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Morand, a student of Cheselden and a surgeon at La Charite in Paris, was the first surgeon documented to seriously consider the possibility of carrying out such an amputation in 1729 (7). In the subsequent decades, there are a number of published case reports and case series regarding the possibility of performing such a procedure and attempts to improve patient morbidity and mortality rates. There are additional numerous discussions regarding the ethics of such a mutilating and dangerous procedure. Subsequently, anecdotal reports of hip disarticulation for wounds and for infection, particularly tuberculosis, accumulated. In 1812, for example, Larrey (8) described a successful amputation through the hip joint in an officer of the dragoons wounded by a missile in a battle before Moscow. Astley Cooper successfully carried out an elective disarticulation of the hip in 1824 in a 40-year-old patient with a chronic infection involving the whole upper end of the femur (9,10). The American Civil War (1861–1865) played a special role in the discovery and development of many of the early principles of orthopedic surgery. At the time of the War, orthopedic surgery was not yet a recognized specialty in the United States. The War began in a time when antibiotics, principles of fluid resuscitation, surgical implants, and diagnostic tools such as radiographs were not available. The study and treatment of extremity trauma during this era provided many of the basic orthopedic techniques that are still in use today, including Buck traction and plaster splints. Injuries to the hip caused the highest mortality of all the skeletal injuries, with mortality rates approaching 90% (11). By 1867, with 111 elective disarticulations of the hip with 46 survivors, a mortality rate of 57% was reported (12). During the Civil War (1861–1865) there were 19 primary disarticulations of the hip for missile wounds with a mortality rate of 95%; 9 secondary disarticulations with a mortality rate of 78%; and 7 cases of reamputation with a mortality rate of 43% (13). An example of a typical patient and good outcome are presented in Figure 1.1 (14). During the next century the operative mortality for all types of hip disarticulation continued to drop, reaching an acceptable level after World War II. Hip disarticulation has remained in the surgical armamentarium primarily as a tool for the control of malignant tumors of the bone and soft tissue, and rarely for trauma. The basic technique of the operation was well described by Boyd in 1947 (15). Figure 1.1. A: Private James Kelly was injured in a skirmish along the Rappahannock River on April 29, 1863. He subsequently underwent a hip disarticulation. During his postoperative care, he was captured and placed in a Confederate prison. Later, he was exchanged, and while in a Union hospital, his wound infection was treated with bromine and chlorinated soda, both antiseptics. B: The same patient with his prosthesis in place. He was noted to “walk quite well after the adaptation of the artificial limb. (Reprinted with permission from Kuz JE. The ABJS presidential lecture, June 2004: Our orthopaedic heritage: The American Civil War. Clin Orthop Relat Res. 2004;(429):306–315. Figure originally from Bengtson BP, Kuz JE. Photographic Atlas of Civil War Injuries: Photographs of Surgical Cases and Specimens—Otis Historical Archives. Grand Rapids, MI: Medical Staff Press; 1996.) Hip Joint Resection Although disarticulations through the hip joint were uncommon, other amputations for trauma and infection were carried out frequently during the 18th century. Tuberculous infections were the predominant cause of chronic infection and infection-related morbidity reported during the 18th century. Mindful surgeons, however, began to consider the possibility of limb-sparing operations. On February 9, 1769, at a meeting of the Royal Society, Charles White (16) described the case of a 14-year-old boy with a large abscess, probably tuberculous, in his left shoulder. He treated the patient by drainage of the abscess and resection of the necrotic portion of the upper end of the humerus. The result was as favorable as it was surprising, with preservation of the arm and a high level of function. White never carried out a hip joint resection on a living patient; however, he did carry out such P.3 P.4 an operation on a cadaver and proved to his satisfaction that it was feasible. The substitution of joint resection for amputation was popularized by Park and Moreau (12). James Syme (17) was an ardent advocate of joint resection but believed that it was not a feasible operation at the hip. It was not until 1822 that a hip joint resection was carried out in a 9-year-old male patient with a chronic abscess of the joint with dislocation of the head of the femur by Anthony White (18) at Westminster Hospital, London. Postoperatively the deformity was corrected and the patient was treated as for an open fracture using a long splint. Although this left the patient with one leg considerably shorter than the other, some mobility was restored to the joint. Twelve months later the wound had healed and the patient had regained a remarkable level of function. Interestingly, Anthony White is also credited as the first to give an account of phlegmasia alba dolens, or deep vein thrombosis, of an extremity (19). His obituary in the Lancet in 1849 gave his contemporaries the ability to honor him with being perhaps “the most eminent surgeon by much in the North of England” (20). Joint resection was the first orthopedic operation for which special instrumentation was developed. Moreau (12) had a flexible saw, “with joints like the chain of a watch,” constructed by an instrument maker in London in 1790. This was passed around the bone by means of a large needle. Bernhard Heine of Wurzburg took this idea a step farther when in 1832 he developed his “chain osteotome” (21). This progenitor of the present ubiquitous chain saw was considered a real advance because it allowed division of the bone quickly through a small incision. Heine received the important Monthyon Prize in Paris for this invention in 1835. Heine also carried out extensive animal experiments studying the process of regeneration of bony tissue following resection (22). Louis Ollier of Lyon also used the operation of resection as a means of studying bone regeneration and the function of the periosteum, both in his patients and in experimental animals. His two-volume work on these subjects gives a good description of the operation of hip resection in a patient (23). By the middle of the 19th century resection of the hip joint was well accepted, being described by Erichsen (24) as “not difficult in performance”. Postoperatively the patients were managed by being placed in a long splint. In the United States, Lewis Sayre became the great exponent of hip joint resection for chronic infections. His first such procedure, carried out in 1854, was on a 9-year-old girl with “morbus coxarius,” probably tuberculosis. The case was thoroughly discussed in his lectures (25). Accompanying this report is an analysis of 59 of his hip resections with 39 survivors. Eight patients died during the immediate postoperative period. The remainder died of late complications, usually of tuberculosis. Sayre toured Europe discussing hip resection and was decorated by the Norwegian Crown for his work. In 1876, at the International Medical Congress in Philadelphia, Sayre demonstrated the operation before a group of surgeons including Lister (26). Gibney (27), in New York, supported Sayre and recognized the value of the operation in preventing and even reversing the progress of “ lardaceous degeneration” or secondary amyloidosis, a common cause of death in bone and joint tuberculosis. Volkmann (28), in Leipzig, was more conservative and believed that hip resection should be done only as a life- saving procedure.