VOL. XXVII, NO. 1 JANUARY, 1945 VoL XL No.

The Journal of
Bone and Joint Surgery

OSTEOTOMY OF THE SPINE FOR CORRECTION OF FLEXION

DEFORMITY IN RHEUMATOID ARTHRITIS *

BY M. N. SMITH-PETERSEN, M.D., CARROLL B. LARSON, M.D., AND OTTO E. AUFRANC, M.D.,

BOSTON, MASSACHUSETTS

“Osteotomy of the Spine” is a slightly misleading title for this paper, but it is an
intriguing one, effective in stimulating interest and curiosity. The operative procedure is
confined to the laminae and articular facets and does not involve the vertebral bodies.

Summary of Recent Progress in Surgery of Rheumatoid Arthritis

In 1941 the authors were granted the assignment of “Operative Procedures for the
Prevention and Correction of Deformities in Rheumatoid Arthritis”, at the Massachusetts
General Hospital. This assignment allowed us to evaluate acromioplasty, excision of the
radial head, and excision of the distal end of the ulna for the relief of pain and restoration
of function to the joints of the upper extremity.’ The technique of arthroplasty of the
hip has been improved, so that more nearly perfect mechanical joints can be shaped.
Progress is also being made in mold arthroplasty of the knee.

Optimum Time for Surgical Procedures in Rheumatoid A rthritis

One problem has been constantly before us, and that is the question of the optimum
time for surgical treatment. Up to the present time, the generally accepted opinion has
been that surgery must wait until the active stage of the disease has passed. This waiting
period is a period of gradually diminishing activities, commonly terminating in recumbency
in the position of minimum pain. The results of diminished or absent function are atro-
phy of muscle and bone (loss of elasticity of ligaments, fascia, and intermuscular septa)
and development of joint deformities. Surgery performed under these conditions is
technically difficult; restoration of motion is slow; and the functional end result less satis-
factory than when surgery is undertaken at a relatively early stage, while the disease is still
active.

Analysis of Development of Flexion Deformity and Its Surgical Correction

Recumbency in the position of minimum pain commonly results in a flexion deformity

of the spine sufficiently marked to interfere with the function of the lower extremities in
standing and walking, and to make the sitting position one of strain and discomfort.
* Read at the Annual Meeting of The American Orthopaedie Association, Hot Springs, Virginia, June 2,
1944.
 M. N. SMITH-PETERSEN, C. B. LARSON, AND 0. E. AUFRA’NC

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Reproduction of sketch and notes made in preparation for the first osteotomy of the spine, March
1941.

Manipulation, followed by support, will improve many of these patients; it will not be of
benefit after bony ankylosis of the articular facets and calcification of the longitudinal
ligaments have occurred. Patients with ankylosis of both hips not infrequently present
this latter extreme condition of the spine. After arthropla.sties, the flexion deformity of
the spine interferes to such an extent with function of the lower extremities that the prob-
lem of correction becomes most important. Analyzing the obstacles to correction, we
came to the conclusion that the ankylosed facets, surrounded by overgrowth of bone,
offered more resistance than any of the other spinal structures. Any surgical procedure
for correction of the flexion deformity must, therefore, be aimed at the facets, articular
processes, and adjacent laminae; osteotomy of these structures, with excision of sufficient
b#{241}e,should allow corrective leverage to be transmitted to the intervertebral discs and
longitudinal ligaments, overcoming whatever resistance these may present.
Preceding the first operation, a diagram was made and the operative steps were out-
lined (Fig. 1). It is rare that a surgeon is able to carry out a preconceived plan of opera-
tion, but in this case that was true; furthermore, the operation is even now essentially the
same. Only six cases have been done; further experience may, and probably will, bring
about improvement in the operative technique.

OPERATIVE TECHNIQUE

The lumbar region is -more favorable than the thoracic, since the latter commonly
presents nkylosed costovertebral joints rendering correction difficult, if not impossible.
Thoracic’osteotomy has been done in only one case; it resulted in subjective improvement,
but there was nO objective evidence of it.
Selection of the lumbar level or levels at which the osteotomy is to be performed de-
pends on the roentgenographic findings; the less marked the ossification, the better the
chance of correction.
TEE JOURNAL OF BONE AND JOINT SURGERY
 OSTEOTOMY OF THE SPINE 3

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THE JOURNAL OF BONE AND JOINT SURGERY

 OSTEOTOMY OF THE SPINE

Operative Steps .,

Through an incision in the mid-line, at least three lumbar spinous processes are cx-
posed. Even if the osteotomy is performed at one level only, the spinous process above
and below that level must be completely exposed and excised in order to allow adequate
retraction (Fig. 2, 1).
The second step consists of the incision and reflection of supiaspinous and inter-
spinous ligaments, followed by the subperiosteal reflection of muscle attachments from the
spinous processes and laminae.
The spinous processes ate then osteotomized into lamellae with a thin osteototne, and
are exCise(l at their bases (Fig. 2, 3). This allows further reflection of the periosteum from
the superioi and inferior aiticular l)rocesses, exposing the intervertebral notch as well as
the articular facets. The reflection of the periosteum must be accompanied by (livisiOfl
of the muscular attachments to the ligarnentum flavurn.
By means of a periosteum elevator, the ligamentum flavuin is detache(l from the
inferior margin of the lamina and inferior articular process. The elevator is then ad-
vanced anterior to the lamina and inferior articular process until it appears in the lateral
ifltervelteI)ral notch just above the articular facet (Fig. 3, 4) ; it serves as a guide to the
direction of the osteotomy through the superior articulat process of the vertebra below and
the inferior articular i)Iocess of the vertebra above. The osteotoiiy is (lone in an oblique
plane, at an angle of approximately 45 degrees with the frontal plane (Fig. 3, ;). The
osteotomes should be narrow and thin-bladed ; both straight and curved osteotomes are
required. Gouges of the same type are sometimes useful. A rongeur with narrow jaws is
indispensable. The osteotomy is performed at one, two, or three levels, depending upon
the extent of new-hone formation in relation to the facets and interVertel)ral discs.
Upon completion of the osteotomy or osteotomies, leverage in the direction of exten-
sion is applied by raising the head and foot of the operating table very slowly. rFhe
gra(lual narrowing and final obliteration of the oblique spaces between the laminae and
between the remnants of the articular Processes marks the “high-spot” of the operation.
The obliquity of the osteotomy ensures locking and prevents any serious (lisplacernent
(Fig. 3, 6’).
By means of delicate osteotomes, bone flaps are raised from the laminae adjacent to
the osteotomy, and the bone lamellae obtained from the spinous processes are inserted by
means of a bone-graft carrier. These grafts bridge the gap between the laminae, and
consequently hasten bony fusion in the corrected position (Fig. 3, 6 and 7).
In closing the wound, close apposition of the split interspinous and supraspinous
ligaments is important. If the approach is developed with proper regard for structures
and structural planes, the closure and nature’s repair of the wound are facilitated.

Postoperative Care
A plaster shell is applied and kept on for four to six weeks, followed by a plaster
jacket or back brace, to be worn continuously for a year or longer. Since complete correc-
tion is never obtained, it is important to guard against recurring deformity by having the
patient wear the brace part of the day for two or three years postoperatively. It is hardly
necessary to emphasize the importance of exercises for control of posture, as well as for
maintaining chest expansion.

ASPECTS OF OPERATIVE -rECHNIQUE DEMANDING EMPHASIS

1. The operative procedure must not be belittled,-there are many points in the
technique that we have found difficult.
2. In developing the approach, it is more important to follow structural planes and
preserve hemostasis than to save a few minutes in operating time. The osteotomy is in
itself difficult, and demands a dry field.

VOL. XXVII, NO. I, JANUARY 1945

6 M. N. SMITH-PETERSEN, C. B. LARSON, AN!) (). li. AUF’RANC

3. The spinous processes must I)e excise(l before an attempt is ma(le to expose the
art icular processes and intervertebral notch.
4. The interspinous ligament and the ligamentum flavum have been found ossified,
sometimes partially, sometimes completely, in excising the ossified ligarnentum ulqvum,
one should keep in mind that the dura is apt to be adherent to it and is, therefore, easily
puncture(l. A leak of spinal fluid is in itself of relatively little coflse(Iuefl(’e, but it (loes tLd(l
another problem to tile operative technique.
5. In introducing the elevator for the purpose of reflecting the periosteum from the
anterior surface of the lamina, care must be exercised in order to avoid injury to the dura
afl(l spinal nerves. The inflammatory process which has resulted in the articular destruc-
tion is a(’companied 1)%’ periarticular adhesions and inelastic stru(’tures, not easily reflected.
6. The bone instruments should be of a delicate type,----they are iflteflde(l to (‘lit,
IR)t crush.
7. flip possibility of overcorrect ion must be kept in mind. If the thoracic spine
presents marke(l flexion, there is apt to be (‘ompensatorV extension deformity of the
cervical spine with motion in the occipitocervical joints only. In the presence of such
deformities, overcorrection in the lumbar region makes it difficult for the patient to see his
l)late on the (lining room table and to read without holding the 1)00k 011 a level with his
head.

KG. 4-A F - ;.

Before treatment. After treatment.

(‘a.se 1, X.B.: aged twenty-three years: duration of condition, eight years.
Operations:
March 1941: Osteotomv of lumbar spine at level of first and second, and SeCOn(l and third
vertebrae.
I)ecember 1941: Osteotomy of thoracu’ spine at level of ninth, tenth, and eleventh vertebrae.
February 1943: Arthroplasty of left hip.
March 1943: Arthroplasty of right hip.
Present condition:
The patient is using (‘rutches and wears a back brace part of the time. He tires easily, I)llt says
he has no pain, and can sit quite comfortably.

‘rio: JOURNAl. 01” BONE ANI) JOINT SURGERY

 OSTEOTOMY OF THE SPINE

Fi;. 4-C FIG. 4-I)

Before treatment. After osteotomv.
l’hie postoperative roentgenogram shows definite widening of intervertebral spaces betwv’n the
first and second lumbar and the second and third lumbar.

Prs-op

FIG. 5-A FIG. 5-B

Preoperative roentgenogra m. After osteotoniy.
Case 2, SB.; aged twenty-four; duration of condition, six years.
Joints in order of inroli’ement were right hip. spine, and left hip. Patient left college to have right
hip fused for “tuberculosis “. Postoperative immobilization in double plaster spica for one
year resulted in anky1osi of spine in flexion, with both hips in flexion and abduction.
(See page 8.)

VOL. XXVII, NO. 1, JANUARY 1941i

8 M. N. SMITH-PETERSEN, C. B. LARSON, AND 0. E. AUFRANC

FIG. 5-A and FIG. 5-B (continued)

Operations:
June 1942: Arthroplasty of left hip. Bony :uikylosis.
.July 1942: Arthroplasty of right hip. Bony ankylosis.
August 1942: Osteotomy of lumbar spine and fusion with grafts from sJ)iIIoUS processes.
Fig. 5-A: Preoperative roentgenogram. l”ig. 5-B: After osteotomy of lumbar spine at level of third
afl(l fourth vertebrae.
Present condition:
The patient returned to college in October 1942. He is still using (‘rutches at times, two canes

most of the time. He is able to sit comfortably, and eight months ago resume(l playing the piano.

FIr.. (i-A FI(;. (i-B

Case 3, B.C.; aged thirty years: duration of disea.se, eleven years.
Joints in order of involi’ement were spine, hips, and jaws. Patient had been ‘‘frozen” in sitting posi-
tion for seven years.
Operations:
February 1940: Arthroplasty of right 101).
April 1940: Arthiroplasty of left hiiJ).
September 1941 : Gauze sponge removed fI’om right iliac fossa. ()perative wound healed per
primam, but a small sinus developed one year later.
October 1941: Osteotomy of lumbar spine at level of se’ond and third vertebrae.
November 1941: Fusion of osteotomized area.
Fig. (i-A: Roentgenogram before osteotomy. Fig. (1-13: I{oentgenogram one week after operation
showed marked correction at level of osteotomv, and consequently fusion was indicated.
Present condition:
The patient is using crutches or (‘anes, occa.sionallv only one cane. He is working eight hours a day,
six or seven days a week, and says he has no pain. He goes fishing and hunting.

FIG. 7-A and FIG. 7-B (See page 9.)

Case 4, R.F. ; aged twenty-four years duration of condition, two and one-half years.
Joints ini’olved: Hips and spine.
Operations:
.Julv 1942: Arthroplastv of left hip.
August 1942: Arthroplasty of right hip.
March 1943: Osteotomv of lumbar spine, and fusion.
Fig. 7-A: Preoperative roentgenogram. Fig. 7-13: After osteotomy of lumbar spine at level of the
secon(l and third and third and fourth intervertebral spares, with fusion at the time of os-
teotomv.

‘ini-: JOURNAL OF BONE ANI) JOIN’I’ SI’R(;ERY

 9

Fzr..7-A FIG. 7-B

Postoperative treatment: Pla.ster jacket was used for three months, followed by brace and exercises.
Present condition:
Patient uses crutches most of the time, occasionally two canes. lie is studying drafting. and says
he has no pain.

Fir.. S-A FIG. 8-B

Case 5, .J .‘sV. : age I thi I’ty-five years : (boat ion of (‘( ndition, ten yeats.

.Joints ineolced: Spine and hips.

Operations:
June 1938: Arthroplastv of left hiJ) for bony ankylosis.
May 1941: Arthroplasty of right hip for fibrous ankylosis.
September 1943: Osteotom of lumb,ir spine with fusion at the level of the third and fourth
vertebrae.
Fig. 8-A: Before osteotomv. Fig. 8-13: After osteotomy of the lumbar spine with fusion.
Present condition:
Patient is able to i’tiii and ride a bicycle. He uses crutches at times, otherwise one or two ‘anes.

VOL. XXVII. No. I. JANUARY I94?

 10 M. N. SMITH-PETE1ISEX, (‘. B. LARSON, AND 0. E. AUFIIANC

1’ir.. 9-A FIG. 9-B

Ca.se 6, H.C. ; age(l thirty-six years ; duration of condition, four years.
Joints involved: Hips and spine.
Operations:
September 1942: Arthroplasty of right hip for fibrous ankylosis.
October 1942: Arthropla.sty of left hip for fibrous ankylosis.
November 1943: Osteotomy of lumbar spine with fusion at level of the fourth and fifth verte-
brae.
Fig. 9-A: Preoperative roentgenogram. Fig. 9-B: Hoentgenogram after osteotomy of the lumbar
with
spine fusion.
Present condition:
Patient is able to navigate about thie house without crutches or canes, but (hoes have occasional
discomfort.

CONCLUSIONS

1. Surgical intei’vention in rheumatoid arthritis should he undertaken early, before

secondary deformities develop.
2. Flexion deformity of the spine frequently results from delayed surgical treatment
of the hips.
3. Such flexion deformity may be sufficiently severe to demand surgical correction.
4. Osteotomy of the spine, performed in a small series of six cases, has yielded
satisfactory results.

1. SMITH-PETERsEN, M. N.; AUFRANC, OTTO E.: AND LARSON, CARROLL 13.: Useful Surgical Procedures
for Itheumatoid Arthritis Involving Joints of the Upper Extremity. Arch. Surg., XLVI. 764, 1943.

1)ISCUSSION
1)11. Goaw.: E. I3ENNETT, I3ALTIMOILE, MARYLAND: Many yeas’s ago I had the honor of opening the
discussion of a paper by Dr. Smith-Petersen--his first paper on the introduction of the Smith-Petersen nail.
That was a subject I could talk on with perfect freedom, because I had had iu great deal of eXperielice with
the operative reduction of fractures of the neck of the femur. Later, I had thie honor and privilege of dis-
cussing his paper on the use of the vitallium (‘up for arthroplasty of the hip. That was also a subject about
which I could talk from experience. Today I am confronte(l with opening the (hiscussioll on an operation on
which I have had absolutely n experience. I can only say that this is an operation designed by IL man who
is one of the master-surgeons of his generation. I (‘an see that it has its place. I know’ none of the older men
are going to do this operation, unless they do a little work on the cadaver. As Dr. Smith-Petersen sai(l, this
operation should h)e reserved for the cases in which all (‘onservative treatment has failed. I think again Dr.

‘rHE JOURNAL OF B0NF AND JOINT SURGERY

 OSTEOTOMY OF THE SPINE 11

Smith-Petersen has presented an operation deyeloped by a genuine master-surgeon. Unless you are a master-
surgeon, do not try it!

Da. H. R. MCCARROLL, ST. LOUIS, MISSOURI: This is an operative procedure I have never done, I have
never seen, and, until about one month ago, I had never heard of. Any discussion by me must, therefore,
be entirely theoretical.
First, there can be no objection to any procedure, regardless of how technically difficult it may be, which
offers the unfortunate patient with a fiexion deformity of the spine from Marie-Strumpell disease some hope
of being able to look the world in the face once more. There are three points, however, which should, I think,
be taken into consideration:
(1) The question as to whether or not these deformities should be fairly complete before surgery is done.
If they are still in the formative stage, the deformity may recur. This in turn prompts the question of
whether or not enough motion remains in the intervertebral spaces to allow correction of the deformity, if
bone already bridges the interspaces along the anterior longitudinal ligament;
(2) The prospect of a surgical correction for the deformity should not prevent us from making every
attempt to prevent the fiexion deformity from developing. During the early stages of the disease, adequate
conservative measures will accomplish this in some patients;
(3) This operation is not one to be undertaken by an amateur. Many of us have attempted exploration
of a spine for a possible disc lesion after a previous spinal fusion. The technical difficulties encountered in
the two operations are essentially the same. Such an exploration is one of the most difficult of all ortho-
paedic operations and should never be considered lightly.
Da. M. N. SMITH-PETERSEN, Bos’rox, MASSACHUSETTS (closing): I have been very fortunate in having
Dr. Bennett discuss all my first presentations of what I have considered new procedures. He discussed one
procedure which he did not mention-namely, that of acetabuloplasty. In his discus.sion he warned me
that this procedure was not going to turn
out as well as I expected; he was right. Evaluating the results of
this operation, five years after I operated on the first case, I found that only 50 per cent. of the cases were
satisfactory to the patient and to the surgeon. Since the advent of mold arthroplasty, we rarely do acetabu-
loplasties.
I want to thank Dr. Bennett for his encouraging discussion.
Dr. McCarroll asked three questions: The first was about tile deformity being fixed before surgery is
done. The operation is not undertaken until conservative measures have failed; it is performed in the lum-
bar region at levels showing a minimum of bony bridging. Such bony bridging may be expected to yield
after osteotomies of the articular facets.
The second point that Dr. McCarroll raised is that of prevention of fiexion deformity. This point can
not be overemphasized, but, in spite of conscientious efforts in this direction, fiexion deformities will occur
every so often.
Finally, Dr. McCarroll points out the technical difficulties of thie operation. I have emj)hasized this
point in my paper, and Dr. Bennett has also referred to it. The operation is a difficult one and should never
be undertaken lightly.
I want to thank Dr. McCarroll for his thoughtful discussion.

VOl.. XXVII. NO. 1. JANUARY 1945