History and Evolution of Hip Surgery

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CHAPTER 1 History and Evolution of Hip Surgery

Nikolaos V. Bardakos, Richard N. Villar

Introduction

The history of hip surgery dates back to the eighteenth century, but it was the introduction of the antiseptic method by Lister in 1865 that marked a series of innovations that, over the years, decreased postoperative infection rates and encouraged surgeons to embark on increasingly complex operations around the hip joint. Until the middle of the twentieth century, when Sir John Charnley introduced the clean air operating enclosure (1964), the development of hip surgery paralleled that of the treatment of tuberculosis. However, with the development of antibiotics and the continued increase in life expectancy, the immense impact of two other hip diseases on patients’ quality of life drew the attention of surgeons: congenital dislocation and osteoarthritis.

Surgical techniques around the hip joint have come a long way. Procedures that are now considered obsolete (e.g., the hanging hip procedure) kept evolving until the advent of low-friction arthroplasty, which was also introduced by Sir John Charnley; this procedure revolutionized the treatment of arthritis of the hip joint. Although the results of hip arthroplasty among older adult and middle-aged patients have generally been excellent, the limitations of this procedure for younger patients (up to the age of 55 years) were soon realized. This led to marked improvements in the techniques and biomaterials used for arthroplasty as well as to the revival of hip-joint–preserving procedures. In the absence of severe degenerative changes, younger, active patients with symptomatic structural abnormalities are increasingly managed with joint-preserving operations, with the goals of improving function in the short term and preserving bone stock in the long term. This chapter will provide an overview of the historical development of these procedures and their current status.

Overview of the evolution of hip surgery

Amputation

With the exception of trauma and acute hematogenous arthritis, tuberculous joint disease was the single most common indication for operative intervention at the hip until the advent of effective antibiotics after World War II. During the eighteenth and nineteenth centuries, amputation of the hip joint was sometimes performed for severe wounds and infections. Successful cases of hip disarticulation were reported by Larrey (1812) and Astley Cooper (1824) for trauma and chronic infection, respectively. By 1867, the reported mortality rate for this operation was 57%; this rate steadily improved and reached an acceptable level only after World War II. Hip disarticulation is used today mainly for cases of malignant tumors. The basic technique was described by Boyd in 1947.

Resection Arthroplasty

The mutilating nature of amputation through the hip joint encouraged surgeons to develop a limb-sparing procedure. The British are credited with the first application and popularization of hip joint resection. After successfully performing a similar procedure on the shoulder of a 14-year-old boy, Charles White carried out such an operation on a cadaver and was convinced of its successful potential. In 1822, Anthony White performed the first successful hip joint resection at Westminster Hospital in London on a patient with a chronic abscess and a dislocated hip. In the United States, this operation was first performed by Lewis Sayre in 1854 on a 9-year-old girl, who had what appeared to be tuberculosis. Sayre reported about 59 such operations, with 39 survivors. In 1940, Gathorne Robert Girdlestone described the five essential steps of the surgical technique; his name has since been closely identified with the procedure (i.e., Girdlestone resection arthroplasty). Girdlestone applied this procedure mainly to patients with tuberculosis, but he also used it with patients with bilateral osteoarthritis to restore mobility. The use of antibiotics has now limited the use of hip joint resection only to cases that involve unsalvageable periprosthetic infections.

It is of note that joint resection is the first orthopedic operation for which special instrumentation was developed. Moreau used a flexible saw that was constructed by an instrument maker in London in 1790; Heine, who was from Würzburg, Germany, developed his “chain osteotome” in 1832, for which he was awarded the Monthyon Prize in Paris in 1835.

Arthrodesis

Arthrodesis of the hip joint was first reported separately by Heusner and Lampugnani, both in 1885. They were inspired by Eduard Albert, who 3 years earlier had performed an ankle fusion. Although Heusner and Lampugnani performed their first operations for old congenital dislocations of the hip, arthrodesis was widely used for the treatment of tuberculosis after Russell Hibbs from New York first reported about its use for that indication in 1911. For this reason, a large number of extra-articular techniques were developed. Trumble (1932) first designed an ischiofemoral fusion that put the graft under compression, and Brittain (1941) added a concomitant intertrochanteric osteotomy for better deformity correction. Watson-Jones (1939) and Charnley (1953) refined the techniques of intra-articular arthrodesis used in the absence of sepsis (e.g., osteoarthritis, congenital deformities). The former, with his transarticular nail arthrodesis, was the first to describe an effective means of internal fixation for this operation; the latter, with his central dislocation and internal compression arthrodesis, led Schneider to introduce the Cobra-head plate in 1966, which has since been the most popular technique of fixation. Hip arthrodesis remains in the armamentarium of the orthopedic surgeon for the treatment of the young or middle-aged manual laborer with unilateral arthritis of the hip, although it is probably not the first choice.

Other Procedures

Lesser procedures of the past for the treatment of osteoarthritis are now considered obsolete and have been abandoned. In 1956, Voss described the hanging hip procedure, which rested on the principle of reducing the joint reaction force by tenotomizing the muscles around a congruent hip joint. Although this was considered effective for providing pain relief and, by some, even for reversing the degenerative process, its results were less dependable and enduring than those of the simultaneously evolving osteotomies. Drilling operations (e.g., forage, medullostomy) and neurectomies are also of purely historical value today.

The modern use of hip-joint–preserving techniques is justified by the less-than-optimal results of total hip arthroplasty among younger patients and the improved understanding of the mechanical basis of osteoarthritis of the hip. In addition to age and activity level, the ideal candidate for a hip-joint–preserving operation must have a mechanically identifiable cause of his or her symptoms. In addition, new surgical approaches have been developed, with the safe surgical dislocation of the hip having gained wide acceptance. The most commonly used techniques will be covered in more detail in the following paragraphs.

Proximal femoral osteotomy

The proximal femur has historically been the site of choice for the realignment of the hip. Intertrochanteric osteotomy (ITO) is the most established hip-joint–preserving procedure. In 1826, John Rhea Barton of Philadelphia performed the first osteotomy on a patient with posttraumatic ankylosis and successfully produced a painless pseudarthrosis. He and Kirmission (1894) were the first to describe proximal femoral osteotomy.

Early on, adult sequelae of developmental hip dysplasia were the most common indications for an ITO (Table 1-1). Early reports of realignment osteotomies of the proximal femur involved either displacement or angulation. Hip dysplasia was the first application of this procedure, although now it rarely constitutes an indication, at least for an isolated femoral osteotomy. Adolf Lorenz (1919) described his “bifurkation” operation, and Schanz (1922)—among others—also introduced a variation of Kirmission’s procedure, mainly for unreduced congenital dislocation of the hip. Both of these procedures were of the pelvic support osteotomy type. Lorenz outlined ten indications for his procedure, with advanced osteoarthritis being the eighth. In his report in 1935, McMurray from Liverpool adopted Lorenz’s procedure, and he is the one who popularized proximal femoral osteotomy for the treatment of osteoarthritis. The so-called Lorenz-McMurray procedure was described—but not performed in reality—as an excessively oblique cut (Figure 1-1). Although it was originally described as a purely displacement osteotomy, it did secondarily employ valgus angulation. McMurray believed that the primary mechanism of pain relief was the bypass of the proximal femur during the transmission of loads from the pelvis to the distal fragment. Displacement osteotomies were widely used in England, with Malkin (earlier) and Nissen (later) being their most eminent proponents.

Table 1–1 Landmarks in the Evolution of Proximal Femoral Osteotomy

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Figure 1–1 The McMurray osteotomy. A, Level and orientation of osteotomy is shown. B, Final result, showing medial and proximal displacement of the distal fragment.

(Adapted from Pring D. Biomechanics of the hip. In: Barrett D, ed. Essential basic sciences for orthopedics. 1st ed. Oxford: Butterworth-Heinemann; 1994: 62-93)

The prototype angulation osteotomy was described in 1950 by Pauwels, who designed a varus osteotomy above the lesser trochanter without displacement; he initially applied this procedure to young adults with hip dysplasia associated with the subluxation of a spherical femoral head. In 1956, he introduced valgus osteotomy for those hips that obtained improved congruity in adduction and for nonunited fractures of the femoral neck. About 10 years after the original description by Pauwels, the procedure came to include the medial displacement of the distal fragment (Figure 1-2).

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Figure 1–2 Action of varus intertrochanteric osteotomy, increasing transverse component Q and decreasing longitudinal component L. R, The resultant compressive force. R1, The joint reaction force.

(Adapted from Pring D. Biomechanics of the hip. In: Barrett D, ed. Essential basic sciences for orthopedics. 1st ed. Oxford: Butterworth-Heinemann; 1994: 62-93)

Early on, Pauwels realized the importance of medial displacement for relieving tension from the iliopsoas and adductor muscles. He was also aware of the necessity of maintaining the overall alignment of the hip. Pauwels’s contribution to the current understanding of hip biomechanics cannot be overemphasized. He was the first to explore the concept of reducing muscle moment arms by changing the orientation of the proximal femur, and he stated that a horizontal sourcil denotes biomechanical equilibrium.

His ideas were taken a step further by Bombelli, who reached the same conclusions through a modified consideration of the primary hip forces. In addition to his theoretical model, Bombelli also modified Pauwels’s valgus osteotomy by adding extension in the sagittal plane for improved femoral head coverage in dysplasia, for the relief of flexion contracture, and for the correction of hyperlordosis. He also suggested that, in the case of a valgus osteotomy, one should exploit the inferomedial capital drop osteophyte (Figure 1-3) and put the lateral capsule to enough stretch to stimulate the formation of the roof osteophyte, both for the purpose of increasing the weight-bearing area of the joint.

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Figure 1–3 The effect of the capital drop osteophyte for increasing the weight-bearing area of the hip joint and decreasing the joint reaction force after a valgus intertrochanteric osteotomy.

(Adapted from Pring D. Biomechanics of the hip. In: Barrett D, ed. Essential basic sciences for orthopedics. 1st ed. Oxford: Butterworth-Heinemann; 1994: 62-93)

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