Excision of the hip: A, Sayre; B, Ollier.
So far as the hand and fingers are concerned little resecting need be done, the surgeon usually confining himself to the removal of sequestra or curetting of carious bone. In cases of compound comminuted fracture bone fragments may be removed; only in cases of lost or destroyed phalanges will amputation be necessary.
The Hip.
—In its structure the hip-joint is one of the simplest in the body. Although it lies deeply it is easily made accessible. [Fig. 219] illustrates the incisions by which the joint is attacked for the purpose of exsection. If necessary either extremity of the incision can be extended or enlarged by a cross-cut. When the joint is disintegrated by disease, especially when partially dislocated, the parts will lend themselves to an easy and simple operation. When, however, the operation is done for ankylosis or for disease, by which great thickening and fixation have been produced, the measure may become difficult. For ordinary purposes the simplest method is to drive a sharp-pointed, strong-bladed knife directly down upon the neck of the bone from a point midway between the great trochanter and the crest of the ilium; then keeping the knife-blade in contact with the bone the incision is carried downward over the trochanter and along the shaft to a length making it sufficient for easy exposure of the bone and of the joint. Nothing is gained in these cases by trying to work through a short incision. A long one heals as readily and makes the operation more simple. It is as easy to make the entire incision in one cut as to divide the muscles layer by layer. The capsule of the neck of the femur being exposed by a wide retraction of wound margins, it is necessary next to divide muscular attachments to the great trochanter by raising the periosteum to which they are attached and saving both. To expose these insertions the femur should be rotated inward and outward, while the capsule is at the same time divided. The ligamentum teres, which offers a theoretical obstacle, usually disappears in the presence of any active disease and is scarcely ever encountered; it can be divided with curved scissors. Now by more or less powerful effort, including flexion and adduction to the extreme limit, with more or less rotation, the head of the bone is forced out from its socket and through the wound. Whether the bone should be decapitated with chain saw, metacarpal saw, or by the exsector of Wyeth will depend partly upon the freedom with which it can be exposed and on the equipment of the operator. It may be advisable to divide the neck with a chisel. The trochanter major should be preserved whenever its removal is not made imperative by the progress of the disease. The head and neck of the bone having been removed, the acetabulum is now more or less easily exposed, especially with retractors, and it should be cleaned with a sharp spoon. The capsule also should be removed, at least when the operation is done for tuberculous or other infectious condition. It is advisable to irrigate, then to wipe dry all the original joint surfaces and raw bone, and finally to cauterize either with pure carbolic or with zinc chloride, which should be washed away with the irrigating stream, the intent being to close the mouths of all the absorbents and prevent absorption from fresh exposure. Sinuses if present should be thoroughly excised, scraped, and treated in the same way. A drainage tube is usually preferable to the use of gauze.
The above is the method usually relied upon for hip exsection. Other methods have been devised, especially by anterior incision; of these the best probably is that of Barker. The cut is made along the outer border of the anterior surface of the sartorius and rectus, and through it the femoral neck is reached. By wide retraction the anterior surface of the joint can be completely exposed and opened, and through this opening the neck of the femur can be divided with a chain saw or chisel, before removal of the head from the acetabulum. The disadvantage of anterior incision is that pertaining to drainage. Nevertheless this can be obviated with capillary drains. Its advantages are that splinting and protection can be more perfectly effected, with less necessity for frequent interference. In other words it makes the subsequent care of the patient easier. Many English surgeons are in favor of it. Ollier devised a so-called osteoplastic excision, made through a curved incision with a downward convexity, the top of the great trochanter being exposed and divided with a chisel sufficiently to permit of its being turned up with the flap, and then being reunited to the main part of the bone after the removal of the neck and head. This method has its advantages in a limited number of cases, but it has not become popular in this country. It would seem to be an advantage to preserve the trochanter, although some surgeons remove it. So long, however, as disease is confined to the head and neck of the bone it is unnecessary to remove this projection.
The after-care of a hip excision is not an easy matter. Most surgeons prefer to maintain the limb in position by the aid of traction, with sufficient weight to overcome all muscle spasm. If the case be such that dressings need only be made at long intervals, then it matters little, but in a septic case in which there is considerable discharge the problem is sometimes a serious one. Various beds or suspension splints have been devised, consisting essentially of frames with cross-strips of stout material, upon which the patient lies. After raising the frame one or two of these strips are released and the parts exposed. This arrangement also permits of the easy management of a bed-pan. In young children a wire splint with a fenestrum, or a plaster-of-Paris spica or breeches with large opening cut opposite the wound, will often be serviceable. The tendency is rather toward adduction, and this should be overcome. Something will depend upon whether the surgeon is working for ankylosis or for a movable joint. In the former case a rigid dressing should be employed as soon as the condition of the wound permits. In the latter passive movement should be begun as soon as the wound is healed.
While the operation is usually performed quickly, and is not regarded as serious, it nevertheless has a considerable mortality, especially in the young and the aged, because of the conditions which necessitate it. After a complete exsection, even by the most ideal method and in the most ideal case, the limb remains somewhat shortened. This may be compensated by raising the heel of the shoe worn on the affected side. In severe cases it may be necessary to supply even two or three inches of artificial support for this purpose. Unless this is done compensatory spinal curvature will ensue.
Fig. 220
