Excision of the Femoral Head and Neck for Ankylosis and Arthritis of the Hip

For many years the tendency has been to regard arthrodesis as the treatment of choice for a stiff and painful hip joint, forwhen sound bony ankylosis occurs the patient is assured of a strong, stable and painless hip. There are, however, certain disadvantages associated with this procedure. The operation itself may be formidable and the period of immobilization in plaster for three to four months which often follows is not well tolerated by elderly patients. Unless the lumbar spine is supple the fixed hip makes it difficult, if not impossible, for the patient to sit comfortably on an upright chair and to put on shoes and stockings. At a recent orthopaedic meeting a demonstration of devices to enable the patient to dress himself portrayed graphically the difficulties that patients with fixed hips may encounter. Arthrodesis is contra-indicated when both hips are affected or when 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 femoral head and the insertion of a fascial flap has proved unsuccessful, for although a limited range of movement may be obtained for a short time, the joint soon stiffens, and becomes painful. During recent years, however, Smith-Petersen has achieved considerable success with his vitallium cup arthroplasty. The operation of pseudarthrosis of the hip has made little appeal to the orthopaedic surgeon. The method advocated by Sir Robert Jones, which consists essentially of the excision of a large wedge of bone from the trochanteric region and the attachment of the gluteal insertion to the stump of the femoral neck, is followed by considerable instability and loss of power, for the action of many of the hip muscles, particularly the glutei, is lost. At a meeting of the British Orthopaedic Association at the Wingfield-Morris Orthopaedic Hospital in 1938, Professor Girdlestone demonstrated the good results that can be obtained in osteo-arthritis of the hip by excision of the femoral head and neck. This is a simple procedure, well borne by the elderly, which effectively relieves pain and restores movement and leaves undisturbed the attachment of the hip muscles. I have now performed this operation in 34 patients and have found that a free range of painless movement is practically assured. This procedure has however one serious disadvantage-the potential instability of the pseudarthrosis. This instability, which varies in degree in different hip conditions and depends to a large extent on the amount of fibrosis present around the joint before operation, can be overcome to a certain extent by the use of a calliper for some months after the operation, or more effectively by a low sub-trochanteric osteotomy of the Schanz type. I have therefore supplemented the excision with an osteotomy in a large number of cases and have found that it provides excellent stability. Plating of the osteotomy followed by Hamilton-Russell traction avoids plaster spicas and allows early movement at the new joint.