The Hip Joint
edited by K. Mohan Iyer
Publishedby
PanStanfordPublishingPte.Ltd.
PenthouseLevel,SuntecTower3 8TemasekBoulevard
Singapore038988
Email:editorial@panstanford.com Web:www.panstanford.com
BritishLibraryCataloguing-in-PublicationData
AcataloguerecordforthisbookisavailablefromtheBritishLibrary.
TheHipJoint
Copyright c 2017PanStanfordPublishingPte.Ltd.
Allrightsreserved.Thisbook,orpartsthereof,maynotbereproducedinany formorbyanymeans,electronicormechanical,includingphotocopying, recordingoranyinformationstorageandretrievalsystemnowknownorto beinvented,withoutwrittenpermissionfromthepublisher.
Forphotocopyingofmaterialinthisvolume,pleasepayacopying feethroughtheCopyrightClearanceCenter,Inc.,222RosewoodDrive, Danvers,MA01923,USA.Inthiscasepermissiontophotocopyisnot requiredfromthepublisher.
ISBN978-981-4745-14-7(Hardcover)
ISBN978-981-4745-15-4(eBook)
PrintedintheUSA
Tothememoryofmyrespectedteacher (Late)Mr.GeoffreyV.Osborne and Mywife,Mrs.NaliniK.Mohan Mydaughter,DeepaIyer,MBBS,MRCP(UK) Myson,RohitIyer,BE(IT) Mygrandson,Vihaan
Contents
Foreword xxiii
Preface xxvii
Acknowledgements xxix
1EmbryologyandAnatomyoftheHipJoint1 K.MohanIyer
1.1EmbryologyoftheHipJoint1
1.1.1TheFibrousCapsule3
1.1.2TheAcetabularLabrum3
1.1.3LigamentoftheHeadoftheFemur3
1.1.4TheIliofemoralLigament3
1.2AnatomicalRelationsoftheHipJoint4
1.3MovementsoftheHip4
1.4AppliedAnatomy5
1.5BloodSupplyoftheHipJoint6
1.5.1AnatomyoftheBloodSupply6
1.5.2ChangeswithAge7
2BiomechanicsoftheHipJoint9 RamRavishankar
2.1FunctionalAnatomy10
2.1.1BonyStructure11
2.1.2ArticularCartilage12
2.1.3AcetabularLabrum13
2.1.4Capsule,Ligaments,andMusculature13
2.2KinematicsandKinetics15
2.2.1ForcesActingontheHipJoint16
2.2.2BiomechanicsAppliedtoTotalHip Arthroplasty23
2.2.3PathologicalBiomechanicsoftheHip26
2.2.3.1Dysplastichips,coxavara,andcoxa valga26
2.2.3.2Femoroacetabularimpingement28
2.2.3.3Labraltears,capsularlaxity,and chronicinstability29
3ClinicalExaminationoftheHipJoint33
K.MohanIyer
3.1Inspection33
3.2Palpation34
3.3RangeofMotion35
3.3.1ActiveRangeofMovements36
3.3.2PassiveRangeofMovements36
3.4NeurologicalExamination37
3.4.1Muscles37
3.4.2SensoryTesting38
3.5SpecialTests39
3.5.1Trendelenburg’sTest39
3.5.2LimbLengthDiscrepancy39
3.5.2.1Truelimblengthdiscrepancy40
3.5.2.2Apparentlimblengthdiscrepancy40
3.5.3Ober’sTest40
3.5.4ImportantTestsforCongenitalDislocationof theHip40
3.5.4.1Ortolaniclick40
3.5.4.2Telescoping41
3.5.4.3Adductioncontracture41
3.5.5ProximalFocalFemoralDeficiency41
3.5.5.1Treatment41
4ImagingoftheHipJoint43
RajeshBotchuandRamVaidhyanath
4.1Introduction43
4.1.1AnteroposteriorPelvicRadiograph45
4.1.2LateralView46
4.1.3FrogLegLateralView47
4.1.4JudetView47
4.1.5Acetabulum47
4.2MRIAnatomyoftheHip49
4.2.1MusclesandTendons51 4.3Labrum57
5DisordersoftheHipinChildrenandAdolescents59 K.Vinodh,SughranBanerjee,K.MohanIyer, VijayaKumarKempanna,RobertJennings,andSharadGoyal
5.1SepticArthritisoftheHipinInfantsandChildren59
5.1.1Epidemiology60
5.1.2Aetiopathology61
5.1.3CausativeOrganisms62
5.1.4ClinicalFeatures63
5.1.5Investigations64
5.1.6ImagingStudies64
5.1.7JointAspiration68
5.1.8DifferentialDiagnosis69
5.1.9Treatment70
5.1.9.1Antibiotics71
5.1.10Prognosis72
5.2ComplicationsandTreatmentofComplicationsin Children72
5.2.1Chondrolysis74
5.2.2DislocationwithCapitalFemoralEpiphysis Intact75
5.2.2.1SequelaerelatedtoAVNoftheCFE andgrowthplatedamage76
5.2.2.2TreatmentoptionsforHunkatypes78
5.2.3Ilizarov’sReconstruction83
5.3DDHorCongenitalDislocationoftheHipJoint86
5.3.1Incidence86
5.3.2Pathology87
5.3.3Diagnosis87
5.3.4GrafAngles88
5.3.4.1Measurements88
5.3.5Management89
5.3.5.1Birthto6months89
5.3.5.26–18months90
5.3.5.318–30months90
5.3.5.4 >4yearsold91
5.4TheIrritableHip93
5.4.1SymptomsoftheIrritableHip93
5.4.2Management94
5.4.3KeyPointstoRemember95
5.5CoxaVara95
5.5.1Treatment96
5.5.2EpiphysealCoxaVara96
5.5.3Diagnosis97
5.5.4DifferentialDiagnosis97
5.5.5Prognosis97
5.5.6Treatment98
5.5.6.1Earlycaseswithaminimalslip98
5.5.6.2Caseswithdisplacement98
5.5.6.3Treatmentofthehealedcaseina youngadult99
5.5.6.4Treatmentofoldercaseswith arthritis99
5.6FemoralAnteversion99
5.6.1Diagnosis100
5.6.2Treatment101
5.7SlippedCapitalFemoralEpiphysis101
5.7.1WhatIsIt?101
5.7.2Introduction102
5.7.3WhoAreatMostRisk?102
5.7.4RiskFactors103
5.7.5Aetiology103
5.7.6Pathology105
5.7.7Classification105
5.7.8ClinicalFeatures107
5.7.9PhysicalExamination107
5.7.10Investigations107
5.7.10.1CTscan110
5.7.10.2Ultrasoundscan110
5.7.10.3Bonescan110
5.7.10.4MRIscan110
5.7.11Treatment110
5.7.11.1Osteotomies113
5.7.12Complications114
5.7.12.1Valgusslip115
5.8Legg–Calv ´ e–PerthesDisease115
5.8.1Epidemiology116
5.8.2RiskFactors117
5.8.3Aetiology117
5.8.4Pathogenesis119
5.8.5Classification119
5.8.5.1Catterallclassification119
5.8.5.2Salter–Thompsonclassification120
5.8.5.3Herringlateralpillarclassification120
5.8.5.4Waldenstrom’sradiographicstages121
5.8.5.5Stulbergclassification121
5.8.6ClinicalFeatureswithPhysicalExamination122
5.8.7DifferentialDiagnosis122
5.8.8Investigations123
5.8.9Treatment124
5.8.9.1Nonoperativemanagement124
5.8.9.2Indicationsfornonoperative management124
5.8.9.3Operativemanagement124
5.8.9.4Typesofresidualdeformity127
5.8.10LateComplicationsoftheDisease128
5.8.11NaturalCourseoftheDisease128
5.8.12Prognosis128
6InjuriesaroundtheHipJoint,IncludingPeriprosthetic Fractures139
K.MohanIyer,VijayaKumarKempanna,SharadGoyal, ShibuKrishnan,andGurdeepSinghBiring
6.1FracturesoftheNeckoftheFemurinChildren139
6.1.1ClassificationofFemoralNeckFractures140
6.1.2Treatment142
6.2FracturesoftheNeckoftheFemurinAdults145
6.2.1Introduction145
6.2.2RiskFactors145
6.2.3BonyTrabeculaeoftheProximalFemur(Singh Index)146
6.2.4MechanismofInjury147
6.2.5Epidemiology148
6.2.6FractureClassification148
6.2.6.1Intracapsularfractures148
6.2.6.2Extracapsularfractures150
6.2.7ClinicalPresentation155
6.2.8Diagnosis155
6.2.9ManagementofFemoralNeckFractures156
6.2.9.1AssessmentandManagementinthe EmergencyDepartment156
6.2.10DefinitiveTreatmentofIntracapsularFemoral NeckFracture156
6.2.10.1Nondisplacedintracapsularfemoral neckfracture156
6.2.10.2Displacedintracapsularfemoralneck fractureintheelderly158
6.2.10.3Displacedintracapsularfemoralneck fractureinyoungadults161
6.2.11TreatmentofIntertrochantericHipFractures162
6.2.11.1Extramedullarydevices163
6.2.11.2Intramedullarydevice164
6.2.11.3Arthroplasty165
6.2.12TreatmentofSubtrochantericHipFractures166
6.2.12.1Cephalomedullarynail166
6.2.12.2Fixed-anglebladeplate167
6.2.12.3Atypicalsubtrochantericfractures167
6.2.13ComplicationsofFemoralNeckfractures167
6.2.14StressFracturesoftheFemoralNeck168
6.2.14.1Diagnosis168
6.2.14.2Treatment168
6.2.15SecondaryPreventionofFragilityFractures169
6.3DislocationsandFracturesoftheHipJoint169
6.4PeriprostheticFracturesoftheHipJoint171
6.4.1Introduction171
6.4.2Epidemiology172
6.4.2.1Riskfactors172
6.4.3ClassificationofPeriprostheticFractures173
6.4.3.1Fracturesbasedonanatomicalsite173
6.4.3.2Fracturesbasedontiming174
6.4.4Investigations177 6.4.5Treatment177
6.4.5.1Nonoperativetreatment177
6.4.5.2Surgicalmanagementof periprostheticacetabularfractures177
6.4.5.3Surgicalconsiderationsinthe managementofperiprostheticfemoral fractures178
7TheAdultHipandItsDisorders193 K.MohanIyer
7.1OsteoarthritisoftheHipJoint193
7.1.1Pathology194
7.1.2Symptoms194
7.1.3Treatment195
7.1.3.1Localtreatment195
7.1.3.2Operativetreatment196
7.1.3.3Surgicalprocedures196
7.1.3.4Prostheses198
7.2RheumatoidArthritisoftheHipJoint201
7.2.1JuvenileRheumatoidArthritis202
7.3TuberculosisoftheHipJoint203
7.3.1Pathology203
7.3.2Symptoms204
7.3.3Signs204
7.3.4RadiologicalExamination205
7.3.5Diagnosis205
7.3.5.1Differentialdiagnoses206
7.3.6Prognosis207
7.3.7Treatment207
7.3.7.1Generaltreatment207
7.3.7.2Localtreatment207
7.3.7.3Stageofconvalescence209
7.3.7.4Operativetreatment209
7.3.7.5Arthrodesis210
7.3.7.6Secondaryoperations211
7.4MetabolicandNutritionalDisorders211
7.5Haemophilia213
7.5.1Treatment216
7.5.2ClinicalManifestationsofBleeding217
7.5.2.1Acutehaemarthrosis217
7.5.2.2Chronichaemarthrosis217
7.5.2.3Treatment217
7.5.3FracturesinHaemophilia217
7.5.4SurgeryinHaemophiliacs218
7.6Paget’sDiseaseoftheHipJoint218
7.6.1Treatment219
7.7MeralgiaParethetica219
7.8BursitisintheHipRegion219
7.8.1TrochantericBursitis(SubglutealBursa)219
7.8.1.1Treatment220
7.8.2PsoasBursitis220
7.8.2.1Treatment221
7.8.3SnappingHip221
7.9AvascularNecrosisoftheHipJoint222
7.9.1Staging223
7.9.2ClinicalFeatures223
7.9.3Investigations224
7.9.4Treatment224
8TotalHipArthroplasty227
SharadGoyal,EdwardA.O.Lindisfarne,DavidBall,and ArdeshirBonshahi
8.1PrimaryTotalHipArthroplasty228
8.1.1History228
8.1.1.1Chronology228
8.1.2Indications230
8.1.3SymptomsofHipPathology231
8.1.4SignsofHipPathology233
8.1.5RadiographicFeaturesofDegenerativeHip JointDisease233
8.1.6Investigations234
8.1.7Treatment234
8.1.7.1Initialmanagement234
8.1.7.2Medicalmanagement235
8.1.7.3Surgicalmanagement235
8.1.8ComponentsofHipReplacement235
8.1.9TypesofHipReplacements236
8.1.9.1Cementedjointreplacement236
8.1.9.2Cementlessoruncementedjoint replacement237
8.1.9.3Hybridreplacement237
8.1.10TypesofMaterialsUsedinJointReplacement Surgery237
8.1.11SurgicalApproaches241
8.1.11.1Transgluteal(Hardinge)approach241
8.1.11.2Posteriorapproach242
8.1.11.3Charnleyapproach242
8.1.11.4Minimallyinvasivetechnique243
8.1.11.5Anteriorsupineintermuscular approach243
8.1.12Complications244
8.2RevisionHipArthroplasty247
8.2.1IntroductionandtheBurdenofRevisionHip Surgery247
8.2.2IndicationsforRevisionSurgery249
8.2.3MechanismsofFailure249
8.2.3.1Asepticloosening249
8.2.3.2Septicloosening254
8.2.3.3Stemfracture256
8.2.3.4Ceramic-bearingfractures257
8.2.3.5Dislocation258
8.2.3.6Periprostheticfracturesandrevision surgery259
8.2.3.7Failureofresurfacinghiparthroplasty261
8.2.4EvaluationoftheFailedHipReplacement262
8.2.5ClassificationsofBoneLoss263
8.2.6SurgicalApproaches265
8.2.7RemovalofImplants267
8.2.7.1Removalofuncementedacetabular cups268
8.2.7.2Removalofcementedacetabularcups268
8.2.7.3Removalofcementedfemoralstems andcement269
8.2.7.4Removalofuncementedfemoralstems270
8.2.8AcetabularReconstruction:Managementof BoneLoss270
8.2.8.1Impactionbonegrafting270
8.2.8.2Impactionbonegraftingofthe acetabulum270
8.2.8.3Revisionofuncementedacetabular components271
8.2.9FemoralReconstruction273
8.2.9.1Cementedfemoralrevision273
8.2.9.2Uncementedfemoralrevision274
8.2.10Single-StageorTwo-StageRevisionfor Infection275
8.2.11ComplicationsandOutcomesofRevision Surgery278
8.2.12RevisionHipArthroplasty:CaseExample280
8.2.12.1Revisionprocedure281
9GirdlestoneArthroplasty311
K.MohanIyer
9.1Technique312
9.1.1PositionofthePatient312
9.1.2Exposure312
9.2PostoperativeManagement313
10OsteotomiesaroundtheHipJoint315
K.MohanIyer
10.1BiomechanicsoftheHipJoint315
10.2ClassificationofOsteotomiesaroundtheHipJoint316
10.2.1ClassificationBasedonIndications316
10.2.2ClassificationBasedonLocation316
10.2.3ClassificationBasedonReliefofPain317
10.2.4ClassificationBasedonNeurologic Conditions317
10.3Salter’sOsteotomy317
10.4Pemberton’sOsteotomy318
10.5TripleInnominateOsteotomy(Steel)319
10.6GanzOsteotomy:PeriacetabularOsteotomy319
10.7ShelfProcedure(Staheli)320
10.8ChiariOsteotomy320
10.9SchanzOsteotomy(LowS/TOsteotomy)321
10.10LorenzBifurcationOsteotomy321
10.11OsteotomyforCoxaVara322
10.11.1OsteotomiesforPainReliefin Osteoarthritis322
10.12FemoralVarusOsteotomy323
10.13FemoralValgusOsteotomy323
10.14BlountOsteotomy324
10.14.1BlountAbductionOsteotomy325
10.14.2BlountAdductionOsteotomy325
10.15OsteotomytoCorrectUnstableIntertrochanteric Fractures325
10.16CorrectiveOsteotomies326
10.16.1ObliqueOsteotomy326
10.17McMurray’sOsteotomy327
10.18Dickson’sHighGeometricOsteotomy327
10.19GirdlestoneOsteotomy327
10.20TranstrochantericAnteriorRotationalOsteotomy ofSugioka328
10.21OsteotomyinPerthesDisease328 11HipResurfacing331 MichaelC.Moss,SharadGoyal,andGyanendraKumarSingh 11.1Introduction331
11.2Indications333
11.3Contraindications333
11.3.1Absolute333
11.3.2Relative333
11.4ThePatient’sPerspectives334
11.5TheoreticalAdvantagesofHipResurfacing334
11.6CurrentConcerns335
11.7AnswerstothePatient’sPerspectives338
11.8OperativeTechniqueofMoMImplantsand Considerations339
11.9AssessingaPatientofMoMHipResurfacinginthe Clinic340
11.9.1Investigations340 11.10Conclusion342
12MinimallyInvasiveTotalHipReplacement345
DayanandManjunathandDeepakShivanna
12.1Introduction345
12.2PotentialAdvantagesforthePatient349
12.3PotentialAdvantagestoHealthCareProviders350
12.4PatientSelectionandIndications350
12.5InstrumentsforMinimallyInvasiveSurgery351
12.5.1DirectAnteriorApproach351
12.5.2AnterolateralApproach354
12.5.3PosteriorApproach354
13ComputerNavigationinHipArthroplasty361 WasimKhan
13.1Introduction362
13.2LimitationsofConventionalAlignmentJigs363
13.3TypesofComputerNavigationSystems364
13.4ComputerNavigationinTotalHipArthroplasty365
13.5ComputerNavigationinTotalHipResurfacing367
13.6LimitationsofComputerNavigationSystems368
13.7Conclusion369
14NeoplasticConditionsaroundtheHip373
RamVaidhyanathandRajeshBotchu
14.1Introduction373
14.2OsteogenicTumours374
14.2.1BoneIslands374
14.2.2OsteoidOsteomaandOsteoblastoma375
14.2.3ConventionalOsteosarcoma377
14.2.4SurfaceOsteosarcoma377
14.2.5PeriostealOsteosarcoma378
14.2.6TelangiectaticOsteosarcoma379
14.2.7Low-GradeOsteosarcoma379
14.2.8SecondaryOsteosarcoma380
14.2.9Small-CellOsteosarcoma380
14.3Ewing’sSarcoma381
14.4CartilageTumours381
14.4.1Osteochondroma381
14.4.2Chondroblastoma383
14.4.3Chondrosarcoma383
14.5Giant-CellTumour385
14.6FibrogenicandFibrocysticTumours386
14.6.1FibrousCorticalDefect386
14.6.2DesmoblasticFibroma/Benign Fibrohistiocytoma387
14.6.3MalignantFibrohistiocytoma387
14.6.4AneurysmalBoneCyst388
14.6.5UnicameralBoneCyst388
14.6.6FibrousDysplasia389
14.6.7Angiosarcoma390
14.6.8Haemangioma391 14.7Myeloma392 14.8Lymphoma393
14.9Metastasis394 14.10BrownTumour395
14.11Osteomyelitis395 14.12Fractures397
14.13StressFractures397
14.14MyositisOssificans398 14.14.1ALVAL399
14.15Paget’sDisease400
14.16Soft-TissueSarcoma401
14.17Chordoma402
15ArthroscopyoftheHip411
GurdeepSinghBiring
15.1Anatomy412
15.1.1Anatomy:LayeredApproachtotheHip414
15.2ImportantAspectsoftheHistory415
15.2.1RelevantPointsintheHistory415
15.3ClinicalExamination417
15.4ImagingoftheHip422
15.5Indications/ContraindicationsforHipArthroscopy byLayer426
15.5.1Overview426
15.5.2Layer1426
15.5.2.1ArthroscopicFAIindications427
15.5.2.2Arthroscopicrelativeand absolutecontraindications429
15.5.3Layer2429
15.5.3.1Labraltears429
15.5.3.2Capsularinjuries432
15.5.3.3Ligamentumterestears433 15.5.4Layer3434
15.5.4.1Anteriorenthesopathy434
15.5.4.2Posteriorenthesopathy435
15.5.4.3Lateralenthesopathy436
15.5.4.4Medialenthesopthy436
15.5.5Layer4437
15.5.5.1Piriformissyndrome437
15.5.5.2Sciaticnerveentrapment438
15.6HipArthroscopy:TheTechnicalAspectsofthe Procedure439
15.6.1PatientPositioning440
15.6.1.1Supine440
15.6.1.2Lateral441
15.6.2Equipment441
15.6.3Portals443
15.6.3.1Centralcompartment443
15.6.3.2Peripheralcompartment444
15.6.3.3Peritrochantericcompartment445
15.6.4OperativeTechnique445
15.6.4.1Anaesthesia445
15.6.4.2Equipment445
15.6.4.3Preppinganddraping447
15.6.4.4Portalplacement448
15.6.5SystematicArthroscopicAssessmentofthe CentralandPeripheralCompartments448
15.6.5.1Centralcompartment448
15.6.5.2Peripheralcompartment449 15.7CommonInterventions449
15.7.1SurgicalTechniqueforLabralTearsandFAI Surgery449
15.7.1.1Microfracture451
15.7.1.2Loosebodies453
15.7.2SurgicalTechniqueforPeritrochanteric SpacePathology453
15.7.2.1Gluteusmediusrepair453
15.7.2.2ITBrelease453
15.7.2.3Postoperativeregime453
15.8SpecificProtocols454 15.9Complications456
15.9.1Categories457
15.10RevisionSurgery459
15.11OutcomesFollowingPrimarySurgery460
15.12Summary460
Index 463
Foreword
byProf.GeorgeBentley,DrS.TerryCanale, andProf.(Dr)M.ShantharamShetty
Prof.GeorgeBentley,MBChM,DSc,FRCS(Eng.),FRCSEd,FMedSci ProfessorEmeritusandDirector,InstituteofOrthopaedicsand Musculo-SkeletalScience,UniversityCollege,London HonoraryConsultantOrthopaedicSurgeon,RoyalNationalOrthopaedic Hospital,Stanmore,UK
Thisthoughtfultextonthehipjointistheresultoftheauthor’s experienceofover35yearssincehisassociationwiththeUniversity ofLiverpoolandtheRoyalInfirmaryandChildren’sHospitalin LiverpoolasregistrarandMChOrth.graduate.DrK.MohanIyerwas anoutstandingstudentwho,underthetutelageoflateMrGeoffrey V.OsborneandourconsultantcolleaguesintheLiverpoolregion, achieveddistinctionclinicallyandacademically.Thisbook,entitled TheHipJoint,isadistillationofhisknowledgeandexperience sincethattime,togetherwiththatofhiscolleaguesfromIndia andtheUK.Asaconsequenceitcontainsvaluableinformationand
practicesfromIndiaaswellastheUK,whichareonlyavailableto thosewhohavepractisedinthechallengingenvironmentofIndian orthopaedicsandtraumatology.
Thetexttakesthereaderfromchildhooddisorders,which areseenlesscommonlyintheWestnowadays,rightthrough adolescenceandearlyadulthoodandtheproblems,everincreasing, ofthehipintheolderpopulation.Thetextreflectstheviewsofthe author,butvaluableadditionalchaptershavebeencontributedby colleagueswithspecialinterests.
Thisbookhasthegreatadvantageofaconsistentthemeand aphilosophicalapproachtopracticalmanagementofhipdiseases andinjuries.Itwillbeappreciatedbystudents,post-graduates,and experiencedorthopaedicsurgeonsalike.
S.TerryCanale,MD ProfessorandChair,UniversityofTennessee-CampbellClinicDepartmentofOrthopaedicSurgeryandBiomedicalEngineering,Memphis, Tennessee,USA
Editor, Campbell’sOperativeOrthopaedics,9,10,11,and12editions
IamhonouredtohavebeenaskedbyDrK.MohanIyertoprovidea forewordtothistext.IfirstbecameacquaintedwithDrIyer’swork onthehipjointwhenIwaseditingthe9theditionof Campbell’s
OperativeOrthopaedics (1992).Hisdescriptionsofhisinnovative posteriorapproachtothehipandtrochantericosteotomyare classicsintheorthopaedicliterature.Inadditiontohisextensive researchandpublicationonapproachestothehipandtotalhip arthroplasty,DrIyerhasproducedanimpressivelistofpublications oninjuriesanddisordersofthehand,wrist,andshoulder.
Thiscurrenttextonthehipjointisaculminationofover30 yearsofresearchbyDrIyer,andIamsureitwillbecomeavaluable assettoorthopaedicsurgeonsworldwide.Hehasassembledastellar groupofcontributingauthorsandhas,ofcourse,addedhisownvast experiencetotheauthoringandeditingprocess.Weareproudto haveDrIyerincludedasoneoftheesteemedsurgeonswhosework hasaddedsomuchto Campbell’sOperativeOrthopaedics overthe years,andwelookforwardtoaddingthistextbooktoourcollection ofessentialeducationaltoolsforourresidentsandfellows.
Prof.(Dr)M.ShantharamShetty
Pro-Chancellor,NitteUniversity Chairman,TejasviniHospitalSSIOT,andWorldBunts’Foundation
AdjunctProfessor,TheTNDr.MGRMedicalUniversity
Iconsideritmyprivilegetopenthisforewordtothemonumental work TheHipJoint bymyillustriouscolleagueDrK.MohanIyer.
Ihavehadthepleasureofknowingandinteractingwithhimfor overthelast40years.DrIyerisanoutstandingsurgeonand clinicianwithaninnovativebentofmind.Hehasauthoredseven books,andthisbook, TheHipJoint isa“jewelinhiscrown”.This bookhasundergoneremarkabletailoring,takingintoconsideration theevolutionofchangesthathavetakenplaceinunderstanding hipproblems.DrIyerhasalsotakengreatpainstoevaluatethe problems,theneedsofAsianpatientsinparticular,andhowto approachdifficultsituations,consideringthefunctionalelements ofthepatient.DrIyerhasputtogethertherichexperienceof contributorstothisbooktomakeitareferenceguideforresidents andsurgeonsintheireverydaypractisethroughouttheworld. Hisdreamandhardworkhavefullybornefruitinthisclassic presentation.IpraytoGodtogivehimthecontinuedstrengthand visiontocontinuehisgoodwork.
Preface
IhavemainlywrittenthisprefaceinmemoryoflateMrGeoffreyV. Osborne,whowaslikeafatherfiguretome.Afterhisretirement fromtheUniversityofLiverpool,hewasbusywritingathesisfor hisPhDinprintingfromtheUniversityofLiverpool,UK,whichhe managedtogetintheend.Duringhislateryearsjustbeforehis retirement,hewasextremelykeentopropagatehisapproachand nicknameditthe“LiverpoolApproach”,alongwithProfessorRobert Owen.
Thefirstforewordtothis, TheHipJoint,listingtherecenttrends inorthopaedicsprevailingallaroundtheworld,hasbeenkindly givenbymyesteemedprofessorGeorgeBentleyChM,FRCS.Prof. BentleyknewmeandlateMrOsborneverywell,andhencethisis afittingtributetohim.
ThesecondforewordhasbeengivenbyDrSTerryCanale,MD, editorof Campbell’sOperativeOrthopaedics,abookthatiscalled theBibleoforthopaedics.Myoriginalresearchonthehipjointfirst cameoutinits9theditionin1992.
ThethirdforewordhasbeengivenbyProf.DrM.Shantharam Shetty,aseniororthopaedicsurgeon.
LateMrOsborneinspiredmewithhisapproachandknowledge oforthopaedics,whichisunforgettable,andIwouldnothave followedinhisfootstepshaditnotbeenforhim.Hewasapatron oftheIndianOrthopaedicAssociation,andhepatientlylistened whenIpresentedmyoriginalresearchonthehipjointdonein Liverpool,withmyteacher,lateDrRasikM.Bhansali,whowasthe chairmanattheConferenceoftheAssociationofSurgeonsofIndia inDecember1982.Despitemyoriginalresearchworkonthehip joint,heinspiredmetodoafollow-upofhiscasesofexcisionofthe
trapeziumandarthrographyofthepseudojointtobepresentedas athesistotheUniversityofLiverpool,UK,fortheMChOrth.degree, alongwithProf.GrahamWhitehouse,thenewlyappointedprofessor ofradiodiagnosisattheUniversityofLiverpool,UK.
Acknowledgements
IamextremelygratefultoProf.GeorgeBentleyforhisappreciation ofmybook TheHip Jointbeingdedicatedtomyrespectfulteacher lateMrGeoffreyV.Osborne,SeniorConsultantOrthopaedicSurgeon, UniversityofLiverpool,UK,andforgivingmethefirstforewordto thisbook,despiteleadingabusy,tumultuouslifeinorthopaedicstill today.IamalsogratefultoDrSTerryCanaleof Campbell’sOperative Orthopaedics forhavinggivenmethesecondforewordtothisbook andtoProf.DrShantharamShetty,aseniororthopaedicsurgeonin Karnataka,India,forhisencouragingthirdforewordtothisbook.
MysincerethanksgotoPrim.Univ.-Prof.DrGeraldPfluger, ProfessorofOrthopaedicSurgery,UniversityofVienna,Emeritus MedicalDirectorandChiefofOrthopaedicDepartment,EKH,Vienna, andHeadoftheMedicalEducationAcademy,forbeingkindenough togothroughthechapter“MinimallyInvasiveSurgeryofthe HipJoint”forthebenefitofthetargetaudienceandtodeemit idealforpublicationinmybook.Iwouldalsoliketoexpress mythankstoProf.FaresS.Haddad,UCLA,London,UK,forhis encouragingguidanceandMrDineshNathwani,Consultantand Hon.SeniorLecturer,TraumaandOrthopaedicSurgery,Imperial CollegeHealthcare,forallhistimelyhelp,withoutwhichitwould havebeenextremelydifficulttocompletethisbook.
FinallyIwouldliketothankalltheorthopaedicsurgeonsfor theirvaluablecontributionsintheirsub-specialities.Iamextremely gratefultoMagdiE.Greiss,MD,MChOrth.,FRCS,SeniorConsultant OrthopaedicSurgeon,NorthCumbriaUniversityHospitals,UK,and FormerPresident,BOFAS,UK,forhisinvaluablesnaps,whichhe hadpreservedinhislifeduringhistrainingandearlyyearsafter becomingaconsultantinorthopaedics.IalsothankDrsK.Vinodh,
Another random document with no related content on Scribd:
What is it that gives these landscapes their enduring charm, and why do we rank them so high? Many a later etcher has had equal skill with needle and acid; some have had even greater. Whistler is more delicate, perhaps, more exquisite, more unexpected in his gift of spacing. Yet neither Whistler nor any other master of etching has the secret power of Rembrandt. I say “secret,” because we cannot argue about it or explain it. It lay in what Rembrandt was: in the depth and greatness of his humanity. When we have wondered at the sensitive instrument of his eyesight, when we have exalted his magical draughtsmanship, when we have admired his instinctive fidelity to the capacity and limitations of the medium used, when we have recognized the profound integrity of his art, there is still something left over, beyond analysis, and that the rarest thing of all.
How it is we cannot say, but there has passed into these little works an intangible presence, of which we cannot choose but be conscious, though it was not consciously expressed,—the spirit of one of the fullest, deepest natures that ever breathed. Whatever Rembrandt does, however slight, something of that spirit escapes him, some tinge of his experience,—of those thoughts, “too deep for tears,” which things meaner than the meanest flowers could stir in him.
GIOVANNI BATTISTA PIRANESI
(1720-1778)
P I
B BENJAMIN BURGES MOORE
THE life of Piranesi was eminently that of a man of genius, characterized by all the peculiarities ascribable to genius, perhaps as failures of human nature, but also distinguished by that which imparts to its possessor an imperishable renown. Those peculiarities are worthy of notice, as they bear so much on the character of his work; but his works, wonderful as they are in point of execution, are less to be admired for this than for the interest of the subjects he chose, and that which he imparted to them. In an age of frivolities, he boldly and single-handed dared to strike out for himself a new road to fame; and in dedicating his talents to the recording and illustrating from ancient writers the mouldering records of former times, he met with a success as great as it was deserved, combining, as he did, all that was beautiful in art with all that was interesting in the remains of antiquity.”
These words were prefixed to an account of Piranesi’s career published in London during the year 1831 in “The Library of the Fine Arts,” and based upon a sketch of his life written by his son, Francesco, but never published, although the manuscript at that period had passed into the hands of the publishers, Priestly and Weale, only to be subsequently lost or destroyed.
P G B P
From the engraving by F. Polanzani, dated 1750
It is impossible to study this little known portrait without being convinced of its accurate likeness It certainly conveys an impression of the man’s dæmonic force, which is not given by the more frequently reproduced statue executed by Angelini.
Size of the original etching, 15¼ × 11¼ inches
P . A S
S
A rendering almost as faithful as an architect’s drawing, which Piranesi’s unfailing genius has transformed into an enchanting work of art This arch stands in the Roman Forum It was dedicated 203 in commemoration of victories over the Parthians
Size of the original etching, 18⅜ × 27¾ inches
Eighty years, therefore, have passed since this evaluation of the great Italian etcher was written, yet to-day he is no more appreciated at his full worth than he was then. At all times it has been not uncommon for an artist to attain a kind of wide and enduring renown, although estimated at his true value and for his real excellences by only a few; but of such a fate it would be difficult to select a more striking or illustrious example than Giovanni Battista Piranesi. Living and dying in the Eternal City, Rome, to whose august monuments his fame is inseparably linked, he was the author of the prodigious number of over thirteen hundred large plates, combining the arts of etching and engraving, which, aside from their intrinsic merit as works of art, are of incalculable value on account of the inexhaustible
supply of classic motives which they offer to all designers, and to which they, more than any other influence, have given currency.
These prints, in early and beautiful proofs, are still to be bought at relatively low figures, while each year sees the sale, by thousands, of impressions from the steeled plates still existing at Rome in the Royal Calcography;—impressions which, although in themselves still sufficiently remarkable to be worth possessing, are yet so debased as to constitute a libel upon the real powers of Piranesi.
The wide diffusion of these ignoble prints, and the fact that Piranesi’s output was so great as to place his work within the reach of the slenderest purse, are largely responsible for the failure of the general public to apprehend his real greatness; for rarity calls attention to merit, to which in fact it often gives a value entirely fictitious, while there is always difficulty in realizing that things seen frequently and in quantities may have qualities far outweighing those of work which has aroused interest by its scarcity. This is why the fame of Piranesi is widely spread, although his best and most characteristic work is almost unknown, and his real genius generally unrecognized.
Born in Venice, October 4th, 1720, and named after Saint John the Baptist, Piranesi was the son of a mason, blind in one eye, and of Laura Lucchesi. His maternal uncle was an architect and engineer,— for in those days the same person frequently combined the two professions,—who had executed various water-works and at least one church. From his uncle the young Giovanni Battista received his earliest instruction in things artistic, for which he appears to have displayed a conspicuously precocious aptitude. Before he was seventeen he had attracted sufficient attention to assure him success in his father’s profession, but Rome had already fired his imagination, and aroused that impetuous determination which marked his entire career His yearning after Rome report says to have been first aroused by a young Roman girl whom he loved, but, however that may be, he overcame the determined opposition of his parents, and, in 1738, at the age of eighteen, set out for the papal city to study architecture, engraving, and in general the fine arts; for even in those degenerate days there were left some traces of that multiform talent which distinguished the artists of the Renaissance.
When he reached the goal of his longing, the impression produced by the immortal city on so fervid an imagination must have been so deep, so overwhelming, as to annihilate all material considerations, although they could not have been other than harassing, since the allowance received from his father was only six Spanish piastres a month, or some six or seven lire of the Italian money of to-day. By what expedients he managed to live we cannot even conjecture, but it may be supposed that he was boarded, apprentice-wise, by the masters under whom he studied. These teachers were Scalfarotto and Valeriani, a noted master of perspective and a pupil of one Ricci of Belluno, who had acquired from the great French painter and lover of Rome, Claude Lorrain, the habit of painting highly imaginative pictures composed of elements drawn from the ruins of the Roman Campagna. This style was transmitted to Piranesi by Valeriani, without doubt stimulating that passionate appreciation of the melancholy grandeur of ruined Rome already growing in his mind, and afterward to fill his entire life and work.
P . A V
In this, as in many of Piranesi’s compositions, the figures are frankly posing, but their presence adds such charm to the scene that none could wish them absent. Size of the original etching, 19 × 27⅜ inches
P . A T B , K N
A fine rendering of that air of glory which the most dilapidated fragments of a Roman Arch of Triumph never lose The Arch of Trajan, one of the finest of ancient arches, was dedicated 114 It is of white marble, 48 feet high and 30½ wide, with a single arch measuring 27 by 16½ feet The arch is profusely sculptured with reliefs illustrating Trajan’s life and his Dacian triumphs.
Size of the original etching, 18⅜ × 27½ inches
At the same time, he acquired a thorough knowledge of etching and engraving under the Sicilian, Giuseppe Vasi, whose etchings first aroused the great Goethe’s longing for Italy. At the age of twenty, thinking, probably not without foundation, that this master was concealing from him the secret of the correct use of acid in etching, Piranesi is reported, in his anger, to have made an attempt to murder Vasi. Such an act would not be out of keeping with the character of the fiery Venetian, for, before leaving Venice, he had already been described by a fellow-pupil as “stravagante,” extravagant, or fantastic, a term not restricted by Italians to a man’s handling of money, but applied rather to character as a whole, in which
connection it usually denotes the less fortunate side of that complete and magnificent surrender to an overwhelming passion which aroused so lively an admiration of the Italian nature in the great French writer, Stendhal. When we, tame moderns, judge the “extravagance” of such characters, it is only fair to recollect that, with all their faults and crimes, these same unbridled Italians were capable of heroic virtues, unknown to our pale and timid age. Men like Cellini and Piranesi, who had much in common, are simply incarnate emotional force, a fact which is, at the same time, the cause of their follies and the indispensable condition of their genius.
After this quarrel Piranesi returned to Venice, where he attempted to gain a livelihood by the practice of architecture. There is reason to believe that at this period he studied under Tiepolo; at any rate there exist in his published works a few curious, rather rococo plates entirely different from his usual manner, and very markedly influenced by the style of Tiepolo’s etching. He also studied painting with the Polanzani who is responsible for that portrait of him which forms the frontispiece to the first edition of “Le Antichità Romane,” and gives so vivid an impression of the dæmonic nature of the man. Meeting with little success in Venice, he went to Naples, after returning to Rome, attracted principally by archæological interests. He stayed at Herculaneum, Pompeii, and Pæstum, where at this time, undoubtedly, he made the drawings of the temples afterward etched and published by his son. The drawings for these etchings of Pæstum, among the best known of the Piranesi plates, are now in the Soane Museum in London.
P T B , P
Size of the original etching, 17¾ × 26⅝ inches
P T T N P
Size of the original etching, 19½ × 26⅜ inches
Having decided that he had no vocation for painting, which he definitely abandoned at this time, Piranesi returned to Rome, and settled there permanently. His father now wished him to return to Venice, but he was altogether unwilling to do so, and replied, characteristically, that Rome being the seat of all his affections it would be impossible for him to live separated from her monuments. He intimated that in preference to leaving, he would give up his allowance, a suggestion upon which his father acted promptly by stopping all remittances, so that, estranged from his relatives, Piranesi was now entirely dependent upon his own resources for a livelihood.
His poverty and suffering at this period were undoubtedly great, but his indomitable nature could be crippled by no material hardships. He devoted himself entirely to etching and engraving, and, when twenty-one, published his first composition. At this time he was living in the Corso opposite the Doria-Pamphili Palace, but even if the
neighborhood was illustrious, it is not pleasant to think what wretched garret must have hidden the misery of his struggling genius. His first important and dated work, the “Antichità Romane de’ Tempi della Republica, etc.,” was published in 1748, with a dedication to the noted antiquary, Monsignore Bottari, chaplain to Pope Benedict XIV. This work was received with great favor, as the first successful attempt to engrave architecture with taste, and from the day of its appearance Piranesi may be said to have been famous. However, he still experienced the utmost difficulty in finding the money necessary to subsist and to procure the materials requisite to his work. Yet, despite his terrible poverty, his labor was unceasing and tireless to a degree that we can now scarcely conceive. It must be borne in mind that, in addition to etching and engraving, he was engaged in the extensive study of archæology, which led him to undertake many remarkable researches. He became a noted archæologist of great erudition, as is shown by numerous controversies with famous antiquarians of the day. Some idea of the copiousness of his knowledge can be gained from the fact that his argument covers a hundred folio pages in that controversy in which he upheld the originality of Roman art against those who claimed it to be a mere offshoot of Grecian genius. In the preface to one of his books, he refers to it as the result of “what I have been able to gather from the course of many years of indefatigable and most exact observations, excavations, and researches, things which have never been undertaken in the past.” This statement is quite true, and when we realize that the preparation of a single plate, such as the plan of the Campus Martius, would, in itself, have taken most men many years of work, we can only feel uncomprehending amazement at the capacity for work possessed by this man of genius.
P . T T C
From this plate it is possible to gain an idea of the greater beauty possessed by ruined Rome when still shrouded in vegetation The Arch of Septimius Severus is seen in the middle distance
Size of the original etching, 18⅛ × 27⅛ inches
P . S A R F
A very interesting historical document which makes it possible to realize an aspect of the Forum at present difficult to conceive
Size of the original, 14⅞ × 23¼ inches
The very spirit of imperial Rome would seem to have filled Piranesi, making him its own, so that the vanished splendor was to him ever present and added to the strange melancholy of the vine-grown ruins which alone remained from the “grandeur that was Rome.” In every age and in every province most Italians have been animated by a lively sense of their direct descent from classic Rome,—a feeling that its fame was peculiarly their inheritance in a way true of no other people, so that this glorious descent was their greatest pride and claim to leadership. In the darkest days of oppression and servitude, when Italy sat neglected and disconsolate among her chains, there were never lacking nobler souls who kept alive a sense of what was fitting in the descendants of classic Rome, and took therein a melancholy pride. But no Italian was ever more completely an ancient Roman than Piranesi, who certainly, in despite of his Venetian birth, considered himself a “Roman citizen.” This sentiment
played an important part in, perhaps, the most characteristic act of his whole life, namely, his fantastic marriage, of which he himself left an account not unworthy of Cellini.
He was drawing in the Forum one Sunday, when his attention was attracted by a boy and girl, who proved to be the children of the gardener to Prince Corsini. The girl’s type of features instantly convinced Piranesi that she was a direct descendant of the ancient Romans, and so aroused his emotions that on the spot he asked if it were possible for her to marry him. Her exact reply is not recorded, although it must have conveyed the fact that she was free, but it can surprise no one to hear that the girl was thoroughly frightened by such sudden and overpowering determination. His hasty resolution was confirmed when Piranesi afterward learned that she had a dower of one hundred and fifty piastres, or some three hundred lire of to-day, a fact certain to arouse a keen realization both of his poverty and of the value of money in those days. Without any delay, he proceeded to ask the girl’s hand in marriage of her parents, who, like the girl, appear to have been so terrified and overwhelmed by the cyclonic nature of the man as to be incapable of the slightest resistance. Whatever may have been the motives of all the parties concerned, the fact is that Piranesi was married to the descendant of the ancient Romans exactly five days after he first laid eyes on her classic features! Immediately after the wedding, having placed side by side his wife’s dowry and his own finished plates, together with his unfinished designs, he informed his presumably astonished bride that their entire fortune was now before them, but that in three years’ time her portion should be doubled; which proved to be no boast but a promise that he actually fulfilled.
According to report, he told his friends that he was marrying in order to obtain the money required for the completion of his great book on Roman Antiquities. However, even if he did marry for money, he maintained all his life, to the poor woman’s great discomfort, as jealous a watch over his wife as could be expected of the most amorous of husbands; so his affections as well as his vanity may, perhaps, have been called into play by his marriage. At any rate, his ideas as to family life were worthy of the most severe Roman
paterfamilias His son, Francesco, born in 1756, relates that, when absorbed in his studies, he would quite forget the hours for meals, while his five children, neither daring to interrupt him nor eat without him, experienced all the miseries of hunger. His domestic coercion and discipline were doubtless extreme, but the family would seem to have lived not too unhappily.
P V “C V ”
The Site of the Ancient Roman Forum showing the Arch of Septimius Severus, Columns of the Temple of Jupiter Tonans and of the Temple of Concord and, in the distance, the Arch of Titus, the Colosseum, etc , etc
Size of the original etching, 16⅛ × 21½ inches
P . T A T
In this plate can be seen a favorite device of Piranesi’s, which is to enhance the size and stability of massive architecture by placing on some part of the ruin a human figure in active motion The Arch of Titus was built in commemoration of the taking of Jerusalem The vault is richly coffered and sculptured, and the interior faces of the piers display reliefs of Titus in triumph, with the plunder of the temple at Jerusalem.
Size of the original etching, 18⅝ × 27¾ inches
Every two years, if not oftener, a monumental book would make its appearance, to say nothing of separate plates, and Piranesi was now a famous man. With the exception of Winckelmann, he did more than any one to spread a knowledge and love of classic art, while his learning and his researches aroused a widespread appreciation of the nobility of Roman ruins, thereby largely contributing to their excavation and protection. His exhaustive acquaintance with antiquity and his impassioned admiration for its beauty, combined with his singular and interesting character, caused him to mingle with all that was most remarkable in the world of arts and letters in Rome,
at the same time bringing him into relation with whatever foreigners of distinction might visit the city. He was, however, then and always a poor man, for his first important work, “Le Antichità Romane,” sold in the complete set for the ridiculous pittance of sixteen paoli, or about seventeen lire, while later the Pope was wont to pay him only a thousand lire for eighteen gigantic volumes of etchings. The very fact that his fertility was so enormous, lowered the price it was possible to ask for his plates during his lifetime, just as since his death it has militated against a correct valuation of his talent. Forty years after he came to Rome, he wrote to a correspondent that he had made, on an average, some seven thousand lire of modern money a year, out of which he had had to support his family, pay for the materials required in his business, and gather together that collection of antiquities which was a part of his stock in trade.
The rapidity with which Piranesi worked, and the number of plates, all of unusually large dimensions, which he executed, are so extraordinary as to leave one bewildered by the thought of such incomprehensible industry. Competent authorities vary in their statements as to the number of plates produced by Piranesi, but accepting as correct the lowest figure, which is thirteen hundred, it will be found that for thirty-nine years he produced, on a rough average, one plate every two weeks. Ordinarily, great productiveness will be found to have damaged the quality of the work accomplished, but this is not true in the case of Piranesi. Although his work is of varying merit, like that of all true artists, and even comprises examples lacking his usual excellence, there is no plate which betrays any signs of hurry or careless workmanship, while in many the meticulous finish is remarkable. Such an output is in itself phenomenal, yet in preparation for these works he found the time to pursue archæological researches and studies, in themselves sufficiently exhaustive to have occupied the life of an ordinary man. Moreover, in his capacity of architect, he executed various important restorations, including those of the Priorato di Malta, where he is buried, and of Santa Maria del Popolo. Most of his restorations were undertaken by command of the Venetian, Pope Clement XIII, who bestowed on him the title of Knight, or Cavaliere, a distinction of which he was proud, as he was of his membership in the “Royal
Society of Antiquaries” in London, of which he was made an honorary fellow in 1757.
P . T A T
Showing the relief of the Triumph of Titus and the carrying away of the Seven-branched Candle-stick from Jerusalem. A particularly beautiful and not very well-known plate, which clearly shows Piranesi’s fine sense of composition, and his keen appreciation of that singularly picturesque contrast between the ancient ruins and the more modern buildings in which they were then embedded.
Size of the original etching, 15⅞ × 24¼ inches
Piranesi, almost without exception, placed a written description of the scene on every one of his plates, using it as a decorative feature. In this case it proves an integral part of a group which makes an interesting etching out of what otherwise would have been a simple architectural drawing.
Size of the original etching, 18⅞ × 27½ inches
The question of how much assistance Piranesi received in the execution of his plates is an interesting one. In a few prints, the figures were etched by one Jean Barbault, whose name sometimes appears on the margins with that of Piranesi. The latter’s son, Francesco, was taught design and architecture by his father, whose manner he reproduced exactly, although none of the numerous etchings which he left behind him show any signs of those qualities which constitute the greatness of his parent’s work. The daughter, Laura, also etched in the manner of her father and has left some views of Roman monuments. These two children, together with one of his pupils, Piroli, undoubtedly aided him, but their moderate skill is a proof that their assistance could not have been carried very far.
P F
S J L
