The Correction of Deformity resulting from Antecedent Disease of the Hip.—From neglect or from improper treatment, deformity may have been allowed to persist, while the disease has undergone cure. It is associated with ankylosis of the joint, or contracture of the soft parts or both. The contracture of the soft parts involves specially the tendons, fasciæ, and ligaments on the anterior and medial aspects of the joint, and is usually present to such a degree that, even if the joint were rendered mobile, these shortened structures would prevent correction of the deformity. The usual deformity is a combination of shortening, flexion, and adduction.
Bilateral Hip Disease.—Both hip-joints may become affected with tuberculous disease, either simultaneously or successively, and abscesses may form on both sides. The patient is necessarily confined to bed, and if the disease is recovered from, his capacity for walking may be seriously impaired, especially if the joints become fixed in an undesirable attitude. The most striking deformity occurs when both limbs are adducted so that they cross each other—one variety of the “scissor-leg” or “crossed-leg” deformity—in which the patient, if able to walk at all, does so by forward movements from the knees. An attempt should be made by arthroplasty to secure a movable joint at least on one side.
Other Diseases of the Hip-Joint
Pyogenic Diseases are met with in childhood and youth as a result of infection with the common pyogenic organisms, gonococci, pneumococci, or typhoid bacilli. While the organisms usually gain access to the tissues of the joint through the blood stream, a direct infection is occasionally observed from suppuration in the femoral lymph glands or in the bursa under the ilio-psoas.
The clinical features are sometimes remarkably latent and are much less striking than might be expected, especially when the hip affection occurs as a complication of an acute illness such as scarlet fever. It may even be entirely overlooked during the active stage, and only noticed when the head of the femur is found dislocated, or the joint ankylosed. In the acute arthritis of infants also, the clinical features may be comparatively mild, but as a rule they assume a type in which the suppurative element predominates. The limb usually becomes flexed and adducted, and a swelling forms in front of the joint at the upper part of Scarpa's triangle; the upper femoral epiphysis may be separated and furnish a sequestrum.
The flexion and adduction of the limb favour the occurrence of dislocation. A child who has recovered with dislocation on to the dorsum ilii is usually able to walk and run about, but with a limp or waddle which becomes more pronounced as he grows up. The condition closely resembles a congenital dislocation, but the history, and the presence of gross alterations in the upper end of the femur as seen with the X-rays, should usually suffice to differentiate them.
Treatment.—In the acute stage the limb is extended by means of the weight and pulley, and kept at rest with the single or double long splint, or by sand-bags. If there is suppuration, the joint should be aspirated or opened by an anterior incision, and Murphy's plan of filling the joint with formalin-glycerine may be adopted. In children, it is remarkable how completely the joint may recover.
If there is dislocation, the head of the femur should be reduced by manipulation with or without preliminary extension; it has been successful in about one-half of the cases in which it has been attempted. Preliminary tenotomy of the shortened tendons is required in some cases. When reduction by manipulation is impossible, the joint structures should be exposed by operation and the head of the bone replaced in the acetabulum. When the upper end of the femur has disappeared, the neck should be implanted in the acetabulum, and the limb placed in the abducted position.
Arthritis Deformans.—This disease is comparatively common at the hip, either as a mon-articular affection or simultaneously with other joints.