency to advise

some form of osteotomy almost as a routine.A good result may be expected if the osteotomyis followed by union of the fracture but unfor-tunately, owing to degenerative changes in thefemoral head and absorption of the neck, thefracture fails to unite in a high proportion of cases.The patient is then left with a stiff, painful andoften unstable hip. I have therefore excised thefemoral head and remainder of the neck in fourpatients with ununited fracture of the femoralneck. In three cases the excision was followed byan osteotomy.

In these two groups the results, like those inpatients with degenerative and traumatic osteo-arthritis, are with one exception most satisfactory.Of the seven patients, six have a good range ofmovement, are free of pain and walk well. In theone case of ununited fracture of the femoral neckin which excision of the head was not followed byosteotomy, the result has been unsatisfactoryowing to shortening and adduction deformity.4. Bilateral Ankylosisfrom Suppurative Arthritis

Four such cases have been treated. In two goodresults were obtained by excision without osteo-tomy, for excellent stability was provided byfibrosis around the joint. In one case the excisionwas followed by an osteotomy and here the resultwas only fair owing to limitation of flexion (400).In the fourth patient, on whom arthroplasty hadbeen attempted elsewhere, a range of flexion ofonly 300 has been obtained after excision of thehead and neck.

5. Chronic Suppurative ArthritisIn this group there are four patients, in three of

whom long-standing infection with multiplesinuses had persisted despite numerous operationsfor drainage and sequestrectomy. Here the in-fection appears to linger in the relatively avascularcancellous bone of the femoral head and it mayprove impossible to obtain sound healing until thefemoral head has been removed. In all of thesecases excision of the femoral head and neck re-moved the main site of infection and allowed thesinuses to heal (Fig. 5).

In the three cases with long-standing infection,adequate stability was provided by periarticularfibrosis; in the fourth case, a child of nine with arecent infection and pathological dislocation, anosteotomy was performed (Fig. 6). The resultsobtained in this group have been very satisfactory.Although the range of flexion is somewhat limited,the hips are stable and painless.

Summaryi. In unilateral traumatic and degenerative

osteo-arthritis, ununited fracture of the femoralneck and fracture-dislocation of the hip, excisionof the femoral head and neck followed by osteo-tomy can be relied upon to give a painless andstable joint with an average range of flexion of750 to 900.

2. In ankylosing spondylitis and rheumatoidarthritis, excision of both hips followed by osteo-tomy has restored to limited activity patients whowere previously bedridden.

3. In bilateral ankylosis of the hips following in-fection, excision of one hip followed by the use ofa calliper has produced a stable joint with an aver-age range of flexion of 60W.

4. In four patients with chronic suppurativearthritis, three of whom had discharging sinuses,excision of the femoral head and neck was followedby healing of the sinuses and restoration of alimited range of painless movement.

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of the femoral head and neck ankylosis and arthritis … · 241 excision of the femoral head...

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