Operative choices

 

When operations are planned on the bony skeleton, the following broad categories of operations are available. Factors such as age and physical fitness are important in making the choice regarding the most appropriate procedure

 

Osteotomies



An osteotomy is the section and realignment of a bone. This realigns the bone and may be used to correct an existing deformity e.g. varus of the tibia. Realignment also redistributes the forces over a joint and a normal area of the joint can be loaded in preference to the pathological e.g. osteoarthritic areas.

Proximal Femoral Valgus Osteotomy

 

 

Hip Osteotomy

High Tibial Osteotmy - Maquet type
Maquet proximal tibial osteotomy 

  Indications Osteotomy

  • Age - young
  • Mal alignment
  • Mobile joint


Contraindications

  • Immobile joint
  • Poliarthritis


 


Arthrodesis

The joint is surgically fused in a position of function. Arthrodeses are usually indicated in the younger patient with mono arthritis. E.g. Posttraumatic osteoarthritis of the hip in a 20 year old active patient.

Indications Arthrodesis

  • Young patient
  • Severe pain
  • Loss of joint motion


Contraindications hip Arthrodesis

  • Ipsilateral knee pathology
  • Other hip affected
  • Lumbar spine pathology


Hip Arthrodesis A hip arthrodesis would be contraindicated in avascualar necrosis of the hip caused by alcohol or steroids as there is a high chance the other hip will develop AVN too.

 

 

Excision Arthroplasty



The joint is excised on one or both sides. Examples are the Girdlestone arthroplasty of the hip. Here the femur head and neck are excised. A Keller's operation of the first MP Joint of the big toe was a popular operation for hallux valgus with joint degeneration. The proximal end of the first phalanx was excised.
Keller's excision arthroplasty for Hallux Valgus
Keller excision arthroplasty for hallux valgus

 

Girdlestone excision arthroplasty of the hip Girdlestone Excision Arthroplasty
Necessitated by sepsis - note the Gentamycin beads


Indications Girdlestone
  • Sepsis e.g. septic hip replacement.
  • Older patient.


Girdlestone operations are rarely done these days, but are a choice where sepsis precludes total hip replacement. They leave a mobile joint but always result in some shortening of the femur and are never entirely pain free.

 

Joint Replacement

Joint replacement is a cost-effective way of rehabilitating a patient with arthritis of the hip, knee and even shoulder.
Moore's Prosthesis Moore's prosthesis
Un cemented femoral component Acetabulum is not replaced. Indication - intra capsular fracture in the elderly
 

Types of joint replacement

  • Hemi replacement e.g. Moore's prosthesis
  • Total joint replacement
    • Cemented
    • Un cemented

 

The “Gold Standard” is a cemented hip. In the active younger patient an un cemented component may be used so that bone stock is preserved for a later revision. At present a hip replacement should last 15 or more years before a revision is needed.

Indications Total Hip
  • Age > 60 yr
  • Grade 3 pain or more
  • Limited walking distance


Contraindications Total Hip
  • Any sepsis
  • Age < 60 yr (except rheumatoid)
  • Neuromuscular disease




Total Hip Replacement Total knee replacement









 

Hip Pain: Decisions as to type of operation

 

An adolescent or child can be offered a osteotomy if the hip has more than 60 degrees of flexion. In severe hip osteoarthritis at this age, an arthrodesis is still a good choice. Between the ages of 30 and 55 years total hip replacements for OA are best avoided. Continue with conservative treatment if possible. An osteotomy can be considered if there is hip motion and a normal area of cartilage than can be moved into the superior weight bearing area by an osteotomy.

In the active older patient a total hip replacement is the ideal treatment for osteoarthritis. Because patients with autoimmune diseases such as Rheumatoid arthritis have limited mobility, a total hip replacement can be done at any age.