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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 hip joint, for when 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
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- of cases
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-
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 of the British Orthopaedic Associa- with ununited fracture of the femoral neck and
tion at the Wingfield-Morris Orthopaedic Hospital fracture-dislocation of the 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
of the hip by excision of the 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
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 few touches of the
The excision is performed through a 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 joint is freely exposed.
sandbags beneath the buttock and shoulder. The Dislocation of the femoral head from the aceta-
chief landmark for the incision is the anterior bulum should precede section of the neck. The
superior iliac spine. From this point the incision anterior superior margin of the acetabulum is re-
is carried posteriorly over the iliac crest for three moved together with any osteophytes which are
to four inches and distally down the antero-lateral present, or, when the joint is fused, the ankylosis
surface of the thigh for five to six inches. The between the femoral head and acetabulum is
interval between the Sartorius and the Tensor divided with a gouge. The head is then levered
Fascia Femoris Muscles is defined at a point out of the acetabulum bv adduction and external
about one inch below the anterior superior spine rotation of the leg.
and with the aid of retractors the incision is
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 and
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 and
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.
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 done primarily the distal part of
artery and vein should be located and divided be- the incision is extended for an inch or so, 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
May 1948 BATCHELOR: Excision of the Femoral Heald and Neck

:;i0 --.... ies '.Pf,40

FIG. i -Bilateral excision for ankylosing spondylitis.

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


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.


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

.AVON
-

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FIG. 5.-Chronic suppurative arthritis treated by excision of the femoral head and neck.
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Fig. 6.-guppurative arthritis with pathological dislocation treated by excision and osteotomy.
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 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
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
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.
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
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 2. Traumatic and Degenerative Osteo-Arthritis
which were taken during the period of traction.
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
maintained for ten to twelve weeks. Weight bear- the pelvis which it produces would throw an ad-
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
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
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 In this group there are four patients, in three of
patient refused to co-operate in carrying out after-
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. i. In unilateral traumatic and degenerative
In these two groups the results, like those in osteo-arthritis, ununited fracture of the femoral
patients with degenerative and traumatic osteo- neck and fracture-dislocation of the hip, excision
arthritis, are with one exception most satisfactory. of the femoral head and neck followed by osteo-
Of the seven patients, six have a good range of tomy can be relied upon to give a painless and
movement, are free of pain and walk well. In the stable joint with an average range of flexion of
one case of ununited fracture of the femoral neck
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 Ankylosis from Suppurative Arthritis tomy has restored to limited activity patients who
Four such cases have been treated. In two good were previously bedridden.
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
head and neck. limited range of painless movement.