Renata Bambelli Osteoarthritis Hip o f the Pathogenesis and Consequent Therapy With a Foreword by Maurice E. Muller Wi th 160 Figures, 70 in Color Springer-Verlag Berlin Heidelberg New York 1976 R. BOMBELLI, M.D.! L.D. in Clinica Ortopedica - University of Milan, Orthopaedic Consultant, Hospital of Busto Arsizio, 20025 LegnanojItaly, Via Lampugnani, 1 ISBN-13: 978-3-642-96358-2 e-ISBN-13: 978-3-642-96356-8 DOl: 10.1007/978-3-642-96356-8 Library of Congress Cataloging in Publication Data. Bombelli, Renato. Osteoarthritis of the hip. Bibliography: p. . Includes index. 1. Osteoarthritis-Surgery, 2. Hip joint-Diseases. 3. Femur-Surgery. I. Title. RD549.B65. 617'.58. 76-23191 ISBN-13: 978-3-642-96358-2 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying machine or similar means, and storage in data banks. Under §54 of the German Law where copies are made for other than private use, a fee is payable to the publisher, the amount of the fee to be determined by agreement with the publisher. © by Springer-Verlag Berlin. Heidelberg 1976. Softcover reprint of the hardcover 1st edition 1976 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. To my wife Foreword Osteoarthrosis of the hip is one of the most incapacitating dis eases of the locomotor system and in the last forty years it has been a source of continuous interest to research workers and to the general public. In spite of numerous studies, however, the pathogenesis of the disease is still uncertain, and in particular the aetiology of "primary" osteoarthrosis is unknown. Over the last 10 years the treatment of osteoarthrosis by joint replacement has become steadily more widespread, and the operations of osteotomy and arthrodesis have gone more and more out of favour. On the other hand, hip replacement is certainly not indicated in young adults, especially those engaged in sport, because of the twin dangers of late infection and of loosening. Professor BOMBELLI has been a friend of Professor PAUWELS for 13 years. At first he accepted both Professor PAUWELS' theory and technique and with these he has had remarkable clinical successes leading to regeneration of the hip. On the other hand, Professor BOMBELLI has also had failures. Professor BOMBELLI'S aims in the present study have been twofold: to study the clinical failures and successes and to eluci date the natural history of the untreated disease over a period of years. He has found that in some patients pain diminishes as the years go by and that during this time a variety of changes can be demonstrated in the hip radiologically. In some cases the appearances suggested that the capacity of bone to remodel and to develop osteophytes was accompanied by a loss of pain; subjectively at least the disease in such hips had" healed". On the basis of his observations both in untreated cases and in patients treated by intertrochanteric osteotomy, Professor BOMBELLI concluded that the natural "healing" process can be accelerated by surgery. He has embodied this concept in a mathe matical analysis which rests upon the belief that good results can be explained by changes induced by surgery in the forces acting on the hip joint. Professor BOMBELLI has observed that, in more than 1000 cases, an extreme valgus osteotomy usually produces an excellent clinical result and that in particular it does so in secondary osteoarthrosis in young adults. He believes that the tendency to lateral subluxation of the femur in the osteoarthrotic hip is due to the presence of forces acting in a lateral direction. The objective of the BOMBELLI valgus osteo tomy is therefore to subject the superior capsule of the hip to tension (by rotating the proximal fragment) in the expectation VII that this will induce osteophyte formation along the superior lip of the acetabulum: in other words, that a physiological "shelf" will be induced. Professor BOMBELLI believes that his good clinical results are due to the resultant increase in the weight-bearing area of the hip. Although one might question the extent to which biological responses can be explained on the basis of mathematical analy ses, the excellent objective results shown by an increase in the radiological joint space, the disappearance of cysts and the disappearance of sclerosis have to be accepted as such. The reader should therefore study this investigation with great care in he hope that Professor BOMBELLI'S results can be reproduced by others: the best hip replacement has an unknown but certainly finite life whereas a hip healed after osteotomy will often last a lifetime. Berne, October 1976 MAURICE E. MULLER VIII Preface This work is the result of clinical, radiographic, and surgical ex perience gained in 13 years of treating 1450 cases of primary or secondary osteoarthritis of the hip by intertrochanteric femoral osteotomy. The study of "Uber den Schwerpunkt des menschlichen Kor pers" (1889) and" Der Gang des Menschen" (1899) by FISCHER, the "Gesammelte Abhandlungen zur funktionellen Anatomie des Bewegungsapparates" (1965) and the" Atlas zur Biomecha nik der gesunden und kranken Hiifte" (1973) by the PAUWELS, precious teaching of this author, father of biomechanics, and the daily observation of X-rays of the hips of patients before and after osteotomy, have allowed me to set forth a hypothesis con cerning the pathogenesis of osteoarthritis of the hip and its con sequent therapy. My hypothesis is not the result of inductive, but of deductive reasoning, obtained from clinical and radiographic observations. The treatment I propose, is not new (though it has some tech nical alterations), nor is it an alternative to today's widespread total hip replacement. It is in my opinion a procedure which has a particular place in the treatment of secondary osteoarthritis of the hip in young people, although it may sometimes be used in cases of primary osteoarthritis of the hip, in older patients. The indications for osteotomy, according to my experience, are more widespread than usually thought, because bone and car tilage have an unexpected capacity for recovery if we remove damaging biomechanical forces and create new more favorable ones. The aim of the operation is to create a healthy ecology in the hip. Nature itself is constantly engaged in counteracting the de caying effect due to causes not yet fully understood, by means of new bone formation: the osteophytes. But nature proceeds slowly: "Natura non facit saltus"; natural healing occurs only after decades. Man, the victim of the pathologic process, has too limited a period of life, nor does he readily agree to suffer for an extended period of time. The operation helps nature to produce in less than an hour what would normally take years. IX I feel a deep gratitude to Prof. FRIEDRICH PAUWELS for his warm and generous teaching, to Dr. ROBERT SCHNEIDER, ASIF's Pre sident, for his inspiring suggestions, to Prof. MAURICE E. Mik LER, Director of Orthopedics in Bern University, for his inge nious criticism, to Dr. ROBERT MATHYS and the other members of the committee of SYNTHES for their generous support. Special thanks are merited by my colleagues in Busto Arsizio General Hospital; doctors, technicians, theatre and ward nurses, who have always given their friendly collaboration. My thankfulness to my confident and affectionate patients, who are not the object, but the subject of the treatment. The architects, MARCO TURRI, at the same time artist and tech nician, and ROBERTO PORETTI, precise and attentive, have in geniously illustrated my thinking. To Dr. GOTZE and to the efficient staff of Springer-Verlag many thanks for their friendly and invaluable understanding. Legnano, October 1976 RENATO BOMBELLI x Contents A. Introduction. . . . . . . . . 1 B. Biomechanics of a Normal Hip 3 C. Biomechanics in Osteoarthritis of the Hip 9 I. Examination of a Deformed Femoral Head 10 II. Search for the Center of Rotation (CR) and the Center of Stress (CS) . . . . . . . . . . . .. 10 III. Consequences of Deformity in the Femoral Head. 15 IV. Detection of CR, of CR and of CS, from X-ray of a 1, Deformed Elliptical Femoral Head 17 V. Appearance of Force S . . . . . . 18 D. Pathogenesis of Osteoarthritis of the Hip 27 I. Osteophytes . . . . . . . . . . . 27 1. Plastic Deformity of the Femoral Head and of the Acetabulum . . . . . . . . . . . . . . . . 27 2. Tension in the Ligamentum Teres and its Syno vial Membrane, in the Joint Capsule and its Synovial Membrane, and in the Synovial Mem- brane Covering the Neck of the Femur. 27 3. Fatigue Fractures of Osteophytes 28 E. Consequent Therapy . . . . . . 49 I. Valgus-Extension Osteotomy 49 1. Effect of Valgus-Extension Osteotomy 49 2. Indication for Valgus-Extension Osteotomy 60 3. Evolution of the Technique of the Valgus Oste- otomy . . . . . . . . . . . . . . . 60 4. Present Technique of Valgus-Extension Oste- otomy . . . . . . . . . . . . 61 II. Varus Osteotomy . . . . . 104 1. Indication for Varus Osteotomy. 104 2. Effect of Varus Osteotomy . . 104 3. Technique of Varus Osteotomy . 105 F. How the Resultant Force R May be Reduced 121 G. Summary 129 References . 133 Subject Index . 135 Xl The radiographical study of cases affected by Osteoarthritis of the Hip, before and after Intertrochanteric Osteotomy, suggests a Pathogenesis of the disease both in cases of primary and of secondary Osteoarthritis*. From a knowledge of the pathogenesis we can deduce a Consequent Therapy. *Primary osteoarthritis: Defect in material, that modifies the shape Secondary osteoarthritis: Defect in shape, that modifies the material XII