0 LDTH W'toT
SUBTROCHANTERIC OSTEOTOMY FOR THE CORRECTION
OF DEFORMITIES RESULTING FROM HIP DISEASE;
REPORT OF CASES.
JOEL E. GOLDTHWAIT, M.D.,
ORTHOPEDIC SURGEON TO THE CARNEY HOSPITAL ; VISITING SURGEON TO THE GOOD SAMARITAN
HOSPITAL : ASSISTANT-SURGEON TO THE BOSTON CHILDREN’S HOSPITAL, BOSTON.
C. F. PAINTER, M.D.,
Transactions of the American Orthopedic Association.
SUBTROCHANTERIC OSTEOTOMY FOR THE COR-
RECTION OF DEFORMITIES RESULTING FROM
HIP DISEASE ; REPORT OF CASES.
By JOEL E. GOLDTHW AIT, M.D.,
C. F. PAINTER, M.D.,
The following cases are reported in order to put on record a
series of ten consecutive osteotomies of the femur performed in
adults for the correction of the deformities resulting from hip dis-
ease, and also to call attention to certain conditions which have
resulted from these deformities and which have been strikingly
relieved by the operation. The cases are of interest partly because
of the degree of the deformity which existed and the immediate
results of the operation ; also, because of the effect which these
deformities have upon the general health and in producing symp-
toms in other parts of the body. The relief of such symptoms aud
the immediate improvement in the general condition have been most
striking, while the improvement in the mental condition, partly due
to this and partly due to correction of the unsightly deformity, has
been equally gratifying.
In all ten cases are reported. Of these eight were men and two
were women. All were of an age and position in which self-sup-
port was necessary, and in each instance it was because of this,
directly or indirectly, that treatment was sought, either from the
awkwardness or unsightliness of the deformity, or because of pain
or symptoms due to strain upon other parts of the body.
Case I. X., male, twenty-six years of age, clerk by occupa-
tion. He had hip disease when two years of age, which resulted
in the present deformity. Treatment was sought because of pain
in the back, due to the muscular strain attendant upon the fol-
lowing deformity : Right thigh flexed to 45 degrees, adducted 35
degrees, with extreme atrophy. There were three inches of actual
shortening and eight inches practical shortening. The hip was
firmly anchylosed. The operation was performed in January, 1896,
and the patient was kept iu bed for seven weeks with weight and
pulley extension and with the leg both flexed and abducted 15
degrees. At the end of the seven weeks all apparatus was removed
and the patient allowed to move about in bed for another week, at
the end of which time he was up, returning to work three months
after the operation.
Result. He now stands erect with one inch practical shortening.
His spine is now straight; he has had no pain in his back since the
operation ; has added two inches to his height and twenty-eight
pounds to his weight. There is, of course, no motion in the joint.
He is at work all the time and on his feet a great deal, and has
been able to indulge in mountain climbing the past summer, and
goes up and down stairs readily. Since the operation he has not
lost a day from work, whereas before that for a number of years
he had lost on the average three months in each year because of
the pain in his back, undoubtedly due to muscular strain. Before
the operation he could get around with the aid of a crutch or two
caues, and he is now able to go without either.
Case II. Mr. W . , thirty-one years of age, a drug clerk by
occupation, had hip disease since childhood, from which he had
recovered with a flexion and adduction deformity, for which he
had an osteotomy performed twelve years ago. This left him at
the time of his second operation, in April, 1896, with flexion and
abduction both of 45 degrees. He sought relief for pain in his
back and difficulty in walking. There were seven or eight inches
of practical shortening and the hip was anchylosed. After the opera-
tion he was in bed with traction and a long outside T-splint for
seven and one-half weeks and one week after the removal of the
Result. He has now 15 degrees of flexion and 10 degrees of
abduction, with three-quarters of an inch real and one-quarter of
an inch apparent shortening. The hip is, of course, still anchy-
JOEL E. GOLDTHWAIT AND C. F. PAINTER.
losed, but lie is at work without pain aud is on his feet most of the
time. Before the operation he went about with the aid of two
canes, while at present no support whatever is necessary.
Case III. Mary D. , eighteen years of age, had hip disease
when five years old. She was a domestic by occupation. When
first seen there were several old healed sinuses about the right hip,
in which there was no motion and which was flexed 60 degrees and
adducted 25 degrees, with one and one-quarter inch actual and four
inches apparent shortening of the leg. She was operated upon
January 31, 1896, aud the leg put up with 15 degrees of flexion.
The bed treatment was continued for seven weeks.
Result. There is real shortening of three and three-quarters
inches with apparent shortening of one and one-half inches. She
walks very well and can sit down easily. At the time of operation,
after the chisel was removed in the manipulation, the anchylosis
at the hip was broken up, and as a result there now remain about
60 degrees of motion in the joint.
Case IV. This patient (B. F.) was a girl, fifteen years of age,
whose hip disease was active in childhood. Her deformity consisted
of two and one-half inches real and five and one-quarter inches
apparent shortening. The hip was anchylosed and flexed to 50
degrees, adducted to 20 degrees, with three inches thigh atrophy
aud one and one-quarter inches atrophy of the calf. Operation
July 8, 1896. The after-treatment consisted of a T-splint with
eight pounds extension and 10 degrees flexion. Seven weeks later
there was a good union. On August 26th she was up, and the
apparent shortening was reduced so that a two-inch-high sole was
sufficient to overcome it. Fig. 1 illustrates the amount of flexion
before operation; Fig. 2 illustrates the spinal deformity in walking,
due to the shortened and flexed leg; Fig. 3 illustrates the result.
Case V. The fifth case is that of a boy (G. S.), nineteen years
of age, who had suffered from hip disease five and one-half years.
The hip was anchylosed in 70 degrees of flexion with 30 degrees of
adduction. He was operated upon at the Carney Hospital on June
3, 1896. As a result of the operation he now has 15 degrees flexion
and one-half inch apparent and two and one-half inches real
Fig, 4. Fig. 5. Fig.
JOEL E. GOLDTH WAIT AMD C. F. PAINTER
shortening. The bed treatment continued seven weeks with weight
and pulley, aud one week longer in bed without apparatus. A
cane was needed before but not after operation. Figs. 4, 5, and
6 illustrate the condition before operation, and Figs. 7 aud 8 after
Case VI. This case (J. B.) was one of combined hip and spine
disease, with great deformity. The patient was a youth, eighteen
years of age. At two years of age he had Pott’s disease, and four
years later hip disease. He had treatment with apparatus for
a time. Unable to do any work. Left hip dislocated on the
dorsum ; a few degrees of motion ; adducted and very marked
shortening, amounting to eight inches. Operated May 29, 1896.
JOEL E. GOLDTHWAIT AND C. F. PAINTER.
Union was delayed in this case on account of the osteotomy being
done too far away from the trochanter. In the early part of Sep-
tember, three months later, however, union was firm, and he used
a Thomas knee-splint for a time. A two-inch high sole accommo-
dates the present shortening. Crutches were used before operation,
and now he can get aloug with one cane. Fig. 9 illustrates con-
dition before operation, and Fig. 10 the condition after operation.
Case VII. This patient (M. K.) was a man, twenty-five years
of age; another case of hip and Pott’s disease with tremendous
deformity. Disease began in childhood. He has never had treat-
ment. At two and oue-half years of age the disease began in the
hip and spine simultaneously; there were numerous abscesses about
II A OSBO
JOEL E. GOLDTHWAIT AND C. F. PAINTER.
the hip, which healed at least twenty years ago. He had never
done any work and had been dependent upon the city for support.
He goes about now as he chooses, and is supporting himself at a
trade which he has learned since his operation. The photographs
show his condition very well : Figs. 11 and 12 illustrate position
before operation, and Fig. 13 the position after operation.
Case VIII. The next case (W. P.) was that of a young man,
eighteen years of age, who had hip disease some years ago. Left
leg adducted and flexed with very prominent trochanter. Thirty
degrees of motion in flexion; one-half inch real and four and
one-half inches apparent shortening. Curvature of the spine and
slight discharge from one of several old sinuses on hip. He was
operated upon February 25, 1897, and was discharged from the
hospital nine weeks later. The femur was dislocated dorsally, and
in the operation the adhesions in the new acetabulum were broken
up. He, however, recovered very well with a few degrees of motion
in flexion and one and one-quarter inch apparent shortening.
During the first few weeks after his discharge from the hospital
adduction seemed to be returning, so that on May 29, 1897, there
were two and one-half inches apparent shortening ; after that date
there was no increase, and he now has 30 degrees of motion in
flexion. No trouble arose from the discharging sinus, and it subse-
quently healed. Since this was written the old sinus opened and a
superficial abscess formed below the trochanter. Fig. 14 illustrates
adduction and shortening before operation, and Fig. 15 the position
Case IN. The next case (J. McG.) was that of a boy, sixteen
years of age. He was an old Children’s Hospital case, entering
the Out-patient Department in April, 1887 ; he was in the house
from January to April, 1888, for a hip abscess. Had been treated
with Thomas fixation-splint. He was provided with a traction and
fixation-splint and discharged in April, 1888, only to return on two
other occasions on account of the abscesses. His last record at the
hospital, which was made in 1891, describes him as having 40 de-
grees permanent flexion, two inches actual shortening and one and
one-half inches apparent shortening. This was in 1891. He is
at present under treatment. It was impossible to maintain the cor-
rected position with weight and extension, so a plaster spica was
put on. He had a few degrees of motion left in the hip, so the
thigh was put up abducted but not much flexed. At the present
writing he is going about without crutch or cane and without flexion
deformity and wears a patten.
Case X. Boy, fourteen years of age (F. K.), operated on June
19, 1895. Hip disease since childhood. Recovered with 60 de-
grees of flexion and 25 degrees of adduction.
Result. Three and one-half inches real and one and one-half
inches apparent shortening.
In such a series of cases the photographs tell most of the story
better than any description could do, as far as the purely physical
JOEL E. GOLDTHWAIT AND C. F. PAINTER. 11
defect is concerned. The influence, however, of deformities of this
nature upon the general health and mental condition, and the effects
produced by the straightening, cannot be shown in any such way,
nor even fully appreciated except by those who have come in
contact with the patients. It certainly was not the least good that
was accomplished for two of these men that they were enabled to
get about and participate in affairs they never had dared hope for,
and the effect in widening out the mental horizon for these poor
creatures has been very marked.
It is instructive to note also how marked lias been the improve-
ment in the general physical condition of all of these patieuts. The
importance of the operation in this regard cannot be too strongly
emphasized — from the extreme difficulty in locomotion, especially
when the attempt is made to get along without crutches or cane,
the physical condition is kept at the lowest ebb, and the resistance
to either the extension of the tubercular process or to the develop-
ment of some other disease is much below the normal. Another
point of interest is the fact that motion which is present in the par-
tially anchylosed cases is preserved, so that fear of losing what little
has been retained in these joints is no contraindication for opera-
tion. Cases III. and VIII. illustrate this point.
All of these patients of necessity had a lordosis and marked
lateral curvature of the spine as the result of the position it was
necessary to take in sitting or walking, and in several the symp-
toms which led them to seek treatment were entirely referred to the
The operation performed in these cases was that described by
Gant — the linear osteotomy being done as close below the tro-
chanter as possible. The only instruments used were the osteotome
and mallet. The after-treatment consisted in keeping the patient
in bed for eight weeks and the application of a long T-spiint reach-
ing up to the axilla, maintaining the thigh in a position of abduction
and flexion of about 15 degrees. An amount of traction sufficient
to steady the leg was used. In two cases the plaster spica had to
be employed because the patients tossed about too much to maintain
the position. The side splint and traction method were found the
more satisfactory because of the ease with which the position could
be watched and corrected, when it was necessary. At the end of
seven weeks the weights and splints were removed if union was
firm, and the patients were kept in bed a week longer and then
allowed to get up and go about on crutches. At the expiration of
twelve weeks most of the patients have been able to use the leg
without any artificial supports.
These cases add their testimony to the other reported instances
of this operation, and show that great physical disability can readily
be overcome with practically no risk and a comparatively short and
painless convalescence; that the effect of physical deformity on
intellectual development is very conspicuous, and that the benefit
derived from the operation is as much along these lines in those of
small mental calibre as it is in the correction of the deformity
itself ; that these deformities are capable of keeping down the gen-
eral health to a point of slight resistance ; that this is possibly more
true in the more highly organized types of individual than of the
lower grades ; and that deformity can be corrected and motion