The Classic: Cartilaginous-cup Arthroplasty in Ununited Fractures of the Neck of the Femur

Abstract

This Classic Article is a reprint of the original work by J. R. Moore, Cartilaginous-Cup Arthroplasty in Ununited Fractures of the Neck of the Femur. An accompanying biographical sketch of J.R. Moore is available at DOI 10.1007/s11999-011-1976-x. The Classic Article is ©1948 and is reprinted with permission from The Journal of Bone and Joint Surgery from Moore JR. Cartilaginous-cup arthroplasty in ununited fractures of the neck of the femur. J Bone Joint Surg Am. 1948;30:313–330.

Appendix

Discussion

Dr. Joseph A. Freiberg, Cincinnati, Ohio: I was fortunate in seeing Dr. Moore’s first case, a nine-year result, last fall. Those of us who saw this woman were really amazed at the excellent restoration of function. Because of my impression of this case, and on the basis of what Dr. Moore told us, I decided to carry out the procedure in the next case that presented itself. I have done the operation in two cases. Unfortunately, neither one was an ideal patient for a reconstruction operation, but I am satisfied with the results. Before I show lantern slides of these patients, I want to mention one or two facts.

First, Dr. Moore did not state that, when you have the head in your hand and are reaming it out with the burr, the head has a tendency to get away from you. This happened to me on one occasion, and I could not be persuaded to put it back. I finished this operation as a Whitman reconstruction. This hip is progressing at about the same rate as though an arthroplasty had been performed.

The second criticism is the difficulty of putting the cartilaginous cup back on the neck at the original angle. If this is not done, the hip-joint relations are permanently disturbed. The cartilage cup should be replaced as accurately as possible. In two of Dr. Moore’s cases, one four months and the other five months after operation, there is limitation of extension. Neither one of these was an ideal case. In the moving picture which Dr. Moore has showed, there appeared also to be some limitation in extension, as in the last case.

Discussion

I wish to show the slides of my cases: This man, aged fifty-two, had had a left hemiplegia in 1944 and a fracture of the femur, treated elsewhere with traction, which resulted in non-union. He came in because of the non-union. He had a contracture of the knee of about 15 degrees, as well as some flexion contracture of the hip. From the postoperative roentgenogram, it appears that the head is not so well placed on the neck as it might be. This is a point which Dr. Moore brought out. In the lateral view the head has not slipped. The amazing thing is the firmness with which the cup was fitted at the time of operation. We did not have any difficulty in keeping it from being displaced. This man is shown four months after his operation. He is exceptionally well pleased with the result. He walks on crutches, with limited weight-bearing. He has now 70 degrees of motion, but he still has some flexion contracture and limitation of extension of the hip to 15 degrees. Clinically, he appears to have an excellent result.

This second man, aged fifty-five, had a fracture of the neck of the femur. He was treated elsewhere, and non-union resulted. The head appeared to be viable. He had a full-thickness tibial graft and a Smith-Petersen nail reconstruction, done in January 1947. He complained of pain. It was not an ideal case for reconstruction. This roentgenogram was made in June 1947, five months after operation. There is one screw in the shaft. The patient has slight limitation of motion. He is putting some weight on the leg, with crutches. He now has 60 degrees of flexion in the hip.

I do not believe that the end results in my cases are as good as those in Dr. Moore’s cases, but I am satisfied with them so far.

Dr. Paul C. Colonna, Philadelphia, Pennsylvania: Although I have not had any personal experience with this operation, the results shown here are very impressive in the treatment of selected cases of non-union of the neck of the femur. Technical difficulties may occur in reaming out some of these femoral heads, however.

The technique described by Dr. Moore presupposes that one is dealing with viable articular cartilage. Unfortunately, many of these loose heads present marked evidence of damage which has been produced by misplaced pins and nails,—not infrequently cartilaginous degeneration or areas of fibrillation. In addition, certain cases present ischaemic or avascular necrosis of the entire loose head. In these instances, it is difficult to say whether any portion of the head fragment should be used. In those cases in which the head fragments cannot be salvaged, other types of reconstruction operation are desirable.

Certain cases present narrowing of the joint space, indicating cartilage destruction. At times there is arthritis, and these cases are best treated by arthrodesis.

However, this still leaves a number of old ununited fractures of the hip with a viable head and a normal joint space, for which this operation may be ideally suited.

This operation, which might be called a modification of the Brackett operation, could have a far wider application than the author has described,—for instance, the utilization of the articular cartilage to produce an arthroplasty. If it is possible to restore function by using the joint cartilage over the head of the femur, why cannot joint cartilage be used in other joints? Will it be possible to restore function by preserving the articular cartilage of many joints by the use of cartilage banks, as we are doing today with bone banks, utilizing both heterogeneous and autogenous grafts?

I would like to compliment Dr. Moore on finding another method for treating non-union and, more important, for using the principle he has illustrated in the restoration of joint function. This may be the answer to many of our problems in the reconstruction surgery of joints.

Dr. I. William Nachlas, Baltimore, Maryland: It has been the concept of arthroplasty that one good articular surface is all that you need to get good motion. Are the beautiful end results that we saw in these illustrations the result of saving that cartilaginous cup, or are they the results of the superb technique that Dr. Moore has used?

Dr. M. N. Smith-Petersen, Boston, Massachusetts: I have had no experience with this procedure. I think that the principle of reconstruction may be a little different from what Dr. Moore thinks it is. He showed some beautiful slides of a ‘‘new head”. I question whether the “cartilaginous cup” actually survives as an articular surface. In my opinion, the cartilaginous cup surrounded by a blood clot is exposed to the acetabulum, which acts as a mold. The blood clot undergoes metaplasia and is gradually transformed into hyaline cartilage. This, then, is new hyaline cartilage, and the photomicrographs will probably show the cartilage cells running parallel to the joint surface rather than perpendicular, as they do in normal hyaline cartilage.

I believe, then, that the principle is really that of mold arthroplasty.

Dr. John R. Moore (closing): The use of homografts of hyaline cartilage is not new. They have been employed by the plastic surgeons and the rhinolaryngologists for many years. The possible application of homografts of hyaline cartilage to orthopaedic surgery is primarily the purpose of this presentation. Cartilage banks may be part of the armamentarium of the orthopaedic surgeon in the future.