History of Hip Joint Preservation Surgery

Joseph Schatzker

For centuries, diseases of the hip have caused pain, ambulation difficulties, gross deformities, and progressive invalidity for children, teenagers, and adults. As the diseases progressed, they drove the afflicted individuals—who began only with pain and a limp—to the use of cane and crutches. Eventually, crippled with stiffness and deformity, the sufferers were driven to the use of wheelchairs and a shut-in existence. The despair of these victims over the centuries led them to seek treatment under the most primitive conditions.

Rhea Barton, an American from Lancaster, was first to carry out the first successful attempt at hip joint preservation by means of a corrective proximal femoral osteotomy (1,2). His patient’s hip was ankylosed in marked flexion and adduction. Barton had the notion not only to transect the bone and thus correct the deformity, but also by movement of the limb during the postoperative period to create an intertrochanteric pseudoarthrosis and thus restore motion. He carried out the procedure on November 22, 1826, without anesthesia and with an ordinary saw. One can only imagine the horror of this operation! The patient survived and according to Barton had a reasonable degree of motion for about 6 years. The hip subsequently ankylosed once again.

As the exact cause of cartilage degeneration continues to elude us, most of the surgical procedures designed to treat the diseased hip have centered on mechanical approaches. Thus not unexpectedly the procedures designed to preserve the hip joint or treat its diseases are all based on the assumption that one can recognize most of the mechanical factors responsible for the development of the joint disease.

History of Hip Preservation Procedures

Because congenital dislocation of the hip was a major problem in Europe as well as in North America, the history of hip preserving surgical procedures parallels the history of the surgical attempts to deal with this very difficult but common problem. Thus there were procedures designed to deal with untreated neglected congenital hip dislocation as well as with the problem of congenital hip subluxation. In addition, before the advent of modern joint replacement, advanced “idiopathic” arthritis of the hip was also a common and very debilitating and crippling disease. This also led to the development of a variety of proximal femoral osteotomies.

The Untreated Neglected Congenital Hip Dislocation

In an attempt to deal with the untreated congenital dislocation of the hip, Kirmisson (3) in 1894 described a subtrochanteric osteotomy which attempted to correct the adduction and flexion deformity and at the same time provide a lateral support for the pelvis. He carried out the osteotomy in an oblique direction beginning about 4 cm below the tip of the lesser trochanter. The distal fragment was then markedly abducted and extended. When the legs were realigned, the procedure not only corrected the deformity but also corrected some degree of leg length and provided lateral support for the pelvis. It improved walking tolerance and lessened the limp.

Similar procedures were subsequently described by von Baeyer (4) and Lorenz (5). While von Baeyer emphasized the tensioning of the abductor musculature as being most important in improving the function of the limb, Lorenz concentrated more on the attempt to get direct support for the pelvis from the distal fragment. To accomplish this he medialized the tip of the distal fragment and placed it directly into the acetabulum. Schanz (6) in an effort to get a broader support for the pelvis described an osteotomy which he performed at the level of the ischium. Because he also abducted the distal fragment, once the leg was realigned the abductors were tensioned and their lever arm was improved which led to an improvement in muscle function. This form of pelvic support, in off-loading the false articulation between the head and the pelvic wall, provided pain relief. In fact all three procedures attempted to achieve the same; namely, improve muscle function by tensioning the abductors and improving their effort lever arm and thereby improve weight bearing by providing support for the pelvis. The Lorenz osteotomy was considered the best for unilateral cases and the osteotomy of Schanz for painful bilateral cases.

The concept of direct pelvic support by these osteotomies was put to rest by the investigations of Scherb (7) and Francillon (8) who in 1932 demonstrated by means of x-rays taken during weight bearing that during stance,
contact between the pelvis and femur did not take place, and that weight bearing, despite the interposition of soft tissues, did not produce any pain.

The late presentation of a congenitally dislocated hip remains to this day a difficult clinical problem. Colona described a procedure of late reduction of the hip into the reamed out and enlarged dysplastic acetabulum. Because of technical difficulties and the inevitable development of arthritis the value of this procedure remains in doubt although more recently there has been some resurgence of interest in this procedure (9). Today most adults with this problem are treated by means of total hip replacement utilizing specialized arthroplasty components as well as various biologic and mechanical techniques for the acetabular reconstruction.

Congenital Subluxation of the Hip

Congenital subluxation of the hip presented totally different biomechanical problems and led to the development of a number of different procedures. Pauwels (10,11,12,13,14,15), a pupil of Schanz, provided a detailed biomechanical analysis of congenital hip subluxation, coxa valga, coxa vara, pseudoarthroses of the femoral neck, and arthritis of the hip. He designed different intertrochanteric osteotomies, each to deal specifically with one type of the biomechanical problem. His approach was to decrease the loading of the joint by restoring the effort lever arms of the muscle forces to normal and by changing the surface area of contact to increase it to the maximum. He also thought that by reducing stress he would achieve a healing response of both the bone and cartilage.

For a residual congenital subluxation of the hip, Pauwels designed a varus osteotomy with the excision of a medial wedge. He considered medicalization of the shaft not only necessary to decompress muscle tension but also to normalize the loading of the knee joint and prevent genu varum and late medial joint arthritis from overload.

For a subluxation with a coxa valga and a deformed large femoral head with a medial capital drop osteophyte, he designed a valgus osteotomy with resection of a lateral wedge and abduction and lateralization of the shaft. The lateralization of the shaft was once again to achieve normal loading of the knee and thus prevent a genu valgum deformity often seen as a result of an abduction osteotomy.

Pseudoarthrosis of the Femoral Neck

Pauwels analyzed the shearing forces acting on a pseudoarthrosis of the femoral neck which contributed to instability. His solution was to neutralize the shearing forces and bring the pseudoarthrosis under compression. To achieve compression, the resultant R of forces acting on the pseudoarthrosis had to be at 90 degrees to it. This completely neutralized shear and achieved stability which was essential for the healing of the pseudoarthrosis. To bring the resultant of forces R to be at 90 degrees to a pseudoarthrosis, one had to perform an abduction or valgus osteotomy with excision of a laterally based wedge combined with lateralization of the distal fragment to prevent overload of the lateral compartment of the knee. In distinction, the so-called classic “Pauwels’ Y-shaped intertrochanteric osteotomy with medialization of the shaft,” was reserved for cases of unstable and mobile pseudoarthrosis where the medialization was designed to provide further support for the neck.

Other issues about the hip such as excessive anteversion were addressed by Leveuf and Bertrand (16). They achieved their correction by means of a trapezoidal excisional wedge osteotomy through the femoral neck or more easily through a subtrochanteric osteotomy. Zahradnicek (17,18) described various pertrochanteric osteotomies for the simultaneous correction of valgus and anteversion as did Bernbeck (19).

The Adult Osteoarthritic Hip

In 1936 McMurray (20,21) designed an osteotomy which contributed to his fame. He was still dealing largely with deformity. Most of his patients had late-stage osteoarthritis of the hip, but he included also patients with nonunion of the femoral neck which at that time was still very much an unsolved problem. He designed an intertrochanteric osteotomy which he combined with medialization of the shaft to achieve pelvic support. He thought that by marked medialization of the shaft, the shaft would come into contact with the pelvis at the level of the transverse ligament of the acetabulum and that this would allow for direct weight transmission. In coxarthrosis, associated with flexion and adduction contractures, the medialization and extension of the distal fragment restored normal realignment of the extremity and brought it into a functional position with restored length. In nonunion the medialization was designed to give support for the neck and thus stimulate union.

Subsequent studies of the medialization revealed that whatever effect it achieved, it was not by virtue of physical support (7,8) but by virtue of decreasing the muscle forces acting on the hip and thus decompressing the joint. Similarly, studies of the alleged contact area of the medialized shaft with the acetabulum revealed that no contact existed. The beneficial effect of the osteotomy in the case of osteoarthritis with coxa valga with its typical medial capital drop osteophyte was subsequently explained by the studies of Pauwels (10,11,12) and Bombelli (22) who showed years later that the McMurray osteotomy allowed the head to achieve a position of “best fit” and in this way it achieved a greater surface area of contact and shifted the center of rotation more medially. The real benefit of the procedure came through the improvement of the surface area of contact, which lessened stress on the joint, and further, through the decompression of the hip by virtue of muscle relaxation. The combined reduction of forces acting on the joint relieved pain and in some cases allowed some degree of joint regeneration referred to later by Nissen (23) as the healing response.

In the 1950s and 1960s in Great Britain and North America the treatment concepts of the osteoarthritic hip by intertrochanteric osteotomy were still quite elementary in comparison with those on the European continent. In Britain and North America one divided the proximal femur in the intertrochanteric zone. It was assumed that this allowed the femoral head to assume its best and most congruous position within the acetabulum. Medialization of the shaft then followed to introduce an element of unloading of the joint by
releasing muscle tension. The osteotomy was then stabilized by various spline devices named after their surgical inventors (Cassel, Bosworth, Ferguson, etc.). The stability which the splines offered was poor and delayed unions and nonunions of the osteotomy were not uncommon. The functional outcomes of such surgery were variable. However, other than neglect and analgesics, one had little else to offer these patients who were in a great deal of pain and who were facing progressive physical impairment and deformity. Invalidity of the elderly as a result of an osteoarthritic hip was very common.

Surgeons working on the continent particularly in Germany, Austria, and Switzerland were much under the influence of Pauwels and his followers. Their surgeries were more carefully planned and the corrections were based on the anatomical deformations of the head and associated changes of the proximal femur and acetabulum. Patients who presented with pathologic changes of hip dysplasia as long as they came to surgery before advanced destructive changes of their joints occurred could expect very good outcomes. The publications of surgeons like Bombelli (24), Schneider (25), and Morscher and Feinstein (26) provided strong support for this fact. The outcomes for idiopathic osteoarthritis, however, remained variable.

Mueller’s (1) monograph on the subject of osteotomies of the proximal femur published 16 years after the founding of the Swiss AO in 1958, is a treasure trove for those interested in the history of the development of the intertrochanteric osteotomy and presents many interesting operative technical solutions. His last publication on the subject of intertrochanteric osteotomy (27) is a more up-to-date and useful publication with current applications. In the intervening years, the AO perfected and largely solved the problem of stable internal fixation. The new implants and operative techniques which Mueller described facilitate many innovative corrective osteotomies and remain current to this day. The precision of the operative techniques allows for accurate and detailed operative planning and assures precise execution of the operative plan. The absolute stable internal fixation, allows early mobilization and rehabilitation with a high rate of union and predictable outcomes. The frequent nonunions and malunions which marred the outcomes of osteotomies fixed with various splints favored in the 1960s and which failed to provide decent fixation (Bosworth, McFarlane, Osborne, etc.) became history. Today the intertrochanteric osteotomy and the techniques described by Mueller continue to be valuable surgical tools in the treatment of structural abnormalities of the proximal femur such as coxa valga, excessive anteversion, femoral retrotorsion (28), and occasionally coxa vara. These deformities are most commonly associated with disorders such as developmental dysplasia of the hip and its sequelae. Another important indication is the ununited femoral neck following fracture. Here the repositioning valgus osteotomy continues to be the treatment of choice in the presence of a viable femoral head. Patient selection particularly in those with arthritis of the hip remains critical. The intertrochanteric osteotomy continues to be an important tool particularly for deformity correction and pseudoarthrosis of the femoral neck. Unfortunately, because intertrochanteric osteotomies require much surgical input in planning and preparation and are difficult to perform exactly according to the preoperative plans and a total hip in comparison is so easy, surgeons tend to shy away from the operation.

Idiopathic Avascular Necrosis of the Femoral Head

Transtrochanteric rotational osteotomies, in line with the principle of the Sugioka (29) osteotomy, were developed in the hope of salvaging a hip for a young adult. The principle of the osteotomy is to rotate the neck and head anteriorly about its long axis and bring into the weight-bearing zone an uninvolved portion of the head. The results of this procedure, other than in the hands of Sugioka, have been unsatisfactory and unpredictable and the procedure has been abandoned. A more classical intertrochanteric osteotomy, particularly a valgus osteotomy (24), was also recommended with the same principle in mind. This has also been abandoned in favor of the total hip arthroplasty.

Coxa Vara Congenita

This disease entity is characterized by a varus deformity of the femoral neck which during growth is associated with a vertically oriented epiphyseal plate and a characteristic inferior triangular fragment which is outlined on one side by the epiphyseal plate and on the other by a lucent line with sclerotic bone on either side. Its etiology is most likely a fatigue fracture of the neck which progresses to a hypertrophic pseudoarthrosis with varus deformity. It is also frequently associated with a retroversion of the head. A neglected coxa vara congenita has a very poor prognosis. The varus increases, the head deforms, and it can even come to a lysis of the head from the shaft.

The most effective corrective procedure for a coxa vara is the classic Y-shaped valgus osteotomy of Pauwels. The required degree of valgus is judged from the preoperative plan in which the pseudoarthrosis must be repositioned so as to come to lie at 90 degrees to the resultant of forces loading the hip joint. This means an inclination of 20 to 30 degrees to the horizontal which is the inclination of a normal epiphyseal plate. Further the tip of the greater trochanter should come to be level with the center of rotation of the femoral head. In unilateral cases one must lateralize the shaft whereas in bilateral cases one can perform the classic Pauwels’ Y-shaped osteotomy in which the shaft is somewhat medialized. The advantage of the medialization is the support provided for a poorly developed neck.

Pseudoarthrosis of the Adult Femoral Neck

Posttraumatic pseudoarthroses of the femoral neck are treated similarly to the coxa vara congenita by means of the repositioning osteotomy. The only logical surgical procedure in the treatment of a pseudoarthrosis in the adult with a viable femoral head is a valgus osteotomy because it results in the neutralization of the shearing forces at the nonunion and brings the nonunion under compressive forces which stabilize the nonunion and result in its progressive healing. Medialization of the shaft alone without reorientation of the plane of the nonunion is doomed to failure because it cannot neutralize the shearing forces which perpetuate the nonunion. The valgus repositioning osteotomy is the best procedure for the stable nonunion of the femoral neck. In the rare instance, where the nonunion is unstable, medialization of the shaft still plays a role since it provides support for the nonunion, however these procedures have a low rate of success.

Epiphysiolysis or Slipped Femoral Capital Epiphysis

The more severe the slip the more diverse are the opinions on the best treatment options to correct it. The more severe the slip the more difficult it becomes to correct the complex deformity of varus, retroversion, and external rotation of the shaft by means of an intertrochanteric osteotomy. This complex deformity develops as a result of the progressive slipping of the head into varus and retroversion with an associated external rotation of the shaft. The callus which forms anterosuperiorly to fill the gradually developing defect becomes the key to an anatomical correction. It is beyond the scope of this chapter to enter into a discussion of the various treatment options. The more severe the slip the less likely is the successful surgical correction of the deformity by means of an intertrochanteric osteotomy. The most commonly used osteotomy is the triple osteotomy of Southwick (30). New possibilities in the form of osteotomies of the femoral neck (27) have become again a current topic. This has been stimulated by the recent new anatomical work of Gautier et al. (31

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