- Email: [email protected]
AN OSTEOTOMY FIXATION PLATE
1315
globulin patterns prognostic significance.
Abnormal or
carry
no
obvious
diagnostic
REFERENCES
Anderson, R., James, D. G., Peters, P. M., Thomson, A. D. (1962) Lancet,
i,
1211.
(1963) ibid. ii, 650. Fisher, A. M., Davis, B. D. (1942) Bull. Johns Hopk. Hosp. 71, 364. Gilliland, I. C., Johnston, R. N., Stradling, P., Abdel-Wahab, E. M. (1956) Brit. med. J. i, 1460. Stanton, E. (1954) J. clin. Path. 7, 172. James, D. G. (1956) Brit. med. J. ii, 900. Longcope, W. T., Freiman, D. G. (1952) Medicine, Baltimore, 31, 1. Mayock, R. L., Bertrand, P., Morrison, C. E., Scott, J. H. (1963) Amer. J. Med. 35, 67. McCuiston, C. F., Hudgins, P. C. (1960) Amer. Rev. resp. Dis. 82, 96. McQueen, E. G., O’Shea, R. F., Summerfield, M. P. (1954) Aust. Ann. Med. 3, 260. Norberg, R. (1964) Acta med. scand. 175, 359. Salvesen, H. A. (1935) ibid. 86, 127. Seibert, F. B., Nelson, J. W. (1943) Amer. Rev. Tuberc. 47, 66. -
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-
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—
AN OSTEOTOMY FIXATION PLATE GEOFFREY OSBORNE Lpool, F.R.C.S.E.
M.Ch. Orth. CONSULTANT ORTHOPEDIC
SURGEON,
LIVERPOOL ROYAL INFIRMARY
THE principle of internal fixation of the osteotomy in of osteoarthritis of the hip-joint now seems to be generally accepted. This method offers distinct advantages over plaster immobilisation. The traditional method of immobilising the hip in a plaster spica for three months, to promote union of the osteotomy, left considerable stiffness of the knee and hip joints to be overcome; and there was sometimes muscular weakness and wasting, and long-continued oedema of the leg. It was inapplicable to the old and decrepit, and had a restricted value in those parts of the world where it is important to preserve enough hip and knee flexion for squatting. The patient did not reach the final state of recovery for six or nine months after removal of the cases
plaster. With internal fixation, a plaster spica is unnecessary, and early hip and knee movements are feasible. Disuse changes are considerably reduced, nursing is easier, and the patient can get about comparatively early, allowing much prompter discharge from hospital. There has been an impression that complete immobilisation of the whole limb in a plaster spica enhanced the effect of the osteotomy operation in promoting resolution of the arthritis, and that results were less satisfactory when internal fixation was used and knee and hip movements were permitted at an early stage. This criticism of internal fixation does not seem to be supported by recent clinical evidence, and the beneficial effects of the osteotomy operation are found whether fixation is external or- internal (Kirwan and Harris 1963, Nissen 1963).
"
tend to strut apart " the osteotomy surfaces and delay union. If they do penetrate the upper cortex, they may fail to control rotational movement, owing to the small width of the blade, particularly if the bone of the great trochanter is porotic. The second type of fixation device is based on the pin and plate normally used for trochanteric fractures and is angulated to conform with the displaced position of the osteotomy. This pattern is generally less secure and may also hold apart the osteotomy surfaces. Moreover introduction of the end of the pin into the arthritic head of femur may reduce the chances of ultimate improvement of the arthritis. In the treatment of fractures the value of increasing the rigidity by internal fixation is being recognised, but many appliances are inadequate in strength and design for this purpose (Hicks 1959, Nichol 1963). The forces causing deformity in the upper femur are very considerable and can easily bend a weak implant or cause the device to move in the bone. Proposed Solution The compression-plate described here was designed after reviewing the whole range of osteotomy fixation devices, and its primary function is to bolt the osteotomy surfaces securely together (figs. 1 and 2). The cortical bone of the trochanter was found to be strong enough to withstand a fairly considerable compression force applied as near to a right-angle as possible to the osteotomy surfaces along the line of the V blade. The V blades of the plate are set at 90° and are similar to the later blade plate suggested by Blount (1952). The blades are made deliberately thick and blunt, to secure an exceptionally good hold in the weak trabecular bone of the trochanteric compartment, and are wide enough to form a good fit against the front and back cortices. The design provides the largest possible surface area of blade which can be accommodated in the space in the upper fragment. It does not encroach on the cancellous area at the inner end of the osteotomy, where the two fragments unite. It provides a much greater resistance to shearing movement in all directions than a flat blade. The operation can be performed
The Problem
The mechanical
problems of internal fixation
of
a
dis-
placement osteotomy in the intertrochanteric region are almost entirely due to the difficulty of securing a rigid hold in the cancellous bone of the upper fragment. In the catalogues of surgical-instrument makers, about twenty different patterns of osteotomy fixation appliances are listed. Most of these seem to be reasonably effective, ’ but none has been found to be entirely and universally reliable. Delayed union and non-union have been reported, and imperfect fixation may result in varus or rotation deformity (Scott 1964). The Nichol osteotomy plate, or its derivative the Wainwright plate, has emerged as the most popular device and apparently has advantages over other types. On the other hand, vertical " spline " or blade plates of this type, if they do not penetrate the cortex of the upper fragment, may
Fig. 1—Compression plate with probe-ended bolt and spring washer.
Removable director is discarded after use.
2 Fixation of osteotomy for arthritis of hipjoint with com-
Fig.
-
pression 11
weeks
operation, man aged
plate, after in a 75.
1316
through a lateral or posterior approach, the upper part of the incision being prolonged to expose the gluteal muscles. After the osteotomy is performed, a hole is drilled in the upper fragment (see fig. 3, A), and the blade plate, with removable " director " attached, is inserted through this drill hole (fig. 3, B). The director is made to come out through the hard bone at the tip of the trochanter. The plate is then clamped to the shaft of the femur and secured with screws (fig. 3, C). The osteotomy surfaces are then impacted, using a Smith-Petersen impactor placed over the director, which is exposed by separating the fibres of gluteus medius (fig. 3, D and E). The director is then removed with a Steinmann pin chuck-handle (fig. 3, F) and is replaced with the probe-ended bolt and spring washer (fig. 3, G). As the bolt is tightened, the two osteotomy surfaces can be seen to be forced together along the line of the blade (fig. 3, H and I). This device has been used for more than thirty cases in the past two years, and in every case the osteotomy has united satisfactorily within twelve weeks. The forces carried by the plate are considerable, and four plates of an earlier pattern broke. Subsequent strengthening of the plate has eliminated any danger of such mechanical failure. In one patient the bolt moved somewhat in a soft upper fragment, and in another case X-rays showed the bolt to be loose after union had occurred. No symptoms have been noted from the presence of the bolt head under
the gluteus-medius insertion, and no other complication of any type has occurred with the device. There is no evidence that rigid fixation of the two osteotomy fragments affected adversely the anticipated improvement in the arthritis. Additional external fixation is unnecessary; and in most cases, after the immediate postoperative pain has subsided, the lack of discomfort, and a secure feeling in the hip, have encouraged patients to move freely. I wish to thank Prof. Robert Roaf for assistance in the preparation of this paper. The osteotomy plate is made by Messrs. Down Brothers and Mayer & Phelps Ltd., Church Path, Mitcham, Surrey. REFERENCES
Blount, W. P. (1952) Instructional Course of Lectures, American Academy of Orthopedic Surgeons; vol. IX, p. 1. Ann Arbor. Hicks, J. (1959) in Modern Trends in Accident Surgery and Medicine (edited by R. Clarke, F. S. Badger, and S. Sevitt). London. Kirwan, E., Harris, N. H. (1963) J. Bone Jt Surg. 45b, 613. Nichol, E. A. (1963) ibid. p. 800. Nissen, K. I. (1963) Proc. R. Soc. Med. 56, 1051. Scott, P. J. (1964) ibid. 57, 359.
Preliminary Communications PRESSOR HYPOREACTIVITY TO ANGIOTENSIN IN ADDISON’S DISEASE REDUCED sensitivity to the pressor effect of exdgenous angiotensin has been observed in cirrhosis of the liver,’
secondary hyperaldosteronism,2 malignant hypertension,3 and potassium depletion.4 Adrenalectomised rats stabilised on 1% saline solution showed diminished responsiveness to angiotensin which was restored by corticosterone, and to a lesser degree, by aldosterone.5 We wondered whether patients with Addison’s disease had pressor hyporeactivity to angiotensin and, if so, whether their tubular and hormonal responses differed from normal. Accordingly angiotensin was infused with the further intention of testing the mineralocorticoid reserve capacity of the adrenals in adrenocortical failure, since angiotensin is the aldosterone-stimulating hormone.6 METHODS
We examined 10 healthy subjects, and 8 patients with Addison’s disease proved by the corticotrophin stimulation test. We gave an infusion of angiotensin II (’Hypertensin’, Ciba), 1 25 mg. per 500 ml. 5% glucose solution, for 6 hours at a speed of 2-20-2-89 µg. per minute. We assessed the bloodpressure at 5-10 minute intervals, urinary electrolytes at 3-hour intervals, and the excretion of aldosterone on the day before, the day of, and the day after angiotensin infusion. The daily intake of sodium was about 88 mEq. The patients were maintained on prednisone 2-5-5 mg. daily; their plasma concentration of sodium was 130-0-148-5 mEq. per litre, and that of potassium 4-0-6-2 mEq. per litre. Urinary aldosterone 7 was estimated by the method of Moolenaar. RESULTS AND DISCUSSION
The
blood-pressure after angiotensin (fig. 1) was lower in Addison’s disease than in healthy significantly To subjects. produce the same blood-pressure elevation, a fivefold increase of the angiotensin dose was needed. The mean urinary sodium/potassium ratio, which is significantly lower in healthy persons after angiotensin, did not change in Addison’s disease. The mean urinary sodium/creatinine ratio which is higher in Addison’s disease, was significantly lowered in both groups-in 1.
2. 3. 4. 5. 6.
Fig. 3-Technique
of
inserting osteotomy plate (see test.)
7.
mean
Laragh, J. H., Cannon, P. J., Ames, R. P. Canad. med. Ass. J. 1964, 90, 248. Johnston, C. J., Jose, A. D. J. clin. Invest. 1963, 42, 1411. Kaplan, N. M., Silah, J. G. ibid. 1964, 43, 659. Friedman, M., Freed, S. C., Rosenman, R. H. Circulation, 1962, 5, 415. Ostrovsky, D., Gornall, A. G. Canad. med. Ass. J. 1964, 90, 180. Davis, J. O., Hartroft, D. M., Titus, E. O., Carpenter, Ch. C. J., Ayers, C. R., Spiegel, H. E., Casper, A., Cavanaugh, E. J. clin. Invest. 1962, 41, 378. Moolenaar, A. J. Acta Endocr., Copenhagen, 1957, 25, 161.
globulin patterns prognostic significance.
Abnormal or
carry
no
obvious
diagnostic
REFERENCES
Anderson, R., James, D. G., Peters, P. M., Thomson, A. D. (1962) Lancet,
i,
1211.
(1963) ibid. ii, 650. Fisher, A. M., Davis, B. D. (1942) Bull. Johns Hopk. Hosp. 71, 364. Gilliland, I. C., Johnston, R. N., Stradling, P., Abdel-Wahab, E. M. (1956) Brit. med. J. i, 1460. Stanton, E. (1954) J. clin. Path. 7, 172. James, D. G. (1956) Brit. med. J. ii, 900. Longcope, W. T., Freiman, D. G. (1952) Medicine, Baltimore, 31, 1. Mayock, R. L., Bertrand, P., Morrison, C. E., Scott, J. H. (1963) Amer. J. Med. 35, 67. McCuiston, C. F., Hudgins, P. C. (1960) Amer. Rev. resp. Dis. 82, 96. McQueen, E. G., O’Shea, R. F., Summerfield, M. P. (1954) Aust. Ann. Med. 3, 260. Norberg, R. (1964) Acta med. scand. 175, 359. Salvesen, H. A. (1935) ibid. 86, 127. Seibert, F. B., Nelson, J. W. (1943) Amer. Rev. Tuberc. 47, 66. -
-
-
-
—
AN OSTEOTOMY FIXATION PLATE GEOFFREY OSBORNE Lpool, F.R.C.S.E.
M.Ch. Orth. CONSULTANT ORTHOPEDIC
SURGEON,
LIVERPOOL ROYAL INFIRMARY
THE principle of internal fixation of the osteotomy in of osteoarthritis of the hip-joint now seems to be generally accepted. This method offers distinct advantages over plaster immobilisation. The traditional method of immobilising the hip in a plaster spica for three months, to promote union of the osteotomy, left considerable stiffness of the knee and hip joints to be overcome; and there was sometimes muscular weakness and wasting, and long-continued oedema of the leg. It was inapplicable to the old and decrepit, and had a restricted value in those parts of the world where it is important to preserve enough hip and knee flexion for squatting. The patient did not reach the final state of recovery for six or nine months after removal of the cases
plaster. With internal fixation, a plaster spica is unnecessary, and early hip and knee movements are feasible. Disuse changes are considerably reduced, nursing is easier, and the patient can get about comparatively early, allowing much prompter discharge from hospital. There has been an impression that complete immobilisation of the whole limb in a plaster spica enhanced the effect of the osteotomy operation in promoting resolution of the arthritis, and that results were less satisfactory when internal fixation was used and knee and hip movements were permitted at an early stage. This criticism of internal fixation does not seem to be supported by recent clinical evidence, and the beneficial effects of the osteotomy operation are found whether fixation is external or- internal (Kirwan and Harris 1963, Nissen 1963).
"
tend to strut apart " the osteotomy surfaces and delay union. If they do penetrate the upper cortex, they may fail to control rotational movement, owing to the small width of the blade, particularly if the bone of the great trochanter is porotic. The second type of fixation device is based on the pin and plate normally used for trochanteric fractures and is angulated to conform with the displaced position of the osteotomy. This pattern is generally less secure and may also hold apart the osteotomy surfaces. Moreover introduction of the end of the pin into the arthritic head of femur may reduce the chances of ultimate improvement of the arthritis. In the treatment of fractures the value of increasing the rigidity by internal fixation is being recognised, but many appliances are inadequate in strength and design for this purpose (Hicks 1959, Nichol 1963). The forces causing deformity in the upper femur are very considerable and can easily bend a weak implant or cause the device to move in the bone. Proposed Solution The compression-plate described here was designed after reviewing the whole range of osteotomy fixation devices, and its primary function is to bolt the osteotomy surfaces securely together (figs. 1 and 2). The cortical bone of the trochanter was found to be strong enough to withstand a fairly considerable compression force applied as near to a right-angle as possible to the osteotomy surfaces along the line of the V blade. The V blades of the plate are set at 90° and are similar to the later blade plate suggested by Blount (1952). The blades are made deliberately thick and blunt, to secure an exceptionally good hold in the weak trabecular bone of the trochanteric compartment, and are wide enough to form a good fit against the front and back cortices. The design provides the largest possible surface area of blade which can be accommodated in the space in the upper fragment. It does not encroach on the cancellous area at the inner end of the osteotomy, where the two fragments unite. It provides a much greater resistance to shearing movement in all directions than a flat blade. The operation can be performed
The Problem
The mechanical
problems of internal fixation
of
a
dis-
placement osteotomy in the intertrochanteric region are almost entirely due to the difficulty of securing a rigid hold in the cancellous bone of the upper fragment. In the catalogues of surgical-instrument makers, about twenty different patterns of osteotomy fixation appliances are listed. Most of these seem to be reasonably effective, ’ but none has been found to be entirely and universally reliable. Delayed union and non-union have been reported, and imperfect fixation may result in varus or rotation deformity (Scott 1964). The Nichol osteotomy plate, or its derivative the Wainwright plate, has emerged as the most popular device and apparently has advantages over other types. On the other hand, vertical " spline " or blade plates of this type, if they do not penetrate the cortex of the upper fragment, may
Fig. 1—Compression plate with probe-ended bolt and spring washer.
Removable director is discarded after use.
2 Fixation of osteotomy for arthritis of hipjoint with com-
Fig.
-
pression 11
weeks
operation, man aged
plate, after in a 75.
1316
through a lateral or posterior approach, the upper part of the incision being prolonged to expose the gluteal muscles. After the osteotomy is performed, a hole is drilled in the upper fragment (see fig. 3, A), and the blade plate, with removable " director " attached, is inserted through this drill hole (fig. 3, B). The director is made to come out through the hard bone at the tip of the trochanter. The plate is then clamped to the shaft of the femur and secured with screws (fig. 3, C). The osteotomy surfaces are then impacted, using a Smith-Petersen impactor placed over the director, which is exposed by separating the fibres of gluteus medius (fig. 3, D and E). The director is then removed with a Steinmann pin chuck-handle (fig. 3, F) and is replaced with the probe-ended bolt and spring washer (fig. 3, G). As the bolt is tightened, the two osteotomy surfaces can be seen to be forced together along the line of the blade (fig. 3, H and I). This device has been used for more than thirty cases in the past two years, and in every case the osteotomy has united satisfactorily within twelve weeks. The forces carried by the plate are considerable, and four plates of an earlier pattern broke. Subsequent strengthening of the plate has eliminated any danger of such mechanical failure. In one patient the bolt moved somewhat in a soft upper fragment, and in another case X-rays showed the bolt to be loose after union had occurred. No symptoms have been noted from the presence of the bolt head under
the gluteus-medius insertion, and no other complication of any type has occurred with the device. There is no evidence that rigid fixation of the two osteotomy fragments affected adversely the anticipated improvement in the arthritis. Additional external fixation is unnecessary; and in most cases, after the immediate postoperative pain has subsided, the lack of discomfort, and a secure feeling in the hip, have encouraged patients to move freely. I wish to thank Prof. Robert Roaf for assistance in the preparation of this paper. The osteotomy plate is made by Messrs. Down Brothers and Mayer & Phelps Ltd., Church Path, Mitcham, Surrey. REFERENCES
Blount, W. P. (1952) Instructional Course of Lectures, American Academy of Orthopedic Surgeons; vol. IX, p. 1. Ann Arbor. Hicks, J. (1959) in Modern Trends in Accident Surgery and Medicine (edited by R. Clarke, F. S. Badger, and S. Sevitt). London. Kirwan, E., Harris, N. H. (1963) J. Bone Jt Surg. 45b, 613. Nichol, E. A. (1963) ibid. p. 800. Nissen, K. I. (1963) Proc. R. Soc. Med. 56, 1051. Scott, P. J. (1964) ibid. 57, 359.
Preliminary Communications PRESSOR HYPOREACTIVITY TO ANGIOTENSIN IN ADDISON’S DISEASE REDUCED sensitivity to the pressor effect of exdgenous angiotensin has been observed in cirrhosis of the liver,’
secondary hyperaldosteronism,2 malignant hypertension,3 and potassium depletion.4 Adrenalectomised rats stabilised on 1% saline solution showed diminished responsiveness to angiotensin which was restored by corticosterone, and to a lesser degree, by aldosterone.5 We wondered whether patients with Addison’s disease had pressor hyporeactivity to angiotensin and, if so, whether their tubular and hormonal responses differed from normal. Accordingly angiotensin was infused with the further intention of testing the mineralocorticoid reserve capacity of the adrenals in adrenocortical failure, since angiotensin is the aldosterone-stimulating hormone.6 METHODS
We examined 10 healthy subjects, and 8 patients with Addison’s disease proved by the corticotrophin stimulation test. We gave an infusion of angiotensin II (’Hypertensin’, Ciba), 1 25 mg. per 500 ml. 5% glucose solution, for 6 hours at a speed of 2-20-2-89 µg. per minute. We assessed the bloodpressure at 5-10 minute intervals, urinary electrolytes at 3-hour intervals, and the excretion of aldosterone on the day before, the day of, and the day after angiotensin infusion. The daily intake of sodium was about 88 mEq. The patients were maintained on prednisone 2-5-5 mg. daily; their plasma concentration of sodium was 130-0-148-5 mEq. per litre, and that of potassium 4-0-6-2 mEq. per litre. Urinary aldosterone 7 was estimated by the method of Moolenaar. RESULTS AND DISCUSSION
The
blood-pressure after angiotensin (fig. 1) was lower in Addison’s disease than in healthy significantly To subjects. produce the same blood-pressure elevation, a fivefold increase of the angiotensin dose was needed. The mean urinary sodium/potassium ratio, which is significantly lower in healthy persons after angiotensin, did not change in Addison’s disease. The mean urinary sodium/creatinine ratio which is higher in Addison’s disease, was significantly lowered in both groups-in 1.
2. 3. 4. 5. 6.
Fig. 3-Technique
of
inserting osteotomy plate (see test.)
7.
mean
Laragh, J. H., Cannon, P. J., Ames, R. P. Canad. med. Ass. J. 1964, 90, 248. Johnston, C. J., Jose, A. D. J. clin. Invest. 1963, 42, 1411. Kaplan, N. M., Silah, J. G. ibid. 1964, 43, 659. Friedman, M., Freed, S. C., Rosenman, R. H. Circulation, 1962, 5, 415. Ostrovsky, D., Gornall, A. G. Canad. med. Ass. J. 1964, 90, 180. Davis, J. O., Hartroft, D. M., Titus, E. O., Carpenter, Ch. C. J., Ayers, C. R., Spiegel, H. E., Casper, A., Cavanaugh, E. J. clin. Invest. 1962, 41, 378. Moolenaar, A. J. Acta Endocr., Copenhagen, 1957, 25, 161.