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The resection angulation operation in the treatment of the painful or stiff hip.

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The Resection Angulation Operation in the Treatment
of the Painful or Stiff Hip
By HENRYMILCH
The resection angulation operation is
designed to eliminate the pain while
preserving stabile mobility in the various coxarthroses. Although it may be
completed at a single sitting, this operation is a combination of two separate
procedures: (1) a resection of the femoral head and neck which serves to decompress the diseased acetabulum and
releases the femur at the hip joint, and
(2) an abductional Schanz type of
femoral osteotomy which serves to restore hip stability. The procedure is
technically simple and with attention
to its details will yield relief of pain in
more than 90 per cent and improvement
in motion in over 70 per cent of all
cases of painful hip limitation regardless
of etiology.
Le operation de resectio-angulation ha
le objectivo de eliminar le dolor in le
varie coxarthroses sin disturbar le stabile
mobilitate. Ben que il es possibile completar iste operation in un sol session,
ill0 es un combination de duo separate
interventiones. (1) Un resection de
capite e cervice femoral con le objectivo
de decomprimer le morbide acetabulo e
relaxar le femore in le articulation coxal
e (2) un typo abductional de ostectomia
femoral de Schanz que servi a restaurar
le stabilitate del coxa. Le procedimento
es technicamente smiple, e si attention
es prestate a omne su detalios, ill0 resulta in un alleviation del dolores in
plus que 90 pro cento e in un rnelioration del motion in plus que 70 pro
cento del casos de dolorose restriction
coxal, sin reguardo a1 etiologia.
T
HE PROBLEM presented by the hip disabled by pain or limitation of
motion is one which has not yet been satisfactorily solved. I n the past,
many different approaches to this problem have been made. These have varied
from relatively simple, conservative medical methods to complicated surgical
interventions. Fcr the most part, the more conservative methods have been
largely abandoned as ineffectual and have been superseded by a number of
different surgical procedures. These have ranged from the numerous operations
designed to ablate the hip joint to those which, on the contrary, aim to improve or restore mobility. There can be no doubt that the establishment of a
firm arthrodesis can lead to complete elimination of pain and a functional result which can with difficulty be differentiated from that possible in a normal
hip. On the other hand, the elimination of pain without sacrifice of motion at
the hip joint is more in consonance with the objectives of modern orthopedic
surgery and has led to the development of numerous mobilizing procedures.
These include the formal arthroplasties, the various interposition operations
and lately the prosthetic replacement operation. In each of these mobilizing
operations, efforts have been directed toward restoring cr replacing the anatomic configuration of the normal femoral head and neck. Unfortunately, the results have not fulfilled their earliest expectations. It is at this juncture that
the resection angulation operation first performed in 1934 and first reported in
1943 is again urged upon the attention of orthopedic surgeons.
The resection angulation operation is neither an arthroplastic nor a prosthetic procedure. It specifically abjures any effort at restoration of anatomical
636
637
RESECTION ANCULATION OPERATION
configuration, frankly confesses inability to reproduce a hip joint surgically
and proposes instead a complete shift in emphasis from anatomical restoration
to the re-establishment of function. Its total and, indeed, its only objeaives
are the suppression or amelioration of pain and improvement in the range of
useful motion.
It resembles the various prosthetic operations in that the first stage in the
operative procedure consists in the resection of the head and neck (figs. 1A
and 1B). It differs from them in that the stability which was unavoidably
sacrificed by the resection is reclaimed by means of the abductional osteotomy
performed as the second stage (figs. 1C and 1D). As contrasted with the
prosthetic operations in which the mechanical axis is medial to the femoral
shaft, and weight is transmitted through a diseased acetabulum to the prosthetic head, the abductional osteotomy effects a lateral displacement of the
mechanical axis and completely relieves the diseased acetabulum of m y
function in the transmission of weight.
At first sight, this intervention appears a new and formidable procedure
which should be submitted to “trial by fire” before being granted general acceptance. Quite apart from the fact that it has withstood the rigors of such a
trial by fire, it must be insisted that the resection-angulation is factually “new”
only in the sense that it represents a combination of two procedures, the validity
of each of which had been thoroughly established for the purposes for which
each had been independently devised.
A
B
Fig. 1A. (left)-The deformed head is partially covered by osteophytes. B. (right)
The overhanging osteophytes have been amputated (acetabuloplasty). Following
transection of the neck at the intertrochanteric line, the femoral head has been
excised.
638
C
Fig. 1C. (left)-The previously angilated blade-plate has been fixed in the upper
end of the femur so that the apex of its angulation lies at the predeteririined level
of osteotomy. D. (right) The distal fragment 01 the osteotomized femur, internnlly
rotated and abducted until the postosteotomy angle is equal to the angle of inclination of the outer wall of the pelvis, has been fixed to the plate.
When this procedure was first undertaken, the lack of any means of skeletal
fixation necessitated the performance of each of the two procedures as separate
operations.2 This had the drawback that the postoperative care of the patient
after one stage of the operation was diametrically the opposite of that indicated
in the postoperative care of the patient after the other stage. While the desirability of preserving the incrsased range of motion obtained by the resection indicated the necessity of mobilization of the thigh, the importance of
insuring solid union at the site of the osteotcmy indicated the absolute necessity for fixed immobilization. In view of the contradictory nature of these two
surgical indications, it became essential to determine the order in which they
were to be performed. In some instances, the head and neck were resected
first; in others, the osteotomy was performed as the first stage. Experience soon
demonstrated the fact that while primary resection of the head and neck with
subsequent osteotomy reduced the technical difficulties to their minimum,
prolonged traction and consequently prolonged hospitalization were imperative
to prevent upward displacement of the shaft before the osteotomy was performed. This resulted in a considerable loss of the range of motion which had
been acquired by the resection.
To overcome these objections, this order of preference was abandoned in
favor of preliminary osteotomy. This rendered the subsequent resection tech-
RESECTION ANGULATION OPERATION
630
nically more difficult, but shrinkage of the siirgically obtained range of motion
was reduced to a minimum by the possibility of instituting motion shortly
after the resection. In all situations where the two-stage operation cannot be
avoided, it would seem that primary osteotomy is to be preferred to primary
resection. Though there are still some who persist in doing the olmatioa at
two distinctly different times, any claimed advantages appear to be highly
problematical and insufficient to warrant submitting the patient to the jeopardy
of double anesthesia.
Since 1943 when Blount's modification of the Moore blade plate was described, the two-stage operation has been supplanted by a procedure which can
be ccmpleted at a single sitting. Originally, resection of the femoral head md
neck was carried out through the anterior ilio-femoral incision, (so-called
Smith-Petersen incision). This has since been abandoned in favor of either
the lateral ilio-femoral approach (so-called Watson-Jones incision ) or of
Mocre's modification of the posterior ilio-femoral incision, ( so-called Gibson
incision). Either of these incisions affords ready access to the hip joint for
resection of the femoral head and neck. W'hile the writer prefers the lateral
ilio-femoral incision, the posterior ilio-femoral incision facilitates the approach
to the lesser tuberosity if its downward transplantation is contemplated.
The abduction osteotomy similarly may he performed through either the
lateral or the posterior ilio-femoral incisions. Although the original proponents
of this method of stabilizing the femoral shaft against the pelvis advised high
degrees of abduction of the distal fragment of the osteotomized femm, an
extensive experience established the fact that the post-osteotomy angle, the
angle formed between a line drawn along the inner aspect of the distal fragment and a line drawn from the upper end of the distal fragment tangent to
the most medial projection of the proximal fragment of the osteotomized femur,
should not exceed the angle of inclination of the outer wall of the level pelvis
against which the osteotomized femur would abut.3 This necessitated preoperative preparation of the blade plate later to be used to fix the osteotomized fragments of the femur, but at the same time it obviated the necessity of roentgenographic control in the operating room to assure adequate but not excessive
abduction of the distal fragment.*
In all types of abduction osteotomy, the correlation between the post-osteotomy angle and the effective angle of inclination of the outer wall of the
pelvis is categorical. If the post-osteotomy angle unilaterally exceeds the angle
of inclination of the level pelvis, congruence between the two and !he avoidance of painful limitation of motion can be accomplished by downward tilting
of the pelvis so that the effective angulation Qf the pelvic wall of the tilted
pelvis is increased to equal the excessive post-osteotomy angle. Because of the
inability to maintain parallelism of the two limbs, if the pelvis is tilted to more
than 15" from its level position, this represents the maximum by which the
post-osteotomy angle may be permitted to exceed the normal inclination of
the pelvic wall.
Where abduction osteotomy is to be performed bilaterally, it is espocially
important to avoid the creation of an excessively large post-osteotomy angle.
640
HENRY MILCH
It must not be overlooked that downward tilting of the pelvis with increase in
the effective angulation on the side of an excessive post-osteotomy angle involves an upward tilting of the opposite pelvic wall with a decrease in its effective angulation. To avoid painful limitation of motion on this second side,
the post-osteotomy angle of the second femur must be kept below the vdlue
of the normal inclination by the degree by which the post-osteotomy angle on
the first side exceeds the angulation of the level pelvic wall.
With due attention to this special detail, the actual technic of the resection
angulation operation offers comparatively few difficulties.
The hip joint is approached through any of the incisions previously nientioned
and the capsule is opened (fig. 1A). If the head is covered by osteophvtic
overgrowths, these are resected and the fernoral head is dislocated. If the
head is buried so deeply in the acetabular cavity that even this doe5 not release the femoral head, the neck may be transected and the head may be removed by morcellation. Where the hip is firmly ankylosed, it may be necessary
to transect the head flush with the iliac surface and then excise the neck after
transection at the intertrochanteric line. After the femoral head has been dislocated and the thigh can be easily rotated externally, the neck of the femur
is transected at the intertrochanteric line (fig. 1B). This releases the pelvis and
restores complete mobility to the femur. The tensor fasciae femoris and the
gluteus medius are approximated and the femur is exposed subp~riosteally
through the fibers of the vastus lateralis muscle. The previously prepared
angulated blade plate is fixed in the proximal portion of the femur just at the
base of the great trochanter. Drill holes are made in the femoral shaft at the
lewl of the angulation in the blade plate, and the femoral shaft is transected
(fig. 1C).The distal portion of the osteotomized femur is abducted until it
comes in contact with the plate acd, after being internally rotated about 2.9, is
fixed to the plate with screws of appropriate length (fig. 1D).
One rubber drainage tube is placed in the acetabular cavity, another is placed
down to the site of the osteotomy. Both are connected to a positive suction
apparatus to prevent the formation of a hematoma. The skin is closed and a
pressure bandage is applied. While the patient is still under anesthesia, the
thigh is flexed to a right angle and is supported by a sling with ten pounds of
traction while the leg is similarlv supported by a sling with three pounds of
traction. The patient is encouraged to flex and extend the thigh maximally as
soon as the postoperative pain has subsided.
Successful completion of the operation merely establishes the possibility of
passive motion. Restoration of active motion depends upon the pe!\;ifemoral
musculature. If, as a result of long disuse, adequate contractile tissne has disappeared, any hope for the restoration of active motion is, naturally, in vain.
If, however, there is a sufficient, even though atrophic, musculature, postoperative care to avoid the development of any contractures is of vital significance.
It must be recalled that excision of the femoral head and neck results in a
relative elongation of the pelvifemoral musculature. This musculature must
be permitted to adaptively become shorter in a concentric manner so that all
motions, and particularly flexion and extension, shall not be impaired. In order
to insure flexion to at least the right angled position necessary to put on the
HESECTION ANGULATION OPERATION
Fig. 2A. (Zeft)-The patient is unable to flex the right thigh (before operation).
B. (right) The patient flexes the thigh normally (after operation).
shoes or stockings, the limb is suspended so that the thigh is at right angles
to the trunk and the leg is flexed to a right angle at the knee. To minimize the
postoperative pain, traction may be exerted through a Kirschner wire inserted
into the upper end of the tibia. Intermittently, and either actively or passively,
the flexed position of the thigh is alternated with complete extensioii. At the
end of three weeks, weight bearing with the aid of crutches is permitted. Unless excessively overweight, the patient is encouraged to begin normal stair
walking at the end of six weeks. Provided the patient’s active persistence in
these exercises can be controlled, return home from the hospital is allowed.
The patient should be kept under supervision for a period of at least six months
after operation. Where bilateral operation is contemplated, a period of at least
six weeks should intervene between the first and the second procedure;.
The resection angulation operation is applicable to all conditions where it
is desired to preserve stable, painless mobility while at the same time relieving
the diseased acetabulum from the stress of weight bearing. All that is required
is a relatively normal femoral shaft and pelvic wall. The operation can be
easily performed by any average, competently trained orthopedic surgeon.
Beyond the blade plate which is commercially available or can be readily
prepared in any hospital workshop, no special aramentarium is needed.
The operation has been employed as a general operation for the redemption
of the destroyed hipe and specifically in the treatment of the following gmdi-
HENnY MILCH
Fig. SA.-X-ray
of the right hip before operation.
tions of the hip, osteoarthritis, (figs. 2A 2B, and 3A, 3B) rheumatoid arthritis,
Marie-Strumpell's disease, Still's disease, Charcot's disease, old pyoarthrosis,
congenital displasia, congenital dislocation, traumatic dislocation, epiphysiolysis, intrapelvic protrusion of the acetabulum and even tuberculosis. AS a matter
of fact Grucal has reported satisfactory results in 219 of a series of 224 cases
of quiescent tuberculous hip joints. In the series of 56 patients in whom 64
resection angulation operations were performed by the writer? pain was eitlier
completely alleviated or reduced to a tolerable minimum in 44 (68.7 per cent)
of the cases. In an additional 16 (25 per cent) of the cases there was marked
diminution in pain and in only 4 (6.3 per cent) of the cases was there no relief
of pain. A satisfactory range of flexion and extension was restored in 34 (53.1
per cent) of the cases and in an additional 19 (29.7 per cent) of the cases
showed marked improvement in their range of motion. Ten patients (15.6 per
RESECTION ANCULATION OPERATION
Fig. SB.-X-ray
643
of the right hip immediately after operation.
cent) remained unimproved and one was definitely worse. In general, as might
have been suspected, the younger patients and those in whom only a unilateral operation was performed showed better results than the older patients
or those in whom bilateral operations were performed.
In large part, these conclusions were confirmed in a recent study by Robbins,
Jacobs and Seidenstein' of the results obtained by different operations on the
hip joint. From a pathologic point of view the patients were divided into
those who presented evidence of arthritic involvement of the acetabulum,
those who did not and a third group of miscellaneous cases. Of Ul patients,
644
HEIWY M l t M
107 were followed for a period of two to sine years with an average of six
years. On these 107 patients, on whom 125 operations were performed, 82 (40
per cent) were of one or another type of prosthesis, 23 (69 per cent) werc resection angulations and 20 (43 per cent) were arthrodeses. Of the 20 cases in
the arthritic group, on whom arthrodesing operations were performed, eight
returned for follow-up examination. Only two excellent results and one good
result were reported. “In this group there were no good results over the
age of fifty. If these results are weighed along with the hardship of prolonged immobilization and the uncertainty of arthrodesis, it would appear
that the procedure while good for younger patients, should be done on older
patients only after careful consideration.” In view of the fact that of the eight
arthrodeses which were re-examined only two showed an excellent result and
that the one gcod result was associated with a pseudoarthrosis, it would seem
that the conclusion as to the validity of any of the arthrodesing operations is
unduly optimistic.
As regards the 46 prosthetic procedures employed in the treatment of arthritic
hip joints, “no excellent results were found. There were eleven good, €aur
fair and thirty-one poor results.” Of the eleven good results, three were in patients over fifty years and eight in patients under fifty years of age. “The €ailure
of the prosthetic replacements in osteoarthritis were mainly attributablc to
their failure to eliminate pain.”
With respect to the resection angulation operations, Robbiris et al. note that
23 were re-examined. “There were seven excellent, five good, four fair and
seven poor results-a total of twelve which were good (52 per cent). Though
they again note that five of the excellent and four of the good resdts were
observed in patients under the age of fifty, no attempt is made to c l a s s 9 the
results with respect to amelioration of pain or the improvement or motion.
Stress is, however, laid upon the limp which necessarily results from resection
of the femoral head and neck. All of the patients which the present writer has
questioned with respect to this particular drawback have been more than
happy to be rid of their intolerable pain at the expense of a limp which is of
variable degree and, in some, barely recognizable.
REFERENCES
1. Gruca, A.: The treatment of quiescent
tuberculosis of the hip joint by excision and “dynamic” osteotomy. J.
Bone & Joint Surg. 32B, 17.1182, 1950.
2. Milch, H.: Resection of the femoral neck
with pelvic support osteotoiny for ankylosis of the hip. Surgery 13:5661,
1943.
The post-osteotomy angle. J. Bone &
Joint Surg. 25:394-400, 1943.
4. -: The excessive post-osteotomy angle.
Bull. Hosp. Joint Dis. 14:23.5-241,
1953.
3.
-:
5. -:
The resection angulation operation
for hip joint disabilities. J. Bone &
Joint Surg. 37A:699-717, 19.55.
6. -: The resection angulation operation
for the redemption of the hip joint.
Bull. Hosp. Joint Dis. 18:45-50, 1957.
7. Robbins, H., Jacobs, P., and Scidenstein,
H.: Hip problems: Procedures at Hospital for Joint Diseases ( 1951-1957).
Presented before the Alumni C o d .
of Hosp. for Joint Dis. Nov. 10, 1960.
To be published.
Henry Milch, M.D., 225 West 86 St., New York, N . Y.
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