Undoubtedly as far back as 1829, the actual recognition of this
condition was due to the pathological research of a French surgeon
Dupuytren, who described this deformity with great accuracy and
insisted that there was no possible chance of correction. From then
on until 1886 nothing was done by medical science to overcome the
deformity, though it is claimed some were made. It was in this year
that the famous Bavarian surgeon, Hoffa, gave to the medical profession
the results of his successful attempts at reduction by opening the hip
joint from behind and enlarging the acetabulum to a size sufficient to
hold the head of the femur.
Orthopedic surgery has to thank the irritating effects on the skin,
of antiseptics necessary in preparing his hands for ordinary surgery,
as it was due to this triviality that Lorenz, a promising surgeon of
Vienna, transferred his energies to the field of bloodless surgery and
gave to us the most valuable early work and present day technique in
the bloodless reduction of congenital dislocation of the hip.
The name, of course, is applied to a congenital deformity which
involves one or both hip joints, resulting in lameness, due to a
misplacement of the head of the femur from the acetabulum. Of all
congenital dislocations the hip joint is by far the most common and
most important. The misplacement is far more often unilateral than
bilateral and far more frequent in females than in males, the cause for
the latter probably being the difference which exists in aspect and
position of the acetabulum as well as the disproportionate laxity of
the capsule in the two sexes. It must be remembered that normally at
birth, the acetabulum covers only about one-third of the head of the
femur, and our most accepted theory as to the cause of this deformity,
is a defective development of the acetabulum or its posterior margin,
which may be primary or secondary to an abnormally prolonged fixation
of the limb in a position of flexion or adduction while in utero. At
birth it is quite probable that the dislocation is a subluxation only,
which becomes complete by muscular action and the use of the limb in
standing and walking.
The pathology of this disease is clearly established, and varies, of
course, with the age of the patient in strain and friction to which
the misplaced parts have been subjected. In children over two and
one-half years of age the acetabulum is usually shallow and small, and
filled with a deposit of fat and fibrous tissue. It is covered with
normal hyaline cartilage and nearly always the ligamentum teres is
present, but is so badly stretched and ribbon-like that ultimately the
artery accompanying it fails to function, resulting in a malformation
of the head of the femur. The capsular ligament is elongated and
thickened to accommodate the upper displacement of the femur, and the
anterior wall of it is stretched tight across the acetabulum like an
hour glass. The interior of the capsule is always partly lined with
synovial membrane. Usually a secondary acetabulum is found upon the
ileum, formed by the direct pressure of the head of the femur through
the capsule and the result of irritation of the periosteum of the
ileum, but it is as a rule, not deep enough to form a secure support
for the head of the bone. The neck of the femur is usually shorter
than normal and the upper extremity of the bone is somewhat atrophied.
The pelvis is usually slightly atrophied on the affected side, and
a lateral inclination of the spine may be present. The long muscles
of the thigh are shortened; while those attached to the pelvis and
trochanter are changed in direction and are usually lengthened.
[Illustration: Typical congenital dislocation of the hip, showing the
“hour glass” constriction of the capsular ligament.]
=Symptoms.=—As a rule congenital dislocation of the hip is not
accompanied by the defective development or deformity elsewhere, and
the symptoms are so diagnostic that there is little difficulty in
recognizing this condition even without the X-ray which is, of course,
a positive diagnosis.
Rarely does the displacement attract attention until the child begins
to walk. Often the child does not walk as early as it should. Sometimes
it may be delayed until the eighteenth month or second year and then
it walks with a limp which becomes more pronounced as the child grows
older until at the fourth or fifth year it is very decided. The limp
is peculiar and its character is explained by its cause; for the
shortened limb, owing to the elasticity of the capsule, becomes still
shorter when the weight is borne upon it, thus causing a peculiar lunge
of the body towards the short side like the normal motion of walking
downstairs. In compensation, of course, the pelvis is tilted towards
the short limb and its inclination is thereby increased, so that the
anterior superior spine lies at a lower level and in advance of the
opposite side. Usually the affected limb is about an inch shorter than
the sound one, and in adult life it is considerably more. The range
of abduction is much diminished, but flexion, extension and adduction
are quite normal, and the trochanter will be found elevated about
an inch above Nelaton’s line. If the thigh be flexed and adducted
to its extreme limit, the neck and head of the femur can be easily
distinguished moving under the gluteal muscles when the limb is
rotated, or the head can usually be readily palpated in front when the
limb is extended. Then, too, by fixing the pelvis and using traction
and upward pressure on the limb, the abnormal mobility or telescopic
motion is easily demonstrated and this, I might add, is a very
important test.
[Illustration: Outline of a radiograph following reduction and removal
of the first cast in unilateral dislocation of the hip. Notice the head
in the socket and the thigh still flexed and abducted.]
Rarely do we find a unilateral anterior dislocation, in which the
head of the bone lies beneath the anterior superior spine, but when
this position is present, the symptoms are much less marked than in
the ordinary form because the relation of the pelvis to the femur is
more nearly normal. The limp and the shortening of the limb are less
noticeable because the tissues attached to the anterior superior spine
form a relatively secure support.
The X-ray, of course, makes the diagnosis complete. Even though the
clinical diagnosis is certain, a radiograph is indispensable in every
case, particularly for the purpose of ascertaining the exact position
of the head and condition of the acetabulum and femur. The acetabulum
is usually shallow and poorly developed, more particularly the iliac
portion of its rim. After the reduction of the dislocation, an X-ray
picture should always be taken within the first few weeks, and before
the plaster of paris cast has been removed, to ascertain whether the
head of the femur is still in place.
[Illustration: Outline of the same case following removal of the second
cast. The head of the femur is firmly fixed in the acetabulum and the
position of the limb is nearly normal.]
As to bilateral dislocation of the hip, the pathology, of course, is
the same as in the unilateral type. The shortening of the limbs is
as a rule equal or nearly so, and when both femurs are displaced
backward, the pelvis is tilted forward thus presenting a marked lumbar
lordosis and protruding abdomen. The pelvis seems to be abnormally
wide, both buttocks are flattened and the thighs are separated by a
considerable space. The characteristic limp in this condition is an
exaggerated waddle, often spoken of as “sailor gait.” Again in this
condition rarely do we find an anterior dislocation, but when such
is the case, the entire body is swayed entirely backward, though the
lumbar lordosis is not increased, in fact usually presents a peculiarly
flattened appearance. Other symptoms differ only in a slight degree
from those of the ordinary posterior displacement. The physical signs
are the same as the unilateral displacement and are even more readily
recognized by the peculiar appearance and distinctive gait of the
patient. The swaggering gait of lumbar Pott’s Disease is somewhat
similar, but this is an acquired clinical condition of the spine in
which the hip joints are normal in appearance and nearly so in function.
Before taking up the usual procedure for the correction of congenital
dislocation of the hip, it might be interesting to touch on several
cases of this deformity in young children that I have reduced without
an anesthetic. If future experience proves as successful as these
cases it will entirely revolutionize the treatment of this condition
especially in children under twenty months of age. To begin with,
these children had just started to walk and it must be remembered that
at this stage the acetabula are nearly normal and there has been no
muscular or ligamentous contraction because very little weight has been
borne on the limb.
First the pelvis is held fixed by the assistant, and the thighs
completely flexed on the abdomen. Next firm pressure is made on the
knee to force the head of the femur beneath the acetabulum and as the
limb is abducted in the flexed position, the head is raised into the
acetabulum with the thumb of the operator’s other hand. The whole
procedure takes but a moment’s time and the child should be placed
at once upon the floor and allowed to walk. Time will tell if the
reduction has been successful, and if failure of retention develops,
the Lorenz method followed by plaster of Paris fixation can still be
used. I should always recommend the trial of this method in children
who have walked not longer than six months, before resorting to the
following Lorenz treatment.
=Treatment by the Lorenz Operation.=—This treatment is based on the
fact that there is normally present an acetabulum of sufficient size
and capacity to retain the head of the femur, providing the limb can be
fixed in a favorable attitude, and as soon as possible weight borne
upon it to deepen the rudimentary acetabulum. The typical operation
of today is best divided into four distinct steps; first, to overcome
the resistance of the tissues surrounding the joint; second, to reduce
the dislocation, or rather to force the head of the femur over the
posterior border of the acetabulum; third, to increase the security
of the articulation by stretching the anterior border of the capsule;
fourth, to fix the parts in a plaster of Paris bandage.
The child is completely anesthetized, and an assistant firmly fixes the
pelvis on the table with his hand. The operator first flexes the thigh
to a right angle with the body and forcibly abducts, at the same time
kneading and stretching the tense adductor muscles and if necessary
rupturing the adductor tendons in order to bring the limb down to the
plane with the body. Next to overcome the contraction of the posterior
tissues, the limb fully extended is flexed upon the trunk and gradually
forced downward until the toes touch the patient’s face. To overcome
the resistance of the tissues on the front of the joint, it is best
to move the patient to the edge of the table and forcibly extend the
thigh downward behind the plane of the body. It is also well to apply
direct traction in the line of the body. This preliminary stretching
is absolutely necessary, because all the tissues about the joint are
so shortened, and it will now be noted that with slight traction the
trochanter can be drawn down to Nelaton’s line.
Next reduction is attempted by grasping the limb with one hand at the
knee and strongly abducting it while the palm of the other hand is
placed on the anterior spine of the ilium with the thumb placed beneath
the great trochanter to act as fulcrum. As the limb is gradually forced
downward to and behind the body plane, the head of the femur is forced
upward until it finally slips over the posterior and inferior border of
the acetabulum. In the more resistant cases a padded wedge-shaped block
placed behind the trochanter will be an aid in pushing the head forward
and upward while the patient’s knee is forced downward. A successful
reduction is usually accompanied by a distinct jar and audible thud,
and it would be observed that the tension upon the ham string muscles
causes fixed flexion of the leg. After reduction has been made, the
limb should be brought down carefully into a straight position to test
the security of the re-position. If dislocation appears during this
manipulation, the tissues must be still further stretched and the
displacement further reduced. If displacement occurs readily due to a
shallowness of the acetabulum the prognosis is not so good as where
the stability remains when the limb is brought down into a straight
position, and one must be more particular in the fixation of it. I have
also observed that the more difficult the reduction the more stable
the end results. The easy replacements are usually just as easily
displaced. Sometimes the head slips into the socket quietly without the
distinct jar or thud but the results in these cases are just as good
provided they are properly cast.
[Illustration: Patient in position for the first cast in a left
unilateral dislocation. The thigh should be a little past a right angle
in relation to the trunk, with about 80° abduction.]
The application of the plaster spica is by far the most important part
of the treatment, as the reduction is usually quite easily accomplished
in children under six years of age. If the cast is improperly applied,
the hip will slip out of the socket and the case is a failure. A pair
of soft knitted cotton drawers are put on and the patient is placed
upon a pelvic rest with the limb held in the position of greatest
stability at a right angle with the trunk, or even slightly more and
about eighty degrees abduction. In a case where the socket is very
shallow, the position to be cast should be about one hundred degrees
flexion, and in abduction the limb should lie slightly behind the plane
of the body to secure the best results.
[Illustration: Correct position and proper application of cast for
double congenital dislocation of the hips.]
The limb and pelvis are covered with ordinary absorbent cotton which
is held in place with a roller gauze bandage. A snug fitting plaster
of Paris cast is now applied around the pelvis and well down over the
knee. I leave this over the knee for five or six days or until the
child ceases to be fretful, then I cut it away just back of the knee
joint to permit motion there. The ends of the drawers are drawn back
smoothly over the cast and are sewed to each other. For about a week
following the operation the adductor region is swollen and discolored
and more or less painful due to rupturing and stretching of those
tendons. After this discomfort has passed away, walking is encouraged
on the theory that the weight bearing and the stimulation of functional
activity will increase the stability of the joint by deepening the
acetabulum.
[Illustration: Proper position of the limb in the second cast for
unilateral dislocation.]
The first cast should remain from three to six months according to
the stability of the joint at the time of reduction. If in young
children the cast becomes offensive, it must be changed as often as is
necessary. When the first cast is removed, the limb is pulled down to
about thirty degrees abduction and the same amount of flexion, without
an anesthetic, and a second cast is applied, which extends only to
the knee, to be worn from three to six months longer. After removal
of second cast, the child is permitted to get about carefully. The
limb will be everted and slightly flexed, which position invariably
causes much concern among the relatives of the patient, but this
abnormal condition disappears after a few months’ time. Sometimes for
even a year following removal of the second cast there will also be a
noticeable hitch in the walk of the child; but this, too, disappears
and in the course of two years’ time one could never tell that such
an operation had been performed. Massage of the posterior and lateral
muscles of the hip always helps considerably towards the relief of any
stiffness or lameness.