—The diagnosis offers few difficulties. The peculiar waddling gait may be seen in extreme cases of bow-legs, but then the hip-joints will be normal. Extreme lordosis may be seen in cases of lumbar spinal caries, but here again the hip-joints will be normal, while the spinal muscles will be rigid and the patient disinclined to walk. Traumatic dislocations and the results of hip-joint disease will be indicated by a history to correspond, as will also early acute joint affections following the exanthems. The diagnosis is to be made principally from coxa vara, considered below, and the various defects following infantile palsy. In coxa vara there is no corresponding abnormality of motion, while in the paralytic cases there will often be failure in muscle power, which is not present in cases of congenital misplacement. Finally in instances which offer difficulties the Röntgen rays now afford a method of diagnosis.
Treatment.
—For a long time after this condition was recognized its treatment was unsatisfactory, and it was not until Hoffa, about fifteen years ago, advanced his operative method of relief that surgeons felt at all like advising operation in well-marked cases. Then came Paci and Lorenz, first with improvements on the Hoffa operation, and then with a method of so-called “bloodless” reposition, which has been under severe test and testimony. Last of all come Bradford and Sherman with their improved methods of operation, which seem to me the most promising of all as well as the most scientific.
Fig. 271
A plaster bandage applied by Lorenz, illustrating the extreme thickness of the pelvic portion and discoloration of the adductor region. (Whitman.)
Lorenz was doubtless correct when he stated that the principal obstruction to reduction is the narrowed part of the capsule, just at the upper part of the acetabulum, and that if this could be torn here sufficiently to permit the passage of the head, reduction could be accomplished by manipulation alone, and maintained if the acetabulum were sufficiently deep. An almost insuperable difficulty in most cases is, however, this narrowed capsule, and the number of accidents, including not only fractures of the femur and the pelvis, but various other injuries which have resulted from too great violence, is altogether too large and too disturbing to justify the use of such force as has often been used. Of more than one hundred children upon whom Lorenz operated when making a tour through the United States, but little over 10 per cent. have given anything like ideal results; while the danger from fracture and laceration of muscles and nerves, as well as of bloodvessels, is fully as great as that pertaining to any open operation. It may therefore be maintained that the percentage of success from the use of manual force without incision does not justify the risks of the method. Sherman argues that if we may open a knee-joint without hesitation to take out a small piece of cartilage, we need not fear to open a hip-joint in order to clear away a small obstacle. The patient is thereby saved from many dangers and exposed to so few that it seems more humane and desirable in every respect.
Sherman’s method is to make traction upon the limb, drawing the femoral head down to a point just below the anterior superior crest, where it can easily be felt, and to here make an incision over it in the direction of muscular fibers so that they are not divided. After division of the capsule the head of the bone is exposed and retractors substituted by long loops of suture, put in on either side of the opening in the capsules. In many cases a tenotomy of the adductor tendons close to the pubis will also be of advantage. The leg is next released from traction and the head of the bone allowed to glide upward, while the finger is slipped into the capsule and down toward the acetabulum. Upon this finger as a guide a long, straight, probe-pointed bistoury is passed, and with it the narrower portion of the capsule is cut through, down to the bone, taking care to not cut off the ileopsoas tendon. The incision must be large enough to give free access to the acetabulum. Traction is then again made with sufficient manipulation so that the femoral head may be forced into its proper cavity. When the head is in the acetabulum the retracting sutures are tied together so as to close the upper part of the capsule, and other sutures are introduced, as needed, to close the wound, leaving space for a cigarette drain. The limb is then put into a position of abduction of from 50 to 90 degrees, rotated in or not, as needed, and a comprehensive plaster-of-Paris spica applied. In this both limbs or only one may be included. The drain should be removed in two days and the dressing left otherwise undisturbed for three months.
Bradford has added somewhat to our methods by showing not only the arrangement of the capsule, but the fact that the acetabulum is often filled with dense fibrous tissue which sometimes obliterates it, and that this tissue can be curetted out, but that if it could be utilized to aid in retaining the reduced head of the femur it would be a great benefit. He operates as follows: The hip is subjected to preliminary forcible stretching of all soft parts which can be stretched by manual or mechanical force. A posterior incision is then made, which, without dividing muscles, permits free opening into the capsule and affords a channel to the deepest portion of the acetabulum. The posterior wall of the capsule is then split, after which all constricting and other obstacles at any point are carefully divided. These may be detected by the finger, and can also be seen by a small electric light passed down inside of a sterilized glass test tube. The capsular wound is then retracted by deep retaining silk sutures, placed at the lower rim of the acetabulum, thus affording a pathway for the reduction of the head. After this has been accomplished as described above, the sutures are tied closely around the femoral neck, and these retain it in position. The other portions of the split capsule are then sewed around the head and neck, to the trochanter and fascia, in such a way as to retain the bone where it has been placed.[37]
[37] American Journal of Orthopedic Surgery, October, 1905.