Once the more acute spastic stage of muscles has been eliminated, a gradual .... are: the necessity of an awkward position for sitting, getting in and out of.
CURRENT METHODS OF TREATMENT
Osteoarthritis of the Hip By OTTOE. AUFRANC
T
HE EARLY ACUTE and severely painful episode as well as the relatively minor aches, pains and limitations of motion of the osteoarthritic hip
may be treated by conservative methods. These conservative methods are very effective in the early stages of the disease. As in the initial treatment of any painful joint, rest is the most effective. This rest is best accomplished by havmg the patient confined to bed. The use of traction in the “line of deformity” is an ehctive way to insure this bed rest. The weight of the traction should be minimal, 5 to 8 lbs., depending on the size of the patient. Any acute spasm of the muscles about the arthritic hip can be readily diminished and often eliminated by bed rest and traction. The additional use of local heat and mild medications may be necessary. Along with this rest in bed, however, active exercises should be added and directed toward eliminating any contracture or deformity of the hip joint. These exercises consist simply of gluteal, abductor, adductor, quadriceps and hamstring “setting.” Internal-external rotation, flexion-extension, and abduction-adduction “stretching” motions are added without strain. These need to be carried out through only a very limited arc of motion and within the limits of an “awareness” of pain. All motions should be active and gentle. Once the more acute spastic stage of muscles has been eliminated, a gradual return to weight bearing with the use of support is encouraged. The temporary use of a slight lift on the heel of the shoe on the involved side makes walking and weight bearing easier. After the flexion deformity is stretched out or relieved, the lift should be removed. Support for the hip in walking is best accomplished by the use of two crutches. In walking with two crutches it is also essential to use enough support on the hands when bearing weight on the involved hip to eliminate any discomfort in the joint or muscles and to limit the length of the stride so that the amount of stretching in extension is not uncomfortable. These first walks with support must be limited to short distances. At the onset of an awareness of discomfort or fatigue, one should stop and rest. Activities may then be resumed and increased as tolerated. The use of gentle manipulative assistance during this period is at times helpful. It might best be described by the use of the terms “power assistance in exercise toward the correction of the deformity.” Once this is accomplished, “active assisted exercises by the patient should be substituted. As an increased functional range of motion is obtained, the use of minimal amounts of resistance to the exercises may be helpful. However, here one needs to be unusually careful not to recreate the synovitis by an ambitious weight resistance program. SURGICAL MANAGEMENT OF THE OSTEOARTHRITIS HIP With the development of firm contractures and increasing pain about the 94
OSTEOARTHRLlZS OF THE HIP
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hip, there is always a gradual loss of joint motion and articular cartilage. If these conditions are unrelieved by conservative measures, secondary changes and strain in the hip and supporting or adjacent joints will begin to take place. If these secondary forces are allowed to continue, they may become irreversible. A more aggressive attitude toward the diseased joint is indicated in the form of surgical intervention. There are five broad indications for reconstructive surgery of the hip. They are: ( 1 ) To relieve or diminish pain in the hip and supporting joints. ( 2 j ‘lo restore or improve function of the joint. ( 3 ) To correct deformity. ( 4 ) To establish stability in the subluxed or dislocated hip. ( 5 ) To prevent the developement of unnecessary changes in the joint involved as well as secondary strain changes or reactive arthritis in the opposite hip, the knee on the same side or on both sides, and in the back. There are several ways to relieve or diminish pain in the hip joint. Most joints (and this is true of the hip joint) will have less pain if put at rest in the position of the deformity they have assumed. The deformity may then be lessened by a gradual change in position with the use of traction or by support in a splint, or pillows, or in a gatched bed. The gradual substitution or inclusion of exercises and weight bearing directed toward correcting that deformity will then be tolerated comfortably and efiectively. The measures used to relieve and diminish joint pain may be listed as: 1. Rest, with or without local heat in traction. 2. Medication for the diminution of spasm and nervous tension, such as salcylates, butazolidin and others. 3. Diminishing the strain put on the involved joint by the use of support in walking with crutches or cane as is indicated. 4. The use of exercises directed toward strengthening the muscles and correcting the deformity about the hip without aggravating the synovitis. 5. The use of local injections of anesthetic and other agents may very well temporarily relieve the pain and discomfort. 6. Denervation operations, such as neurectomy (for the hip: obturator, femoral and sciatic branches ) , chordotomy, rhizotomy, subdural injections ( anesthetics, weak phenol, etc. ), These procedures should be reserved for malignant disease. They should not be used for degenerative arthritis of the hip. 7. Joint decompression operations, such as aspiration (of blood or fluid), acetabuloplasty (removal of bony prominences ) , synovectomy, arthroplasty, osteotomy, arthrodesis. For practical purposes, the major surgical procedures used to relie\-e pain in the hip are: arthrodesis, or fusion or ankylosis of the joint to eliminate motion entirely; arthroplasty, to improve the range of motion and correct deformity; osteotomy, to change the weight bearing lines of function through the diseased joint. Arthrodesis: A successful surgical procedure that completely eliminates the motion in a painful joint will completely eliminate the pain. Thus, a successful arthrodesis eliminates pain in a painful joint. There are, however, inherent disadvantages and objections to having a completely stiff hip joint. In the main,
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they are obvious, but some of the objections need to be reviewed. A loss of motion created by an arthrodesis requires that other joints absorb some of the motion that is lost. The greatest strain and increased amount of motion necessary for further ambulation thus is thrown on the opposite hip. The knee on the same side and the back also take additional strain. If all of these joints are normal (or, in a young individual who is flexible and probably has hard work to do), perhaps arthrodesis is the method of choice for relieving pain. It is important to realize, however, that the convalescence is prolonged in attempts to obtain an arthrodesis in the hip. The use of a hip spica cast is often necessary to insure successful fusion. There is also a moderate percentage failure rate in fusion procedures, and as in any other type of surgery, second operations are necessary at times. The obvious disadvantages of a fused hip are: the necessity of an awkward position for sitting, getting in and out of cars, going to the theatre, and, in some instances, difficulty with normal ciressing, such as putting on one’s own shoe and stocking. Arthrodesis is not an irreversible procedure. If after a successful arthrodesis the patient fmds the limitations imposed on him by the stiff hip are intolerable, an arthroplasty can be carried out even after many years of fusion. The chances for a useful movable hip are good, although, in a certain percentage of cases two operations may be required to accomplish the desired result. Arthroplasty is probably the procedure of choice in those individuals who would like to maintain motion or increase the range of motion. They must be willing to put up with minor aches and pain at times during periods of overuse. If they persist in managing their hip properly after surgery, these pains and nuisances can be diminished and, in most cases, eliminated with maturity of the new hip (fig 1). Second operations are necessary in some cases to accomplish the desired results or to improve motion. At present there are two main procedures to accomplish arthroplasty of the joint. One is by the interposition of a Vitallium mold between the reconstructed bony surfaces, and the other is by replacement of the fcmornl head with a Vitallium prosthesis to function as a head of the femur in the socket. Both are useful procedures if properly applied. The proper application of mold arthroplasty to the hip condition consists of reshaping the head of the femur and acetabulum down to bleeding bone, and interposing a Vitallium mold which fits comfortably on the head and in the acetabulum in stable positions of function. Debridement of all scar, synovia, capsule and fascia1 strands of tissue is necessary after the surgical procedure. The rearrangement of muscular attachments to pull toward a functionally stable joint is as necessary as the bony reconstruction. Adequate amounts of time must be allowed for the soft tissue and bone to heal firmly while the joint is being guided and protected through its range of function and motion (fig. 2). If there is adequate bone stock, and if it is necessary to reconstruct the joint surfaces of both the acetabulum and head, a Vitallium mold arthroplasty is probably the procedure of choice to maintain motion in the hip. It is also a more versatile procedure in that the Vitallium mold principle with rearrangements of muscular attachments can be applied to a wider variety of
OS'I'EOAH'I~HHITISOF THE HIP
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Fig. 1.-A typical osteoarthritic hip (age 53 at operation), preoperative and three years postoperative. It is now eight years after surgery and the patient is free of pain and support. She uses a cane for long distance walking. She has a full range of motion wnlch is equal to her norrnal side. There is one-half inch of shortelling. conditions which might have developed as a result of extensive changes in late degenerative arthritis. The same principles of surgical technic aiid after-care apply when a orosthetic head replacement is used in reconstruction of the hip for motion. In the absence of an adequate amount of good bone stock in the head and in the presence of good motor function, particularly in abduction, the Vitallium head replacement prcsthetic of the intramedullary stem type is an excellent reconstruction procedure to relieve pain and to maintain motion. T'nc complications of fractures of the neck of the femm, in many instances, are ideal for this reconstruction. This is particularly true where there is a large area of avascular necrosis of the femoral head or in a situation where the head is completely dead as a result of the loss of blood supply. In some cases of osteoarthritis where there has been a considerable collapse of the head and acetabulum as well, it is a good substitute procedure. In this instance, however, it is also necessary to reconstruct an adequate acetabulum to receive the prosthetic head. Patients without abductor control of the hip get better functional results with a reconstruction which uses the mold, thus allowing freer me of muscle transplant to improve function. If, on the other hand, the abductors are gone and one uses the prosthetic replacement to push the shaft down and out, abductor control will have less effective function than before. Thus, one must be careful in the application of either type of procedure to study carefully the available stock of bcne and muscle and plan surgery accordingly. Hips with a mold reconstruction tend to become more stable with the passage of years. Those patients who had their reconstructions 15 or 20 years ago almost without exception say they have no pain or discomfort in their hip.
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Fig. 2A (top).-A 54 year old woman with disabling pain in both hips and marked limitation of all motion. Them was a fixed adduction and flexion deformity. All motions, iictive and pissiive, were painful. U’alking, except for a few steps, was impossible.
The ranges of motion which are functional in these patients are more than idequate for the individual’s need. Those patients who have exercised and stretched carefully to get as much out of their reconstructed hip as possible have improved noticeably as much as 15 and 18 years after their surgery. However, in some instances, patients have been able to get a full range of iriotion within a year after surgery. These are the individrials who work diligently but not stubbornly toward improving their hips. Patients with prothetic rep1:wement procediires or reconstriictions wilI have adequate functional results provided the same principles of postoperative management are carried out. There is one definite disadvantage, however and that is the development of some “toggle” motion in function in all prosthetic hips. A small amount of toggle motion is not painful. If one allows his patient to use the hip with too much force and through too wide a range of motion early postoperatively, this toggle motion tends to increase and hecomes painful. Hence, one needs to be more careful about the postoperative inanagement and evaluation of bony condition after reconstruction to be sure there will be no more melting down of bone or increased toggle motion itbout the hip. There is one advantage in the prosthetic head replacement, particularly applicable to elderly people in whom one does not expect too much in the way of prolonged or fatiguing functional activities. The patients seem to get an earlier mobilization with less pain. 11’~must not be mislead, however, by the fact that they can get along earlier and with more comfort than those with mold reconstructions because it has been our experience that some allow full weight bearing too soon and this results in an increasing absorption of the bone about the prosthetic. The early firmness that leads the patient and his doctor into a false sense of security for too much liberty in the way of function gives way to increasing disability. A cautious physiologic inanagement then becomes more profitable for the long stretch in any type of reconstruction. The principle of the Vitallium mold allows for adaptive reparative changes to take place during the healing process with a more or less constant molding of growth and healing around the mold (fig. 2). The friction and pressure of exercising and movement molds the healing into firm, smooth fibrocarti1ag;e and, in some instances, hyaline cartilage. This makes up for the inevitable incongruities of surgical reshaping of bone (fig. 3 ) . In function there are four surfaces which glide over one another: two of soft tissue and two of mold. This eventually allows a large surface area over which pressure is taken and over which pressure can vary with motion or change in position. In principle the prosthetic replacement of the femoral head depends on __
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Fig. 2B (bottom).-Two years after operation. The patient denies pain. She walks with crutches, and is able to walk short distances with canes. She has comfort in all positions. Improvement in strength and motion is progressive and should continue. A molding of the soft bone has taken place with minimal settling down. Large molds are used intentionally. It is now S years since surgery, and she continues to improve. She can walk without support for several blocks. She has been instructed to use at least one cane for any distance walking.
loo
Fig. 3.-Osteoarthritis following sepsis and subluxation of the hip. Ideally suited for mold arthroplasty. There has been no flare up of the infection and the patient walks without a limp or without support. She has motion equal to the normal hip. She denies pain and says that she has not had pain since surgery. fixation to bone of a more relative sort for its stability. The stern is fixed. more or less, as a wedge in the intramedullary area of the proximal femur. In function it will act as a wedge and to some extent as a grinding force as a result of the intermittent pressure forces of weight bearing and the friction forces OF motion. Although these same forces act on the mold, there is less of a fixed fulcrum and the motion of function becomes a polishing one more than a grinding one. It can be seen from the mechanical factors that the stem of the prosthesis becomes a grinding force in motion. The outside of the head of the prosthesis, however, and the acetabulum make up a two-surface joint; one of a large metal head, and one of a bony socket with a fibrocartilage lining. The fixation of any inert material will loosen from any tissue which is exposed to stresses and strains greater than the capillary pressure in the surrounding fluid over a time interval long enough to cause the death of local cells. If this pressure can be distributed or shifted frequently over a large enough surface to negate the necrotizing effects of the amount of pressure or length of time of its application, the loosening effect will be less cr negligible. Because of these facts, an attempt is made to distribute the pressure over as large a surface as is practical with the size of the patient (fig. 2).
Fig. 4A (top).-An 83 year old woman with disabling pain and marked limitation of motion and deformity. She was unable to walk except for a few steps with personal and two crutch assistance. Fig. 4B (bottom).-1 year postoperative. The patient has no pain. She is able to take care of herself without assistance and walks well with one crutch. She can walk without limping without support for short &stances but feels more secure with a single crutch under the left arm. (This is often true of right handed elderly patients with a right hip. They do not have enough arm strength to walk well
with
a cane.)
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Several of our patients have had a mold reconstruction on one side and a prosthetic head replacement on the other. These were not and should not be done as experimental procedures. In all bilateral hip reconstructions, one side will often be better than the other for no apparent or technical reasoil. Later on, the better side may be reversed, so that no logical conclusion can be drawn trom either one. If one hip is always better than the other, the procedure may mifairly receive the creciit or blame when, in reality, the surgeon or the available material may actually have decided the outcome. The functional results of bilateral hips are often equally good. One side for a while may be better than the other, and then the sides will reverse. These variations of function are present in patients with two molds as well as those with two prostheses; also, in those with one of each. A choice of type of procedure can be made fairly accurately in advance. However, the final decision must be made at the time of surgery in the light of operative findings and probabilities. Alternate procedures have been necessary at times, and this possibility is easier to deal with if it is anticipated. Mold arthroplasty and prosthetic replacement are good sound surgical procedures. To relieve pain iind to maintain motion they must be applied properly from both a technical and after-care point of view. It must be remembered that nonsurgical conservative measures are very helpful in the treatment of osteoarthritis of the hip. They can often produce temporary relief from pain and, in some instances, improve the range of motion. When the joint pain becomes intolerable and/or the motion so restricted as to interfere with every activity ( including rest ), a surgical reconstruction to maintain motion may be classed iis a conservative measure. In such conditions, the age of the patient is not a factor in the decision. Successful relief of pain and restoration of motion has been obtained in patients beyond 80 years of age. (fig. 4). Otto E . Aufranc, A1 .D., Visiting Orthopedic Surgeon, Mussachusetts Generul Hospital; Chief of Fmcture Service, Armsuchirsetts General Hospitul; Assistant Orthopedic Stirgeon, Hnr.t;nrrl Rledicul School; Consulting Orthopedic Stirgcon, hltrssuchirsetts E!ye u n d E m Infirmur!y, Boston, Mass.
