The Classic: Treatment of Malum Coxae Senilis, Old Slipped Upper Femoral Epiphysis, Intrapelvic Protrusion of the Acetabulum, and Coxa Plana by Means of Acetabuloplasty
This Classic Article is a reprint of the original work by M. N. Smith-Petersen, Treatment of Malum Coxae Senilis, Old Slipped Upper Femoral Epiphysis, Intrapelvic Protrusion of the Acetabulum, and Coxa Plana by Means of Acetabuloplasty. An accompanying biographical sketch of M. N. Smith-Petersen, MD, is available at DOI 10.1007/s11999-008-0671-z. This article is ©1936 by the Journal of Bone and Joint Surgery, Inc. and is reprinted with permission from Smith-Petersen MN. Treatment of Malum Coxae Senilis, Old Slipped Upper Capital Femoral Epiphysis, Intrapelvic Protrusion of the Acetabulum, and Coxae Plana by Means of Acetabuloplasty. J Bone Joint Surg Am. 1936;18:869–880.
In February 1935 a patient, aged fifty-five, was admitted to the Orthopaedic Ward of the Massachusetts General Hospital with the diagnosis of “bilateral intrapelvic protrusion of the acetabulum”. The case was discussed on ward rounds and the general opinion was that nothing could be done for this patient, and that she would have to adapt her life to the hip-joint condition. This did not seem a constructive attitude, and the patient was allowed to stay on the ward in the hope that some operative procedure might be developed which would give her relief from pain.
The question to be answered was this: “What is the source of this patient’s pain?” The answer was: “The impingement of the femoral neck on the anterior acetabular margin”. Such impingement would result in “traumatic arthritis” with characteristic changes of the joint surfaces as well as of the synovia. Since the joint surfaces have no nerve endings, their function in itself cannot be the source of the pain; as they slide over one another, even though the hyaline cartilage is markedly thinned, they will not give rise to symptoms. What does give rise to pain? The impingement of two surfaces—one covered by synovia, the other by cartilage—will give rise to congestion of the synovia, synovitis, and, because of periosteal irritation, hypertrophic changes.
The success in this case naturally suggested that the same procedure might be successful in other types of cases in which similar impingement was present. Malum coxae senilis came to our minds first. Since the operation was one that did no harm, we felt justified in applying it to a condition for which we had no adequate treatment. It has now been performed in eight such cases and the response has been so favorable that we feel free to publish a description of the procedure, in spite of the fact that it has been used for too short a time to enable us to give “end results”.
The procedure has also been applied to two cases of “old slipped upper femoral epiphysis” with impingement of the projecting anterior femoral neck on the anterior acetabular margin. In each case there has been improvement in function and relief from pain.
Fractures of the acetabulum with intrapelvic displacement of the head of the femur present the same mechanical problem as did the first case,—that of intrapelvic protrusion of the acetabulum. Consequently this operative procedure might be very effective in relieving pain and restoring function in this type of case.
By the procedures described sufficient exposure of the anterior acetabular wall is usually obtained, but in some cases the iliopsoas muscle remains too taut to be retracted. In these cases it is advisable to reflect subperiosteally the origin of the sartorius and the abdominal oblique muscle from the anterior crest of the ilium, exposing the anterior portion of the iliac fossa. The iliacus may then be reflected subperiosteally down to the upper margin of the anterior acetabular wall, but at this point the periosteum is divided along the line of the intended osteotomy.
By moving the hip in flexion, extension, abduction, and internal rotation, the surgeon now determines if the plastic procedure has been sufficient. If not, further excision of the superior acetabular margin and of the superior anterior capsule is done. The surgeon must be radical in performing this plastic procedure, but he should not remove so much of the superior aspect of the acetabulum as to allow the head of the femur to become displaced anteriorly. Of this there is relatively little danger, since hyperextension is rarely obtained and this is the motion which would allow the femoral head to dislocate.
The procedure follows structural planes throughout and consequently there is little or no shock. The two blood vessels encountered are the deep iliac circumflex and the ascending branch of the internal femoral circumflex. The former is easily eliminated; the latter sometimes gives rise to a little difficulty because of its extensive ramifications in the fat anterior and inferior to the hip joint. Furthermore, it is accompanied by motor branches from the femoral nerve.
The closure of the wound is very simple indeed. When the retractors are removed the iliopsoas drops back into place over the anterior aspect of the head and neck of the femur. The direct apposition of the posterior surface of this muscle to the anterior aspect of the head and neck of the femur is of great advantage,—two moving surfaces are very much less liable to form adhesions to one another than are two surfaces in more or less constant apposition, such as would be true of the capsule and of the underlying joint surface. The direct head of the rectus is sutured to its origin, and the superficial portion of the wound is closed in layers.
Postoperative convalescence is remarkable because of the relative absence of pain. The patient complains of soreness, but rarely of acute pain. The extremity is suspended with five pounds of traction, simply to overcome muscle spasm and thereby to diminish pain. The position should be one of extension with maximum abduction and maximum internal rotation. At the end of two weeks the patient is allowed up on crutches and, as a rule, he leaves the hospital at the end of three weeks; the maximum period of hospitalization is four weeks. He is taught exercises which he thoroughly understands by the time he leaves the hospital and which he carries on at home.
As already stated the main effect of this procedure is relief from pain: however, there is also considerable improvement in function. The increased function is the direct result of the removal of the acetabular wall, thus preventing impingement. If the anterior femoral head and neck are very prominent, it may at times be advisable to do a plastic operation on these as well as on the acetabulum. There is no danger of new bone formation or exostoses as a result of this procedure, since mechanical interference has been eliminated and since medullary bone is in apposition to the moving posterior surface of the iliopsoas muscle. The removal of the anterior capsule is probably an important factor in eliminating pain, because of its sensory innervation. It is important to remove sufficient capsule, including the Y ligament of Bigelow, to diminish the chances of adhesions and of scar formation. Another point to be emphasized in the technique is this: The acetabular wall should not be exposed subperiosteally, but its periosteum should be removed with it. This will tend to prevent new bone formation.
In one case the iliopsoas bursa was encountered. It was distended and inflamed, and unquestionably had been a source of pain.
As has been stated in the introduction, the success in the above case led us to apply it to cases of malum coxae senilis.
This case is important because the patient had two more years to go before he could obtain a pension. If it is proved that this procedure does not give permanent relief, it may at least be useful in producing temporary relief and improved function over an important period of time.
Eleven cases have been treated by this method,—eight of “malum coxae senilis”, two of “old slipped femoral epiphysis”, and one of “intrapelvic protrusion of the acetabulum”. They have all done well; the relief from pain is the outstanding feature; gain in motion is definite but not marked. Most of the patients still have a perfectly definite, noticeable limp.
The outstanding feature of the postoperative period is the slight amount of pain complained of; some patients state that they have no “pain” at all, others say they have “soreness”, but none complain of acute pain.
The affected extremity is suspended with five pounds of traction in the optimum position,—maximum abduction and internal rotation, minimum flexion.
Following two weeks of recumbency the patient is gradually allowed to sit up and is trained to use crutches. The period of hospitalization should be a minimum of three weeks, a maximum of four. When the patient leaves the hospital he should be thoroughly trained in exercises to maintain the corrected position.
Gentle manipulation for the sake of increasing the range of motion has been carried out in some of the cases at the end of the operative procedure. It is the author’s feeling that this is distinctly worth while and should be done routinely.
A plastic procedure has been proposed for the relief of hip-joint conditions resulting from interference with the normal mechanics of the hip joint. Such conditions are “malum coxae senilis”, “intrapelvic protrusion of the acetabulum”, “old slipped upper femoral epiphysis”, “fractures of the neck of the femur with malposition”, “Legg-Calvé-Perthes disease”, and “fractures of the acetabulum”.
Sufficient time has not elapsed to obtain true end results, but the author feels justified in rendering this preliminary report because the method is non-destructive and seems effective in relieving pain in conditions for which there is no other adequate treatment.