AMNIOTIC ARTHROPLASTY FOR TUBERCULOSIS OF THE HIP
`
`A PRELIMINARY CLINICAL STUDY
`
`G. K. VISHWAKARMA. A. K. KHARE
`
`From Safdarjang Hospital, New Delhi
`
`Arthroplasty of the hip using an interposed multi-layered cap of amniotic membrane is reported in 28
`patients with tuberculous arthritis. The disease had been present from one to seven years, and five patients
`had multiple discharging sinuses. Follow-up was from 30 to 46 months.
`Amniotic tissue caused no inflammatory reaction, or obvious rejection, and 25 patients were free of
`symptoms, with a good range of movement and a stable joint. The three failures were caused by dislocation,
`fracture of the femoral neck and extra-articular bone formation respectively. Amniotic arthroplasty seems to
`be capable of providing a painless, mobile and stable joint in patients with tuberculosis of the hip.
`cal application of fetal membranes presents interesting
`The hip joint is important. not only for walking, but also
`for the squatting, kneeling or bowing required by custom
`possibilities and there have been more than 20 articles on
`and tradition in Indian society. Tuberculosis of the hip
`the subject since 1970. though reports on their use in
`has crippled many patients in Asia and elsewhere. New
`joints are rare. Davis ( 191 0) first reported the use of fetal
`antituberculous drugs have made direct surgery possible
`membrane for skin covering, while Stern (1913) and
`and this has varied from debridement or excision of the
`Sabella ( 1913) used amniotic membrane for burns and
`ulcerated skin. They both reported no infection, relief
`joint to arthrodesis.
`In the West, tuberculosis has declined in the past
`from pain and an increased rate of epithelialisation.
`few decades. and arthrodesis has provided one satisfac(cid:173)
`Brindeau (1934) and Burger (1938) used amnion in
`tory solution for the infected hip. Few attempts have
`forming an artificial vagina. De Rotth ( 1940) reported its
`been made to provide painfree movement and stability of
`successful use in conjunctival defects and Douglas ( 1952)
`investigated fetal membrane as an allograft for large
`the joint. Wilkinson's (1957) joint debridement pro(cid:173)
`wounds. In 1962. Massee eta/. confirmed that fetal mem(cid:173)
`cedure failed in adults and was only partially successful
`branes produced few, if any, adhesions when used in the
`in children. The Girdlestone excision arthroplasty sacri(cid:173)
`ficed stability for movement but resulted in a grotesque
`abdomen as a replacement for parietal peritoneum.
`Trelford et a/. ( 1975) used amnion as a biological dress(cid:173)
`gait and marked limb shortening.
`ing for full
`thickness wounds while Ninman and
`Katayama. Itami and Marumo (1962) attempted to
`retain movement in tuberculosis of the hip. They com(cid:173)
`Shoemaker ( 1975) recommended amniotic membrane
`for the treatment of burns. Volkov in 1973 reported the
`bined joint debridement with the interposition of fascia
`use of amniotic membrane in congenital dislocation of
`or OMS membrane (woven fabric catgut compressed
`the hip.
`into a thin membrane and chemically strengthened by
`immersion in chromic solution). The results were not
`Vishwakarma, Krishnan and Khare ( 1980) reported
`experiments on the interposition of amniotic membranes
`encouraging. and the procedure was given up. Inter(cid:173)
`position of soft tissues had been widely employed in
`in dog joints, artificially made arthritic by destruction of
`the articular cartilage and complete synovectomy and
`non-infective conditions and included the use of fascia
`capsulectomy. The findings were interesting: the range of
`(Campbell 1924). skin (Kallio 1957) and peritoneum
`movement achieved was comparable to normal, a cleft in
`results were
`(Kuznetsov 1962). Persistently poor
`the plane of movement appeared in the multi-layered
`obtained and the procedures were discarded.
`amniotic cap after two months, and there was progress(cid:173)
`Biological tissue would be ideal for interposition
`ive formation of fibrous tissue in the peripheral layers.
`arthroplasty, provided that it did not elicit any host reac(cid:173)
`Functional metaplasia was apparent from the appear(cid:173)
`tion and was capable of functional adaptation. The clini-
`ance of fibrocartilage which indicated adaptation to
`stress. Another finding was that synovial-like tissue lined
`the walls of the cleft; its origin remained uncertain. There
`were no
`rejection phenomena or
`inflammatory
`responses.
`This animal study encouraged the trial of interposi(cid:173)
`tion arthroplasty of the hip for tuberculosis, using a cap
`
`G. K. Vishwakarma. MS. FICS. Professor and Director
`A. K. Khare. MS. Senior Resident
`Central Institute of Orthopaedics. Safdarjang Hospital. New Delhi.
`India.
`Requests_ for reprints shoul~be sent to Profe~sor G._ K. Vishwakar~a~
`1 · 191!6 Britis:t Editorial Society of Bone and Joint Surgery
`0301 620X 1!61013 $2.00
`
`6H
`
`HIE JOlTRNAL OF BONE AND JOINT SURGERY
`
`

`

`AMNIOTIC ARTHROPLASTY FOR TUBERCULOSIS OF THE HIP
`
`69
`
`of amniotic membrane with the twin objectives of eradi(cid:173)
`cating the disease and providing a painless, stable and
`mobile hip.
`
`MATERIAL AND METHODS
`The study was conducted at the Central Institute of
`Orthopaedics. Safdarjang Hospital. New Delhi. from
`1980 onwards. on 28 patients with tuberculosis of the
`hip, all of whom had an amniotic arthroplasty. The diag(cid:173)
`nosis of tuberculosis was based on clinical and radiologi(cid:173)
`cal
`findings and
`laboratory
`investigations.
`It was
`confirmed by histopathology but not by bacteriology.
`Larson ·s ( 1963) hip disability rating scale was used to
`assess function before and after operation.
`The youngest patient was aged 10 years and the
`oldest 70 years (mean 27 years), with only five over 40
`years of age. The duration of the disease ranged from one
`to seven years. Details are given in Table I. Five patients
`had discharging sinuses with superadded bacterial infec(cid:173)
`tion before operation. The organism was Pseudomonas
`aeruginosa in three cases, Escherichia coli in one and
`Klehsiella sp in the fifth. One patient had a healed sinus.
`Twenty-four patients had fibrous ankylosis with absent
`or restricted movement and four had bony ankylosis.
`The degree of radiological destruction ranged from mild
`in 5 cases and moderate in II . to severe in 8 cases. with
`complete disorganisation in 4 patients.
`Follow-up was from 30 months to 46 months. Anti(cid:173)
`tuberculous drugs which included streptomycin, INAH.
`ethambutol, thiacetazone and rifampicin were given for
`three weeks before operation. Preliminary traction was
`used in some cases with fibrous ankylosis to help correct
`the deformity.
`Preparation of the amniotic cap. The amniotic cap was
`prepared according to a technique which has been stan(cid:173)
`dardised at this centre. Fresh placentae were collected
`from the maternity centre and washed in running tap
`water for 10 minutes. Amnion was separated from the
`chorion, and amniotic membrane, denuded of mucus,
`was collected in a beaker containing normal saline.
`Layers were then cut into squares and piled on a glass
`mould the size of a femoral head. There were 50 to 60
`layers in each cap, the mesenchymal surface of the mem(cid:173)
`brane always facing the glass mould. The amniotic cap
`was dried at ambient temperature for six to eight hours
`and a purse-string suture was then applied (Fig. I). The
`dried cap was sterilised in I% {J-propiolactone for two
`hours before operation, according to the technique of
`LoGrippe eta/. (1957). Repeated bacteriological studies
`revealed the efficacy of the P-propiolactone as a sterilis(cid:173)
`ing agent.
`Technique of operation. In adults the hip joint was
`exposed by a posterior approach; in children an anterior
`approach was used to avoid contamination of the wound
`by faecal matter. The iliopsoas tendon was routinely
`divided. Trochanteric osteotomy with subsequent distal
`transfer of the trochanter was used in cases with bony
`
`VOL. 68 B. No. I. JANUARY I'IX6
`
`ankylosis to allow a better exposure, and also in cases of
`total destruction of the head and neck of the femur to
`improve abductor power and, in some cases, to avoid
`impingement of the trochanter on the edge of the aceta(cid:173)
`bulum.
`The femoral head and the acetabulum were then
`reamed to expose healthy bleeding cancellous bone. The
`femoral head was shaped in a valgus direction and the
`acetabulum in cephalad and medial directions to pro(cid:173)
`duce some medial displacement of the reconstructed
`joint (Fig. 2). Care was taken to obtain smooth surfaces
`and reasonable congruity. Total synovectomy and cap(cid:173)
`sulectomy were essential parts of the technique, the most
`crucial stage of the operation being the excision of the
`anterior and medial capsule and synovial membrane.
`Care was needed to avoid injury to the femoral vessels.
`The posterior and superior rim of the acetabulum were
`excised to the extent that part of the head was uncovered
`when the limb was in neutral position.
`
`Fig. I
`Fig.:!
`Figure 1-A cap including 50 to 60 layers of amniotic membrane being
`prepared on a glass mould. Figure 2--Diagram to show the medial dis(cid:173)
`placement of the hip at operation. The heavy lines show the postopera-
`tive position.
`
`The prepared amniotic cap was then placed over the
`femoral head and anchored loosely to the neck with a
`purse-string catgut suture. In cases with total destruction
`of the head and neck (Cases 3, 4 and 9), a Colonna type
`of reconstruction was performed, the abductors being
`transplanted distally and the proximal shaft, covered
`with an amniotic cap, being placed in the acetabulum. In
`Case 20, also with total loss of the femoral head and
`neck, reconstruction was attempted by osteotomising the
`greater trochanter and placing the medial portion
`together with an iliac bone graft into the acetabulum,
`interposing an amniotic cap. All small bony fragments
`were then removed by cleansing with saline solution and
`suction. The wound was closed in layers with suction
`drainage for 48 hours. The limb was supported in a
`Thomas splint in abduction.
`Postoperative care. Static quadriceps exercises and active
`ankle and toe movements were started as soon as the
`patients recovered from anaesthesia. On the fourteenth
`day, after the removal of stitches, passive hip exercises
`were started three times daily in all directions except
`adduction; this facilitated the formation of a cleavage
`
`

`

`70
`
`G.K.~SHWAKARMA, A.K.KHARE
`
`between the layers of the amniotic cap (Vishwakarma et
`a/. 1980). Patients were also encouraged to perform
`active hip exercises.
`The splint was removed after four weeks and
`resisted active exercises were started. During the fifth
`week patients started walking with crutches, taking no
`weight on the affected limb. They were discharged from
`hospital after six weeks and continued antituberculous
`drugs at home for periods ranging from 4 to 18 months,
`usually 6 to 10 months. Partial weight-bearing was
`allowed at 18 weeks and full weight-bearing after 20
`weeks. Crutches were discarded after 24 weeks.
`
`RESULTS
`The wound healed by primary intention in all but two
`cases, in which superficial infection was controlled by
`antibiotics. In no case was there recurrence of the disease
`during follow-up. The results were evaluated by the
`Larson hip disability rating scale (Tables I and II). The
`operation was a success in 25 patients, who had no pain
`
`and gained a good range of movement. All 25 could
`manage their daily chores, 22 of them could squat, 24
`could sit cross-legged, and all of them could relax com(cid:173)
`fortably on chairs. There was an average 0.5 em increase
`in shortening after operation. Bone condensation was
`seen radiographically in 21 cases, but in four patients
`(Cases 2, 4, 14 and 22) there was minimal resorption,
`which, surprisingly, did not compromise the result.
`Radiographs of four patients, with postoperative clinical
`photographs of one of them, are seen in Figures 3 to 14.
`Failures. One patient (Case 3) had a dislocation after a
`Colonna type of arthroplasty. Another patient (Case 26),
`an elderly man with long-standing tuberculosis and
`secondary infection of the hip, did not gain a satisfactory
`range of movement postoperatively; at a revision opera(cid:173)
`tion he sustained a fracture of the neck of the femur
`which failed to unite. The third failure (Case 23) suffered
`re-ankylosis from massive extra-articular bone forma(cid:173)
`tion. None of the three failures was caused by the amnio(cid:173)
`tic element of the arthroplasty.
`
`Table I. The clinical findings before operation in 28 patients having an amniotic arthroplasty for tuberculosis of the hip
`
`Caae
`
`Age
`(yt'llrS)
`
`Sex
`
`Duratioo
`of
`diseaae
`(years)
`
`Lanoaseore
`
`Pain
`
`Fuactloa
`
`Galt
`
`Fixed
`flexioa•
`(dqr~~s)
`
`Range of
`flexioa
`(degr~~s)
`
`Total
`SborteoiDg Lanoa
`seore
`(em)
`
`2
`3
`4
`5
`6
`7
`8
`9
`10
`II
`12
`13
`14
`15
`16
`17
`18
`19
`20
`21
`22
`23
`24
`25
`26
`27
`28
`
`18
`10
`15
`20
`18
`32
`29
`45
`25
`24
`60
`34
`40
`23
`16
`15
`20
`16
`29
`26
`16
`16
`14
`29
`60
`70
`14
`22
`
`M
`M
`M
`M
`M
`M
`M
`M
`M
`F
`M
`M
`F
`M
`F
`M
`M
`F
`M
`M
`F
`M
`F
`M
`M
`M
`M
`M
`
`3
`3
`3
`4
`7
`4
`4
`
`2
`
`4
`3
`
`7
`3
`2
`2
`2
`4
`5
`7
`4
`3
`2
`4
`7
`3
`2
`
`0
`0
`10
`0
`0
`0
`0
`10
`0
`10
`10
`10
`10
`10
`0
`10
`30
`10
`10
`20
`0
`0
`0
`0
`10
`0
`0
`0
`
`6
`6
`12
`6
`6
`6
`14
`15
`8
`15
`12
`12
`14
`12
`12
`12
`4
`14
`14
`6
`15
`14
`6
`14
`12
`6
`12
`6
`
`4
`4
`6
`6
`4
`4
`8
`4
`6
`8
`6
`6
`6
`4
`4
`4
`4
`6
`6
`4
`6
`6
`4
`6
`6
`4
`8
`4
`
`40
`70
`80
`10
`50
`15
`60
`20
`30
`30
`30
`45
`40
`45
`15
`60
`120
`15
`60
`80
`80
`60
`60
`50
`40
`50
`60
`40
`
`0
`0
`0
`10--70
`50--80
`0
`60--80
`20--70
`30--100
`30--60
`30--90
`0
`40--90
`0
`0
`60--90
`0
`0
`60--90
`0
`0
`0
`0
`50--70
`0
`0
`0
`0
`
`5
`4
`4
`7
`3
`I
`3
`
`4
`I
`I
`2
`2
`3
`3
`2.5
`4
`2.5
`2
`3.5
`4
`1.5
`4
`2.5
`2.5
`3
`2
`
`10
`10
`28
`19
`16
`20
`23
`38
`19
`36
`37
`30
`37
`26
`22
`29
`38
`38
`35
`30
`21
`22
`10
`22
`30
`10
`22
`12
`
`• All except four patients had a fixed adduction or abduction deformity; all except eight had a fixed rotational deformity. There was no free
`abduction/adduction or rotational movement in any patient before operation
`
`THE JOURNAL OF BONE AND JOINT SURGERY
`
`

`

`AMNIOTIC ARTHROPLASTY FOR TUBERCULOSIS OF THE HIP
`
`71
`
`DISCUSSION
`Amniotic arthroplasty aims to provide painfree move(cid:173)
`ment and stability for the tuberculous hip joint. Arthro(cid:173)
`desis of the hip does not suit patients in the East, because
`social customs necessitate squatting, kneeling and sitting
`cross-legged. Other possible operative procedures might
`well have helped to eradicate the disease but might not
`have succeeded in providing a painless, mobile and stable
`hip with safety.
`Of the 28 cases in this series followed for more than
`30 months. 25 were successful, and primary healing took
`place even where discharging sinuses were present before
`operation. This seems even more significant since the
`dosage of antituberculous drugs after the patient was dis(cid:173)
`charged tended to be irregular. This was partly because
`the patients were free of symptoms and believed that they
`had been cured.
`Trelford eta/. (1975) and Walker, Cooney and Allen
`(1977) demonstrated clinically the healing effect of
`amnion as a dressing for pyogenic wounds, but gave no
`
`explanation. Vishwakarma, Krishnan and Khare ( 1981)
`found that for infected bedsores and degloving injuries of
`the limbs, dressing the wounds with amnion not only
`controlled infection but also resulted in the rapid appear(cid:173)
`ance of healthy granulation tissue covering exposed
`bone, which soon made the wound suitable for a split(cid:173)
`thickness skin graft. The possibility that the specific anti(cid:173)
`bacterial substance lysozyme (Fleming 1932) was present
`in amniotic membrane was considered by Robson,
`Samburg and Krizek ( 1972) but they concluded that this
`was not so. Gruss and Jirsch ( 1978) have shown that
`amniotic membrane applied to infected and contami(cid:173)
`nated wounds decreases the bacterial count. The pres(cid:173)
`ence of a weak antibody-like substance in amniotic fluid
`has recently been demonstrated and there is a strong pos(cid:173)
`sibility that it is elaborated in the epithelium of amniotic
`membrane (Galask and Synder 1970; Sachs and Stem
`1979).
`Induction experiments have shown that human
`amnion can induce the formation of epithelial cells in the
`
`Table II. The results after operation in 28 patients having an amniotic arthroplasty for tuberculosis of the hip
`
`FoUow(cid:173)
`up
`(months)
`
`Cue
`
`Larson score
`
`Pain
`
`Function Gait
`
`Range ( tkgrees)
`
`Fixed
`flexiont
`(degrees) Flexion
`
`Exten(cid:173)
`sion
`
`46
`20
`100
`46
`20
`100
`46
`Hip dislocated
`40
`90
`20
`44
`30
`100
`20
`44
`90
`15
`30
`44
`40
`110
`20
`43
`30
`100
`20
`42
`110
`20
`40
`43
`15
`30
`100
`40
`15
`110
`40
`40
`15
`40
`40
`110
`90
`10
`30
`38
`15
`40
`100
`38
`37
`110
`20
`45
`37
`15
`110
`40
`37
`90
`20
`30
`90
`15
`40
`36
`15
`40
`110
`36
`35
`30
`70
`0
`35
`90
`20
`0
`35
`40
`120
`20
`Extra-articular ankylosis
`34
`100
`20
`40
`33
`32
`110
`20
`30
`31
`Fracture of neck of femur
`90
`30
`40
`0
`40
`30
`100
`20
`t After operation only two patients had a fixed deformity in the coronal plane
`
`35
`35
`30
`35
`35
`35
`35
`35
`35
`35
`35
`35
`35
`35
`35
`35
`35
`30
`35
`30
`35
`35
`30
`35
`35
`20
`35
`35
`
`25
`25
`25
`25
`28
`24
`28
`28
`30
`30
`28
`30
`30
`28
`28
`30
`28
`24
`30
`20
`28
`25
`14
`30
`28
`14
`28
`28
`
`8
`8
`6
`8
`8
`8
`8
`10
`8
`10
`10
`10
`10
`10
`8
`10
`8
`10
`10
`6
`8
`10
`6
`10
`10
`4
`10
`10
`
`20
`
`10
`10
`
`10
`
`20
`10
`
`I
`2
`3
`4
`5
`6
`7
`8
`9
`10
`II
`12
`13
`14
`15
`16
`17
`18
`19
`20
`21
`22
`23
`24
`25
`26
`27
`28
`
`VOL 68-B. No. I. JANUARY 1986
`
`Total
`Shorten-
`Adduc(cid:173)
`Abduc(cid:173)
`Larson
`ing
`Rota(cid:173)
`tion
`score
`(em)
`tion
`tion
`- - - - - - - - - - - - - - - - - · · - - - -
`50
`40
`30
`4
`84
`20
`30
`83
`40
`5
`5
`64
`83
`4
`R6
`4
`83
`1.5
`3.5
`87
`91
`2
`89
`3
`92
`1.5
`91
`2
`90
`3
`2.5
`92
`3.5
`88
`87
`4
`91
`3
`4
`86
`3
`79
`90
`3
`69
`4
`4.5
`82
`88
`2
`58
`4
`91
`3
`88
`3
`46
`4
`88
`3
`91
`2
`
`20
`30
`30
`30
`30
`20
`30
`30
`30
`30
`20
`30
`30
`30
`20
`30
`20
`30
`30
`
`30
`20
`
`30
`30
`
`30
`40
`30
`40
`50
`40
`40
`40
`50
`40
`40
`50
`50
`40
`40
`40
`20
`20
`40
`
`50
`40
`
`40
`40
`
`

`

`72
`
`G. K. VISHWAKARMA, A. K. KHARE
`
`Case 22. Radiographs of the right hip before and 35 months after
`operation . showing a well-formed joint space. Clinical photographs of
`the patient squatting and sitting cross-legged after operation.
`
`Fig. 5
`
`Fig. 6
`
`Fig. 7
`Fig. 8
`Fig. 9
`Case 9. Radiographs of the left hip. Figure ?- Before operation. showing total destruction of the joint. Figures 8 and 9- At 6 months
`and 43 months respectively after a Colonna-typc arthroplasty with an amniotic cap.
`
`Fig. 10
`Fig. II
`Case I~- Radiographs before and 40 months after amniotic arthroplasty. A well-marked joint space
`has developed.
`
`THE JOl .R'-'AL OF HONE AND JOINT SURGERY
`
`

`

`AMNIOTIC ARTHROPLASTY FOR TUBERCULOSIS OF THE HIP
`
`73
`
`Fig. 14
`Fig. 13
`Fig. 12
`Case 13. Radiographs of the left hip. Figure 12- Before operation. Figures 13 and 14--At 20 months and 38 months respectively after opera(cid:173)
`tion. Note the joint space. the contour of the femoral head and the new bone formation at the lateral border of the acetabulum.
`
`chorio-allantoic membrane of the fertilised chicken egg
`(Sawyer, Abbott and Trelford 1972) and this method
`indicates one avenue of research. Induction phenomena
`have not been seen in the clinical situation as yet. but the
`complexities of the amnion cell suggest that it may have
`multiple functions . Vishwakarma et a/. ( 1980) observed
`the formation of joint-type tissues when multilayered
`amniotic cap was interposed. and this indicates that the
`human amnion may be capable of inducing the forma(cid:173)
`tion of diverse tissues.
`More study is needed of the immunology of the
`amniotic membrane. There was no immunological reac(cid:173)
`tion or rejection phenomenon in any of our patients.
`Embryonic cells may be immunologically inert because
`of the absence of antigen which determines histo(cid:173)
`compatibility (Boyd and Hamilton 1970). Unusual
`immunology could be due to fetal membrane collagen
`(Burgeson eta/. 1976). Attempts to detect antibodies or a
`cell immune response to amniotic membrane have never
`succeeded. Study of the fetomaternal relationship has led
`to the comparison of the status of the fetus with that of a
`parasite that successfully avoids host rejection (Faulk
`and Galbraith 1979). A glycoprotein occurring in
`trophoblast and amniochorion is considered
`to be
`important in suppressing detection of the fetus as
`"foreign" to the mother. by acting on maternal lympho(cid:173)
`cytes and preventing rejection throughout pregnancy
`(Mcintyre and Faulk 1979). lmmunodiagnostic tech(cid:173)
`niques continue to be important in the effort to ascertain
`the precise action of immunobiologically active glyco(cid:173)
`protein of the extra-embryonic tissues. Antigenicity of
`the amnion. for whatever reason. appears to be low and
`violent host responses have not yet been demonstrated
`(Trelford and Trelford-Sauder 1979).
`A painless joint with some mobility was achieved in
`most of our cases. It has been postulated that pain origi(cid:173)
`nates mainly from the capsule and to some extent from
`the muscles. Kellgren ( 1939) and Kiaer ( 1950) provided
`clinical evidence that pain could arise from cancellous
`
`bone. and nerve fibres have been demonstrated in the
`interior of bone (Gardner 1950). Blood vessels are sup(cid:173)
`plied by nerves, possibly part of the vaso-sensory appar(cid:173)
`atus. In our cases some pain relief may have followed the
`release of iliopsoas. quadratus femoris and the short
`external rotators of the hip; this decreases the compres(cid:173)
`sive forces on the hip joint and improves the distribution
`of pressure by correcting flexion and adduction contrac(cid:173)
`tures. Complete capsulectomy destroys the nerve supply
`to the joint.
`Nerve fibres in the cancellous bone may be neutra(cid:173)
`lised by the metaplastic formation of fibrocartilage at
`both the articular surfaces (Vishwakarma et a/. 1980)
`and a contributing factor may have been the formation
`of a pseudo-synovial membrane and synovial fluid which
`kept the new joint lubricated. The average range of
`movement after operation in the 25 successful cases was
`flexion 100. extension 15 . abduction 35' . adduction 25'
`and rotation 40 ·.
`The basic objectives of the procedure were achieved.
`Better. quicker results might have been possible. if
`muscles had not been wasted by chronic disease. Ade(cid:173)
`quate physiotherapy could not be given after the patients
`were discharged, most of them to their own villages.
`Excision of the posterosuperior rim of the acetabulum
`seemed
`to help achieve increase in abduction and
`rotation, in addition to the freedom of movement at
`the joint newly formed by
`the amnioplasty · itself.
`Vishwakarma et a/. ( 1980) have demonstrated experi(cid:173)
`mentally the formation of a near-perfect joint with a cap(cid:173)
`sule. Medialisation of the joint. with valgus reaming of
`the femoral head and neck. added to the remarkable
`stability of the reconstructed joints. while the realign(cid:173)
`ment of muscles around the hip improved their function.
`Law ( 1962) demonstrated that with the passage of time
`and the growth of fibrous tissue around the joint. nerve(cid:173)
`endings from the surrounding muscles may infiltrate the
`structures and restore some joint sensation.
`Condensation of bone around the acetabulum and
`
`VOL. 68 B. No. I. JANUARY I'IX6
`
`

`

`74
`
`G. K. VISHWAKARMA, A. K. KHARE
`
`head of the femur was found in all but four cases (Case 2.
`4. 14. 22). providing some indirect evidence of a healing
`process induced by the amnion. In the four cases with
`some resorption, this was minimal. This also substan(cid:173)
`tiates that the major source of blood supply to the
`remaining portion of the head and neck is provided
`through the neck and is not entirely dependent on circu(cid:173)
`lation through the capsule. (Freeman 1978).
`An average of 0.5 em increase of shortening was
`caused by the operation. This is insignificant and in
`Cases 4 and 9 gain in length was achieved by trochanteric
`arthroplasty in the absence of the femoral head and neck.
`There was also an increase in leg length in cases with a
`wandering acetabulum when the new acetabulum was
`created at the original site (Case I).
`The potential of the application of amniotic mem(cid:173)
`brane to surgery is now being realised and is as wide as
`imagination and experiment can make it. An arthro(cid:173)
`plasty for tuberculosis which includes joint debridement
`and the interposition of an amniotic cap not only seems
`to eradicate the disease but also to induce bone forma(cid:173)
`tion and speed up the healing process. Amnioplasty
`offers a satisfactory solution to the problem of hip joint
`tuberculosis, especially for patients in the East, where an
`adequate range of movement is a priority.
`
`This project was supported by a grant from the Indian Council of
`Medical Research, New Delhi (India).
`
`REFERENCES
`
`Boyd JD, Hamilton WJ. Tht• human placenta. Cambridge: W HefTer &
`Sons. 1970.
`Brindeau A. Creation d'un vagin artificiel a I' aide des membranes ovu(cid:173)
`laires d'un oeuf a terme. Gynec Ohstet (Paris) 1934;29: 385-92.
`Burger K. Experimental and clinical studies on transplantation of the
`fetal membranes. Orv Heti/1938;82:800-1.
`Burgeson RE, El Adli FA, Kaitila II, Hollister DW. Fetal membrane
`collagens: identification of two new collagen alpha chains. Proc
`Nat/ A cad Sci LSA 1976:73:2579 83.
`Campbell WC. Mobilization of joints with bony ankylosis: an analysis
`ofllOcases.JAMA 1924:83:97681.
`Davis JS. Skin transplantation: with a review of 550 cases at the Johns
`Hopkins Hospital. John.v Hopkins Hosp Rep Balt1910; 15:307-96.
`de Rotth A. Plastic repair of conjunctival defects with fetal membranes.
`Arch Ophtha/mo/1940;23:522 5.
`Douglas B. Homografts of fetal membranes as a covering for large
`wounds-especially those from burns: an experimental and clini(cid:173)
`cal study (preliminary report). J Tenne.uee Med Assoc 1952;45:
`230 5.
`Faulk WP, Galbraith GMP. Trophoblast transferrin and transferrin
`receptors in the host-parasite relationship of human pregnancy.
`Proc R Soc Lond(Biol) 1979;204:83--97.
`Fleming A. Lysozyme: president's address, Proc R Soc Med 1932;26:
`71 84.
`
`Freeman MAR. Some anatomical and mechanical considerations rele(cid:173)
`vant to the surface replacement of the femoral head. Clin Orthop
`1978:134: 19-24.
`Galask RP, Synder IS. Antimicrobial factors in amniotic ftuid. Am J
`Ohstet Gyneco/1970: 106:59--{)5.
`Gardner E. Physiology of movable joints. Physiol Rev 1950:30:127-76.
`Gruss JS, Jirsch DW. Human amniotic membranes: a versatile wound
`dressing. Can Mt•d Assoc J 1978:118:1237-46.
`Kallio KE. Arthroplasia cutanea. Acta Orthop Scand 1957:26:327.
`Katayama R, ltami Y, Marumo E. Treatment of the hip and knee-joint
`tuberculosis: an attempt to retain motion. J Bone Joint Surg [Am]
`1962:44 A:l!97 917.
`Kellgren JH. On the distribution of pain arising from deep somatic
`structures with charts of segmental pain areas. Clin Sci 1939;4:
`35-46.
`Kiaer S. Afferent pain paths in man running from the spongiosa in the
`femoral head and passing through the lumbar sympathetic gang(cid:173)
`lia. Acta Orthop Scand 1950:19:383-90.
`Kuznetsov NN, 1962. Cited hy Volkow MV. Arthroplasty of joints
`using amniotic membrane. In: Chapchal G. ed. Arthroplasty of the
`hip: 5th International Sympo.vium /972 in Nijmegen. Netherlands.
`Stuttgart: George Thieme, 1973.
`Larson CB. Rating scale of hip disabilities. Clin Orthop 1963;31 :85-93.
`Law WA. Late results of vitallium-mold arthroplasty of the hip. J Bone
`JointSurg[Am)1962;44-A:1497 517.
`LoGrippe GA, Burgess B, Teodoro R, Fleming JL. Procedure for bone
`sterilisation with beta-propiolactone. J Bone Joint Surg [Am)1957;
`39--A: 1356-64.
`Massee JS, Symmonds RE, Dockerty MB, Hallenbeck GA. Use of fetal
`membranes as replacement for pelvic peritoneum after pelvic exen(cid:173)
`teration in the dog. Surg Forum 1962; 13:407-8.
`Mcintyre JA, Faulk WP. Antigens of human trophoblast: effects of
`heterologous and anti-trophoblast sera on lymphocyte responses
`in 1•itro. J Exp Med 1979; 149:824-36.
`Ninman C, Shoemaker P. Human amniotic membranes for bums. Am J
`Nur.v 1975:75:1468-9.
`Robson MC, Samburg JL, Krizek T J. Quantitative comparison of bio(cid:173)
`logical dressings. Surg Forum 1972;23:503-5.
`Sabella N. Use of the fetal membranes in skin grafting. Med Rec NY
`1913;83:478-80.
`Sachs BP, Stem CM. Activity and characterization of a low molecular
`fraction present in human amniotic ftuid with broad spectrum
`antibacterial activity. Br J Ohstet Gynaeco/1979;86:81--{;.
`Sawyer RH, Abbott UK, Trelford JD. Inductive interactions between
`human dermis and chick chorionic epithelium. Science 1972; 175:
`527 9.
`Stem M. The grafting of preserved amniotic membrane to burned and
`ulcerated surfaces. substituting skin grafts. JAMA 1913;60:973.
`Trelford JD, Hanson FW, Anderson DG, Mendel VE. Amnion auto(cid:173)
`grafts, permanent structure. J Med 1975;6:243-7.
`Trelford JD, Trelford-Sauder M. The amnion in surgery, past and
`present. Am J Ohstet Gym•co/1979; 134:833-45.
`Vishwakarma GK, Krishnan R, Khare AK. Amniotic arthroplasty of the
`hip: an experimental study. Paper presented at the Indian Ortho(cid:173)
`paedic Association Conference, Bombay (India), September, 1980.
`Vishwakarma GK, Krishnan R, Khare AK. Use of amnion in infected
`wounds: paper presented at the Indian Orthopaedic Association
`Conference, Srinagar (India), May 1981.
`Volkov MV. Arthroplasty of joints using amniotic membrane. In:
`Chapchal G, ed. Arthroplasty of the hip_· 5th International Sym(cid:173)
`posium 1972 in Niimexen. Nether/and.v. Stuttgart: Georg Thieme,
`1973.
`Walker AB, Cooney DR, Allen JE. Use of fresh amnion as a bum dress(cid:173)
`ing. J Pediatr Surx 1977:12:391-5.
`Wilkinson MC. Partial synovectomy and curettage in the treatment of
`tuberculosis of the hip. J Bone Joint Surx [Br]I957;39--B:66--79.
`
`THE JOURNAL OF BONE AND JOINT SURGERY
`
`