Chapter 9. Surgical treatment of the 19th–20th century

9.1. Arthroplasty

Speaking about the possibility of surgical treatment, it is also necessary to note the presence of eclecticism in the choice of surgical technology. Since the end of the 19th century, the introduction of resection arthroplasty has served as an impetus for the introduction of an operative method of treatment. However, despite the immediate satisfactory clinical results, there was a high probability of developing complications such as shortening of the limb, joint instability and infectious pathology. Interposition arthroplasty with auto-fluidic tissues such as capsule, fascia, tendon, and others prevented ankylosing of the limb. However, infectious complications and shortening of the limb also remained a likely scenario.

At the next stage of technology development, arthroplasty was introduced using synthetic polymer-based materials.

However, despite the development of endoprosthetics, organ-preserving approaches, in particular corrective osteotomies, also developed.

The possibility of fibular osteotomy in the context of limb biomechanics restoration is of particular interest. It is known that patients with fractures of the fibula in the middle third of the diaphysis is not observed the progression of varus gonarthrosis.

Modern endoprosthetics with three-component endoprostheses provided the possibility of early loading on the limb; however, it is necessary to understand that the operation of total arthroplasty itself does not have a decisive effect on the course of the disease.

Most authors consider the history of knee replacement since the introduction of resection arthroplasty. In 1826, John Barton (Fig. 9.1) proposed resection of the articular surfaces of the knee joint at the level of the subchondral bone. The effect of this intervention was the preservation of mobility in the joint for up to 5 years, while indications for such interventions were tuberculosis gonitis and other infectious lesions (Fig. 9.2).

Fig. 9.1. John Barton (1794–1871) — American surgeon

Fig. 9.2. Economical resection of articular surfaces at the level of the subchondral zone

In 1862, William Fergusson (Fig. 9.3) noted that the higher the level of resection, the less pronounced the pain syndrome in the postoperative period, but inevitably developed instability of the joint, which required external immobilization (Fig. 9.4).

Fig. 9.3. William Fergus­son (1808–1877) — British surgeon

Fig. 9.4. Fergusson resection arthroplasty

A number of authors proposed to supplement resection arthroplasty with interposition arthroplasty (1863). As interposition materials were offered — joint capsule, wide hip fascia, patient’s skin, supra-patellar bag.

In 1860, in France, A.S. Verneuil (Fig. 9.5) first proposed the interposition of soft tissues between the ends of bones after their resection (Verneuil A.S., 1860).

Fig. 9.5. Aristide Verneuil (1823–1895) — French surgeon

The most promising at that time should be noted synthetic materials such as cellophane, nylon, and even metal frames. Interposing soft tissues prevented the appearance of osteophytes and preserved the volume of movement necessary for physiological biomechanics, while at the same time there was a high probability of limb shortening, infectious complications, and repeated ankylosing.

The surface of the femoral condyles is exposed and a niche on the tibia is prepared. The patella is dislocated outward. The interposition of the broad fascia of the femur of the contralateral limb between the femur and tibia (Fig. 9.6).

Fig. 9.6. Knee Arthroplasty by Willis C. Campbell (M.D. Memphis, Tenn). The broad fascia of the thigh

Fig. 9.7. Volkov Mstislav Vasilyevich (1923–2001). Laureate of the State Prize of the USSR, academician of the Russian Academy of Medical Sciences, Doctor of Medical Sciences, Professor

Fig. 9.8. Oganes Vardanovich Oganesyan (1933–2010). Academician of the Russian Academy of Medical Sciences, Doctor of Medical Sciences, Professor

The main problem after arthroplasty was shortening of the limb and rotary ankylosing. To solve this problem, hinge — distraction devices were proposed. However, the complexity was in the single-plane layout of the systems, which limited their use.

Very significant is the opinion of Movshovich I. A. 1983 (Fig. 9.9), who argued that, despite the appearance of endoprosthetics due to a large number of complications, resection arthroplasty with a detailed description of the technique of replacing articular surfaces with an articular capsule, according to the author, remains very relevant (Fig. 9.10).

Fig. 9.9. Movshovich Ilya Aronovich (1923–1966) — Doctor of Medical Scien­ces, Professor, surgeon, orthopedic traumatologist

Fig. 9.10. Resection arthroplasty by I.A. Movshovich

Movshovich I.A. (1983): «With the advent of the method of joint replacement, interest in arthroplasty has significantly decreased. Nevertheless, this method of joint mobilization remains in the Arsenal of operative orthopedics. It is safe to say that its use will be permanent».