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Indications for Orthopedic Surgery in Chronic Arthritis
Indications for Orthopedic Surgery in Chronic Arthritis T. A. POTTER, M.D., F.A.C.S. Assistant Professor of Orthopedic Surgery, Boston University School of M edicine; Visiting Orthopedic Surgeon, Robert B. Brigham Hospital; Associate Visiting Orthopedic Surgeon, Massachusetts Memorial Hospitals, Boston
THE MULTIPLICITY of symptoms and signs in chronic arthritis makes it most difficult for one physician to understand the problem fully and to treat the case with good results. Sooner or later, when chronic inflammation has made serious inroads into the various joints, the physieian will realize that the problems confronting him fall within the realm of orthopedic surgical procedures. Certain principles have been laid down for the prevention of deformity that inevitably occurs in most arthritic joints, and these should be exercised diligently in a conservative orthopedic program of treatment. It is fully realized that a hospital 01' elinie for rheumatoid diseasCfl is the best place for the combined supervision of the internist and the orthopedic surgeon caring for these patients. These orthopedic principles encompass many procedures, one of which iR the supervision of the patient in the positions of lying, standing and sitting. The Recond factor in the orthopedic management is instruction in and the maintenance of good posture because faulty posture is found in almost every patient who suffers from this chronic disease. A third phase is the application of muscular training in order to gain strength and efficiency for the already weakened muscles and ligaments and for the prevention of deformities. A fourth is the correction of deformities and disabilities by various surgical procedures, both minor and major in nature. These particular procedures are used after the acute stage of arthritis has been overcome. The fifth and final stage in the treatment is the assistance and guidance of the patient in the newly formed field of medicine comprising rehabilitation. Conservative orthopedic measures will often suffice to rehabilitate the patient. These measures consist of serial changes of plaster casts to correct a flex ion deformity, traction on an extremity, such as an arm or leg, combined with corrective exercises with emphasis on progressive resistance exercises, skeletal traction, such as the use of turn buckles attached to Kirschner wires particularly around the knee joint, and the
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often employed intra-articular injections of corticosteroid substances. Many times, however, the physician is faced with already developed articular deformities in a patient who seeks definitive treatment or in one who has failed to carry out a conservative program that was carefully laid down by the rheumatologist. Before the orthopedic surgeon operates upon a deformed joint it has been suggested that the following conditions be considered: l 1. Is the arthritis active? 2. Does the patient's physical condition permit extensive surgical procedures? 3. If one considers the age of the patient, his physical state, and the number of operations required, is the expected gain in function from these procedures worth the effort? 4. Should the operation be delayed for the institution of other forms of treatment. 5. Will the patient be able to cooperate in the after-care with proper morale and willingness to endure pain? 6. Does the hospital have the necessary facilities for carrying out successful treatment? 7. Are the patient's financial resources sufficient to carry him through the entire treatment or have the resources of the community or insurance plans been mobilized to care for the costs? We then have a series of orthopedic surgical procedures at our command for the treatment of these patients. This list may be partial and, certainly, there are many more operations that have been devised by certain physicians and clinical groups, but by far and large the ones listed below are those employed most often in this country. Procedure No. 1: Joint Biopsy
Many times, when the exact diagnosis as to the specific type of chronic arthritis is in doubt, it is necessary to procure a bit of tissue from the joint for pathological examination. This problem arises most often when there is a question of synovial tumors, joint tuberculosis, monarticular arthritis or where laboratory results are conflicting and the x-ray and clinical examination of the joint are not too revealing. Biopsies are of two types: Ca) closed method and Cb) open method; arthrotomy. The closed method is utilized most often in the knee joint for monarticular arthritis. This can best be carried out with local procaine (Novocain) anesthesia, using a special double cannulated needle sueh as has been devised by Bickel of the Mayo Clinic. This instrument allows one to obtain small pieces of synovial fringes within the suprapatellar pouch. At the same time, one can obtain joint fluid for chemical and bacteriological analysis. There are limitations to this procedure, principally the dirth of tissue procured and the fact that one cannot select representative gross specimens as one can visibly on open biopsy. Thirdly, it is hardly applicable to children. Nevertheless, in some clinics this has been routinely employed for joint biopsy. The open method, or arthrotomy of a joint, can be carried out either under general or local anesthesia, preferably local anesthesia except for
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the major joints, such as hips, the spine and sacroiliac joint. Through a small incision, usually 1 to 2 inches in length, the synovium and joint can be examined. A small bit of tissue can be removed under direct vision, selecting representative sites for pathological examination. This causes little inconvenience to the patient. Needless to say, a representative specimen of synovial fluid should always be obtained prior to the actual surgical manipulation within the joint. Procedure No. 2: Manipulation
The minor surgical procedure of manipulation is used chiefly for the relief of adhesions within or about the joint and for contractures ill muscles and tissue parts. It encompasses the forceful stretching of the joint under anesthesia, preferably general anesthesia. Manipulation is wmally employed in the knee, hip, foot, ankle and shoulder, and prineipally in rheumatoid arthritis, although occasionally it is helpful in osteoarthritis, particularly of the hip joint when there is limited motion and minimal bony overgrowth. Very short lever forces are utilized in the procedure. The joint should be stretched only once or twice and not repeatedly to maximum arcs of flex ion and extension. One must always bear in mind that the leverage forces might be so great as to fracture atrophic bones. Avoidance of tearing of soft tissues and blood vessels is of particular importance in and about the shoulder joint. Usually, adhesions are felt and heard to separate and if such sounds are of great intensity there is a likelihood that fracture occurred. Therefore, x-rays should be taken immediately after manipulation. If, in any case, the surgeon feels that further stretching 'would cause fracture, he should stop and repeat the procedure in one to two weeks. Physical therapy and exercises should be carried out on a progressive basis. It is often helpful to instill 1 per cent procaine or lidoeaine (Xylocaine) into and about the joints that have been manipulated, followed by corticosteroid suspension injected into the joint space to prevent reformation of adhesions and decrease pain and reflex muscle spasm. If manipulation has been carried out to improve funetion, a plaster cast is applied immediately after the procedure and is bivalved within :i6 to 48 hours to allow physical therapy to be initiated. If the manipulation under anesthesia is not successful, other orthopedic surgical procedures should be considered and carried out at a later date. Procedure No. 3: Synovectomy
The complete or partial removal of the synovial membrane is called synovectomy. This proeedure is most often employed at the knee,2 and only occasionally at the elbow, metacarpophalangeal joints and in the ankle. It is indicated when there is persistent thickening of the synovial membranes which interferes with function. There is growing feeling, however, among orthopedic surgeons who operate upon arthritic joints,
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that early synovectomy may have its place in the treatment of arthritis. It has been observed that after successful synovectomy of a knee joint, reeurrences do not occur when exacerbations are seen in other joints. Therefore, it is felt that by subtotal removal of the synovium, particularly in rheumatoid arthritis, a good measure of prevention of further damage of the joint can be obtained. Early synovectomy of the metacarpophalangeal joints has been utilized successfully to prevent Herious deformity of the hand, and synovectomy is the operation of choice for chronic proliferation synovitis as seen in the knee joint of the rheumatoid arthritic. The hyperplastic synovial membrane whieh is thiekened will often cause chronic effusion, limited motion, and flexion deformiticH ill the knee joints. The following indications for synovectomy are applicable to mOHt arthritic joints: 1. The presence of chronic villous hypertrophy of synovial membrane. 2. Persistent symptoms due to internal irritation from loose bodies, bone spurs, and torn fibroeartilage. 3. There should be relatively intaet hyaline cartilage covering the bone ends. 4. There must be no appreeiable flexion deformity. 5. The x-ray shows the bone to be dense and not to contain rheumatoid cysts or oHteoporotie and eollapsed bone. Many times synovectomy is combined with or augmented by the further removal of arthritic tissue from the joint in a proeedure known as debridement. Procedure No. 4: Joint Debridement
In this proeedure the surgeon removes all of the arthritic tissue within the joint. It is most widely used for disabilities in the knee but may also be utilized in elbow, shoulder and ankle. Debridement ineludes all hyperplastic or degenerated tissue within a joint and, as well, the menisci, overgrowth of bonc at the lateral margins of the femur, tibia and patella, loose bodies, potential or actual, and irregularity of the hyaline cartilage on the weight-bearing surface. The operation can be carried out under a tourniquet in which all visible bleeders are tied or cauterized. At the completion of the operation at the knee joint, a suprapatellar puncture is made for internal drainage of blood into the vastus medialis musele. Cortisone, injected intra-artieularly at the time of wound elosure, has minimized the postoperative reaction in these procedures. After closure of the skin, a large compression dreHHing is used and over this a long leg cast is applied. The cast is bivalved in five to Hix days so that the exercise program can be started. Early and progressive exercises must be carried out to prevent the development of painful adhesions. If these should occur, a
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manipulation is performed about three weeks postoperatively in order to re-establish joint function. New synovial tissue forms slowly in the surrounding eonnective tir:-;sue after the synovial membrane has been exercised. As r:-;tated above, in the observation of many tmrgeolls this newly formed synovia has normal characteristics and is not involved in recurrent arthritic inflammatory processes. Procedure No. 5: Soft Tissue Procedure for Releasing Flexion Deformities
Soft tissue surgery is required mor:-;t frequently at the knee, occasionally at the hips, elbows, fingers and toes. In all of these joints the contracture of the articular capsule on the flexion side is corrected by releasing the proximal end of the articular capsule. Shortened tendons are lengthened by step incision or a double-L type cut and then resutured in the elongated position. Sometimes lengthening of both the articular eapsule and tendons is required. The indications for this type of procedure are persistent flexion deformities that seriously interfere with function and have not responded to conservative measures. At the knee joint the soft tissue procedure carried out most commonly is posterior capsulotomy. In this operation a lateral incision is made, extending upward from the fibular head for a distance of 6 to 7 inches. The fascia lata is divided and this step in the procedure overcomes about 50 per cent of the deformity. The biceps femoris is lengthened by the method of Hibbs and the capsule of the joint is dissected from the pmiterior joint surfaces along with both heads of the gastrocnemius musele. When correction of the deformity has been completed, the knee can be placed in full extension and maintained by a plaster cast. After woulld healing, motion of the joint is initiated. Sometimes contracture of the popliteal artery and peroneal nerve is so severe that gradual extension through serial casts is used in order to prevent paralysis or circulatory deficiency. Soft tissue release about the hip can also be carried out in the anterior portion for ftexion and adduction contractures. A common procedure is the relear:-;e of the adductor tendon from its attachment to the pubic ramus. Thir:-; operation, which is possible under local anesthesia, is often a considered choice after arthroplasty when physical therapy fails to stretch out the adductor tendon. Flexion contractures of the fingers can also be overcome by release of the capsule through lateral incision at the interphalangeal joint. Hyperextension of the toes may be corrected by dorsal capsular incisions combined with lengthening of the extensor tendons. In all periarticular procedures, the hope is to restore function in a relatively normal joint. If clinical examination and x-ray demonstrate markedly eroded or destroyed articular surfaces, these procedures are
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doomed to failure because adequate range of motion and function cannot be restored in the particular joint. In such circumstances other forms of orthopedic procedures, arthroplasty, arthrodesis or osteotomy, must be carried out. Procedure No. 6: Osteotomy
The cutting of a bone about a joint in order to realign that joint is the procedure of osteotomy. It is most often employed where there are changes to be made in the weight-bearing line of function through the diseased joint. In the past, the procedure has been employed frequently for ehronic osteoarthritis of the hip. A subtrochanteric osteotomy has been applied in order to place the neck and head of the femur in a more superior or valgus position for weight bearing. By doing so, motion was increased because less diseased articular cartilage was swung into alignment on the weight-bearing surface of the acetabulum. These procedures have been used a good deal in Great Britain to date. The osteotomy site must be controlled by multiple pins inserted through the bone and incorporated in the cast or by angular plates and screws. In any event, there must be x-ray evidence of healing before motion can be started and often within the period adhesions will form in the joints requiring a long period of physiotherapy. Supracondylar osteotomy of the femur to correct fiexion deformities of the knee joint can also be used in the same fashion as for the hip, employing either the multiple transection pins or angular plate. In most instances, the deformed joint is held in acute fiexion with some useful motion due to preserved cartilage surface, or a bowing of the knee into the valgus position is present. This last deformity is a most unstable one for weight bearing. These patients have been through conservative treatment with casts, braces and crutches in an attempt to straighten the leg. When one reviews the x-rays, it is noted that compression of the lateral femoral condyle or upper tibial plate produces the condition. Therefore, osteotomy has sometimes been combined with the insertion of bone graft in order to make up the deficit of length or height of the particular bone. Here again, this procedure is most often employed in the upper end of the tibia or lower femur. Osteotomy is also employed in the chronic rheumatoid hand where deformity of the fingers has been unsightly. Realignment of a finger into 30 degrees of fiexion has been a gratifying procedure. Osteotomy through the wrist joint for acute fiexion or lateral deviation, or combinations of these deformities, will improve hand function by placing the fingers in a more natural and receptive position for tendon function. As in the case of other osteotomy sites, union is more assured by the insertion of cross pins incorporated in the plaster cast, or by use of intramedullary rods. Osteotomy of the foot is performed where there has been marked
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inversion and supination of the foot as the result of longstanding rheumatoid arthritis. This is seen most commonly in juvenile rheumatoid arthritis (Still's disease) as the result of deformities occurring in childhood. Wedge osteotomies through the midtarsal area are necessary to realign the foot so that the metatarsal heads and great toe will come to lie evenly within the shoe during weight bearing. These wedge osteotomies heal promptly by cast immobilization. Forward flexion deformity of the spine, in which ankylosing spondylitis shows complete ossification of all bony and ligamentous structures, may occur in spite of conservative therapy such as exercises, braces and plaster body jackets. Corrective osteotomy in the lumbar area has been utilized in a few of these cases in which the spine was markedly bowed forward. A wedge of bone is removed from the lumbar area that is compensatory for the dorsal kyphos deformity. An abnormal lumbar curve is thus created. Following osteotomy a spinal fusion is carried out and immobilization is obtained by bivalved plaster jackets. This procedure, as simply outlined, is a most formidable one and damage to intrathecal structures, such as spinal cord and nerve roots, during the operation procedure may occur. The cosmetic correction of an otherwise unsightly appearance has been the most gratifying result of lumbar osteotomy. Procedure No. 7: Articular Resection
This procedure consists in the resection of the proximal or di8tal portions or both sides of the joint. It is of particular value ill the treatment of chronic arthritis of the small joints of the foot or hand when they are grossly distorted from undue pressure or friction bursa that can lead to subcutaneous septic processes. Articular resection is mOHt often used in the foot, particularly at the metatarsophalangeal jointH when the foot is spread to any great degree and the pressure comes upon the undersurface of the metatarsal head. All of these heads can be removed if necessary to correct the deformity of cock-up toes. It is unwise to remove a single metatarsal head because adjacent heads will hypertrophy from overpressure and reproduce the painful symptoms of metatarsalgia. A better procedure is an osteotomy of the neck of the metatarsal involved or an ostectomy of the base of the metatarsal head, relieving the pressure. In the hand with ulnar deviation and dislocation of the proximal phalanges the metacarpophalangeal joint can be resected. In this operation the distal end of the metacarpal bone, as well as the proximal end of the proximal phalanx, is trimmed squarely across. It is necessary to bring the extensor tendon to the medial side of the joint in order to maintain function. When severe arthritis occurs at the acromioclavicular joints, a reseetion of the outer inch of the clavicle is an excellent procedure.
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When supination and pronation are prevented by ankylosis of the proximal or the distal ulnar-radial joint or both of these, the distal end of the ulnar or the radial head can be resected. This usually permits good supination. It must be stated, however, that articular resections are not performed in the major joints of the body since they lead to instability in these areas. Procedure No. 8: Arthroplasty
This operation forms a new movable joint when bony ankylosis has been present or where there has been marked distortion of the articular surfaces. Satisfactory results have been obtained in ankylosis of the hips,8 elbows and knees; less satisfactory results have been obtained in the fingers and in the jaw joints. Briefly, the technique of such an operation is to divide the bone at the line of the former joint, refashion the joint ends to stimulate the normal articular surfaces, and then to either sew a sheet fascia lata or some other membrane, such as plastic3 or metal material, over the joint surfaces. These interpositioning membranes or metals will prevent the recurrence of the ankylosis. Fascia lata is the most satisfactory material for interposition operation in the upper extremities. However, fascia wears out quickly in the weight-bearing joints and it is particularly weak and defective in the rheumatoid arthritic patient. In hip arthroplasty the use of nonoxidizing metals or replacement of the femoral head by metallic prosthesis has proved most satisfactory. Before arthroplasty is performed the patient is given a series of musclesetting and strengthening exercises which will later move the new joint. The preoperative and postoperative physical therapy program is one of the most important features in arthroplasty. Indeed, an excellent technical procedure can be completely ruined by faulty or haphazard physical therapy in the preoperative or postoperative period. In ankylosis of both knees, arthroplasty of onc of them might be sufficient. When both hips are ankylosed, bilateral arthroplasties may be necessary to permit assumption of the flexed position, as in sitting. If both hips and knees are ankylosed, arthroplasty is advised on the proximal joint, that is, the hip, prior to operation on the knees. For hips, a vitallium mold type of arthroplasty,7 in which the cup is fitted over the femoral head after the acetabulum and femoral head have been shaped, is an accepted procedure by most orthopedic surgeons. Well fitting articular surfaces can be formed easily in the major joints but the bones do not remain as they are shaped. Osteoporotic bones, particularly of rheumatoid arthritis, and the weak atrophic muscles are poor materials in which to operate. With function, however, the bone ends will reshape and often good function is seen in non-weight-bearing joints. Distortion is much less noted when metallic molds are fitted over the articular surfaces. Vitallium is one of the best metals employed in
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bone surgery and its use results in no irritation of the surrounding soft tissue or bone, as is the case when certain types of plastic or stainless steel are utilized. When the femoral head has been greatly misshapen from either disease or injury or from extensive overgrowth in osteoarthritis, it is often difficult, sometimes impossible, to reshape the femoral head. In such instances, a more nearly normal alignment and anatomical reconstitution for better function can be secured by replacing the femoral head with a metallic prosthesis. Many types are available today, but those employed most often were designed by Austin Moore 4 and Frederic R. Thompson. 9 These replacement prosthetic devices consist of a vitallium head and of an intramedullary stem, which will lock the appliance within the femoral shaft, producing the much needed rigidity and stability of the apparatus. 5 In the upper extremities arthroplasty is performed chiefly at the elbow and at the finger; movable joints can be obtained but they are usually so unstable that they interfere with use. Prostheses of the hinge type or of a metal tack have been used in the hands but are of limited value. A joint that lends itself well to arthroplasty is the elbow which is reached through a posterior incision and, after the ankylosis has been chiseled away, the ends are reshaped and a single layer of fascia is placed over the exposed bone. At the knee joint, fascia wears away quickly with use but plastic and metal prostheses have both given good results. Nylon membrane 6/1000 inch 6 has withstood wear satisfactorily for periods of four to six monthH and is not irritating to the tissues. Should it disappear, reshapening of the articular surfaces and re-formation of a fibrocartilage occur over the end of the bone. Nylon replacement has been found to have been satisfactory for continued motion and function years after arthroplasty. Metal replacements within the knee joint, for example covering the entire end of the femoral condyle, have been used. These are prostheses which incorporate a stem that anchors the apparatus within the femoral shaft. When collapse of the tibial condyle has occurred, a metallic prosthesis may be applied to the depressed tibial table. This is usually used in combination with other procedures, such as joint debridement or synovectomy. In the main, the indications for arthroplasty are the following: 1. To relieve pain. 2. To correct deformity. 3. To improve function of the joint. 4. To reconstitute stability in the affected joint. 5. To prevent changes in neighboring joints or secondary strain or traumatic arthritis that inevitably occurs; for instance, when arthritis involves one hip, the opposite hip or knee will undergo secondary changes. 6. To improve the cosmetic appearance of an unsightly distorted
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joint, such as the fingers, an elbow, and in some instances, the hip and knee. The proper technique of arthroplasty consists not only in reshaping the articular bone surfaces and the application of interpositioning material but also in removing scar tissue, irregular bone surfaces, synovium, and in some instances the joint capsule. It is also important to transfer certain muscle groups so that adequate power will be utilized to produce a stable joint. Procedure No. 9: Arthrodesis
This is the procedure of surgical erasion of the joint, utilized principally for the elimination of pain and the correction of a deformity. It is performed only occasionally in chronic arthritis. Arthrodesis has itR befo\t results after operation in the wrist, the ankle, and some of the small joints in the fingers. When a wrist joint becomes involved with chronic arthritis, palmar flexion deformity of 10 or 15 or more degrees will lead to weakening of the grip. Painful motions, therefore, occur throughout the hand alld wrist. This can be obviated by an arthrodesis of the wrist in about ;)5 degrees of dorsiflexion. Improvement in appearance, reduced pain and vast improvement of the muscle power of the flexors, thus providing a stronger grip, will be brought about. Chronic arthritis of the ankle as the result of injury, such as trimalleolar fracture with irreparable damage to the joint, can best be surgically corrected by arthrodesis. In this instance, plantar flexion of the foot in the position of function for males at approximately 95 to 100 degrees and for females at 100 to 105 degrees so that high heels may be worn, is the procedure of choice. When rheumatoid arthritis affects the hands producing ulnar deviation and flexion of the metacarpophalangeal joints, arthrodeses of the fourth and fifth fingers can be done. Fixation of the bones is obtained by crossed intramedullary wires. When ankylosis occurs, a strong buttressing effed has been created so that the other fingers do not drift-the ulna "drift" deformity. In the foot rheumatoid arthritis involves the talonavicular joint, very often causing a peroneal spastic flatfoot. A fusion of the talonavicular joint in the correct position of function by inversion of the foot to proper alignment, restoration of the longitudinal arch and the insertion of a bone graft has been used succeRsfully. Arthrodesis of the hip joint is used principally for degenerative joint disease of a single hip in a relatively young person, preferably a male, who performs more or less heavy labor. In selecting this procedure for correcting the hip pain and disability, one must be quite certain that there is a normal hip on the opposite side, a flexible lumbar spine, and that the knee on the side to be fused has excellent function. Fusion of
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the knee joints is sometimes employed when there is complete destruction of the knee that shows a deformity either in knock knee or bow leg, or a severe fiexion, extension, subluxation or dislocation deformity. In addition, if there is osteoporosis of the bone, leading to marked softening and the above deformities, or if there are subchondral bone cysts of the rheumatoid nature, then arthrodesis should be considered. Elderly arthritic patients who because of their age or infirmity are not candidates for other surgical procedures, such as arthroplasty, synovectomy or joint debridement, should be offered fusion procedures to obviate the pain and instability. Early solid fusion can be hastened by internal fixation, using an intramedullary rod or an external bone compression clampl that exerts constant pressure on the reshaped ends of the joint, leading to successful fusion as early as six to eight weeks. Arthrodesis of the hip or knee has some obvious disadvantages, however, in that the patient is awkward in getting about, particularly on public conveyances, has abnormal posture for sitting and, in some instances, difficulty in normal dressing habits, such as putting on stockings and shoes. Nevertheless, arthrodesis is an excellent orthopedic procedure that is utilized by many orthopedic surgeons as a method of obviating pain and creating stability in the joint operated upon. Procedure No. 10: Denervation Operations
Many surgical procedures have been attempted to interrupt the pain pathways to relieve pain in severe chronic arthritis. The sensory nerves that supply the articular capsule can be cut so that the pain from a joint can be relieved. Operations of this type are performed occasionally at the hip, knee and elbow, and the most common is the obturator neurectomy performed for relief of pain in the hip. The obturator nerve or, in exceptional cases, the accessory obturator nerve, supplies the anterior capsule of the hip joint. Resection partially denervates the articular capsule and when both posterior and anterior branches of the posterior capsule with the accompanying nerve to the quadratus femoris are cut, an almost complete denervation of the hip is performed. This procedure, while simple, leads to no serious sensory or motor sequelae in and about the hip joint. It can be employed on debilitated patients. However, its results are not predictable and only about one-third of the cases have successful relief of pain. Other procedures, such as chordotomy or rhizotomy, have also been employed for intractable pain in or about the pelvis and hip joints. These procedures should be reserved for the patient with malignant disease. Lumbar sympathectomy has also been advocated as a procedure to relieve pain in a chronic arthritic hip. At best, the results of these procedures have not been followed for sufficient time to warrant their general use.
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Rehabilitation When disabilities and deformities of the arthritic patient have been corrected, the orthopedic and medical responsibility has not ended. It is part of the overall treatment to return the patient to some useful form of activity. While the disease is becoming quiescent, a working plan should be set up. This should evaluate the physical disability after contemplated treatment, including surgery, has been carried out. In some cases, standing and walking should not be the goal if a stable, painless joint is not likely to follow. Such patients should be trained for a sitting oceupation. It is best if the patient can return to his previous work; for others job retraining through various agencies is necessary. A well planned surgical program will give gratifying results not only to the patient but to his physician as well. REFERENCES 1. Charnley, J.: Arthrodesis of Hips in Treatment of Osteoarthritis. Am. J. Arthritis 2: 169, 1960. 2. De Palma, A. F.: Diseases of Knee. Philadelphia, J. B. Lippincott Co., Hl54, p.502. 3. Kuhns, J. G. and others: Nylon Membrane Arthroplasty of Knee in Chronic Arthritis. J. Bone & Joint Surg. 35A: 929, 1953. 4. Moore, A. T.: Metal Hip Joint, a New Self-Locking Vitallium Prosthesis. South. M. J. 45: 1015, 1952. 5. Moore, A. T. and Lunceford, E. M.: The Self-Locking Hip Prosthesis in Osteoarthritis of Hip and Other Conditions. Am. J. Orthopedics 2: 155, 1960. 6. Potter, T. A. and Kuhns, J. G.: Observations on Arthroplasty of Knee. Surg. Gynec. & Obst. 7: 359, 1958. 7. Smith-Petersen, M. N., Larsen, C. B. and Aufranc, o. K: Vitallium Mold Arthroplasty of Hip Joint. J. Bone & Joint Surg. 27: 1, 1945. 8. Steinbrocker, 0.: Current Methods of Treatment: Osteoarthritis of Hip. Arthritis & Rheuma. 4: 89, 1961. 9. Thompson, F. R.: Operative Management of Osteoarthritis of Hip. Am. J. Orthopedics 3: 74, 1961. 10. Wilson, P. D.: M. CLIN. NORTH AMERICA 21: 1623, 1937. Robert B. Brigham Hospital Boston 20, Massachusetts
THE MULTIPLICITY of symptoms and signs in chronic arthritis makes it most difficult for one physician to understand the problem fully and to treat the case with good results. Sooner or later, when chronic inflammation has made serious inroads into the various joints, the physieian will realize that the problems confronting him fall within the realm of orthopedic surgical procedures. Certain principles have been laid down for the prevention of deformity that inevitably occurs in most arthritic joints, and these should be exercised diligently in a conservative orthopedic program of treatment. It is fully realized that a hospital 01' elinie for rheumatoid diseasCfl is the best place for the combined supervision of the internist and the orthopedic surgeon caring for these patients. These orthopedic principles encompass many procedures, one of which iR the supervision of the patient in the positions of lying, standing and sitting. The Recond factor in the orthopedic management is instruction in and the maintenance of good posture because faulty posture is found in almost every patient who suffers from this chronic disease. A third phase is the application of muscular training in order to gain strength and efficiency for the already weakened muscles and ligaments and for the prevention of deformities. A fourth is the correction of deformities and disabilities by various surgical procedures, both minor and major in nature. These particular procedures are used after the acute stage of arthritis has been overcome. The fifth and final stage in the treatment is the assistance and guidance of the patient in the newly formed field of medicine comprising rehabilitation. Conservative orthopedic measures will often suffice to rehabilitate the patient. These measures consist of serial changes of plaster casts to correct a flex ion deformity, traction on an extremity, such as an arm or leg, combined with corrective exercises with emphasis on progressive resistance exercises, skeletal traction, such as the use of turn buckles attached to Kirschner wires particularly around the knee joint, and the
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often employed intra-articular injections of corticosteroid substances. Many times, however, the physician is faced with already developed articular deformities in a patient who seeks definitive treatment or in one who has failed to carry out a conservative program that was carefully laid down by the rheumatologist. Before the orthopedic surgeon operates upon a deformed joint it has been suggested that the following conditions be considered: l 1. Is the arthritis active? 2. Does the patient's physical condition permit extensive surgical procedures? 3. If one considers the age of the patient, his physical state, and the number of operations required, is the expected gain in function from these procedures worth the effort? 4. Should the operation be delayed for the institution of other forms of treatment. 5. Will the patient be able to cooperate in the after-care with proper morale and willingness to endure pain? 6. Does the hospital have the necessary facilities for carrying out successful treatment? 7. Are the patient's financial resources sufficient to carry him through the entire treatment or have the resources of the community or insurance plans been mobilized to care for the costs? We then have a series of orthopedic surgical procedures at our command for the treatment of these patients. This list may be partial and, certainly, there are many more operations that have been devised by certain physicians and clinical groups, but by far and large the ones listed below are those employed most often in this country. Procedure No. 1: Joint Biopsy
Many times, when the exact diagnosis as to the specific type of chronic arthritis is in doubt, it is necessary to procure a bit of tissue from the joint for pathological examination. This problem arises most often when there is a question of synovial tumors, joint tuberculosis, monarticular arthritis or where laboratory results are conflicting and the x-ray and clinical examination of the joint are not too revealing. Biopsies are of two types: Ca) closed method and Cb) open method; arthrotomy. The closed method is utilized most often in the knee joint for monarticular arthritis. This can best be carried out with local procaine (Novocain) anesthesia, using a special double cannulated needle sueh as has been devised by Bickel of the Mayo Clinic. This instrument allows one to obtain small pieces of synovial fringes within the suprapatellar pouch. At the same time, one can obtain joint fluid for chemical and bacteriological analysis. There are limitations to this procedure, principally the dirth of tissue procured and the fact that one cannot select representative gross specimens as one can visibly on open biopsy. Thirdly, it is hardly applicable to children. Nevertheless, in some clinics this has been routinely employed for joint biopsy. The open method, or arthrotomy of a joint, can be carried out either under general or local anesthesia, preferably local anesthesia except for
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the major joints, such as hips, the spine and sacroiliac joint. Through a small incision, usually 1 to 2 inches in length, the synovium and joint can be examined. A small bit of tissue can be removed under direct vision, selecting representative sites for pathological examination. This causes little inconvenience to the patient. Needless to say, a representative specimen of synovial fluid should always be obtained prior to the actual surgical manipulation within the joint. Procedure No. 2: Manipulation
The minor surgical procedure of manipulation is used chiefly for the relief of adhesions within or about the joint and for contractures ill muscles and tissue parts. It encompasses the forceful stretching of the joint under anesthesia, preferably general anesthesia. Manipulation is wmally employed in the knee, hip, foot, ankle and shoulder, and prineipally in rheumatoid arthritis, although occasionally it is helpful in osteoarthritis, particularly of the hip joint when there is limited motion and minimal bony overgrowth. Very short lever forces are utilized in the procedure. The joint should be stretched only once or twice and not repeatedly to maximum arcs of flex ion and extension. One must always bear in mind that the leverage forces might be so great as to fracture atrophic bones. Avoidance of tearing of soft tissues and blood vessels is of particular importance in and about the shoulder joint. Usually, adhesions are felt and heard to separate and if such sounds are of great intensity there is a likelihood that fracture occurred. Therefore, x-rays should be taken immediately after manipulation. If, in any case, the surgeon feels that further stretching 'would cause fracture, he should stop and repeat the procedure in one to two weeks. Physical therapy and exercises should be carried out on a progressive basis. It is often helpful to instill 1 per cent procaine or lidoeaine (Xylocaine) into and about the joints that have been manipulated, followed by corticosteroid suspension injected into the joint space to prevent reformation of adhesions and decrease pain and reflex muscle spasm. If manipulation has been carried out to improve funetion, a plaster cast is applied immediately after the procedure and is bivalved within :i6 to 48 hours to allow physical therapy to be initiated. If the manipulation under anesthesia is not successful, other orthopedic surgical procedures should be considered and carried out at a later date. Procedure No. 3: Synovectomy
The complete or partial removal of the synovial membrane is called synovectomy. This proeedure is most often employed at the knee,2 and only occasionally at the elbow, metacarpophalangeal joints and in the ankle. It is indicated when there is persistent thickening of the synovial membranes which interferes with function. There is growing feeling, however, among orthopedic surgeons who operate upon arthritic joints,
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that early synovectomy may have its place in the treatment of arthritis. It has been observed that after successful synovectomy of a knee joint, reeurrences do not occur when exacerbations are seen in other joints. Therefore, it is felt that by subtotal removal of the synovium, particularly in rheumatoid arthritis, a good measure of prevention of further damage of the joint can be obtained. Early synovectomy of the metacarpophalangeal joints has been utilized successfully to prevent Herious deformity of the hand, and synovectomy is the operation of choice for chronic proliferation synovitis as seen in the knee joint of the rheumatoid arthritic. The hyperplastic synovial membrane whieh is thiekened will often cause chronic effusion, limited motion, and flexion deformiticH ill the knee joints. The following indications for synovectomy are applicable to mOHt arthritic joints: 1. The presence of chronic villous hypertrophy of synovial membrane. 2. Persistent symptoms due to internal irritation from loose bodies, bone spurs, and torn fibroeartilage. 3. There should be relatively intaet hyaline cartilage covering the bone ends. 4. There must be no appreeiable flexion deformity. 5. The x-ray shows the bone to be dense and not to contain rheumatoid cysts or oHteoporotie and eollapsed bone. Many times synovectomy is combined with or augmented by the further removal of arthritic tissue from the joint in a proeedure known as debridement. Procedure No. 4: Joint Debridement
In this proeedure the surgeon removes all of the arthritic tissue within the joint. It is most widely used for disabilities in the knee but may also be utilized in elbow, shoulder and ankle. Debridement ineludes all hyperplastic or degenerated tissue within a joint and, as well, the menisci, overgrowth of bonc at the lateral margins of the femur, tibia and patella, loose bodies, potential or actual, and irregularity of the hyaline cartilage on the weight-bearing surface. The operation can be carried out under a tourniquet in which all visible bleeders are tied or cauterized. At the completion of the operation at the knee joint, a suprapatellar puncture is made for internal drainage of blood into the vastus medialis musele. Cortisone, injected intra-artieularly at the time of wound elosure, has minimized the postoperative reaction in these procedures. After closure of the skin, a large compression dreHHing is used and over this a long leg cast is applied. The cast is bivalved in five to Hix days so that the exercise program can be started. Early and progressive exercises must be carried out to prevent the development of painful adhesions. If these should occur, a
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manipulation is performed about three weeks postoperatively in order to re-establish joint function. New synovial tissue forms slowly in the surrounding eonnective tir:-;sue after the synovial membrane has been exercised. As r:-;tated above, in the observation of many tmrgeolls this newly formed synovia has normal characteristics and is not involved in recurrent arthritic inflammatory processes. Procedure No. 5: Soft Tissue Procedure for Releasing Flexion Deformities
Soft tissue surgery is required mor:-;t frequently at the knee, occasionally at the hips, elbows, fingers and toes. In all of these joints the contracture of the articular capsule on the flexion side is corrected by releasing the proximal end of the articular capsule. Shortened tendons are lengthened by step incision or a double-L type cut and then resutured in the elongated position. Sometimes lengthening of both the articular eapsule and tendons is required. The indications for this type of procedure are persistent flexion deformities that seriously interfere with function and have not responded to conservative measures. At the knee joint the soft tissue procedure carried out most commonly is posterior capsulotomy. In this operation a lateral incision is made, extending upward from the fibular head for a distance of 6 to 7 inches. The fascia lata is divided and this step in the procedure overcomes about 50 per cent of the deformity. The biceps femoris is lengthened by the method of Hibbs and the capsule of the joint is dissected from the pmiterior joint surfaces along with both heads of the gastrocnemius musele. When correction of the deformity has been completed, the knee can be placed in full extension and maintained by a plaster cast. After woulld healing, motion of the joint is initiated. Sometimes contracture of the popliteal artery and peroneal nerve is so severe that gradual extension through serial casts is used in order to prevent paralysis or circulatory deficiency. Soft tissue release about the hip can also be carried out in the anterior portion for ftexion and adduction contractures. A common procedure is the relear:-;e of the adductor tendon from its attachment to the pubic ramus. Thir:-; operation, which is possible under local anesthesia, is often a considered choice after arthroplasty when physical therapy fails to stretch out the adductor tendon. Flexion contractures of the fingers can also be overcome by release of the capsule through lateral incision at the interphalangeal joint. Hyperextension of the toes may be corrected by dorsal capsular incisions combined with lengthening of the extensor tendons. In all periarticular procedures, the hope is to restore function in a relatively normal joint. If clinical examination and x-ray demonstrate markedly eroded or destroyed articular surfaces, these procedures are
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doomed to failure because adequate range of motion and function cannot be restored in the particular joint. In such circumstances other forms of orthopedic procedures, arthroplasty, arthrodesis or osteotomy, must be carried out. Procedure No. 6: Osteotomy
The cutting of a bone about a joint in order to realign that joint is the procedure of osteotomy. It is most often employed where there are changes to be made in the weight-bearing line of function through the diseased joint. In the past, the procedure has been employed frequently for ehronic osteoarthritis of the hip. A subtrochanteric osteotomy has been applied in order to place the neck and head of the femur in a more superior or valgus position for weight bearing. By doing so, motion was increased because less diseased articular cartilage was swung into alignment on the weight-bearing surface of the acetabulum. These procedures have been used a good deal in Great Britain to date. The osteotomy site must be controlled by multiple pins inserted through the bone and incorporated in the cast or by angular plates and screws. In any event, there must be x-ray evidence of healing before motion can be started and often within the period adhesions will form in the joints requiring a long period of physiotherapy. Supracondylar osteotomy of the femur to correct fiexion deformities of the knee joint can also be used in the same fashion as for the hip, employing either the multiple transection pins or angular plate. In most instances, the deformed joint is held in acute fiexion with some useful motion due to preserved cartilage surface, or a bowing of the knee into the valgus position is present. This last deformity is a most unstable one for weight bearing. These patients have been through conservative treatment with casts, braces and crutches in an attempt to straighten the leg. When one reviews the x-rays, it is noted that compression of the lateral femoral condyle or upper tibial plate produces the condition. Therefore, osteotomy has sometimes been combined with the insertion of bone graft in order to make up the deficit of length or height of the particular bone. Here again, this procedure is most often employed in the upper end of the tibia or lower femur. Osteotomy is also employed in the chronic rheumatoid hand where deformity of the fingers has been unsightly. Realignment of a finger into 30 degrees of fiexion has been a gratifying procedure. Osteotomy through the wrist joint for acute fiexion or lateral deviation, or combinations of these deformities, will improve hand function by placing the fingers in a more natural and receptive position for tendon function. As in the case of other osteotomy sites, union is more assured by the insertion of cross pins incorporated in the plaster cast, or by use of intramedullary rods. Osteotomy of the foot is performed where there has been marked
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inversion and supination of the foot as the result of longstanding rheumatoid arthritis. This is seen most commonly in juvenile rheumatoid arthritis (Still's disease) as the result of deformities occurring in childhood. Wedge osteotomies through the midtarsal area are necessary to realign the foot so that the metatarsal heads and great toe will come to lie evenly within the shoe during weight bearing. These wedge osteotomies heal promptly by cast immobilization. Forward flexion deformity of the spine, in which ankylosing spondylitis shows complete ossification of all bony and ligamentous structures, may occur in spite of conservative therapy such as exercises, braces and plaster body jackets. Corrective osteotomy in the lumbar area has been utilized in a few of these cases in which the spine was markedly bowed forward. A wedge of bone is removed from the lumbar area that is compensatory for the dorsal kyphos deformity. An abnormal lumbar curve is thus created. Following osteotomy a spinal fusion is carried out and immobilization is obtained by bivalved plaster jackets. This procedure, as simply outlined, is a most formidable one and damage to intrathecal structures, such as spinal cord and nerve roots, during the operation procedure may occur. The cosmetic correction of an otherwise unsightly appearance has been the most gratifying result of lumbar osteotomy. Procedure No. 7: Articular Resection
This procedure consists in the resection of the proximal or di8tal portions or both sides of the joint. It is of particular value ill the treatment of chronic arthritis of the small joints of the foot or hand when they are grossly distorted from undue pressure or friction bursa that can lead to subcutaneous septic processes. Articular resection is mOHt often used in the foot, particularly at the metatarsophalangeal jointH when the foot is spread to any great degree and the pressure comes upon the undersurface of the metatarsal head. All of these heads can be removed if necessary to correct the deformity of cock-up toes. It is unwise to remove a single metatarsal head because adjacent heads will hypertrophy from overpressure and reproduce the painful symptoms of metatarsalgia. A better procedure is an osteotomy of the neck of the metatarsal involved or an ostectomy of the base of the metatarsal head, relieving the pressure. In the hand with ulnar deviation and dislocation of the proximal phalanges the metacarpophalangeal joint can be resected. In this operation the distal end of the metacarpal bone, as well as the proximal end of the proximal phalanx, is trimmed squarely across. It is necessary to bring the extensor tendon to the medial side of the joint in order to maintain function. When severe arthritis occurs at the acromioclavicular joints, a reseetion of the outer inch of the clavicle is an excellent procedure.
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When supination and pronation are prevented by ankylosis of the proximal or the distal ulnar-radial joint or both of these, the distal end of the ulnar or the radial head can be resected. This usually permits good supination. It must be stated, however, that articular resections are not performed in the major joints of the body since they lead to instability in these areas. Procedure No. 8: Arthroplasty
This operation forms a new movable joint when bony ankylosis has been present or where there has been marked distortion of the articular surfaces. Satisfactory results have been obtained in ankylosis of the hips,8 elbows and knees; less satisfactory results have been obtained in the fingers and in the jaw joints. Briefly, the technique of such an operation is to divide the bone at the line of the former joint, refashion the joint ends to stimulate the normal articular surfaces, and then to either sew a sheet fascia lata or some other membrane, such as plastic3 or metal material, over the joint surfaces. These interpositioning membranes or metals will prevent the recurrence of the ankylosis. Fascia lata is the most satisfactory material for interposition operation in the upper extremities. However, fascia wears out quickly in the weight-bearing joints and it is particularly weak and defective in the rheumatoid arthritic patient. In hip arthroplasty the use of nonoxidizing metals or replacement of the femoral head by metallic prosthesis has proved most satisfactory. Before arthroplasty is performed the patient is given a series of musclesetting and strengthening exercises which will later move the new joint. The preoperative and postoperative physical therapy program is one of the most important features in arthroplasty. Indeed, an excellent technical procedure can be completely ruined by faulty or haphazard physical therapy in the preoperative or postoperative period. In ankylosis of both knees, arthroplasty of onc of them might be sufficient. When both hips are ankylosed, bilateral arthroplasties may be necessary to permit assumption of the flexed position, as in sitting. If both hips and knees are ankylosed, arthroplasty is advised on the proximal joint, that is, the hip, prior to operation on the knees. For hips, a vitallium mold type of arthroplasty,7 in which the cup is fitted over the femoral head after the acetabulum and femoral head have been shaped, is an accepted procedure by most orthopedic surgeons. Well fitting articular surfaces can be formed easily in the major joints but the bones do not remain as they are shaped. Osteoporotic bones, particularly of rheumatoid arthritis, and the weak atrophic muscles are poor materials in which to operate. With function, however, the bone ends will reshape and often good function is seen in non-weight-bearing joints. Distortion is much less noted when metallic molds are fitted over the articular surfaces. Vitallium is one of the best metals employed in
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bone surgery and its use results in no irritation of the surrounding soft tissue or bone, as is the case when certain types of plastic or stainless steel are utilized. When the femoral head has been greatly misshapen from either disease or injury or from extensive overgrowth in osteoarthritis, it is often difficult, sometimes impossible, to reshape the femoral head. In such instances, a more nearly normal alignment and anatomical reconstitution for better function can be secured by replacing the femoral head with a metallic prosthesis. Many types are available today, but those employed most often were designed by Austin Moore 4 and Frederic R. Thompson. 9 These replacement prosthetic devices consist of a vitallium head and of an intramedullary stem, which will lock the appliance within the femoral shaft, producing the much needed rigidity and stability of the apparatus. 5 In the upper extremities arthroplasty is performed chiefly at the elbow and at the finger; movable joints can be obtained but they are usually so unstable that they interfere with use. Prostheses of the hinge type or of a metal tack have been used in the hands but are of limited value. A joint that lends itself well to arthroplasty is the elbow which is reached through a posterior incision and, after the ankylosis has been chiseled away, the ends are reshaped and a single layer of fascia is placed over the exposed bone. At the knee joint, fascia wears away quickly with use but plastic and metal prostheses have both given good results. Nylon membrane 6/1000 inch 6 has withstood wear satisfactorily for periods of four to six monthH and is not irritating to the tissues. Should it disappear, reshapening of the articular surfaces and re-formation of a fibrocartilage occur over the end of the bone. Nylon replacement has been found to have been satisfactory for continued motion and function years after arthroplasty. Metal replacements within the knee joint, for example covering the entire end of the femoral condyle, have been used. These are prostheses which incorporate a stem that anchors the apparatus within the femoral shaft. When collapse of the tibial condyle has occurred, a metallic prosthesis may be applied to the depressed tibial table. This is usually used in combination with other procedures, such as joint debridement or synovectomy. In the main, the indications for arthroplasty are the following: 1. To relieve pain. 2. To correct deformity. 3. To improve function of the joint. 4. To reconstitute stability in the affected joint. 5. To prevent changes in neighboring joints or secondary strain or traumatic arthritis that inevitably occurs; for instance, when arthritis involves one hip, the opposite hip or knee will undergo secondary changes. 6. To improve the cosmetic appearance of an unsightly distorted
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joint, such as the fingers, an elbow, and in some instances, the hip and knee. The proper technique of arthroplasty consists not only in reshaping the articular bone surfaces and the application of interpositioning material but also in removing scar tissue, irregular bone surfaces, synovium, and in some instances the joint capsule. It is also important to transfer certain muscle groups so that adequate power will be utilized to produce a stable joint. Procedure No. 9: Arthrodesis
This is the procedure of surgical erasion of the joint, utilized principally for the elimination of pain and the correction of a deformity. It is performed only occasionally in chronic arthritis. Arthrodesis has itR befo\t results after operation in the wrist, the ankle, and some of the small joints in the fingers. When a wrist joint becomes involved with chronic arthritis, palmar flexion deformity of 10 or 15 or more degrees will lead to weakening of the grip. Painful motions, therefore, occur throughout the hand alld wrist. This can be obviated by an arthrodesis of the wrist in about ;)5 degrees of dorsiflexion. Improvement in appearance, reduced pain and vast improvement of the muscle power of the flexors, thus providing a stronger grip, will be brought about. Chronic arthritis of the ankle as the result of injury, such as trimalleolar fracture with irreparable damage to the joint, can best be surgically corrected by arthrodesis. In this instance, plantar flexion of the foot in the position of function for males at approximately 95 to 100 degrees and for females at 100 to 105 degrees so that high heels may be worn, is the procedure of choice. When rheumatoid arthritis affects the hands producing ulnar deviation and flexion of the metacarpophalangeal joints, arthrodeses of the fourth and fifth fingers can be done. Fixation of the bones is obtained by crossed intramedullary wires. When ankylosis occurs, a strong buttressing effed has been created so that the other fingers do not drift-the ulna "drift" deformity. In the foot rheumatoid arthritis involves the talonavicular joint, very often causing a peroneal spastic flatfoot. A fusion of the talonavicular joint in the correct position of function by inversion of the foot to proper alignment, restoration of the longitudinal arch and the insertion of a bone graft has been used succeRsfully. Arthrodesis of the hip joint is used principally for degenerative joint disease of a single hip in a relatively young person, preferably a male, who performs more or less heavy labor. In selecting this procedure for correcting the hip pain and disability, one must be quite certain that there is a normal hip on the opposite side, a flexible lumbar spine, and that the knee on the side to be fused has excellent function. Fusion of
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the knee joints is sometimes employed when there is complete destruction of the knee that shows a deformity either in knock knee or bow leg, or a severe fiexion, extension, subluxation or dislocation deformity. In addition, if there is osteoporosis of the bone, leading to marked softening and the above deformities, or if there are subchondral bone cysts of the rheumatoid nature, then arthrodesis should be considered. Elderly arthritic patients who because of their age or infirmity are not candidates for other surgical procedures, such as arthroplasty, synovectomy or joint debridement, should be offered fusion procedures to obviate the pain and instability. Early solid fusion can be hastened by internal fixation, using an intramedullary rod or an external bone compression clampl that exerts constant pressure on the reshaped ends of the joint, leading to successful fusion as early as six to eight weeks. Arthrodesis of the hip or knee has some obvious disadvantages, however, in that the patient is awkward in getting about, particularly on public conveyances, has abnormal posture for sitting and, in some instances, difficulty in normal dressing habits, such as putting on stockings and shoes. Nevertheless, arthrodesis is an excellent orthopedic procedure that is utilized by many orthopedic surgeons as a method of obviating pain and creating stability in the joint operated upon. Procedure No. 10: Denervation Operations
Many surgical procedures have been attempted to interrupt the pain pathways to relieve pain in severe chronic arthritis. The sensory nerves that supply the articular capsule can be cut so that the pain from a joint can be relieved. Operations of this type are performed occasionally at the hip, knee and elbow, and the most common is the obturator neurectomy performed for relief of pain in the hip. The obturator nerve or, in exceptional cases, the accessory obturator nerve, supplies the anterior capsule of the hip joint. Resection partially denervates the articular capsule and when both posterior and anterior branches of the posterior capsule with the accompanying nerve to the quadratus femoris are cut, an almost complete denervation of the hip is performed. This procedure, while simple, leads to no serious sensory or motor sequelae in and about the hip joint. It can be employed on debilitated patients. However, its results are not predictable and only about one-third of the cases have successful relief of pain. Other procedures, such as chordotomy or rhizotomy, have also been employed for intractable pain in or about the pelvis and hip joints. These procedures should be reserved for the patient with malignant disease. Lumbar sympathectomy has also been advocated as a procedure to relieve pain in a chronic arthritic hip. At best, the results of these procedures have not been followed for sufficient time to warrant their general use.
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Rehabilitation When disabilities and deformities of the arthritic patient have been corrected, the orthopedic and medical responsibility has not ended. It is part of the overall treatment to return the patient to some useful form of activity. While the disease is becoming quiescent, a working plan should be set up. This should evaluate the physical disability after contemplated treatment, including surgery, has been carried out. In some cases, standing and walking should not be the goal if a stable, painless joint is not likely to follow. Such patients should be trained for a sitting oceupation. It is best if the patient can return to his previous work; for others job retraining through various agencies is necessary. A well planned surgical program will give gratifying results not only to the patient but to his physician as well. REFERENCES 1. Charnley, J.: Arthrodesis of Hips in Treatment of Osteoarthritis. Am. J. Arthritis 2: 169, 1960. 2. De Palma, A. F.: Diseases of Knee. Philadelphia, J. B. Lippincott Co., Hl54, p.502. 3. Kuhns, J. G. and others: Nylon Membrane Arthroplasty of Knee in Chronic Arthritis. J. Bone & Joint Surg. 35A: 929, 1953. 4. Moore, A. T.: Metal Hip Joint, a New Self-Locking Vitallium Prosthesis. South. M. J. 45: 1015, 1952. 5. Moore, A. T. and Lunceford, E. M.: The Self-Locking Hip Prosthesis in Osteoarthritis of Hip and Other Conditions. Am. J. Orthopedics 2: 155, 1960. 6. Potter, T. A. and Kuhns, J. G.: Observations on Arthroplasty of Knee. Surg. Gynec. & Obst. 7: 359, 1958. 7. Smith-Petersen, M. N., Larsen, C. B. and Aufranc, o. K: Vitallium Mold Arthroplasty of Hip Joint. J. Bone & Joint Surg. 27: 1, 1945. 8. Steinbrocker, 0.: Current Methods of Treatment: Osteoarthritis of Hip. Arthritis & Rheuma. 4: 89, 1961. 9. Thompson, F. R.: Operative Management of Osteoarthritis of Hip. Am. J. Orthopedics 3: 74, 1961. 10. Wilson, P. D.: M. CLIN. NORTH AMERICA 21: 1623, 1937. Robert B. Brigham Hospital Boston 20, Massachusetts