Biomechanics of the Hip: As Applied to Osteoarthritis and Related Conditions

319 Pages·1985·18.91 MB·English

by  Docteur Paul G. J. Maquet (auth.)

Paul G.J. Maquet
Biomechanics
o f the Hip
As Applied to Osteoarthritis and
Related Conditions
With a Foreword by William H. Harris
With 651 Figures, Some in Color
Springer-Verlag
Berlin Heidelberg NewY ork Tokyo 1985
Docteur PAUL G.J. MAQUET
25, Thier Bosset, B-4070 Aywaille
ISBN 978-3-642-50962-9 ISBN 978-3-642-50960-5 (eBook)
DOl 10.1007/978-3-642-50960-5
Library of Congress Cataloging in Publication Data
Maquet, Paul G.J., 1928- Biomechanics of the hip. Bibliography: p. Includes index. 1. Hip
joint-Surgery. 2. Osteoarthritis-Surgery. 3. Hip joint. 4. Human mechanics. I. Title. [DNLM:
1. Biomechanics. 2. Hip Joint-physiology. 3. Osteoarthritis-etiology. 4. Osteoarthritis-surgery.
WE 860 M297b] RD549.M325 1984 617'.581059 84-14041
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Foreword
Dr. MAQUET, the foremost disciple of Professor PAUWELS' and the orthopae
dic heir to the PAUWELS' concepts of osteotomy of the hip for arthritis,
has assembled in this one book the strongest and most lucid contemporary
statement of the principles and practice of this very important school of
hip surgery. Professor PAUWELS' contributions to the understanding of the
biomechanics of the hip and to the concepts and execution of osteotomy
of the hip for arthritis are outstanding and timeless. With clarity, Dr. MAQUET
articulates this position and refines it further in the light of his own investiga
tion.
While other investigators, of course, differ on individual concepts or princi
ples in this book or disagree with specific positions, assumptions, or conclu
sions, it is clear to all that this book is a benchmark work.
Dr. MAQUET, as Professor PAUWELS always did, illustrates his text lavishly
with beautiful examples of individual cases illuminating the principles ad
vanced. But in addition, he has gone further and presents long-term follow-up
data, quantifying the results of these surgical precepts as experienced in his
own practice.
It is a work that has been long sought and is richly received.
Boston, Massachusetts, 1984 WILLIAM H. HARRIS, M.D.
v
Preface
Towards the end of his life, Pauwels (1973) summarized his views on the
surgical treatment of three different conditions of the hip - pseudarthrosis
of the femoral neck, congenital coxa vara and osteoarthritis of the hip - in
a superb atlas, magnificently illustrated with long-term follow-up results.
He taught me his concepts. He used to check the planning of my hip opera
tions, and he critically evaluated the postoperative X-rays. The results repea
tedly confirmed his theories.
Having had the privilege of discussing these theories in many parts of
the world, I have frequently been asked the same questions and been con
fronted with the same objections. The questions have dealt primarily with
the technical procedures and postoperative care. The primary objection was
that Pauwels never published a statistical analysis of his results.
In the meantime I had devised new instruments and implants which facili
tate the Pauwels' operations and enable any orthopaedic surgeon to carry
them out with accuracy. I also developed surgical procedures which fulfilled
the basic principles by other means. I achieved the same good results which
Pauwels obtained from his own operations. On the other hand, I repeatedly
observed poor results whenever an operation failed to ensure congruence
of the joint surfaces. All these facts seem to indicate that correct application
of the principles is essential.
These considerations led me to review my own experience of joint-preserv
ing operations on the osteoarthritic hip. This may seem preposterous in
the present era of total replacement. However, in spite of the initial universal
enthusiasm for this new method, the potential complications of total arthrop
lasty of the hip cause many surgeons to reflect before opting finally for
this drastic solution. Although I implant a total prosthesis when I find it
necessary, I remain convinced that it makes more sense for the patient to
heal with living tissues than to be subjected to the definitive ablation of
the joint which a total replacement arthroplasty implies. If the result of
a joint-preserving operation deteriorates after some years, as does sometimes
occur, the hip can still be replaced and the patient has gained some years.
The reverse is not true. After a failed total replacement, there are really
no possibilities other than another replacement in poorer conditions or a
Girdlestone operation.
In the course of my fruitful monthly scientific meetings, kindly organized
by Mrs. Pauwels, with my good friends Professor Benno Kummer and Dr.
Willy Baumann, they persuaded me to write about my clinical experience
along the guide-lines laid down by our famous teacher, Professor Friedrich
Pauwels. In this book, pre-operative planning and surgical techniques have
been emphasized more than in Pauwels' work and, after reviewing all the
patients I could, I have attempted to analyse the results. Therefore, the pres
ent book should be regarded as a modest complement to Pauwels' atlas.
Aywaille, Autumn 1984 PAUL G.J. MAQUET
VII
Acknowledgements
I am deeply indebted to the many other individuals who made this mono
graph possible, and first of all to my wife, Josette, who traced the patients
and did all the exacting secretarial work. Mrs. Germaine Pelzer and Mr.
Fran90is de Lamotte of the Laboratoire de Photoelasticite of the University
of Liege carefully analysed photoelastic models which we had designed after
a thorough study of the mechanics of the hip. Mr. Vu Anh Tuan, of the
Institut de Math6matiques of the University of Liege, solved the difficult
problem of analysing in three dimensions the forces exerted on the hip when
walking. Drs. Marcel Watillon and Francis Hoet analysed short-term results
of the osteotomies after Drs. Hugues Hachez, Franz Langlais, Philippe Roure
and Pierre Thomas had computerized my medical records. Last but not
least, my friend Mr. Ronald Furlong, FRCS, very competently edited the
final version of the text. For his infinite patience and for his innumerable
questions I am very grateful.
VIII
Contents
Chapter I. Biomechanics of the Hip 1
I. Previous Works . . . . . 1
II. Forces Exerted on a Normal Hip 2
A. When the Subject Is Standing on Both Legs 2
B. When the Subject Is Standing on One Leg 2
C. During the Single-Support Period of Gait 3
1. Problem . . . . . . . . . . . . . . 3
a) Co-ordinates of the Centre of the Femoral Head
in the System of Axes Originating in Ss 4
b) Force K .... 6
c) Plane of the Forces . . . . . . . . . 6
d) Force M ............. 8
oc) Direction of if Using the First Approach 8
fJ) Direction of if Using the Second Approach 8
e) Reaction R 11
2. Discussion 14
3. Conclusion 15
III. Mechanical Stressing of the Normal Hip Joint 16
IV. Mechanical Stressing of the Normal Femoral Neck 16
V. Cartilage Reaction to the Articular Compressive Stresses 22
VI. Bone Reaction to the Articular Compressive Stresses 22
VII. Mechanical Significance of the Neck-Shaft Angle 24
A. Hip Joint 24
B. Growth Plate 27
C. Femoral Neck 30
D. Conclusion 34
VIII. Significance of the Subchondral Sclerosis in the Acetabulum 37
A. Normal Hip Joint . . . . . . 37
B. Primary Osteoarthritis . . . . . . . 37
C. Osteoarthritis with Subluxation . . . 39
D. Osteoarthritis with Protrusio Acetabuli 41
E. Different Types of Osteoarthritis 42
IX. Conclusion . . . . . . . . . . . . . 45
Chapter II. Principles of a Biomechanical Treatment of Osteoarthritis
of the Hip. Critical Analysis of Different Surgical Procedures. Instinctive
Attempts to Relieve Stress in the Joint . . . . . . . . . .. 47
I. Modifying the Biology of the Tissues 47
II. Reducing Joint Pressure ..... 47
IX
A. McMurray Osteotomy 47
B. Multiple Tenotomy . 50
C. Shelf Operation 50
D. Pauwels' Approach to Osteoarthritis of the Hip 50
E. Remarks on Bombelli's Concepts . . . . . . 50
III. Instinctive Attempts to Reduce the Stress on the Affected Hip 52
A. Limping . . . . . . 52
B. Using a Walking Stick 53
IV. Conclusion . . . . . . 56
Chapter III. Surgical Treatment of Osteoarthritis of the Hip 57
I. X-rays . . . . . . . . . . . . . . . . . . 57
A. Before the Operation 57
1. Overall Anteroposterior View of the Pelvis 57
2. Anteroposterior Views of the Affected Hip 57
3. Lateral View of the Femoral Neck
and Three-quarter View . . . . . . . . 60
4. Anteroposterior View of the Lower Limbs 60
B. During the Operation 62
C. After the Operation 62
II. Hanging-Hip Procedure 64
A. Rationale . . . . 64
B. Experimental Study 64
1. Material and Method 64
2. Results 64
3. Discussion . . . 67
C. Indications 68
D. Operative Procedure 68
E. Postoperative Care 70
F. Postoperative Evolution 70
G. Incorrect Indications 74
H. Conclusion 75
III. Varus Intertrochanteric Osteotomy (Pauwels I) 76
A. Rationale 76
B. Indications 77
C. Pre-operative X-rays 78
D. Pre-operative Planning 78
E. Instruments .... 79
F. Operative Procedure (Adults) 84
1. Position . . . . . . . . 84
2. Approach . . . . . . . 84
3. Delineation of the Wedge to Be Resected 85
4. Resection of the Wedge . . . . . 85
5. Derotation ......... . 85
6. Positioning the Compression-hook 86
7. Suture ....... . 88
8. Using the Resected Wedge . . . . 88
X
G. Postoperative Care 89
H. Postoperative Evolution 89
I. Incorrect Indications 101
J. Procedure in Children 101
K. Conclusion 101
IV. Valgus Intertrochanteric Osteotomy and Tenotomy (Pauwels II) 102
A. Rationale 102
B. Indications 107
C. Pre-operative Planning 107
D. Operative Procedure 111
1. Standard Procedure 111
a) Delineating the Wedge to Be Resected 111
b) Tenotomy of the Abductor Muscles 111
c) Resection of the Wedge 111
d) Derotation .... 111
e) Fixing the Fragments . 112
f) Suture ...... . 114
2. Valgus Osteotomy Combined with a Shortening of the Leg 115
3. Correction of a Flexion Contracture . . . . . . . . 117
4. Correction of an Adduction Contracture or Deformity 117
5. Too Much Valgum 118
E. Postoperative Care 118
F. Postoperative Evolution 121
G. Reducing the Compressive Stresses in the Joint
Rather than Restoring Normal Anatomical Shape 129
H. Conclusion ............. . 133
V. Lateral Displacement of the Greater Trochanter 134
A. Rationale 134
B. Indications 136
C. Pre-operative Planning 139
D. Operative Procedure 140
E. Postoperative Care 140
F. Postoperative Evolution 141
G. Lateral Displacement of the Greater Trochanter Complement
ing a Varus Intertrochanteric Osteotomy . . . . . . . . . 144
H. Lateral Displacement of the Greater Trochanter Complement
ing a Valgus Intertrochanteric Osteotomy 148
I. Conclusion ...... . 149
VI. Shortening of the Opposite Leg 150
A. Rationale 150
B. Pre-operative Planning 151
C. Surgical Procedure 151
D. Results 155
E. Conclusion 159
VII. Changing Indication . . . . . . . . . . . . . . . . . . . 163
VIII. No Indication for Any of the Operations Previously Described 166
IX. Reoperations . . . . . . . . . 170
A. After a Hanging-Hip Operation 170
B. After a Varus Osteotomy 175
XI
C. After a Valgus Osteotomy 182
D. Conclusion ..... . 185
X. Age of the Patients and Duration of the Postoperative Results 186
XI. Long-term Results . . . . 189
A. Lasting Positive Results 189
B. Secondary Deterioration 191
XII. Osteotomies Distal to the Lesser Trochanter (Lorenz, Schanz,
Milch) . . . 201
A. Rationale 201
B. Indications 204
C. Pre-operative Planning 205
D. Operative Procedure 205
E. Postoperative Care 205
F. Postoperative Evolution 208
G. Additional Procedures 209
H. Conclusion 210
Chapter IV. Osteoarthritis with Protrusio acetabuli 213
I. Rationale . . . . . . 213
II. Indications 214
III. Abduction Contracture 218
IV. Conclusion . . . . . 220
Chapter V. Avascular Necrosis of the Femoral Head 221
I. Legg-Calve-Perthes' Disease . . . . . . . . 221
II. Avascular Necrosis of the Femoral Head in Adults 238
A. Rationale 238
B. Hanging-Hip Procedure . . . . . . . . . . 240
C. Varus Intertrochanteric Osteotomy ..... 244
D. Lateral Displacement of the Greater Trochanter 244
E. Valgus Intertrochanteric Osteotomy 244
F. Conclusion . . . . . . . . . . . . 252
Chapter VI. Dysplastic Hips 253
I. Introduction 253
II. In Infants 256
A. Innominate Osteotomy 256
B. Lowering the Lateral Aspect of the Acetabulum 258
C. Varus Intertrochanteric Osteotomy ..... 260
D. Combining Different Surgical Procedures 260
E. Spontaneous Recurrence of the Valgus Deformity of the Femo-
ral Neck . . . . . . . 269
III. In Children and Adolescents 270
A. Colonna Procedure 270
B. Varus Intertrochanteric Osteotomy 272
C. Varus Intertrochanteric Osteotomy Supplemented
by Lateral Displacement of the Greater Trochanter 274
XII