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H. K. Lewis &.CO. ltd. 

meoical a sciENnric Booksellers. 

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135 Gower St.. London, w.c.i 





By the Same Author 





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Composite drawings. Outlines and dimensions of tiI>i:i 1 grafts to bring 
about e\l i a-a rl icula i arthrodesis of hip. Illustration at left indicates influence 
ol Wollf's Ian upon am stress-bearing graft. 1 rochanter ends of grails become 
ninth larger in diameter and slrongei because more stress comes upon that 
portion ol I hem. \s sircss increases from iliac ends lonard trochanter, grafts 
coincidentally gradually increase ihcir diameter, thus becoming cone sitaped. 
Drawing from \-ra\ laken iwenlv two years after implantation of grafts. 






M.D., LL.D., F.A.C.S. 

Past President, American Orthopaedic Association; 
Chairman, Rehabilitation Commission of the State 
of New Jersey 

Assisted by 


Associate in Orthopedic Surgery, Columbia University 
(New York Post-Graduate Medical School) 













To My Wife 


A MI I AMORIM I( )SIS iii (lie l real m m l ol condi 
lions ol the lii|> lias hern wrought hy (lie e\c'i 
increasing application ol surgic al procedures lo (lie 
numerous diseases and distortions ol this joint. Many ol the 
conditions lierctolore regarded as hopeless can now he ovei 
come h\ means ol surgery. I 1 1 e rapid and e\tensin' c\ol lit ion 
ol this operative work pins the epoc h making influence ol 
the World \\ at has justified the publication ol this work. 

Although I have h\ no means minimi/ed the importance 
ol c onset'\' at iv e methods, it has been m\ c hi el aim to In ing to 
the attention ol the medical prolession those surgical pro 
eedmes which ha\e stood the test ol time, and which have 
contributed so largely to the rec lam at ion ol cripples sullei ing 
Ironi hip conditions. Ihe select ion ol n 1 a t c 1 i a 1 loi inclusion 
within the covers ol this hook has been based upon the lol- 
lowing two criteria: 

1. All the' pi <>c echo es. c onsenat i\c oi operative, which I 
use. have Iicen incltided. 

2. I ha\e also included those procedures which I do not 
use but which are comnionlx employed bv surgeons ol 
experience' and mature judgment. 

Ihe inspiration lot the assembling ol this material has 
been largelx derived Ironi the appeals ol mv graduate and 
undergraduate' students ol the' past iluiiv years lor a book 
dealing with the treatment ol hip conditions, no book ha\ 
ing ever been writ ten in any language on this subject. Eli esc 
students asked Ini a book which covered not only those con 
servative methods ol treatment which time and experience' 
have demonstrated to be sound, but also the technique <>l 

i \ 



operative methods. A detailed dese i ipiion ol operative tecli 
ni(|ue is especial ly important since ort I toped i( textbooks have 
ncvei thoroughlv coveted tins phase ol the treatment ol hip 
conditions. In answer to these appeals, therefore, I have tried 
in this hook to present a complete survey ol the problem ol 
hip disease. 

An ellort has been made to provide a bibliography which 
is selective and usable rather than complete, and credit has 
been given, according to the knowledge ol the author, to the 
ideas and methods ol others. II any omissions or errors have 
occurred, they will be gladly corrected. 

Acknowledgment must be made ol my obligation and in 
debtedness to the members ol the' American Orthopaedic 
Association and to the prolession in general, especially to the 
late Sir Robert |ones, to Royal Whitman, and to mv manv 
foreign colleagues. Sincere gratitude should be expressed to 
all those who have so ably assisted in this work, especiallv 
Mr. Paul P>. II ocher of Harper and Brothers, and Miss 
Florence Fuller ol the publishers’ staff. Appreciation is also 
due Mr. Ernst Weigman for his cooperation in the prepara¬ 
tion of the original illustrations. 

Frf.d H. At m i 

A Vie York, N. Y., 

May, t 


i' \<a 

Pri i \ci.i\ 

1 IS I Ol 11 1 I S I RA I IO\S.\\ 


I. I \ I R< )l)l C I IC) X I 

II. \km am i \ i akh \i oi mi Scrcion i or I Iir Work . I> 

I- Ice 1 1 () < > | »c l ill i \ c Hone Mill and Ice li ni< | uc ol lis 

I'sage; I lie 1T at t n i c () 1 11 1 < »| hr I it () petal ing I able: 
Details. IMasiei-ol Pai is Handage and leehnieiue 
ol Its l sc. Mediotl ol Preparing and Storing 
IMasiei-ol-l’ai is Hanclagcs; IMasiei ol Pat is St rcngl li¬ 
en e t s; Ret|ni t einenis ol a IMasiei -ol-Pai is Handage; 
IMastcr-ol Pat is lethnitjiie; Removal ol a Plaster- 
ol-Pai is Spiea. 

III. Sl'RtaCM LWIIMVRKS, PrI Ol’l RA I IVI Pri rara i ion 

wo Incisions ........ 2 °, 

Prcopetalive Preparation. Snrgital Approaches. 
\nterolatetal \pproath; Posteiiot Approach; Lat¬ 
eral Appt oat li. 

IY. Trac i i ri s. 2 

Prat litre ol the Neck ol the lemur. Treatment ol 
I resit I- rat lines ol the Neck ol the Femur: Treat¬ 
ment ol I'nunilcd Fiat lints ol the Neck ol the 
Femur; Discussion. I i ansi roc ham ei ic Tract lire’s ol 
the lemur. F l a c lines ol the Acetabulum. 

V. 1)isi oc \ i ions. 

Congenital Dislocation. Pathological Analoim: 
Tliologv; Clinical Features; Diagnosis; Prognosis; 

(ilassi Ik al ion ol Cases; Closed Reduction; Results 
ol Manipulative Method; \eeidents and Compli 
cations; Open Reduction. Traumatic Dislocation: 



i ll AITKK 


i' u;k 

Closed Reduction: Open Reduction. I *a i a I \ l i c Dis- 
loc ai ion ol i lie lli|): Methods ol I i eat men l in 
Ordei ol Prclerence. 

\ I. 1 t m act cot s Dtsi asi 01 mi II ip Joint . i .j.j 

Etiology. I*athology and Moihid Anatomy. Svmp- 
toms and Physical Signs. Diagnosis: Absolute 
Diagnosis; Dillerential Diagnosis. Prognosis. Treat¬ 
ment: General Treatment; Local I reatment; Con¬ 
valescent I reatment; I 'reatment ol Deformities; 
Operative I reatment; Author’s Technique; Hass- 
11 i I > I is Ee< hnicpie. 

\ II. Synovitis, Imictiocs and Gonorrheai Arthritis, 

Si i’im ra it y r Ari'iiri ns, inch dint; Osteomyelitis 

and Act I I El’IPIIS SIIIS. 1 S.j 

Suiovitis: I reatment. Infectious or Rheumatoid 
Arthritis: Gonorrheal Arthritis. Suppurative Ar¬ 
thritis: Pyogenic Arthritis, Osteomvelilis. Syphilitic 
Arthritis. Neurotrophic Arthritis. 

\ 111. Arthroplasty to Overcome Limited Motion and 

Ankylosis . . . . . . . .201 

Types of Ankylosis. Etiology. Prophylaxis. Diag¬ 
nosis. Prognosis. I reatment. 

IX. Coxa Vara . 

Anatomical IA pes. Etiology. Classification. Clini¬ 
cal Features: Cervical and trochanteric Coxa 
Vara; Other Varieties; Congenital Coxa Vara. 
Treatment: Cervical and Erochanteric Coxa Vara: 
Epiplnscal Coxa Vara (Adolescent 1 raumatic). 
Coxa Valga: Etiology. 

X. P \ l< A I Y I 1 C Dl IORM 11 its. 

Abduc lion-llexion Contractures: I reatment. Ad¬ 
duction Contractures and Paralysis ol the Glutei: 
Paralysis ol the Glutei. Paraluic Hip and knee 
Elexion with knock-knee. Paralytic Dislocation. 

XI. Os 1 i-.oar n iRiris . . . . 2 C) 

Pathology. Symptoms and Diagnosis. Prognosis. 

Ereatment: Non-operative I reatment; Operative 



I i cal mull: (•cncral Discussion ol \i llnodcsiii” 

()i)ci alicms; Partial \i I In oplasl v. 

\ 11 . Misci i i wMH's C!om)I i io\s.275 

Neoplasms: Malignant (nowilis: CNsis ol ilic 

I'ppcr laid ol the Icmut. ()sico( liondi i 1 is 1 )c 
Ioniums juvenilis. Snapping Nip. 1 I \ s t c r i c a I I lip. 

I lemoplii I iac Disease. I’Ikh omel ia. I n 11 a pel \ i c Pro 
tiusion ol \( el aim I uni. (loxa Mai>na. 

Ixmx or Pi kso\ \i Nwiis.2S7 

I\1)1X Ol Si i; p ( Is ........ 2(S() 


Composite thawings showing outlines and dimensions 
nl lihial guilts to bring about c\l t a-atl i( ular atlliro- 
desis ol the hip and inlluenee ol W'olll s law upon any 
stress-bearing grail ...... k rout ispiecc 


Dtawings ol tippet end ol Intuit ol various animals 
disclosing relationship ol level at lop ol lenun with 
axis ol shall approximating conditions brought about 

bv a tit Inn \ i ec < msl me t ion 

operation .... 


• mi 

i . 


Klee 11 ic a 11 v driven c ire uhit s 

ivvx and 

drills . 



Motor attaehed to miniature lathe 

and sci ew-c lilting 

dev ise . 

1 o 

. > • 

Mullen's 1 1 ac t in e ot t hopedic 

opet ;tl ing table . 

1 2 


Mithors 1 1 ac lure < >i t hoped ic 

<)]>et at ing table; detaiIs ol 

distal portion ol traction arm and 

loot hold 

1 3 


Ih ac t ic a 1 application ol 11 ac 




1 )etai Is ol 11 ac t mn arms 

1 1 

/ • 

M o t o t c h i 11 

4 ° 


Method ol di tv mg in peg . 

1 1 


1 miniied 11 ac line ol net k ol 

lenun . 

pt eopei at iv e \-rai 

1 -’ 

i o. 

Same c ase, \-rav taken nine 




i i. 

Same case, v iav taken six ve 

at s a 1 let 


1 1 

1 L\ 

A rav taken live months allc 

i operation with insertion 

ol nails, showing nonunion and maiketl absorption 
ol nee k ol lenun ........ 

i t p Diagrams show ing vascularization ol anemic head 

ol lenun through blood vessels ol autogenous bonc- 
gralt peg (I'lginr // in Color) .... pi. jy 

). boiled ox-bone and nails as shown in v tav disclosing 

loose non-union . . . . . . . . ,|S 



I' H; l • K K 

i(>. 17. A ta\s <>I Smilh-Pctersen nails in place 

18. A ra\ showing kirsclmci wire which has wandered into 

pel\ is. 

19. H ip ten acid inn. 

20. Iechnicjne ol use ol wedge in authoi s reconstruction 

operation lor ununiled Iracture (Color) 

21. A ra\ showing result ol technioue shown in Figure 20 

22. A ra\ ol non-union ol neck ol lemur, six months alter 

Irac line 

23. Postoperative result in same case, alter leverage at top 

ol lennn was elongated In wedged femoral head 

21. Photograph in case ol ununited fracture of neck ol 
1 elt lennn ol ten years' duration . . . . . 

25, 2(1. W hitman reconstruction operation, showing line ol 
section ol trochanlei and point on shall to which il 
is to be transferred. 

27. Relationship of reconstructed neck to weight-beating . 

28. Double congenital dislocation of hips . . . . 

2C). Unilateral congenital dislocation ol hip . 

30. Twist ol neck in congcnilall} dislocated femur, look¬ 

ing front above downward ...... 

31. Lordosis in double congenital dislocation ol hip . 

32. Broadening ol perineum with prominence ol tro¬ 

chanters in double congenital dislocation . 

33. Congenital dislocation of hip, showing palpability of 

acetabulum in absence ol head, as diagnostic leature 
of considerable importance ...... 

3 1 Pnlli’s brace. 

33. Kneading ol adductors, allecled thigh being in llexion 

3(i. First maneuver in reduction ol dislocation 

37. Second maneuver ......... 

38. Third maneuver, characterized b\ adduction and inter 

nal total ion added to llexion ...... 

39. Third maneuver (coutitiuecl) ...... 

|o. Third maneuvei (concluded) ...... 



5 r > 



f >3 


(, 5 






8 1 











IK.l'RK l'.VC.K 

|i. (llioscn position lor splinting ...... 102 

12. \ | > 1 > I i c ation ol plastcr-ol-Paris tolls over stockinet and 

cotton wadding ......... m;; 

IP l.oii” double plastei -ol l’ai is spiea billowing reduction 
ol congenital dislocation ol hip 

I p A ravs taken through plastei a lew (lavs alter redni lion 
ol a double congenital dislocation ol hips . 

15. \nterior reluxation ........ 

Various shell operations lot siabili/alion ol hip in con 
genital dislocation ........ 

|S. Author’s shell operation ..... 120. 

Congenital dislocation ol hip; \-ra\ taken live wars 
alter operation ......... 

Diagram ol bifurcation operation ..... 

Deepening ol acetabulum In building out tint with 
bone grafts .......... 

Old tuberculous hip. ankvlosed in marked llexion and 
addtu lion 

Same case. Adduction llexion dclormitv overcome In 
< i 1 c it Li 1 osteotomy ........ 

Vdvanced tuberculosis with complete destruction of 
head and partial destruction ol neck; symptoms re¬ 
lieved In extra-art ic it I a 1 arthrodesis bv tibial malt . 


17 • 

5 () - 
.") 1 • 

. >. >• 




1 1 s 

I 2 I 

I ‘CO 

I I 2 

. ).) 

I lib 

pp. Some ol the mote iinpot taut methods ol extra-art ic uiai 

at lhrodesis ol hip . . . . . . 1 bp 

p b. I ec h n ic pie ol a it In odes is ol t u here 11 Ions hip with tibial 


pp. Second step in arthrodesis technique . . . . ipi 

pH. Postoperative' result eight veins alter aitlnodesis bv 

tibial gralt tec Imiquc . . . . 1 pp 

pi). I echnic|ue ol Icmoral grail lor inhere ulous disease ol 

•''P. '71 

bo. A-iav showing lesulls ol ext 1 a-ai I ic u lai arthrodesis bv 

aulhoi’s modification ol the I lass-1 lihhs procedure . ipp 

til. Sliding grab Iron) ilium in place ..... ipti 



A -rav showing lech nit pie in cases of extensive destruc- 
lion l>\ tuberculous disease «>I hip .... 178 

(>3. I echnicpte ol graft in cases ol extensive destruction . 17c) 

()]. Ini])lanta(ion ol denuded trochanter under an osteo¬ 
periosteal door I Klin 011 lei surfac e ol ilium . . 180 

();5- Landmark for aspiration or injection ol hip joint . . 188 

(ili. Old acute epiphysitis, with destruction ol head and 

neck and dislocation upward ol trochanter . . ipy 

(>7. Erection ol hone grail shell over lop ol trochanter . 198 

()8. A-ra\ to illustrate a common occurrence in tuberculosis 

ol hip ........... 2o(i 

69. Same case alter removal of most ol tibial grafts and an 

arthropiastv restoring motion to within 20 degrees 
of normal .......... 207 

70. Same case, showing satislac lorv, paitdess motion at left 

hip ........... 208 

71. Femiu sepat tiled I rout pelv is . .212 

72. 73. Surfaces smoothed and transformed into rcgulai 

spherical convex and concave surfaces b\ arthro- 
plastic hip rasps ....... 213, 214 

7P Flap ol Itisciti and fat being heed Iroin underhing 

muscles of tliigh . . . . . . .215 

75. Improper method ol dissecling-out a lasc itd 1 rtinspLint 21 (» 

7(1. Fascial and fat transplant in place ..... 217 

77. Diagram to illustrate lengthening ol lever arm tit top 

ol femur where it has been shortened following ar- 
throplastv to restore motion {Color) . . . .218 

78. Angles ol inclination ol lemoral neck Irom normal to 

two stages ol coxa vara ....... 224 

7<). Motoi chill holes in circular osteolomv .... 234 

80. Holes connec ted with Jones's saw in circular osteotome 235 

81. Apposition of Iragmcnls in cireulai osteolomv . . 237 

82. Diau ing i 11 11 si rating princ iples ol c uneiloi 111 osteotomv 238 

83. 'Fransverse osteotomy . . . . . . . . 239 

84. Kpiphysetil separation (Iraciure) til upper end ol femm 242 


i'll,IKK i’a<;k 

SI )\s|)il ii ii.ii \ tvpe i>l iiidix part ic nlari v pione to 

sepal at ion ul capital cpi | )l i \ sis ol Icimii . . 2.13 

Sli. Maneuvers ol reduction ol epiphvscal sepaialion al 

111 >| H I (.‘11(1 ol IcilHI I . . 2 | |, 2.| 5 

Sj. 1 | > 1 pli\seal sepal al ion al 11 p pci end ol lemiii. A ia\ 

showing results ol reduction . . 2 pi 

SS. L\pe ol individual paiiicnlarlv prone to epiplivseal 

separation .......... 2)7 

Si), l.pi|)li\seal separation al nppei end ol leiinn . 2 p) 

()o. Author s method ol applying plaster-ol I'aris spica 250 

<) 1. Side view: application ol spua over hexed knee . 250 

<)2. Lpiphvseal separation Irom jiinip ..... 251 

i)‘P Skiagram taken six weeks altci rednclion in same case 252 

() P Adv anced osteoai tin itis ....... 2<>(> 

After Sissons Drawing from Xray 

Veterinary Anatomy 

Upper end of lemur of various animals discloses relationship of lever 
at top ol lemur will) axis of shall approximating very closely conditions 
brought about by my reconstruction operation. I bis is in contrast to 
condition brought about I»\ Whitman and Uolonna operations, in which 
outer end ol lever arm is great Iv depressed, thus shortening il and di¬ 
minishing iis mechanical ellecliveness. Also in both these operations the 
great trochanter, which makes up a pari ol this lever arm. is removed. 



Chapter I 


s oilers to the bone mii 
to apply bis ingenuiI \ 

■1. .md skill. Yet there is probably no large joint upon 
which less sin gers had been attempted up to the past dm is 
years. In lac t. alt hough art h rodesis ol the knee joint lor t u bei 
culosis and other conditions had been frequently undertaken 
bs a large number ol surgeons in the course ol many years, 
no one had es en attempted to des ise an operation lor art hro 
desks ol the hip joint until the author offered such an opera 
t ion * in 1 <)o8. 

It mas be that the peculiar c harac ter ol this joint has been 
the main obstac le to the development ol surgical procedures 
lot its diseases and disabilities. Not only is it a ball and 
socket joint, w hic h increases the dilhc ulties ol adequate treat 
ment. but it is also a weight bearing joint and subject to the 
stresses and strains ol ac t is c* function lor that purpose. This 
joint is unique among the larger joints in that act ise weight¬ 
bearing is dependent upon the coordinated pull of the most 
powerful muscles ol the body upon physiological bone levers, 
the most important ol which is the neck ol the lemur. In the 
absence ol these bolts levers, then restoration lurlhei tests 
the versat i I ity ol the surgeon. 

A lurlhei problem presented is the- deep situation ol the 
joint, making access and diagnosis diflicult. For a long time, 
successlul surgical reconstruction was deemed impracticable, 
il not impossible, foi instance, a congenital dislocation ol 
the hip in wliic h the acetabulum was so shallow that the 1 hip. 
even though reduced, would not stay in place, was regarded 

’ Sllicc, I II. \ilhrilis deformans ol the hip. /. /. W. /.. -,o: iq-- kjoS. 



as a hopeless problem, and no operation was proposed until 
i <> i p* No suggestion to this end was made even in the final 
report ol the Oonnnission lor the Study ol Congenital 1)is 
loc ated Ilipol the American Orthopaedic Association (ic) 22 ). 
Thirty years ago, there were no motor-driven tools or frac¬ 
ture orthopedic tables and roentgenographic diagnosis was in 
its inlancy. These have been no small factors in changing 
the aspect ol the problem, contributing to the most far- 
reaching advances in treatment ol lesions ol the hip within 
the relatively short space ol three decades. In addition to 
advances in technicjue, a better understanding ol the bio- 
physiological conditions within the joint has developed and 
has had the effect of opening up avenues of attack which 
have led to far better results than had hitherto been obtained. 

It is vitallv necessary, therelore, that any one undertaking 
treatment of pathological conditions ol the hip joint be lully 
cognizant of the new light that has been thrown upon the 
whole subject within a very short space ol time. 

It is of importance to understand the interrelationship 
between the biophysiological requirements ol the joint and 
its treatment. Among the various problems ol equal impor¬ 
tance, might be c ited frac ture ol the neck ol the femur—one 
of the most widely discussed problems in surgery today. The 
multiplicity of methods which have been proposed lor its 
treatment is evidence ol the interest it arouses and also ol 
the lack ol understanding ol its underlying biophysiology. 
This was emphasized by the fact that lot the annual Iracture 
oration before the Clinical Congress ol the American College 
ol Surgeons in i<)g p Dr. Kellogg Speed f c hose as his subject 
fracture ol the neck ol the lemur and justified his choice 
with the remark that the problem ol subcapital fracture ol 
the* neck ol the lemur is. as yet, unsolved. In fact, he chose 

I he C i isolved Tract lire” as the- title of his oral ion. 

In congenital dislocation ol the hip. il it is possible to re 

* \lbee, I II. I In' hone "Tall wedge. \Vie York \l. /. ( \ug.(. H)i j. 

| Speed, k, I lie unsolved liaclnre. Si/j'g., Oy net. Ohs!., Go: •{ 11. i < . 



dun.- the* hip. the* i ini <>l the* acetabulum t ail he augmented 
Nil flu ientlv id hold the head <>l the leiiun Imnly in plate. 
II It is impossible to redtite the head ol the leinui into the 
sotket. a so-called shell technique has made it possible to 
build l>\ bone grail a new socket highci up on the ilium. 

I his technique has been made available lot the case ol re 
current 01 permanent dislocation, whcthci ol congenital, 
traumatic, paralytic <>i pathologic origin. 

both intra-art it ulai and e\t i a art it ular arthrodeses lot 
treatment ol chronic joint lesions have resulted in tapid 
healing ol these conditions, not onl\ saving many months 
and years ol clisabililv but also preventing the complication 
ol marked underdevelopment ol the whole extremity and 
distortions such as marked joint laxity (knock-knee and genu 
recurvatum) which resulted Irom long-continued splintage. 

Furthermore, hips long ankvlosed Irom any cause what 
ever mav be restored not only to motion but also to stabilized 
weight-bearing strength and active joint lunction. Ibis 
follows because the contoiu ol the upper end ol the lemur 
is changed bv massive bone gralts, thus affording the propei 
leverage to the musculature. 

I hese techniques so briefly touc hed upon were previously 
considered impossible, or at least impracticable. They have 
been made available because ol concurrent developments in 
diagnostic measures, preoperative and postoperative control 
ol the extremity bv means ol the Iracture orthopedic table, 
and operative versatility made possible by motor-driven pre¬ 
cision tools, permitting accurate cutting and molding ol bone. 
T>v such means, operating t ime and the hazards ol shock have 
been markediv diminished, and in innumerable wavs the 
execution ol complicated and otherwise prolonged technical 
operations has been made feasible. 

1 reatment ol subcapital Irac ture ol the nec k of the femur 
is not a mattei ol mec hanics alone, as it has been almost uni 
\ ersallv considered. In (act, an entirely new conception is 
nccessarv to take - this dillic lilt problem out ol the category 



ol mere met 'Manic s and place u where ii belongs, in cnnjunc- 
tion with therapeutics based on physiology and biology. 

Ii is a peculiarity ol the human mind in the mass that it 
is more inclined to accept than to question. This habit ol 
thinking underlies the unquestioning acceptance of two 
erroneous beliefs concerning subcapital frac ture of the neck 
ol the lemur, the Inst being that treatment ol this fracture 
is solely a mec hanical problem, requiring only reduction and 
immobilization; and the second that the head and neck ol 
the lemur isolated by I met lire, because of their intra-articu- 
lar situation, are adequately supplied with blood by way ol 
the ligamentum teres and are capable of forming callus. 

By attempts to inject the blood vessels ol the ligamentum 
teres in the cadaver with metallic mercury, Wolcott* re¬ 
cently showed that in ir, per cent not a vestige ol blood 
supply was anatomically demonstrable from this source. I 
can safely say that during the course of twenty years ol ob¬ 
servation at the operating table in qi2 cases of removal of 
the head of the femur following non-union, non-existence 
of circulation was evidenced by absence ol complicating 
bleeding from the ligamentum teres in all but one case. My 
experience tends to show that in the cases ol non-union, the 
blood vessels erf the ligamentum teres supplying the proximal 
fracture fragment were destroyed with rupture ol the liga¬ 
ment at the time of the initial trauma. 

As a result o! these observations, the proper treatment of 
this fracture is, in many cases, based upon a tripod, ol 
which one element represents reduction and mechanical 
mobilization, another the physiological or vascular require¬ 
ments and the third the biological or osteogenetic needs. 

Reduc tion and mec hanical immobilization have been made 
possible by the development ol new apparatus—motor-driven 
tools, fracture orthopedic table and the double plaster spica. 
Once one realizes that there is no blood supply to an isolated 
femoral head, it becomes evident that this must be lurnished, 

* Person;!I cotmmmic at ion l<> the nullioi with permission to quote. 



il |><)vsii)U\ l>\ othct menus. Such .1 head isolated l>\ 
subcapital Irarture const it ulcs iu hut a joint mouse. \ lack 
<)I osteogenesis 01 ( alius lorming c apabi I it v is a dim l 1 esult ol 
the dearth ol blood-supply'. |ohnson 1 showed that the ostco 
geneti( rapabilitv ol a cross-section ol hone is in direct rela 
tion to its blood-supply. I he hone gralt, because it is capable 
ol conduct ing bloodvessels when placed across the Irarture 
line, not onh brings the necessarv supplv ol blood to the 
capital Imminent Iron) the vasrulai cancellous tissue ol the 
trochanter, but also lurnishes bone cells locallv to the in 
ac t i\ c I rac t m e junct ion. 

Open sunken ol the hip is principally a development ol 
the past three dec ades. I'hirt\ vents ago entering the hip 
joint surgirallv was thought to be liaught with great ha/ards. 
Methods ol procedure were relatively primitive, and there 
was by no means the understanding of the underlying princi 
pies governing the surccsslul treatment ol lesions ol the hip 
that we hav e toclav. 

I he bone grab alone lias placed a majot part toward this 

[ohiison. R. VV . \ pin s i < >1 (i ( at sind\ ol (lie blood so j >j »l \ ol the dia 

|> 1 1 \si/. limit g / niiil Surg.. «|: 1 . \ty2~. 

Chapter II 


H OSI’I FAFS arc, as a rule, poorly equipped lor liar 
lure work, and in many instances surgeons of the 
general staff, overstimulated by their zeal lot gen¬ 
eral surgical operations, allow their fracture eases to take 
a subsidiary position. For this reason, many hospitals have 
devoted their linances to the most minute details of equip¬ 
ment for their favorite departments, and have sadly neglected 
to provide an adequate armamentarium for Iracturc and 
other bone work. A strong impetus to rectify this discrepancy 
was afforded by the large number ol fractures and other bone 
injuries accruing from the World Whir. 

A complete armamentarium for the bone surgeon should 
contain the following: 

t. Frac tion operating table; 

2. Fleetro-operative bone outfit; 

g. Suitable retractors, sharp-pointed and rake, and ol 
varying sizes and depth of tooth; 

I. bone c lamps; 

5. bone elevators (V.g.. Fane’s); 

h. Double tenaculum for aiding in extracting and hold 
ing head of the femur (author's); 

7. I lip shapers (convex and concave) lor arthroplastv; 

8. Materials lot external and internal fixation ol I rag 
merits, including kangaroo tendon ol various sizes: 

(). Various metal nails. Iracturc plates, screws and tools 
lot (licit application: 

(a) Smith Petersen nail: 

(b) Vail's nail; 




it ) lelson Ransolioll Mavcr threaded nail: 

(d) Moore adjustable nail with nut: 
c) I > 11 n n cl I -mdc which is attached to the \lbce 
tnotoi and aids in the accurate placement <>l the 
hone pen, through the neck and head ol the 

We I > c ■ I i t • \ c ■ that llic wood screw, adapted only lor soli ma¬ 
terials. should ilever he used in hone, and onl\ a sell-lapping 
screw, oi a suitable screw with a mechanical lap, should be 

Furthermore, the author is convinced from a vers careful 
laboratory investigation, that silver wire should be entirely 
omitted Irom the surgeon's armamentarium; it is a very treach¬ 
erous agent because ii is so likel\ to break at the twist, where it 
is fixed. It is surprising how little force a large strand ol silver 
wire will withstand at the twist junction when placed in an 
accurate machine lor testing tensile strength. In many instances, 
the* wire* will begin to yield at the* twist or knot before the 
dial ol the testing machine has begun to register. 

to. (Xsteotomes ol various w idths. The author novel undci 
am circumstances uses a bl unt-edged chisel. 'There is 
so little flexibility in hone that it brushes or breaks 
verv rcadih nuclei the* chisel, and lot that reason, a 
thin-edged osteotome is prclerable. 
it. Rongeurs ol various types; 
t 2. I .ion jaw lore eps; 

t(.ouges w ith long handles and ol various w idths; 
ip lleavv mallet; should be* large and ol solid metal. 

although one ol lignum vitae is very good; 
tSuitable materials lor external lixation diessings. The 
importance ol this should be emphasized, and it ts 
I in t ltetmote believed that every surgeon having am 
thing to do w ith Irad tires should thoroughly mastei 
plaster ol Paris lech nit pie. Suitable* materials consist ol 
plastei ol Palis rollei bandages and "si rengl hciiers" 
(the* laltei arc* ol the greatest .service), as well as cotton 
sheet wadding, stockinet. or llannel: 



11). I he 1 >al kan I >ed I rame; 

17. I homas brace and other necessary apparatus. 

I ni I t i<i kooi-i i< \ 11 vi- Ijom Mir.i. a\ 1 > Technique 

of I ts l T S\(. 1 

In modeling the grail into dowels, wedges and inlays, 
and in making use o! the different well-known mechanical 
devices, such as tongue-and-groove joints, dovetail joints, 
mortises, etc., the motoi outlit is indispensable. An accurate 
c abinet maker s lit may mean success in many instances where 
an ordinary crude coaptation would mean failure. Especially 
is this true at the hip. 

It is only when the most precise cabinetmaker’s lit has 
been secured, that the lull inlluence ol Rouxs law of Iric- 
tional stimulation to osteogenesis is obtained. This is a most 
potent influence in stimulating callus formation or securing 

T he ideal electromotor outfit should measure up to the 
following recpiirements: 

1. It should permit ol the thorough and rapid steriliza¬ 
tion ol every part which comes in contact with the 
surgeon 01 the held of operation, including the elec¬ 
tric cable for transmitting the power. 

2. It should permit of ready application to all tvpes ol 
osteoplasty, whethci situated superficially or in a deep 
wound; whether the work to be clone is the proc uring 
of a graft, the preparation of its bed. the drilling of 
holes, the removal of bone I01 the correction of de¬ 
formity or curing disease, or to allow the proper ap¬ 
proximation and alignment ol bone Iragments in eases 
ol fracture. 

i >. It should permit acc urate control and guidance ol the 
motoi cutting tool in all wounds and at all angles. 

I he flexible shaft lormerb used in dental out tits but 
given up some years ago, is not suitable lor trails 
milling the power to the cutting tool, because, lor the 



same reason given l>\ the dentist, it causes the ( titling 
tool to \ iIn ate 01 "c hat ter and does not a I low the tool 
to he directed in c\er\ coneeivable direction. 

|. It should permit eas\ and convenient control ol the 
elect tic current and speed ol the cutting tool. 

It should he light in weight, small in hulk, and permit 
ol eas\ transportation. 

(>. The motor should he universal and adapted to till 
types ol motor electric current. 

The motor instruments—saws ol diUcrent types, drills, 
dowel-shapers, etc.—should he held in place in the 
motor hv an automatic' catch, hooting their speedy 

(S. The motoi cutting tools should he constructed sitni 
larlv to those long used hv the artisan lot working 
hard materials—should he ol sullic ient variety to meet 
evet \ t c'<piirentetit ol hone carpentry or machine work, 
and should include all kinds ol automatic tools. The 
twin saw lot inlay work should (log. t) he so con 
stt tic ted that it c an readily he adjlisted—to the Iraclinn 
ol a millimeter—1>\ the gloved hands ol the surgeon at 



the operatin'*' table. Dowel shapers should have inter¬ 
changeable ( inters <>l sizes varying sudicicntly to meet 
all rec111itenients. Various motor driven dies should 

Motor Attached to Miniature Lathe and Screw Cuttino Dense 

Threading die 
inside of guide 

fi Bone Graff Peg made by cuffer No 1 (No2) tv;7/ aufomafically 
and accurately fii info a drill hole made by drill No 1 (No 2) 


Jowe/s or 
female differs 

Bone graft screw 
. in process 
of making 

of making 

bone peg 


Fig. 2. 

allow threads to be put on pegs of any si/e, thus trans¬ 
posing them to screws (Fig. 2). Corresponding si/e 
drills and taps make the threaded holes for the recep¬ 
tion ol the bone-graft screws. 

(). idle motor should furnish enough power to drive 
rapidly a twin saw or large drill through the thickest 
cortex ol human bone without tendenev to stall. I hc 
motor tool is best attached directly to the motor shalt; 
the motor covered by <111 adjustable sterili/.able shell, 
enabling the surgeon to hold the motor in his hands 
while the tool is c utting; the weight ol the motor itsell 
( j pounds) has been found to be an advantage rather 
than a drawback in its application. 

Tin Fraciirk Ortiioim me Opfratim; Tabli: 

In recent years, several excellent Iracture orthopedic tables 
have been developed. 1 lie author, however, has had no ex¬ 
perience with these new tables, as he has used exclusive!) 


the one which he designed dhi twcnlv vears Some ol 

die important leal tires ol 111 is ladle are detailed. 

I he lahle is ( ompai at i\civ light In weight. 11 s lop is con- 
siiniled ol Monell melal. which is non-corrosive and non 
o\idi/adle. 1 lie liaine is made ol bra/ctl tubular malciial, 
lo allord the lightest and strongest sirnctnre possible. All 
loin wheels aie swiveled, die two al the loot end being Ini 
nished with loot locks to 1 1 \ the ladle and prevent it Iron) 
rolling. When lolded it]), this table is as short as the usual 
general operating table, and because ol this and the lac t 
that there are no parts projecting when it is not being used 
lot traction, it is ol use for general surgery. 

1)1 I All s 

The Irucks ol tlu 1 table rest on swivel rollers, permitting 
it to be moved about easily, while a locking apparatus 
f ig. '■>) over the two at the lower end, operated by the loot, 
permits it to be easilv lived in the desired place. The ability 
to move the table about easilv is ol the greatest convenience, 
in that at any time during the operation, the table can be 
sci moved that better light is secured in the depth ol the 
wound, or the clinical observers can be afforded a better 
view ol the operative procedure. 

A sliding leal at the loot and a hinged leal at the head 
allow the table to be lengthened as muc h as necessary, while 
a removable shelf steadied In a rest c an be used lor instru¬ 
ments or to support the arm or leg of the patient. 

The long hat lion turns are telescoped and therefore allow 
sitllu ient shortening so that they c an be swung under and 
out ol the way when the table is being used lor general pur 
poses and traction is not recpiircd (Fig. |). 

Ilt/t rests are ol two sizes. I he head ol the table is movable 
up and down Iron) the hip rest, so as to allow the applica 
t ion ol v at ions widths ol spit as. 

* All>ee, I II \ new IiaicI iiic*oii hoi>(*<li< onri ;i( iiu» i;ibk*. \// /'<*'. (»' xncc. 
Ohsl | unc, bSu, 11) i s. 


1 lie loot end ol the table can he elevated to any de¬ 
sired height, by means of a wheel with handle (Fig. r )t I>). 
I his abihlx to raise 01 lozen llic fool end ol the table by 

lii.. 3 . Author's fracture orthopedic operating table. table opened to its 
lull extent, showing sliding leaf at loot, hinged leaf at head, removable arm- 
shell with rest, long traction rods with fool bars, arm suspension apparatus, 
perineal posl, swiveled rollers with locking apparatus, etc. (From AI bee’s 
“Orthopedic and Reconstruction Surgcrv," Saunders.) 

graduated adjustment is an important innovation, in that it 
allows sand-bags or pillows to be placed beneath the sagging 
ends ol tract tire fragments, to elevate these I ragmen ts in the 
proper alignment. This is readily accomplished by a few 
turns ol the wheel, the handle ol which is accessible to the 
surgeon, by whom it may be grasped under a sterile towel, 
so that at any time dining the operation the surgeon has the 
mechanism ol the table under his complete control. The 
surgeon is enabled bv depressing this portion ol the table 
and inserting a sand-bag under one Imttock, to have com¬ 
plete control ol the 1 upward rotation of the patient's hip or 
pelvis in am degree desired, both before and during the 
operation. Also a double-ended rake retractor mav be hooked 



beneath the movable leal ol the table and am desired tia< 
lion down and outward or retraction may be exerted by a 
U'w t m ns ol the wheel ( P>). 

I n.. |. \uthors I r;ictlire orthopedic opcr;il ing t.ible. Details ol distal poi 
lion ol traction arm and loot hold. y. (.rip ol screw lot “line" adjnsinient ol 
traction: /. collai to preveni draping sheets l’rom becoming “jammed" in 
threads ol screw: //. adjusting screws: v, bos lor tool bat and bed rest; 
;e. sliding heel rest which slides back to release loot and plastei splint from 
table: \, broad Hal steel loot bat which after cutting bandages is withdrawn 
from slot in traction arm. thus freeing completely patient s foot from table. 
From Albee's “Orthopedic and Reconstruction Surgery." Saunders.) 

I k., j. [’radical application of traction. Foot bandaged 1 >\ p to foot bar. 
bandage passing o\et projection \ ol loot bar. leg is swung into desired de¬ 
gree of abduction and fixed by turning set screw in. (.toss traction is made 
l>\ elongating ji and fixed by tightening <>. flexion is scented In elongating r 
and fixed by tightening i/. (heater traction is seemed by turning grip ol 
screw '. I owet hall ol table y is lowered by turning tc. lo mercoinc posterioi 
displacement ol a short lowci fragment ol the femur, a pillow or block and 
sand bag t’ ma\ be placed nuclei offending fragment and table again elevated, 
levering Iragment into place, while internal fixation agent (inlay bone graft, 
kangaroo suture, ccite or I ane plate) is applied. In a similar y\ay rotation of 
patient's 11 link may be controlled by placing a sand bag between hip and 
moyable portion ol table. \ levy tin ns ol wheel up or down controls situation 
verv satisfactorily. (From Albee's “Orthopedic and Reconstruction Surgery." 

Lengthenin'; ol the traction arm is accomplished l>\ two 
adjustments. Coarse adjustment is attained by graduated tele 
scoping ol the arm: and a more powerful, line adjustment, 
accomplished l>\ means ol a st rew. This st rew feeds as well 
distallx as proximallv when the wheel is turned. Failure ol 
this hack Iced has proved a great annoyance in otliet traction 



tables. I he screw threads are covered by a metal cull' which 
prevents jamming <>I sheets 01 towels into the threads while 
trac t ion is being made. 

I k., (>. Screw adjustment ot proximal ends of traction arms, a mechanical 
device lor shitting centers of rotation of traction arms to points corresponding 
with. 01 grcatei ot less than, interval between hip joints ol individual. 
Crank o turns bar i\ halves of which have worm threads cut in opposite 
directions, turning crank motes riders q and o' sinutltaneouslv. keeping 
them alwats equidistant from centei of table, Pivots ol arms n and n' are 
thus made to travel along lines from t to 3 and 1' to 3' respectivclv, enabling 
ttbdiKlion or adduction ol these arms to describe arc ol a new circle with 
each new position, fraction arms can be fixed upon quadrant /, /', in tint 
given position, by set screws in, in', (from A 11 ice's ‘'Orthopedic and Recon¬ 
struction Surgerv." Saunders.) 

The loot is held in position by a muslin bandage placed 
ovei it and hit hiding in its folds the movable flnl bar, placed 
against the plantar surface ol the loot and the curved plate 
beneath the heel. These flat bars (loot plates) are very strong, 
being made ol steel. These plates lit into the distal extremi¬ 
ties ol the traction rods, at which point the small sliding 
aimed /dale prevents compression ol the heel and obviates 
dropping clown of the foot clue lo the ohlicpiitv ol its dorsal 
aspect where the bandages enc ircle it during the application 
of a large amount ol traction. This sliding plate prevents 



tlu' loot from skidding downward away I mm tlu* loot piece. 
\ltet plasm ol Paris dressings have been applied, and the 
restraining muslin bandages cut. both ol these sliding plates 
are rentox cal. thus I reeing tlu' pal ient s limb I mm the tract ion 
arm without disuniting the plaster. 

Si) i'u’-ti(l j list men I of ju'lvu cuds of traction aims (Fig. (i). 
1 'lie proximal ends ol the trad ion arms are universally ad 
jnstable b\ means ol a heavv screw plated crosswise to the 
table. This screw bat is plat ed (to correspond with the hoi i 
/out a I plane ol the It ip joint) slightly above the peri neal post. 

I he ilirection ol the threads ol this screw are reversed on 
the opposite sides ol the center, so that when the attached 
(tank is tinned, the ends ol the traction bat unilormlv con 
verge upon or diverge from the centet ol the table. This ett 
aides the surgeon to make his adjustments in accordance with 
the distance between the hip joints ol each individual case, 
so that traction remains constant throughout abduction <>t 
adduction, which is usualiv desired. However, by plac ing the 
axes ol the traction arms farther apart, the amount ol trac 
lion ma\ be increased as abduction is increased. In the man 
agement ol dislocations and fractures near the hip joint, this 
ma\ be an important and valuable adjustment, particularly 
in fracture dislocations ol the lemoral head through the (loot 
ol the acetabulum. 

I in IM vsti K-ot Paris lhvxnvm vxn 1 icnixiot i or I is Usi 

1 ‘la.sta -of I‘(in.'s. 1 he plaslet-ol-Pat is should be that used by 
dentists, ol verv supei ior cptalilv and rapidly setting. It is 
packed in ait-tight tin pails to prevent hydration from the 
air. It may be said in passing that to further prevent India 
lion, the pails should be stored in the intervals between use 
in dry localities, and when in use the hand introduced into 
the pail should be pet fee l Iv di v. 

It will occ asionally be lound that because ol some accident, 
din ing the process ol mainline t in e oi from a break in the 
hermetic seal, a panic ttlai spec imen ol this plaster will not 



harden properly. Such ;i specimen should either he returned 
at once to the manulactliters, or put through ;i slow baking 

Crinoliu. Although a number ol different fabrics have 
been used as material lor impregnation with plaster ol Paris 
(gauze, dextrin gauze, Manuel, etc.) it has been round that 
c rinoliu (gauze sized with some stiffening substance) is by far 
the most satisfactory for this purpose. An unsized bandage 
is worthless in this connection, while crinoliu ol too fine a 
mesh is unsatisfactory because a superfluous amount of 
plaster is left in the bandage when it is rolled, causing it to 
set too rapidly and to become too brittle. A bandage con¬ 
taining too much sizing is open to the objec tion that the ex¬ 
cess of sizing material prevents the plaster from setting. The 
mesh should number 28 x g2 threads to the square inch. It 
comes in 12 yard bolts, which should be divided in babes, 
each 6 yards long by 1 yard wide. Each half is then torn longi¬ 
tudinally into strips, 3, 5 and 8 inches wide, respectively. In 
his own practice the author has found these to be the only 
three sizes required. 



After the bolt of crinoliu has been divided into two ecpial 
portions, each (i yards in length, the selvage is removed by 
tearing, and roller bandages are produced by tearing the hall- 
bolt lengths longitudinally. After winding these strips into 
loose rolls, the ravellings on the edges are removed by 
rubbing the point ol a pair ol scissors oxer the ends and 
pulling away the ravellings thus dislodged. 

//// fjregnat ion of I lit' Crinoliu Bandage with Plaster. Phis 
is best done bx placing a pile ol plaster upon a smooth broad 
board (suc h as a bread board) and drawing the c rinoliu band¬ 
age through it. The bandage is held to the lelt ol the pile, 
slowly unrolled, and dragged through the edge ol the pile ol 
plaster. While the bandage is being drawn through, the 



|»1;is(c"i is iuMk'iI I>\ Ii. ind thoroughl\ into the meshes the 
meshes should hr rubbed just lull. ;iud no more. No addi¬ 
tional plaster should he sprinkled on the bandage, and (are 
should he taken that the hitler is not wound loo tight. 

S 'taring. I lie completed plasterol Paris bandage is wrapped 
in a single lavei ol par;illm papei which is impervious to 
moisture, and secured with an elastic band, or, lor lack ol 
this material, in two or three layers ol newspapers or wrap 
pin;; paper, and packed in tin pails with accurately lilting 
covers. (The tin pails in which the plaster comes serve well 
foi this pur pc >se.) I he pails should be kept in the driest place 
available. Plastei ol Paris, whethei loose oi in bandages, 
should never be stored in a basement. II lor any reason the 
ait tioht seal ol the pail becomes broken and the plaster lails 
to harden well and cpiicklv, it may be possible to restore it 
bv placing the tin container, with the cover oft, in a very 
slow oven for a period ol several hours, alter which the cover 
is replaced and the containei set away in a dry place. 

IM.ASTI R-C > 1 " - PARIS "SlRl- XC.TI I KN KRS ’ 

In addition to the orclinan roller form ol plaster-ol Paris 
bandage, the so-called “strengtheners” are ol much value 
when used at points ol great mechanical stress, c.g., at the 
groin, in the c ase ol the spica. These are made prec iselv like 
the ordinary plaster-ol-Paris bandage, with the e\cej)t ion that 
instead ol being rolled they are reduplicated into i_> loot 
lengths of <| thic knesses, i.r., a bandage of (i yards (t <X feet) 
is lolded in 2 loot lengths ol <) thicknesses. These <) folds are 
then loosely rolled up, and an elastic band put about each, 
and they are either placed in a separate container, or, il put 
in the same tin with the rollei bandages, the\ are wrapped 
in a special I \ colored paper lor purposes of identification. 

Instead ol plastei ol Paris "strengtlicners” metal is some 
times used lor this purpose- tin./inc .oi sheet iron although 
die autlioi prelers the plaster "st rengt licners" except In the 



rare instances in which unusual strength is required or when 
a cast lias been weakened by lenestration. 

Rl (llIRl M I \ I s <)| A I’l As I I R-C )l |‘AR IS 15 AN DAG E 

I he crinolin should be ol such quality that iu applying 
the bandage it can be made to conform smoothly to the 
irregularities ol the part to which it is being applied. W hen 
in the hands ol a surgeon who is a master of plastet-of Paris 
technique, it should respond readily to every fold in the 
lilting process, without wrinkling. 

1 he bandage should be so wound and so impregnated 
with plaster that when properly immersed in water it will 
become immediately saturated and, during the process of 
application, will not “telescope." II too tightly wound and 
containing too much plaster, it will become “gummy" with 
dry spots bom uneven penetration ol the water: if too loosely 
wound, it will “telescope,” i.e., the center pushes out of one 
end, il Hat, awkward ol application, and does not take the 
form of a roller bandage. The strongest and most efficient 
bandage is one that contains just enough plaster to hll the 
meshes of the crinolin and no more. 

The plaster should harden with sullic ient rapidity so that 
when the surgeon has completed the Imal layers, the bandage 
will be of such consistency as to give good splint support and 
yet be malleable enough to withstand molding and stay 


Padding. Several materials have been used as padding, 
cotton sheet wadding, stockinet, llannel, all ol which are ac¬ 
ceptable. I he authoi prefers to use sheet wadding, purc hased 
in large tolls and torn into strips varying from | to 12 inc hes 
in width, and tolled into bandages. ()ne advantage ol cotton 
wadding is 1 hat it yields to St ille’s cutter in removing the cast 
in a way that the ot her mat cm ta Is do not. Emphasis should be 
pul on die importanc e ol the* e\ en applic ation ol this sheet 
wadding, due* regard being paid to the protection ol all super- 



Ik i.i11 \ |) 1. ic c'c 1 Rom prominentvs, .11 ilir same time preserx 
i n o i t > exen (list ri l)iii ion throughout the rest ol the linil). 
\nolhet adxaulagc is. that on account ol its yielding propci 
lies, it nevet lurnislies a constricting edge to c ause distal 
swelling ol the limb. The attthot prelets to hold in plate 
the wound dressing (postoperativelv or otherwise) by means 
ol the sheet watltling bandage, rather than by applying a 
gan/e bandage direct l\ oxer the dressing, because the general 
swelling ol the limb Irom exudate allet any operation max 
cause the edge ol the gauze bandage to become taut and to 
act as a local constricting band, causing I ml her swelling ol 
the limb distal to that point. 

Sal it) alion of the l i la.\ln -of-Ptn is Pondage. Tepid waiter is 
ordinal il\ used, always in a container (preferably a pail) ol 
sullit ient depth so that with the bandages standing on end 
thex will be enlirelx submerged. T he higher the temperature 
ol the waiter (within certain limits) the quickei the plastei 
hardens. The wrapper. il it is permeable to water, may be leit 
on 01 remoxed. as preferred; the author prefers its remoxal. 

I he bandage is plated on end in the waiter and allowed to 
remain standing until air-bubbles haxe ceased to rise, when 
it is reads lot use: time is no guide to the completion ol 
saturation, the absence ol air bubbles being the criterion. 

Attempts to hold tn to squeeze the bandage while it is sub 
merged, with the idea ol making it absorb water more 
rapidly. cause agglutination ol the ends ol the bandage and 
present the watei Irom penetrating to its center. 

Allet remoxing the bandage Irom the water, il should be 
held I>x eat It end, w ith the object ol presenting so lai as 
possible the escape ol the fluid plastei. It should then be 
xetx gentlx wiling out hx a hall turn ol the bandage, so that 
when handed to the surgeon it is in the shape ol a flattened 
roll with about (i inches unrolled. The saturated bandage 
should newer be stptee/etl in the center or xigorouslx wrung, 
because therebx too much plaster is lost and frequently the 
bandage is telescoped. 



. tl>l>H( iiIioii <>) the Plaster -of Par is Bandage. Ii is didirult 
to l; i\c* (lcai and comprehensive directions lot applying an 
ideal plaster ol Paris bandage. Dexterity can be acquired only 
by actnal experience. 

I he best method is to allow about (i to <X inches ol the 
bandage to be unrolled in advance ol its actual application. 
C.reat care should be taken to have the bandage smooth, 
without wrinkles, and with its first layers so placed that 
slight, even compression is exerted throughout the extent ol 
the splint. I he plaster should be constantly rubbed in during 
the application. 

1 he limb is lirst entirely and evenly bandaged with two 
or three thicknesses; this insures a more uniform bandage 
and promotes more rapid hardening, since it gives a largei 
area for drying. It is difficult to state exactly how many layers 
should be applied in the average case; the quality of the 
plaster, the rapidity of drying, the character of the lesion, and 
the mechanical stress that w ill come upon the splint, largeh 
determine this. Roughly estimated, the average plaster-of- 
Paris dressing, when completed, consists ol 6 to to thick 
nesses, but the splint should always be made as light as safety 
will permit. 

The ‘‘strengtheners" above desciibed may always be used 
to strengthen that part of the splint on whic h increased stress 
is to come, thus avoiding a generalized increase of bulk and 
weight ol the cast; incidentally, the use of ‘‘strengtheners" 
lessens the time of application. 

In the case ol a prolonged application, the water should 
be changed at Irequent intervals, since it becomes saturated 
with plastet and hence thickened and tails to penetrate the 
bandages readily. The surgeon should be catelul to mold 
the plaster about the bony prominences, and be on the alert 
to increase this coaptation effect at the propet time, belote 
the plastet becomes too hard. Rubbing In dry plaster ot 
plaster c ream on the exterior ol the dressing hastens harden¬ 
ing and gives a smoother surlace. 


Win'll ii is neccssars to maintain the plasm in position 

|(ii .1 long time', to keep n ( lean, part ienlarh about the 

fenestra, and free from contamination and saturation by dis 
charges, \arnishi 1 il» the cast is excellent practice. 

Ii is adsisable to turn down a ( nil ol the sheet wadding 
o\ei the edge's ol the cast at its extremities when it has been 
partialis applied, so that the remain ill” portion ol the cast 
can he placed ovci it: this not only serves to hold the cotton 
at the edge. to secure its padding ellect. but also to present 
the patient from dislodging 01 pulling out tlu' cotton at this 
point. II it is necessary to trim the cast, the formation ol 
such a cuff should he delayed until the trimming has been 

completed, when one 01 two layers ol the plastei ol Paris 

bandage mas be added loi this purpose. 

Where traction as well as fixation is recpiired, moleskin 
st ickers. or w'hates ei tract ion st raps are used, are placed upon 
the limb at the desired points, emerging at a point two 01 
three inches above the malleoli, a spreader being applied 
below the loot and weights attached in the usual manner, 
or the traction straps mas be incorporated in the plastei at 
their exit, and the plastei mas be extended oser the otliei 
leg, including the foot, while the patient is still held on the 
Iracture table. P>s molding the plastei snugly to the plantai 
surface ol the foot of the insolsed side, counter pressure may 
be exerted to the traction on the normal limb. Thus the 
ecjuisalent or better of Anderson’s* counter-traction is se¬ 

Plaster dressings well applied and ol good material will 
last many weeks or months. 

K) sins SI Ol A IM.AXI I KOI I’.SKIs sl’ICA 

In the author s experience, this is best done by a Stille 
c utter. II this is not accessible, a saw or .1 lieasy jac k knife 
seises the purpose. I o solten the plastei along the line ol 

• Anderson, It. New method lot c 1 cat i ol> Wic unes. Smo. C.ynet . Obsl., 

:> r - 207, 1932. 



incision, vinegai can be used alter die sin lace to be cut lias 
been well scarified with a knife. Hot watei also serves the 
same purpose. Having cut the gutter, the dressing is spread 
with a special chimp. 

It is best to cut along the outer margin ol the foot behind 
the external malleolus and up the external surface of the 
leg. rather than along the instep and inner surlace ol the 
thigh, where the plaster is usually thinner and hugs the limb 
more closely. In removing a cast which has been applied lot 
postoperative fixation, the held ol operation should be care- 
lullv avoided. 

Chapter III 


T ill 11i|> joint is (lev]>1 \ placed and surrounded l>\ 
numerous powerlul nnisclt's. I lie' psoas and iliaens 
iniiM les arc in Iront ol the articulation. behind it 
arc the (]ilac 1 ra11is lemoris, the obturator interims, the two 
L*eniel 1 i. and the pvri lonnis. I o the on let side lie- the ,1* Inlet is 
inedins and minimus and rectus lemoris, and to the innei 
side are the pectineus and obturator externus. 

Die upper border ol the greater trochanter is on a level 
with the (inlet ol the hip joint. Xelaton s line extends Iront 
the anterioi superiot spine ol the ilium to the most promi 
nent part ol the tuberositx ol the ischium, running across the 
(enter ol the acetabulum and passing oxer the top ol the 
greater trochanter. 

Lite head ol the lemiti lies just below and to the outer 
side ol the central point ol Poupart's ligament. 

I he hi]) joint is a typical cnarlhrndial (ball-and-socket) 
diarthrosis. The rounded femoral head is received into the 
acetabulum ol the pelxis. 

I he cartilaginous lining ol the acetabulum is horseshoe¬ 
shaped—broadei aboxe and behind and deficient below at the 
cotyloid notch and in the depression at the bottom of the 
acetabulum which is occupied by a mass of fat, covered b\ 
svnovial membi ane—the so-called synovial gland. 

I lie transverse ligament bridges over the eolxloid notch, 
completing the ticetabuhir tint, and converts the notch into 
a loramen through which artictilai xcssels pass. 

I he cotyloid ligament is the thick librocart ilage, ti iangu 
I a i on sir t ion, at ta( lied to the tint ol the a< etalnil tun. deepen 
ing its rax it v. 



1 lie cajisuhn ligament surrounds ihe joint and is attac hed 
t<> the pelvis near the i ini ol the acetabulum outside the 
cotyloid ligament; to the femur, in front, to the intertro¬ 
chanteric line; behind, to the line ol junction ol the middle 
and outer thirds ol the net k: above, to the base ol the greater 
trochanter. Ihe insertion ol the capsular ligament is not in 
a plane at right angles with the long axis ol the femoral neck, 
but is oblujite, and, therefore, every fracture of the neck of 
the femur is at least partially inlracajjsular; there is no such 
thing as an ext racapsular variety of fracture of this struc- 
t tire. 

Accessory hands, which are differentiated portions of the 
capsule, greatly strengthen the joint. Of these, the iliofemoral 
hand (ligament ol Bigelow) is the strongest and most im¬ 
portant. It is attached above to the ilium, below and behind 
the anterior inferior spine; interiorly, it spreads out triangu¬ 
larly to the anterior intertrochanteric line of the femur. Its 
inner (iliofemoral) and outer (iliotrochanteric) borders are 
very thick and strong; its intervening portion is thin and 

The jjuhofemoral band is the weakest; it extends Irom an 
area between the pectineal eminence and the cotyloid notch 
to the nec k ol the lemur. 

The ischiofemoral band extends from the ischium just 
below the acetabulum to the base of the great trochanter, 
internal to the digital lossa. 

The ligamentum teres (round ligament) attaches the head 
of the lemur to the transverse ligament and the margin of 
the cotyloid notch. 

The synovial mem Inane lines the inner surlace ol the 
capsule whence it is reflected on the neck ol the lemur as 
lai as the articulai margin and on the two tree stir I aces ol 
the cotyloid ligament, thence being continued to the pad 
ol hit at the bottom ol the acetabulum and asa tubular cover¬ 
ing ol i Ik- I igament uni teres. 



1’ri 01-1 RA I l\ I 1*RI I’ARA I ION 

( )n the da\ before onnal ion, the operative site and a 
i;eneiants area (>1 the surroundi11 u, skin is slia\ ed and set nhhe*I 
\ im»ta>us 1 \ with green soap. Ml traces ol the soap are removed 
with water, and the part is washed with ben/ene to remove 
as much surface oil or grease as possible. A r ( o per cent solu 
lion ol alcohol is then applied. Altci this dries, the region 
is painted with a hall-strength solution ol tincture ol iodine 
and covered with sterile towels. In the operating loom, these 
towels are removed and the pa it is again painted with a hall 
strength solution ol tincture ol iodine. 

Onehotn before operation, an adult patient is given 1 1; or. 
ol morphine sulphate, and 1 iri ,, gr. ol atropine sulphate. 

In the selection ol an approach, earelul consideration 
should alwavs be given to the placement ol the inc ision in 
suc h a wav as to avoid damage to important anatomical struc 
tines. An equally important consideration is to have the 
incision generous enough to permit the operation to be done. 
An adequate incision necessitates less retraction. Undue 
pulling ol the soft parts leads to devitalization ol tissue and 
possibility ol infection. 

I he author does not lavor the no-hand contac t technique 
ol Lane, or the clamping ol towels or other materials to the 
wound edges as he believes that as much or more is lost than 
gained, particularly in bone work where an excess ol instru¬ 
mentation is nccessarv. I he edge ol the skin wound is likelv 
to be dev italized bv crushing'ol c himps and the drying effec t 
ol the lain ic. 

The chic! concern is the hair lollides, sebaceous and sweat 
glands and the organisms which they uiav contain. It is be 
lieved that operative ha/ard as to inlection is minimi/cd 
when the lollowing points are observed: 

1. Thorough preoperative preparation: 

2. Adequate approach with minimum retraction: 

g. Reasonable speed with minimum ol traumatization; 



|. I Ik* use* ol as little absorbable suture material as will 
answei both lot the closure ol the solt parts and the 
fixation ol the bony elements; 

f>. Every provision to avoid hematoma, and it is believed 
that a continuous link suture ol No. t chromic catgut 
accomplishes this better than any other method; 

(). Closure ol the skin with No. o plain catgut; 

7. Thorough puddling ol the suture holes as well as the 
line ol incision by smashing g 1 (> per cent tincture ol 
iodine into them by repeated sharp blows with the 
gauze ol a sponge; 

(S. Rigid immobilization ol the parts, usually by well- 
molded plaster ol Paris cast. 

There is no more trustworthy means ol avoiding infection 
than good immobilization and when dealing with infection 
the On concept should be the guide. This method consists 
ol dressing the wound with either vaseline gauze or paraffin- 
vaseline compound, without windows in the cast and avoid¬ 
ing too Irecjuent changes of the cast. Instillation ol specific 
autogenous bac teriophage should be used, through catheters 
or rubbei tubes into the depths ol the wound. 

Surgical Ai’I’koachks 

The relatively small size ol the hip joint, no less than its 
position ol great depth from the surlace, and its relation to 
very important structures, all conspire to render surgical ap- 
proac h difficult. This difficulty is well illustrated by the great 
number ol routes which have, Irom time to time, been de¬ 
scribed bv different operators. Moreover, it is evident that 
no one approach will satisfy all conditions; a route which is 
ideal lor drainage ol the joint may prove quite unsuitable 
lot plast ic work 01 arthrodesis. 

The names ol such surgeons as Lisfranc, Sedillot. Percy, 
Roux, 1 .angenbec k, l.ticke. barber, Koc her and mam others 
are associated with methods ol opening the hip joint. In 



times past. arlhrotoim <>l the hip was done' in desperate haste 
lot desperate conditions. Present da\ surgical methods have 
made the ion less let hal in character, and have vouch 
sated to the sin geon a greatci sense ol security. Nevei lheless, 
the operation icmains a major surgical procedure, one not 
to he undertaken lightly, and 1 c‘<jnirino surgical experience 
and pidgincm as well as skill and dellness m the - handling 
ol tissues. 

\mong the lesions which ma\ require arthrotoim are 
at ute in lee t ions ol t he h ip joint; t u here til os is: I rat t tire ol the 
femoral neck: traumatic 01 paralytic dislocations; arthritis 
with pain! ul motion or loose bodies; ankylosis; unreduced 
displacement ol the nppci lemoial epiphysis; obscure art 11 
litis demanding tissue examination: congenital dislocation 
at all ages; and paralysis, notabh that due to poliomyelitis. 
It is ol great importance to select the method ol approach 
best suited to the condition and case in question. 

The dangers which max be encountered in arlhrolomy 
ol the hip are those common to am serious surgic al procedure 
perlormed upon patients who. as a rule, are not in good 
physical condition. Consequently the operation must be clone 
with reasonable speed and with due regard lor the tissues. 
1 he automatic machine tools have done muc h to reduce the 
surgical shoc k from trauma. Nowhere in surgery are carelul 
technique and rigid asepsis more necessary. 

The three princ ipal methods ol approach to the hip are 
the anterior, the anterolateral, and the- posterior. \ fourth, 
the lateral approach, is not to be recommended. For all ultra 
at tic ttlai work I use the Smith -lVtersen-Spi engel approach 
(anterolateral), the degree ol lateral exposure depending' on 
how lat back the 1 incision is carried along the crest ol the 
ilium. In fractures ol the nec k ol the lemur the vertical in 
cision ol Smith-Petersen with a very short posterior arm is 
preferred, the length ol this varying with the obesity ol the 
pat ien t and the 1 lecessi I ies ol ex pc is me in the part ic u lai ease*. 



\< utc inlections demanding drainage are die only condition 
loi which I use the posterior approach. 


Sm it h-Pet erscn-Sprcngcl A pproai h.* From a point three 
to lour inc hes below the anterosuperior spine, a vertical in¬ 
cision following the external border ol the sartorius muscle 
is made upward to the spine ol the ilium, thence carried 
backward, billowing the iliac crest for two-thirds of its ex¬ 
tent. By means ol a sharp periosteal elevator the gluteal 
muscles are reflected with the periosteum ol the ilium ad¬ 
herent to them, until the capsule ol the hip joint has been 
exposed. No other approach can compare with this in the 
extent ol exposure and the facility it offers for all plastic 


Kochcr Approach. Kocher makes an incision from the 
posterior margin ol the base of the trochanter major upward 
to the posterosuperior angle of the trochanter, and thence to 
the posterosuperior iliac spine. The gluteus maximus is then 
divided in the line of its libers and the edges are retracted. 
The gluteus medius is separated at its insertion into the 
trochanter major and turned upward. The pyriformis, ob¬ 
turator interims and gemelli are divided at their insertion 
into the trochanter and turned inward. The capsule is in- 
c ised, and then the superior hall ol the trochanter major 
divided from the main bone with a saw and turned upward 
with its attached muscles. By adducting the diseased limb 
across the sound one and rotating it outward, the head ol 
the lemur is dislocated posteriorly. 

I .angcnbcck Approach. In I.angenbeck s approach an in¬ 
cision is made from the posterosuperior iliac spine to the 

* Smith Peterson. M. X. \ new supra at Iit ttlar subperiosteal approach to 
ilic hip joint. Ini. /. Orlhof). Sing., i j: ,">!)-• >‘1 1 7• ^ ''hnilai approach was 
used In Sprengel about one hundred years ago in Cermanv. and latei In 



post erosu pet iot an^le <>l the grcalet trochanter. I lu* gluteus 
maximus is divided in die line <>l its libers and die edges are 
rctiacicd. I liis exposes die postciioi margin ol die gluteus 
medins and die snperioi margin ol the pyi i limn is. I liese 
.lie retracted and. il necessary, the pvriloimis is divided 01 
loosened at its insertion. I his is a rapid and easv approach 
with little - (list in bailee to the tissue's. I he joint exposure is. 
however. I ini i ted as the snperioi mai o i 11 ol the tendon ol the 
pvrilorinis is at least i s inch abov e the postci osnpcrioi 
margin of the neck ol the lemur. I his Lu tor also makes 
ill. linage dillic nit. 

l)i\on I jij)Kitu h. lot Inrther exposure, Dixon recoin 
mends loosening the glutens medins and minimus at tlieit 
insertions, and then retracting them backward. I he division 
ol all these muscles may. however, weaken the stability ol 
the joint. 

Osborne \ j) j>) om h. As the outcome ol many experimental 
operations on the cadaver, Osborne* ol the University ol 
Manchester, surest.s a combined Uangenbeck-Koc her ap¬ 
proach. Rinding Langenbeck's method less mutilating than 
Ixoc lier's. but the exposure somewhat limited, he has com 
bitted the - best points ol both. 11 is method depends on the 
observation that the tendon ol the pvrilorinis t ints along the 
posterosnperior margin ol the neck ol the femur, and that 
the geniellie mass t ints obliquely at toss the nec k. 

W ith the diseased limb adducted across the sound limb, 
an incision is made from a point t , inches below the 
postetosttpei ior iliac spine to the posterosnperior angle of 
the greate 1 troc hanter and then down the posterior edge ol 
the trot liantci for 2 inc lies. 

I lie gluteus maximus is div ided in the line of its libers 
and the edges retrac ted. I he Inst part ol the incision corre¬ 
sponds to a line just above the lowet edge ol the pvrilorinis. 

I he limb is rotated internally and the tendons ol the pv 1 1 

’ Osborne, k. I’. Approaches u> the hip: a critical rc\ ieu and a s 11_<» gest ec 1 
lieu ionic, ll)il. /. S//r 14.. is p), nr;o. 



lormis and the ^cnicdlit mass divided (lose to tlieii iuser 
lions, the two tinned inward to he held by the assistant. The 
capsule ol the joint is next exposed and incised. lint 1 1ct ex 
posnte can he gained, il required, by retracting*; the <juacl- 
ratus lemoris downward and the glutens medins upward. 

I here is no dillicnlty Irom hemorrhage, but the following 
vessels will be encountered: A branch Irom the sciatic artery 
which inns between the tendon ol the pyrilormis and the 
superior gemellus; the ascending branch ol the internal cir¬ 
cumflex artery; a branch ol the gluteal artery running along 
the upper bordei ol the pyrilormis, and this should be re¬ 
tracted upward. It will be noted that the reflection <>l the 
genie! I ic mass protects the sciatic nerv e Irom injury. 

J he advantages ol this route would appear to be: Exposure 
ol practically the whole ol the posterior surface ol the joint 
and the neck ol the lemur; no interference with the greatei 
trochanter (cj. Korher); slight and easily reparable displace¬ 
ment ol the tissues; adequate provision for drainage. 

As the result ol his investigation Osborne concludes that, 
lor all "quiet” work, the Smith-Petersen approach is the one 
of election, but for "infected” cases of any type requiring a 
direct attack on the joint or head and neck ol the lemur, 
with subsequent drainage, he recommends the combined 
posterior route just described. 

Obey Al>j))oai h. The patient lies face clown on the table. 
Incision is made in a straight line running Irom the postero 
lateral aspect of the femur obliquely upward and bac kward 
toward the sacrococcygeal articulation, direc tly ovei the neck 
ol the femur and in the line ol the libers ol the gluteus 
maximus. The libers of the gluteus niaxinius are separated. 
The underlying fat is pushed aside bv blunt dissection, care 
being used to avoid the sc iatic nerve which is in the region 
ol the medial extremity of the incision. The tendon ol the 
obturator interims, the 1 quadralus lemoris, and the gemelli 
and pyrilormis are now exposed and separated bv blunt dis 
sec tion, and retracted to expose the posterior sin lace ol the 



j111111 capsule. I lie joinl capsule is <li\i(led llie whole length 
o| ihi 1 incision, and drainage or removal ol (issue aeeoin 
nlished. In oidei lo maintain drainage (lie capsule may he 
sinnved (O the gluteal lascia. 01 cigarette chains max he 
.stitched to the capstilai margins. Closure is simple, the edges 
ol the wound being approximated with catgut sutures and 
the skm sin n red with silk. 

1 A I I l< At \ I’l’RC) \( I I 

Murplix and l.exei advocate the lateral approach loi 
at tInoplast\. hut I consider the anterolateral superior. In 
lact. I do not use the lateral approach lor am operation on 
the hip. 

Oliin Lateral l ji/noacli. Lhe patient lies on his side with 
the' thigh Hexed to lortY-live degrees. A curved incision 
through skin and subcutaneous lat is made, starting at the 
anterosnperioi spine and running to the posterosnperior 
spine. Lhe curve is Hat, l -shaped, w ith its lowest point about 
i inch below the tip ol the greater trochanter, lhe apo 
neurosis ol the glutens niaxiinus is divided vertically and 
retracted backward. Lhe trochanter major is now cut 
through about t inch below its tip. Lhe direction ol this 
osleotoim is oblique, so that the upper end ol the cut is at 
tlm upper sin lace ol the lemoral nec k. I his detached bag 
inent is pulled upward, and carries with it the' musc les whic h 
have insertion at the greatei trochantei. that is. the gluteus 
medius. gluteus minimus, pyiilormis, and gemelli. The 
anlerioi margin ol the gluteus medius is dissected Ironi the 
posterioi margin ol the tensoi lasc iae lemoris. I his exposes 
the tippei surface ol the joint capsule and the acetabulai 
margin, llie capsule is divided vcrtieallv, and the head ol 
the 1 leimti dislocated b\ adduction and internal rotation ol 
the thigh. I he Iragment ol the (roc liautei is sutured in plac e 
either b\ catgut stitches or ;t bone pin. 

Chapter IV 


i. Fracii ki or iiii Nick op iiii I imi k 

A 1 IK)l'(.ll operatixe intervention and the implanta¬ 
tion ol metal nails 01 other foreign agents have 
been practiced in the treatment ol fractures of the 
neck ol the femur ior oxer thirty-five years, yet there is 
no other Iracture in which union fails so frequently. The 
surgeon who is consulted regarding the insertion of a bone- 
graft peg months after the fracture has occurred and when 
conservative measures have failed and much absorption of 
the femoral neck has taken place, is impressed by his suc¬ 
cess at this late stage even though appreciating that an earlier 
operation would have saved months or years ol com alescence 
or invalidism and would have contributed to a much better 
functional result. 

Statistics haxe shown that there is a mortality of approx¬ 
imately 20 per cent in aged patients with fractures of the 
hip joint, and that of those remaining only about yo per cent 
secure good bony union. This appalling situation constitutes 
a real challenge to try to improxe the treatment that has 
been used in the past. The old dictum—“Treat the patient 
and disregard the fracture”—is not good adxice. 1 he best 
way to treat the patient is to treat the Iracture. Pain is re- 
liexed as soon as the fracture is accurately immobilized, and 
the patient has a much bettei chance to recoxer. 

Realizing that the end results ol both c onset \ at i\e and 
operatixe fixation by metal nails or other means ol this 
most troublesome Iracture were extremelx poor, the Ameri¬ 
can Orthopaedic Yssociation in 1928 appointed a committee 



id make .1 (omparal i\c siueh in this <<>mii)\ and abroad ol 
iIk' end results lollowiny e\ei\ accepted method ol Heat 

Two reports weir made l»\ this committee, one m icygc), 
and ailotltei m tqyo. I he Inst piesented the end results 
ol unimpacted Iractures ol the neck ol the lennu w ithin 
the capsule in persons o\ei si\t\ Years ol aye. I lie second 
w as a comparative stitch ol true end results ol the same type 
ol I rad lire in persons undei si\t\ Years. treated hy various 
methods, and in persons ol am aye treated h\ open opera 
t ion. 

No case was considered .1 true end result unless at least 
one Year had elapsed between the 1 be”inning ol treatment 
and the date on which the end result was recorded. 

1 lie first report (i<)2<)) was based on a review ol ay 1 
Iractures. the results in 201 cases beiny suitable lor study. 
The second report (tqyo) was based on a review ol pi) 
Irai tines ol which ytiy were suitable lor study. ()l the ^ (»5 
cases, 2()2 had been 11 eatecl by c losed methods and toy, b\ 
open surgical attack. 

1 he mortalitv rate lor all ayes treated by open suryical 
methods was onl\ 2.7 per cent as compared with q.2 per cent 
in cases under sixty Years treated by closed reduction. 

In these serious Iractures the question ol prime impoi 
tame is proved bony union one year or more alter the be 
yinniny ol treatment, and in this respect open methods 
ayai 11 show up in strikinyh favorable contrast to results by 
c losed methods. 

Proved llony Union 

Closed Reduction Percent 

■'series 1. (Patients ovc*r si\(\ irraled b\ c losed methods) yo. | 

Series 2. (Patients under sis I \ treated In closed melliocls) 

\verage percentage ol firm hone union II. closed re- 
duc 1 ion | 1.1 

Punish Fracture (iommiliee 22 

Ojien ()ju ration 

I’aiieuis ol all ages. Smiili Petersen method li|.8 



1 'lie* statemeiU iliai I rad lire ol the neck ol the lemur 
shows a much more mat Led tendency to heal in children and 
voting persons than in adults is erroneous. With Literal 
Iractures ol the neck ol the lemur there is great danger ol 
pseudat throses, and in isolated fractures ol the head ol the 
lenun there is great (Linger ol aseptic necrosis. From serial 
roentgenograms made in typical cases, it appears that after 
lateral Iractures ol the neck of the lemur in voting persons 
between eleven and seventeen years of age aseptic necrosis ol 
the upper end ol the femur may develop very gradually after 
roentgenologic and clinical healing of the fracture has taken 
place. The disease pictures show a resemblance to Perthes' 
disease, which, according to these observations, occurs as a 
sequel to a traumatic vascular injury causing a metabolic 
disturbance of the head. 

Isolated fracture of the head of the lemur usually remains 
undiagnosed for a long time. The early symptoms subside, 
but after three to six months the condition becomes worse 
again because of local necrosis in the capital epiphysis. 
Later, the head appears flattened and shows a trough-shaped 
depression. Because of the danger of secondary necrosis ol 
the head, apparatus to relieve weight-bearing must be used 
I’oi at least six months in cases ol Iraeture ol the nec k ol the 
femur, even in young persons. 

In tc)ig the author described* the use ol a bone-graft 
peg lot non-union taken from the crest ol the tibia ol the 
same patient and in i<)2<) reported 1)1.7 pet cent ol proved 
bony union with this method. Campbell j~ at about the same 
time reported close to the same percentage ol results, and 
in 1 C)g2, in a series ol 10 cases, reported bony union in too 
per cent. Most ol these eases had been previousb treated 
unsuccessfully by various mechanical methods (including 
metal nails. A comparison ol the foregoing results is 

* In: XI 011> 1 )\. |. It. Clinics ai \lere\ Hospital, t’liila.. u)i;{. 

(Campbell. \\. O. Central or inltacapsulai liaomes ol the neck ol ihe 
lemur. 1‘iut . California I1111I. Mi ll.. oi;p ‘\‘J. p. tjsj. 



most inst i uc l i \ e when one c onsiders that ill I lie (a sc ol 11 esh 
fractures uni) the 01T4in.1l 1114c lo repait still present. the 
ncitentage ol non union xaried Iroiu 22 to (i|.<S when me 
chanical nielhods alone weie used, whereas m (lie ease ol 
non union will) conditions much more unlav01 able to union, 
the' autogenous hone 1 41a11 resulted in a much hi4he* 1 pea 
centa4e ol good results, nainelv. pi.7 pea cent. 

\\sis ol these' statistics drive's one to llm that 
the' rec|uireanea 11s ol this panic ulai fracture are suc h that 
mec hanic al immohil i/at ion alone will not sullicc unless sup 
plemented h\ biophxsic> 1 <>4-ic' inlhiences. Irom whic h the con 
e lusion max be drawn that Irac ture ol the c entral port ion ol 
the' neck ol the lemur presents obstacles to union not present 
in ot hea Iract tires, ex en in those si t uated less than 1 ! 7 i 11c lies 
awax. 1 refer to fractures at the base or transtrochanteric 
region where union almost alwaxs occ urs. ()l these obstacle's 
to union, the following' seem to be the most important: 

(a) Its location within a joint, so situated that a solu 
tion ol continuity 111 r<> 11411 it cuts oil the proximal 
fragment from Us princ ipal source ol blood supple, 
namely, that Irom the trochanteric region; 

( 1 )) The rotation of the fragment, ax tilsion or tear at the 
time ol Irac ture ol the ligamentum teres resulting in 
complete or partial obliteration ol the blood supple 
exen Irom this source, d one cwisis; 

(c) It can be lurlher claimed that from a mechanical 
standpoint this Iracture is unlaxorable because ol the 
lac t that the proximal fragment is practic ally a sphere 
in a slipperx joint caxitx and xerx likelx to liioxe at 
the slightest body movement 01 muscle spasm. I'm 
ther, the Iracture being in a joint, the Iracture space 
is immediately Idled be synovial II it id which is in 
hibitory to c allus lormat ion. be the same token, there 
is no periosteum with its osleogenetie influences, nor 
is there blood supplx coming to the point ol Iracture 
Irom the pet iphery. 



ll is impossible to speak in definite terms as to the relative 
amount ol blood-supply to the* bead and proximal portion 
ol the neck ol the lemur, coniine, from these two sources, 
but it is certainly sale to say that considerably more than 70 
per cent comes Irom the trochanteric region of the femur, 
and that in some instances, it all comes lrom this source. 

These statements have been confirmed by Wolcott * who, 
in some very interesting work, has injected both the nutrient 
vessels ol the upper end ol the lemtit and those ol the liga 
mention teres with mercury and found that in a consider 
able portion ol cases the small and unimportant blood 
vessels ol the ligamentum teres did not extend into the head 
at all, and that the age ol the patient had very little, il any, 
influence upon these findings. 

Since callus potentiality has been proved repeatedly by 
my own animal experimental work and by of others 
to be in direct relationship with the amount ol blood brought 
to the part, the importance of this consideration is evident. 

It is principally in this respect that this fracture differs 
radically from others. In other skeletal fractures blood comes 
from every direction—from both fragments, and particularly 
from the blood-supply of a collateral nature which is con¬ 
ducted to the point of fracture by the overlying adherent 
soft parts. It is believed that in fractures of the central 
portion of the neck of the femur that result in non-union, 
practically till blood-supply is cut off, except that which 
is available from the broken end ol the distal Iragment. 
II the overlying capsule should be torn, there is little like 
liliood of the torn edges becoming stillic ientlv adherent 
to aid in the establishment ol a blood supple ol am con 
sec pi ence, especially since dense capsular tissue is unsatis¬ 
factory for (bis purpose. An important consideration beat 
ing upon this is the relative prognosis ol an inlracapsulai 
fracture .and one only '■/ inch larthet out m the neck at the 
base of the transtrochanteric region, in which instance cap- 

* I’i i son, 1 1 coiiimiiiii( al ion. 



Mil. 11 .mil exlrai apsul.u tissue is .ill;i< lied t<» tlir (IisI;1 1 end 
<>l Hit- proximal liagmcnl. thus serving lo bring lo it a stilli 
cieut blood supplv. Nonunion |>rac tii allx ne\ei o< <atrs in 

Sll( li 1 1 .!( t III I'S. 

Ii is (lilliiult to explain careful roentgenograph ic studies 
oi non union ol stibc apilal Irai t tires on am assumption otliet 
than that ol I a n 11 \ blood supple. I'lie surest ion ol erosion 
Irom the rubbing ol one fragment end on anothei will not 
sulltee. since in mam instance's ol extensive disappearance 
ol bone, no motion ol one Iragtnent on the other had c'\ et 
been allowed to occur. 

It is lm conviction that the blood supple ol the liga 
mentum teres, il one exists, is almost universally destroyed 
at the' time ol the Iraeture in those case's coining biter to 
non-union. This statement is based upon the experience ol 
mvseH and associate's at the operating, table during the past 
ten years, during which time in |t2 eases the lemoral head 
has been removed while doing the authors arthroplastic: 
reconstruction. In ottlx one instance has there been am 
bleeding ol consequence Irom the stump ot the ligamentum 
teres. When one realizes that am extreme traumatic rota¬ 
tion ot the head, which should be expected, at the time ol 
Iraeture must tear this ligament, such bindings should not 
cause sin prise. 

Tn view of these biophysiologie conditions, it is apparent 
that the treatment should be largcb directed in accordance 
with these requirements. Vs the' problem of non-union is 
so much more d illicit It. ol solution than that of I resh I Vac t tires, 
it is consistent to maintain that the unusual lx successful 
results and experience in the lormer (in author's series cji.y 
per cent proved bom union) are eminently applicable to the 
problem ol the latter. I 1 i esc* results, coupled with a percent 
age ol resul ts hot h in I resh and tin united Ii ac l tires lai above 
those universalis reported with purelv mechanical methods 
when applied to I resh 11 act it res. leads me to recommend loi 
operative cases the employment ol the autogenous tibial 



bone-gralt peg in .ill (uses oi Iracture ol the central portion 
ol i lie neck ol the lemur, i eserv i ng (he mam pul a I i\ e methods, 
Smith-Pelersen nail and Kirschnei and other wires lor those 
cases where open reduc tion is not considered wise. 

I he urgent indication is to bring blood not only to the 
point ol Iracttire, but to the anemic capital fragment. This 
objective can be accomplished in only one satisfactory way, 
and that is by an autogenous bone gralt so put in that it not 
only mechanic alls reduc es and immobilizes the fragments, 
but also lurnishes an osteogenetic call us forming influence, 
serving at the same time as a vasculat conducting scaffold. 

I have been employing the gralt in this way and studying its 
results lot l went v lour years. Inning Inst reported il in tpig. 

This function ol the early and profuse vascularization by 
the bone graft cannot be too much emphasized. Sit Arthm 
Keith in his work at the Museum ol the Royal College of 
Surgeons has demonstrated this extremely well. It is well 
known that the Haversian canals of a graft composed solely 
of cortical bone will canalize and enlarge in a lew months 
to such proportions that a narrow canal may develop with 
its incidental vascularity. This is particular!) striking when 
the urge to the passage ol blood through the gralt is present, 
as when it replaces loss ol bone across a hiatus; and the author 
has accumulated over the past twenty years a mass ol evi¬ 
dence to prove this assertion. With the ligamentum teres 
torn, 01 its blood vessels absent or destroved, this reparative 
urge is certainly present under favorable conditions to in¬ 
fluence the conduc tion of blood Irom the vasc ular spongiosa 
of the trochantei to the anemic head and area ol the Iracture. 

It is apparent that in this fracture, it is not enough to 
achieve exact reduction of the fracture fragments and their 
mechanical maintenance in position. Something more is 
necessary to secure a better percentage ol results. 

The bone-gralt peg is the treatment ol choice lor selected 
c ases ol Iresli liac tores and lor all cases ol ununited Irac ture 
of the neck ol the femur at any portion ol the neck, where 



ilu* ( liagmenl is ol siillu ieul length lo receive il 
1,1 \ oi ,il>l\. .nul. it .i m.mi[uilat i\c method oi without mci.illii 
internal lixing agent lias been employed. (lie liisi evidences 
ol absorption ol bone oi non appearance ol callus should be 
nnmcdiatch lollowed b\ (Ins treatment. 

t ri \ i \i r vi oi ruisii i ic\( : 11 r i s <> i 11 n m (as or 11n t t \t t ie 

because the whole pnestion ol treating, Ircsli Iraclnres by 
open oi ( losed met hods is slid in a stale ol I h i \. and depends 
so much upon the Imdings In the individual case. 1 shall 
discuss methods ol treatment in the order ol mv personal 
prelereme. rather than cl ass i I \ them as open and (losed. 

i. bone-graft pee, operation, in selected cases: 

l>. Whitman abduction method ol closed reduction; 

‘j. Leadbettei method ol (losed reduction: 
p Smith-Petersen operative technique: 

Rirsclmer or other wires and nails, including Caenslen, 
M oore and \ all's nail. 

Bonc-xitifl Pc g Ojx’mtion (AJbcc). 1 first described this 
opera t ion in i <) i > in \I urphv s Cl hues. The joint may or may 
not be exposed in Iresh Iraclure, but always in non-union. 

I)\ an anterioi incision straight downward lioin die antero 
superioi spine: a second incision is made ovei the great 
irochantei lor the purpose ol inserting the bone-gralt peg. 
I he net k ol the lennu is inspected through the anterioi 
inc ision. Eversion ol the loot and limb causes the lemoral 
Iragineiiis to separate anteriorlv. and the ends ol both are 
then thoroughh Ireshened with osteotome and mallet. I he 
loot is then restored to the antcroposiei ioi axis and sullic ient 
abduction (about ;o degrees) and traction applied b\ means 
ol the Iraclurc table, lo bring the' Ireshened Iragmenl ends 
into ( lose apposit ion. 

\iteniion is next turned to the short incision ovei the 
irochantei which has been carried down lo the lascia cover¬ 
ing the \ ast us ext ei n us. 1 liesc si met tires arc' now hot h spl i t 



longitudinally so as lo expose the lateral surface ol the great 
trochanter. I he point ol application ol the- chill lies \/, inch 
below the bony ridge to whic h the 1 lascia overlying the vastus 

externus is attached. Since the direction ol the chill must 
lollow the central line ol the neck, due consideration must 
he given to the angulation ol the neck with both the axis of 
the femur and the vertical intertrochanteric plane. In the 
average adult, the neck makes an angle of 1 go degrees with 
the femur, and 12 degrees with the vertical intertrochanteric 
plane, when the loot is in the anteroposterior plane. 

With the motor ch ill held in the direction thus indicated, 
a hole \/> me li in diameter is cli illed through liotn the lateral 
aspec t ol the great trochanter to the broken end ol the distal 
fragment. Ibis point is determined bv instrumental pa I pa 
lion ol the- head ol the chill between the - opposed liagments. 



I lie reading on die diill (at I). lug. “) indicates the length 
ol penel i at ion through the distal I raiment. With the diill 
head against the - Ireshcned end ol the capital Iragmcnt, it 

is now carried into this fragment until the reading shows 
sufficient penetration. Ihe degree ol penetration through 
both fragments usually required is - or S cm. (21/, inches) 
and is determined by a study ol the roentgenogram. T he 
drill is left in silu while a graft is taken Irom the crest ol the 
t ihia ol the same side. 

1 he tibia is exposed In a generous incision over its lowei 
third. I lus lower portion is prelerred on account ol the 
grealet thickness and strength ol the cortex. \ portion is 
( lioscai where the c rest is straight and regular, and the muse le 
and soil tissues dissected away. Willi the motor saw, longi¬ 
tudinal cuts are made on each side ol the' (rest at a suitable 
angle with each of hei and at an in ten a I sullic ient to provide 



.1 |>cg I >> iiu 11 in diamelci altei shaping. I wo transverse 
saw (ills arc now made ai an interval equal lo the reading 
on the di ill. and the segment loosened by means of an osteo 

I it>. (). I’mmilcd liarture of netk ol Icmm. l'i (.'operative v-iay. 

tome and penile blows ol a mallet. 1 he selected end ol this 
segment is seized by two Oehsner clamps. The other end is 
inserted in the pent il sharpener cutter attached to the dowel- 
shaper, by means ol which the end is shaped to a blunt 
conical point lavorable not only lor subsequent engagement 
in the dowel tool, but also lor reception in the drill hole 
already prepared in the lemoral Iragments. The pencil sharp¬ 
en c*r attachment is now replaced by the dowel tool and the 
peg run through it. During both these shaping processes, a 



drip ol normal saline' is ;maii;^'(l in lull < 1\ on the 
tool, not onl\ lo liaslcn Us culling lull also to prewemt am 
possibililN ol undue' healing. Mu' saline solution also pie 

I k., m. S.iinc eisc as !■ ij>ure (). I’osiopei at ive v-rav. nine inonllis alio 

opei ai ion. 

\enis deli\(!i at ion ol the grab h\ exposure to the air. More' 
o\cr, in the industries, eithei oil or saline solutions are used 
in the ( lit t i 11 o ol hard si i list at ices, lor the purrx >se ol el earing 
debris Ironi the' path ol die' earning instrument, as well as 
loi iik 1 easing the' speed ol < lining and lor diminishing Irie 
lion. I lie' Irunne'll s or \ all s guide mas he used to aid in 
the pie (per d i ree l ion ol the drill. 

I lie' drill is now removed Ironi the' trochanter, and the 1 



pt'g' inserted in iis place and driven home will) the bone 
drill and mallei. Willi die end ol die handle of a wooden 
mallei against die great trochanler (Fig. <S. 1 >) ( lose to (lie peg 

I k., ii. Same case as Figures 9 and 10. A 1 a\ taken sis years after operation. 

grail, I insure close approximation ol die fragments b\ 
si 1 iking (lie palm ol die hand or a sand-bag against the head 
ol the mallet. 

Flic deep last ia is c losed by interrupted sutures ol No. 1 
(hroinit catgut and the skin with a continuous suture ol 
No. o plain catgut. 1 lie limb is put up in a position ol slight 
abduc tion, in a double plaster ol Paris spica extending to the 
base* ol die* toes on the allcclcd side and to the knee on the 
sound side lor a period ol eight to ten weeks. Preopei at i\e 



.md postopci ill ive roentgenograms are .shown in F inures <). 
10, and ii. 

1 cl us examine in detail some ol die points in this lech 

Ik., i 2 . \ r; i \ s (antet opostci iot .mil lateral) taken miincdialclv a ltd inser- 
linn < >1 nails showed apposition oi 1 1 a^meiiis lo he \er\ sal i si a (1 < >r\. I 1 1 i s taken live monlhs allct opetaiion, shows non-union and marked ah 
sorption ol no k ol femur. and extrusion ol nails. 

niipie. I)\ means ol die *_»radtlated drill and palpation be¬ 
tween the Ira,laments, one can determine die point lo widt h 
die dtill hole oiiL>ht to he (allied. 

I wish to eniphasi/e that the introduction ol a nail or 
st rew, ot am material other than an autogenous bone ^ral'l. 
does not meet the requirements 01 overmine the physiologic 



.md biologic barriers to union (Tig. 12). Nails arc foreign 
bodies and have no biologic or physiologic properties, e\ 

( cpt dcstrue 1 ion. as those <>l us w ho have been removing nails 

t in. 1;;. I)i;igram showing vascularization of anemic head of lemur through 
blood-vessels of autogenous hone-graft peg. 

for years and observing their destructive influence can em¬ 
phatically attest. 

Accuracy ol lit of the autogenous bone-gralt peg is anothei 
essential (Pigs. 14 and 14). This can be accomplished only b\ 
the use ol electrically driven automatic machinery which 
brings about a lit commensurate with that ol a glass stopper 
in a bottle. The insertion ol the graft should not produce 
compression by loo tight or inaccurate a lit, nor should there 
be a dead space, hik'd with air. blood clot, or tissue debris, 
between the surlace of the grab and the host bone tissues. 
In ollici words, there should be the closest coaptation ol the 
Haversian canals ol the host and grab tissues so that early 
and complete vascular canal i/at ion ol the grab will take 
place. Obviously a graft ol irregular c ross-sect ion is not de¬ 
sirable. The square peg in a round hole is a misfit here as 



in excix ollici limn.m endeavor. I lie earlx and complete 
\ ,im i ilati/al k in which will occui best in an accuralclx lilted 
autogenous peg grail is not onlx essential to surxixal ol the 

Cancellous bone 

Haversian canals 

I IC. I | . 

grail, hut senes to earn blood and callus lot ailing material 
to the aneinii capital Iragnient and to the point ol Iraetnre. 
Roiled hone is undesirable and in no sense a substitute. 
Roiled bone, cow horn or ivory, because ol then relative in¬ 
herent weakness, must be largei in diameter than a metal 
nail oi screw and are, therelore, more undesirable because 
the\ displace more cancellous bone at the Iraetnre junction. 

I hex do not serxe as an ostcogenetic scaflold or xascular 
stimulant to osteogenesis (Fig. ir,). 



II hit man I bd in I ion Method <>\ (.’dosed Reduction.* “ I'lie 
lintl) having been powdered, ;i lilted covering ol stockinet, 
extending lioni die neck to die toes, is applied lo protect 

lie. i"i- Boiled ox-bone was liisi inserted. Ii broke and absorbed, leaving 
Iragmcnt shown just above nails which were inserted two months later in an 
added ellort to secure union. \ loose non-union is disclosed b\ \-ray. 

the skin IVoni wrinkles. kite patient is then placed in a 
fracture-table and aneslhctised, since complete ninsculai 
relaxation is essential to ligamentous tension. The two ap- 
posed and extended limbs are supported bv assistants, and 
the shortening is reduced by direct manual traction aided by 
pressure on the troehanter. the limb meanwhile being 
rotated slightly, as indicated by the position ol the patella. 
The two limbs, nuclei manual traction, are then abducted 
I>\ the assistants, the sound side indicating the normal range 
to whic h the otliei must correspond. \t this stage the opera- 
tot must assure himscll that the two limbs are ecptalh ab 
■ Whitman. R. I lie abduction ircatmcnl. I.tnait, 2: 72(1. in;ji- 



diuli'd on a level pelvis, and dial die anatomical landmarks 
on die two sides cm respond absolutely. 

I lie trunk and limb are bound u illi sliccl wadding, mam 
lavers being applied about die ( lust and pelv is. and the bom 
prominences ol die limb being earelullv protected. \ final 
covering ol ( '.anion llanncl bandage assures an ev en clast ii 
still.lie lot the plastei splint. \ long spiea. extending Irotn 
tin' a \ i 11 a rv I i n i‘ to 1111‘ extremities ol the toes, is then eon 
stria ted. I his is strengthened bv reverses at the points ol 
strain and. lor greater security, a steel bar bent to the propel 
angle is inserted in the trochanteric region. I hi* long spiea 
when propel Iv applied supports the limb in lull abduc 
lion, to assure adjustment bv ligamentous tension: in lull 
extension, to maintain the normal lumbar lordosis; in 
slight rotation, to turn the Iractured margin awav Irom the 
capsule: in llexion at the knee, to lessen the strain, the loot 
being held in the neutral attitude. J he patient usually re¬ 
mains lor a time on the table, the drying out ol the plastei 
being hastened bv electric heaters. Meanwhile, the support 
is earelullv trimmed about the margins and cut awav sulli 
(icntlv to permit lull llexion ol the thigh on the uninjured 

I he patient is then placed on the bed, the head ol whic h 
has been raised lor a loot 01 more, with cross-boards beneath 
tin 1 mattress to prevent sagging. I he inclination is vetv im 
portant. It enables the patient to look about the room and to 
dispense with pillows. It increases the blood-supply ol the 
injured part, and as compared with the reverse position, 
usuallv employed with trac tion, it should lessen the lendenev 
to congestion ol the thoracic organs and aid the digestive 
pr<H esses. ' 

\nderson, utili/ing the well leg Im countert rail ion and 
abduc t i on." pulls the legs down in a nearlv paiallcl position. 
It m.iv seen) paradoxical to expect abduction with the legs 

\ iiclci son. R. \cu mriliocl lor 11 t-;i ling 1 1 cicuircs. S iii^. (Ixnct. Obsl., i: 

-‘>7- Mi.r-i. 



so (lose together, hut radiographic evidence proves that ab¬ 
duction does occur. During the movement ol reduction, the 
traction lorce pulls the acetabulum down on the injured 
side, while counter! i act ion forc es the well acetabulum up, 
thereby changing the angle ol the transpelvic line with the 
axis ol the injured leg Irom an acute to an obtuse angle. 

1 his in turn lorces the angle ol the neck with the shaft ol 
the injured lemur into the normal position of lgy degrees. 
Skeletal traction transmits tension to the hip joint capsule, 
its ligaments and adjacent muscles, thereby accomplishing 
apposition and immobilization. Thus the fragments are held 
in fixed position between a taut, muscular and ligamentous 
envelope—an internal splint, as it were. 

Technique uf ,/ fjjAyi ng I lie . I /ijMii ul us. First, a well-padded 
plastei ol Paris cast is applied to the well leg extending Irom 
the toes to the mid-thigh. The countertraction stirrup is ap¬ 
plied to this cast alter the plaster hardens. The Iracture ends 
are anesthetized with 2 percent novoeaine, a local anesthetic. 
A Steinman pin is driven through the tibia on the side ol 
the Iracture at a point two lingers' breadth above the tip 
ol the internal malleolus. This pin is incorporated in a 
padded plaster-of-Paris cast extending Irom the toes to about 
four inches below the knee-joint. The traction stirrup is ap 
plied over the pin after this cast hardens. 1 he Iracture is 
then reduced, using the Whitman maneuver. 

lullioi's Comment. The Whitman method ol closed re¬ 
duction is mec hanic ally sound and usually brings about a re¬ 
duction and fixation ol the Iracture. Every effort should be 
made to check the' position of the fragments postoperatively, 
with v-rays of the- neck ol the lemur taken in two planes at 
right angles to each other. Often a Iracture which seems to 
be in good position in the anteroposterior films is shown to 
be in bad alignment in the other plane. I do not recommend 
this met hod ol 1 real merit ol I rac 1 ure ol the neck ol t he lemur 
in operable cases, because, although it lurnishes a means ol 
hi inging the 11 act 11 red I ragmen ts into proper posit ion, it does 



iKt( 1 111 nisi) the- biophvsiologic al aid whic h makes it possible 
h>i these' Iragmcnts to unite-. I lie mechanical ec|iii\aleiil ol 
the \ndcrson method has been accomplished lot many years 
b\ the author through the use ol the loti” double' plaslci 
spic a appl ied on the I ran m e <>i t hopeclie table while t t ac t ion 
is exerted on the Irae lnred leg and c ounter!tae l ion on the 
well lee. 

/ .(’(id be! I r) Method <>) (dosed lied ltd ion I he patient 
is anc'sthel i/ed on the Iran me table. I lie- uninjured lee is 
harnessed to the loot stirrup. I he injured ley is then Hexed 
at the hip at »)c> degrees. with the lower ley at <)<> deyrees to 
the thigh. Direct manual traction in the axis ol the Hexed 
thiyh is made, toyethei with slight adduction ol the lemoral 
shalt. In this position the thiyh is internally rotated ap 
proximalelv | j deyrees. I he ley is slowlx circumducted into 
abduction, the internalh rotated position being maintained, 
l he amount ol abduction varies with the individual and 
c an he measured ace match , representing the difference in 
deyrees ol the angle made by the Iractured neck with the 
shall and the angle between the neck and the shall on the 
normal side, as evidenced b\ the roentgenogram. 

\lter the leg has been brought down in the measured de¬ 
gree ol abduction and internal rotation, the heel ol the in 
j tired ley is allowed to i cst on the outstretched palm. II the 
reduction is complete the ley will not evert itsell. Should 
there be no interlocking ol the Iragments, however, the leg 
will slowb rotate externallv. The observation is made that 
as the ley is circumducted into a position ol abduction and 
internal rotation without tension, the position ol the ley 
tends to assume the proper degree ol abduction and internal 
rot at ion. II abducted loo lar. one wi II I eel the delin i le tension 
ol the adductors which can be neutralized by allowing the 
ley to assume a smaller angle ol abduction. II internal rota¬ 
tion is too great, the ley. nuclei the heel palm lest, will rotate 

' I eailheiiei', l.. \V. A treat iiu’iil lor tract tire ol the; neck ol (he lemur, 
/. Hour t. jniul Star.. iy i|;{l. I 



outward until the proper decree ol internal rotation is 
reached. One can approximate the desired decree ol su< h 
aluluetion and internal rotation by a study ol piemanipula- 
t i \ e roentgenograms, lor. at the time ol the actual manipula¬ 
tion, the liner decrees will be adjusted automatically by 
muscle tension ol the hip. 

With the hip reduced a one layer thickness ol gla/ed cot¬ 
ton is placed about the torso Irom the nipple line over the 
affected hip to a point about hallway between the hip and 
the knee. I hen a lorn* strip ol lelt, \/> inch thic k, is placed 
about the pelvis, extending from just above the iliac crests 
to the trochanters, and completely encircling the pelvis. 
This is all the padding necessary and allows very tight ap¬ 
plication ol plaster. The body portion is first applied as 
tightly as possible, sung coaptation being the aim. Firm 
pressure ovei the injured hip is necessary. Below the hip 
no padding is applied. Two plaster slabs molded carefully 
to the contour ol the leg, one posteriorly and one anteriorly, 
are bandaged closely to the skin. No padding is placed be¬ 
neath the heel as this is molded well and the plaster coaptecl 
tightly. This east remains on lor a period ol eight to ten 

liil/io r’.\ Comment. It has been the author's practice to 
apply over several layers ol sheet wadding, a double spica 
cast extending to the 1 toes on the injured side, and to the 
l ubei c le ol the tibia on the mi in jin cd side. This type ol cast 
holds the fracture securely but permits the thorax and most 
of the abdomen to be exposed. On the clav altei reduction 
and on subsequent (lavs, the patient is turned on his lace 
night and morning. I hese measures have practicallv elimi 
nated pulmonarv and abdominal complications. II it seems 
necessary to apply tract ion it c an be secured as easily as with 
the \nderson x well leg turn buckle method bv applving 
moleskin traction straps to the leg. I he lower ends ol these 

' Anderson, k. New method loi l renting h.u lines. (iyih t. Obit., 

:t 1 : - (, 7 » 1 93 2 * 




st i a | is are i nec >i |><m alec 1 

into the plastei , 


double spic 

a is 

then applied and 


pi asl ct molded 

In mix against 


planiat sin lac e ol 

the <>| 

pposi 1 e 1 < iot. 

Ihe 1 eadhel tea 

met h 

od is sound mec 

ban ic 

a 1 lx and In 


about a reduc t ion 

ol dm Iracture but < 

1( ICS 

not bullish 


other. I>i<)i>h\si<>I oij, it; iI reepiiremenl ol .in ideal treatment ol 
li.n line ol the neck ol llic Icinui die 1 eeslablislnncnt ol 
blood su|>|>1 \ in tlu 1 anemii capital I raiment. Cases should 
Ik' followed eaiclullx h\ \ raxs and at the lust e\ idem c ol 
bone absorpt ion ai l lie Iracture junet inn a bone <>i a 11 should 
he inserted. 

Smith Pete)sen Ohnnhve ieehniij lie. Ihe Sin it h Petersen 
approach is made as described in Chapter III, p. 2 cS. I lie 
fracture is reduced. and in this manipulation it should he 
kept in mind that adduction, accompanied by lateral pies 
sure applied to the inner aspect ol the thii>h, is helplul in 
unlocking the fragments. W hen the Irac ture is in alignment, 
the position is most easilx retained by internal rotation, ex¬ 
tension and abduction ol the hip. I he nail is now driven in 
through the lateral surface ol the trochanter, at a point be¬ 
tween the insertion ol the gluteus merlins and minimus and 
the origin ol the vastus lateralis, these muscle attachments 
having previouslx been reflected suhperiosteallv. 

As the nail enters the proximal Iraipnent there is a lend 
enc \ to separation ol the I raiments. I his tendency is oxer- 
come hx the use ol a most xaluable tool, “the impactor. 
whic h Ills ox et the head ol the nail so that the force of the 
blows is transmitted directly In tlic cortex ol the lemur in 
the subtrochanteric region, thus approximating the frag¬ 
ments. llx alternatelx striking the nail and usinu, the im 
pactor, the nail is drixen home. Impaction ol the Iracpncnts 
is extremelx important, and the nail should not be struck 
altei impaction has been brought about, since hx so doin<> 
we tend immcdiatelx to distract the Irajpnents. 

before closing the capsule the - success ol the procedure 
should he put to the text by moving the 1 hip through a wide 



innge in llexion, abduction, adduction and rotation. I here 
ls ll<) change in the Iracture line as these mani]iiilal ions are 
carried out, and it gives the surgeon confidence in the ah 
solute fixation, so that he will start lunction early. 

l ie.. i(i. tic. 17. 

1' Kis. ill and 17. \-ra\s of Smiili-Pciciscn nails in place. 

I lie capsulai Map is now sutured hack in position. Since 
it carries with it a portion ol the reflected head ol the rectus, 
it is a strong struc ture and repair is satisfactory indeed. The 
muscular Map Irom the lateral aspect ol the ilium is hest 
sutured hack into position with the hip in abduction, there¬ 
by relaxing - the muscles contained in the Nap. The same is 
true ol the repair of the insertion ol the tensor fascia lemoris 
muscle. The remaining closure ol the wound needs no de¬ 
tailed descript ion. 

Because ol the dillic ulty in plac ing the Smith Petersen nail 
accurately, Henderson has offered the following ver\ in 
genious remedy, which he states was lormerh advocated by 
Johansson of (iothenburg and King ol Australia. The modi 
hcation mentioned is hrielh as lollows: 1 he hip should he 
reduced in the ordinarx manner, and anteroposterior and 
lateral roentgenograms taken to he certain that the position 
is correct. A Kirschner wire is then introduced through the 



trochanter, neck and head, and a slight disiance into the 
aeelalxilai wall. Xnteropostei iot and lateral i ocnlgcnogi ams 
are taken to (lelerniine that the position ol the wire is cot 
i ca t: il the' position is not correct, the wire can easil\ he 
withdrawn and reinserted. When satisfied that the line ol 
the wire is correct, a special cannnlaled Smith Petersen nail 
is threaded o\et the wire and driven in. \nothei antero 
posteriot him is taken (01 the llnoroscope ma\ he used) and 
discloses whethet the nail is salch embedded. although it 
should not he so lar in as to engage the aceltihulnm. I his is 
the onh untoward tiling that ma\ happen, because the nail 
must lollow the wire. W hen it is determined that the nail 
does not engage the' acetabulum, the wire is withdrawn, the 
wound c losed and a plaster ed Paris cast applied. The c ast is 
split at the end ol a week and movement ol the hip begun. 
\t the end ol three weeks, the cast can he removed and the' 
patient allowed to he upon crutches. W hen roentgenological 
examination discloses bom union, the nail tttav he with¬ 
drawn. ustialh about live months alter the operation. 

No external fixation is used b\ Smith-Petersen and the 
patient is allowed out ol bed as soon as the wound permits. 

iuthor's Comment. The flange nail destroys and com 
presses the' cancellous hone within the neck ol the lemur. 
Wthough this method meets the mechanical recpiiremenl ol 
a successful treatment ol Iractnre ol the neck ol the femur, 
it not onl\ lails to lullill the physiological recptii ements, hut 
it is actualh antagonistic to them. 

At best the conditions lor callus to span the Iractnre junc¬ 
tion and unite the' fragments is poor, therefore, postoperative 
splint immohil i/at ion ol the limb is considered by the author 
as advisable. In am event, at the' Inst appearance of bone 
absorption at the Iractnre junction or the non-appearance 
ol callus when il should conservatively be expected, the nail 
should be w ithdraw n and a bone-gi aft peg inset ted. 



I’ixnlion of /■ rail in eel A (’<h <>l i'enim will/ Kirschuc) 
II nix (I clson iniil Hu nsohoj)).' I lie silt 1 ol I rad tire is an 
c.sllid i/cd 1)\ llic introduction ol 10 u> 1 r, c.c. ol 2 net c ent 

In.. iS. Wisdom ol eilhei I hreadi ng nails 01 placing mils upon them is 
shown l>\ this \-ia\ which shows a kirschnci wire which has wandered into 
pelvis. (Conrlcsv ol I) 1. Austin Moore.) 

novocaine solution into the hcmatoina at the site ol fracture. 

I lie I rad tire is ilien reduced, Ihe |)rocednre is carried out 
on the \ ray table and a him is then taken to determine the 
accuracy ol the reposition ol the I raiments. Measurements 
are made on this him whic h enable the surgeon to ascertain 
the points ol entrance, direction and depth to which the 
w ires are to be inserted. Ihe point ol entry is determined b\ 
c 1 raw ill” a line through the* longitudinal axis ol the neck and 
measuring the distance between the* lip ol the greater tro¬ 
chanter and the point where this line meets the lateral con- 
tout ol the lemur. The direction ol the wire is determined 
by measuring the* tingle made by this line with the lateral 
outline ol the thigh. I he depth to which it is necessaix to 

* I clson. 1 ). Is ., and Ransoholl, V S. Ircaimcnl ol Iradmed neck ol 1 lie 
Ici 1 m 11 liv asal lisalion with sled wiles. /. Hour s Join! Surg., 17: 727. ni'SV 



Imii\ (hr wire' is dctei minc'd I >\ iikmmii ill” the distance Irom 
the ccnici (> i llu' <>l (lie leinin in (lie periphen < >1 (lie 
sli.ill. I' measurements liiusl lie collected to allow lot 
die distortion ol the \ rav shadows. 

\o skin anesthesia is used. I he wire is introduced with a 
niotoi driven drill. \ movable eollai slabili/iii” prom; is 
lust applied to the apparatus. I his proii” is pushed tlnou”h 
the skm until it stiikes hone, and the movable eollai is 
linked at the predetermined distance on the stale, \ltei the 
lust wire is introduced, its position is checked with a roent 
Lpiidpain. II the position is sat islactorv, two other wires are 
introduced Irom dillcreiil angles, an attempt beiti” made to 
(loss them in the capital I raiment. Am (halites nccessaiN 
are made billowing \ ra\ checkup. I he skin is then depressed 
as I. u as possible and the wires are cut. No di ess i lie, is applied. 

No external immobi I i/at ion is used. In some cases, a short 
posterior splint w ith an S-inch ( loss rod is applied to the 
ankle to pi event external rotation. 

Alter fixation, the patient is allowed to sit up in bed im 
mediatelv, and ma\ be placed in a wheel-chair, within a da\ 
or so. At the end ol ten weeks, il the \-rav shadow shows 
sufficient union has taken plac e, the wires are removed undo 
local anesthesia through a it inch lateral incision. 

Maver has modified the relson-Ransohofl nail l>\ thread 
ill”' it to prevent crecpiii”. Moore has pine still lurihei In 
devisin” an adjustable nail with a nut threaded on il at the 
tiochanter end around which he lashes a line sol’t stainless 
wire (,oi| inches orthodontic) connect in”' all ol the nails 
ovei which lie draws the soil parts. 

lullio) .\ C.oinninil. Largely to a\oid the destruction and 
compression caused be a nail ol as lar”e cross-section as the 
Murphv. Smith I'etei sen oi \ a 11 nails, I elson and Ranso 
boll in t <);; l su””csted the use ol multiple Kirschnei wires. 
I his irealmeni does not lurnish am ol the biophvsiolcnp’ral 
inlluences ncccssan to prewent absorption ol the neck. It 



seems to ollci no advantages over the othei purely mec hanical 

1 have Ire<|nen11 > seen these wires gradually work out 
through the' skin, an evidence ol the lack ol complete nn 
tnohd i/at ion ol the Iracture. Moore bv inserting y to r, nails 
in different planes and lashing tlieii distal ends lirmly to¬ 
gether with wire, secures complete innnohiIi/ation hut does 
not lurnish the hiophysiological influences required by the 
Irac lure. 

tut At Ml \ I Ol I’M Mill) IRACIIKIS Ol Mil \ICK Ol lilt 

I I M I It 

Methods ol treatment in order ol preference: 

1. Bone-gralt operation (Albee); 

2 . Reconstruction operation (Albee): 

g. Whitinan reconstruction operation; 

I. Ellis Jones operation; 

y. Artificial impaction. 

Pathology. Anatomical dissection ol the ununited Iracture 
shows many interesting details. Ihe cancellous structure, 
the cortex and the cartilage ol the capital fragment are 
markedly atrophied: the end of the fragment is covered with 
a pannus, on the outer rim ol which is attached the new 
librous lotmation. Over the end of the base ol the neck is a 
fibrous covering, which is usually somewhat heavier than the 
covering ol the head. When this covering is removed, the 
bone is found to be in good condition, the atrophy is onlv 
moderate, and usually the remains ol the old strengthening 
bands in the anterior portion ol the cortex are found. Re¬ 
tween the fragments can be demonstrated new joint lorma- 
tion, that is, one or more cavities lined with epithelium and 
containing v iscous joint fluid. A true pseudarthrosis is almost 
always present and librous union ol Iragments is practically 
nevei seen. I'nder pressure, sliding ol the opposed joint 
sin lac es upw ard c an be demonstrated, the amount varying 



Inini i ! iiuli in .1 lull null. When ilie sliding is ininiiiuun 
m deyrcc. die hip is lairlx stable. while the- lexcrse is line 
(>| a hip that allows motion ol an inch. I lie weight hearing 
strain is home enlirelx h\ the hea\\ lilnons liyamcnls and 
scar tissue attached to the base ol the neck. 

I want lo emphasize that il is absoluteh essential to entei 
between die fractured liaymenls ol minnited I rat lure's ol 
the neck ol the lennn and rcanoxe die' sxnoxial membrane 
that is almost always lound on the ends ol these I raiments, 
and freshen them up in such a wav dial they will come in as 
perfect apposition as possible alter application ol the bone 
ora1 1 pey and artificial impaction. 

Fins is nercssarx lor the lollowin^ reasons: 

t. It is important that the closest apposition without in 
terposiny synovial membrane or connective tissue be 
brought about between the' two lemoral Irayments with 
lavorable conditions lor union and establishment ol 
blood supply. 

\s the ends ol the bone tire olten iireyulat in shape 
and do not lit into each other, the sin laces should be 
transformed into pcrlectlv plane surfaces so that the\ 
will In with the yreatest accuracy. 

Vs it is believed that the* svnovial lltiid is an inhibitor 
ol bone growth, il is desirable also to furnish condi¬ 
tions which will permit the' encroachment ol callus 
between die lemoral I raiments to push out the synovial 
fluid, or better, to c oapl the bone I raiments so ac c ur¬ 
ate I \ that die sxnoxial lltiid is completely kept oul. II 
the sxnoxial lltiid does not ol it sell have a particular 
inhibitiny, influence, il iniisi be yranted dial the pres 
dice ol am fluid inhibits and delays union. 

Si i \i dun Keith, die' Ihitish patholoyisl, makes a xeax 
sliony point ol earb and prolusc ease ulari/al ion ol massixe 
bone ry i alls. I lie autogenous bone-yrall tissues act in an 
unusual w ax as a vascular conduct iny scaffold. 



lione-g) a) I l > ' , o () j/r) at ioii . Iii i'\ci\ (,isf ol ill I ill ] i I e< I Ii;k 
line ol the neck ol the Innui in which the capital fragment 
has sulltc tent length to receive favorably a bone-peg and 
ol snllieient length to Inrnish a level to permit the abductoi 
nurse les to earn out their lunction, the bone-gralt peg is 
the preferable treatment. II this leverage is loo short, the 
\lhee reconstruct ion operation, which restores its length, 
must he used. 

Reconsl nu I ion () j/erat ion [.-l l bee). In spite ol the wide ap 
plic'ability ol the bone-grail peg operation, there will always 
be a certain number ol cases ol long standing non-union in 
w hic h there has been muc h erosion because ol lac k ol blood- 
supply. ill-nourishment ol the capital Iragment and the erod 
ing effect ol ill-advised locomotion, in which one must enr 
ploy a diflerent type ol procedure. I or this type ol c ase, I 
use a partial arthroplastic 01 reconstruction operation.* 

I he approach is that dew ised by Smith-Petersen and is very 
similar to the Sprengel approach, with modifications to meet 
the requirements ol this operation. 

With the wide osteotome used lor splitting the spinous 
processes in operation lor Pott s disease, the muscles are 
stripped down Irom the side ol the ilium b\ subperiosteal 
separation, and are separated Irom one another directlx 
downward Irom the anterior superior spine. The capsule ol 
the hip joint is completely exposed. I he joint is entered b\ 
a T inc ision with the stem running directly downward along 
the neck ol the femur. The head ol the 1 is made about 
:> ! inch Irom the rim ol the acetabulum, for the purpose ol 
protecting this rim both nice haitic allv and as to blood supply. 
and ol lurnishing a cull ol capsule to act as a lining ol tlm 
outer portion ol the joint and lot the neck to rest against 
w lie'll the' joint has been reconstruc ted. 

dare should be taken to make the incision into the cap¬ 
sule' sullic lent lx spacious so that the clifliculiy ol getting the 
head out ol the acetabulum will be minimi/ed. The liga 

' Wilier. I . C) 11 lio|)(‘c!ic .md rec ohm i lie I ion singc'ix. 1 * 1 1 i la.. Saunders. 1919. 



null!11 hi teres is thru sexercd I>\ means <>l a i L > iiit li <>slcolonic 
thrust deep inlo the joint. and am adhesions ol die capsule 
to die petipherx ol die head are carclnll\ separated with a 
si alpel. 

lhe linil) is then stroii”lx exerted h\ adjusliti” the I rat 
tine table, so as to make room loi the delivers ol the head. 
W ith two loti” i 2 inch chisels or osteotomes, the head is 
plied out ol the 1 acetabulum, with a motion much like that 
used in eat in” with c hopstic ks; one osteotome is thrust into 
the inner and one into the outer substance ol the head, and 
the two are used as lexers against the soli parts to pry the 
head out ol place. A bettei technique is to use the lorceps 
lon”s. 01 a double cerxical tenaculum to seize the lemorai 
head and extract it. I he instrument shown in l i”iue i<) was 
recently designed lor this purpose. 

\s soon as the head is delixered. the 1 patient's limb and 
loot should be inxerted bx the acljustnient ol the table, so 
that the loot points direcllx upward, l hen, with the scalpel, 
the soli parts are sewered strai”ht down on to the anterior 
sin lace ol the troc hanter (c are beiti” taken not to separate 
them I tom the bone) in the lortn ol an inxerted "1 . In 
the dells thus made in the soil parts with the scalpel two 
osteotomes ate- placed, a i l a inc h one to make the bone in¬ 
cision ol the loti” anil ol the "I. and a t inc h one lot the 
short arm. I Itese osteotomes then are driven in tliroii”h the 



l rod inn ter synchrououslx. so as to separate the bonx lexer 
i lit act .uni unbroken. I lie broad osteotome in driven Irotn 
aboxe downward beneath the circumflex arterx so as not to 

sexer it. oi the periosseous soli parts. I 1 i e bone muse le level 
(a), w'liieh should be about | inches long. is then pried out 
ward bx the osteotomes st ill in plat e and a greens tit k I rat t lire 
is produced at the lower end. thus separating the lexer Ironi 
the main portion ol the trochanter. Care should be taken not 
to separate the muscles and soil parts Irotn the bonx lexer. 
The cut made in and at right angles to the trot hauler tie 
termines the amount ol shortening ol the limb and should 
not be made until the limb has been pulled down to the 
maximum bx the Iracture table: it is then made as high up 
in the trochanter as possible, in laet. just lexel with the rim 



ill the acetabulum. In this \\.i\ the minimum amount ol 
shortening is produced and this is less than by a 11 \ olhei 
( >] h i at ion \ et de\ ised. 

Ik.. 2i. \ ia\ showing result ol technique shown in limine 20. 

I lie last step is to fracture the hone-muscle lexer outward 
at its extreme lower end In using the wide osteotome (driven 
Ire mi above downward without separation ol soil parts). 
Formerly Iragments ol cancellous hone were removed From 
the c ut surface ol the trochanter and shall bv means ol a 
curette, and placed in the angle ol the gap thus lormed. 

I he stump ol the neck is then rounded so as to cause mini¬ 
mal in ital ion ol the ac clabulum. 

I lie assistant is direc ted to adjust the table so that the 
limb is brought to the limit ol physiologic abduction at the 
hip. and at the same lime the upper end ol the lemui is 



lilted forward and guided into die acetabulum. The bone 
lever is thus automatically held by the limb posture in the 
oblique relation to the shaft ol the lemur with its upper 

I at.. 22. X-ia\ ol non-union ol neck of lemur. sis months after fracture. 

end above and lateral to the rim ol the acetabulum. 

M\ recent innovation is to shape the excised lemoral head 
into a wedge (Fig. 20, b) by means ol motor saw. osteotome, 
etc., rare being taken to remove all ol the articular cartilage, 
and to place this wedge in the angle between the shall and 
the troc hanteric lever. This has been round to be lai superim 
to bone fragments lor this pur pc >se. It pre iduccs a linn lit and 
immediately holds the bone-muscle lever In its proper rela¬ 
tion without wailing I01 callus formation and reduces the 
time of plastei immobilization to three weeks (Figs. 20, 21). 

T he uppei end ol tlu' bone musc le lever is pulled lorward 
and held with medium kangaroo tendon sutures placed in 



the sin roundino attached soli tissues. I lie wound is non 
ivadv 1 1 ii closure. \ 11 dead spaces are overcome bv means 
ol coni muons suture ol No. i chromic catgut. 

lie.. 23. Post opcm live result in same case as 1 i” 11 if 22, a her leverage ai 1 < > | > 
ol lemur was elongated l>\ wedged lemoial head. 

Mechanical It lion of Bone-muscle I.ever. The mechanics 
ol this operation ma\ lie lurther elucidated by a description 
ol the mechanical action ol the hone-muscle lever. I lie in¬ 
sertions ol the short trochanteric or abductor muscles ate* 
card till v lelt intact on t he t roc hauler 01 proximal etui ol the 
level (Ho. no ( [p \ s || )( . approach to the hip does not inter 
lere with the innervation ol these muscles, the ability to ab 
duct, lost with the* leverage act ion ol the neck ol the I cm in, is 
restored (l io. u|). I lowever, the lever substitution lor the 
lemoral neck is outside ol the lorn* axis ol the' lemoial shall. 



precisely as in the <>\ and many otliei animals (see figure 
lac ing page i). At the same time, w heat ilu- leg conies to the 
n 1 i< 11 ine ot beyond, dislocation is prevented by the outward 
excursion ol the proximal end ol the' le\ei and the resultant 

lac. ‘j |. Photograph in case ol ununilrd Iraclurc ol neck ol left feimn ol 
len years' duration. I his patient had been compelled to use crutches lot 
whole period ol len tears. N'eck ol lemur had enlireh disappeared and there 
was a marked I a \ i l \ ol head at point ol non union, this photograph, taken 
cighleen monllis al'ler operation, shows splendid a I >ch u t i no and weight 
hearing function, following reconsiruction operation with hone muscle lever. 
1 ’aiienl was walking without rrulcli oi cane, with painless, free motion. 

tension not only on the troehantci ic muse Its. but also on the 
soil pails surrounding them. Phis action holds the newh 
formed femoral head lirmly in the acetabulum and prevents 



it tiding on the lim ol (lie ;n elalmlum. leading lo hone- ab 
soi pi ion ol dii' l im and possible remote dislocation and 

In die i.isi's ol ai throplast irs ol dir hip in which die 
patient lias weak abdnctoi powei billowing opeiation, I 
erect the same t\pe ol bone muscle lexer. In this type 1 ol 
ease, a wedge 141 all taken Iroin the' side ol the' ilium is used 
to hold the hone muse le level in its new posit ion tsee p. 2 1 <Sp 
I lie increase ol efliriencx ol the abductors billowing this 
lengthening ol the lexei lhe\ at t upon results in a much 
hettei n a i t. usuallx eliminating die posilixe I rendelenburg 
si<4n w idt h so mam ol these pat i enls ha\ e. I his same print i 
pie is also used to elongate this lexer at the top ol the lenitti 
hexontl its anatomical length in cases where the must ulatiuc 
has been weakened, as in inlantile paralxsis invoking the 
gluteus meditts. etc., must les. 

At the conclusion ol the operation, the lee, is put up in 
a double spica, extending Irom the tips ol the toes on the 
operated side, and to the tubercle ol the tibia on the other 
side. The plaster is so molded as to hold the upper end ol the 
lemur anteriorly and is kept on loi a period ol three and 
one-hall to lout weeks. The lee, is then allowed gradually to 
lesnme the normal position. I he patient is persuaded to 
begin walking with crutches immediately alien the remoxal 
ol the fast, and dailx massage and manipulation at hip and 
knee are at once inst it tiled. 

I he choice ol operation is determined hx the condition 
ol the fragments, and in some borderline cases the selection 
ol operation cannot he determined until the head and neck 
o! the let mu hare been exposed. 

II hilnimi Recous!nt< lion ()jiemlion.* “An incision is 
made in the shape ol a hall l . beginning about 1 inch be 
hind the anterior supei ior spine and extending downward 
and backward, crossing the lemur at a point g inches below 
the apex ol the I rot banter. I lie inlet \ al between the lensoi 

XX hii man. R the i ft (him i lit 1 ion o|)cialion for miiiiiilt'il fracture of the 
lift k ol ihe lemur. .S104. C.\mi. Olisl., 171). itjai. 



vaginae lemon's and gluteus medius muscles is exposed; the 
c apsule is opened and 111 c* head ol the lemur is removed 
(Figs, ipr, and idi). 

I ion. yr, and jti. W'hiimaii i econst rut t ion opeiation, showing line ol section ol 
not h.inter anti point on shall to which it is to he transl'ei letl. 

I lie anterior margin ol the gluteus minimus is followed 
to its insertion, and at this point with a wide, thin chisel, 
the base ol the trochanter is cut through in an oblique di¬ 
lection corresponding to the' angle ol the nec k (T ig. 25, A), 
inc hiding all its muscular attac lunents and often a part of the 
capsule. This llap ol bone and musc le is tinned upward and 
the upper extremity of the lemur, having been somewhat re 
modeled by c utting away the projections ol the posterior in¬ 
tertrochanteric line, is freed from any restraining tissues and 
is thrust completely within the acetabulum at an angle ol 
about 2 y degrees ol abduc tion. 

“The trochanter is then drawn downward, as far as its 
attac hments will permit, and sulltc ient cortex having been 
removed Irom the lateral aspect ol the lemur, the two bare 
surfaces are apposed, the axis ol the trochanlei being there¬ 
by changed from a direct ion upw ard and inw ard, to outward 
and upward. In this position (Tig. idi, 1 >) it is sec tired eitliet 
by a chill 01 a peg. but usually b\ suture passed through the 
bones. I he wound is c losed in layers and a long plaster spica 



ic patient is cn 

is applied fixing the* liml) in extension and abduction. W lien 
icpaii lias Millie ientl\ ad\am ed. 01 in about lour weeks, ibis 
ma\ bt' replaced b\ a short spira and 
couragecl to beai weight in 
ordei to hasten the recon 
stmet inn ol the art ic illation 
I>\ a Innctional adaptation 
ol the limb to the new con 
ditioiis. When weight may 
be borne without discom 
fort. the support is removed 
and must uiai control is re 
established l>\ systematic 

Intho) s (.om mail . I he 
t ransplantat ion ol the at 
lac linieni of the trochan 
tei ic muscles downward on 
the femoral shall does not 
restore the physiological 
I unction ol these muscles. 

Normally, they act upon a 
lever composed of the head 

and neck of the lemin. II this lever is shortened by the loss c>I 
the head and neck the elhc iency ol these muscles is very muc h 
diminished, resulting in a loss ol abduction power and an 
unstable waddling gait. I lie- Albce reconstruc tion operation 
restores the physiological length ol the neck and makes it 
possible loi the abduc tor musc les to lime lion normally. 

I-Ills Iones' 7 Vc linu/ne.* “With the patient lying on the 
sound side on a frac ture table and with the injured leg under 
the control ol an assistant, a (i inch, straight, external 1 .angen 
beck incision is made, extending from the iliac crest down 
ward over the* trochanter laterally alonu the shall ol the* 

c|ii;iic leverage afforded abductor nicis 
c lev 

|onev I trochanteric transplantation in the Ucaimcnl ol tract tires of 
the neck ol the lemur. /. Ilonc v /oinl Siirg.. i |: nrp. 



lemur i<> ;i point g inches below (lie doe banter. With a motoi 
saw oi osteotome a hone gralt, g inches in length, \/, inch 
in width, and :}/ t inch in thic kness, and including the longi¬ 
tudinal mid-third ol the trochanter, is removed limn the 
external lateral surlace ol the lemur. The removal ol the 
gralt affords an excellent view ol the femoral neck and lull 
exposure ol the Iracture. The Iracture is reduced by lexer- 
age and manipulation. A drill hole is passed, as in tlu- Albee 
method, through the trochanter and neck into the head ol 
the lemur, the length ol the drill hole having been pre¬ 
viously estimated Irom a roentgenogram ol the opposite nor¬ 
mal hip joint. The hone gralt is shaped, the periosteum re¬ 
moved, and the graft is driven with its trochanteric end 
outward into the bed prepared. The wound is closed in the 
usual manner. I he patient is turned on his hack rec umbent 
on a sac ral rest and a double plaster spica is applied in the 
required amount ol abduction and internal rotation. 

' T he advantage of this method is that through a single 
incision the bone graft is obtained as part ol the operative 
approach to the hip joint. Also, the removal ol the mid- 
third of the trochanter as part ol the bone gralt lullv ex¬ 
poses the entire nec k and avoids blind pegging,' since with 
lull exposure of the entire length ol the fragments, the angle 
and length ol the drill hole is very easily determined. 

“The trochanteric bone gralt is mainly composed ol spongv 
bone, the lacunae ol which are Idled with hematopoietic 
tissue, extremely favorable to early vascularization. The gralt 
consists of barely suliicient cortical bone to maintain linn 
internal fixation ol the Iracture. T he environment ol the 
bone graft is little* changed bv transplantation, since the 
operation consists ol transposing the trochanteric gralt into 
a recipient bed ol cancellous bone ol which the* gralt itsell 
is mainly composed. 1 his is in distinct contrast to the dense 
cortical structure ol a tibial bone gralt, composed almost 
entirely ol compact bone, made up ol a strong thick I tame 
work with small connective tissue spaces which do not con- 



(.mi IH‘in.1 (<>]x>ic't i« (issue, a 11<I is nol so rr;i<lil\ \ asi ulai i/ed. 
\ I so, in (lie use' ol a m all i m | >1 a 11 led into llie 
neck, we have noted in a study ol roentgenograms a much 
slowet adaptation ol the dense cortical hone to the spoil”} 
bed. as indic ated h\ larch 11 a I >c< n I i/at ion. 

We have not found it neccssarv to dowel the ”iall. I he 
use ol this rather ohloii” oralt m a round hole insures a suit” 
lit, Intlhei contributin'* to Inm fixation. We emplov a ."> M 
inch chill hole to receive a o i all approximatelv inch in 
width and ."> , inc h in thic kness, the ”ialt bein'* composed 
ol cortic al hone, approximately l , inc h to .‘f iS inc h in thic k 
ness, and if, inch of cancellous hone. Ihe cancellous hone 
is sullu ientlv vielclin” to permit firm impac tion into the bed. 
The average length ol the bone oralt employed is 2 1 /> inc hes. 

I lie troc hantei ic delect made b\ reniov in” the ”rail Irom 
the external aspect ol the' leintii is firmly repaired at the end 
ol ci o h t weeks as in the healiii” ol a pel it roc hanterir liar 
lure. No muscle attachments are disturbed and the lateral 
contours ol the troc hanter are nol altered.'' 

I ul hoi's Comment. It is too earl \ to determine the true 
value- ol this method. Mv reac lion, based upon an inadecpiate 
experience with the opei at ion, howev er, is that the approach 
in tlun subjec ts is undoubtedlv a lavorahle one. In stout sub 
jeers I have lound in one instance that it produced a verv 
deep wound, and in that case I would have far preferred 
the anterioi Smilh-Petersen approac h. I o he- sure the- <»ralt 
contains a lari>e amount ol cancellous hone: but bv the same 
token, however, its streii”lh is jiroporlionalelv fatally di¬ 
minished. I rom a vciv extensive ex|)erience in the use ol 
the pc;j, in both Iresli and untmited Iraclnres. I have been 
impressed with the value ol the strength ol the ”talt. 1 he 
rc-adiness ol the vascularization ol the compac t bone content 
ol a ”i alt when ac c uralelv implanted by automatic shapiii” 
electrical tools, howcvei. has been underest imated, and thus 
Irom this standpoint, the cancellous nature of Jones' ora ft 
loses Us si”iiilic anc C-. 



.hlificial Impaction. II there is any virtue in artificial im¬ 
paction it is undoubtedly alum; the same lines as that ol the 
autogenous bone-grall peg, hut loan infinitely lessei degree, 
namely, it so enmeshes the cancellous hone ol one Iragment 
into the other that il this enmeshment is not disturhed, hlood 
vessels will spring across Iroin one Iragment to the other. 
I his is the first essential step toward union. Unfortunately, 
this enmeshing contac t is most diflic tilt to attain, and there 
is great danger ol the very flimsy enmeshment giving way. 
I his has been impressed upon me hv the accumulation ol 
experience. Artificial impaction should always follow the 
insertion ol the bone-gralt peg. I he immobilization of the 
peg thus insures the permanency ol the cancellous hone 

My method ol accomplishing impaction is somewhat dif¬ 
ferent from that ol Cotton. # I use a large wooden mallet 
with the tip end ol the handle sawed off at right angles to 
its shaft, leaving a plane surface ol considerable size. This 
end of the handle is placed against the outer surface ol the 
trochanter just below the peg while the head end ol the 
mallet is struck with something heavy, preferably a sandbag 
(f ig. (S, 1 >). Such a dead massive blow sets the upper end ol 
the lower fragment ol the- lemur in motion and thus accen 
mates the impac t ol one Irac lined surlace against the other. 


Santos ■j' builds up a very strong argument for the use ol 
the autogenous bone-graft peg. He made a carelul study ol 
the changes In the femoral heads in 15 cases after complete 
intrac apsttlai frac ture ol the nec k ol the lemur. He lound 
that the- life ol the proximal fragment depended 011 the c i 1 
(illation through the ligamentum teres. The vessels in the 
ligamentum teres were more* abundant in young persons. 

* Colton, I . |. \iiili(i;il im|ciction in hip fractures. Sin -g. ('.yn<<. Obsl., py 
307. MI- 7 - 

I s.niios, ]. V. Changes in ilic lieul ol the femur after complete inti.nap 
suhn fracture of the neck. lull. Si /up, cm: |jn. i<i;{o. 



Ihii were inadequate in mam clderlx persons, liom union 
oc( urred in most cases in w hic h the 1 head remained alive, 
and there was adequate reduction and Fixation. Even in the 
presence ol nec rosis ol the proximal liagmcni. union might 
take' place with elite ietil reduction or impaction Inllowcd l>\ 
immohili/al ion. Weight bearing should he avoided until t c 
pail ol the Fracture is completed. I he replacement ol the' 
dead hone look place by inxasion ol newly lottned tissue 
I rom the lound ligament and h\ \ asc tilai i/at ion through ad 
hesions Formed between the capsule and the eroded sin lace 
ol the Irac title. 

I lie head ol the Icmui ma\ undergo necrosis altei com 
plc'te mi i ac apsul.u fracture ol the neck ol the Icmui in spite 
ol the presence ol the ligamentum teres. Secondarx \ use it lari 
/alion max oi max not occ ur. In some cases the hloochsupplx 
max penetrate the spongiosa through the lovea hy way ol 
the round ligament or through adhesions along the surlace 
ol the eroded neck or articular cartilage. When this occurs, 
considerable parts ol the Femoral head max he presen t'd and 
actixe hone regeneration max Follow. II the necrotic head 
tails to obtain a secondary blood-supply From the liga- 
mentum teres, simple destruction and lragmentation ol the 
articular cartilage and hone result. II connect ixx* tissue ex 
tends I rom the 1 ligamentum teres into the eroded head, there 
is replacement ot cartilage and hone about the Fovea with 
absorption ol the deep layer ol articular cartilage, the' process 
continuing to regeneration. 

When bony union occurs in spite ol necrosis ol the head, 
it is brought about by new bone coming From the distal Frag¬ 
ment. When the head ol the lemur remains alixe altei the 
I rac tine and the Iragmcnts are in good position, bony union 
ol the I rac t me wi 11 ocean in t he ilia joi it x ol cases. It has I >ecn 
obserxed that in unions sec ured bx the use ol the bone grail, 
there is much less tendency to flattening and mushrooming 
ol the- head which is undoubtedly chic- to the more complete 
\ asc til. u i/at ion ol the pa it. 


I here are lour main causes ol non union: 

1. Displac ement ol I raiments; 

2. Excessive mobility ol fragments; 

g. Necrosis ol the head ol the lemur; and 

|. Necrosis and erosion ol the- nec k fragments. 

1 he most important lac tors in obtaining bonv union are 
exact reduction and fixation ol liniments. Necrosis ol the 
head is an important c ause ol non-union. When the circula¬ 
tion ol the head is completely interrupted and the entire 
structure dies, any callus that is formed lot the repair ol 
the Iracture must come from the distal I raiment. Idnion 
between a completely necrotic head and a living distal frag¬ 
ment is more c 1 illicnlt to obtain than union between two 
I i \ in” I raiments. 

Still lurther reasons lor using an autogenous peg are 
pointed out by Ereund,* who examined nine fractures of 
the neck ol the lemur in old persons which had occurred 
Irom three to nine years previously. From a careful study ol 
2og sections he came to the following conc lusions: 

Preservation of the vascular connections (round ligament, 
cervical periosteum, newly formed strands) is ol great im¬ 
portance in the life ol the head ol the lemur. II these con¬ 
nections are entirely interrupted, the marrow and spongiosa 
become necrotic after phagocytes from the reticulum ol the 
marrow have initiated decomposition ol the dead latte tissues 
and have themselves died off. The importance of the round 
ligament is still eery much underestimated. W hile it is true 
that the marrow tissues and spongiosa mav sometimes be 
come necrotic when this ligament alone is preserved, in other 
instanc es its preservation may entirely prevent nec rosis. Eater, 
by way ol this ligament, necrotic tissues are removed and 
gradually replaced by newly formed marrow and spongiosa 
to the fracture surfaces with the formation ol a nearthrosis. 

* l ieund, t. t chci die mikroskopischen Vni^acn^c ini lliicliko|>l nacli 
Sclienkel lialsbi cicclicn. I ii(liou''s lull. /. jiulli. hint., ^77: 11)30. 



\Im> when mil nan is <>l the pci iosteum ol (lie lemornl neck 
,ne pi esei \ ed ami w lien miniei linn si rands hel w ecu 11 a < mini 
fragments are formed. regeneration proceeds Irom ilie sin 
hu es ol die nearthrosis. 

•_>. I k \\s | KOC 11 \\ i I Kl( I K \( I I Kl s (>] 1 I 11 FlMi ll 

One ol the most interestin'; contrasts in the held ol hone 
and joint surgerc is the marked dillercncc m the healing ol 
t ranscervical Irac tines ol the nei k ol the leimn and trails 
trochanteric Iraclures. Although these transtrochanteric Irac 
tures occ ur <>nl\ an inch lateral to the neck, solid bony union 
followin'; closed reduction occ urs in about po per cent. The 
reason for tins apparent inconsistence is evident when it is 
remembered that bone repair is in direc t relationship to the 
blood-supply ol the I raiments. I he trochanteric region ol 
the lemur leeches an unusualh profuse blood-supply Irom 
the muscles which surround it and for this reason, if reduc 
lion is acc match done and a good position of the Iragments 
maintained, union practicalh always occurs. The W hitman 
reduc tion and a double plaster <>1 - 1’ai is spic a are used. \l 
the end ol eight weeks the cast is removed and il roent¬ 
genograms show an adequate amount ol callus, the patient 
is allowed to gel mil ol bed and begin cautious weight 

I' KAC: It Kl S or till Ad IAIUI.IM 

I Irac tures arc usualh the result ol lorec applied di 
teeth to the greatei t roc ha liter act ing in t lie d i red ion ol the 
nec k ol the* lemur. I he diagnosis, dillerent iat ing this conch 
lion Irom Iracture ol the neck ol the lemur and dislocation 
ol die hip. is b\ means ol the roentgenogram. I he lines 
ol Iracture mac be - confined entirclc to die acetabulum, or 
mac extend into die ac claim I uni bom the surrounding 
pelcic bones. I he treatment ol this type ol nipnc, with 
out displacement ol die 1 lemoral head, consists ol inmiobib 
/■iiioii ol die hip in the Whitman position loi a period 



ol six nocks alter which unrestricted weight hearing is per¬ 

Fractures ol the acetabulum with penetration ol the head 
ol the lemur through it into the pekic cavity present a more 
dilhc tilt problem. I he head ol the lemur loc ks behind the 
acetabular rim in suc h a way as to make reduction by direct 
traction impossible. In order to pull the head of the fenun 
out ol the pelvic cavity, it is necessary to exert traction in 
the direction ol the plane ol the neck of the femur. Under 
general anesthesia with the patient on the Albee fracture 
table, moderate traction is made on both feet to pull the 
head ol the lemur down to the center of the perforation 
through the lloor ol the acetabulum. The pelvic ends of the 
traction arms to which the leet are attached are displaced 
laterally as far as possible. Both legs are then abducted to 
their physiological limits. By this maneuver, traction is ex¬ 
cited along the plane of the neck and the head ol the femur 
is withdrawn from its intrapelvic position. 

A double plaster-of-Paris spica cast is applied which re¬ 
mains on for eight weeks. Cautious weight-bearing is then 

The end results in fractures ol the* acetabulum vary with 
the severity of the injury. Most ol the cases ol simple fissure 
frac ture have practically no residual disability. Osteoartln itic 
c hanges frecjuently develop following the more severe crush¬ 
ing fractures of the acetabulum. Occasionalk, these changes 
become so marked that an arthrodesis ol the hip is necessan 
l<>r the rclief ol pain. 

Chapter V 


( .<>\<.i \11 \i Disi.oc \tio\ 

Definition. Congenital dislocation ol the hip consists ol .1 
partial 01 complete displacement ol the head ol the lemin 
Irom the acetabulum, probabh due to congenital mallorma 
lion ol the parts entering into the- lonnation ol the hip-joint. 

llistoiy. \lthough congenital dislocation ol the hip was 
known to the ancients, the histon ol its treatment dates 
Irom DnpiiMren's description ol its pathological anatom) 
in 1X2(1. 

Iieij item v anil Occurrence. It is the commonest and most 
important ol congenital dislocations and constitutes about 1 
to 2 per cent ol all orthopedic conditions. 

\bout XX per cent ol the cases ocean in girls. Ileredits is 
a marked factor. I here is Irecpientlv a history ol alcoholism 
1 part icularl\ on the maternal side) and ol hereditan svpli i I is. 

Scaglietti ' slates that congenital dislocation ol the hip is 
more Irecpient in I mope than in America and in the low¬ 
lands than in mountainous regions. In the province of 
bologna, Italy, there is an average ol 2 such dislocations to 
even 1.000 inhabitants, but in some (listrids there arc more 
than gaud in one communilN the average is pgg. Congenital 
dtslocal ion of the lufi constitutes 77.5 fun cent of all con¬ 
genital defoiniities. It is | times as Irecpient as club loot, the 
inc idence ol which is iX per cent, and 2X times as Irecpient 
as torticollis, the incidence ol which is per cent. 

S< ;ij»l id I i. () \ ( I i ni (< >sl .isl it ,i I slu<|\ ol (;iscs ol (oni»cnil;il d islot ;i l ion ol 

1 hr hi|>. Internal. Ibsl. Sur**.. ',(i: 137, i<)‘TT 




I'A II i< >I.O(,K :ai, \\ATO\h 

1. Acetabulum. 1 lie aeclabulai <; i \ i t \ is gradually ob 
lilcrated l)\ lailure ol development ol its inn and thicken 
inland elevation ol its I loot. I he loss ol depth is move rapid 
than dec rease ol its diameter. The normally rounded shape 
beeomes converted into a triangulai depression w ith its apex 
in I rout and below, its base above and behind. The Moot is 
thickened by a hypertrophy, which can be appreciated on 
the pelv ic snrlace ol the ilium bv means ol rectal examina¬ 
tion. I he rim is most deficient above and behind. In the 
roentgenogram the external snrlace ol the ilium and the Moot 
ol the acetabulum are neat ly in a straight line, instead ol the 
t ight-angled projection at the upper part of the acetabulum. 
The contents ol the shallow acetabular cavity consist ol an 
overgrowth ol cartilage, the remains ol the ligamentum teres, 
and the Haversian gland, covered by the anterior portion ol 
the capsule ol the hip more or less adherent to the floor. 
The acetabular contents just enumerated are represented bv 
roentgenography as a wide, light band between the pelvis 
and the remnants ol the lemoral head. 

Formal ion of a Xew Acetabulum. A true new joint docs 
not form beneath the displaced lemoral head. I here is 
formed merely a depression lined with periosteum, worn 
away on the outei surface ol the ilium, and in it the lemoral 
head tests more ot less insec inch . with a lold ol the capsule 
intervening between the bones. 

2. Head of Femur. From a clinical standpoint, the head 
of the lemur is of mote importance than the acetabulum. 
Had distortion ol the 1 femoral betid renders non-operative 
treatment almost impossible. 1 he head ol the lemur nor 
mally transmits the bodv-weight and ac ts as a pivot on which 
the movements ol the hip take* place. In congenital disloca 
lion, the- body is borne' bv the tension ol the soli parts be 
tween the trochantei and the pelvis, the 1 head becoming the 
short arm ol a two-armed lever. 



I lie pathological c I t a ti nes are at ictpli i( . I he head I >ei omes 
coniea]. the- neck short, and the tippet end ol the lemni 
atrophied and smaller. I lie usual conditions lound are .1 

I 11.. 2S. Double condoned dislocation of hips, il rom Albee's "Orthopedic and 
Reconstruction Surt’cn Saunders.) 

small, atrophied head. Ilaltened on its median and posteriot 
aspects: a short anteverted nec k with its anu,le diminished in 
a position ol coxa vara or coxa \alt>a. I he atrophy tnav he so 
extreme that the head is absent. Ilatteninn ol the head is 
due to attrition on the ilium (Lins. 28, «><))■ II the head rests 
"dead” on the pcl\is. it becomes bullet shaped or. to quote 
Loren/, like "a much used hammei whose striking surlace 
becomes spread out and ittrnecl up around the rest ol the 

A' Cch of the lemiu. I he nec k is shortened, depressed, 
and anteverted. I he .shortening- is sometimes so <>rent that 
the head seems to be applied direc 11\ to the tippet end ol the 
shaft. I I 1 i s. ol course, means a shorten in”' ol the limb. 



I he condition ol anteversion is ol extreme importance. 
I he normal angle between the axis ol the neck and the trails 
verse axis ol the condyles is 12 decrees. In this condition it 

tic. 29. t congenital dislocation of hip. (from AI lice's "Orthopedic 
and Reconstruction Surgerc," Saunders.) 

may he increased to tjo degrees, although iisna 11\ onl\ to 
ahont 15 degrees (Tig. go) and is due to anieveision ol the 
neck, which seems to come oil directly in Iront ol the shaft. 
Torsion ol the shall may .also exist. The practical applica 
(ion ol this phenomenon is, that to bring the head ol the 
lemur completely w ithin the acetabulum, the thigh must be 



totaled inward, in I hese c ases. until the pat el la looks directIv 
and ent it civ inward. 

p I’clvi \bnormal it ics ol the pelvis depend upon 

Ik.. ■*< >. I wini ol iH'tk in < oiigenit al I \ disloi alol lemur, looking Iroin above 
downwind. Iiom Bradford and Lovett's "treatise on Oilho|)edic Niii'j’cia 
\\ nod.! 

whether the dislocation is unilateral or bilateral, and upon 
the position ol the head ol the lemur. 

up Double Dot.sal Distocution: The delormitv is svmmet- 
t ieal. Lite pel\ is is tilted lorward, the plane ol the inlet mak¬ 
ing an angle ol cjo decrees (instead ol the usual jr, degrees) 
with the hot i/on (Figs. ;i, 32). The normal lumbosac ral 
lordosis is increased. 1 he sacrum being tilted out and greatlv 
curved. Fite innominate bones lie more vertically, the iliac 
crests being nearei together and the ischial tuberosities 
evened. I he whole innominate bone is small and atrophied. 

(b) l ’nilateral Dislocation: I he pelvis has a lateral in- 
el i nation, t he shape ol the pelv ic inlet being ol diet uely ovoid. 

Soft Dints, (a) (.a/i.siilr: i lie- capsule is stretc hed and 
distended, covering the head like a hood. It assumes an hour¬ 
glass contraction ol varving degree between the head ol the 
lemur and the- ilium on account ol compression bv the 
iliopsoas tendon which crosses the capsule; the round liga¬ 
ment passes through the constriction. Flic greatest obstacle 
to reduction is ollcred bv the strong internal part ol the 
capsule which is stretched lighllv across the entrance ol the 
acetabulum Iron) its posterioi aspec t; the aperture leading 



bom the distended capsule i<> the true acetabulum may be 
merely a small buttonhole. Orrasionally the auterioi part 
<)l the capsule blends with the soli tissues ol the Moor ol the 

Ik.. ;j i . lordosis in double congenital dislocation ol 11 i ] >. ilrom |ones and 
I .oven's "Orthopedic Surgery," Wood.) 

I k.. *'2. Broadening ol perinenin with prominence ol trochanters in double 
congenital dislocation. (I'ront |ones and I ovelt’s "Orthopedic Surgery, Wood.) 

at et;il)11 1 tun. In effect, the capsule becomes a suspensory liga¬ 
ment. iintlei ooino h\perlroph\ particularly at its auterioi 
and lower portion. 

(//) /./oil in e ii I uni Teres. Ihe round ligament is extremeh 
attenuated or altogether wanting. It is usual I \ present up to 
the third yeat ol the dislocation, but disappears altei the 
loti11 It yeai. 

(i. Muscles. Abnormality ol the muscles between the lemut 



.md pelvis is the chid (.disc <>l lailure to gel (he head ()|)|»o 
Mic ilie acetabulum and is die main hindrance to its retell 
lion there. 

loren/ divides these mi rules into three m (» 1 11 > s. nr..: the 
pelxicrural groups. pclvit rnchanlcric. and pel\i lemoral. 

(a) I'clv/a it i til (iioitl). litis comprises the hamstrings, 
‘^i .K i I is. pel vi( port ion ol the reel ns lemons, sartoi i ns. tensoi 
vaginae lemoris. and mosi ol the adductot muscles. I hcv all 
run in tin.' same axis as the lemur. W hen the lenun is short 
ened. the\ contiact to take up the slack. 1 hex present the 
most lormidable obstacle to reduction, which olten cannoi 
be overcome except bx division ol the adductors and ham 
strings, preliminarx to operation, and by the preopet at ix e 
apI> 1 ii ation ol weight extension lor some weeks. 

(h) Prlvihoclttuiln it (• ioii/i. I he snperlu i a 1 set ol these 
muscles includes the glutei; the deep set, the obi in ators. 
<]iiaclratns lemoris. and the psoas tendon. All show marked 
functional incompetence, especiallx the glutei: this is demon 
suable clinicallx bx the patient’s inability to stead) the palsx 
when standing on the affected leg: the pelxis droops ( I ren 
delenburg's sign), and inc ompetenc x of these nnisi les is the 
cause ol the typical waddling gait. The opposite condition 
exists in coxa xara. in which the patient standing on the 
allected leg niiscs the pelxis on the sound side. 

rite (,Illicit s Maxima .w On account of the shortening ol 
the limb, the libers ol ibis muscle run more horizontally 
than normal, which changes the direction of the fold ol the 
buttock. I lie elevated trochanter major projects above the 
upper border ol the gluteus maxinuis and is more readilx 
IeIt beneath the skin. I he ischial tuberosities are more oi 
less uncovered bx ils lovvei libers. 

I lie jtsoas I cud on is displaced outward and winds outward 
and backward, compressing the capsule. The pelxis rcallx 
l esi s in n as in a sling, the tendon acting as a suspense >rv I iga 
mein ol the bodv weight and dragging the lumbai spine lot 
"•ud. ()n a(< (Mint ol its out ward displacement, it occasional l\ 



creak's ;m opening lor a crural hernia (nol a femoral hernia 
through ihe normal lemoral ring) beneath Poupart’s liga¬ 
ment. In open operations it is the greatest obstacle to repo¬ 
sition ol the head in the acetabulum, and is recognized as a 
tight hand beneath the head. 

(c) Pelvi femoral Group. The lower part ol the adductor 
magnus and the adductor longus are particularly shortened. 

Summary of Muscular Anomalies. I lie greatest obstacles 
against reduction are the musc les arising from the pelvis and 
inserted below the middle ol the lemur, viz., the hamstrings, 
rectus, tensor vaginae lemons, and the major portion ol the 
adduc tors, the pelvicrural group. Rebel can. however, be ob¬ 
tained il necessary by tenotomy, viz., (a) at the innei side ol 
the thigh, just below the symphysis pubis; (b) at the outer 
side of the thigh, just below the anterior superior spine; and 
(r) at the inner side of the knee for the adductor niagnus 
and inner hamstrings. 

ranches of the Dislocation. The usual position of the dis¬ 
placed femoral head is upward and backicard onto the 
dorsum ilii. Another, less freejnent, location ol the head is 
(interim at the point beneath the anterior superior spines. 
Further classification of positions is ol no practical value, as 
in all of them the primary displacement is probably upward 
and backward onto the dorsum ilii. 

The dislocation may be complete or incomplete. Ihe 
latter, in which the head is not entirely out ol the acetab¬ 
ulum, is only a step in the process. 

This dislocation may be unilateral or bilateral. It occurs 
on both sides in 2<) to g<) per cent ol the cases; on one side 
only, in hi to 71 per cent and ol these about yg per cent 
occur on the 1 iglit, and about pi per cent on the lelt, side. 

1 riot.c >c.v 

Many theories have been advanced to account I01 the dis 
location, the generally accepted one being the develop 
mental theory. 



1. Develolmieulal theory. I his is hast'd on the assump 
lion that the acetabulum is not primarily a socket hut is 
jointed l>\ n g roii'III oj judinc cartilage ii/i and mound I lie 
head oj the femur, and that in congenital dislocation the 
growth ol the acetahnlat cartilage tails to keep pat e with the 
growth ol the head. In support ol this theory, the 
Follow iny data are presentetl: 

(a) 1 ’he marked hereditary lat tor. 

( b ) I ransinission through hold male and lemale parents, 
and occurrence in collaterals. 

(e) (.nls are more lietpienih alien ttc 1 than hoes, heeanse 
earlv developmental errors are more common in the more 
primitive lemale type. 

(d) The inc idence ol co-existing anomalies. 

(e) hilateral involvement. 

(/) Ore nr retire in other in cm hers ol the same lamily. 

2. Mechanical Theory. It is argued hy some that prolonged 
intrauterine flexion, especially flexion and adduction, causes 
stretching' ol the capsule ol the hip-joint, behind and below, 
and causes the head ol the lemur to distend it. Exaggeration 
ol the normal intrauterine llexion ol the letal ovoid is pro 
dttced hy oligohydramnios, multiple pregnancy, hydro¬ 
cephalus, etc. 

Other evidences ol abnormal intrauterine Forces are con¬ 
genital genu rerun at uni, congenital club loot, etc. 

\dditional theories, less plausible and hence less generally 
accepted, are: 

g. Iniriiuleriiie Iraunui. 

j. linlli Iraunui. 

V Museulai eonlriul/on due to a central nervous lesion. 

6 . Pa roly.\is of anlenor hoi ioinyel 1 1 is. 

Cl IXICAI I I \ I l 'KI S 

I he three leading clinical phenomena ol congenital dis 
locat ion ol t he hip are t he cliarac terist ic gait, lumbar lordosis, 
and the specific deformity. 



1. Gail. I he* "ait in bilateral dislocation has been \ati 
onslv described as a "duck-like waddle,” “sailor s "ait,” etc., 
but bailies adequate description. In unilateral dislocation it 
is a limp or a lurch toward the aliened side. This abnormal 
"ait is due to lunelional disability ol the "luteal muscles, 
shortening ol the lemur and displacement ol its head, com¬ 
bined with lumbar lordosis and abnormal lateral mobility 
ol the lumbar spine. 

2. Lordosis. Abnormal lumbar lordosis is more marked in 
bilateral than in unilateral dislocations, and is accompanied 
by a correspondin'} protrusion ol the abdomen. 

", Deformity, (a) Unilateral Deformity. The distance 
I torn the anterior superior spine to the tip ol the inner mal¬ 
leolus is shortened. T he "Teat trochanter lies above Xelaton s 
line and is prominent. The "luteal lold is directed upward, 
due to the stretching' of the skin oxer the great trochanter 
and the altered direction of the gluteal libers. 

( b) Bilateral Deformity. The lower limbs appear too short 
for the body, the disproportion in length ol the thigh as re¬ 
gards the lower leg being the more marked. T he perineal 
space is increased, that is, the thighs are lar apart at theft 
upper extremities, the trochanters are prominent, the but¬ 
tocks broad and Hat, and the ischial tuberosities uncovered 
by the gluteus maximus. 


l etna I Diagnosis. A I imp or wac Idle accompanying a c h i 1 cl’s 
Inst attempt to walk and without pain; historx ol trauma, 
or antec edent disease oilers firrina /rtr/c evidence ol congenital 
dislocation ol the hip. It then dexolxes upon the surgeon to 
determine whether the head ol the letmu is out ol the acetal) 
idai cavity and, il so, what is its location. 

Putti * stresses the importance ol early roentgen tax signs 
in the diagnosis ol congenital dislocations and reports the re 

* full i. X. . \ n;il \ sc*s ol i he roentgen s\ni|)tom iriacl ol prcclisloc al ion slates. 
Inlrnuil. Ibsl. Sni'j’., r,~: -y-. i- 



k' si. 1 1 cs that 

m c 

Mills (>1 si tidies w hic h lu- made ol men10141 ams ol 1101m.1l 
jni.inis .md ml.nils dew eloping disloc at ions in .111 .ilU'iii|>l to 
discovri si^ns ol |>rt“<lisleu .11 ion st.itrs. 
disloc .11 ion is .1 pole-lit i;il 
c i mi plete disloc ;it ion in id 
111 list lie 11 cat cd as such. 

I he- lollow in;4 dia^nosl ic 
si^ns were noted: 

1. Millennial obliquilx ol 
die mol ol the acetabulum / 
m roeni»>eno<>rams ol in 
lants Ironi iwelve limns to 
ei'^lil da\s ol at>'e. \\ liile the 
importance ol die- decree ol 
obi iquitx is 1 rial ivc. i 1 seems 
that the- more oblique the 
line- ol the rool, the 41 calei 
the likelihood ol disloca¬ 
tion. I lie greater 11 e<|uem \ 
ol the more oblique rool in 
t he female is in aeeoi d w ith 
the 41 eater inc idem e ol con 
genital disloc at ion in the le 
male. 1 lie changes described 
max be noted at birth. 

2. Retaidation ol the tip 
pearanc e and hx poplasia ol | 
the lemoral epiphysis. I hese 
si'^iis max be- detected onlx 
altei Irom three to lour 

I ic;. ■'/{. Congenital dislocation < >1 
hi|i. showing palpabili(\ ol acelahnlmn 
in absence - ol head, as diagnostic lea 
line ol considerable impoi lance. (Irom 
Albees "Orthopedic and Reconstrne 
1 ion Sin get \ Saunders.) 

mouths ol lile. 

( '.mu jjlrlr 01 I J m‘l 1 al Dislocation. I ll is point c an be ellec 
tuallx determined bx roentnenonraphv. The normallx placed 
lemoral head lies in the oroin below Ponpari s ligament and 
is crossed bx the lemoral artery. On rotation and palpation, 
iI head and trochanter can be mtide- out (I r>. 4g), 1 lie axis c>I 



rotation ol the lemur comes hallway between these two 
points in congenital dislocation; il coxa vara ot an allied 
condition exists, the axis ol rotation is at the center ol the 
lemoral head. Clinically, the question can be answered b\ 
rotation ol the limb accompanied by careful palpation. It 
is to be noted that the movements described by the lemoral 
head in congenital dislocation are in a direction opposite 
those ol the corresponding loot. As a title, il the trochanter 
lies below Nelaton’s line, the head is in the acetabulum. 

Freiberg * states that in the early diagnosis of congenital 
dislocation ol the hip, the obvious, visible abnormalities play 
the most important roles. Asymmetrical skin folds in the 
thigh are most frequently overlooked. If the (teases on the 
mesial aspect of the thigh are deeper on one side than on 
the other, some explanation must be sought. Realizing that 
at birth and during early infancy there has been no com¬ 
pensation for the shortening of the distance from the pelvis 
to the knee, which exists if the hip is dislocated, the soft 
tissues, skin and muscles, must fold or crease. After the child 
is two years ol age, these solt tissue lolds are less prominent 
because the skin and muscles compensate by shortening. In 
bilateral dislocations of the hip, no asymmetry of skin folds 
is seen but abnormally deep folds on both sides may be noted. 

Second in importance in the earlv diagnostic signs is ever¬ 
sion or external rotation ol the affected leg. If this external 
rotation of the leg is noted, and abduction is attempted pas 
sively, it will be found that this motion is markedly limited. 
A normal child’s leg will abduct passively from 70 to 80 
degrees. II abduction is limited to jo or 50 degrees, some 
explanation should be sought. 

Most deceptive ol the early signs ol dislocation is shorten 
ing ol the affected leg. l he actual shortening max be so 
slight that measurement with a tape line is inconel usixe. II, 
on the otliei hand, the knees are Hexed, and the hips are 

* 1 • 1 eilx'ig, |. \. I .illy diagnosis and treatment of congenital dislocation ot 
I lie hip. ,/. / \/ I., tin*: <Si), 1 <)‘j |. 



llc'M'd so llu' Itrt i c'sl i'\ t'l1 1 \ on .1 1 1i ni examining table 
.in i 11 cm ] ii. 1 1 i l \ in I cm io( 11 ol llu 1 1 c • o s I k‘( (lilies apparent. In llns 
position, il one leg is shorter the other, there will lie .i 
delinite \ ;iri;it ion in the level ol the- knees. 

Position of the 11 rad. I Ins is usually on the dorsum ilii. 
II the head is m an anterior position, it is usually also 
siipei ioi to tlie aeetabitltun. In \onng subjects, ‘‘tclcscciping" 
(lice vertical mobility) ol the head ran he accomplished b\ 

11\i11o the pel\ is. 


Points of 

1. (,o\a \ ara. 

2 . I ra lima (lieu I lire 
ol link: separa¬ 
tion ol epiphysis). 

Lstreme bowlegs. 

Lumbar I’ott s dis¬ 

j. Pseudoliypertroph- 
ic paralysis. 

(i. Paralysis ol polio- 

Pathological dis¬ 
location (osteitis 
with destruction 
ol head). 

1 lev at ion ol trot hau¬ 

1 lev at ion ol I rot hau¬ 
ler. (.ait. 

Waddling gait. 

Waddling gait, lor¬ 
dosis (oca asionally). 

Gait and attitude 

Waddling gait. Short¬ 
ness ol 1 imb. 

Ivleva t ion of hoc ban¬ 
ter. \bnormal gait. 
I .ordosis. 1 .asilv ol 

Points of Difference 

Net k and head not lelt. 
No abnormal mobil¬ 
ity. \ lav. 

Pain on manipulation 
in recent cases; none 
in chronic. I-sternal 
rotation of the femur. 
\\is ol rotation ol 
femur at center of 
head. A-rav. 

Hip-joints normal in 
appearance and func¬ 

Acquired, painful dis¬ 
ease. 11 ip-joints nor¬ 
mal. A-rav. 

No other points ol it 
semblance. 11 ip-joints 
normal. Neurological 
tests. A-rav. 

A-rav. I lip-joints nor¬ 
mal. Acquired. Paral¬ 
ysis apparent and may 

A rav c one lusive. (iliar- 
ac tcrislic history. Axis 
ol rotation ol femur 
in center ol trot hau¬ 



/ )i{)(’rcnlini Diagno.u. e I lie most confusing condition is 
coxa vara. I lie lalile on page (Si) indicates the most impor 
i,ml leal lives in die differential diagnosis between congenital 
dislocation ol the hip and other conditions. 

I’R< H,\< ISIS 

W ilhont trealnienl the outlook is bad. Spontaneous cure 
is impossible. Deformity, lameness, and shortening rapidly 
and progressively inc rease during the adolescent period. With 
increase ol age and weight, pa ini 111 muse le spasm and rigidity 
occur. leading in obese patients to practical invalidism. 

Julius Wolff propounded the theory, accepted almost uni 
versally, that the bone develops depending on the functional 
stresses placed on it. In a congenital dislocation of the hip 
there is an absence ol the normal functional stimulation ol 
the acetabulum and the femoral head, and a delayed or patho¬ 
logic development ensues. On this basis, the eailier the dis¬ 
location is reduced, the less severe will the secondare bony 
abnormalities have become, and the more perfect will be 
the end-results. 

With treatment, the results vary with the method used. 
Manipulative, bloodless reduction gives less than ho per cent 
of cures. 

The author s operation for deepening the acetabulum by 
bone-gralt wedge offers success in a large percentage ol cases 
(even in the 40 per cent ol failures by the bloodless method) 
and produces a strong joint with good motion and without 
pain and shortening. 

II the results of treatment ol congenital dislocation are to 
be improved treatment should be begun at a much eatliet 
age than that in whic h it is customarilv undertaken. In lact. 
treatment should be begun as soon as the diagnosis is made. 
In Italy * educational propaganda among general prac ti 
lionets and parents is leading to a marked increase in the 

* I’utli, V. I .ii I\ treatment of congenital dislocation ol the 1 1 i|>. /. Hone 
Joint Sing., 11: 798, 1 <)-<). 



ihiiiiIk'I ol verv voting children brought loi cxaminal ion. 
In 1 1 H‘ I'nitcd States the dcloi mitv is not i isi i;t 11 \ detected 
until altei a child begins to walk. I rarclv have patients <>l 
this i \ | h’ releired to iuc‘ eailier than two years ol age, al 
though I would treat them carlici il the\ were brought to 
me. I do nol agree w ith I ait bank ' that red net ion should not 
be attempted belore eighteen months ol age. In dealing with 
\et\ young children one should remember that structures 
are \et\ delicate, and breaking the bone or stretching the 
arterv or ner\e undid) should be avoided. Also, innnobili/a 
lion has to be maintained lor a longer period. 

1 'he normal relat ionsh ip ol the head and s h a 11 ol the lenun 
to the \erlieal and hot i/ontal planes ol the pel\ is are ol im 
portanee when considering the methods ol tretilment lot con 
genital dislocation ol the hip. I he ideal is reposition at the 
level ol the original acetabulum with stabilitv and mobilitv 
assured, but it is physically impossible to accomplish this 
reposition in certain resistant young patients and in most 
older subjects.'!' 

Obstac les to a sat islac ton reduction are maldevelopmcnl 
ol the acetabulum, hour-glass contraction ol the capsule, and 
the shortened pel\itroc hanteric musc les. I'airbank * has dis 
cussed the anatoim ol congenital dislocation ol the hip based 
on a stuck ol >“) museum specimens ol pi dislocated hips, as 
well as upon a huge numbei ol eases operated upon per 
sonallv. Ills conclusions are most interesting and valuable, 
lie believes that the underlying lauli in the development 
ol the dislocation is primarilv a poorlv developed acetal) 

c .i ,vsstr tc: \ i ion c it c: vsi s 

l ot purposes ol treatment, cases ol congenital dislocation 
mav be divided into the billowing groups: 

laiiliank. (.ont’onital disloc.'il ion of llic hip. Hiil. /, V/ii"., 17: "So. i(|‘{o. 
t Cnlonna. I*. Cnngcuiial dislocaiion ol ihc hip in oh In siilijccis. /. Hour A 
loi nl S in i |: 277. i c)‘{a. 



1. I hose m whit li it is possible either by bloodless or open 
operation to secure reduction with a stable hip. 

2. 1 hose in which it is possible by c losed or open methods 
to reduce the hip, but which, because ol shallowness ol the 
acetabulum or torsion ol the neck ol the lemur, will not 
remain reduced. 

3. Those in which it is impossible to pull the head down 
siillic ien1 1 y to reduce the hip. In suc h cases a shell must be 
erected on the acetabulum or, rarely, one may resort to bifur¬ 
cation. In late years 1 have included in this group cases that 
lormerly 1 attempted to reduce at the cost ol considerable 
trauma. The unfavorable results in the way of ankylosis or 
limitation ol motion at the hip have led me to believe that 
it is better to erect an acetabulum high on the ilium rather 
than to use so much force in reduction that one runs the 
risk of subsequent ankylosis. 

Infants up to two years of age. Predislocation is becoming 
more frequently recognized in these young children. The 
simple abduction treatment of Putti prevents dislocation 
in these cases. Putti * states that the early recognition and 
treatment of the condition is ol importance not only lor the 
prevention ol dislocations but also because, according to the 
experience of the Rizzoli Institute, congenital preluxation 
is the causative factor in 40 pet cent ol cases ol arthritis de¬ 
formans ol this joint. 

Children from two to four years of age. Those children ol 
about two to four years in whom manipulation easily re¬ 
duces the dislocation, present suc h a pet lect lunctional re¬ 
covery that it is dillicult to see how anything better could be 
desired. The important point is that the reduction must 
be simple and easy ol pet lormanc e. 1»v this 1 mean that, 
under an anesthetic , traction followed by llexion, abduction, 
and rotation should be able to put the head ol the lemur 
bac k into its socket and that it goes back with a c lick which 

* t’niii. V. Statistics regarding the results of the treatment of congenital 
nrel u\at ion of the hip. hUermU. Sin g., r,(>: t;{8, 



c an be Ml <n ,n i ttall\ lie.111 1 . In I licse cai l\ cases (here is one 
.uni onl\ one serious obstacle lo reduction, and that is the 
constrict ion ol the ( apsule. 

In children, congenital dislocation ol the hip should 
al\v.i\s he treated in the lust place l>\ nianipulation undei 
the guidance ol roentgenograms, so that the head ol the hone 
(.in he followed as it approaches and enters the acelahuhuu. 
\s a general rule up to the age ol three to lour years inanip 
illation under roentgenographic guidance will elicit this re 
duction. and then, il the limb is kept in an abduction plastei 
lot about si\ to nine months, permanent recovery lakes place, 
so that altei a few sears no abnormality can be detected in 
walking, and the roentgenograms show a normal joint, or 
one with a shallow socket.* 

Children front four to fourteen years oj age. In those chil¬ 
dren in whom manipulation, aided In an anesthetic and the 
\-ia\ screen, fails to reduce the dislocation, open operation 
is necessarv. These children are generally aged from lour to 
fourteen years. The hip is exposed In the anterior incision. 
The capsule is cut open by a longitudinal incision over the 
femoral head, and it is lound that a narrow constriction leads 
into the acetabulum. The incision in the capsule is pro 
longed through this constriction, so that the socket is lullv 
exposed. It is now quite case. In means ol manipulation aided 
In Murphv's shoehorn retractor, to place the head into the 
socket, but it generally becomes evident that it is not likely 
to sta\ in this position because ol the shallow charac ter ol 
the acetabulum. \i this juncture three courses mat be* 
lot lowed: 

i. I he head mas simple be kept in its socket by abduct ion 
ol the limb fixed in plastcr-ol-Paris, trusting to the pressure 
ol the head to deepen the ( a \ i t \ in which it lies. I his plan 
should be used onl\ in I hose c ases where the soc ket is reason 
able well lormed. as tested by its ability to hold the head 
when the limb is allowed to lie* in the same line as the trunk. 

lies (fiovcv ( <>m i*i*iiiI«1 1 (Iislot;iiion ol the hip. />;//. /. N///"., i p |S(>, ipu*-. 



2. I lie next and most obvious plan consists in deepening 
the acetabulum by means ol a gouge 01 bun so as to accom¬ 
modate the whole head, which is then pushed into the new 
soc ket and the capsule c losed over it. I his closure of the cap¬ 
sule will have to be in a transverse direction alter the manner 
ol a pyloroplasty, so as to overcome the constriction and at 
the same time shorten the capsule, tying the lemur close to 
the pelvis. I his method ol operation has the great merit of 
gaining good security lor the joint, and from this point of 
view it is the best treatment which is available. Hut, unfortu¬ 
nately, the price paid lor this security is the danger that the 
joint will become ankylosed. This is accounted for by the 
I act that the acetabulum is robbed of its cartilage by the act 
ol scooping out a new socket, while the head of the bone, 
which has been dislocated for a long time, has a very poor 
cartilaginous covering. This leads to a close fibrous union 
occurring between the bones. In the case of a unilateral dis¬ 
location, a firm but more or less fixed hip will give a good 
functional result, but if the deformity is bilateral then the 
double stiff hip will give a sadly crippled condition. 

3. The third available method is to leave the natural car¬ 
tilaginous floor ol the acetabulum and to try to hold the 
femoral head in place by constructing a bone-graft shell to 
the upper edge ol the socket. 

There is a growing tendency in the United States and 
Great Britain to lavor open reduction not only when manip¬ 
ulative reduc tion has failed, but almost as a routine, even in 
the youngest children. The decision for or against open opera¬ 
tion depends very largely on the view held by the individual 
surgeon as to the degree ol development ol the capsular 
isthmus in young children, and the obstruction this offers 
to reduction. The results ol manipulative reduction prove 
conclusively that in the youngest children, at am rate, the 
reduction is complete in the- vast majority. Is it right to in 
diet the extra risk ol open operation on all because very oc¬ 
casionally capsular constrict ion, an .abnormal ligamentum 



lcres. in sonic less oh\ ions lac tor prevents a slalilc recluc 
t ion being obtained l>\ maniptilat ion? Simple open redtu I ion 
which comprises the important details <>l dividing the psoas 
and enlarging the isthmus, is uncpicstionablv a tiselnl pro 
cedure m lavorable cases, which ate rarely met with helore 
tin' age ol loin, though more commonlv al terwards. 

In recent Years Oallowav * has been the strongest advo 
cate ol a more extended use ol open reduc tion in all children 
ol two and .1 hall Years ol age. Open reduction /n a' lias no 
advantage whatsoever over the closed method, providing re 
duction is complete and permanent. 

The next cjuestion involves the importance ol antetorsion, 
the influence ol this on the results, and the advisability <>l 
correcting this deformity bv osteotomy. Opinions differ 
widelv. Lorenz, Bradford, and (.ill regard it as unimportant, 
the Inst going so far as to sav that its correction may lead 
to posterioi subluxation. On the other band, most writers 
are not prepared to disregard it, though they differ as to 
how. when, and where it should be corrected. Osteotomy is 
the usual method. Soutter and Lovett say antetorsion im¬ 
proves with weight-bearing, especially alter two or three 
vears. Hibbs. Calot, and others do osteotomy in the lower 
third of the bone, while Lroelich snaps the atrophied femur 
over the edge ol the plaster some months after reduction. 
Ra ida also does a manual osteoclasis. Sc liede and Codivilla 
use a nail driven into the trochanteric region to control the 
upper Iragment. As to the degree ol antetoision demanding 
correction, Bradlord and Lovett say <)t> degrees antetoision 
is incompatible with normal gait and must be corrected. Our 
experience is that il hips are reduced early, sav before the 
fourth year, it is rare to meet with a case which demands 
osteotomy. In the oldei cases, whic h should become less and 
less numerous, a degree ol antetorsion ol real importance, 
/.c\, over pci degrees, is more common, but still rare, failure 

* Galloway. II. I*. II. I he open operation lot ion!>eiiilaI dislocation ol the 
hip. S tog. Gy tier. Ohs!., 37: 67 j. 1923. 



<>l l Ik* upper lip <>l the ;u elabulum to pow out seems a Car 
more potent laetor leading to re-dislocation than any de 
lorniity in the lemur. 

I he next problem is: Should anything be done, and if so, 
w hat, to the adolesc ent w ith this deformity who suffers little 
or no discomfort, and never complains ol real pain? fair- 
bank has shown how lar from perfect were the anatomical 
results alter reduction in the older cases, even though the 
head ol the lemur, or what was lelt of it, remained in the 
acetabulum, (boss erosion from absorptive arthritis was pres¬ 
ent in most instances. 

A bone-gralting operation to make an upper lip for the 
acetabulum when the lemur can be brought down to the 
reejuisite level, is the procedure ol choice for cases beyond 
nine years of age. Unless this can be ac hieved w ith reasonable 
ease it is better to leave the head of the femur where it is, 
after constructing a bone-gralt shelf oxer it cm the ilium 
(see p. 120). 


Technique of Closed Reduction. Too much emphasis is 
placed on different stereotyped methods in “bloodless” re¬ 
duction of congenitally dislocated hips. In the treatment of 
predislocation and subluxation in very voting infants, up to 
two years of age, the abduction method described by Putti # 
in 1 <)2<) is the most satisfactory. No anesthesia is used, l he 
legs are fixed to a triangular pillow - or brace in such a way 
as to hole I t hem In ext rente abduction (l ig. g |). This position 
is maintained until roentgenograms show sullic ient deepen¬ 
ing of the acetabulum to maintain reduction. The period ol 
treatment is usually seven to nine months. In one case one 
type ol manipulation w ill be most suecesslill; in another case 
a cpiite different type. Ihe important thing is that through¬ 
out the manipulation the surgeon should always lollow the 

* field, \'. I ; 111\ (mil mrnl of c:c)ni>cnil;il disloc ation ol ihe hi|>. /. Hone c 
Joint Sing., 15: id. 193;}. 



mull.min .mil <il llii' li'iiun ,ni(l do tlii' 111'; 1r\ 

.i ii l<>iiiii ol adduetoi 11111si'li' strctihmg. (idl(lencss .111< 1 ;k 
curacx should be obsen ed throughout llir pi o( rdtn c. I have 

lound the principles ol manipulation laid down by Loren/ 
and Calot to be die most satisfactory. On general principles 
the method ol Calot is prelerable to that ol Loren/. I do not 
advocate the old method ol overstretching and laceration ol 
the muscles about the hip or its capsule, as these struct tires, 
il they are in tone, aid in retaining the head in position alter 
reduction, hath case should be judged on its own merits and 
studied as to the postoperative position which gives most 
stability to the head in the acetabulum. 

/. Dislocation hi Children I 'wo lo I Inrc Years of ,/gc 

(.-/) I Unilateral Dislocation. Preliminary Measmes: Prior 
to manipulation aiming at red in t ion, it is necessai y to stretch 
the adductoi muscles and other contracted periarticttlai 
structures by cin iimdiu lion ol the hip in all dirci lions, and 
I>v kneading and massage. 

I lf- 3"). Kneading of adductors (on right side), aliened thigh being in 
flexion. I high is carried into abduction alien having previous^ been placed 
in flexion at an angle of yo degrees. (Alter Calol.) 

l ie. ■{(). I iisi maucuvei made b\ two persons; an assistant makes traction 
on aliened thigh, grasping il with his two hands a little above knee. Surgeon 
applies his two thumbs direclls ovei head ol lemui in ordei to push il into 
ai el a Ini I uni. (Irom \ I bee's "Oil lu>|>edi( and Ret oust run ion Surgerx," 
Saundci s.) 




Massage <>l lhi‘ Idd inlois: I lit.' j>t■ 1 \ is is immobilized l>\ 
m assistant who Ilexes the sound thigh upon the abdomen. 
\ second assistant makes traction on the extended allected 

under thumbs ol surgeon who presses head I mm below upward, reduction 
liein” elletied in a variable decree ol abduoion. according to character ol 
individual case, ilrom \ I bee’s "Orthopedic and Reconstruction Sullen," 

liml). I’ollowed by abduction and flexion to <)o degrees. W hen 
the adductors stand out as a linn cord at their point ol origin, 
the operator practises deep kneading and massage with the 
knuckles applied at the point ol tension. I h is preliminary 
measure alone will sometimes effect a reduction (Tig. gy). 

Maneuvers nj Reduction: I he lemoral head is made to 
follow the anatomical movements exec tiled in the reduc tion 
ol traumatic dislocations. 

1 'irsl Maneuvers: I lex the' knee to <)o degrees and exert 
direct traction on the 1 Hexed knee without abduction, adduc¬ 
tion, 01 rotation (big. g(j). 



(a) Make the traction with one hand, and with the othet 
press the head outward and inward to assist reduction. 

(b) I wo individuals make the maneuver, one pulling on 

added to flexion. Child is laid on its sound side; assistant grasps thigh at its 
lower third, carries it in llexion to go degrees, then in forced adduction and 
internal rotation ol go degrees. Surgeon presses with his thumbs upon head 
ol femur, which has become much more accessible in this position of lotted 
adduction. One mac have four persons for performing this maneuver, two 
for pushing head ol femur and two for traction on knee. (Allen Calol.) 

the knee, the othei making direct pressure on the head ol 
the lemur. 

Second Maneuver: Abduction ol the I high to cjo degrees 
(no rotation) (Tig. ^7). 

Hex the thigh to cjo degrees; abduct ii with one hand; 
w ith the other press Irom below upward upon the head. Pro 
gressively increase the abduction. 

Third Maneuver: .Adduct ion and internal rotation to cjo 
degrees. I he child lies upon the sound side. An assistant 
Ilexes the thigh to a right angle, adducts and internallv ro¬ 
tates to cjo degrees while making traction on the knee. Hie 
operator’s two thumbs are simul laneouslv placed on the head 
above, pushing it toward the acetabulum. Alter the head is 

In,. >’(). I bird manemei uonlintiedi. \ssistanl ai knee, making continuous 
and strong tiartion Umanl him. raises himscll gradually in order lo reach 
position ol ahdniiion. Surgeon continues to press upon head ol lemur. Second 
assistant shown here immobilizes pel\ is. i M’tei (allot.) 

Ik.. |o. 

I bird maneuver until lulled). I high brought gradually loan ahdtn 
lion ol (jo degrees. (Alter (allot.) 




in place, an assistant makes traction and gradually Ininas 
about an abduction ol 90 degrees (Figs. ^8-90). 

Relent ion of the Red net ion. To insure the head’s remain 

I k.. 11. Chosen position. Flexion 70 degrees; abduction 70 degrees; rotation 

o degrees. (After Calot.) 

ing in its new position, immobilization in a plaster spiea ex¬ 
tending from the umbilicus to the toes is maintained for five 
to six months in two positions, each being continuous for 
two and a half to three months (Fig. j 1). 

(a) First Position, First Plaster: The position is expressed 
by the formula 70:70:0; which means 70 degrees flexion, 70 
degrees abduction, o degrees rotation with the leg Hexed on 
the thigh to 90 degrees. The plaster is applied by the ordi¬ 
nary circular method in common use in this country 
(Fig. (2). The child is kept recumbent for two and a hall 
months (Figs, j9 and | (). 

Lange’s Position: For certain cases that are dillic illt to hold 
In posit ion, Lange has advised the lollowing posit ion: Hyper- 
extension and abduction ol the thigh to ]7 degrees with the 
knee extended: loot totaled strongly inward; linn pressure 
maintained over the trochanter by molding the plaster in¬ 
ward in this region. (Fig. |f>.) 


"" X l , l» li ‘ ;"'<>" "I plastcr-ol I’aiis rolls over the stockinet and cotton 

w adding. 




(b) Second Position, Second Plaster: I lie position is ex¬ 
pressed by the loimul.i i rp^ndio, which, being translated, 
means 1 r, decrees llexion. go degrees abduction, and (io de- 

I u.. ||. \-r;i\s Liken through plaster a lew da\s after reduction of a double 
congenital dislocation of hips. Wisdom of always doing this is demonstrated 
in this case l>\ fact that both hips are shown to have slipped. One femoral 
head is above acetabulum and the other below. In such cases if it is found 
that the hips will not stay in place, an open operation and the author's bone- 
graft construction of an acetabular rim is the operation of choice. (From 
\lbee's "Orthopedic and Reconstruction Surgery." Saunders.) 

grecs internal rotation. Reduce the llexion and abduction ol 
the priniar) position very gradually until the limb is almost 
straight upon the operating table. While traction is made on 
the loot, manipulate the upper thigh until internal rotation 
exists to suc h a degree that the patella is directed toward the 
sound limb. The plaster spica is applied as in the first posi¬ 
tion and is retained lor two and a hall months. 

Trealinenl aftei Pinal Removal oj Plaster, \lter remov¬ 
ing the last spica, recumbency is enjoined for two to three 
weeks, with daily Iriclion and massage ol the limb. \l the 



end ol I i \ e weeks, die patient m.i\ gel up on Ins Icet, walking 
.il Inst l>\ holding onto .1 ehaii 01 table. \t the end ol sewn 
to ten davs. in this manner. he is allowed to walk with the 

I ii.. i",. \nleiioi lelusalion; I'm torreOion one is ollcn obliged lo make in 
lemal miation ol the knee ol more than i)o des>rees. (Alter (• a 1 o I.) 

assistance ol a companion; and three to lour weeks later, 
wnh the aid ol two canes but slid assisted by a companion: 
alter having been two or three months upon his feet, he ma\ 
be allowed to walk without support ol am kind. 

One year alter final removal ol the plaster spit a, the patient 
should walk normally, without limp, il the reduction is sue 



cesslttl and there is no severe bony mal loi illation. Massage 
should be administered at I ret]itent intervals. 

( 71 ) Bilateral Dislocation. I lie same preliminary stretching 
and the same maneuvers are applied as outlined above loi 
unilateral dislocation. Both sides should be reduced at one 
sitting il possible. II the shock ol the Inst reduction shows 
untoward effects, the patient should be given a rest ol seven 
to ten days before the second hip is treated. Both hips are 
immobilized as outlined lor unilateral dislocation, and the 
subsequent treatment is the same. 

2. Dislocations in Children Five to Six Years of Age and More 

Unilateral Dislocation. Preofieral ive Treatment. It is 
necessary to overcome three obstacles before attempting re¬ 
duction, viz., (a) elevation ol the head of the femur above 
Nelaton's line; (h) the contraction of the capsule; and ( c) the 
partial occlusion of the acetabulum by the capsule. 

(h) and (c) may be overcome by the maneuvers described 
under the treatment of cases two to three years old. 

Elevation of the Trochanter. Manipulate, stretch and mas¬ 
sage the periarticular structures, and bring the thigh in the 
plane of the pelvis in abduction, and attempt reduction after 
the methods detailed above. 11 attempts to put the head in 
the acetabulum are unsuccessful, put the child to bed and 
apply continuous heavy extension to the limb by adhesive 
straps, weights and pulley for ten days to two weeks, when 
another attempt at reduction is made, with thorough stretch¬ 
ing of the shortened structures about the hip. II again ttn- 
successlul, repeat the extension lot ten days to two weeks. 
II alter three such attempts at reduction the femoral head 
toils to enter the acetabulum, then an open operation is indi¬ 

Darns Method.* Ihe method described l>\ (.. (.. Davis 
may be divided into the following steps: 

* Dic kson, I . I). I he I).i\ is method lot closed reduction ol congenital dis¬ 
location ol the 11i| j. /. Ilnur c /oinl Surg., 7: 873. 1 cjj7. 


i. I 'lie* child, undci anesthesia. in placed in a prone posi- 
t ion on a u c II padded table. 

•_>. | lie hip on the aliened side' is acutely lle\ed with the 

knee Lent until the knee lies against the side ol the cliesi in 
a position ol ac ute axillary llexion. I his brings the head 
lioni a hih position on the dorsum ol the ilium to a low 

With the knee held firmly against the side ol the c hest, 
downward thrusts are made on the troehantei with the heel 
ol the hand, l liis stretches the adductors. As the adductors 
stretch, the' perineum, which is elevated when the thigh is 
Hexed, approaches the table and when all possible has been 
gained in this wa\ the doubled up list ol an assistant is placed 
under the knee, thus raising the perineum snllic iently to per¬ 
mit further stretching. As this stretching; proceeds, the head 
slips Irom the posterior plane ol the pelvis onto the anterior 
plane. I he indications that this has occurred are the follow¬ 
ing: (a) Feeling the head slip lorward: (b) noting when the 
knee lies definitely dorsal to the plane of the hip joint; and 
(c) feeling the forward movement ol the head with the lingers 
ol the unengaged hand placed in the groin. 

p With the head on the anterior plane, the hip is gracln 
alh brought Irom the position of ac ute axillary llexion to a 
position ol right angle flexion by a “pump handle'' move¬ 
ment, Inin pressure being maintained on the trochanter with 
the heel ol the hand while this maneuver is carried out. As 
the thigh approaches a right-angled position, the head slips 
upward into the acetabulum through the cotyloid notch. 

I he hip 01 hips are then |>!ac eel in plastei in a right-angled 
position or as neai this position as the stability of the reduc¬ 
tion will permit. 

1 hronghont the procedure little force and no violence is 
nsec 1. No I e\ ei age action is necessa rv, the lorce being a ppl ied 
directly to the* nppei end ol the' lemur. II the thigh is held 
closely to the < lust wall until the head slips forward, there is 
no possibility ol causing a fracture or epiphyseal separation. 



I hr si red liing ol iI k* adductors is accomplished gradually 
and with little* trauma, so that there is nexci a reaction ol 
any consequence. In I at t, the child snllers so little Iron) the 
procedure, that it is the ])iat tic e to let it he taken home the 
clay al ter the redact ion. 

A 'nda's Method* “At the first sitting the* dislocation is re¬ 
duced and lived in a plaster ed Paris spic a in the original 
()o-<)o decrees attitude ol Loren/., except that the dressing is 
carried below the knee. This attitude is maintained lot two 

“At the second sitting, two weeks later, the anterior dis¬ 
tortion is evaluated by a study ol the roentgenograms made 
before reduction, but particularly by the evaluation ol what 
may be gained by palpation ol the hip joint structures. The 
abduc tion is carelully reduced to about 25 or go degrees and 
the patella is brought into the sagittal plane. II the head re¬ 
mains deeply placed in the tissues ol the groin, and in its 
proper relation beneath the femoral artery, it may be assumed 
that no abnormal anterior distortion is present. The limb is 
then lived in this attitude, which is maintained until the end 
ol the period of fixation treatment and no third sitting is 
required. II, on the contrary, it be lound that in this attitude 
the head of the femur becomes prominent in the groin, and 
il upon even slight outward rotation ol the extremity it be¬ 
comes displaced slightly laterally to the line ol the lemoral 
.artery, it may be assumed that a degree ol anterior distor¬ 
tion exists which is inimical to the* ultimate security ol the 
joint. In those cases in which such a state ol affairs is lound 
to be present, the extremitv is rotated inwardh to a degree 
sullic ient to place the* head deeply into the groin and in its 
propel relation to the line ol the femoral artery. I he amount 
of energ) expended in this manipulation need not be small, 
since 1 there is al this time no danger ol dislocation oxer the 
posterior rim ol the* acetabulum. \ plaster ol Paris spica is 

* K. 1 i (I a, C ongeiiiuil disloc ;il ion ol die !ii|> joint, (///. /. Sici”., (>: 18",. 



applied m lilt* ton cried ;it l it udf, an altitude in which tin 
hip joint dements me in appro\imulel\ physiological rcla 
lions, 01 at least one Irom which such relations ma\ he at 
I .lined without I nether basic all era l ion. I his h\al ion dressing 
is designed to remain in plac e loi three months. 

I'llirc I sitting. 1 Ins is recpiired onlx in those cases in 
which, as above outlined, it lias been lonnd nec essai x to ini 
pose inward rotation upon the exiremilx. I he imposition ol 
the nec ess. n\ decree ol inward rotation demands that a cot 
reel ion ol this secondurx distortion be made, since upon re 
lease Irom fixation dressings the head ol the leinnr would be 
levered forward as soon as an attitude consistent with pro 
gression was assumed. 

\t this sitting, upon remoxal ol the plaster, the exlrcmitx 
lies, as it were, upon its inner side, with the knee flexed. I he 
knee is grasped with one hand and the shall ol the lennn 
ad jac 'ent to it with t he other. ;md ;i tract me is pic id need in the 
suprac ondx lar region b\ manual force. This Irac litre invari- 
abl\ oceans in the segment aboxe the epiphvsenl line, a fact 
originallv pointed out b\ Braudes. The fracture is completed 
and then one hand grasps the head and nec k ol the lemur, 
the other the Hexed knee joint. Outward rotation ol the 
lowei fragment is made, the nppei hand maintaining die 
oi initial relation ol the head and neck at the hip joint. The 
lowei I raiment is rotated ontwardh until the patella lies 
outside the' sagittal plane. A plaster-ol-Paris spica is applied 
in the corrected attitude, in about 20 decrees of abduction 
and slight flexion at the hip and knee joints. 

I his plaster is designed to remain on for two months, 
thus gixang, in the ideal case, a period ol fixation ol some 
what less than six months. Dining the last month of fixation 
1 real m ent. the' pat ient is to stand and make at I empts at ambit 
lation in so lai as that max be possible. 

Mthough Krida s results seem to be xerx good, 111 a 11 \. 
i 11 < I tiding mx sel I. do not I eel that 1 lie I racl tiring ol t lie I cm in 
is necessarx except in a small minoritx ol cases. 



KISIIISOI MAN 11 * 1 '] ATI VI' Million 

Iii his rcwieu ol 1 <S 11> eases, Mallei * attributes failures in 
reduction to inellective application ol traction preliminary 
to manipulation, and insists upon application ol a carefully 
molded cast following reduction. In old cases he recommends 
open reduction without an attempt at closed manipulation, 
as the laltei procedure is uniformly unsuccessful. 

Putt if states that it is a complete delusion that one can 
have a result permanently satislactory in function in a hip 
incompletely reduced. Phis delusion has led to a too optimis¬ 
tic view of the results. Clinical and roentgenological observa¬ 
tions of cases examined from live to thirty years after the end 
ol treatment demonstrate irrefutably that every subluxated, 
or transposed hip, every hip in which one has not obtained 
from the first, or not preserved, normal anatomical relation¬ 
ship between the femoral epiphysis and the acetabulum, 
every such hip is inevitably destined to become the subject 
of that precocious articular senility, which is usually diag¬ 
nosed as osteoarthritis. In other words, no complete and per¬ 
manent restoration ol junction occurs apart Irom perfect 
anatomical reduction. 

Putti t brought out that the greater part ol the complica¬ 
tions arising in the treatment ol the luxation must be attrib 
uted to the traumatic factor, and that in order to reduce the 
trauma to a minimum it is necessary to intervene early, after 
a diagnosis made a few days alter the birth ol the child. 

Lagomarsino states that the c hanges in the congenitally 
dislocated hip following its reduction depend upon: (1) the 
lime at which the reduction is clone, (2) correct centering ol 

* Mallei, I . I raumalic dislocation ol llie* hip (1S ju cases). Internal, tbsl. 
Snrg., 3(1: 2S, i<)2‘»,. 

| I’ntli, V. I a 1 1 % Ircalmcnl of (011nc11il.1l dislocation ol the hip. ,/. Hone i 
/oinl Sine.. 1 r,: iti, i()■;•{. 

;) I’utti, V. Report at the Congress ol Orthopedics. /. I. \l. /., too: 135-,. 

1 ii.rc 

^ I agomai siuo, K. II. Subsequent changes in the congenitalK dislocated hip 
reduced b> the I’aci I men/ method. Iillernnt. Sine., tin: r, 3, 11)35. 



the cephalic ossi l\ ing mu lens until t lift c is pci Ur t i emit ion 
l>\ reconstruction <>l tlu- ;uclabulat root. (g) the gentleness 
.mil smoothness ol manipulat ion during icduclion and snl> 
.setpient handling, (|) the reconstructive power ol the re 
dined hip. and ( j) the extent ol osteoc hondral changes insli 
tnted I)\ the reduction, l o a certain extent the last two hu 
tots are governed h\ the Inst three. I here are no inlallihle 
signs upon whic h an accurate prognosis can he based. 

Professor Annova//i ol Milan, who based his conclusions 
on t ,li t o c ases, stated that in children treated nuclei two years 
ol age. the percentage ol good results was Sa per cent: in 
children nuclei live and more than two years ol age. hh pet 
cent, while in children more than live sears old the per 
rentage ol favorable results diminished gradual 1 x. These 
statistics show the need of resorting to the manipulative 
method as earls as possible. 

Statistics sars so tremendously, particularly regarding the 
lesnhs ol manipulative treatment of congenital hi]) disloca¬ 
tions, some surgeons claiming as high as qo per cent ol 
"cures." others as low as 10 per cent, that too much credence 
cannot be given to am single set of figures. Reviewing 
broadls the statistical tables of a huge number ol orthopedic 
surgeons, it is probable that success, lunctional or anatomi¬ 
cal, or both, is obtained by manipulative treatment in less 
than Go per cent ol till cases of all varieties. 

Mthottgh perfect lunctional result is impossible without 
pet lect anatomic al reposition, yet undoubted!v many satis 
lac ton anatomical repositions are accompanied by unsal islac 
ton lunctional results. The general tenor ol results is affected 
b\ several lac tot s, notable selec tion ol cases, age limit, uni¬ 
lateral vet sits bilateral involvement, etc. As regards the age 
limit. I.oten/ places it at the end ol the seventh veai in hi 
lateral, and at the end ol the tenth seat in unilateral dis 
loc ations: I folia, at eight to ten Neats in unilateral and six 
to eight seats m bilateral cases. In selected cases, however 
(with plastic condition ol the soli parts, relaxed ligaments. 


''lender build <>l die patient, ele.), die age limil may be in 
( reased. 

A(:ta 1)I \ I s AM) COM l-l |(: \ I |( )\s 

1. Fracture ol the neck or shall ol the lemur. This is not 
an uncommon accident. The neck is die usual site. 

2. Rupture of Serve Trunks with Paralysis. The nerves 
usually involved are the crural and great sciatic. Crural 
paralysis is temporary, as a rule, and uncommon, and is the 
result ol hyperextension. Paralysis ol the great sciatic is more 
serious. It is due to contraction or compression of the nerve 
between the femoral head and the pelvis, to overllexion, 01 
or to hemorrhagic effusion within the ner\e trunk. Recover) 
is the rule, within six to twenty-loin months. Peroneal paralv 
sis is the most persistent type and is often permanent. 

Sciatic paralysis # was found by Loren/ in 23 of 755 cases, 
and c rural paralysis was lound by Taylor in () ol 70 c ases in 
which a congenital dislocation of the hip has been reduced. 
Froelich states that the nerve involvement nearly always 
occurs in children between the ages ot live and nine vears 
and in cases in which the original shortening was over 5 cm. 

y. Rupture of blood-vessels , with concealed hemorrhage. 

j. Crushing of the femoral head , with subsequent absorp 

7. Death,: is a result ol manipulation, is verv rare. 

(i. Hernia (Naratli), due to displacement ol the iliopsoas 

on \ u 1i)t c: 11< )\ 

The oj)en operation, which allords the opportunity to 
stud) the pathology and which involves much less dangei 
than forcible manipulative and mechanical procedures, max 
be used to advantage mote often Ilian it is customarily em 
ployed. Examination ol the pathological c lianges ollen reveal 

* Como I’. 1 cs accidents nervous dc la reduction dc la Insalion congenital 
dc la handle. Rev. d'orlh<>l>, it): fn ■ ((‘5—- 


.in horn ylass const riel ion <»I the capsule. 01 marked ante 
uusion ol llu' lemoral neck. 01 an acctabulum Idled with 
adherent tissue covered o\ei with the inlerior capsule. In 
ihi' present e ol sue h alterations it is lulile to use the closed 

Mam ddlerent methods ol open reduction have been de 
\ ised. lyianni, Richard. Corner. Iiisili, I .iimhot te, Lever. 
I ul)l>\. I el)am;m\. I liomas. I’atschke, 1 udloll. l aii hank. 
Davis. Dixon. Willis, lierslein. ( larke. Sherman. Iiradlord. 
(.allowav, and liuryhard ha\e repotted cases treated In open 
opera! ion. 

Lite Inst surgeon on this continent who strongly opposed 
the manipulali\e method and ad\ocated open reduction was 
the late Ham M. Sherman ol San Francisco.* Discouraged 
w ith the yenerallv unsatislactorv results ol the manipulative 
method, he had abandoned it in i<)i<), and employed the cut 
tint; operation in all ol his subsequent cases. 

In |unc, t ()2o. (.alloway, who had been usiny the open 
method ever since heariny Sherman’s paper, strongly ad 
vorated this procedure and presented an impartial view ol 
his results. 1 he technique ol choice which he now uses 

(itillowa y / c< Inin/ur.-f " 1 he patient is placed on the table 
with a sand bay, under the Hunk, so arranged ;is to raise the 
pel\is on the side to be operated on. Deyinniny at a point 
jusi below the crest ol the ilium and limn 2 to y inches be 
hind the anterior supenoi spinous process, an incision is 
cairied lorward just below the crest to a point immediately 
below the tip ol the antenoi supei ioi spinous process. I lie 
inc'ision is then carried down about y inches in the lony axis 
ol the tliiyh. I he Inst inc ision should inc lude merely the 
skin and supei he i a I I a sc la. Skin towels, backed with water 
piool male-rial, are then c lamped on the edyes ol the wound. 
W ilh a Iresli knile the belwc-en the rectus and tensoi 

' It cl ol i' l lie Vtaci i( dii () 111 k >| )d(‘( I i ( \ssoc id I ioi i. 

< • d 11 (>\\ d \ II P. II ! j>( . t //., j). 



lasciae lemoris is now located and opened up; then the in¬ 
cision along the ( test ol the ilium is deepened to the hone. 
In young children it is necessary to do this with some care 
because the hone is so thin and soli that it can easily be ( tit 
through. W ith a periosteal elevator the muscles are easily 
stripped Irom the ilium and the capsule ol the hip joint 
Inlly exposed. By rot tiling the limb inward and outward the 
head is now readily lelt, usually a little below the level ol 
the anterior superior spinous process. 

"While the limb is held Inlly rotated inward a longi¬ 
tudinal incision is made through the capsule, this incision 
being ;m inch, or slightly more, in length. The capsule is 
always surprisingly thick, and this incision should be carried 
down through it with great care so as not to wound the 
cartilage of the head. The object of rotating the limb inward, 
before commencing the incision into the capsule, is that this 
effectually guards against any possible wounding ol the liga¬ 
ment um teres. The moment the joint has been opened, some 
synovia] fluid escapes and the glistening head can be seen. 

"The longitudinal incision through the capsule is now 
converted into a crucial incision by incising the anterior and 
posterior margins ol the longitudinal cut to the extent of 
from t/j to a j ol an inch. 

"II the limb be now rotated outward the ligamentum 
teres, which is nearly always surprisingly large, comes into 
view, and, by following it in toward the pelvis with the 
linger, the* acetabulum is located. 

"In practically every instance, deep in toward the joint, 
a constriction is felt in the capsule; to the finger it gives the 
sensation of a sharp crescentric lold, the free concave margin 
of which looks upward toward the tool ol the acetabulum. 
This is divided I reel\ in a downward direction, using lor 
this purpose 1 a hernia knile which is introduced Mat-wise 
along the I cl l index linger, cutting edge turned toward the 1 
constriction a It cm it has been introduced to sullic ienl depth. 


! 15 

In some' nisi.un is the 1 head may. without any dillie nilv, 
he 1 maneuvered into plate l)\ ahelne l ing the' limh and tolal 
in” ii inward, lint usual I \ il will he lonnd ol advantage to 
use a hip skid. I lie insl rumen t I use 1 is one which has I urn 
sIioh1 1 \ modified Irom a model kinellv Inrnished me h\ I)r. 
W. R. Mat Auslanel. I liis inslrnmenl is introduced into t he- 
acetabulum and holds the 1 soil tissue's out ol llm wa\ w hile 
acting as a kind ol ■.shoehorn' along which the* head is slid 
deeply into the acetabulum. 

“Always redisloeale the head once or twice 1 so as to test 
the position ol greatest stability. It will usually be found 
that abduction ol Irom 15 to (io degrees and pronounced in 
ward rotation will maintain a perlcctlv stable reduction. 

' With a continuous suture ol plain catgut, the deep tissues 
are quickly brought together, particular care being used to 
bring ilm muscles which were di \ ideel along the 1 c 1 erst ol the 
ilium into place again. Isuallv no attempt is made to close 
the opening in the capsule: in I act, the moment the head is 
reduc ed the incision in the capsule tails together sc> perlee t1\ 
that olten il cannot be seen. 

“A plaster ol lkn is spit a is applied Irom the nipples to 
just ahme the 1 ankle, the knee being slightly bent so as to 
maintain the position ol internal rotation. 

“ An \ rav piet tire is take n through the plastei two or three 
(lavs latci. About three weeks altei the 1 operation, the plastei 
is removed and the stitches taken out. I'lie plaster is then 
reapplied without changing the position ol the limb, except 
that the knee is bent to a less degree. I rom that time on the 1 
child is encouraged to heal weight on the 1 limb. In Irom six 
to eight weeks the plastei is again removed and reapplied, 
this time the dcgi ee ol abduct ion and i 11 ward rot at ion being 
slightly lessened. 

"due 01 two other c hange.s ol the 1 plaster a 1 e* made, at In 
tea \ a Is ol about six weeks, and eac h time 1 the limb is brought 
nearer to the normal position. W ithin live 1 01 six months all 


dressings are disc aided and die* c hild allowed lo go about 
1 reely." 

llowovlh and Smith ' stale that open reduction is almost 
always successful primarily. When redislocation occurs it 
usualb takes place shortly alter the removal of the plaster. 

I herelore the hip should be carelully watched at this time, 
particular attention being paid to roentgenograms made with 
the patient standing. Secondary manipulations to improve 
the* reduction have been ol little value. 

Galloway states that he was "chi\en to the open method 
by the distracting uncertainty and frequent failure which 
attended my lottner clients at manipulative c ute. 

He considers "the ideal lime lor operating is between two 
and three years. In a general wav the operation becomes 
more dillic till and uncertain as the age advances, although 
exceptionally, in children horn live to twelve years of age, 
or younger, who have not been subjected to manipulative 
or othei treatment, the ligamentnm teres is usuallv intact 
and is an important guide in locating the acetabulum. In 
older children, and m those who have had a previous tin 
successlul manipulative reduction, the ligamentnm teres is 
usually absent, or is found detached from the head and 
can led up in the acetabulum." j~ "In children past three, 
and occasionally even in younger patients, alter opening 
the capsule I reel y and c l i \ i c 1 i 11 g the constricted part, the 
Imgei in the 1 acetabulum detects this cavity more or less 
occupied by a kind ol fibrous mass, part ol which represents 
the remains ol the ligamentnm teres. W hen this condition 
is encountered, (.allowac introduces his leit index linger and 
passes the convex side ol a shallow gouge along its pahnat 
surface into the acetabulum, and with a kind ol combined 
pushing and leverage motion strips this mass Irom the tool 
and walls, and pushes it towards the llocn ol the socket. 

' I lemni ih. M. H. and Siniili, II. \V. Congenital dislocation ol the* lii|> 
Healed In open opeialion. /. Hone J. /ninl Sin ■»., ip ape). 1 • 

)■ Calloway, II I’. II. I.m. til., p. ip,. 



taking the ^mmIoI care not lo wound the* (at1 tlaginous lin 
ing: ilu' I i'll index Imgei .ill the t line guiding and controlling 
the edge ol the inst 1 innent. 

While- .iis not .1 1 u,i\ s ,i l.iii i i ilc i ion. and e;idi < use must 
he indivicluallv judged, it is li lt that as a rule eases ovei 
1 1\ e years ol age will not lend themselves to a salislactoi v 
reduel ion 1 >v this met hod. 

In old cast's. Allison surest s sectioning the lesser tro 
ehantei. thus doing awav with the resistance ol the psoas 
muscle. In addition the head is brought lot ward as nine h as 
possible. I In ee weeks later, during witi< 1 1 time heavy skeletal 
traction has gradual 1\ brought the head down to the uppei 
level ol the at etabnl urn. a second operation is done. I lie 
acetabulum is cleared ol dense. Iibrous tissue and the head 
replaced without dillieulty. In one ease he did an osteotomy 
three months lalet to correct internal rotation ol po decrees. 

Pal mil v over nine xears of age. Often oi closed redact ion? 
Closed reduction alter the age ol sixteen is possible rarelv 
and just i I ted even more rarelv. I tec a use < > I the undue violence 
necessaiv. Sue c essl ttllv reduced cases alter this age have, 
however, been reported. Skeletal traction by the Kirschnei 
method was used.* 

No method ol closed reduction yet presented may be re¬ 
garded as generallv leasible in the age group nuclei considera 
tion. What is the utilitv ol putting the head into the ace¬ 
tabulum il the result is a still hip, because ol the extensive 
liauma in getting it into place? I n bcttei to have an inch 
ol shortening and have the head ol the lemur upon the side 
ol the- pelvis undei a bone-gralt shell and with a mobile 

S liell ()jternltons. I he- "shell operation or formation ol 
an artificial lip to the acetabulum is a most useltil one for 
oldei c ases and is being performed with i tic leasing I rec pi cue v 

so < > .i< • 11ssI( • 11. I | l<.ij>| >< >) i .in I 11 C .on”less 1 11 1 itii;i i ional d'C)i 1 1 1(>|>i - ilit-. 
I’m is. i o.‘><». 

I K.. |(i. Vai ions s 

opci al ions lot stabilization of hip in congenital 
disliK a l ion. 




l>\ surgeons throughout the world, which is evidence ol ap 
piec iation ol ns \alue. 

Mam \ a 1 iat i(>ns ha\ e been reported k (I' it*. |<M lo uieel 
the exigencies ol varving anatomical and mechanical condi 
i ions, dependin'; on whelhei oi not the hip can he reduced, 
oi how high up on the ilium ii must he siabili/ed. 

I lie operation is sound Irom the anatomical point ol view. 

I lie making ol an ellicient shell is (omparativel\ easv: the 
dillicultv lies in making the shell at preciselv the right level. 
When relapse is seen to he occurring a Iter manipulative re¬ 
duction followed h\ prolonged fixation, or when simple re 
dnction oilers hnt little hope ol a line- lor example, in a 
snhlnxated hip at loin years ol age upward, this operation 
is invaluable, l airhank believes the procedure should alwavs 
be added to open reduet ion when the condition ol the pat ient 

In most cases ol old unreduced congenital dislocation, oi 
in cases in which reduction can he accomplished hut cannot 
he held, some t\pe ol shelving operation offers the best 
means ol stabilization. The procedure also offers the best 
chance lor functional improvement. The operation is in 
cheated lor old congenital dislocations in which the head is 
tiding well up behind or anteriorly to the acetabulum on 
the posterior portion ol the ilium, as well as lor cases ol 
subluxation I rom infantile paralysis. 

ihe similarity ol the various shell operations is obvious; 
the pi ini ipie involved is the same in all. There are two points 
in regard to the application ol this type of operation which 
might he emphasized: (l) The hip should he reduced or at 
least brought as lai clown as possible bv heavy traction ap 
plied either bclore operation or at the time ol operation, and 
(2) the shell should cover as much as possible of the entile 

l.iiibaiik. I ambeau. Vance. 1 )elaj>i - iiii , i c. Maintain'. Diijaiicr. I lallopcaii. 
S|>ii/\, Dickson. Vllison. Sum, Wallace. Obci. timer C.ill, I lixeli, I anibollc. 
I esii. I ubl>\. I cDaniam. I'lioinas. I’alsdikr. Iiidloll, Davis, Dison. Willis, 
I >ei si ei 11 ( l.nke. Itiadlonl. Sherman. C.allouav, and Dcnlsi blacndei. 



upper sm hue ol I lie Icmoral head, bm should not extend 
lar enough laterally to intcrlere with abduct ion. It is not 
ne( ess;u \ t(» ha\ e the shell pit out ovci the trochanter d the 

head is pi csciit. 

I he bony shell relieves 
pain and fatigue in both 
young and old, helps to 
improve loeomotion, and 
maintains the length ol the 

Shell C) jjn al ion of 
Choice* The joint is ap¬ 
proached by the Smith- 
Petersen (or Sprengel) in¬ 
cision. Adequate traction 
is applied to the limb in 
order to lengthen it as much 
as possible. W ith the single 
small motor saw parallel 
cuts are made, about t.y 
inches apart in adults and 
less in children, through 
the outer table of the ilium 
in a position immediateh 
above the acetabulum (Pig. 17). The upper ends ol these 
saw cuts are connected by a horizontal cut made with the 
single saw. With an osteotome, this (lap ol bone is turned 
down so that it conies to lie snugly upon the capsule 
ol the hip joint (see A,, fig. pS). Ihe bone shell still re 
mains attac hed to the 1 ilium in a hinge like manner .it its 
lowei portion. Willi the small single saw 01 the twin saw 
blades, a rectangulai block ol bone ol the' same width is 
removed from the outer table ol the ilium a short distance 
above the Map ol bone already mentioned. I his block ol 
bone is completely detached, is placed as a stint or brace. 

* Vlhcc. I It linin’ ”i.ill S111 n»• 1 \. I’liila.. Saimdcis, ii)iy 


.md Listened l>\ one ni luo kangaroo loiulon suluros plated 
in dull I Kilos (sec l> . I' m. | Si. \ doulilo plasloi < > I 1 ’at is 

spit a is applied e\lciidin<> Irnm die waist lino lo die loos 

on both sides. Ii is nsnallv necessan to apply traction 
to die limb postopcrat i\olv bonoatb the c ast. Ilns is accom¬ 
plished 1>\ placing moleskin adhesive upon the inner and 
outer side ol the thi ( t»h as well as on the upper hall ol the 
lowei let*. \s the plastei is applied, the lowei ends ol the 
moleskin straps aie incorporated in it at .1 point about three 
to loin inches above the' ankle joint, hollowi 11 o this the conn 
tcitraelion is set aired by molding the plastei hrml\ against 
the plantai surlace ol the loot on the uuoperated side. I his 
traction is continued until the cast is removed at the end 
ol se\en or eiuht weeks, altei whic h massatre and missive and 



;icii\c motion arc canted out to restore motion to the lti|> 
and I unction to the limb (Pig. pj). 

Die kson slates that the c Itiel cause ol trouble following 

Ik;. 49. Congenital dislocation ol hip. X-ray taken five years after operation. 

shelf operations has been the failure to improve the weight- 
bearing position ol the head by restoring it to appro\imatel\ 
its normal position above the true acetabulum. This pie 

* Dickson. I I). Shell' operation in treatment ol congenital dislocation. 
/. Hone X loint Sing., 17: |;j, 19;}.-,. 


vents am imprmement in lilting ol the pelvis and Kirrei 
lion ol lordosis, an important ad\anla<>e secured I>\ a shell 
oper.u ion propel l\ done. \tlempts to set m e loo much leith 
will rc‘snit in the same e\cessi\e pressure against the head 
which occurs in these older cases il the head is restored to 
the acetabulum with absotption ol ailicnlai cartilage and 
rigidity or ank\losis ol the joint. 

('.ill's Shelf ()henilion . “An incision is made alone!, the an 
leiioi third ol the crest ol the ilium to the anlerosnpcriot 
spine and continued in a curve downward and backward, 
a ft cm the method ol Smith Petersen. I he tensoi laseiac 
lemons and a portion ol the glutens meditts a re heed sub 
periostealb horn the ilium. Lite anterior portion ol the in 
eision is carried l>\ sharp dissection downward between the 
tensor fasciae lemoris and the sartorius musc les, followin'; 
the anterioi border ol the pel\ is until the anterior interim 
spine ol the ilium is reached. Below and posterior to this 
point it is lound that the periosteum is closely attached to 
the ilium where the capsule ol the hip joint blends with 
it. I he further procedures necessary from this point de¬ 
pend on the type ol dislocation. Ilnee types ol operation 
are desc ribed by (.ill. I \ pe No. 1 is not described because 
ol its similarity to m\ own technicpie. 

('will's ()jjenilion. I'yjie Xo. 2. " I he capsule ol the hip 
joint is opened b\ cutting it with a knife 01 pair of scissors 
c lose to its attachment to the ilium, beginning at the inleriot 
spine ol the ilium and extending backward i.r, to 2 inches. 
I hrou^ii this inc ision the linger can be insetted into the 
ac eta I mi la 1 cay 11 v. 

I he head lies in the 1 eapsulai pocket, above and posterior 
to the acetabulum. It is usually impossible to pass the linnet 
into this pocket, owin,” to the* constriction ol the capsule, 
and it is usually impossible to reduce the head throui>h this 
hour-**lass constriction. Another incision is therefore made 
in the capsule. I)c*i*innin^ about midway in the incision al 
ready made and extending at a rii>ht an^le to it up to the* 



Iicad <>l the lemur. through this second incision die head 
can he delivered into the wound. 

With scissors or knile or curved goitre the arctabulai 
cavity is enlarged hy removing Irom it the lihrotts tissue 
wide li is lound to hll it. In no instance in this series ol cases, 
in this t\|)c‘ ol dislocation, lias the acetahulai cavitv heen 
lound sullic iently large to hold the head ol the lemur. Altei 
removing the lihrotts tissue and sometimes even some ol tlu’ 
cartilage lining ol the acetabulum, the head ol the leniui can 
he placed in it. lint even then the acetabulum is not large 
enough to give stability to the lemur in this position. It is 
therelore enlarged and reinforced hy turning down a hone 
Hap Irom the side ol the ilium and hy turning clown the 
tool ol the acetabulum as desc ribed in Type t. The head re 
mains securely in the acetabulum il the lemur is maintained 
in slight abduc tion. The capsule is brought up over the hone 
(lap which has heen turned clown, hut it cannot he sutured 
in am fashion. The wound is closed as described in I'vpe t. 
and the alter treatment is similar.” 

(.fill's OIteration. Type No. 9. “The capsule is opened and 
the head exposed in the manner alreadv desc ribed in I v pe 
2. In order to allow the head to go forward, it is necessarv 
that the capsule he cut through cnlirelv in the perpendiculai 
int ision w hic h begins at the middle ol the horizontal inc ision 
and extends upward and backward to the head ol the lemur. 
II am portion is allowed to remain encircling the neck ol 
the 1 femur, it is impossible to bring the head ol the lemur 
lot ward w cl I into the' we mud. 

‘‘Moderate traction is now made on the extremitv to see 
how I a r down the head ol the lemui can he 1 brought. I his 
will largely depend, ol course, on the age ol the patient and 
the' amount ol the upward dislocation. It is Irec|uentIv lound 
that the head can be brought to a position just below the' 
ant et iot in I erior spine ol the ilium. 

“The original acetabulum is identified. It is usual lx lound 
to be verv small and IrequcutIv it is cnlirelv obliterated. 



t's|K'( l.lll\ lit I IlC oldc'l t .ISC'S. Willi .1 fill \ f(l ^ou^c the ace 
l;il)uhun is enlarged upward and backward until the head 
nl die lenun can be placed in il with moderate- traction. It 
will remain there tl the lenun is sIioh11\ abducted, but the 
ca\it\ cannot be made lariye enough to hold the head ol the 
lemur unless abduction is maintained. A bone Map, olten 
times one inch or mote in width, is then tinned down above 
and behind the head as il lies in the depression made above 
the original ;tc et aim lum. Il is necessat \ to maintain the lenun 
in abduction constant!) until plaslet ol Paris is applied, lest 
on adduction the head should slip out and break down the 
bone Hap. I bis accident has ne\ei happened in out ex¬ 

“Where the thickness ol the- pelvis above the- newly con¬ 
structed acetabulum permits, the- osteotome is driven in 
deepb altmc the head ol the lemur, allei the- Map has been 
detached from the side ol the pelvis, so that the entire newly 
constructed tool ol the acetabulum is reflected downward 
and the wedyc pieces ol bone are driven in deeply above the 
tool. Ibis makes the reconstructed acetabular tool very 
solid and sec tire, and brings it into c lose apposition w ith the 
entnc- head ol the lemur. 1 lie wound is closed in the usual 
manner. I he plaster c ast is applied with the extremity in 
i*<) to y,o decrees ol abduc tion and in internal rotation. 

I he alter-care is the same as in the preceding types. The 
purpose ol this treatment is to secure as much mobility of 
the hip as possible. Six weeks in plaster cast is ample time to 
sec lire stability ol the reconstruc ted acetabular tool. In latei 
cases where lar<>ei pieces ol bone ha\e been taken bom the 
(test ol the ilium and driven in deepb above the reflected 
rooI ol the acetabulum, the cast has been removed at the end 
ol loin weeks. \t the end ol twelve weeks, the patient is 
allowed out o! bed with crutc hes and begins to bear weight 
on t lie- operated hip.” * 

’ (.ill. It. ( oiu'ciiieil tl isliit ;it ion ol the hip. /. Hum /oinl S //; o., m: 

l <|- s - 



Dickson I cclniuj in' * i. The Smith Petersen incision,which 
inns Ivc>m well buck on the iliac crest clown onto the thigh, 
is used. 1 his inc ision is the only one whic h gives sullic ient 
exposure to allow the subsequent steps ol the operation to 
be carried out elite ic u11\. The skin edges are protec ted In 
towels lastened with tetra clamps. I he incision is deepened 
in the usual manner until the capsule of the joint is reached 
and free I \ exposed. 

2 . 1 he dislocated head is now completely freed of till 
structures which interfere with complete mobility. This is 
accomplished In freely and completely cutting away till the 
thickened capsule and In dividing till librous bands. Muscle 
attachments which interiere, particularly those to the greater 
trochanter, tire preserved as I a r as possible by stripping up 
their periosteal attachments. (Generally, it is necessary to 
divide the tendon ol the iliopsoas which is usually markedh 
shortened; no ill effects have followed this. The importance 
ol completely freeing the upper end ol the femur cannot 
be overemphasized; attempts to preserve the capsule prevent 
this and are unnecessary as it regenerates later. 

g. I he head, neck, and upper part ol the greater tro¬ 
chanter Inning been completely freed, traction cm both legs 
is gradually increased. As the traction lorcc acts, the elevated 
side of the pelvis is allowed gradually to sink until the 
patient is lying Hat on the table. At this point a lexer is 
placed behind the femoral head and neck and. il the tippet 
end of the lemur has been adequately Ireed. the 1 head readih 
sli| >s lorward onto the ridge between the posterior and an¬ 
terior planes ol the pelvis into a position above, or above and 
slightly in front of, the acetabulum. Fraction is then grad 
ually increased until the 1 head has been pulled down in its 
anterior position to a point beyond which it will not descend 
w ithout the use ol unjust ihable lorcc; this is as a rule about 
an inch to an inch and a hall, both lower extremities are 

* Dickson. I . I). I lie shell operation in the treatment ol congenital dis 
location ol the hip. S//rc>. O'vmr. Olisl., Si, i 



tlu'ii m ai 111.111 \ abditi led .iikI llir irailion is lightened l«» 
lake up tin' which usuallv lollows this maiicuvn. I lie 
head is now in the position in which, bv turning down a 
II.ip oi shell ol hone lioni die side ol the ilium, n is to he 
held pelnianentIv . 

p I he shell is formed as lollows: A woodcutters gouge, 
the si/e depending upon the si/e ol die shell to he lormed. 
is used lo linn down a flap ol hone Irom the side ol the 
ilium. I lus II,tp should hi' t.r, lo 2 inches in depth and at 
least o.y inch thick at its hasc. 1 he llap should stall well 
anterioi to the head and he continued <>\er it and well down 
posteriorlx. so that w hen the shell is completed il Ills ovei 
the uppei part ol the head like a eap. It should he under 
stood that the shell turned down is not merely a ledge ol 
hone projecting Irom the ilium hut a modeled covering loi 
the lemoral head. \ large wedge ol hone is then removed 
Irom the crest ol the ilium, or several wedges il so desired, 
and this is securelv lived between the turned down shell ol 
hone and the side ol the ilium. Idling the spaee between 
l hem. The wedge ol hone acts as a brace for the in rued down 
llap and provides a Inin shell above the head capable ol 
resisting a lairlv strong upward thrust without giving wav. 

At this point the condition ol tin- adductor tendons ol 
the thigh is examined: il they are under tension, an assistant 
does an open tenotoim ol these tendons belore closure ol the 
wound is commenced. 

(i. C losure ol the wound is made in the usual manner bv 
layers. Drainage is rarelv used and. il used, consists ol a piece 
ol rubber dam placed just under the skin and removed in 
i welve lioni s. 

7. \ plaster ol Paris < ast is now applied to include both 

hips and to extend down lo jusi below the knee on the side 
which has been operated upon. I lie patient is transferred 
directly to bed Irom the opcialing table, strong irailion on 
the extremitv operated upon being maintained conslanllv 
by an assist am during this transfer and until the irailion 


apparatus attached to the bed has been arranged and is 
act ing. 

A jlo-l real innil: Fraction is maintained constantly lot si\ 
weeks. At the end ol the lout lit week, the c ast is bi waived 
and mild flexion and rotation movements are given daily. 
Alter six weeks traction is discontinued and physiotherapy 
continued with gradually increasing range ol motion in¬ 
sisted upon. Weight-bearing is started at the end ol six weeks 
with clutches and at the end ol eight weeks unrestricted 
weight-bearing is permitted. It is necessary to maintain su¬ 
pervised exercises lor several months following operation in 
order to sec me lull range ol motion. 

In 11)27 Hey (doves # suggested that mobility and stability 
with an actual reduction ol the dislocation might be accom¬ 
plished il the capsule surrounding the head be placed in a 
reamed-out acetabulum located at its original site. He sug¬ 
gested perforating the door ol the newl\ formed acetabulum 
with a drill, and passing by means ol a suitable curved 
aneurysm needle, a stout tendinous ligature oxer the pelxic 
brim through the hole in the acetabulum and out into the 
thigh, to be attached to the capsule covering the head. I his 
ligature was then to be tightened and the free margin of the 
capsule (irmly attac hed to the brim ol the pel\ is or to 
Poupart’s ligament, (olonna has carried out this idea in the 
following operation: 

Colon mi's O j>c) til ion .f “Preliminary stretching and tenot¬ 
omy is done and a long plaster spica applied to the opposite 
side. Several weeks ol heaxy skin traction permit the head ol 
the femur to be drawn down neat the level ol the original 
acetabulum. When this is accomplished, the child is pie- 
pared for open operation and an incision similar to that 
used in the Whitman reconstruction operation is employed. 

* (.roves, I \\ . II. I reauncut ol congenital dislocation ol the hip, with 
special relcrc'iicc to open operative reduction, (ones Birlhdax, Xol. i., i«|irS. 
pp. 73-t)(i. 

I C,olonna. I'. C . Congenital dislocation ol the hip in oldei subjects. /. Hone 
C jnnil Sin^.. i p ^ 77 . 



I lie grealci trochanter with its attached nmscles is ( hiselcd 
through and mined upward, and the capsule cmeting the 
head is r.ilhei easilx dissected Iree Iroin the surrounding 
tissues. W hen the isthmus ol the capsule is reached, ii is cut 
through and the head ol the 1 hone 1 inspected through this 
aperture to note the shape <>l the 1 head and the appearance 
ol the ligament uni teres. I he aperture in the' capsule is then 
closed with several chromic sutures. I he rectus lemoris 
tendon at its origin I rout the' anterior inlerior spine is iden 
tilled and divided. With the Doyen reamer a rapacious ace 
tabulutn is lortned as near l he 01 initial site as the prel iminan 
traction has made possible. 1 he head ol the bone with its 
coverin'*- ol capsule is then placed in the newly lortned ace- 
tabuluni and. with the limb in abduction, the greater tro 

c banter is sutured back, into place. Abet the wound is c losed, 
a loti” plastei spica w ith the limb in complete extension and 
moderate abduction is applied. Care is taken not to remove 
the moleskin Irom the thigh and leg at the' time ol open 
operation, so that immediate postoperative traction can be 

It is leh that this tvpe ol opertition in children between 
the ages ol three' to ten years is worth) ol a more extended 

I I ial. 

Pulli's Method. "A straight incision is made beginning 
about 2 inches above the anterior superior spine ol the 
ilium and canied along the < i est down to and beyond the' 
anterioi superioi spine. The muscles, rectus lenioris. and 
teiisoi I a sc i a lenioris are separated and well retracted l>\ 
bl in it c I isse'e t ion. I he capsule is exp< >sed. An incision is made 
tinoiigli the capsule. Spec ial retractors are used to expose the 
head ol the lemur to lull view. I lie capsule is examined loi 
consli ic tions. It is usualK shaped like' a runnel and this <>c- 
casionalb prewents reduction. \ special instrument in the 
lorm ol a dikitoi is inserted through this narrow const riel in** 
portion ol the capsule lorcibh dilating it. \ special in 
xtru111(Mit in the lorm ol a skid, similai to that ol a Mmpli\ 



skid, is introduced into the dilated portion ol the capsule 
and into the normal acetabular cavity. The knee is grasped 
and the lent ora I head abducted and in vet ted over the si id i n^ 

instrument into the acetabular cavity. Dressings are applied 
and the thigh is placed in right angle abduction and slight 
internal rotation similar to that used in the closed method. * 

lii / in cal ion O deration. The bifurcation operation ol 
Loren/ is limited in adults to use in a small number ol se¬ 
lected cases ol traumatic, pathologic or congenital disloca¬ 
tions ol the hip, in inllammalorv processes involving the hip 
joint, and lately in Charcot's disease. It is claimed that the 
advantages ol the 1 operation are rebel ol pam, a good lime 

' I’utli. \ C .on»ciiil;il <iislo< ;ii ion ol the hip. S i/i"., ('•xini. ()b\l., p_* | |(). 

i i|-S. 


131 .nnl cosmetic result. i \ c - simplicitv ol the 1 opera 
lion and a shell t period ol rermnlicncv. I lie danget ol in 
j n i \ to llie vessels l>\ die Iragmenl and ol 
non union should he enipliasi/ed. I lie operation lacks all 
semblance ol surgical precision (l it;. 50). 

Ilibl>\ ' Osteotomy lot 1 11 1 (”('<') Mi> 11 of llie Xccfi oj llie 
Irnim. Mam cases ol anteversion are due to a twist in the 
shall ol the leiinn w hic h 11ilibs correc ts In an osteotomy on 
the lowei third ol the shall before attempting to reduce the 
dislocation. Alter dividing the bone, llibbs twists the lowet 
fragment outward to the decree that the head is abnormall\ 
anteverted. Alter union, the patient is allowed to walk lot 
eight to ten weeks, until external rotation is corrected h\ 
exercise and locomotion, and the lev; takes its normal place 
in walking, the patella and toes pointing forward. At this 
point in the treatment 11 i b I is reduces the dislocation. 

llie lower third ol the leimn is selected because at this 
point there is least interlerence with muscular attachment 
and because both Iragments are large enough to permit per 
lect control. When the dislocation and consequent ante- 
version ol the neck is bilateral, double osteotomy is per 
lormed at one sitting. 

Sc licde controls internal rotation by driv ing a long nail 
through the greater trochantei and neck ol the lemur, using 
it as a handle. I had lord uses a knitting needle in like man net 
lor the same purpose, both Sc licde and bradlord Inst do an 

A subtrochanteric osteotomy, either circular ot transverse 
lineal (see ( 11 1 apt cm IX. Coxa Vara), inav also be used to 
correct the anteversion ol the neck ol the lemur. 

Si cc//’v Ojirn linlurl lon.f When coni routed with the im 
possibilitv ol reduction at operation. Swell has reduced the 
head alien osteolomv just below the lessen trochanter. I here 

llililis. R. V \iitcv ci sion < > I llie ms k ol llie lemm in connection with 
coiii’cnilal (Iisloiai ion ol iln hip. /. I \l /.. (j- : i.Sin. Mpy 

I S\\ ct 1. I’. 1 I lie ope 1 ,n ion loi ns I no ion ol < ri i a in t v pcs ol i on.m'ii il at d is 
location ol llie liip. /. Ilnur g /ninl Sin^., m: 11)28. 



is always shortening I rout the o\ei I a j >| >i it” position ol the 
I raiments, hut this is less than belore reduction. Although 
there is ;in;itoinic;il distortion, function is said to be good, 
and the patient is spared the prospect ol increasing' pain 
caused l>\ use ol the dislocated hip. Swell suggests that bettei 
alignment and increased length might be secured by suitable 
measures, such as redressment and traction. 

Swell admits a certain leeling ol anxiety in performing 
this operation. Fractures in this region have been responsible 
lot so much anxiety that one hesitates to induce a solution 
ol continuity, il suc h is avoidable. I would prefer either the 
construction ol a new acetabulum at a highei level on the 
ilium, or a two stage operation consisting ol shortening ol 
the femur bv mortise and subsequent teduction of the dis- 
loc at ion. 

Steindler, Kulowski and Freund,* in summarizing the end 
results ol the treatment ol congenital disloc ation, sax: "We 
can say that the extreme optimism concerning results in the 
closed method, as it is shown by some (.ernian and Italian 
authors, does not seem to be entirely justified. Results be¬ 
come definitely worse with the duration ol the observation 
period. A systematic after-care and long lasting follow up ol 
the patients is absolutely necessary (roentgenograms should 
be taken at least twice a year in the first live years alter re¬ 
duction. and at I east once a vear in the lollowing years). 
Results ol definite significance are given only h\ patients 
who, after reduction in childhood, are grown up to man¬ 
hood and womanhood. 

" Fhe lac t that beyond r, Years ol age the satislac toix re 
suit rapidly decreased would indicate that the upper age 
limit for open reduction in general would be about 8 Years. 

I his agrees with Dickson, who recommends open reduction 
lot all pat ienls I>et weeti ] and <). 

" Fhe significance ol the palliative methods lies in then 

* Sicincllcr. \.. Kulowski, | , and l ivimcl, I Conucnilal dislocation ol tlu 
hip. /. /. W. /., io.j: ‘{oil, 



i)ir\cnl i\e dials on (he lunclional < 1 i II k 11 11 i evs coming on 
(luring ,md bevond pubertv ;uid on (lie l.iir sc«| ncl.ic- seen 
in nnredneed disloe,ued hips in middle age, (lie scrondaiv 
;n tin it is due to die sialic n isulhcicncy. 

It seems to us horn this point ol view the simple shell 
operations will undoubtedlv 14.tin in lavor because ol the 
lesser danger ol operative lailure and ol postoperative com 
plications. In \ iew ol the increasing evidence ol late de 
generative sequelae ol the unstahle, unreduced hip, it mav 
he assumed that the luture will Imd the indication held ol 
the palliative operation extended rather than restricted. 

Iunc 1 ionalIv available statistics show an encoui au,inu, per¬ 
centage ol acceptable results lor shell operations.” 

I i< vi via 1 u: Dtsi,00 v 1 io\ 

I he rundainental guiding pi inc ipies in treatment ol trait 
math dislocation are the same as lor congenital dislocation, 
with a marked dillerence. however, in the length ol time 
required lor immobilization. In the congenital cases one is 
dealing with an elongation ol the capsule existing since 
birth, whereas in traumatic dislocation it is a tear ol the 
capsule which will rapidlv unite il the hip is reduced and 
held in position lor a period ol three or lour weeks. Im¬ 
mobilization should not be prolonged beyond this period 
unless there is some urgent indication to the- contrary, such 
as an extensive Iracture ol the rim ol the acetabulum that 
would jeopardize the lup staving in place. 

Itaumatic dislocation constitutes onlv about 2 pel cent 
c > I all chslc nations ol the hip,* and is ol rare occ urrence in 
c hildren. WiI son and Cochrane, who have dearly described 
the salient features ol this condition, stale: " \ll dislocations 
ol the* hip a 1 c* eithci anterioi 01 postei ioi in type. Ibis is 
easv to understand when it is remembered that the ace¬ 
tabulum lies on the summit ol the ridge lorn led bv the junc 

’ Wilson. I’. I>.. ;md Cine In .me. VV V. Iiaclcncs and dislocations. Id. ”, 
I’llila., I i])|)incoll, ii)uH. 



lion ol I lie anlerioi and posterior planes ol the pel\is and 
that these slope away sharply on either side. When the head 
ol the- lennn leaves the aeelahnlnm, it therefore tends to 
seek a position ol equilibrium in the anterior or posterioi 
direct ion. 

"Mechanism. Dislocation ol the hip results almost always 
Irom the action ol indirec t violence or leverage, usually with 
the hip Hexed to qo decrees. Bigelow was the first to call 
attention to the important role played In the iliofemoral 01 
A ligament in the mechanism ol dislocation and to the pus 
sibility ol ulili/ing it as a Inlet um lot sec uring reduc tion. 
Owing to its great strength, it is practically never torn, and 
by its action in limiting displacement it gives rise to the 
characteristic attitudes ol deformity bv which the carious 
tvpes ol dislocation are recognized. 

".Interior Disloc ation. Fire anterioi type ol dislocation is 
usually produced by violent hyperabduc tion ol the hip. The 
neck and greater trochanter are forced against the outer 
rim of the acetabulum, a fulcrum being thus provided, and 
the head is pried out through a rent in the anterior and 
inner portion of the capsule. Primarib the head lies in the 
low position at the thyroid foramen, but, il the thigh is 
rotated outward, it rises to the high or pubic position. If, 
on the othei hand, the thigh is rotated inward by a contin¬ 
uance ol the original force, the low anterior dislocation mac 
be concerted into a posterior one. 

“Posterior Dislocation. The posterioi dislocation is the re¬ 
sult of force applied to the leg when the hip is in the position 
ol flexion, adduction, and internal rotation. Leverage is 
again brought into play, but this t line- in a different manner. 
Internal rotation ol the thigh tightens the Y ligament and 
winds n around the neck ol the lemur. I he ligament thus 
becomes the fulcrum, and as the movement continues, the 
head is lorcc'd out through the lowei part ol the capsule 
posteriorly. Ptimarily it lies in the sciatic notch or the low 
position, but, il the movement continues, it mac lodge in 



iIk' high position on the dorsum ol the- ilium. \ common 
.undent I>\ which iliis mechanism is produced is ;m .into 
mohile collision in which the passengei is thrown lorward 
from his scat, the illicit i»ein<>- Ile\ed and adducted and the 
knee striking the hack ol the lorward seal with an inward 
t wist. 

" Pathology . Dislocation ol the hip is always accompanied 
|>\ considerable injurs to the- struct tires surroundin'*- the 
joint. I lie capsule is torn. I he adduc tot musc les and the 
obturatoi externus aic- usuallx lacerated in the anterior luxa¬ 
tion. while in the- posterioi tvpe the short external rotators 
and part ic ularlx the obturator interims musc le are liable to 
injurs. I lie tendon ol the latlei max become interposed 
between the neck and the acetabulum and interlere with 
reduction (dislocation below the tendon bigclow). 

The sciatic nerve, on account ol its close relation to the 
head, max be injured in dorsal luxations. It has twice been 
I'nund at autopsx completely torn across. It may be hooked 
up over the neck when attempting reduction, and this is 
part ic ularlx likelx to happen when com ci ting a dorsal into 
an anterioi position. Wide movements ol'circumduction are 
espcc iallx to be axoided. 

"Contractures ol the pel\ ic lemoral musc les soon take 
place in the untreated case. As time goes on a new capsule 
ol scat tissue hums around the head ol the leniiu fastening 
it seen rely to the side ol the pelxis. Within lour weeks’ time 
ligamentous shreds, lat. and new connective tissue (ill the 
acetabulum. I bis mass ol tissue adheres lirmlx to the car¬ 
tilage- so that, altet six weeks, sharp dissection is necessarx 
lor its remoxal. 

"Diagnosis. Interior Dislocation, \nterioi dislocation is 
c hai ac teri/ed In abduction and external rotation of the- leg, 
the knee being Hexed. II the head lies in the- thyroid lora 
men. the external rotation and excision ol the foot are less 
maiked. while the abduction is increased. II the head lies 
in the high 01 pubic position, there- is less abduction but 



more external rotation. In both cases there is moderate 
llexion ol the hip as well. It is impossible to extend or addnet 
the limh. 1 here is absence ol shortening, and in the thyroid 
position there is even slight lengthening. Inn it is difficult 
to make accurate comparative measurements, and they are, 
therefore, ol little value. In the high position the head can 
he I el t in Iront ol the pubis, but in the thyroid type it is 
difficult to locate. I lie greatei trochanter is absent Irom its 
usual position, being displaced inward, and a depression re¬ 
mains instead. Occasionally there is pain and numbness in 
the distribution ol the femoral nerve. 

“Posterior l)islo< at ion. Posterior dislocation, on the other 
hand, is c haiacteri/ed by adduc tion and internal rotation ol 
the thigh, combined w ith moderate flexion of the hip. W ith 
the patient recumbent, the knee is directed inward and lor 
ward, the loot is inverted, and the heel olten rests cm the 
dorsum ol the opposite loot. Flexion ol the hip is usually 
more marked when the head is in the low rather than in the 
high position. Passive movements are possible to a certain 
extent, but abduction and external rotation are prevented, 
while active movements are completely abolished. The head 
ol the lemur can be felt indistinctly in its posterior position 
through the gluteal muscles, while the trochanter lies an 
teriorly and above Xclatons line. There is shortening, whic h 
can be recognized when both knees are Hexed. Dislocation 
into the vic inity of the great sciatic notch (dislocation be 
low the tendon) presents the 1 same general features as dis 
location onto the dorsum ol the ilium, but the deformity is 
not so marked. In stout subjects it may be overlooked. 

Dislocation of the 1 hip presents such a typical clinical 
picture that there is practically no other condition with 
which it can be coni used. However, a roentgenogram should 
always be made, partly in order to verily the position, but 
c hicily lor the purpose ol demonstrating the presence or ah 
sci ic c of an associated fracture o! t he art ictilai surlaces." 

Dorsal dislocation is the type 1 usually encountered, and 



i ocnlgeiiogr.iph ic r\ ion Imp mil l\ icvcals lingments 
til bom' loin awa\ Irom the lint <>l llu 1 acetabulum l>\ the 
strong ligaments. or broken oil l>\ llie impact ol the < 1 is 
lot at mil; head. 

( a ( tsi i) ki in <: t io\ 

"Trail mail. I mined iale reduction is indicated in all cases 
and the earlici this is attempted the less the dilhcull\ ol ic 
placement. It must necessarih he postponed when the patient 
is m a state ol shoe k liom otiiei assoc iated injuries. 

"A general anesthetic is always necessary in ordei to se 
cure complete muscular relaxation. I he patient should he 
placed on loldeel blankets on the llooi in ordei to obtain a 
Inm support and to permit the surgeon to work above him 
in a position to perlorm the neressaix manipulation and 
nt ili/e his strength to the best aehantage. An assistant fixes 
the pehis with his hands in order that the lorce may be tip 
plied directh to the hip-joint. . . . 

"All methods begin with flexion ol the hip. This converts 
high into low dislocations, brings the head down to the ace 
tabulum, and relaxes the A ligament. The knee is likewise 
always flexed lot greatei ease in the control ol the manipula 
lion and the more efficient application ol traction. In this 
position the "A ligament is then put nuclei tension to pro\ ide 
a I tiler uni and h\ leverage and tract ion the head is replaced.” 

/bgc/cne's * Method, a. Inlaioi Dislocation. ' Flex the 
limb toward the perpendicular and abduct it a little to dis 
engage the head ol the bone, then lilt upward, rotate the 
shall strongb inward, adducting it, and then extending the 

In simpler terms, the leg should be Hexed and abducted, 
then while exciting 11 act ion in the axis ol the limb, c ire uni 
dlie t in ward, l hat is. move I he ki tee i11 a c i i c u lai direel ion in 
wai d and extend the leg. 

l)i”clou. Mechanism ol Dislocations and trac lures ol the 1 lip. liosion. 
little. It l on n, !(),)(). 



"h. Po.slci ioi 1 ) ocn I ion . \\ ill) the knee bent ;ni(l the lup 
Hexed adduct and internally rotate to disengage the head 
Irom behind the socket. If the hone can now he ahdncted 
heyond the perpendicular, the capsule and other tissues are 
prohahly so lorn or relaxed that reduction may he accoin 
plished without much dillieulty; the thigh need only he 
lore ibiy lilted or jerked toward the ceiling with a little 
simultaneous circumduction or rotation outward to direct 
the head ol the hone toward the socket.’ 

"The essential is to exert strong traction in the axis ol 
the thigh, while the hip is Hexed, adducted, and internally 
rotated. II reduction does not occur, circumduct outward 
while maintaining the traction; that is, abduct, externally 
rotate, and then extend.’’ 


I he patient is placed on the fracture table and traction 
applied to both legs to bring the head ol the lemur down to 
as near the level ol the acetabulum as possible. For anterior 
dislocations the Smith Petersen approach is used. For pos¬ 
terior dislocations I prefer the incision described by Miltner.* 
An inc ision is made from the postero-inferior spine ol the 
ilium to the base ol the greater trochanter, or on down to the 
insertion ol the gluteus maximus. The fibers ol the gluteus 
niaximtis muscle are split longitudinally, exposing the sec¬ 
ondary capsule which surrounds the head ol the femur and 
holds it to the pelvis. File secondary capsule is opened and 
by forceful internal rotation the head and neck ol the fennn 
are swung anteriorly and away Irom the acetabulum. In the 
ordinary dorsal dislocation the scarred obturator intertills, 
gemelli, and pyrilormis muscles are now exposed. These 
muscles may lie between the neck ol the lemur and the pel\ is 
and stretch across the upper and outer aspect ol the ace¬ 
tabulum. Myotomy ol these musc les is ttsualb necessary to 

* M ilincT. I . |.. .mil Wan, I - I . C > 1 1 1 n a n mal ic el isloe at ion ol the hip. .S'cci'g., 
Oyucc. ()l>sl., : 8.J, l‘)‘}3- 



<>j\i' lull ,K ( rss to ilu' sot kct ol the lii|> joint. \lter the ic 
moxal ol .ill ol the* sc .11 tissue' horn the ;u I'labulum, the head 
ol the' lemiii is replaced h\ eireiundiu I ion and traction. 

While iomplelc reduction l>\ open arlhrotomx is the goal 
sought in all eases ol old dislocation, the' surgeon may he' 
forced to acii'pl certain aiternalixe procedure's, sue It as the' 
"shelxing" operation, resection ol bone, arthrodesis, or, in 
exceptional instane'cs. lie 1 max he' content with simple' oste- 
otomx' to ee)rreet the delormilx. 

following reduction a plastet <>! Paris double spiea east is 
applieel lot lout weeks il no Iracturc ol the tint e>l the ace 
tabnlum was found at operation. 

()e e asionallx the entire superioi t int ol the acetabulum is 
carried upward l>x the head. When reduction is attempted, 
the fragment ol the rim max enter the acetabulum in ad¬ 
vance ol the head and thus tender reduction ol the disloca¬ 
tion impossible except bx ojirn oj)n at ion. 

\fter the tint is lifted Irom the acetabulum, the head ol 
the lenuu is easilx skidded into the caxity. Johnson * ol 
Nebraska Itxes the' I raiment in its proper position by ;i 
tempor.nx steel chill drixen through it and into the ilium. 
\n autogenous bone-peg is much more satisfactory and 
physiologically sound. In this type ol ease the double plaster- 
ol Pal is spiea cast remains on lor eight weeks. 

I he prognosis must be xerx guarded in these cases as 
changes in the' head ol the lemur ocean almost routinelx as 
a result ol disturbance ol the blood-supply plus the original 
trauma ot the pressure lories which follow dislocation. II a 
piece ol the lemoral head has been crushed or broken oil 
during the eh sloe at ion the late findings are I hose of roughen 
mg and partial disappearance ol the cart ilage—changes sim 
ulating adxanecd arlluitis. In the' very old ease's, the head 
may be flattened oi roughened because' ol weight bearing in 

|olins()ii. II I. t hone injuries about the bin joint. \//>g. C.'y nee. j(): i()2Q. 



;i deformed position ;in<l die aseptic necrosis which follows 
the disturbance ol Flood supply. 

I\\K.\ t vt tc I) i si .oo.vt i< >\ or tin 1111> 

\l I I I tons < )l I Kl A I MINI IN OKOHt < >1 fkl II R1 NCI 

1. Closed reduction; 

2. Keystone bone-grall operation: 

g. Shell operation: 

p Arthrodesis. 

The indications lor open operation in paralytic disloca¬ 
tions of the hip are: i. the inability to replace the head of 
the lemur, owing to contrac ture ol the soft parts, and 2. re¬ 
peated dislocation alter reduction, owing to laultv develop¬ 
ment ol joint structures (shallow acetabulum), or extreme 
relaNation ol the capsule. When thorough stretching ol the 
contrac ted structures and reduction of the dislocation by the 
closed method fails (see p. <)(>), I use an autogenous key¬ 
stone bone grab* to deepen the overhanging tint of the 
acetabulum, and reel the ballooned portion ol the joint 
c apsule, thus gaining a stable and satislactot\ joint without 
sacrificing any ol the joint elements. 

Keystone Bone Graf I in Treatment of Congenital and It 
(jnired (Paralytic) Dislocation of the /// f> (Alhee). Ml ev 
isting contractures having been overcome by forcible manip¬ 
ulation or open division, and the dislocation made easily re¬ 
ducible by long continued weight and pulley traction oi 
manipulation under general anesthesia, the- hip-joint is 
leached by a Smith Petersen approach or an inc ision is made 
from the anterior superior spine ol the* ilium to the great 
trochanter, then backward t to 2 inches in the direction ol 
the ischial tuberosity. The skin and subc utaneous structure’s 
are dissected bac k and the trochanter exposed. I he trochan 
lea l i]), with its attached muscles, is 1 timed upward, giving a 
free exposure ol the superior and posterior portions ol the 
* Alhee. I . It. Itonc-l>iall Scu^eo. I’hil.e. Saundeis. i()i-,. 



c apst11c ol l lu’ j< tiiil, l < I in wn 11 its at I ached poll ion < »l l lie 
stiperioi and posleriot acc‘l a I >i 1111 n l lim. I his portion ol the 
capsule is seen and I i'll to he lax il I lie head is in I he acclaim 
Inin, and il the head ol the lem in is disarl undated il distends 
die capsule h\ pressure Irom beneath and lurthei displace 
ment ol die head is resisted. I’pon man i pn lat ion ol die 
I t-iii in . the head is readih I eh as a rounded hard snrlace slip 
ping about beneath die capsule. 

I lie amount ol deltricnrx ol the acelabnlai rim. as well 
as the degree ol 1 a\il\ ol the capsule, can be very easily de¬ 
termined at ibis stage b\ direct palpation through the oxer 
King capsule and manipulation ol the limb. Aboxe the cap 
side attachment to the acetabnlai rim, the bone snrlace at 
the ilium is c I eared ol soli tissue, and with a thin osteotome 
the bone is ini iscd just aboxe the insertion ol the capsule in 
a setnii ire ulai line in this posterior superior anterior stir- 
lace, to conlorm to the natural curxature ol the superior i im 
ol the acetabulum. I'liis semicircular bone inc ision produces 
a strip <>l the upper curved bone margin ol the acetabulum 
with its attached and undisturbed capsular segment. This 
curved acetabular bone segment is pried outward and down 
ward with the osteotome to deepen the acetabulum sullr 
i ientlx to oHei an obstrui tion to displacement ol the femoral 
head, i.r., it is made to oxerhang and more securelv grasp 
the head ol the leinni (Fig. r,t). I he downward and outward 
prxing produces still more laxity and wrinkling ol the cap 
sular ligament. 1 he slack is taken tip bx reeling the capsule 
with a row ol mattress sutures ol kangaroo tendon placed at 
light angles to the long axis ol the neck ol the lemur. I lie 
stitches are so placed as to make the reel ol the capsule lie 
ecpiidistant Irom the two ends ol the capsulai bone inscr 
tions. Ibis reeling avoids entering the joint, takes up the 
slack ol the capsule, and at the same time helps hold the 
new lormed acetabular rim in position. 

I o fill in the' bone gap produced bx the prxing downward 
and outward ol the- mixed bone rim segment, and lurlbei 



t<> secure' the permanent fixation <>l the new-formed ace 
tabular rim, a segment ol hone having a triangular or key¬ 
stone c ross set lion is obtained locally from the crest of the 

ilium or Irom the crest ol the tibia, long enough (when cut 
into three or more portions) to lill in this gutter. 

I he keystone type ol grab is sell retaining, and is held in 
place automatic a 11 \ and needs no pegs <>i sutures. 

I he limb is placed in an abducted position and fixed by 
a long double plaster <>1 Pat is spit a reaching Irom the thorax 
to the toes on the operated side' and to just below the knee 
on the other side. Phis spiea is 1 elt on lot six weeks, alien 
which passive and active exercises are instituted, togethei 
with massage and guarded lunctional use ol the limb. 



Shelf O/ienilion (. llhee). I lit' keystone Lpalt operation is 
prelerable to the shell opei at ion. except lot those cases in 
which it is unwise to brinu, the head ol the lemui down to 
the level ol the at el a I hi I inn (see | >. ilmi lot tec Ini it | tie). 

Com l>lcle Ihmilxsis ol llifi Muscles. I rlInodesis. II ^eneial 
paralysis ol the muscles controlling the hip demands it. an 
arthrodesis ma\ he ti ustwoi duly done in cases oxer ei^lit 
tears ol a^e h\ proxidin^ lart>e malts Irom the outer table ol 
ilium 01 elsewhere, and t>enerouslx contacting them to both 
lemui and pelxis on each side' ol the' joint (sec 1 Chap. VI, 
I uberc tilotis Disease ol the Nip Joint, p. 17b). 

Chapter VI 


1 )i’li ii 1 1 Km. I u herc ti Ions disease <>l the I) ip-joint is a cl iron i( 
desti in live process c aused hy Ii. tuberculosis whic h results 
in various decrees ol loss ol function and delonnity. 

1' I 101.0(0 

Relative F)etjueuey. As regards tuberculosis, the hip is the 
most iniporlant ol all the monarticular joints. As to fre¬ 
quency ol involvement, it is second only to the vertebrae. 
In a series ol over 7000 cases ol tuberculous disease ol the 
skeleton, W hitman lound that over |o per cent were Potts 
disease, while more than 28 per cent were hip disease—the re¬ 
maining ^2 per cent including all the other joints. 

Age. Whitman's data also indicate the preponderance ol 
hip disease in the first decade, 88.1 per cent: ol this 88.1 pel 
cent, ly.b per cent were in the age period ol Irom three to 
si\ years. 

Sex. Probably on account ol their greater activity and 
therefore more frequent traumatism, boys are more often 
affected than girls (55: jp. 

Side Affected. The right side appears to be more Ire 
quentlv involved than the left (53 percent right to 17 per 
cent left). 

P \ 1 iioi.oov \\n Morkii) An \ tosn 

As to the primary inlection (osseous or svnovial), there 
is a divergence ol opinion, but from a practical standpoint 
the matter is unimportant. In a well-developed case ol tuber 



( uloiis hip disease. llu' |11 i(>1 (>l* i< .il appe.names .nr ;is I<>I 
l< iu s: 

lluiri in caning amount, and tisualh semipiu ulenl oi 
purulent and containing more oi less debris. occupies the 
joint ravitv. flic .synovial mem Inane is thickened. irregular, 
ol ota\ edematous appealalter, and ulcerated in places. I he 
articular ((nlila^e is usually rilltei librous. wasted and pitted 
in character. or is undergoing necrosis, dull yellow, and he 
i <>i11ino detached in Hakes. I he hones are. as a rule. hare, ol 
worm-eaten appearance, or present definite rarities and sr 
(|nest t a. 

I he contoin ol the head and neck ol the lemin ma\ he 
•_;i cat 1 \ tillered. Ihe head ma\ he conipleteh detached and 
lound loose in the joint rarity. having hern separated at its 
epiphvseal attac liinent. I lie neck, hr absorption. nia\ be 
shortened or h\ alteration ol its angle converted into a condi¬ 
tion ol < o\a vara. A "w andering acetabulum” is Irequenth 
lound. and is the result ol pressure by the lemoral head on a 
diseased ;u etahulum, extending its rarity upward and hack 

I he capsulai ligament is soil and relaxed, and the round 
ligament eroded. Ichor trom the joint olten traverses the 
periarlirulai tissues, pointing ;ts an ichor pocket in Scarpa’s 
triangle oi in the neighborhood ol the great trochanter, oi 
perforating the base ol the acetabulum and appearing as a 
pelvic ichor pocket. 

Re/jan by Xahnal Rroees.s. II leit to nature, the tuber 
c uloiis process undergoes healing b\ absorption (rarely, b\ 
calcification) and connective tissue encapsulation; or, il sec 
ondarib inlected, by suppurat ive separat ion ol diseased bone 
and e\ac nation or discharge ol sequestra, accompanied b\ 
distoition ol the joint or delcniliitx ol the 1 limb: this is 
e\ en t u a 11 \ sue < eedcal b\ ankclosis. usualb < > I the librous type, 
oi bv disloc at ion. 



S’! mi'toms and Physical Signs 


I lie disease is insidious in its onset. Pain and limp are the 
important symptoms, though several other subjective phe¬ 
nomena are encountered. 

Stiff //c.v.v. Stillness ol the joint in the morning is an early 
symptom and is possibly due to diminution in the amount ol 
synovial fluid. 

Lameness. Limp is also an early symptom and. in the be¬ 
ginning ol the disease, is due to voluntary effort to avoid 
pain from ueight-bearing by the diseased limb. The patient 
Ilexes the knee, tilts the pelvis downward, and steps with the 
loot exerted. Lameness in the later stages ol the disease, how- 
exer, is due largely to structural changes within the joint and 
the consequent alterations in the relative positions of the 
bones ol the limb to the trunk. 

Pain. This usually follows the nerve distribution, down 
the front ol the thigh or at the inner side of the knee-joint. 
In more adxanced cases, it max be localized in the joint, and 
is then due to pressure ol adjacent bony surlaces or to in¬ 
creased tension on ligaments and muse les. 

Protective Attitudes. To diminish movement at the hip- 
joint and consequently to prevent pain, the patient learns 
to assume x arious post tires—such as supporting the loot ol 
the affected side bx the toes of the sound limb and actually 
producing extension on the affected leg bx pressure of the 
normal limb. 

Night (dies. These are due to sudden relaxation ol muse it 
lai immobilization lrom the eflect ol sleep and max signify 
ulceration ol the attic ulai cartilages. 

Constitutional Disturbances. General debility is the title 
from the onset. Malaise, irritability, restlessness, loss of ap¬ 
petite. I ass it tide and dec tease in weight are noted. An evening 
rise in temperature tisuallx increases with ichor formation. 


II sinus formation and mixed inlection ensue cachexia and 
aim loid disease nia\ appear. 

fin SICAI sk.xs 

I lie patient should he allowed to walk helote removing 
the clothes, and both gait and attitude studied. I he subject 
should then be stripped and the exam it lal ion cot id tic led in a 
systematic and orderlv fashion, beginning with observations 
as to general appearance and then proceeding to palpation 
ol the' joint, manipulation ol the legs to determine motion, 
measin enients. investigation lot ichor lot anal ion, and radio” 

General t nsjieelion. I lie c hild may appeal well-developed, 
robust and w el I nourished: but is usually underweight and 
has a prematurely aged, anxious expression ol countenance. 

Dishn lions of the Limb. In addition to the protective atti 
tilde ol the- limb noted nuclei symptoms, other alterations ol 
position are noteworthy, and on a basis ol these abnormal 
positions hip disease has been divided into three different 

First stage: Pure flexion, or llexion with slight abduction, 
ntav indicate a pure synovial lesion or disease ol the bone 
not as vet in communication with the joint. The distortion 
is a voluntarv ellort to minimize the shock and jai upon 
the diseased limb. 

Second stage: flexion, abduction and eversion, and. on 
attempted correction, lordosis ol the lumbar spine and ap¬ 
parent lengthening ol the limb the latter due to downward 
tilling ol the pelvis to bring die abducted leg parallel with 
its lellow. I he cause ol this attitude is probably a voluntarv 
attempt to relieve pain. 

I bird slage: l lexion, adduc tion and inversion, with ap 
parent 01 real shortening. Phis c hange of position is due to 
the overpowering ol the abduc lot In the adcliic lot musc les, 
apparent shortening is produced In the necessitv ol uptilt 
ing the pc-lvis to approximate 01 parallel the adducted limb 



lo iis Icllou. Real shortening, however, may occui as ihe re 
Mill <>I ahsoi pi ion ol ilie head ol the icnuir. “wandering'’ ol 
the acetabulum, atrophy <>l the hone, inlcrlerenre with 
metabolism and growth, coxa \ara or pathological disloca¬ 
tion ol tlu' femoral head. 

I.imj). Lameness becomes progressively worse. I he child 
tends to drag the leg, and the rhythm ol the gait changes— 
a long step alternating with a short one. The toe is held 
pointed in and the patient steps upon the anterior part ol 
the loot. In addition, late in the disease, the hip and knee- 
joints are Hexed and there is lumbai lordosis. 

I / / <’) til ion in Conlom of Ihe Region of the ll/je Wasting 
ol the affected limb, especially in the gluteal region, is prob¬ 
ably largely due to disuse. The normal fold in the groin dis¬ 
appears with abduction and external rotation ol the leg and 
increases in depth with adduction and internal rotation. I he 
position ol the gluteal fold is lowered; and its depth dimin¬ 
ishes with the leg Hexed, abducted, and rotated outward; it 
becomes elevated and diminished in depth on flexion, ad¬ 
duction, and internal rotation. Adduc tion ol the thigh makes 
the trochanter more prominent; on abduction, it is less. A 
cold abscess is usually indicated by a fullness around the 
joint outline. Enlargement ol the iliopsoas bursa may be 
indicated l>\ a bulging ol the groin. The inguinal lvmph 
nodes may be lound enlarged. 

Ra\fmlion of the Joint and Xeigli hot i ng Sh net arcs. Much 
information may be gained by card til palpation, f irm pres 
sure with the lingers behind the great irochantei will olten 
disclose an effusion into the capsule and will elicit tender 
ness. The sin rounding soft tissue should be examined lot 
inflammatory exudate and abscess. Digital exploration ol the 
rectum is highly important, often revealing an intrapelvic 
exudate. I he trochanters should be compared in si/e: in 
crease is often an early accompaniment ol hip disease. (Ate 
lul measurements ol Bryant's triangle will demonstrate the 
condition ol the femoral head and neck—decrease indicating 


ele\ at ion <>l the* trochanter horn disease <>l these suite lines 
01 o| the acetabulum. I lie iliac lossae should he investigated 
loi the presence ol abscess (ichor). I he ”10111 is oileil Idled 
u ult enlai i>ecl l\ mpltal k glands. 

Mu^ ultn S '/himii. I his is a |m>\ ision ol nature lor allevi 
at ino' pain h\ innnohili/at ion ol the allected region, and is 
partl\ relle\ in character. and partly \ ol iinlai \. \ 11 decrees 
ol spasm are encountered. from tonic contraction appreciable 
onl\ oil the extuane ol movement, to rigidity so »»1 eat as to 
surest ankylosis. 

To detect muscular spasm. Ilex the sound lhi>>h, when any 
exist ill)*’ lordosis will beat once reduced and persistent flexion 
ol the suspec ted hip revealed i I lionets' test); also, abduction 
ol the sound limb will be accompanied by adduction ol the 
allec ted one, and vice versa. 

Joint M(n>emenls. The normal movements ol the hip-joint 
are flexion, extension, abduction, adduction, rotation, and 
c itc unichic t ion. The ratine of the first live movements should 
be carelullv jjaut’ed. but, in view ol the pain usually caused, 
manipulation ol the sound limb should Inst be performed 
to ”ain the patient's confidence. 

flexion, abduction, and adduction are investigated in the 
dorsal position. I he left hand steadies the pelvis (the finders 
behind, on sacrum and ilium: the thumb in front, on the 
.inlet lot supcrioi iliac spine), while the Hexed knee is seized 
bv the othet hand and the limb is put through the desired 
mm ements. 

Rotation and h\pet e xtension are performed with the 
patient prone. W ith the open lelt hand on the sacrum. the 
linnets can palpate one trochanter, tlu‘ thumb the- other, 
while rotation o practised b\ "raspin'* 1 the loot. Lot hypet 
extension. Itx the pehis with the left hand. 141 osj» the ankle 
with the ri”ht, and lilt the limb. In a normal condition ol 
the joint. h\pet extension is possible to about ‘>0 decrees. 

Measurements. I licsc inc hide the amounts of real and up- 
patent let i”t hen i it”. teal and apparent shortening: the decree 


ol llexion, abduc l ion, and adduction; and the circumference 
ol the lind). 

Real lenglliening is extremely rare and ol no practical im¬ 
portance. .l/jjjtiK'nl lengthening is due to abduction ol the 
limb and downward tilting ol the pelvis. It is the difference 
between the lines Irom umbilicus to internal malleolus on 
the two limbs. 

Real shortening is estimated by the comparative measure¬ 
ment Irom the anterior superior iliac spine to the internal 
malleolus ol both sides. Afifiarent shortening , due to adduc¬ 
tion ol the lemur and upward tilting ol the pelvis on the 
affected side, is measured by lines Irom the umbilicus to the 
internal malleolus. 

Degree of Flexion. With the patient Hat on his bac k upon 
.c table, raise the extended limb by the toes until lordosis is 
overcome and the lumbar vertebrae touch the table. Have 
the leg held in this position by an assistant. The degrees of 
llexion can then be estimated. 

Estimation of Abduction and Adduction. With the patient 
in the dorsal position, legs parallel, obtain three sets ol 
measurements for the two legs: (a) Irom anterior superior 
spine to internal malleolus; (b) from umbilicus to internal 
malleolus; (e) between the anterior superior spines. If the 
apparent shortening exceeds the measured shortening, the 
affected limb is adducted; i! it is less, the position is one 
of abduct ion. 

Circumference. Atrophy ol the hip. thigh, and leg is an 
early feature. The muscles are not soli and flabby, but tense 
and Inin. A tape measure should be passed around cone 
sponding planes in thigh and leg, and the measurement com 
pared In the lwo 1 hubs. 

Ichor Rocket (Abscess Formation). Ichor is usuallv pri¬ 
marily lot tiled within the joint, but it may be extra-articular. 
In escaping, the route is the weakest portion ol the capsule 
(its posterioi inferior segment). The location ol an ichor 
pocket is no indication ol its point ol origin. IIle usual di 


lections .mcl ultimate lot at ions ol iehoi pocket lormations 
in hi|> disease’ are as lollows: 

i. Outward- mulct attachment ol rectus Ictnoris muscle. 

12. Inward. 

>>. Backward- Pillowing internal cite mnllcx artery. 

|. Upward along sheath ol psoas nurse Ic. 

r,. Inward- through Hoot ol acetabulum. 

(i. Downward—In gravity. 

Roentgenoarajjlix. Considerable inlot mat ion may be 
gained Irom an \ rax plate as to the state ol the joint space, 
sMtovial membrane, bones, and soli parts. Appearances sug¬ 
gest i\e ol tuberculous disease are as lollows: 

Joint C.avilx. Increased distance between the lemoral head 
and the acetabulum and displacement ol the head Irotn the 
pehis olten indicate the presence ol II it id within the joint. 
Ilony debris max be apparent. 

Sxnovial Mem Inane. Thickening ol the points ol reflec¬ 
tion and localized patches. 

Bones. Separation ol the epiphysis at the lemoral head. 
Alteration ol the angle at the neck and the shall ol the lemur. 
Pathological dislocation ol the head ol the lemur. 

A cloudy, indistinct bony outline. A pitted, worm-eaten 
appearance at the bee edge ol the cartilage on the lemoral 
head. An eroded, irregular head with areas of disease in the 
bone. Irregular acetabular outlines, and occasionally a per- 
loration at the base ol the acetabulum. 

S oft Bails. An ichor pocket max sometimes be detected by 
a c leat area resistant to the v-ravs. 

I he \-rax studx is ol the greatest serx'ice in all but thexery 
earliest stages ol the disease, not only in arrixing at the’ diag¬ 
nosis but in guiding the surgeon in the selection ol Ins treat 
mein and its management throughout the’ whole course ol 
the - disease: as long as the bonx elements ol the joint remain 
markedlx Iragile and porous oi rarelied. the joint should be 
protected not onlx Irom the crushing and deslruciixe itillu 


('linns ol niolion but also Irom weight bearing and muscle 
pul I. 

^ carelul \ i a\ st 11(I\ will aid in determining when the 

l i<.. w’. Old tuberculous )i i|>. mikylosed in marked llexion and adduction. 

density ol the osseous elements ol the joint is restored sufli 
eiently to allow weight-bearing; when the Phelps brace may 
be changed to a long or a short spina; the long spina changed 
to a short one, without crutches; or fixation treatment ma\ be 
eni irelv dispensed wit It. 

I )l AC.XC >s t s 

\H.S()1 III 1)1 \(.\(>sls 

I'he following history and physical signs are practically 
pathognomonic ol tuberculous hip disease: 

History, (ilnonu il\ ol the allet lion and its restriction to 
one joint (monarticular); intermittent but progressive in 
( tease ol signs and sy mploms. 


llliludr. (i) I at l\ in the - disease, llcxion. abduction and 
c\ ersit >11 ol iht’ liml): (2) laic in die disease, lle\ion, addin 
lion and inversion. 

I i<.. s, 1 iiic* (list .0 I-inure -, 2 . \dduclion lies ion delormiu overcome I >\ 

circular osteoloim. 

(’fill . I rreo nlarit \, a lone, si e| > alien ia I ill” with a si 1011 one. 
1 le\ion ai all joints ol the aliened liml), with llcxion ol the 
t (>es. 

I<nnl Oiillini'. Wasting ol the limb, particularly the but¬ 
tocks. with alienation in the normal lolds in buttocks and 

1 .1 in 1111Imu (>1 Molion ami Muscle Sj>asm. The most \ahi 
able ol all phvsiral sions. The most important restriction ol 
molion is that ol rotation and h vperexlcnsion (patient on 



Drfonnil y. Distortion ol the allotted litttl) by abduction, 
adduction, external, and internal rotation. 

,\ ray. I lazy, bony outlines; increased distance between 
bead ol lemur and pelvis. Thickened synovial membrane. 
Separation ol epiphysis. Coxa vara. Dislocation. Worm-eaten, 
eroded bone and cartilage. Wandering acetabulum in very 
destructive cases. Clear space indicating ichor pocket forma- 
t ion. 


There are many pathological conditions more or less inti¬ 
mately connected with the hip-joint which may be mistaken 
lor tuberculous disease, l ot brevity and clearness, these will 
be indicated with their points ol resemblance and of differ¬ 
ence in the following tabulation: 


1. Local irritation 
(vaginitis, etc.) 

2. \cule adenitis 

3. I,ocal injury(con¬ 
gestion of epiph¬ 
ysis; ellusion into 

.]. Anterior polio- 
inyelit is 

r y Ac ute ai tin it is 
and epiphysitis 
( p n e 11 in on i a , 
diphtheria, ty¬ 
phoid, exanthe¬ 
mata, gonorrhea) 

Du 11 ai. Diagnosis 

Pain Is of 

Flexion thigh: 


on movement 

Flexion thigh 

I.imp, pain, discom- 
1 or t 

Focal pain in 


in region ol 


Flexion thigh; 





Points of Difference 

Cause apparent on in¬ 
spection. No involun¬ 
tary muscle spasm 
No muscle spasm. In¬ 
guinal glands oh- 
x ions. X-ray 
l emporarv. X-rav 

Paralysis. The usual 
diminution or ab¬ 
sence ol reflexes. 

Sudden onset, high le¬ 
xer, sex ere constitu¬ 
tional disturbance, lo¬ 
cal heat and swelling. 
Polvarticular. Gonor¬ 
rheal urethritis. 11 ol 


I)11 i i ki n 11 \i Diagnosis (com .) 


Points n\ 

ti. Rheumatism 

l umbar Pott’s 

8. Knee-joint dis¬ 

(j. Coxa vara 

to. Hysterical joint 

i i. Periarticular dis¬ 

i 2. Perinephritis and 
appendic itis 

13- “Crowing pains” 

i I. S< urv \ 

i y. Xtthiilis deform¬ 
ans of hip 

In (hildren. occasion- 
a 11 \ a single large 

I imp. Restrict ion of 
movement in one 

11 ip disease often ac¬ 
companied by pain 
in the' knee 

Distortion neck of 
femur. Shortening. 
I imp 

Joint sensitiveness. 
Lameness. Pain 

Symptoms resemble 
those ol tubercu¬ 
lous hip 

Psoas contraction 

Night c lies. Local 

Pain on motion 

Occasionally monar- 
t i( ular 

Points of I)iHerein e 

short duration, mus¬ 
cular atrophy not so 

Sudden. Migratory. Le¬ 
ver. Salicylates relieve 

Rigidity in lumbar 
spine. Only move¬ 
ment limited is ex 
tension. Distribution 
ol superfic ini pain. 

Local signs 

Movements free except 
abduction and rota¬ 

Usually later life-period. 
Variable. Inconsist¬ 
ent. A-ray 

No muscle rigidity or 
limitation ol rotation. 

11 istoi \. I .imitation of 
mo\ ement resit ic ted 
to extension. X-rav 

Muscle strain. Not pro¬ 
gressive. No restric¬ 
tion ol motion, etc. 

Crucial symptoms. En¬ 
largement shaft of 
long bone. Knee 
lather than hip. \rti- 
fit ia 1 leeding. X-rn\ 

Adult life. Other evi¬ 
dence ol a general 
disease. Pain only 



Dim KRi' \ 11 ai. Diagnosis (con i.) 


if). Atrophic poly¬ 

17. Sacroiliac disease 

18. Pelvic disease 

ip. Disease ol the 
bursae about the 

;*o. Fracture ol the 
neck of the le¬ 
mur in (hildhood 
(traumatic coxa 
\ at a) 

21. Epiphyseal Irac- 
l tire 

22. Congenital dislo¬ 
cation of the hip 

Points of 

Childhood. Severe 

pain. Muscle 

spasm. Distortion 
of limb 

Limp. Localized pain. 

Discomfort. lamp 

Local swelling and 
sensit i\ eness. 1 .imp. 
Certain limitations 
of motion 

I .imp and discomfort 
with some muscle 

Limp. Pain. Restrict¬ 
ed movement 

I imp 

Points of Difference 

when using limb. 

Successive involvement 
ol other joints. A'-rav 

No must le spasm at hip. 
Symptoms and atti¬ 
tude ol sciatica. Pain 
on lateral pressure of 
pelvis: motion free at 
hip-joint. X-ray 
Cause explained by ap¬ 
pearance of abscess. 
Muscle spasm, except 
possible il iliopsoas 
abscess. X-ra\ 

No muscle spasm. Ilio¬ 
psoas bursitis; swell¬ 
ing in Scarpa's tri¬ 
angle; gluteal bursitis; 
local swelling in but¬ 
tock. X-ray 

1 fistorv of the accident 
with immediate dis- 
abilitv and shot tell¬ 
ing. and elevation of 
1 nx hauler. X-ra\ 
Adolescence. Limb ad¬ 
ducted, foot rotated 
outward. 1 . to '., 
inch shortening. In¬ 
jury. 1 1 sc* of limb. 
Motions ol abduction 
and rotation restrict¬ 
ed: other motions 

usuallx free. X-ray 
1 imp congenital. No 
symptoms ol disease, 
no muse le spasm 


I * K < >C.\C >SIS 

I iuk IioikiI. In exceptional c ases lull lunctional recoxcry 
from tuberculous disease ma\ lake place. I here is, however, 
usuallx more 01 less restriction ol moiion which in severe 
cases amounts to complete ankvlosis. I he lunc tional result 
depends on a number ol lactors, t 1 /;.: 

11) I he pathologx ol the joint when treatment was insi 1 
t tiled: 

(2) Nature ol the treatment employed; 

15) The se\etu\ ol the* tuberculous process; 

( I) Indix idual resistance; 

(5) Length ol the treatment. I bis should occupy a period 
ol no less than two years to effect a cane. It should be con¬ 
tinued until the patient can beat lull weight on the nflec ted 
region without pain or muscle spasm, and should be main¬ 
tained long alter all aclixe svmptoms haxe ceased. 

l.ijc. Under good treatment, the mortality is not high. In 
most instances it is dependent upon abscess formation. In 
non suppural i\e cases the death-rate is less than half that of 
suppurative cases. In the United States the axerage mortalitx 
is probably to to 1 <S pet cent. 

The cltiel immediate causes ol death are the following, 
but it should be borne in mind that about 75 per cent of 


are directly or indirectly due to secondary 

infect ion 

( 1 ) 

M diary t ttberc ttlosis. 


I ubei < ulotts men ingit is. 

( 3 ) 

Pulmonary tuberculosis. 

Amyloid disease. 


Exhaust ion. 


Inlet c m t ent affect ions. 

Lri a i m i n i 

C.l \ 1 ■ K \l tut XI MI'M 


in all c ases ol tuberc ttlosis, wherever locatec 

1. the im 

portanc e ol sunshine, I resit air. hygienic surroundings, nom 
ishing lood. etc ., c annot be ox crest imated. 




('icn(’) a I C.ousidcruhotis. Advanced tuberculous disease oT 
the hip is treated in an entirely dilTerent manner in children 
and in adults, From a general standpoint, the therapeutic 
key-note in the treatment ol tuberculosis ol the bones and 
joints with children is conservatism: with adults, operation. 
With children, however, the striking exception is in tuberc u¬ 
losis of the vertebrae, which should have operative treatment. 
A tuberculous bone lesion which has been shown by the 
v ravs to be definitely localized, should, however, be exc ised 
providing that it is surgically accessible, whether the patient 
be an adult or a child. 

Much discussion has taken place relative to the proper 
attitude ol the surgeon toward operative interference with a 
tuberculous hip. Between the school of conservative absti¬ 
nence from all operative interference and the school of radi¬ 
cals who advocate early surgical intervention, a middle 
course is desirable. Conservative measures should be given 
a thorough trial in every case in young children and be sup¬ 
plemented by surgery when indicated. In older children, 
adolescents and adults, the pendulum in later years has 
swung rightly toward operative intervention whenever bone 
destruction of any degree is shown by v-ray. The type of 
operation must be selected to meet the exigencies ol the 
particular case at hand. 

The .v-ray is the guide par excellence to treatment. II the 
structures iu the hip-joint do not show marked rarelac t ion. 
and the symptoms are correspondingly mild, the short plaster 
spica should be employed and atrophy thereby avoided. II. 
on the other hand, atrophy ol the femoral head in a child 
(osteoporosis) is already marked and there is dangei ol crush¬ 
ing, the hip should be protected Irom muscle spasm and 
weight-bearing by a suitable traction brace (Phelps' pre¬ 
ferred), 01 by a long plaster spica Irom toe to costal border, 
with crutches; or, in the severest cases, by the recumbent 


position in bed with traction in line oi dclormitv. applied 
l>\ means ol pnl!e\ and weight. in order to ptoc tire the Best 
possible fixation. 

In the ease ol a child with a nioderateh sexere process, a 
short plaster spica should he employed and the' patient 
allowed to >>ct about on c rule lies, latei beiii” allowed to 
walk. Supporting treatment should be bc^ini fai lx: lott ed 
I ced ini;. rest periods (Ivin” down), heliotherapy, and tuber 
c id in. 

In a more advanced case, the patient should be kept in bed 
with traction and weight applied (the ai>e ol the child in 
pounds, pins one) in the line of the defo) inilx , until quies 
cence is established (absence ol pain or extreme sensitive¬ 
ness. nii>ht cries, etc.), when a brace (Phelps') or a loti” plastei 
spit a she mid be appl ied and the pal lent permit ted to ”() about 
with c i inches. 

Ill thesexerest c ases ol t ubcrc ulous osteil is ol the hip the 
desideratum is bom ankvlosis and in the severest cases a short 
plastei spica extending to the knee is applied, and earl) 
walking permitted. I he rarefied femoral head thus under¬ 
goes mechanical crushing, lollowed by linn ankylosis. The 
autlioi attains the same results in adults bx surgical inter 
vention (arthrodesis), bx two plaits mortised together be¬ 
tween the <>reat trochanter and the peh'is, to be described 
more lully later. In c hildren, however, he believes that in the 
mild cases the prognosis should be more optimistic , and that 
the treatment should be planned to abort ankylosis b\ pie 
\ cut 11114 c 1 ush ill” ol the joint sm laces and the- fragile osseous 
elements ol the joint b\ the influences ol weight bearing, 
muscle spasm, and motion during the acute static < * I the dis 
ease. 1 herelore. the wisdom ol traction and pullev, with 
patient in bed. crutches, brace, etc., desciibed herein. 

(.eneralh speakiti”. unless arthrodesis or other permanent 
method ol fixation is emploved. one should maintain a con 
servative attitude toward discarding braces and othei appa 



rains, because <>l the treacherous nature ol osseous tubercu- 

I he local treatment will he considered in the older ol its 
natural sequence, Irom the management ol the most acute 
symptoms through the stage ol recumbency; the ambulatory 
treatment: convalescent treatment; treatment ol deformities 
and complications; and the operative treatment. 

/'lie Acute Stage. When a patient is first seen, with pain, 
spasm, and flexion ol the hip, he should be put to bed on a 
lit in mattress and his discomfort and musc le spasm relieved 
by traction. This is best done by weight and pit I lev. The 
child's bod) should be secured by some means; a Bradford 
Ivame or sand-bags are effective. Apply adhesive strapping to 
the affected leg (long lateral strips, reinforced by circulai 
ones), and to their free ends fix a wooden stirrup to which 
a weight is attached by means ol rope and pulley. The 
amount ol weight should ecpial (in pounds) the age ol the 
c hild, plus one. More perfect extension can be secured by 
elevating the foot of the bed. II relief is not rapid, lateral trac¬ 
tion may be applied In passing a sling about the upper end ol 
the femur, attaching a weight to its free end, and allowing 
the latter to hang over the edge of the bed. The pel\ is should 
be fixed by a similar sling and weight acting in the opposite 
direction, li mav be necessarx to increase or diminish the 
weight ol extension to secure perfect rebel. Remember that 
trac tion should be made in line with the deformity. whatevei 
it may be, relying on alteration ol the line ol traction at a 
later date to overcome the malposition. At the end ol some 
weeks, pain and musc le spasm will have disappeared, allow¬ 
ing removal ol extension and fixation ol the hi]) in the re¬ 
cumbent posture. 

lienunbent Treatmenl . The following methods may be 

(i) Long Llaslei -of-Rai is Sjiica. Extending Irom the costal 
border to the ankle 01 toes. The limb is put up in slight ah 
due t ion, wit It Ilex ion at t he h ip and slight I lex ion at the knee. 


Traction can he supplemented l>\ placing moleskin snaps 
with tlun lower ends coming out through the plaster just 
above the ankle. 

(2) I'll oma.s IIIl> S blnil. I his consists ol a main brace ol malleable iron. , inch wide and -;iinch thic k, extend 
ing liotn the lower tingle ol the scapula to the middle ol the 
call'. The lumbar portion is straight, but that portion met 
the buttoc ks and illicit is molded to t licit respective shapes. 
To this upright ate' attached chest, thigh, and let; bands, 
eac h bridged oser with straps and buc kles. I he Iratite is 
wound with thin boilet fell and cosered with leather. A 
‘‘nurse" (Mat iron bar) is attached to and projects Irom the 
lower extremits ol the upright to prevent attempts at walk 

Complete recumbent fixation is necessary until all pain 
and muscle spasm are absent and no tendency to deformits 
exists. To lest the result ol treatment, have the patient get 
about in an ambulators splint lot about three days. II the 
acute svmptoms do not return, ambulatory treatment is to 
be continued: il the\ do return the recumbent treatment is to 
be resumed and continued until the joint can be controlled 
I>\ ambulatory methods. 

I in bnlahn \ L real incnl. The autlioi prefers the Plicl/rs' 
hat lion s/jlnil with crutches alter subsidence ol sesere pain, 
muscle spasm, etc., until walking with a short spic a or a con 
sale-scent brace without crutches is allowed. The change 
Irom tec unibencs to walking should be made gradually, with 
Irecjitent rest periods. 

Plash') S jihnl and /Is M odifitnltons: i. Lono Plaster Sjnca 
with lli&li Pool and Li niches. The limb is enc ased in a 
plastet spica Irom pe ls is to toes, a patten is worn on the loot 
ol the sound limb, and the patient allowed to use crutches. 

2. Short Pla.sln S/nia (Lorenz). With the limb sligluls 
Hexed and abduc ted, a shoi t plaster spic a is applied extend 
ing to a point at ot just below the knee: the pels ic portion 
is a ppl ted lat era 11 s below t he i 1 lac c rest s, an let iorl s a I ios e I he 



symphysis, and posteriorly above the cenlet ol the sacrum. 
A hiy*h shoe worn on the opposite loot, and the use of 
crutches are advised. Weight beat ing by the affected limb is 
ad\ ised. 

Phelps' Traction 11 / p Splint. Ibis splint alfords both 
vertical and lateral traction. It extends from the axilla or 
lower thoracic region to a point beyond the loot, is supplied 
with an adjustable loot piece and traction straps, and two 
bod\ bands (thoracic and pelvic) completed by straps and 
buckles. I'o the pelvic band and the upright opposite the 
hip joint, a Thomas ting is obliepieh attached. Semicircailai 
bands clasp the regions ol knee and ankle. A special feature 
is a Hat leather pad at the upper third ol the thigh, fastened 
to the upright by cords to produce lateral traction. Vertical 
extension is sec tired by trac tion straps below. 

Bradford /lip Splint. This splint is designed particu¬ 
larly lot overcoming musc le spasm and securing abduction. 
Two lateral steel tods, longer than the limb, are connected 
below bv a Hat steel bar with windlass and above b\ a ring 
open in front. The special feature ol the splint is a steel rod 
welded to the ring on the side ol the healthy limb and so 
molded that it passes above the svmphysis pubis and under 
the perineum, the latter portion being made sullicienth long 
to avoid pressure on the buttock with the patient seated, 
kite ire ling straps hold the splint against the limb. A high 
sole is worn on the normal side. 

cow ,\t t sc t \ t i to \ t mi x t 

The epiestion ol allowing the patient to begin to walk 
gradually with the- following aids, may be considered when, 
alter a long period, there are no active svmptoms and no 
musc le- spasm. These points may be- ascertained b\ nightlx 
removal ol the apparatus lot a month ot more, thus allow 
itig voluntary motion at the joint without weight bearing. II 
the- hip is judged to be- in a satisfactory condition lot modi 


lnil weight healing, one <>l the- lollow int; splints should be 
it ic'd: 

( mivnlfM rill l\i\> S/illill (Plimpton). I lie Plimpton eon 
n.iIc'm cii t splint is a Phelps' splint minus l he ttppei hand, with 
.1 li'^lit innci hat added. I Ins apparatus exerts a lorm ol 
traction, hut with the heel oil the ground, the patient step 
pint; on the toes. I lie lower end is (tit ;> inches Irotn the 
Diomid and a piece 1 welded to its inner part, extendin'; 2 
iik lies helow the sole ol the hoot and terminatin'; in a hull) 
oils tip ■, inch m diameter. I lie upii^ht extends Iron) the 
anteiioi superioi spine to a point i t niches beyond the 
hottom ol the heel, the loot heinu, held at ii”hl angles. 

C.i)ir,’iilrs( ( ill l.iilcxil llnne. I his consists ol a lateral brace, 
pel\ it hand, and perineal crutch. I lie hrace is jointed at the 
knee. Its special Icalure is the attachment ol the' lower end 
to the sc tie ol the hoot. 

ini 11< l \ t \ 11 xt or i)t t iikmi i its 

\ tuberculous lop ma\ become delormed in several direc 
lions, usuallx in (l) llexion, (2) adduction (rarelv abduction), 
;) llexion and abduction. (.]) llexion and adduction. I he 
malpositions ol excision and inversion are usually dependent 
on abduction and adduction and disappear with removal ol 
their cause. 

Earlx dclormitx is practicallv alxvaxs the result ol muscat 
lai spasm: while late in the disease process it is due to the 
contract ion ol solt parts or to structural changes in the hones, 
01 it is ,1 combination ol these two elements. 

Correction ol these dclormilies max he obtained in three 
wavs, viz., 2,1 adu.illx, rapidly, or bx operative means. 

(< 1 ad uni (',<>))('( lion. Ibis, the most conservative means, 
max he cmploved hx weight and pullex, hx traction splints, 
plastei bandage's, 01 hx the double I liomas splint. 

1. Wci^hl imil l’iillc\. When usin<_> this method, there are 
sc'xeial essential lealures to he' observed to obtain success: 
Inst, the- antc'iioi superioi spines must be on the* same level; 



sec < >11(1, the I it m I);n vertebral spine should touch the matt less 
ol the bed; third, traction must at Inst be maintained in the 
axis ol the limb in its delcnmed position. 

1 he a dec'ted limb can be supported by a pillow ot by an 
adjustable wooden triangle. In heavy patients counterexten¬ 
sion is secured by raising the loot ol the bed: but, as a rule, 
this is insulin ient lor the light bodies ol c hildren, with whom 
two perineal hands, one from each side ol the upper cornel 
ol the bed-lrame, give adequate counterextension. It is also 
desirable to swathe the body to the bed-frame or to apply 
shoulder straps to prevent the patient Irom sitting up. Addi 
tional fixation may be secured by a long lateral splint ex¬ 
tending beyond the loot and with a cross bar below. The 
bed clothes should be raised Irom the feet by a "cradle.” 

In using the weight and pulley method lot correcting de¬ 
formity, the amount ol weight must be increased Irom day 
today. Altera lew clays ol traction in the delormed position, 
the axis ol traction should be gradually altered toward nor 
mal. I his mode ol reducing deformity is slow and is useless 
for correcting true bony ankylosis ot structural bony de¬ 

2. Traction S/jIiiiI (1 aylor). For stretching plastic and con 
traded soli tissues, this method is sometimes successlul. Its 
chicI advantage is that it permits ol locomotion and thus 
obv iates the deletei ions eflects ol recumbency. Its great dis¬ 
advantage is that with the splint, it is dillicnit to secure trac 
t ion in the desit ed diret l ions. 

'P Plash') Ha Ullages. When plaster is used, it is Inst applied 
to the limb in its delormed position and allowed to remain 
lout weeks oi more. Occasionally the delormity will have 
become collected at the end ol this time: il not, a second ot 
third cast is applied, with the limb each time in a more ecu 
rcc led |x>sit ion. 


DIM KA 1 111 1 III A I \l I X 1 

Indications l<n oj/cralion are briclls .is lollows: 

\ ii age ai i>i I k‘y< >11(1 .111 <) I esi cm c. ( \s ,i rule, <»| >c‘ i a l i«>i l is 
contraindicated in \ i»11 n l*‘ childhood and inlaniA except as 
an emergency. oi u Ill'll the disease is uncontrolled h\ con 
sci s at is e treatment.) \n extra art iculai art hrodesis should lie 
reef mu net idol in all eh i Id ret l over leu years ol age where the 
disease is progressing in spile ol conser\at ive 1 1 calment. 
The resistance ol the patient should he built up bs lielio 
therapy and diet bclore and altei the operation. 

\hsi ess formation. with steads alliance ol the disease as 
disclosed both b\ \ rax and physical examination. 

Pi'i sistent loss ol health. 

Ungovernable pain. 

Whenever there is constant relapse ol the adduction de 
lorniitv in spite of ionsenati\e lneasures to overcome it, such 
as traction in bed. braces, etc., alter Ion” periods ol stub 
t reat ment. 

II the adduction delormitx recurs lollowiii” (hint's 
osteotomy, because ol the hip not being completely anky- 

In adults e\en il the bone destruction is moderate. 

Uncontrolled pool hygienic surroundings. 

Procedures. The operative possibilities consist principally 
ol extra art icular arthrodesis by bone grafts, excision ol focus 
when well localized and extra-articular, local curetting when 
sinuses set ondarih inlet led exist, and amputation and 
arthroplasty rarely. Intra-articular arthrodesis is obviously 
inadvisable because ol the dangei ol exacerbating the inlec¬ 
tion and its untrustworthiness il used alone. 

l.\lrn-artK itItn arthrodesis. I ubcri ulosis ol the hip is a 
condition most unfavorable to intra-art iculai arthrodesis, 
fit h ii spontaneous oi operative. I lie reasons lot this are ob 
\ious: (i) Inhibition ol osteogenesis bs the tubercle bacillus: 
the peculiar anatomy ol the joint 1 1 equent Is causing re 



cession ol hone sm lines Ironi each othei ns bone destruction 
progresses, or lollowino intra ;n t iculai removal ol bone by 
ilie surgeon loi arthrodesis purposes, because ol the ball and 

lie. \dv;uu'i'd tuberculosis with complete desl ruction ol head and par 
lial destruction ol neck, this case resisted all conservative treatment. 
Symptoms were relieved hv cxlra-ariieulai arthrodesis l>\ lihittl graft. 

soc ket contour ol the hip joint (peripheral desti tution ol the 
lemoral head causes n to become smaller, whereas peripheral 
destruction ol the acetabulum causes it to become larger). 
Also, because ol the anatotm and mechanical relationships 
ol the hip and pelvis, as extensive destruction ol bone pro 



ALBEE 1919 



HASS 1922 


HIBBS 1926 


WILSON 1927 

SCHUMM 1929 

I K.. Sonic ni I lie more important mcihoils ol oxtia arli(iilai a 11 lit odesis 
ol hip. I In | hi 11 >osc ol i 11 iisi t at i n<> \ a l ions methods is io i \ i • [lie sin^eoii a 
(hone ol proredme in indi\idual cases. 




grosses the diseased bom surfaces ol the lemur and pelvis do 
not lend to approximate because ol impingement ol the in 
side ol the trochantei against soil parts at and above the rim 
ol the acetabulum. Since the tubercle bacilli inhibit the 
active osteogenesis which would normally take place, dead 
spaces Idled with caseous material are left between the bom 
elements, and spontaneous ankylosis and cure become im¬ 
probable. Even il intra-artic ular arthrodesis is attempted, the 
impossibility ol removing all tuberculous material, and the 
possibility ol causing metastatic infection or sinuses with 
secondary inlection, the low osteogenetic potentiality ol the 
bony elements ol the joint, and the consequent failure to 
sec tire fusion render the operation untrustworthy (Fig. 

Bracing in cases ol extensive destruction and caseation, 
largely for the same reasons, has been signally unsuccessful. 

Extra-articular arthrodesis is a most satisfactory alterna¬ 
tive. By strongly bridging the joint with a tibial, femoral or 
iliac graft or grafts mortised into the bone elements on both 
sides ol the joint, complete fixation is secured. The im¬ 
mobilizing influence of union of the femur to the pelvis 
makes it unnecessary to enter the infected area. 

author's i i ciiMoi t 

Four l'analions of the Author's I echnit]ue .IdufAed to 
Fnrying Degrees of Destruction. In an extensive experience 
with extra-articular arthrodesis of the hip during the past 
fifteen years, I have been convinced more and more that it 
is distinctly advantageous to tlu- surgeon to have more than 
one type of operation to select from in meeting the variety ol 
mec hanical requirements which I have above discussed. Any 
proposed extra-articular arthrodesis is best brought about be 
tween the great trochanter on one side ol the joint and the 
side ol tlw ilium just above the rim ol the pelvis on the 
other, and since- die- proximity ol the trochanter to the side 
ol the- pelvis and the lim of the- acetabulum varies widely 
in accordance- with the degree ol joint destruction and tele 


scoping. I imI) .iddin l ion and Ilexi<>n. i lie open at i vc In Im i< |nr 
must \.n\ ac 101 < 1 i 11 l* 1 \. \s in cverv surgical procedure, the 
simplest technicpie assocTiled with the minimum ol trauma 
.md shock to ilir patient should he chosen, and also one 
which will undelete the least with a Inin re at 1 hropla.siy, 
should the latter he desired and prove leasihle. 

loom tlm technical standpoint eases suitable lot extra 
articular arthrodesis ol the 1 hip can he- divided into two 
groups. on the' basis ol pathological linduigs, and each ol 
these subdivided into two types, as to the charactei ol opera 
l ion. 

(ttou/) i. In the Inst group the destruction is moderate 
in amount and the great trochanter remains widely separated 
from the side ol the pelvis, so that a bone ora It cannot be 
obtained from the side ol the ilium or the immediate locality 
in sullic ienl length and strength to serve as a bridge lor the- 
extra-articular arthrodesis. Therefore, the surgeon is com¬ 
pelled to go to the tibia or the outer portion ol the upper 
end ol the lemur lor graft material, because of the necessity 
ol obtaining not onlv long but strong grafts (Pigs, yd and r, 7). 

!'<’( Imi<jtie fo> (•ruuj) /a. The patient is anesthetized to 
muscular relaxation and placed upon the fracture orthopedic 
table. I he surgeon lorciblv collec ts the adduc tion of the 
diseased hip bv manual counter-pressure, plac ing one hand 
against the buttock and the other against the inner aspect of 
the knee. His assistant at the same time, by adjusting the 
Iracture orthopedic table, places the well leg in the limits 
ol physiologic abduc lion, and cautiously swings it into a posi 
tion ol abduction the traction arm ol the table holding the 
diseased leg. The amount ol abduction in which the lattei 
is placed depends upon the amount ol bonv shortening’. I’liis 
method ol correction, pa it 1 v bv the mechanics ol the table 
and pai 11 v bv manual pressure, is adopted in ordet to guard 
against ovei stretching the lateral ligaments ol the knee-joint. 

\ somewhat curved incision starting at the crest ol the 



'1 11 * 111 • - i11c Ii cvs posterior lo (lie anterioi superioi spine 
and ( ai ricd down below die great 1 roc banter, is made 
ill rough the skin. I lie gluteal muscles are separated sufli 

I n,. ->(>. I cclmi(|uc ol arthrodesis <>l inhere ulous hip with lihial plaits. 

I ii si slop. 

eiently to e\p<ise the side ol tlie iliuni at the points ol niortise 
loi the insertion ol the proposed tibia] grabs. 

Because ol the thinness and elastic itv ol the bone roinpris 
ing the outer table ol the ilium, a mortise suitable to receive 
the grails c an be sat islactorilv made with a l inc h c hisel 
driven through the outei table ol the ilium oblic|iiel\ up¬ 
ward between il and the innei iliac table, with the handle 
ol the chisel in close proximilv to the trochanter. W ith the 
cutting end ol the chisel still in the mortise prepared b\ it. 
located l inch poslerioi to the anterior superioi spine, and 


1 inch Ik'Iou tltr iirsl <>l llii' ilium, the handle is depressed 
onto l he outei surlace ol t hi'l roehantei .it itsauleiioi holder, 
and usei I as a guide loi some t tilting tool, such as the si a I pel, 



I if.. -,7. SckiihI sic]). 

to mark on the peri osseous strum tires the line where the 
motoi saw is later to prepare a gutter lor grab No. 1. 

The same preparation is made lor grail No. 2, except that 
the mot tise in the ilium is made about 11/, to 2 inches posteri¬ 
orly to the lust one. and the scalpel mark is made on the 
posterior outer surlace ol the great trochanter. 

Saw cuts are now made I., inch in depth with the motor 
saw, following the scalpel marks just made on the trochanter. 
With an osteotome driven into these saw cuts, fragments ol 
the trochanter are displaced with the peri osseous soil parts 
as hinges, ante) iorl\ horn the saw < ut for grail No. 1 and 
posteriorly from the saw cut lot grail No. 2. so as to produce 
gutters to receive the two g 1 alts. 

I he anterioi internal surlace ol the tibia is then laid I>are 
Irom the tubcrosit\ ol the tibia downward. With the motor 



twin s;tu set with the Eludes approximately inch apart, 
a oralt is removed by saw cuts made downward Irom the 
tuberosity ol the t iI>ia about q inches. With a small motor 
saw. this strip ol bone is then cut into two segments. The 
tippet ends ol the grails are cut in an oblique way like the 
end ol a chisel. 

I he upper end ol grail No. 1 is inserted into the mortise 
ol the ilium with its lower end lying in the anterior guttei 
prepared in the trochanter. The oblique surface at the upper 
end is outward. With the author s bone drift or set (of which 
the carpenter's nail set is the prototype) placed on the tro¬ 
chanteric end ol the graft, the graft is now driven into the 
iliac mortise by blows ol the mallet upon the bone set. 
In this manner its trochanteric end is made to slide along 
the trochanter gutter and its proximal end to lit snugly into 
the moltise of the iIiuni. 

draft No. 2 is put in by precisely the same technique. The 
firmer the grabs are driven into the iliac mortise, the (loser 
do thev hug the bottom ol the trochanteric gutter because ol 
the obliquity ol the cut end ol the iliac end ol the graft. This 
plan ol operation automatically immobilizes the grafts at 
both ends in a most gratifying way and makes immobilizing 
bone ligatures unnecessary (Fig. y<S). 

The soft parts with fragments ol the trochanter are drawn 
ovei the ends ol (lie grail by means ol interrupted strands 
ol medium kangaroo tendon. The gluteal muscles are care¬ 
fully drawn about die grails by means ol chromic catgut 
sut ures. 

I he skin is closed with continuous suture ol o catgut. 
Suture holes and the edges ol the wound are puddled with 
gi/, percent tine lure ol iodine. 

Trch n i <j lie for (•ion/> ib. Ihe upper portion ol the ap¬ 
proach lot (his procedure is verv similai to that described 
when tibial grabs are used. In this instance the inc ision must 
extend generously downward y inches from the tip ol the 


trochanlci so as to 141 \ c ‘ live exposure ol the anlci o external 
aspect ol the tippet end ol the lemur. I lie soli structures 
are sepat at ed. lca\ino the periosteum on the I ei 11 u 1 . With 1 lie 

I K-. N I’ostnperalhe result eit^hl Years utter operation. liitliiciire ol iur- 
< I1t111ic.1l siitss 011 strait may tic noted. Joint lias been completely ankylosed 
In bone. 

motoi saw and sharp id, inch osteotome, a slrono graft about 
f> inches lotto and < omprisino about one filth the diametei 
ol the shall ol the lemiii from the tip ol the great trochanter 
downward is obtained with a pedicle ol must le at its upper 
end. I he lower end ol the lenioial orall is now swung .inlet 1 
mb on the must le and soli tissue pedicle at the tippet end 
as an axis until its anterior end comes in contact with the 
s 'de ol the ilium. When the desired location on the ilium 
is thus detet mined a Map or door ol the outci table ol the 
'hum is tinned slighth upward and backward b\ means ol 



I lie moloi saw ;iiid I,,-null osteotome, so lh;il the tippet end 
ol the grail (lormerly the lower end) can he thrust backward 
beneath it (fig. r,(j). bone fixation ligatures are not necessary, 

and hone drift it is firmly placed and will not he displaced. 
Idle musc les and fasciae tire now replaced over and around 
the graft with continuous suture ol chromic catgut and the 
skin c losed in the usual wav. 

The 1 lass or llihhs procedure is somewhat similar to this 
method, except that llihhs' method is not truly extra-ai tic n- 
lar, as hotli his diagrams and the desc ription ol his technic|iie 
show that the neck ol the lemur is exposed and the cortex 
removed. The operation is therefore necessarily within the 
tuberculous area, which is to he avoided. Furthermore, it 
recpiircs an extensive operative held, wide resection ol 
muscles, and muc h shoc k. The procedure is the most cliflicit 11 
of the loin types ol teehniepie presented. 1 have so modified 
lhis opei at ion that it is extra-articular, but the great trochan- 


U i and attac hed must les arc nine 11 more damaged ilian when 
the lihial grafts are used, and il leaves more tinlavorahle con 
(lit ions loi a future arthroplasty- a possibility w hic h should 

Fin. 60. 

aluavs he horne in mind in planning an arthrodesis (Eig. (to). 

Postoperative Dressing. Extensive dressings ol »att/e and 
sterile cotton are applied, and then a plaster o! Paris spica 
Snim above the costal margin to the base ol the toes on the 



operated leg, and i<> below the knee-joint ol the opposite leg, 
in a posture ol abduction sullicient, il possible, to overcome 
practical shortening. 

With the plaster still in a semiplastic state, it is carelullv 
molded over the operated area, lor two purposes: to lavor 
immobilization, and to aid in the control ol bleeding. 

The plaster on the uninvolved leg is removed at the end 
ol live weeks. The remainder ol the plaster is left alone until 
ten weeks from the time ol operation. 


(; ion!> 2. I lie operative technique loi this group is illus 
n.Hrd l>\ Figures (i i I i |. I hr head and a large potiion ol die 
nee k ol die leiiiin have heen disintegrated with ulesioping, 
causing the trochantci i<> I>ei ome more oi less closely approxi 
mated to the superiot i ini ol the acetabulum and the side 
ol the pel\ is. 

1 « >i com i'ii ienee in discussing the opcral i ve tei hit iipte this 
group max he subdivided into two types: 

l<’( Inuij ue for (iiouj> 2d. (.roup ea comprises those eases 
in which the destitution has heen so extensive that the 
troihantci lias approximated the rim ol the acetabulum to 
a sitllii ient degree—within lb, inch oi less—so that a sliding 
grab Irom the outer table ol the ilium including the crest 
Fig. (it ) is adequate to real li Irom the side ol the ilium into 
the trochanter and also bullish adequate contact with these 
honv elements and still allow the surgeon to keep outside 
the tuberculous joint. The side ol the ilium has already been 
laid bare l>\ the Smit h Petersen approach and liu nishes a 
ver\ satislactoi \ gralt in that this outer table is not only 
curved so that it approximates the trochanter and ilium satis- 
lactorilc (Fig. (>2). but also enables the surgeon to secure as 
broad a gralt as he wishes. This technique is somewhat less 
diflicult ol execution and consumes less time than obtaining 
a gralt Irom the tibia or lemur, as described under Croup t. 
I he surgeon, altei si/ing up the mechanical conditions, may 
t hci el ore < Inn ise this t vpe ol technique rat her than the ot het 
two already described. 

I'rdnuijitr foi (iron/) 2b. In certain extreme cases, (.roup 
■_d). in which the trochanlci is prai lit alls resting against the 
side ol the ilium, and in w hich an inira-arl icuhit arthrodesis 
has been prcwiously attempted, with complete removal ol all 
tuberculous tissue, the following simple technique may be 
used: I he troehantei ma\ be denuded ol its pi'iiosti'um and 
]>ei iossi'ous structures, both on its outei and inner stn lai es 
(Fig. by,). I lie outei table ol the ilium just above the acetal) 
ul.u rim is then lilted externallv. and the denuded troihan 



lei implanted helical It the lattet l>\ swinging the hip into 
the abducted posture which automatically elevates the tro 
t hantet into the crew ice thus made (Tig. (i j). It may he neces 

I lC. C>2. 

saty to supplement this procedure by implantation ol a graft 
obtained from the outer table ol the ilium, higher up near 
the crest. These ver\ extreme cases are rare: I have encoun¬ 
tered on I y two ol this t \ pc. I his technic pie is partially intra- 
art ic lilac. 


In am event one should design die operative proc echo e 
so dial die ” ral t used will he 1 11111 1 \ moil ised into doth I emu 1 
and pelvis u idiom enlei in^ the I tthex 11 Ions joint and it will 

I lave to he led to the judgment ol the sui^eon as to just what 
technique should he chosen, al\va\s remembering that the 
simplest technique feasible will he most sal islac torv. 

1' i t her ol the pi oc ed m es cl esc 1 abed nuclei Croup l* is easier 



ol execution th;ni those lot (.roup i, providing the trochan- 
U‘i is near enough to the side ol the pelvis so that it can be 
we II cat i ied out. 

He. (>|. 1 1111>I,iiiiaiion nl denuded irocliantei under an osteoperiosteal (loot 

I rom oniei sin lace ol ilium. 

Relative Difficulties of Tec/niitjiie. The simplest technique 
is a I ), hut lot the reasons already discussed it is applicable 
only in rare instances. 

Where the great trochanter is in (lose pro\iniit\ to the 
l im ol the acetabulum, the simplest bone grab operation pos¬ 
sible lot extra-ariiculai arthrodesis is applicable: the sliding 


down ol a Broad ora It Ironi the outei table ol the ilium into 
the split Hoc hauler (2a). 

Ihe tihial i alts (da) are next in order ol diflieult\. 

I he most dillirult operation, part ienlat l\ as to extent ol 
operative field and tissues involved. is il>. the modification 
ol the 1 lass 1 I i Bbs technique. I lie original I lass I I i BBs 
operation is not extra-articular. But about | oi r, indies ol 
the ontei portion ol the 1 great trorhanlci and the shall ol 
i he lent nr ('an Be used to act < >m pi rsl i an ext ra-art k tilai art lire> 
desis. I his. however, is an operation ol "teat magnitude in 
that an in< ision has to Be made Irom just Below the i rest ol 
the ilium to nearl\ one-third down the thiu,h m order to 
rotate the graft into position (Fig. r,r,). 

C.tiulion. A word ol caution concerning the execution ol 
bone-gralt teilmicpie is stimulated By recent publications ol 
postoperative \-ra\ findings, in which it was claimed that 
exit a-artic ulat arthrodesis ol the hip had Been ac complished. 
But with unsatisfactory results in a considerable percentage. 
I he \ raws showed that the same inadequate and imperfect 
technique had Been practised as has Been so frequently ob- 
ser\ed dining the past twenty years when certain surgeons 
have drawn unfavorable conclusions from their attempts to 
accomplish extra articuhu arthrodesis of tubercular spines, 
although the operative technique was inadequately carried 
out. I wish to emphasi/e the necessity of the graft Being of 
sulluicnt strength, ample length, accurate lit. and carefully 
mortised on eilhci side ol the joint, il good results are to Be 

i rvss i nuns i ic;i i x km a 

In the I lass-lliBBs operation as described By IliBBs:* "An 
incision is made through skin and subcutaneous tissue Irom 
2 itic lies Behind and above the anterior superioi spine, down 

Hil»l>s It A | il cl i mi i iki I \ 1 cjxn I of I \\ flit \ i.isc’s ol hip |niiil I tilled ulosis 
lie.ilcd I) \ .in Opel ;il ion devised io cl i in i iki I c molioii I >\ losing the joint. /. 
Hour ^ loml Shi;;,. S: i yi»G. 



ovet I lie great trochanter, g inches on ilic shaft ol the lemur. 

I he deep last ia is split, the tensoi fascia lemoris retracted 
medially, and the liber ol the gluteus meditts and minimus 
separated by blunt dissect ion. exposing the capsule. The 
periosteum ol the lemur is incised along the line ol the base 
ol the trochanter, elevated and retracted medially: the an¬ 
terior three-lourths ol the trochanter with 2 inches of the 
cortex ol the lemur is separated with a chisel, leaving the 
musc le and periosteal attachments undisturbed (Fig. gg). 

‘‘The capsule is split, the superior aspect ol the neck ex¬ 
posed and the cortex removed. A mass of the ilium includ¬ 
ing the upper rim ol the acetabulum is elevated without dis¬ 
turbing the muscle or periosteal attachments or breaking 
loose the mass above. J lie trochanter is now transposed bv 
tinning its lower end up under the elevated mass ol the 
ilium, its base making snug contact with the cancellous bone 
ol the nec k, the cortex hav ing been removed. The periosteum 
<>l the transposed bone is sutured to that ol the iliac mass 
above and to that ol the lemur below. I he mass is also 
caught by the tip of the remaining one fourth ol the tro 
chanter; when the thigh is abducted 1 g degrees and Hexed 
go degrees, it is held securely in place. The muscles and 
fascia are closed with sutures ol plain catgut, the subcutane¬ 
ous tissues with plain gut, and the skin with silk. A double 
spic a plaster is applied, which has already been prepared and 
bivalved. By this means direct and massive bone contact has 
been sec ured between the ilium and the lemur, with con¬ 
tinuous periosteum which produces a situation lavorable 
to bone growth, and essentially similar to the situation pro 
duced by spine fusion, where the continuity ol bone and 
periosteum is primarily ol healthy bone which lust becomes 
fused: ultimately, however, lusion ol the diseased bodies 
takes place. It was hoped that in the c ase ol the hip the pi i 
maty lusion would be ol the transposed trochanter, ilium 
and femur and ultimately ol the head and acetabulum as 


well, linallv showing .1 massive area ol lusion which is neces 
saiv 10 stand the lone excited upon it l>\ the long lemur. 

(•hormlev s claims the lollowing advantages ol using the 
crest ol the ilium: it is easilv obtained in am exposure ol the 
hip. and the cancellous hone ol the iliac crest furnishes ideal 
hone lor grading purposes. I he "tall lies in position in ( lose 
contact with the sm lace ol tlu' neck and the ilium. In many 
cases it seems made to lit act match in this position. It acts 
as a "living buttress" which is met hanic al Iv as strong a struc 
tural support as possihlv can he made. T he simplic ity of the 
procedure makes lot speed in operation and lessens the 
danger ol shoc k. 

* C.iioimlcv, R. k. Surgerv ol iho hi|> joint. /. Iionc cF Joint Sing., i‘>,: ~S (, 
1 93 1 • 

Chapter V11 


S'. NOVI 1 IS 

I T is not easy to detect the presence of llnid in the hip- 
joint because of its deep situation, surrounded by large 
muscles. It is usually impossible to palpate any disten¬ 
tion ol the capsule. The diagnosis is made from the absence 
ol roentgenographic changes and the characteristic physical 
findings—painlul limited motion with marked muscle spasm 
and the tendency of the patient to hold the limb in flexion 
and adduction. 

Its occurrence in childhood arouses the suspicion that one 
is dealing with an incipient tuberculous process. Differentia¬ 
tion can be made only by minute examination into the his¬ 
tory (both personal and antecedent), by noting the response 
to treatment, by careful and prolonged observation ol the' 
clinical course of the affection and by roentgenology. 

The cause of synovitis ol the hip in children is to be lorn id 
in trauma, rheumatism, or as a secpiel to a mild lorm of in 
lections arthritis contracted in the course ol such ailments 
as tonsillitis, diphtheria and other throat involvements, 01 
following osteomyelitis or epiphysitis ol a relatively benign 
t ype. 

The course of the usual non tuberculous svnenitis ol the 
hip in children is ordinarily short, rareb more than two ot 
three weeks. Its c linical manifestations are a limp, restricted 
motion and iransiloiv muse ulai atrophv. I lie- adult t\pe is 



;iYNO( ialc'd w ith 01 follows rheumalism, ”011011 lira, syphilis 
and ai tin itis deformans. 

I K I \l MINI 

Svno\itis ol the hip in child ten 1 should hr managed pre 
( isrlx as a c ase ol inripirnt t nhrn ulosis ol that joint, hut the 
child should hr card nlh w atc hed aim apparent recovers to 
note the permanent \ ol the ( tire. In the c ase ol adults, test 
and weight-extension (with plastet ol Paris spiea, il ncrcs 
sarv) are in order, Caution should he exercised in using 
the joint loo eat l\. 

I xt 1 c: 1 tc )t s on R111 1 m \ I Oil) .\K 1 Ill-til is 

Infectious or rheumatoid arthritis is primarily a disease 
ol the synovial membrane and the soil tissue surrounding 
the joint. (Veil 1 states that the clinical course and labora 
tarv findings indicate that the rhemmitoid type ol arthritis 
is a c hronic inflammatory process. 

The c linic al features are infiltration of the periart ictda 1 
tissues, llexion deformity, restricted motion and local pain 
and disc omlort. Roentgenograins show distention of the cap¬ 
sule ol the hip joint and a varying amount ol decalcilica 
lion ol the head and nec k of the femur. Yen rarely cartilage 
destruction is seen. 

With the exception ol those cases caused In infectious 
processes elsewhere in the hod\ rheumatoid arthritis is lie 
cpientlx caused In local inlection or metabolic disturbance 
.ind the elimination ol the loci ol infection is the chiel 
therapeutic indication. Physical and mental rest is \er\ im¬ 
portant. I lie diet should have a low carbohydrate and a high 
vitamin content. Wood elimination and a copious walci in 
take are necessary. Colonic irrigations may be given in cases 
ol intestinal toxemia. Ileal, exercise's and massage are val 
liable. In cases showing no improvement under treatment 
b\ these measures, the hot climate ol Florida may have a 

* Coil. It. I . Rheumatoid aillnilis. / I. \l. /., 100; |o a()j Ki'j'j. 



”(«)(! dic'd. I lie only drills ol value arc colloidal sulphur, 
iron lor anemia, arsenic and strychnine as tonics, and salic y¬ 
lates lot the relicl ol pain. 

Fixation ol the joint by a short plastcr-of-Paris spiea or 
rest in bed may be nec essary in the more severe c ases. Usually 
the use ol crutches with no weight-bearing on the affected 
limb lor a lew weeks is sufficient. 

CaiNORKIII At. Aid t licit is 

Oonorrhcal inlection invades the hip with lai less fre¬ 
quency than the knee-joint, although it is not uncommon in 

Etiology. I he process is part ol a systemic. hematogenous 
infection with the gonococcus, usually originating in the 
urethra or its adnexa. It complicates from 2 to to per cent 
ol gonorrheal urethritis. It affec ts women as well as men, and 
is not uncommon in children. 

Pathology. The following pathological conditions are en¬ 

1. Hydrops Articuli: T his is often monarticular. The on 
set is frequently sudden, the joint becoming quickly dis¬ 
tended with fluid whic h disappears slowly. The temperature 
is only moderately elevated (qq to 102°). 

2. Serofibrinous Synovitis: 1 his form, which is Irequently 
polyarticular, is characterized by very little lltiid, a plastic 
inflammation, with exudate within the joint, and considera¬ 
ble pei iarticular inflammation. 

q. Pm/rye in a Articuli: Mere there is a definite collection 
of pits within the joint, accompanied b\ proluse inflam¬ 
matory exudate and a varving degree ol destruction ol the 
joint structures. 

]. Phlegmonous Inflammation: lit this type, the character¬ 
istic feature is diffuse infiltration ol all the joint structures, 
with dense adhesions which eventually produce ankylosis. 

('.linital Features. The non-suppurative cases are usually 
subacute and accompanied by a pecttliai edematous boggy 



swi lling, (listomlot l. weakness, and siiIIness on use ol flu* 
joint. More sex eve eases are eliavaelevi/ed by local heat and 
nnisele spasm. 

In snppnratixe cases the skin is ted, gla/cd, and hot, the 
joint is swollen. exquisitely tendet to pressure and to jarring 
and its motion is limited. I here are also signs ol systemic 
(list m bailee. Ie\ er. etc. 

/h Inal diagnosis is based on the monart icttlai 
lot ali/ation and the obstinate, painlul s\v el I i tie,, with a his 
toi\ ol 01 the presence ol a urethral discharge. In (hj)erenhal 
diagnosis, gonorrheal aithritis must be distinguished Irom 
traumatic , tubeic itlotis, and sxphilitic synoxitis. I he dis¬ 
tinguishing point ol dillerentiation is the primary locus in 
the genitalia. 

Prognosis. In mild cases, with ellieient treatment, the out¬ 
look lor functional recoxerv is good. In the suppurative and 
serofibrinous inllammations, ankylosis usually occurs. 

Treatment. 1 he eradication ol the locus ol infection in 
the urethra, bladder, seminal vesicles, is essential. Rest in 
bed. support ol the joint, and local applications ol heat or 
cold are necessai v. 

Immobili/ation with weight traction should be done im- 
mediatelx. I he hip joint should he aspirated and the fluid 
obtained examined both microscopically and culturally to 
determine the character ol the infection. In aspirating the 
hip the trocai max he inserted from the front or the side. 
It max he thrust into the joint just ahoxe the greater tro 
chanter, passing directly inward. II the anterior approach is 
desired the joint max he reached Irom a point on the same 
lexel, but in Iront ol the thigh. I pon reaching the lemoral 
head oi neck, the shat]) point ol the trocai max he with 
drawn and the dull end used as a probe to locate the exact 
point of entry. 

In this maneuver, the skin should be drawn to the side so 
that the puncture holes in skin and muscle will be out of 
alignment upon withdrawal ol the trocar. As soon as the 



most ;u tile symptoms have subsided ;i short plaster of Paris 
spu a cast should be applied. I he duration ol immobilization 
varies with the pathological stale ol the joint, but should 

I k., (i-,. Landmark for aspiration or injection ol hip joint. In an adult, 
needle is introduced tit a point t ,- t on. helou hori/onlal plane of pnhic spine 
anil 2 on. external to femoral alien. 

not be too protracti‘d in any case. As soon as the infection 
subsides active and passive exercise and massage should be 
cautiously started. II suppuration occurs the joint should be 
inc ised and drained. Vaccines are ol debatable value. 

II contract tires 01 ankylosis has occurred surgical methods 
will be necessary to mobili/e the joint. (See Chap. VIII. p. 

St I’l'l k All v t Akl I I k 11 IS 

I’voca'Aic ak 111ki ris: os rio\n l in is 

Pyogenic arthritis, acute osteomyelitis (or epiphysitis) is 
not tin uncommon event in inlants, in whom it is manilested 
as an ac ute c'piphysit is. Sejiat at ion ol the epiphvsis ol the 


189 head ma\ follow, with disinlegi at ion ol that strtn 
t m e and dislot a l ion. \ t out i i hut ing t a use is usual I \ 11 ainna, 
with 01 without metastatic inlection Irnm a pvogcnh lot ns 
elsewhere, or as a sei|tiel to pneumonia <>i one ol the e\an 

()l 2t7 cases ol pyogenic osteomyelitis treated h\ liisgard 
there was associated art liril is in f, i t ilit idem e ol 2 '’.", 
per (rut. Ol these 7,t eases. |2 (i<).^ per t ent.) arose by direct 
extension from an adjacent diaphyseal inlet lion. I he large 
weight bearing joints ((instituted ()2.f, per t ent ol this group. 

I he svinptoins are fulminating, sudden onset w ith hyper¬ 
pyrexia and prostration. Ihe hip-joint is tendei on move¬ 
ment and to pressure, swollen, and its sttrlaee temperature 
ma\ he ele\atetl. Syphilis w ith seeontlaix inlet lion is also a 
cause ol this ton (lit ion. Osteomyelit is ol the ilium in children 
frequently extends into the hip joint. Young f states that the 
diagnosis ol acute osteomyelitis ol the ilium is by no means 
ease. This is perhaps partly because the physician fails to 
remember there is such a disease. On the other hand, the 
patient ma\ present such a preponderance of constitutional 
sMiiptoms that little attention is paid to the initial local 

II a child complains ol pain in the region of the hip fol¬ 
lowing a trauma to the region, and on examination is found 
to be acuteh ill with high lexer, leucocytosis, tenderness, 
and increased local heat about the hip. but relatively free 
motion ol the hip-joint, then osteomyelitis of the ilium should 
be suspected. I his. we believe, is so because: (t) The pain ol 
inlection in the hip-joint is often, although not always, re- 
Ierred to the knee. In osteomyelitis ol the ilium, the pain 
is always about the hip with oltentimes inability on the part 
ol the patient to locali/e the site ol discomlort definitely. In 
none ol the cases reported oi in out cases has pain been 

* I4is”;nd, |. I). I lie relation ol |)\oi>eni( arthritis to ostconwclitis. .s///»., 
■ Ohsl .. 7 |. l()3i>. 

IXomig. I Wuic osteomyelitis ol the ilium S'l/i"., (•yiin. Ohsl.. -S: aoi. 
• 931 - 



i clerred lo the knee. (2) Me\ion and abduction mnli acUire 
occurs ver\ carl\ in septic invohement ol die hip-joint; in 
osteomyelitis ol tin- ilium no contractures are present until 
later. (3) Pyogenic inlection in the hip joint manifests itself 
early by almost complete fixation ol the joint cine to muscle 
spasm; hut in osteomyelitis ol the ilium in the Inst lew 
days ol the disease, motion in the hip is free. (4) II osteo¬ 
myelitis ol the pelvic hones is suspected then the ilium is 
the hone by far the most likely to he affected. Acute osteo¬ 
myelitis ol the pubis and ol the ischium is so rare that it is 
hardly necessary to give it consideration. 

By far the most frequent complication of osteomyelitis of 
the ilium mentioned in the literature is invasion and de¬ 
struction ol the hip-joint. Treatment should he directed 
toward saving the patient s life and. secondly, preventing 
destruction of this joint. 

Following incision the extremity should he kept in trac¬ 
tion with the hip abducted and slighth Hexed to prevent 
deformity ol the acetabulum and possible dislocation of the 
hip. l itis occurs due to the upward pull ol the hip muscles 
forcing the head ol the lemur upward and inward into the 
softened ilium. 

The convalescence is long and oftentimes complicated b\ 
recurring abscesses. The patient should he protected from 
hearing weight on the affected side until there is \-ra\ evi¬ 
dence that the ilium has fully regenerated and the hip-joint 
is as normal as one thinks it will become. 

Besides being mote dangerous as regards life, the disease 
is also <111 itc* disabling il the patient survives. I his is not 
only due to the sinuses and tec in tent abscesses common to 
all osteomyelitis, but also to the Irequent involvement ol 
the hip joint resulting in painful limited motion and. at 
limes, complete ankylosis. 

Santi * states that osteomyelitis ol the hip Irequenth starts 

*S.mli. I Osi conic cl il is in (lie first cons ol lilc. Iulcniiil. Ibsl. S ui^., Go: 
- 1 1 • "J.'i.j- 



as an inlet a ion ol the synovial membrane and spreads into 
the hone secondarily. lit niuslings pmnlenl arthritis may oc 
( in without involvement ol hone. Osteomyelitis ol the hip is 
most common at the age ol six months. Inn mav become 
manifest ver\ soon abet birth. The lesion commonlv pro 
dtites a dclormitv ol the head and net k ol the letmn and 
ol the acetabulum with lesulting dislocation ol the lemur. 
I he dislocation ma\ be eonlnsed with congenital dislocation 
ol the hip. W hile the epiphvsis is the most Iretpient site ol 
osteomyelitis in the Inst years ol lile. the body ol the dia 
phvsis is a eotninon site ol bacterial emboli because ol its 
abundant blood-snppiv. Involvement ol the metaphysis is 
l'ret[uent both in infancy and tiller the second ycat ol lile. 
Roentgenographv is ol the prettiest \ til tie* in the diagnosis 
ol osteomyelitis. 

Treatment. The Inst consideration is treatment ol the 
generali/cd septicemia which is always present in these cases. 
Transfusions are ol great help. Prompt incision is imperative 
lot the evacuation ol the pus liotn the hip-joint, lemur, 01 
ilium. Traction with weights or a spica east are applied im- 
mediatclv to prevent dislocation ol the hip. 

The treatment ol a group ol cases ol osteomyelitis about 
the hip, with or without complications, entails a multitude 
ol considerations. In most ol these cases, we have deep 
wounds extending into the bone through thic k musc les, w ith 
varying degrees ol infection. The ideal wound dressing must, 
therelore, have a degree ol solidity snllic ient to restrict the 
tendenc v ol the 01 ilice at the dermis to c lose earlier than the 
depths ol the wound. At the same time, this tampon should 
be such that it can be inserted in practically a fluid state, in 
ordet to Mow uninterruptedly to every recess ol the wound: 
it should then become send solid, thus tending to conserve 
the original contour ol the wound, avoid adherence to the 
bone, and, bit bv bit. extrude automatically as granulations 
till up the depths ol the wound, or as the coni i act ions ol heal 
ing and cicatrization demand. 



II llie consistency <>l the tampon can be altered by chang- 
i1114 the relati\e amounts ol the ingredients composing it, 
loo eat ly e\tfusion can be a\oided in wounds ol great depth, 
and, conversely, rapid extrusion can be favored in shallow 
wounds where earlier c losure is desirable and possible. With 
these requirements in mind, I am now using, instead of the 
\ aseline and vaseline gauze (On treatment) applied in earliei 
cases, different mixtures ol parallin and yellow vaseline, the 
proportions depending on the nature of the wound. In deep 
wounds, parallin and vaseline are used in a strength of ten to 
one; in suppurative wounds, where early c losure is desired, 
the mixture is lour parts ol parallin to one part of vaseline. 

The mixture is always put into the wound in a melted state, 
at about t to F., this being accomplished by immersing the 
jar containing the mixture iu a water bath for some time 
before the mixture is used. It is then inserted into the wound 
by means of a large syringe. 

I do not favor the vaseline, vaseline-gauze dressing for 
several reasons: 

1. It is impossible to control satisfactorily the consistency 
of the vaseline, vaseline-gauze tampon. Due to the ingredients 
comprising it, this tampon cannot, at best, be unilorm in its 

2. Later experience lias shown that, even when an excess 
of vaseline is added with the vaseline gauze, the gauze is still 
apt to become adherent to the bone at the bottom ol the 
wound and so resist extrusion ol the tampon and delay 

g. The wound granulations are likely to strangulate 
through the meshes ol the gauze. 

None ol these complications ever arises with the parallin 
and vaseline dressing, which, because ol its proper degree ol 
solidity for the* particulai case, the unilormits ol its con 
sistenc y, and its slippery sin lace, will always extrude muc h 
more satislac tot iIy than the vaseline, vaseline-gauze dressing, 
ac ting in a manner apparently somewhat similat to the bipp 



tampon. Furthermore. it lias been IouikI that laboralorx hied 
j > 1 1 a e; c ■. when ini nxlueed. ac is laxorablx in the presence ol 
the tampon. I have been nnahle to lind any short comings ol 
this dt essilie, as com|KtrecI with either the hipp oi the \ aselitie, 
\ asel ine-gau/e dressing. IJipp. however, may he contrail) 
cheated because ol the possible nnlavoi able chemical action 
ol the iodoform upon the bacteriophage. 

r< < lnii(] lie. I he usual sec | nest ret tomx and sane eri/at ion 
are completed, and a cull it re is taken. (II a specific phage 
has alrcaeh been lonnd Irom a culture previously taken hom 
an existing sinus, two-thirds ol a test tube ol this phage is 
ponied into and over the wound, so that the whole snrlacc 
is bathed.) 1 lie wound is then packed with a parafim and 
vaseline mixture, usually ()0 per cent parallin to to per cent 
vaseline. The parallin and vaseline are heated to t to F. and 
poured in as ;t licjnid, or lorced in by pressure through ;t 
large syringe. In most cases, the syringe is the method ol 
choice, in ordei to insure penetration ol the mixture to the' 
innermost recesses ol the wound. 

One end ol a rubber catheter is inserted through the 
paraffin-vaseline wound tampon to the bottom ol the bone 
cavity. 1 he othet is allowed to project through the dressings 
and cast (which are applied as usual), with a sterile gau/e oi 
cotton over the end. II the laboralorx examination ol the 
culture reveals that it is possible to develop a bacteriophage 
spec ific lot the organism presented, to c.c. ol this phage are 
injected through the rubbei catheter each day. Cate should 
be taken when making these injections not to infect or con 
laminate the end ol the lube. Should the' bacteriophage ap 
pear spontancousb in the wound, injec tion ol the laboratory 
bred phage is still ol advantage in that it accentuates the 
action ol the nati\e phage, and may be a more specific one. 

I his practice is ol still 1 11ith cm advantage because, d an 
original phage does not complclelx destrov a culture, the 
organisms that sm\i\e gi\e use- to a resistant strain which 
max he- pathogenic loi its host but is not allected bx the old 



l);u leriophagc. In huge wounds. several catheters may he 
inserted, some ol which are imillirenesirated. Inasmuch as 
the catheter is Imnly imhedded in the paralltn vaseline tam¬ 
pon, the injected phage fluid cannot Mow backward between 
the cathctet and the- tampon. It must, therefore, make its 
wav unraxl between the tampon and the wound granula¬ 
tions, and thus, by reason ol its own bulk, spread widely. 
Furthermore, since the phage is. by nature, a multiplying 
organism it will thus automatically spread over the wound 

At the end ol eight weeks the plaster spica is removed and 
the wound dressed, great care being taken not to traumatize 
the granulating surlaces. I he discharge around the edges ol 
the wound is wiped oil very gently with sterile gauze and the 
skin cleansed with ben/in. 

II the wound is not entirely healed when the cast is re¬ 
moved. it is again bathed with a test-tube of the prepared 
specific phage fluid and a catheter or catheters inserted to 
the depths ol the wound. A pat allin-v aseline tampon is used 
as before and a cast applied for eight weeks. A culture is also 
taken at this time to determine whether the bacterial llora 
of the wound has changed, and also whether a more specific 
race ol phage can be obtained. Periodic injections through 
the* catheter are given as before. 

Those cases in which a native phage develops usuallv do 
very well without the insertion ol a laboratory-bred phage. 
However, in view ol our latest investigations, we feel it is 
wise to inject periodically a race ol phage ol the highest 
potency, in order to have at work lor a maximum period of 
lime a phage ol the highest specificity. In this way, am 
possible decrease in potency ol the native phage is olfset. 

We have done extensive research to determine the relative 
effectiveness of plain and irradiated vaseline, and have es¬ 
tablished that t here is no dill emu e in t heir ell eel upon eit her 
bacterial cultures or different race's ol the bacteriophage. 

I he method described has the following advantages: 



i. It is .simple* in its application, requii i11 j_» a miiiimimi 
amount ol laboi on the part ol the surgeon and his stall. 

l>. It does not interfere with the i mmohi I i/at ion ol the 
part, not does it lavoi edema ol the granulations 01 the* soil 
structures because ol incqualilN ol pressure at or in the im 
mediate neighborhood ol the wound, since there is no 
window in the cast. Ilus is cpiite contraix to the (.arid 
Dakin or maggot method ol treatment, both ol which must, 
ol necessity. ha\e a window in the cast. I believe that a 
uniform pressure over the wound and neighborin'; tissues 
isuch as this method affords) will avoid exuberant granula 
tions and edema —an important consideration in the healing 
of a wound, as is exemplified in the case ol varicose ulc ers. 

1 lie parallm \ aseline tampon automatically yields to 
the enc roac hment ol granulat ion, healing, and c losure ol the 
wound, thus gradual In extruding and keeping up a constant 
ph\siologic al pressure upon the surface ol the wound at till 
times. Ibis is more effective than frequent dressings bv the 
surgeon, and. in addition, avoids the possibility of reinfect¬ 
ing the wound b\ a foreign llora of bac teria. 

p Ibis dressing is lavorable to the appearance ol the 
native bacteriophage and to the periodic introduction ol a 
la bora tore bred phage. 

j. It requires a ver\ short period ol hospitalization. 

The l brs of Bacteriophage. In addition to its application 
to inlected joints and bone wounds, the bacteriophage lias 
proved a most efficacious specific agent in combating lesions 
suc h as I in un< les. bods, carbuncles, and phlegmons, l or 
these conditions it may be applied in two ways: 

i- It may be- thoroughly rubbed ovci the* surface ol the 
wound and the* lesion covered bv sterile pads soaked in bac¬ 
teriophage; or. il the lesion is ol extensive si/c* oi depth, it 
may be dressed with the paraflin and vaseline tampon with 
a cat I let ei incorporated lot periodic introduction ol bar 
tei iophage. 



-• li ilia) Iic injected subc ulancously inlo the soft pin ts 
by means <>l a hypodermic needle about the periphery ol the 

In baeterieniia, particularly with Sla/j/iyloeoeiiis aureus, a 
baeteriophage prepared with asparagin as a medium and in¬ 
jected into the blood stream, has, in the hands ol Dr. Mae 
Neal * reduced the mortality from practically too pci cent 
to less than 50 per cent, even when there have been two 
positive blood cultures (Slajdiylocoeeus aureus). Not only is 
the bacteriophage a successful local therapeutic agent, but it 
has the added advantage ol helping to establish a possible 
general immunity on the part of the patient. Also the bac¬ 
teriophage is, to some degree, effective in experimental 
animals when injected at a site distant from the infected 

Certain cases ol septic hip disease are followed by listulae 
and sinus formation, destruction ol the epiphysis and the 
production of a loose, llail-like pseudarthrosis. the "pseudo 
arthrose flottante” of the French. 

The ultimate condition is Irecpiently difficult of differ¬ 
entiation from congenital dislocation ol the hip by means ol 
physical examination alone; the v-ray diagnosis is final in 
suc h c ases. 

Remodeling the Ihj 1 Join! in Healed Rases. II the path 
ological dislocation is loose and it is possible to pull the 
femur down, or il the case has been lolloweci horn the be¬ 
ginning and the length ol the limb has been maintained, the 
riding up ol t he t roc hantci on the side ol t he pel vis has been 
prevented by the author in several instances l>v approaching 
the* hip through the Smith Petersen incision and turning 
down ovet the* lop ol the* trochanter a large area ol the outei 
table ol the* ilium just above the location ol the acetabulum, 
and fixing il there bv means ol brace grabs, also obtained 
from the outei table ol the* wing of the* ilium (Figs. (>(> 
and (>7). 

* New Voi k Post-C a actuate Hospital. 


I In* end results in i.w's nl sn|>pnr;il i\c ;»rl h 1 ills <>l the 
hip am ver\ nnlavorable. 

Rev like ' reports on .1 series ol 2() cases ol osteomyelitis 

I k . (ili. () I (1 acme epiphysitis, with destruction ol head and neck and disloca¬ 
tion upward of trochanter. 

ol the hip joint region in which there were S deaths. In all 
ol the survivin'; patients, healino was obtained with ankylo¬ 
sis but without listnlae. 

Ankylosis is more Irecptent in the eases complicated by 
osteomyelitis ol the ilium and femur. Six to nine months 
alter the - healino ol all sinuses, an arthroplasty (see p. 212) 
c an be clone. 

* Rcm like. Die akuli Osteomyelitis del lliilij>elonks»c/cnd. Ik/i. /. /,•//». 
( hir., 1*3: aoS, KJ32. 



II lhere* is marked scarring <>l the solt tissues, which Ire 
<|uently oc c urs in these c ases, arthroplasty is usually not clone 
because the scat will not permit active muscle control ol the 
new joint. 

S'! PHI!.I l ie Ak 1 HRITIS 

In (K<iiiired \\j)lrili.s, alony with the rash ol the secondav\ 
stat»e, a characteristic synovitis may appear. The hip ma\ 
become painlul on motion and the capsule distended. Fltis 
condition may disappeat with the rash or may become 
chronic with rout i lined painlul mol ion ol hip, synovial thick¬ 
ening', and increased joint Iluid. This lesion may be con 



I nsec 1 u i i It eat lx 1 11 1 km ( til os is ol I lie I) i | >. In t hr ter I ia i \ stage 
ol s\ pliilis gummatous sxnoxilis max dex elop. I Ins condition 
resend lies tnhercnlons sxnoxilis Inn is U'ss prone to suppura 
lion and is tree from pain and limitation ol motion, ( lion 
droat tinit is max develop. c Itarac tei i/ed hx I'liiinnala neai the 
arti( nlar sin lace. 

In congenital .sx/t/iilis, the characteristic lesion is epi 
physitis accompanied hx a serous ellnsion into the joint, 
(.honchoarthritis and pxarthrosis are occasionally seen. 

Diagnosis max he made hx the W’asserniann or Kahn hlood 
and spinal llnid tests. 

T) rut mail ol the sx pliilis hx the 1 specific medication ap- 
propriate loi the panic ulai stage ol the disease manilested 
hx the' patient is the most important therapeutic measure. 

During the statue ol acute sxnoxitis, weight-hearing and 
motion ol the hip should he restricted by spica cast 01 
(intc Ik's. Kite presence ol gummata near the hip joint neces 
sitates protection Irom weight hearing to prexent crushing; 
and Iractnre. 

N i i ion roi’iiic: Am mu ns 

In the course ol tabes dorsalis and syringomyelia (lharcot 
hi]) max dexelop. The characteristic lac k ol pain in the pres¬ 
ence ol marked joint destruc tion differentiates this condition 
from other lesions. The condition starts with swelling and 
distention ol the capsule. Two distinct processes are present 
at tlie- same time: \ marked destrnclive inllnence which leads 
to the solution ol the head ol the femur and acetabulum, 
and an attempt at repair. The hip joint max become a loose- 
hag ol semi-fluid deti it is. 

Diagnosis. I'abes dot.sail.s shows Romberg s sign. Argxll 
Robertson pupil, lost knee-jerks, positive Wassermann re¬ 
action and characteristic colloidal gold spinal fluid reaction. 

Sy imgoni yrlili.s characterized hx lac k ol pain sense and ol 
temperature sense, with preserx at ion ol tactile- sense in the 

same ai ea. 



Trentinenl . The most important therapeutic indication is 
the protec tion ol the hip from weight bearing with a spica 
east and crutches. In the syphilitic cases cautions treatment 
ol the teniary syphilis h>1 lowed I>y arthrodesis ol the hip with 
a massive bone ‘•rail from the side ol the ilium is a satislac- 
lory procedure. Arthrodesis is not satisfactory in the cases 
clue to syi in^omyelia. 

Chapter VIII 


A NkYLOSIS <>l the hip m;iy he fibrous <>i bony Itom 

/■A articulai and ligamentous (bailees, i.c., the eondi 
A V tion in which two or more joint surfaces become 
bound together and immovable. It must here be staled that 
even case ol stillness ol the joint does not necessarily indi¬ 
cate ankylosis, r.g., musc ular contraction in joint disease, or 
joint immobility In mi shortened muscles, tendons, fasciae, 
and skin from am cause. ()l the fibrous varieties, the tuber¬ 
culous is the commonest. Much can lie done to prevent 
permanent malposition during the development of ankylosis 
b\ weight extension in the propel direction, and by proper 
ambulatory splinting and support. 

Tvi'l-'.S c )1 \\ kl I.C ISIS 

i. Fibrous luhylosis. In thisvariety, bands ol fibrous tissue 
connec t the joint sm hu es. I he degree ol movement de¬ 
pends upon their extent and length, fibrous ankylosis is 
produced b\ injure (e'.g., dislocation and fracture of a joint) 
also b\ pyogenic infection, gonorrhea, tuberculosis, rheu¬ 
matic or gout\ diatheses. 

-• Bony \nkylosis. In this form, there is osseous union be¬ 
tween the artic ulaling surfaces. I lie' usual c ause is suppura¬ 
tive arthritis, but the condition may also oc c ur in lion-sup¬ 
purative lesions, sue h as syphilis, inhere ulosis. etc . 

hikylosis ni the /nolifciiilivr t\j>c of non-t liberations 
arthritis (arthritis delormans). as described by Xichols and 
Richardson. According to these investigators, .ankylosis is 




produced in three ways, viz.: Prolderation ol the perichon 
driimi which is readily transformed into cartilage or hone; 
in other instances, new hone is formed from osteoblasts aris¬ 
ing in the hone-marrow; rarely, fibrous tissue is transformed 
into hone. 


I he causes ol ti ue ankylosis are acute and (lironic inflam¬ 
mation of a joint from any cause whatever, suppurative or 

Proimix i.axis 

T he danger ol ankylosis may he lessened or even elim¬ 
inated by judicious treatment ol its primary cause, viz.: 
(1) Early incision and thorough drainage of suppurating 
joints; (2) by avoiding too prolonged immobilization of joint 
fractures; (3) early and efficient protection and fixation of a 
tuberculous joint, by limiting the extent of the lesion, will 
modify the degree of eventual ankylosis; (4) traction and 
the avoidance of wide open drainage ol infected joints, which 
exposes the synovial membrane to drying. Complete bony 
ankylosis is not always an undesirable condition il the limb 
and the joint are in a favorable mechanical position. T his 
is most forc ibly illustrated by the joints concerned in locomo¬ 
tion, i.c., a knee joint, lirmly ankvlosed in lull extension, is a 
lat more useful agent in walking than a knee joint with onl\ 
5 degrees or 10 degrees ol mobility. 

l)i AC. X< ISIS 

The exlcait ol the ankylosis is estimated b\ several factors, 
the etiology, examination under anesthesia, radiography, and 
manipulation. Differential diagnosis between librous and 
bony ankylosis is made as follows: In the librous variety, 
even though it be firm, forcible manipulation beyond a cer¬ 
tain point c auses pain, which does not occ in on extreme 
movement in bom ankylosis. When the dillerentiation be- 



Iween tin' librous .iml the- 1 »<>i i\ varieties still remains un 
(ill.lilt, tin- \ ra\ oi examination midei anesthesia will 
usual lx settle the dillerenee and establish the pathologic al 
\ai iet\. 


I he probabilitv ol ankylosis superv cuing in a given ease 
depends on the nature ol the pathological process and the 
eharaelei ol the treatment. Suppurative processes nsnally 
lerminale in horn ankvlosis; tnherenlons processes, in fibrous 
ankvlosis. There are. however, exceptions to this rule in 
both instances. In the case ol partial librous ankylosis, il 
active movement and manipulation are not followed by 
blither limitation ol the function of the joint, the outlook 
for nselillness is good: the (outran is also trite, fibrous 
ankvlosis is often made worse ratlici than belter by loreible 


The limb should preferably be fixed in a position of ab¬ 
duction. sufficient to compensate almost completely for bom 
shortening ol the limb with the thigh Hexed to or 15 de¬ 
grees. and the loot slightly rotated outward. The usual po¬ 
sition ol the hip alter any irritating condition ol the hi])- 
joint is that ol flexion, adduction, and internal rotation. 
This is the deform it v we lit id in all untreated or impel feet Iv 
treated hip-joint affections. I he posture produces lumbar 
lordosis and a \ci\ awkward limp. If the hip is lixed in the 
slightly Hexed and abducted position, lumbar lordosis and 
probable consequent backache are avoided, and walking is 
rendered much easier. The gait is more natural il the foot 
is rotated a little- inward ratlici than straight forward. Un 
fort 111 iatel v, t Iiese preeaut ionai \ measures are often neglected, 
and it is the rule rather than the exception to lind ankylosis 
in the position ol deformity, namely, flexion and adduction. 


l oi t lie lee hnique ol osteotomy lor correct ion ol deformity 
see page 244. 

1 'ibrous Ankylosis. Having ascertained that all inllamma- 
t ion is at an end, the | >r< nee hire is as lol lows: Oradnal st 1 etc h- 
ing ol the adhesions by manipulation; application of hot wet 
packs lollowed by massage should precede manipulation of 
the joints. When to manipulate requires judgment based 
upon a great deal ol experience. Massage should precede and 
lollow manipulation. In conditions resulting in marked 
osteoporosis an excess ol massage should precede manipula¬ 
tion because ol danger ol crushing the bony elements ol the 
joint or frac turing the neck of the femur. Adjunc ts to manip¬ 
ulation are baking and vibratory massage. Various forms of 
electricity and elec tric light baths may also be tried. 

Forcible stretching under anesthesia is a reprehensible 
practice il promiscuously performed. Unless it can be ap 
prehended during manipulation that the adhesions are gi\ ing 
way, force should not as a rule be employed. Acc idents at¬ 
tending brisement force are: Separation of an epiphysis; fat 
embolism; the lighting up of an old process; rupture of an 
artery or vein; gangrene ol the limb; permanent paralysis 
from nerve stretching; and Iracture ol the bone near the 

Bony Ankylosis. I he only means of securing mobility in 
bony ankylosis is by operation. II correction ol malposition 
only is desired, osteotomy is sullicient. I lie formation of a 
new joint is the desideratum, however, in even case. I he 
reconstruction ol a joint should not be undertaken lighth. 
but with due consideration of the merits ol the individual 
case and with varying prospects ol success, according to the 
joint in question. Il is useless to construct a nearthrosis il 
stability of the limb is thereby destroyed, or il the limb is 
less useful to the individual with partial mobility than when 
lit inly ank\ losed. 

f'ormerly it was the 1 opinion ol the 1 author, as well as that 
of others, that in the case ol bony ankylosis, il the 1 position ol 



the limb good (d iglit llexton ;ttnl abduction), it was 
betlei lei alone, unless the condition was or the 
patient insisted upon mobililx b\ operation. Ilowcxcr, sin( c 
bone reconsi rnci ion methods ha\e made possible the provid 
ing ol lex erage lot the abductor and oilier muscles with 
marked increase ol box lion. siabiliix and weight bearing, 
the pendulum has swung si rough toward arthroplasty. 

In analx/ing the reason loi skepticism on the part ol some 
regard ini’ the wisdom ol mobih/ing ankvlosed hips, one 
linds considerable dilierence ol opinion among the best <»I 
surgeons. In most instances, howexer, the lailure to secure 
aetixe muscular stability, which many times results bom the 
usual type ol operation, is the reason. Henderson, rexiewing 
the end results ol arthroplasties ol the- jaw. elbow, knee and 
hip, lound those lor the hip the poorest. The problem is 
obxiouslx more complicated in weight bearing joints. The 
occupation and social status ol the patient, as well as his 
temperament, are olten determining factors in deciding 
whethet 01 not to operate, where the relationship ol the le 
nun to the pclx is is laxorable. I he patient must be a mentallx 
stable indix ichtal who is willing to go forward w ith the neces 
sat \ prolongation ol postoperati\e physiotherapy. W hen the 
hip and knee on the same side are both ankxlosed, the ad 
xantagesol arthrophistx are much enhanced. 

Stability bx musc le ac tion is \ ery important at the hip, 
and, although the rotarx nature ol the joint lends itsell to 
at tbioplastx, ttnlorlunate results hax e followed at tinoplastx 
when s t a I) i I i t x was not obtained. 

\rl Itroplast x in cases ol t ttberc til os is shot t Id bc“ ap| m niched 
with a great deal ol < onset \ at ism: and onlx when the 1 bonx 
ankylosis is complete and the roentgenogi am shows e\ idcnce 
ol complete disappearanc c“ ol all disease and a complete 
Itomogcneilx ol bone siriicitire throughout the' oprralixe 
held, should opcatition be ttdxised (Tig. (i<S). 

M in pi tx in t (jo | tcpoiled his teclmicpie lot arihroplasly of 
t he hip, ;m d in i (job I I oil a reported lix e art h roplast ies ol the 

I k.. (IS. \ r;i\ 10 illustrate ;i common occurrence in tuberculosis of hip. 
(,;ise lailed lo respond lo conscn alive treatment ovci a period ol si\ \ears. 
will) resultant knock knee and knee la\il\. I-Mra atliculai lihial hone j>ralis 
relieved symptoms, fused hip and cured condition. 




liip. hum that time' on, an incrcasinig nnmbci aic lonnd in 
the literature. In lad. in m\ hands artlnoplasl\ ol the hip 
has become so dependable and well rctgaidcd that uhenevet 

Ik., (ii). Same ease as I igurc (is alter removal ol most ol tibial grails and 
an a 11 Ii i ophist \ restoring motion to within 20 degrees ol normal. Stumps ol 
grafts were lelt to increase length ol lever at top ol lenitu lor trochanteric 
muscles to pull upon, thus increasing strength ol abduction and weight- 
boa ling. (.real (onsei vat ism should he exercised in selecting sutli cases lot 
mobili/ing opei at ion. 

dointg an operation to sullen a joint, il that case is a possible 
favorable one for Intnre arthroplasty, I so plan my arthrodes- 
inn operation as to make it as lavorable as possible for the 
Intnre mobilizing; operation. I he points in favor ol a Inline 
restoration ol motion to a joint are: Favorable age and 
temperament ol patient: satisfactory decree ol preservation 
ol overlvini»- soil parts and muscles; and sal islaclorg 'general 
t <nidilion ol limb, in< 1 tiding, bone at the sile ol the propt>sc<I 
operation. J herelorc, in doing, an arthrodesis, in a case 
which is lavorable lot a Intnre mobili/inn operation, I prelet 
to t.ike bone lot the igtalt elsewhere, rathei than to disturb 
nndnh periat tic tilai structures 01 important surrounding, 



muscles l>\ obtaining the bonc-grall material locally. At the 
hip. tibial oi iliac grails are preferable, because ol their ade 
<piac\ c>I length and strength, thus making ii unnecessary to 

I ii.. ~o. Same case as ligiires (is and (ic), showing sacislacloi \ . painless motion 

at 1 ell hip. 

incorporate them in the- joint itself. II there has been an ap 
proximation ol the great trochantei to the rim ol the ac e¬ 
tabulum. because ol telescoping Irom bone destruction, then 
grail material Irom the outer table ol the ilium can be 
obtained ol sullic ient dimensions. Obtaining bone Irom the' 
great trochantei has, besides the disturbance ol the hip 
musculature, an additional disadvantage in that it shortens 
the trochantei femoral necT leverage, an important item in 
musc le control ol the' lup. \t the knee", lot the same reason. 
I no longer employ the' patella as a source lor ariluodcsing 


2( D \ftei its diseased portion h;is been muoud. the 
|>. iiill. i is Lit .is intact as possible loi the Inline art In oplast v. 

To be chtssed as a good result in arthroplasty ol the hip, 
there should be a minimum amount ol voluntary lle\ion ol 
at least decrees, h \ ei v tiling being considered, a hip that 
possesses •>-, degrees ol painless. ;u l i\e mol ion. isl.n snperioi 
to a still hip. Not only should the hip joint have motion to 
allow propel silting, but it should be painless and Innclion 
in Lx onmt ion. pat t it nlai l\ in bearing the w eight ol the body. 
It is 1 a 1 bettet to ha\e a still, immobile hip than one accont 
panied b\ weakness and lack ol satislacloix weight bearing 
01 abduction. One antlioi goes on to sa\ that “the more 
nearly the joint is similar in si/e and shape to the original 
joint, the greater w ill be the stability I lence. arthroplasty is 
not a resection!" I bis statement should be challenged. A 
ball and soc ket joint situated at the hip cannot have pn sr 
a desirable amount ol motion and still be stable, because 
passive stability could only result horn the capsule acting as 
(heck ligaments to motion, and this, in itsell, would prevent 
adequate motion. Desirable stability with a large range ol 
motion must come Irom muscle control. One frequently sees 
excel lent I \ 1 n net inning hip joints when there has been, from 
disease, an extensive destitution ol bone and no semblance 
ol a ball-and-socket joint remaining. Lite reason for this is 
muscle control which is the all important consideration as 
to whethet a hip is stable and whether there is a satisfactory’ 
amount ol active motion and weight-bearing. 

1 he mechanics ol the Inp can be resolved into simple 
terms. I he hip joint itsell is a Inlcrnm point situated at the 
end ol a level (namely, the neck ol the lemur). I lie distal 
end ol ill is level (t lie great t roc hauler) is coni to I led bv means 
c >1 power I n I muscles that are a bl c. bee anise o I 111 is mec hat l tc a I 
setup, to pull ot actively lilt the limb at an angle with the 
pel\ is. I his ac live abduction is a most impoitanl Icalnrc of 
Ioc omul ion in that it is tlie essenc col weight beat ing. In otliei 
words, it is impossible lor an individual to bear weight satis 



laclorilx on a limb when the lti|) is mobile unless the musc le 
coni ml is such that llic limb can be held so that il will not 
swine, into addne l ion. I his is brought about by the median 
ieal ac tion ol the abdnc toi musc les ol the hip pulling on the 
distal end ol l his lew ci. 

II this statement, used as a premise, is true and il it is 
possible to maintain this muse ulai control, then c arelul 
modeling with the bead ol the femm lully Idling a deep 
new made acetabulum (with the cl i I lit idly ol securing a tree 
range ol motion incidental thereto) is not necessary 01 de¬ 
sirable. 1 he deeper the new acetabulum is made, and the 
corresponding' Icmoral head lilted to il. the less the chance 
ol securing a good range ol motion. Therelore, in selecting 
cases lor arthroplasties ol the hi]), one should be sure that 
the muscles about the hip are reasonably preserved. Formerly, 
it was my practice to rule out cases in which there had been 
extensive shortening ol the neck ol the lemur, either Iron) 
bone destruction or Irom a telescoping ol the head and neck 
ol the lemur into the pelvis, loi the reason that even il the 
abductor muscles were intact one could newer expect satis- 
lac lory lime lion in active abduc tion because the troc hanter 
remoral-neck lexer would be still lurther shortened In the 
modeling ol the new donned hip, and thus lurnish inade¬ 
quate lexerage lor the abduction or weight bearing muscles 
to pull upon. 

I bis was lully realized twenty years ago when designing 
nix' reconstruct ion-arthroplasty lot mumited Irac luresol the 
hip with remoxal ol the head ol the lemur, and placement 
ol the denuded trochanlei in the acetabulum: because ol 
this, the lexerage action ol the neck ol the leiinu that was 
lost was restored In lengthening the* lexci on the outer side 
ol the long axis ol the shall < >1 the lent nr In erect in g. lateral lx 
and obliquely to the shall, a bone muscle lexer with the in 
serl ion ol the hip abduc tors to its upper end undisturbed. 
Later, in order both to inc rease the length ol this lexer and 
to assure its maintenance, the removed Icmoral head was 


sh.i]>ci 1 .is ,i wedge .ind placed mi .is lu hold n oulu.iul. In 
1 1 1is wav. one is able in such eases. c\cn in llic (omplelc ab 
sente dl i lie head and neck ol the lei i nil. with die denuded 
tiochantei placed in (lie acetabulum. lo establish a lc\ci 
ec 11 la 11 \ as long .is the normal tiochanici neck level ol a 
normal joint. W’hethei the insulting reconstructed joint I < >1 
lows a non union, oi a shallow modeled ac ciabnlnm ol an 
a i th i <»]ihist\ loi ankylosis, the mec hanic al conditions bronchi 
about in the alien e lnannci prevent dislocation when the 
limb approximates the midiine. which is a real ha/arch unless 
provided against. I he modus ojirimidi is as billows: As the 
limb seeks the midline, the tipper end ol the erec ted bone 
gralt level travels larther and larther awav Irenn the rim ol 
the ac el a I ml mil and the side ol the pelvis, and thus not onl v 
puts an ine leasing tension on the short alnhietoi muse les but 
also on the surrounding' lascial struc tures, thus holding*' the 
head ol the lemm sec 111elv in the ac etabulum. 

liecattse ol the verv satislactorv experience with this me¬ 
chanical setup in a I a l o e number ol cases ol ununited I rac 
tures ol the hip. I Iicgai i ten vears ago to applv the same prin¬ 
ciple to cases ol paralysis ol the abductor muscles and also 
to c ases ol ai throplastv w here, bec ause ol bone destruc¬ 
tion, the trochanter-neck lever is practically absent or much 
shortened, and a satislac torv result by arthroplasty alone not 
possible. I herelore. in recent years, the destruction ol the 
head and neck ol the lemur (with telescoping) has not been 
considered a contraindication in selec ting cases lor operation, 
in that I have lotuid in doing an arthroplastv that a hip joint 
could be modeled with the head ol the lemur much smaller 
than the ac etabulum, w ith suflic icnl lascia and lat to lill in 
the interspaces, and that the mechanical influences brought 
about bv the provision ol leverage action lor muscle control 
on the outei side ol the troc hanter not onlv prevented dis 
local ion. but a I lowed ac l ivc abduc t ion and sal is lac lory weight 
beat ing. 



■ litllio) v / <’( Inin/ite. I he patient should he placed on a 
liacime orthopedic table. I he Smith Petersen approach al 
lords such satisfactory exposure that ii is the incision ol 

choice lot all intra at ti( ular operations. I he incision begins 
at a point about | inches below the anterioi superiot iliac 
spine, and is c at t ied along the outer bolder ol the sartorius 
muscle, upward to the anterior spine and thence backward, 
following the iliac crest. The gluteal muscles are detached 
and reflected subperiosteally bom the wing of the ilium 
downward en masse, thus giving a wide exposure ol the hip- 

by means ol a large carver's or Murphy's gouge, the lemm 
is separated Irom the pelvis (Fig. 71), care being taken to 

21 .? 


make the hone incision in mk Ii a ua\ that a rounded I'cmoral 
head and a corresponding aeetahnlai ca\il\ are shaped. I lie 
aeetabnlnin is not shaped nearly as deeply as lornierly, be- 

eanse ol the I act that I Imd the present tcchnupie obviates 
the danger ol dislocation, and further that this is a ven satis 
factory influence in In inline, about a greater decree ol lilti- 



male motion. Ihe various ranei s ”oti”es and chisels are ol 
or eat veilin' in 1 > 1 a s i u hone work, especial l\ in arl In oplast ics. 
I he la roc \ ariet\ ol c til I ill” eeloes and curval tires ol ilie chisel 


I it. . j|. I l.ijt ol hist ia .uni lal Inin” licvd Irom imclcrlv Ini' muscles ol ilii^h. 
il min \ 11 ices "On hojK'dit .uni Ret onsi run ion Sur^erv.'’ Sauiulcrs.i 

or ”ou”e enables the surgeon to select the propel tool lot 
almost am enier^em \ . 

Alter the general contours ol the joint are thus blocked 
out. the sinlaces are merely smoothed and translormed into 
regular spherical comes and concave sinlaces by aitliro- 
plastic hip rasps, modi lied Irom Murphy’s (bios. 72 and 7^). 

I he concave and convex rasps are placed in between the 
lemoral head and the acetabulum and these sinlaces 
smoothed and shaped bv a to and Iro motion ol the 1 handle, 
in the manner ol a spoke ol a wheel. I he tools will execute 
this work laslci il an assistant pushes upward on the patient s 
knee. I liese instruments enable the surgeon to shape ac 
curatclv the nine) portion ol the joint which cannot be 
01 gotten at bv an ordinaiv inslrumenl. 




I lie next step is to applv traction to the limb, to sepa 
late the head 1 1 out I he ac via I hi I inn. so that the hone part irles 
can he washed out by means ol a ejass cannula connected 

Ilf.. Impropct method ol disscc'ling-nut ;i lascial transplant. IW iliis 
method no lai is left adherent to fascia. (Irom Xlhee’s "Orthopedic and Re¬ 
coils! nut ion Surgerv." Saunders.) 

with a 1 on n tain ol saline sol lit ion over the table, and to allow 
the easy insertion ol the last ial Map. about to be obtained 
from the tlii^li, lower down. A semicircular skin incision is 
made on the outer side ol the thi^li. midway between the hip 
wound and the knee, and a < piadi i lateral piece ol last ia lata 
with as much lat as is obtainable, about | inches loti”' bv 
'> l (, inches wide (in adults) is secured. I lie subcutaneous 
layer ol lat is div ided in equal halves, one hall bein^ lelt 
attached to the skin and the othet hall to the raft, which 
is subsequent!) to be removed (Fi*>s. y| and 75). With 
a small curved needle, stav sutures are plat ed in what are to 


hr ilit' I wo i m km coiners .ind llir List grail is di.iun in 
and pushed into ihr iniiri ronlmes ol llir nru joint In some 
instrument, as lai as possible between the new joint surlaees. 

Additional sutures are then placed about the periphers ol 
the e; i a 11. I he last ia is carelulh approximated by a eon 
t innous snt tire ol No. i chromic catgut. 

II. at this point, il is thought that the leverage action ol 
the net k ol the lemur is not siiIIk ienl. a bone I raiment, con¬ 
sist in i*' ol the tip and the on lei sin lat e ol l he I rot hauler til a 
\ ;i r \ i 11 o 1 c • n i* t h (approximaleb gi,', inches) is separated with 
a broad thin osteotome, with the insertion ol the abductor 
muscles intact, and swung outward Irotii the shall ol the 
lemur from 20 to degrees. In producing a green stick 



limitin' at its lowet end. Inlo litis iriangulai spine, between 
t be remaining port ion ol 1 lie shall < >1 i he lemur and 1 lie bone 
I ragmen 1, a segment ol the crest and outer table ol the ilium 

iii.. 77. Diagram to illustrate lengthening ol lever arm at top ol I'emui 
where it lias been shortened bellowing arthroplasu u> restore motion, loss 
ol hone ma\ be from destruction In disease 01 trauma plus necess;tr\ remcnal 
ol bone at opeialion. Ibis same principle and operation are also applied in 
lengthening ol this le\ei bevond its anatomical length when the abductoi 
muscles ba\e been weakened In infantile parahsis 01 olhei cause. 

is fit ted (Fig. 77). Ellis grab mav be supplemented by I rag 
incuts ol cancellous and cortical bone, also obtained Irom 
the ilium. This bone muse le le\ei operation mav be done at 
the same time as the at tin oplasl\ 01 at a later date, as the 
surgeon thinks best. Dressings and slickers to the thigh are 



,i|)|)lu'd. W ill ilu’ liml) m modelair abelue I ion. .1 plaslci <>1 
i11 js s|)i(,i is . pplieel Irom abo\e tlu* costal margins on ilic 
opposite side to the toes, with slickers cotiiiti” out lliroii”h 
the plaster. al>o\c the ankle-. I 10111 1to uo pounds ol trae 
limi with pnllcx and weight is applied immediately and 
liiailllaine'd I01 three weeks a 11 e-1 die- u-inoval ol die' plasle-i 
spica (tin e t- weeks postoperativcly), 01 until a l ayloi trac¬ 
tion braee or I hennas knee' braee is applie'd. and locomotion 
with e rule lies is allowed. 

1 his braee should be 1 continued lor at least tlire'e months 
belore weight bcarini; is permitted. dining which time-. 01 
longer, elaiI\ massage and . 1 e 1 i\e- and passive motion are e .11 
lie-el out. 1 Taction is most neeessaiA and should be applied 
belore 1 the- patient mines out Irom under the' inlhtenee ol 
the anesthetic, because ol the' dew ilali/imj, and crushing' 
effect that wonlel otheiwise be produced on the hise ypalt 
b\ the iuvol unian e out rae t ion ol the power I til t h ie, h muscles. 
I have found that with a pnlle\ and rope erected ovei the 
bed. Listened to a sii 11 yj, beneath the knee, the jratient is able 
to help \e'i\ materialh in inobili/ine, the joint b\ eonstantlv 
pnlliin; the' hip into flexion. I bis en^a^es the patient's at¬ 
tention. and is a real help as a part ol the postoperative 
pin siothe i apv. 

A ball-and-socket joint, partic 11 lari\ the hip, with its alia 
tomie provision lor muscular eontrol. cannot be stabilized 
b\ modeling ol tbe- joint contours alone; the' lit of a ball-and- 
socket joint in machineiA ma\ be so an urate as to be w ithin 
a lew microns and si i 11 the' mot ion be as I rce as with a lo< >se 

I Im stabilitN ol a Ireelx movable hip-joint, particularly in 
weight bearin;_p which is the most important consideration, 
must be- through the medium ol muscle eontrol. espeeialb 
the short troe hanlerie muscles and tlieii pull upon the tro 
e liantei de-moral nee k Ie \ e i. In most artbroplastie procedures, 
this level is eitliei shortened to such a decree that it 110 
lone*ei bine lions. 01 it ma\ be entireb obliterated, lienee-. 



the necessity lor its elongation 01 restoration bv surgical 
means, citliei at the primal) operation 01 later at a second 
operat ion (see ( Tap. VIII. p. -1S). 

Min])h y'.s /'('(Inin/lit..* Murphy used three incisions; the 
original one was 1’ shaped, beginning l l/, inc hes above the 
trochanter and i inch behind it, extending down 2 inches 
below and passing’ under and in front of it tip to a point 
opposite the commencement. Sometimes the- skin was divided 
down at the lowest point ol the 1 to form the large inter¬ 
posed Map. I he second inc ision was along the iliotrochantei 
line t inc h below and in Iront ol the trochanter and upward 
lot about 5 inches in a straight line with the anterior su¬ 
perior spine ol the ilium. The third was a modification ol 
the second, in that the incision was curved and convexed 
bac kward behind the troc hanter. I I is next step was to free 
the trochanter bv a chain saw and retrac t it upward with the 
attached muscle. 

The ankylosed head ol the femur was severed from the 
ilium, as near the anatomical line as possible, with a car¬ 
penter's curved chisel. It was driven oblicpielv into the ace¬ 
tabular cavitv for i inc h. The head was Irac lured out and 
the acetabular cavity fashioned w ith a spec ial globular burr. 
A corresponding cup-shaped cavitv was made to conform to 
the femoral head. 

A Map of lat and fasc ia lata, and subcutaneous lattv tissue 
(l/j inch thick) was inserted behind the head and neck ol 
the femur, and the edge was sutured to the acetabular margin 
and to the capsulai ligament with phosphor bronze wire. 
I he head was replaced. I lie trochanter was nailed in place. 
I he fascia was re-approximated bv chromic catgut and the 1 
skin sutured with silkworm oi horsehair. No drainage was 

1 he held operated upon was dusted with bismuth sub 
iodide powclei and tlm wound sealed with gati/c saturated 
with collodion. \ pad ol plain sterile gauze, moistened with 

* XI oi |> 1 1\. ). II. V1 11 11<>|> 1 :isIy ol l hr hip. /. Hone V /oml S101;.. 8 : ytii). !<)-(> 


()', pci cent alcohol and (ii pet (tail phenol, was plated n\ei 
die hip | oi inches hcvnncl (lie line <>I inc ision on eilliei 
side. \ Raiitcv splint and bucks extension with lm> to gy 
pounds were applied. I it it 11 legs were dressed in an a 1 x 11 it led 
posit ion. 

Passive motion was instituted in three or loin weeks. 

In tlu' majoritv ol cases ol ankylosis ol the hip reported by 
Murphy, there resulted a good range ol motion and ability 
to walk without support. 

Ban's Irclni i <i IK\* “The hip is exposed by the Olliei 
Miknlic/ incision. 1 lie trochanter, with its attachments, is 
turned back and the neck and head ol bone, as well as the 
part ol the ilium immediateb above the acetabulum, are 
exposed, lhe capsule is split parallel with the neck and 
stripped Irom the underlying bone. With a wood-carver’s 
gouge, the head is separated bom the acetabulum. Quite 
olten. one can find no line ol demarcation between the 
femoral head and the acetabulum. One must then chisel 
through the bone where one supposes the old articulation 
to have been. 1 he head is now delivered completely Irom 
the acetabulum. It is rounded oil and then filed down, mak 
ing it as smooth as possible. The acetabulum is now curetted 
and teamed out. making it huge enough to receive the head. 
I he smallest possible amount ol bone should be removed. 
Indeed we should cleave to the old lines ol the joint, both 
head and socket, il possible, l he head ol the bone and the 
acetabulum should be kept as near the not mal si/e as possible. 
Remember we are doing an arthroplastv and not a resec tion. 
\ll fibrous tissues in the neighborhood ol the joint should 
be sac tilled. All tissues whic h tend to form bone should be 
handled with the greatest care. 

I he pig's bladder membrane, w hic h has been prev iouslv 
immersed in salt solution loi ten minutes, is now placed 
about the newly lormed head and sewn with lorlv dav 
ehromic catgut to the librous covering at the distal portion 
I'*.h i. H s. Vnlimphisiv of the hip. /, Hour C. foint Sing., X: pip. n, a (i. 


<>l the lemoral neck. I hits the head and the neck of the bone 
are covered by a sat , as it were, dare must be taken not to 
tear or perforate the membrane. 

I he covered head is now replaced in the newly formed 
acetabulum. The trochanter is nailed to the shaft, at the 
point Irom which it was removed. The fascia lata is brought 
together with lorty-day chromic catgut. This skin is sewn 
with subcutaneous silver wire, (beat care should be used to 
ensure complete haemostasia, as no drainage is used in these 
cases. The leg is now encased in plaster, from the nipple 
line to the toes, the position being one of 25 0 abduction 
and slight internal rotation. 

“Ajter-treahnnit. The leg remains in the plaster cast for 
forty-eight hours, so as to control, by pressure of the bandage, 
any possible hemorrhage. The cast is then removed, and the 
leg placed in a Thomas traction splint, with a pull of 20 

“In this manner the leg is left absolutely alone until the 
twenty-first day. The splint is then removed and the silvei 
wire pulled out. For one more week the patient is allowed 
to remain in bed and to use voluntary active movements ol 
his own hip. At the end ol the fourth week he is given 
crutches and allowed to bear weight on his affected leg. 
Voluntary motions and active exercises are encouraged. 
Massage and passive motion are instituted. Shortly alter- 
wards, mechanical therapy and thermotherapy are started. 
As soon as possible, a cane is substituted lor the crutch. 
From now on the range ol motion gradually increases. One 
should not forcibly try, nuclei anesthesia, to hasten matters, 
but by gentle massage and mild passive motion, progressively 
stretch the peri-articular tissues. Limitation ol motion is not 
generally due to a poor arthroplasty, but is due to the still 
ness and unstretc hableness ol the peri-articular tissues inc i 
dent to the pathology which caused the ankvlosis. Clare 
should have been taken preceding or at the time ol operation, 
to remove 1 all scats and thick fibrous tissue." 

Chapter IX 


(General Considerations. In (he normal adult, the angle 
between the long axis ol the neck and that ol the shall ol 
the I'eimir is i go degrees, hut in a certain proportion ol peo¬ 
ple it is slighth less or slightl\ more, the variation depending 
upon the height, sex. width ol the pelvis, muscularity and 
racial characteristics. I his angle, therelore, varies from i2cS 
to 1 g2 degrees; in children, it is a lew degrees more, in the 
aged a lew degrees less than in adults. X-ray findings in this 
condition are final in diagnosis. 

A considerable increase in this angle ol inclination ol the 
femoral neck is called coxa valga; a considerable di in i n ill ion 
is called coxa vatu, which results in the ease ol extreme de¬ 
crease in the angle, in limitation ol abduction or in actual 
adduction. In general, alteration ol form in a part leading 
to add net ion ol that portion ol the limb beyond the de¬ 
formity is called a "varus” condition; its opposite is a 
"valgus" condition. It must be borne in mind, however, that 
the terms "varus" and "valgus" merclv denote position, and 
do not explain the lundamenlal pathological lesions under 
lying the delormity. Hxcept in congenital cases, the factors 
influencing the shape ol the femoral neck are the supei 
imposed body-weight plus vielding ol the neck at its most 
malleable point, from a variet\ ol causes. 

Definition. Coxa vara is the c linic al term signifving dow n 
ward bending ol the nec k ol the* femur sullic ient!\ to cause 
clinical manilestation, the condition being unilateral 01 bi¬ 



Anatomical I '> n s 

. I nalom k til / \jx’s. Bending ol the lemoral neck may occ ur 
.ii any one ol three portions. I hus, the following anatomical 
types are recognized (Fig. 78): 

Ik.. y.S. Angles ot inclinalion of femoral neck from normal lo two si ages of 
coxa vara. Last drawing indicates coxa valga. 

1. Cervical Coxa Cara. This is the type encountered in 
most instances. Bending affec ts the neck as a whole, its axis 
being a curved line. 

2. Ej)ij)hyseal Coxa Cam. I his deformity is most marked 
at the epiphyseal junction. This is the type most frequently 
encountered in adolescents. 

g. Coxa Cara Troi lianln ica. In this type bending occurs 
at the junction ol the neck and shall. This is a rare form, 
inasmuch as the neck is broadest and strongest at this point: 
it is Irecpient ly due to 1 ickets. 

Beside the angle ol inc lination (between neck and shalt), 
the- femoral neck also points lorward on an angle ol declina 
lion (appreciably by viewing the 1 2 upper end ol the lenun 
from above) made by the long axis ol the neck with the trans¬ 
verse axis of the knee-joint. This angle of declination is nor¬ 
mally about 12 degrees. In coxa vara, the head is usually dis¬ 
placed backward and the neck mav undergo torsion on its 



long axis. (Mikulicz slates that in to 15 pet cent ol normal 
individuals the head points backward.) I hits we mav have 
the I ol lowing: 

I 'arielies. (a) Neck bent downwaid and backward, the con 
\c\it\ looking forward and upward. Ilns is the commonest 
distortion. Result: decreased abduction with cxlernal rolic 
lion and evasion ol the loot. I he trot banter is elevated and 
flexion limited. Adduction, external rotation, and extension 
are in some cases increased. I he head is twisted backward, 
probabh under the influence ol the bodv-weight. 

ib) Downward bending ol the neck. Slight limitation ol 
flexion, but increasing limitation ol abduction. Next in lie 

1 hese two are the onl\ varieties ol bending ol any clinical 
importance. Othei uncommon varieties are: 

(c) Depression ol the lemoral head with posterioi con 
vexity ol the neck. Limitation ol external rotation with in 
\ersion ol the loot and leg. 

(d) I orsion ol the neck on its long axis. 

(e) Forward convexity ol the neck willioul downward 

(I) kalse coxa vara," clue to bending ol the upper ex¬ 
tremity ol the shall. 

F I IOI 0(0 

Coxa \ara is not an uncommon affection. The unilateral 
is much more hecpient than the hi lateral form. Males are 
much more Irequenlb affected than females on account ol 
the influence ol strain or injurs in causing or increasing 
the distortion. In unilateral cases the left leg is more often 
involved than the right because it is more often used in 
"rest ing.” 

Coxa vara is an aflec tion ol growing bone: hence it is cm 1 
countered mainly in adolescents, in whom the added factors 
ol instability ol the epiphyseal line, the greatei delicacv ol 



the sii ii( tmes and relatively greatei length <>1 the femoral 
neck predispose to the delormity. The assumption that the 
predisposition ol the femoral nec k to delormity is the result 
ol local disease, such as local tickets or local osteomalac ia, 
cannot he substantiated and, as Whitman states, is simply a 
convenient hypothesis. That the affection is symptomatic ol 
late tickets is aflirmed by some, although signs ol general 
rachitis ;ue wanting in the ordinary type ol coxa vara in ado¬ 
lescents. I he essential physical cause ol coxa vara is increased 
strain upon a diminished resistance ol the neck ol the lemiu 
(inherited delicacy, or weakening by injury or disease), 01 
disproportion between these two elements. 

In many instances, coxa vara is due to lessened inclination 
of I lie femoral neek from early rickets, which becomes exag¬ 
gerated until it becomes a delormity during later childhood 
or adolesc ence. 

GeneraI weakness, inc ident to rapid growth; direct injnrx, 
such as Iracture or the strain ol a laborious occupation, are 
contributory factors. II we could exclude the traumatic 
fac tor (cases of frac ture of the neck ol the lemiu and separa 
tion and fracture ol the epiphysis), coxa vara could be attrib 
uted in most instances to the immediate 01 remote effects ol 
ric kets. 

A ven considerable proportion ol the epiphyseal coxa vara 
is of doubtful origin; we refer to the border line cases ol 
gradual “sliding" ol the capital epiphysis (to which mote 
extended reference will be made later) where the influence 
ol trauma is absent or negligible. 

Ct Assn-1c: \ 1 ION 

For convenience ol description the lollowing classification 
(modified Irom I ubby) may be employed: 

./. ht/niied Coxa I'aia. 

1. Cervical and trochanteric coxa vara. 

2. Epiphyseal coxa vara (adolescent). 



•5. S\ Diplomat it co\a \ at a. 

(a) l)tic‘ to 11011 i 111 lanuuat 01 \ processes. 

(a) Ru kets. 

(It) ()steomala( ia. 

(e) Senile osteopoiosis. 

(I>) Due to inllammaloi \ processes. 

(a) Osteomyelitis. 

(b) I ubei 1 nlosis. 

(c) \i tin it is deformans. 

(c) 1 1 amnat it coxa \ ai a. 

(a) Separation ol the epipltvsis ol the neck in 
children and adolest ents. 

(h) Fracture ol the net k ol the lemur in t hildren 
anti atlolest ents. 

(t ) 1- rat t m e - ol the net k ol the leniin in adults. 

B. C.on^niildl Coxa l ain. 

1. With no other deformity present. 

2. \ssot iated with congenital dislocation ol the hip or 
othei deformity. 

Ct.lMCAI. Ft A l l RI S 


Mechanical Deformity. The great trochantei is elevated 
aho\e Xelaton's line, the amount ol elevation depending 
upon the degree ol depression ol the lemoral head 01 net k. 

Fhe trochantei forms a marked prominence at the hip whit h 
is increased on Hexing and adducting the hip. Fhe displace¬ 
ment ol the net k downward and backward, which occurs in 
the majority ol cases, lollowing the lines ol least resistance, 
causes the trochanter to be thrown lorwartl anti the limb to 
undergo external rotation. Normal abduction ol the thigh 
depends on the length ol the lemoral net k, t onsctpicntl\ 
diminution ol this angle ol inclination lessens the range ol 
abthit lion. I his limitation ol abdut lion is due partly to in 
creased tension on the interim portion ol the capsule and 



part I y to the lac t that the letnoral neck and (mchantci im¬ 
pinge on the tint ol the atetabulum, the disability being 
Ini lhet aggravated by contrac ture ol the pelvitroc hanteric 
muscles. Also backward and downward distortion ol the neck 
allets the relationship ol the head and acetabulum, favoring 
luxation ol the head when the femin is Hexed or abducted. 

lo sum up: the derangements ol motion ate limitation ol 
abduc tion, internal rotation, and flexion; increase ol adduc¬ 
tion, external rotation, and extension. 

1 here is apparent and actual shortening ol the limb. 
Actual shortening is clue lo the upward displacement ol the 
shall ol the lemur and is rarely more than one inch in the 
adolescent type ol the deformity, although the apparent short¬ 
ening (the result ol adduction and compensatory uplifting 
ol the pelvis) may amount to from 2 to ;; inches, and 
oftentimes more in extreme cases. 

S\mf)loms and Signs. As a result ol these mechanical altera¬ 
tions, the ordinary (cervical and trochanteric) form ol coxa 
vara presents the following signs and symptoms: discomfort, 
awkwardness, Innj /, shortening, atrofj/iy, restriction of 
motion, and deformity. 

I he more disabling features ol coxa vara, as compared 
with analogous conditions at the knee-joint (genu varum 
and genu valgum), and the greater distress ensuing bom the 
hip distortion, are due to the sublimation ol the letnoral 
head in coxa vara; while in the distortions ol the knee-joint 
there is practically normal opposition ol the two joint stir 
I arcs. 

In 11 n 1 late ltd coxa vara, the symptoms and signs are in¬ 
fluenced l>\ the degree ol distortion and its duration. 1 he 
commonest complaints are stiffness and weakness, accentu¬ 
ated In resuming activity alter a period ol rest. These sensa¬ 
tions are rel'et red to t he thigh and 111a) amount to acute pain, 
espec iall\ after overactivily. l.nnf) is the chiel disabling lea- 
ture lot which relief is usually sought; it is accompanied by 



external rotation ol the lii|> and. according to Whitman * 
it resent I ties the limp ( a used 1 >\ a I km led 11 at t in e ol the neck 
ol the femur. Differentiation front the hitter condition is 
made l>\ the ac tual shortening in coxa vara (due very plainly 
to the elevated bulging trochanter and the unequal limita¬ 
tion ol motion at the hip joint). Moderate degrees ol muscle 
shiism and atrophy ol the thigh musc les are olten present. 

In bilateral coxa vara, the gv ill and alliliide are striking 
phenomena. 1 he gait is c haractei i/ed by swaying ol the body 
to overcome the' adduction and prevent the knees liotn 
"interfering.” In extreme cases, the legs may cross one 
another and make walking extremely dillicnlt. The normal 
lumbar lordosis disappears in the ordinary loitn ol hi lateral 
coxa vara on account ol the lessened pelvic inclination caused 
bv backward displacement of the femoral neck with conse¬ 
quent thrusting forward of the shall ol the femur. Whit¬ 
man')' calls attention to the involuntary crossing ol the legs 
during flexion when the patient is recumbent in cases of 
bilateral coxa vara ol advanced degree. 


A rare distortion is downward or downward and forward 
depression ol the neck. In the latter event, the mechanical 
disturbance differs bom that ol the ordinary type in that, 
although abduction is limited as in the ordinary form, in¬ 
ternal instead ol external rotation occurs and there is limita¬ 
tion ol extension instead ol llexion. Bilateral involvement is 
the rule in this type ol deformity. Clinical manifestations 
are slight permanent flexion at the lops, with consequent in¬ 
crease ol the lumbar lordosis (the opposite ol the condition 
in the ordinary type). 

1 his variety occurs in early hie, but the condition is usu¬ 
ally obscured bv associated distortions ol otlici parts. The 

Whitman. R. \ treatise on orthopedic surgery. Id. ”, I’hila., Lea, t<)o'{. 
P- . r > 1 1 • 

) Luc. til., p. ',17. 



symptoms ma\ be slight and consist only ol more or less dis- 
comlort extending over ;i period ol years. Many ol these 
cases are caused by tic kets. I he symptoms usually begin in¬ 
sidiously. Disc omlort olteu c eases altet inclination ol the 
affected bony parts insures their stability. 


I lie congenital lorm ol coxa \ at a w as In st described in 
iN<)() by Riedel.* Numerous instances have been recorded 
by various observers who have noted the condition many 
times as the only anomaly present: while in other cases it 
has been observed in association with congenital dislocation 
ol the hip, delective development of the upper end of the 
femur, and with various other congenital anomalies. 

I he c linical leal tires ol congenital coxa vara are a waddling 
gail, lumbai lordosis, elevation of the I roc hauler above 
Xelaton’s hue, adduelion, and slight external rotation. 
Crossing ot the legs has been observed on kneeling. Sitting 
is accomplished in "Turkish fashion, and during recumbency 
the limbs are oftentimes rotated completely outward. 

X-ray examination shows a neck depressed to a right tingle 
or less, and the head not completely Idling the upper part 
of the acetabulum. The epiphyseal line is vertical and not 
oblicpte, as in t ickets, and is broad and irregular. 

Congenital coxa vara is very Irequently con I used with con¬ 
genital dislocation ol the hip, which it very much resembles 
cl inically. 

Nothing is known ol the etiology ol congenital coxa vara. 
It occasionally oceans in several members ol one lamilv. It 
is often associated with congenital dislocation ol the hip and 
ma\ constitute one ol the causes ol lailure ol reduction ol 
the latter because of inability to obtain lull abduction. 

I afferent ial Diagnosis. In most instances, the diagnosis is 
made without dillu idly, panic ularly il the v ia\ is employed. 

* krcdel, I Coxa vara congenita, ('fnlralbl. f. C.liir.. a*}: ;)•><). i8g(i. 



1. ('.on vt’ni tal (Iislocu 11 <> ii <>l lln' In/} (ante) i ( >i \. i i 1 1 • t \ ) 
can be c'\( hided l)\ the . i;j,e ol I he patient and the history 
o! tlu' c .isf. while ton Ii l mate >r\ evidence is ollered by the 
j )h \ s i t a I siy,ns. w I i ieh alonr arr usually suflie irnt loi a cliag 
nosis. In <a)i i oei i ita 1 dislocation, il llcxion and adduction ol 
the thio11 are ]iiat tisetl to an extreme decree, the lemoral 
head and neck are Ieh in die but locks. In co\a \ara, on the 
other hand. onl\ the prominent trochanlei is palpable. Ah 
normal mobility ol the hip joint, present in congenital dis¬ 
location. is absent in coxa vara. In rotating the limb in coxa 
vara, the nppei end ol the lemur rotates around an axis 
through the head: in congenital dislocation, it rotates on ;m 
axis midway between the trot hail ter and the head. Ill is point 
can be determined b\ palpation except in the case ol very 
thick superimposed tissues, linallv, the \ ray will lurnish 
indisputable e\ idence. 

2. Tuberculous coxitis, or tuberculous hip disease, may be 
confused with coxa vara il the latter is in an acute state 
cliniealh and no v-ray study is made (i.c., spasm, lixation 
and ptiin). lint in a tuberculous hip, motion at the joint is 
limited in even direction by muscle spasm, while other signs 
ol the disease ate present. In the case ol coxa vara, there is 
deformity only and no sign ol attendant disease, while reflex 
muscle spasm is absent (except in very acute cases where il 
is incident to trauma or strain), restriction ol movement 
occurs onl\ in abduction, flexion (rarely) and internal rota¬ 
tion. Measured shortening is a late phenomenon in tubercu¬ 
lous hip disease, while it is the initial sign in coxa vara; 

I in thermore. it depends, in the c ase ol coxa vara, on eleva 
tion ol the trochantei above Xelaton’s line from disloi I ion , 
while such elevation in tuberculous hip disease is due to 
(Icslruchon ol the lemoral head oi the acetabulum. 

I k i \ I Ml XI 

I he objectives to be- gained Irom operative procedures 
in coxa vara are primarily to restore motion at the hip. pal 



ticularly in abduct inn, which has been lost because ol the 
change in the angle between the neck and the shall ol the 
lemur; to a lesser degree, to restore rotation and overcome 
shortening at the hip. 


Methods ol treatment for cervical and trochanteric coxa 
vara in order of preference are: 

1. Forcible abduction and fixation in plaster-of Paris: 

2. Circular osteotomy (Brac kett); 

g. Cuneiform osteotomy (Whitman); 

j. Cuneiform osteotomy (Mayer); 

5. Linear osteotomy (Cant). 

Forcible Abduction and Fixation in Plastcr-of-Paris. On 
the assumption that the affected neck is malleable in coxa 
vara occurring in young children with acute rickets where 
the symptoms have rapidly increased in extent and severity, 
forcible abduction ol the thigh may be effective in restor¬ 
ing the angle ol inclination of the femoral neck. In this 
maneuver, the head being fixed by the inferiot portion of 
the capsule, the trochanter impinges on the rim of the acetal) 
ilium as a lulcrum, while the leg in abduction acts as the 
long arm of a lexer. After wide abduction has been obtained, 
a long plaster ed-Paris spica is applied and allowed to remain 
for two months or more. On removal ol the spica, an \-ra\ 
examination should be made to be assured of correction. 
After final removal ol the spica, a support should be used in 
walking for some time (a Thomas hip splint or crutches and 
massage should be systematically employed during convales¬ 

Author's Com incut. Inasmuch as the orthopedic surgeon 
usually encounters these cases only alter the acute stage has 
subsided and there is little plastic it\ ol bone present, the field 
for this form ol treatment is \cry limited. Osteotomy at the' 



lesser Hoc hantei is. ,is a rule, the only ellcclive treatment. 

().\tcotonix. Section ol tlu- lemni should he perlormed 
onl\ altet thorough dietetic and medic inal antirac hitic* treat 
inc'iit has been <41 \ c‘ n a prolonged trial d there is evidence 
ol acute rickets. Vs a rule, however, the 1 surgeon lust sees the 
case lone; a It cm the acute stage has disappeared. 

There are two methods ol performing osteotomy which 
have the sanction ol good surgery: circular osteotomy and 
the cuneiform osteotomy. 

C.iit iilm Osteotom y. Credit is due Brae kett * for perlect- 
iii” the tec Ini ic pie of c ire nlar osteotomy. I 1 is opera t ion resent 
Tie's that ol Sii Robert Jones. It is mechanically excellent 
and produc es no shortening. Brackett describes his osteotomy 
as a "c urved Cant by the open method.” Anterior incision 
over the hip-joint exposes the bone Irom the outer side ol 
the great trochanter to the inner side of the neck and its 
junction with the femoral shaft. The iliacus musc le is lifted 
and retracted inward as far as the lesser trochanter. A blunt 
dissec tor is then placed vertically downward on the inner side 
ol the bone at the junction of the lesser trochanter and the 
neck, and is left in position. A very narrow osteotome is 
used to make a curved incision with its convexity upward 
and inward, beginning on the outer side of the trochanter 
and ending at the point ol junction ol the neck and lesser 
trochanter where the blunt dissector is in place. Section is 
made vertical!) downward (the patient in the dorsal posi¬ 
tion) Irom the anterior to and through the posterior surface 
ol the bone. When the leg is abducted to correct the addin 
lion delormity. the 1 convex end ol the lower Iragment turns 
in the hollow ol the upper fragment. 

The point at which the curved incision begins on the 
outer side ol the troc hauler varies w ith the amount of adduc ¬ 
tion to be overcome. The greater the degree ol adduction 
deformity, the higliei on the- lemur is the- point ol origin 

Hiaiktil. I . C.. V stmh ol 1 tic (lilleieni approaches lo the hip joint. Bos- 
Ion M. w S. /.. i(i(>: 23^, 1 () 1 2. 



<>l the incision. II llexion deformity is marked, the vertical 
(anteroposterior) line ol osteotomy is deflected slightly hac k 
u ard to produce a slight ovei hanging ol the anterioi edge 

ol the tippet I ragmen t. 

Author's Comment. I al¬ 
most invariably employ cir¬ 
cular osteotomy in prefer¬ 
ence to linear osteotomy, 
not only because the latter 
is not meclianicalh sound, 
but also because circular os 
teotomy avoids the coiner 
on-corner effect and the 
dead space left to be Idled 
in as well as the overriding 
ol fragments. It is also pref¬ 
erable to cuneiform osteot¬ 
omy because it avoids the 
shortening resulting from 
the removal ol a wedge ol 
bone Irom the shaft and 
also precludes the possible 
sliding and overriding' ol 
the fragments, even though 
the cut ends are in apposi 

from a mechanical standpoint, then, circular osteotomy 
is preferable to all others in that there is no loss ol substance 
and no displacement ol fragments when the limb is abduc ted, 
on account ol the mechanical lacloi ol a circle within a 

I k., 79. 

Modification of Brackett's lechni<jne. 1 have modified 
bracken's technique l>\ prolonging the inner portion ol the 
curved inc ision downward to make a long lip cm the internal 
aspect ol the uppei fragment, just below the trochantei 
minor, so that the c entral point ol the convex surlaee ol the 



lowet IKi^mcnt is exae 11 \ opposite the central point ol the 
concave surface ol the tippet Iragment. thus providing .in 
additional safeguard against sliding b\ and possible displace¬ 

ment ol the two fragments and a broader surface of contact. 
The motor drill is used in making the circular osteotomy, 
the holes being connected with Jones’s saw (bigs, yij and (So). 

Circular osteotomy possesses definite advantages over other 
methods as lollows: 

i. It blocks am lendencN ol the fragments to slip by one 

•2. I he line ol weight-bearing is so nicely adjusted to that 
ol the shall, the ccntet ol the convex surface ol the 
lowet Iragment coming exactly opposite the center ol 



lhe concave surface ol the upper fragment, that they 
exactly coincide (I' ie;. S t). 

3. Free dissection ol overlying structures affords the oper- 
ator an unobstruc ted view ol the exac t field ol opera¬ 
tion and allows inspection ol anatomical conditions be- 
lore and alter operation, so that the most exac t mechani¬ 
cal coaptation is sec tired in every instance. 

Cuneiform Osteotomy. Whitman prefers, in youngei 
patients, a cuneilorm section ol bone taken Iron) the shaft 
ol the lemur on a level with the lesser trochanter. He directs 
attention to several points ol importance in the technicjue, 
as follows: 

Vigorous preliminary stretching and massage of contrac¬ 
tu red muscular and ligamentous structures which limit ab¬ 
duction should be practiced. The operative incision begins 
at a point 1 inch below the apex of the trochanter and is 
carried directly downward about 3 incites. The periosteum 
is inc ised and elevated to expose the femur. 

Prior to the performance of every cuneiform osteotome 
an \-ray examination should be made, and with the exact 
anatomical condition of the femoral head and neck before 
him, as obtained from the roentgenogram the surgeon 
should plan his work with as great nicety as any artisan con 
fronted by a mechanical problem. Operation, in every case, 
presents an individual problem and should not be perlormed 
by any fixed formula. Tracing paper (or ordinary tissue 
paper) is laid over the \ ray plate and the outlines ol the 
upper extremity ol the femur are obtained and transferred 
to heavy cardboard. The exact si/e, shape, and inc lination ol 
the femoral neck are thus secured. The* surgeon now experi¬ 
ments until the* wedge removed bom the infrat roc 'banterat 
legion ol the cardboard model is suflic ient to produce an 
angle ol inclination ol 130 degrees when the shaft is lulls 
abducted to close the cuneilorm opening. It will be lound 
that the si/e and shape ol the wedge will vary with the si/e 



ol the lemin .iiid tlie decree <>l coxa vara, and that n<> two 
cases are exactly alike. 1 >\ this accurate and simple method 
ol experimentation the surgeon, on approaching the- opera! 

ino table, will know exactly what si/e and shape ol wedge 
it is best to remove. In any event, the resulting shortening 
ol the lemur will measure approximated one-hall (he width 
ol the base ol the wedge. 

In making (lie wedge (big. Sg), the lowei section is cut at 
right angles to the slial t ol the lemur, while the tippet sect ion 
is made more oblique. Alter removing the wedge, the limb 
is strongly abducted: this almost invariably fractures the' 
cortical bone on the inner aspect ol the shaft opposite the 
trochanter minor, even though this was not severed at the 
beginning ol the osteotomy. 

\ltei the tippet fragment impinges on the' tint of the 
acetabulum, the lowei Iragment is swung still further out 



w.nd in <iI>(Ii k lion uniil the < uncilorm opening between the 
Iragments ol the shall is c losed by apposition of the cut siir- 
laces. I he normal angle between the neck and the shaft is 

thus restored. A long plastei ol Paris spica, including the 
loot, is applied with the limb in wide abduc tion, and is re 
tained in position lor eight weeks or until there is linn union. 
Alter solid bony union is assured, adduction ol the limb to 
the midline ol the body restores to a degree, the loss in length 
of the lemiii from the previous coxa vara. A short plastei 
ol Paris silica worn lor lour to six weeks alter removal ol the 
long silica is the only alter-lreaiment recpiired. 

Another method ol wedge osteotomy has been devised by 
Leo Mayer. In this operation, the wedge ol bone is removed 
from iht* area direc tly below the linea intertroc hanteric a. 

The si/e of the wedge depends upon the degree ol <lelormit\ 



to be collected. Ii is evident (hat this <>|>ei al ion. despite die 
removal ol hone, increases the length ol the lemur, since it 
converts the right angle ol the co\a vara into an obtuse 

I K.. S ;. I i ;ms\ erse osteotome best done when there is ankylosis at hip joint, 
thus allowing beitei control ol tipper lemoial 1 1 iigmcm. Danger ol slipping 
and possible displacement is emphasized In nn net to corner contact ol frag¬ 
ment in cases where tippet lemoial fragment is mobile. 

angle. Iii one case ol an eight vcar-old child, this increase 
measured ;> cm. 

1 lie operation is particularly applicable to 111 i 1 cl ten and 
adolescents. Alter preliminarv tenotomy ol the adductors a 
longitudinal incision is made directly over the great tro¬ 
chanter. and the bone heed until the operator has deter¬ 
mined the location ol the trochanlci minor. With this as a 
guide, the bone incision is made Ire nil the tip ol the great 



11oc lianlci lo ;i |x>int slightly above the trochanter minoi 
and a suitable wedge excised below this primary bone in 
cision. I he cortex on the medial side is not ( hiselled through 
but is allowed to remain intact to keep the I ragmen ts from 
slipping. 1 he delormity is reduced by abducting until the 
two cut areas are brought into contact. 

Lilian Osteotomy. In the method ol lineal osteotomy de¬ 
scribed by (hint, the femur is divided just below the troehan 
ter minor at right angles with the shaft, by either the open 
or the .subcutaneous method. Alter division ol the lemur, its 
shall is rotated inward until the loot is in normal position, 
and is then abducted to the fullest extent and immobilized 
in this position in a long plaster-of-Paris spica, which mas 
or may not be changed at the end ol live or six weeks and 
left on lot ten to twelve weeks. When linn bony union has 
occurred, a matter of ten or twelve weeks, massage, exer¬ 
cise, and manipulation should be systematically employed 
(Fig. 84). 

Author's Comment . I believe that this operation is not 
mechanically sound. Its only claim to attention is the fact 
that when subcutaneous osteotomy was in vogue it was the 
only procedure available. When the hip is not firmly anky- 
losed a great deal ol consideration should be given before 
this procedure is clone. It should be employed onl\ when 
subcutaneous osteotomy must be performed, a circular 01 
c uneiform section ol the lemur being impossible b\ the sub¬ 
cutaneous route. 

1 el pi 1 vsi ai c:<>\.\ vara (adoi.i set \ 1 -traumatic:) 

Warclle # divides cases ol slipped epiphysis ol the head ol 
the femur into two groups. In one group he places the cases 
with disordered glandular func tion in which epiphyses othei 
than the epiphysis ol the head ol the femur are also involved. 
In discussing ibis group lie cites the theory advanced b\ 

* W arclle, t. X. Slipped epiplnsis ol the head ol the lemur. S 'mil-. C.v/ier. 

ObO., -,S: 255, 193 p 



kochci in i S(> | the- slipping ol llu' epiphysis ol the head 
i>i ilu- In11in mav he due to .i locah/cd osU'oinalai ia which, 
tending to ocean in the arms ol most rccenllv lormcd hone, 
weakens the attachments ol the epiphyseal caitilage and 

Ihe other group ol cases are those in which indirect 
trannia has imohed the epiphysis and no joints olhn than 
the hip joint tire imohed. In both groups the body-weight 
and muscular action are secondary lactors increasing de¬ 
formity. I he process alivax. s starts in adolescence; there ma\ 
01 mav not he a history of slight trauma or slight strain; 
quiescent periods alternate with recurrence ol the disturb 
ante: the epiphysis slips a little at a time, the gait he 
comes tillered and the symptoms increase accordingly until 
llexion can he accomplished only in tin obliquely outward 
direction, similar to the llexion in eases ol osteoarthritis of 
the hi]> (see Chap. XI, section on Arthritis Delormans). I he 
clinical course ol the affection conforms very closely to that 
obseryed in juxta-epiphyseal fracture ol the upper end of the 

I he dixiding line between epiphyseal Iracture or separa- 
tion and epiphyseal coxa vara is very indefinite, depending 
wliollv on the degree ol trauma which caused the disjunction 
or delormity. Sponttmeous recovery bom ti partially displaced 
epiphysis at the hip is responsible lot a class ol cases present 
ing in adults ratliei indefinite symptoms ol some long-stand 
ing trouble in this region which have been attributed to 
otliei < a uses. I he history ol the case may 01 may not disc lose 
active symptoms at some time in llu- adolescent period, which 
subsided gradually with Iteedom Iron) symptoms for possibly 
mam veats, when Irom some cause (trauma 01 osieoarth 
litis) the- symptoms again recurred. 1! no intercurrent disease 
is in evidence, the only signs on physical examination are as 

Verv slight shortening ol the limb. Slight limitation of ah 
due lion and rotation. A rav examination shows a llatlened 



and somewhat "mushroomed" femoral head, especially its 
superiot and inner aspects, with giving away ol the head at 
the epiphvseal line (log. <S |). 

til.. N|. I piphvscal separation (fracture) al tippet end of femur. Note giving 
a\\a\ of hone in region of epiphvseal line, this is ;i <ase of adolescent coxa 
vara (epiphvseal Ivpe) in a man of eighteen years. (From Vlbees ''Orthopedic 
and Reconstruction Surgery," Saunders.) 

The cause ol such Irecpient disjunction at the temoral 
head is, in the first place, due largely to the fact that this is 
one ol the last epiphyseal cartilages to ossify and disappear; 
and. In the second place, to the I act ol its mechanical dis 
advantage in sustaining trauma, muscle-pull, and weight- 
heating. The preponderance ol adolescents over children 
under ten, with respect to epiphyseal separation, is due in 
part to the increased severity <>l injury in older children hut 
in greater measure 1 to the anatomical development ol these 
parts. I he epiphysis and the epiphvseal cartilage ate propor¬ 
tionately large) and thic ker in young c hildren than the shall 



ot the femur. I he head and net k are both laid down in one 
huge mass ol cartilage, and (here is no distinct line uni i I 
ossification extends along the neck Iron) the shall toward 
the head. On account ol its thick 
ness, the resilient cartilage, (linin'; 
tliis pet iod. ac ts as a "shock ah 
sorbet and is less liable to (list up 
t ion. 

Conti ibulorv c auses ol epiphyseal 
separation are tickets, scurvy, inani¬ 
tion. septicemia, jnenua. syphilis, 
and prolonged mere urial treatment. 

I lie dv spit uitarv t\peol individual 
is peculiarly susceptible to this acci¬ 
dent (Rig. 85). Macausland # stated 
that obesity and endocrine disturb¬ 
ance were observed in at least tej 
ol his | y patients and possibly these 
lactors were jiresent in othei eases. 

I he majoritv ol his eases were 
around twelve years of age. 

Cases ol epiphyseal separation 
have been seen bv the author with 
such diagnoses as "tuberculosis," 

"hernia," "ruptured musc le libers." 

"Irac ture ol the nec k or upper end 
ol the lemur." "sprain," and even 
sue It an absurditv as "sprained in¬ 

I lie symptoms 01 phy sic al signs ol 
this condition arc those ol Irac ture 
ol the neck ol the I cm in . with the 
I oil owing additions and exceptions: 

1 1 auitia may be v ct v slight. ( a ejitl us, wh tc h, however, is 

I here is marked fulness at the front 

l ie. 85. Dyspiluitarv tvpc 
ol individual pai 1 ic111 a 11 y 
prone 1 to separation ol capi¬ 
tal cpiphy sis ol lemur. I It is 
patient had snllcred slipping 
ol capital epiphvsis ol both 
leinoi.i prior to lime of ibis 
photograph. Kversion ol leel 
is c ha 1 aelerist ic. (From VI 
I tees ''Oil ho| ted ic and Re 
const r 1 le t ion Suigcrv," Satin 
(lei s.i 

rarely obtained, is so 

* Macausland. 
I "in I i 7 : • 

\ R. Sepaialion ol the capital leinoral epiphyses. /. Ilnur e 
13 - 1 93 :") • 


acetabulum. i 


and Reconstruction Sur<>eiv.” Saunders.i 



ol the joint, due to the invariable displacement <»l the upper 
‘■‘•'d ol the Icmei I raiment lorward in front ol the head. II 
the ease is recent, musculai spasm is jn onounc ed, due to the 

Ik.. Xy. I-.| >i |)h\sea I separation (fracture) at uppei end of femur. Perfect 
reposition ol parts In maneuvers shown in Pi "lire Sti. (Irom At bee's "Ortho¬ 
pedic and Reconstruction Sunsets," Saunders.) 

1 act that there is solution ol the continuity ol the bony parts 
within the joint capsule. I he loot is stronjyb exerted on ac¬ 
count ol overriding or displacement ol the 1 fractured end ol 
the neck anterior to the head. And. it may be added, the tare- 
lied posteriot portion ol the lemoral neck cannot be blamed 
here for this displacement. 

T he surgeon does not olten see many ol these cases until 
sometime alter disjunction and faulty union have taken 

A collect diagnosis and proper treatment ol this class ol 
epipliyseaI coxa vara are obviouslx ol the exitest importance, 
in the first place, because ol the necessity ol integrity ol the 
epi pliysea I carl i la*>'e in the <>ro\vt h ol bone, and hence the im 
portancc ol as pet led a reposition ol the sliding epiphysis as 



is possible: in the- sound place, on account ol the added dilli 
cult\ o| obtaining and holding die capital epiphysis in ton 
sequence <4 its spheric al shape, shortness, and iliac cessibilil\ 

I n., ns. | \|:tol ioc 1 i\ pal 1 ic ukii't\ prone to iliis injiio an adolescent 
ol mcisuilai and ohese plixsicpie—the chspit uitai \ l\pe. (tmiii \lbees "Or¬ 
thopedic and Ret oust i tit t ion S111-t>er\." Saunders.) 

to trac tion and splinting. In the third place. proper diagnosis 
and treatment are ol paramount importance because ol the 
danger ol impaired function on account of the proximity 
ol the lesion to the hip joint. 

In these cases the scheme ol treatment is a restoration of 
the disjdaccd lemoral head on the neck. This is necessary 
because ol the lac t that, the' displac ement being w ithin the 
hip joint, serious interference with the func tion ol the 1 joint 
would result il the displacement was not corrected. I he pro¬ 
cedure' here diliers Irom that in cervical coxa \ara in that 
reposition has to be made at the site of deformity. 

On account ol the' slowness ol development, these' cases of 
epiphxseal coxa vara are not. as a rule, recogni/ed soon 
enough uflei sliding <d the eajnlal ejnfi/iysis has occurred to 



allow ol reposition ol the head In manipulative methods 
without open operal ion. I ream tent net essil ales cutting down 
on the site ol displacement, a separation ol whatever union 
has occurred (usually ol the Itbrous type) and a prying back 
into position ol the lemoral head by means ol an osteotome 
or some other instrument. 

Treatment. The methods ol treatment in ordei ol prefer¬ 
ence are: 

t. Closed reduction; 

2. Open reduction with the insertion ol autogenous bone- 
gralt peg; 

3. Partial arthroplasty. 

1. Closed Red ml ion. II the sliding of the capital epiphysis 
is ol recent origin, manipulation, under an anesthetic, con¬ 
sisting ol strong traction, abduction and marked inward rota¬ 
tion obtained by means of a traction table, should be tried. 
I he limb is lived in this position in a long plaster-of-Paris 
spit a, and radiographed to see il good reposition has been 
obtained. However, on account ol the uncontrollable head, 
the possibility of securing good reposition is remote and 
operation is usually necessary. 

In either event, il the Iragments are replaced thee can be 
held in perfect apposition l>\ employing the position ol ah 
duction and internal rotation as pointed out by W hitman; * 
but because of kudlv blood supply to the epiphvseal frag 
mein, I have, in later years, been inserting the autogenous 
bone-gralt peg in selected cases, and have realized improved 

2. Often Rednelion unlit or unllionl the Insertion of tin 
Autogenous Iiotte-grafl Reg (Sni 1 1 It-Petersen ajt/trotn It). Ihe 
Iracttired end ol the lemoral neck (lowet Iragment) usuallv 
presents in the wound. This mav be verv puz/ling on account 
ol the head lying lai behind and being cm 11 iredv obscured bv 

* Whitman, k. lurlhci observations on injuries lo i lit' neck ol ihe teinin in 
earls I i If. Mill. Her., ~r t : i. ic)oc). 



the 1 hi k (lit;. S ()). !l 11 h* li.ii line has existed lor some lime. 
111ere max he linn mahmion. II so. ilie neck is separated 
I mm the head l>x means ol a chisel wliieli is then used to 
pi \ ilii' 11 .laments into posi 
lion ai tin' same lime that 
strong traction and inward 
rotation are applied to the 
1 iin 1). (.ood apposition is se- 
i tired and tin- parts are put 
in a long spiea in abduct ion 
and marked inward rotation 
I ig. <)o). In order to hold 
the forced inward rotation, 
the leg is Hexed on the thigh 
to a right angle d igs, pi 
ip;). In this wax. the stnmg 
inward rotation lories the 
anlei iorlx displaced neck 
hack into apposition with 
the head and causes the 
posterior parts ol the cap¬ 
sule and the uni uptured 
soil parts to become tense, 
thus acting as a splint. 

Fhe 20 and go degrees ol 
abduction rotates the upper 
edge ol the I met tired end 
ol the neck under the lip 
ol the acetabulum, as shown 
in f igure 8 ( 5 , thus prexent 
ing am possibility ol an up¬ 
ward displacement from the 
1 Inougli a short trochanteric incision, a tihial bone-grab peg 
max be inserted, as Ioi fracture ol lhe neck to laxoi the estab 
lishment ol blood-supply to the head and stimulate repair. 
At the end ol three weeks, the part ol the plastei which is 

I n.. X(). I |»i|> 1 1\sc;iI sc|>;iralinn (li.ii 
tine) .11 iippi'i end ol lemur. I lead 
lies tree in ai el atm I nm, behind and 
below neck, ils epiphvseal (cenieal) 
snrlaie tonkin” direeth forward. Neck 
is dislodged from acelabnlnm. exerted 
and dislocated upward, (loom \ I bee's 
"Orthopedic and Reeonst rni I ion Sm 
eer\." Sanndei s.) 


la) snasm or o 



<>'ci ihc lei; is removed and the let*' extended. \n exten¬ 
sion ol plaster is applied Imin the knee over the loot. This 
is ehant>ed to a short spit a at the end ol six weeks. The 

In.. ()o. Auilioi s inclhod ol : 11 > | > I \ i 1 1 phistci '-of-Paris spicu lo hold strolls’ 
inward rotation, also abduction. (I roiu Min i s "Oi thopcdic and Reconsinic: 
l ion Sm ”cr\Sa nuclei s.) 

In., i)i. Side \ iew. showing application ol spit a o\ci Hexed knee. (Prom 
Albee's "Orthopedic and Reconstitution Sun>er\." Saunders.) 

short spica is eontinued until live months alter the opera 
lion. The motion ol the hip is only slightly limited in all 
dii ect ions. 

y ( . Partial . I rlliro/jlaslx. In traumatic coxa vara of long 
duration, where displacement is considerable and union firm, 
I do not conect the malnnion by chiseling the bone I rai¬ 
ments apart. Inn perlorm a junlial arthrof>last\ in order to 
remove any bone that blocks Iree motion at the hip. In main 
cases this necessitates the removal ol a considerable amount 
ol bone due to the forward projection ol the neck ol the 
lemur, by extensive removal ol bone, inward rotation ol the 
limb is largely restored. 



\ double plastei (>1 I’.n is i .isi is applied which remains on 
loi three weeks. I lie patient is then pennilted to exercise 
and I icc* in we it'll I bearing. Vigorous manual massage and 

Ik.. (|i!. I piphvsial sc|>;n ;ii ion from jumping oil slice! car while in motion. 
I’aiieni did not tall, lull landed on his ri”lu loot with j>reat lorce. (Iiinii 
\lhee s "()i tho])edi( and Reeonsi nu 1 ion Sur<*er\ Saunders.) 

manipulation is carried on eat li da\ to aid in restoring active 
must til.n control <>l the hip throughout its new range ol 
mot ion. 

Author's Comment. 1 he majority ol patients with old 
traumatic epiphyseal separations come to operation because 
ol a complaint ol pain on u eight-bearing. They are nsualh 
in early middle age and have been content to get along since 
adolescence with marked limitation ol motion at the hip. 
Mam ol them have been able to indulge in spoils. As thc\ 
grow older, there is a gradual onset ol pain with bone pro 
lileration and lurther limitation ol motion at the hip. A 
typical osteoarthritis develops, hollowing the partial arllno- 
plast\ there is no complaint ol pain, and these patients are 
usually able to resume ncaii\ normal activity. 



Coxa Vai.oa 

Most writers dismiss the snI)jeel ol coxa valga with the 
briefest possible mention. I he condition is undoubtedly 
rare. but it nevertheless demands some consideration. 

I n., ()‘j. Nki;ij>r;mi taken six weeks alien open redutlion ol liaetine. showing 
position ol united fragments. (I tom \lhee s "Orthopedu and Reconsl ruction 
Sin “ei \Saunders.) 

Coxa valga is ;t condition diametrically opposite to coxa 
vara and consists ol n/mund displacement of the femoral head 
with abduction ol the femur. The symptom-complex consists 
chiefly of abduction, external rotation, and limitation of ad¬ 
duction, together with other less distinctive svmptoms and 
signs. An increased tingle ol inclination ol the lemoral neck 
is generally considered a toxa valga. 

I I 101.0(0 

Congenital Coxa J'alga. Congenital coxa valga max be as 
sot iated with congenital dislocation ol the hip. It is then a 
< picst ion whet Itet the valgus condit ion ol t he neck is primary 
or secondary to the dislocation and due to the constant pres 
sure ol the pelvis against the dislocated head in walking. 



(hits exerting si lain on the epi phxseal line and causing 11 1 > 
ward bending ol the head. I his condition ol ( o\a xalga in 
congenital dislocation accounts lot the dillienlty, in some 
cases, not onl\ ol redne ing hnt ol retaining such a delormed 
head in the acetabular < a\ il\. 

Congenital coxa xmlga max also occur not associated noth 
other abnormalities. Young has reported several instances ol 
coxa valga in which no other delormitx was present. 

lii/uired Coxa l alga. Acquired coxa valga tna\ be due 
to: i. Traction b\ a pendant limb plus absence ol the body 
weight above plus abcvance ol action ol the pclvilemoral 
muscle group, as in the lollcm ing conditions: 

(a) Inlantile paralysis ol all varieties affecting the lowet 
limbs, and even loss ol activity ol the lower limbs from other 
causes, max be lollowed b\ coxa xalga. 

(b) Amputation through the thigh in early c hildhood, with 
the inevitable loss ol lunetion and remoxal ol the bodv- 
weight Irom above and the upward thrust ol the femora 
from below, is lollowed in some instanc es by coxa xalga. 

2. Dexiations ol the femora Irom their normal relation 
ship to the pel\ is. as in the c ase ol (a) tuberculosis of the hip 
with abduction ol the lemur: (b) scoliosis, with its unequal 
loading ol the hips; (e) genu xalgum: and (cl) in rare in 
stances, in case ol lraeture ol the shaft ol the lemur. 

g. Iraumatism, as exemplified in very rare instances bx 

(a) impaction and malunion ol fragments in fracture ol the 
lemoral neck: (b) separation of the capital epiphysis ol the 
lemm : (c) a direc t blow applied to the great trochanter: and 
(d) a lraeture ol the lowei end ol the lemur. 

p l xcessixe malleability ol the bones, in very rate cases, 
in the course ol or following (a) rickets, (b) osteomalacia, etc . 

file condition is relalixely unimportant and \ cay rarely 
et it on titered as a clinical ent it v. ()nc oi more* ol the* lol lowin<> 
signs and sym|)toms max be present: 

(t) I’ain and discomloit in the rc*gion ol the hip joint: 
(2) limping in unilateral case's, and a waddling gait in hi 

u a< 



lateral cases; (_g) lengthening ol a fraction <>l an inch; (4) 
abduction and external rotation, with limitation ol adduc¬ 
tion and internal rotation; (5) flattening ol the trochanteric 
region and depression ol the great trochanter below \ela- 
ton’s line. 

It may be mistaken lor inhereadosis of the hip; but in 
coxa valga pelvic inclination does not compensate lor length¬ 
ening of the limb. 

Extreme adduction with inward rotation and fixation in 
a plastei -ol-Pai is spic a may afford correc tion. 

Equalizing the length ol the limbs by a high sole on the 
boot of the sound side may improve the gait. 

In cases with great discomfort and disability, circnlai 
osteotomy (see treatment of coxa vara in this chapter) will 
effectually restore the mechanical relationship ol the bom 

Chapter X 


I. \lU)l (: ! I <»\ 1 I 1 \l<>\ CoXIKACIl ri s 

C ( )\ I R \(. 1 1 ()\ (>1 the h i |) in llexic >n and a lx hid ion 
is most likcl\ to occur where the hip llexors retain 
some' degree ol lionet and the glutens maximus is 
weak. I h is contracture is olten overlooked. I he presence ol 
this delormilx is most easi 1 \ detected by laying the patient 
on his back ovei the edge ol the table and hyperextending 
the thi^h while the pelvis is held. Ihe hip must not be 
allowed to abduct or rotate out during the examination. 
Inilateral fixed llexion ol the hip causes the body to be 
pulled lot ward w hen the' affected extremity is placed on the 
ground in w alking. W hen the delonnity is hi lateral it pre¬ 
vents walking. 

I HI \ I \l 1 XT 

I lie methods ol treatment ol this delonnity in order ol 
preference are: 

1. I asc iotoim at the anterioi superior spine (Soutter); 

2. Mayer's operation. 

Soulln'\ I-'iim ioIoiii y. All methods ol stretching the con¬ 
tracted tissues are ineffective. A \cr\ satislac ten v and. at the 
same time, a simple procedure is an operation devised by 
Soutter.* I he technique ol the operation is as follows: 

\ longitudinal incision 2 or y inches in length is made 
with the anterioi superior iliac spine at its center. With an 
osteotome, the tip ol the' cartilaginous spine with the perios 

' Sonina. R. \ lieu Opel nl i oi i loi hip eonl i ;ic 1 ill es in pol iom\cl it is. lioslon 
\ I . Z S. /.. 170: ;(8o, 1 <) 1 ). 




lemn .md the underlying superficial portion of cancellous 
hone is chiselled away loi ‘.’</\ lo i inch beyond the anterioi 
superior sj)ine, and below it as lar down as the anterioi in 
lerior spine, and stripped down. I'pon hyperextension of the 
lemur the lensoi lasciae lenioris is put upon the stretch, its 
detached point ol origin coming away from the ilium, leav¬ 
ing an interval ol 1 or 2 inches. II the anterior lateral edge 
ol the lascia lata is shortened, it should be severed through 
the same wound by scissors 01 scalpel. The skin is closed 
with a continuous suture ol plain catgut No. 1, and the 1 limb 
is put up in a long plaster-ol-Paris spica from toes to costal 
border, with the hip in hyperextension. Recumbency is 
maintained foi eight weeks. 

Mayer's Operation for Paralytic Abduction Deformity. 
Mayer points out that, in solving the problem ol correcting 
this deformity, the process ol its development has to be re¬ 
versed by the operation; in other words, all those structures 
which have gradually shortened 011 the outer aspect ot the 
hip have to be lengthened until the leg can be adduc ted, and 
then some means devised to replace the pull ol the paralyzed 

Alayer’s Technique.* “A 14 inch incision is made along 
the outer aspec t ol the right thigh. 1 he skin is dissected bac k 
sullic iently to give a wide exposure ol the lascia lata. A trans¬ 
verse incision through the lascia is made a little below the 
level of the great trochanter. This removes the Inst obstacle 
to the adduction of the limb, namelv, the contracture ol the 
fascia lata and at the same time permits the retraction ol the 
gluteus maximus muscle and the exposure ol the trochanter. 
T he tip ol the troc banter is then cut oil with the c hisel, lib¬ 
erating the shortened abductoi muscles. It is then possible 
to adduct the limb to within to degrees ol the vertical line. 
It is evident, however, that shrinkage ol the hip capsule pre¬ 
vents the complete adduction ol the limb. A transverse in 

* Mau'i, 1 . An 1111 c is 11 ;i I 1 \ | >c‘ ol paiahlic alicluclioii clclormilx ol I lie lii|>— 
an ojicialioii lot i 1 s cure'. S'i/rg., C-xim., |o: |21, 1925. 


( Mon is. t hcrcToi e. made through (lie capsule ol ihe joini 
neai it s al lac Innenl I<» I lie neck < >I i lu - lemur. 

' Immediateh altei this the leg can he swung well <>\ci l<» 
i lie I ell side ol I lie hod \ and the right heel hi c u il* 1 11 into con 
tact will) the lell. Ihe abduction coni rail lire, thus having 
heen overcome, the next problem is how to keep the limh in 
the adduc ted position. 

I'o do this .i 2 inch strip ol the lascia lata is dissected 
awav from the lower hall ol the this'll. Above, the lascia is 
left attached bv a broad pedic le. I his strip ol lasc ia 2 inches 
wide and S inches long is then drawn upward and inward 
through a subcutaneous channel, and Listened under tension 
to the spine ol the pubis and to the inner portion ol 
Poupart's ligament bv means ol strong chromic gut sutures. 
\t the point ol reflection the pedicle ol the lascia is 
reinlorced In means ol several sutures so as to prevent tear 
mg ol the tissues. Ihe wound is closed, no attempt being 
made to suture the tip ol the trochanter to its original site. 
\ plaster spic a is applied holding the leg in adduction ol i r, . 

" Al ter | weeks this is remm ed and ac l i\ e and passi \ e exer¬ 
cises begun at onc e. 

P>\ means ol this operation. Mayer lias heen able to over 
come entirely the 1 abduction del'ormitv. The lumbar curve 
disappears and the* limp is scarcely perceptible. There is 
slight power ol voluntary adduction. In spite ol the I act that 
the tip <>l the trochanter has heen chiseled oil. the abduc tors 
rccovei almost normal strength. \o unpleasant secpielae. due 
to the removal ol the strip ol lascia. develop. 

II \ t)i)t (a i ox ( c ix i k \c i iris vxi) P vtcvi v sis oi ini (drill 

I he methods o! treatment in these 1 < ascs in orelci <>l prc‘lei 
enc e ale: 

1. I enotomv ol adduc toi tendons: 

2. Substitution ol vastus externus oi crecloi spinae loi 
paralv/cd glutei (l.ange Ki eusc her); 



g. I iansplantalion ol tensoi fasciae lemoris into fern in 

(! -coo); 

|. I t ansplantation ol tensor fasciae lemoris into the pos 
terioi superiot spine ol the ilium (Dickson); 

r,. I ransplantation ol tensor lasciae lemoris and ereetoi 
spinae (I ley (doves). 

Tenotomy oj th<’ .Iddiu/oi t endons foi Addinloi Con 
Iraelnre from Spa.slic Paralysis. In the usual ease ol spastic 
paralysis the liip is somewhat Hexed and internally rotated 
and adducted, the knee adducted and Hexed and the loot in 
eeptintts. II both limbs are involved, and in eases with am 
decree ol adductor spasm, the patient will cross one 1 eg oxer 
the other when an attempt is made to walk (scissors gait). 
M use Ic training, brac es, and stretching haxe not proven to 
be ol value in treating this type ol contracture at the hip. 
The only satisfactory treatment is the lengthening ol the 
musc les which are responsible lor the delormity. 

With the patient on the fracture orthopedic table and the 
leg abducted to put the adductors on the stretch, a short 
incision, i or a inches in length, is made oxer the adductoi 
longus tendon just below the inguinal told. I he tendon is 
exposed, the linger hooked around it. and .y, to i inch ol it 
excised. The leg is further abduc ted, and ecptal amounts ol 
the adduc tors brex is. grac ilis and magnus, and even the pec 
tmetis are removed, as well as any othei restraining bands ol 
tissue. Some surgeons recommend division and excision of a 
portion of the obturator nerve at the same time. The limb is 
immobilized in marked abduction in a long plastet-ol Paris 
spic a. 

iwrai.x sis ot mi c;i t i l l 

The gluteus medius is very Irccpientlx aliened in inlantile 
paralysis. This muse le is one ol the most important stabili/ 
ing forces in weight-bearing and in walking. Its principal 
func tion is to hold the pelvis steady ot abduc t (he pelx is 


25 ( ) 

when weight is placed on die Iiin!> and to abduct the 1 in 11» 
when the weight is placed on the opposite limh. I he gait 
associated with weakness 01 paralysis ol this muscle is pet 
lee 1 1 \ characteristic-. W hen the patient hears weight on the 
aliened 1 imh the opposite side ol the pel \ is sags and lie in list 
lurch to the aliened side to maintain his balance. I he treat 
ment ol this condition presents one ol the most dillic till 
|ireihlems in hip sin gel \. 

Paralysis ol the glutens maximus is not so liecpientlx 
found in infantile paralysis. When the patient hears weight 
on the affected side the trunk shills cpiic klv to that side and 
hack and the patient hurries to get the other loot in position 
loi weight hearing, \pparalns is entirely ineffective in the 
control ol these deformities. \ number ol operative pro¬ 
cedures have been devised to substitute other muscles lor 
the paralvzcd glutei. 

Substitution of Pastas Fxlennts oi Frector Sfntiae for Par¬ 
alyzed (Uutei (Lange-Kreuschet Operation).* rhe vastus ex- 
ternus is used as a substitute lor the paralyzed glutei. The 
origin of the vastus exteriors is detached Ire nil the base ol 
the great trochanter and by a series of sutures is anchored 
to the c i est ol the ilium to assist abduc tion ol the thigh. 

II the \asttts externus is paralv/eci as well as the glutei, 
which is olten the case. Lange substitutes the erec tor spinae 
after lengthening it with "silk sinew." by which attachment 
was made to the lesser trochanter. 

I lie lat issimus dorsi I roni the sound side can be su list it u ted 
for the smallei glutei.f 

/ ra nsjtlan tat ion of the Feasor Fasciae Fentons into the 
leuiai i/.egg's Ofinalionf.f When powei to abduct the leg 
has been impaired oi lost because ol paralysis of the gluteus 
medius, I .egg transplants the tensor lasciae lemoris into the 

* im. /. C hlli. Sintr., |). ii) i \iiji.), ii)ii>. 

I Wilkie t). IV I). I rent iiieiil ol liacturcs ol llie neck ol the teiuui. .S"t/rg., 
C .\ni i . Ohs !., | |: -,!»<). ii)~y. 

; I c*jc**>. \ - I - I ) ansplanl ai ion ol lensoi lasciae lemoris in cases ol weakened 
glutens medius. /. /. .1/. /..Ho: ii|<j, i()«<{. 



lemur. 1 lie lascia lata is exposed by an incision which com¬ 
mences ai the anterior superior spine and extends backward 
and downward over the great Irochanlei and lor about g 
indies down the lemur. The Iasi ia lata is incised downward 
Irom the anterioi superiot spine along the line where it 
thins out; this incision is carried to a point 3 inches below 
the great trochanter and then transversely backward lor 11/, 
inches. The libers ol the vastus externus are now divided 
and the lemur exposed about 21/, indies below the tro 
chanter. A periostea! Ilap is turned down and a groove is 
made in the bone 1 inch long, i/> inc h wide and deep enough 
to penetrate to the marrow. Drill holes are made through the 
lateral walls ol this groove. A suture is run through the free 
end ol the lascia lata and its end passed through these drill 
holes and knotted over the lasc ia lata. The Ilap ol periosteum 
is replaced and sutured. With 20 degrees ol abduction, in 
which the leg is to be held by plaster, there should be mod¬ 
erate tension on the fascia. 

Transplantation of the Tensor Fascia Femoris into the 
Posterior Superior Spine of the Ilium foi Paralysis of the 
Glutei (Dickson). When anterior poliomyelitis has caused 
paralysis of the gluteus maxiinus and medius, Dickson trans¬ 
plants the tensor fasciae femoris to the posterior superior 
spine ol the ilium. Even il this muscle has been affected b\ 
the paralysis, the joint is stabilized. If the function of the 
musc le is intac t, he has found an astonishing amount ol ab 
duction and extension ol the hip possible alter the trans¬ 

Dickson's Feehnifjue.* With the patient lying well ovei 
on the side, the skin incision is made. This starts at the an¬ 
terior supcrioi spine and runs posteriori) along the c rest ol 
the ilium to the 1 posterior superior spine. Anteriorly, it is 
prolonged downward Irom the anterioi superior spine onto 
the thigh lot a distance ol about font inc hes, passing along 

* Dickson, I . I). \n operation lor stabilizing paralytic hip. J. Hone Joint 
Sm n., <p 1,1 ejay. 



die liuiei borclei ol 11 ir tensoi lasc i.ic lemons (lata). I lie 
skill .mil subcutaneous lat are rellerled back, exposing the 
last ia covering llie tensoi last iae lemoris (lata), the gluteus 
mctlius and the* gluteus niaxiinus. 

I lie tensor last iae lemoris is next separated Ironi the 
sari or ins and ret l us lemoris anterior I \ lor a distance ol about 
I or ", ilit lies, and Irom the gluteus inedius lor about g indies 
posteriorly; tare should be taken In this dissection not to 
interfere with the nerve supph to the muscle. I be nerve to 
the tensoi last iae lemoris, coming Irom the superioi "luteal 
nerve, emerges Irom beneath the gluteus inedius at about its 
lowei third and passes into the under surlacc ol the muscle 

The tensoi last iae lemoris (lata), having been Ireed well 
down towards the knee, is separated Irom its origin at the 
crest ol the ilium by chiselling oil a shell ol bone. As 1 al oe 
a shell as possible is taken: usually a good substantial piece 
about 2 inches long can be secured. 

I lie atrophied gluteus inedius is now carefully lilted up 
and through the tunnel thus lormed beneath it. the sewered 
insertion ol the tensor fasciae lemoris (lata) is passed, to 
emerge through an iiu ision in the fasc ia made at the anterior 
border ol the gluteus niaxiinus. This tunnel beneath the 
gluteus inedius should be made ( lose to its insertion into the 
greater trochanter to allow the transplanted muscle to pass 
as lar posteriorly as possible. 

I he thigh is now slrongb abducted to allow the insertion 
ol the tensoi last iae lemoris (lata) to pass well posteriorh 
and reach the posterioi superior spine if possible. It will al 
most invariablv reach this position il the abduction is cai 
lied lar enough. \t this point, a groove is made in the 1 crest 
ol the ilium into which the shell ol the bone adherent to the 
origin ol the tensor fasciae lemoris (lata) is securely fastened 
with Ao. g t liromit i/cd catgut oi silk suture. If. even with 
extreme abduction, the tensoi last iae lemoris (lata) is too 
slioit to reach the posterioi superioi spine, a strong band 
ol last ia attac hed to the < rest ol the ilium tail be turned 



ii|>, and l>y suturing the tensor lo this, a linn atlaelnnent fot 
the transplanted nnisele can he secured. Occasionally, when 
nnahle to bring lhe muse le as lai posterior as was desired, we 
have raised a Map Irom the side ol the ilium below the c rest 
and attached the nnisele at this point. It is usually only in 
the oldei cases that we have Found it necessary to resort to 
fixation below and slightly anterior to the posterior superiot 

I he posterior edge ol the transplanted tensor Fasc iae 
lemoi is is then linnly sutured to the undei surface ol the 
gluteus maximus, the sutures through the gluteus maxiinus 
being placed as iai posterior as possible, thus drawing the 
transplanted muscle back and anchoring it. II the muscle has 
been displaced as Fat posterior as it should be, it will, in its 
new position, pass oxer the anterior hall ol the greater tro¬ 

I he wound is c losed, all dead spaces being carefully obiit 
crated, and the limb put up in plaster in extreme abduc don. 

At the end ol three or Four weeks, the cast is cut clown and 
daily exercises given. The exercises consist in placing the 
patient in a prone position and teaching him to extend the 
hip on the pelvis with the thigh abducted. The east is re¬ 
moved and the extremity allowed gradually to come clown 
From the abducted position at the end ol six to eight weeks, 
and the patient allowed to use the extremity. 

Frans/jlanlalion of J'ensor Fascia Fenians and Frector 
Sj/inae (Hey droves' Melliod).* Hey droves has adopted a 
combination ol I .egg's and Kreuse lier’s operations. 

“A long inc ision is made down the outer side ol the thigh 
exposing the iliotibial band ol the laseia lata Irom the level 
ol the trochantei to that ol the outer condyle. 1 he laseial 
band is divided just above the knee and isolated Irom the 
deep tissues up to the insertion ol the tensoi laseiae lemoris. 
It is taken backwards through tlm tendinous origin ol the 

■ I lev C.i o\es, I . VV Some c oni ri but ions lo reconstructive sui »et \ ol I lie lii|>. 
Iliil. /. S///".. i |: |S<>, iu-7- 



vastus cxlci nus just I »c - 1 (»\\ i hr prominence ol llir threat 1 1 < > 

( hunter. \i this sta”c the loti” ine ision m llir thi;j,li is < loscd 
cxe (. [>l al i hr n|)|)ri j»a 1 1. I hr lowci ] >a 1 1 < >I t hr crrrt<>i spinar 
nnisrlr is now exposed t limit” h a separate vertical incision. 
\IX >111 hall llir ihirknrss ol litis muscle is isolaird and di 
\ idea 1 I rom its origin at the ati”le bet ween the iliac c rest and 
sacral spinous processes. \ luniirl is made henrath the skin 
and subcutaneous tissues counce lino the two wounds, and 
the iliotibial band is drawn up to the back, pulled tense and 
its end is brought through the tendon ol the erector spinar, 
doubled back on itscll. and sewn bv separate stout silk li”a 
titles, the Ie” bciti” held in abduction all the time and put 
up in this position alter the closure ol the wounds and the 
conclusion ol the operation. I he new muscle which now 
I<>i ins an abduc toi ol the hip joint is a digastric musc le ha\ 
in” the erector spinar lormiti” its posleriot belly, and the 
tensor lasciae lemoris its anterior, whilst the strong I a sc ia 
lata Ic»rms the' intermediate tendon. Acting together the two 
components ol this muscle will be a pure abductor, whilst 
the anterior helix will also be a llexor, and the posterior an 
extensor ol the l" 

III. Pxicu'iiic II11* \\i> Ik \ i t Itixiox writ t Ix\oc;k Ixxt i 

In cases showing the Iliad deloiniitv. hip llexion. knee 
llexion and knoc k knee. Silvei and Yomi” divide the ilio 
tibia! band neat the knee. Iorbes ' extends the idea under 
bint* this procedure In separating the libers ol the la sc i a 
lata which can be proved to be acting as llexors ol the knee 
and inset t ni” them as a cvlindrical c < > t c 1 into the 1 cptadrireps 
tendon and the paled la. while the lc” and 11 i are held in 

I (ii lies. VI. I lie ic-nsoi lasciae lemoris. / Hour V ]nn\l S/era.. |ul\ H|i>(>. 
|»- V s !)- 



IV. Pakai a i ic Dislocation 
(See Dislocation <>l the I lip, p. i tcj.) 

Author '.s Comment. Each case ol paralysis ol the hip is an 
individual problem. A carelnl pieoperati\e survey ol the 
contract tires and remaining muscle power usually reveals that 
none ol the above procedures alone is adequate to correct 
the disability. It has been my c ustom to use these procedures 
as a basis lor the modifications nec essary in eac h case. 

Chapter XI 


O S I I () A R I I I RI I IS (art In it is del 01 mans) is (|uile 
eommonlv a monailiculai affection, limited to the 
liip joint. In this monailiculai lonn, the alleetion is 
]>rat tit a 11 \ confined to adults. I lie mudi usc‘d synonym 
'malum coxae senilis" is rcallv a misnomer, inasmuch as a 
large percentage ol cases begin in middle lile or earlier. 
Males are much more frequent Iv allected than lemales. 

Pa morex.v 

I he affection is characteri/ed h\ destruction and absorp¬ 
tion ol the artieulai cartilage ol the lemoral head, which 
becomes elmrnated, polished, and worm-eaten in appearance, 
due to disintegration ol the- underlying hone with the lorma 
lion ol c honchophvtes. whic h latei become converted into 
osteophytes, with marked lipping ol the acetabular margins. 
1 liese osteophytes may eventualh lill and obliterate the ace- 
tabulai ca\it\ and permit the- head ol the lemur to become 
dislocated. I his lesion is never suppurative, but is a degen 
erative piocess. I here is nevei am indication of sal i si ac ton 
sell repair, and lixation and immobilization for years would 
be ol no avail in advanced cases. I he femoral head becomes 
markedlv flattened oi cylindrical in shape at its upper aspec t, 
and the motions ol the joint become altered Irom a ball 
and socket action to dial ol a hinge joint. Ibis change ol 
shape ol the lemoral head from that ol a sphere 1 to dial ol a 
evlinder, pi ac tic alls limits motion to llexion and extension: 
rotation, abduction, and adduction become limited in varv 
iug degrees up to almost complete absence. I his limitation 


Advanced osteoarthritis. Hip lias heroine dislocated 
acetabulum Idling 11j> with hone. 


because of 


o! motion is due to .1 < haii”e ol conlortnal ion ol the joint 
.md not so nun li to musc le spasm, although in the mote 
acute t asc s muscle spasm max also he a laeloi in causing 
limitation ol motion. I Ins condition ol osteoarthritis ollen 
becomes engrafted upon a lormcr healed art In it is ol a tuhei 
c tiloiis 01 pyogenic type. 

St Ml'KIMS \\n l)l \(.\<)S[S 

\y mbloms. I lie clinical manilestat ions are usually suh 
at me. and consist ol neuralgic pains simulating sciatiea, most 
acute eluriii” locomotion, and stillness on resuming move 
Hunts ol the joint alter a period ol lost. I he onset ol the 
symptoms is \er\ insidious, as has been implied. Stillness in 
the joint is followed by a slight amount ol pain which ;_>rad 
ually increases but is experienced on locomotion only. I he 
pain is more likelx to be rclcrred to the knee than elsewhere. 
It max simulate sciatica in othet cases, or be referred down 
the- anterior sin lac e ol the illicit to the knee. Pain in the 
knee max be ol suc h sexeritx that many eases are treated for 
loti” periods as allections ol the knee-joint. In other cases, 
the pain max be rclcrred backward to the sciatic region. 

Limitation ol motion pro”) essix elx increases, and ntoxe 
incut is c > I ten accompanied by creakin” or xpatin” within the 
joint which is perceptiI>lc to the patienl. Late in the disease, 
thickening about the trochanter occurs; and the latter is 
usuallx displaced upward, cm ill” to the intrinsic alteration 
ol the joint, \sidc Irom the shortening, distortion ol the 
aflc'c teal limb always takes place in llexion and adduc tion, 
with excision ol the leet and is almost inxariablx ac com 
panied bx muse ttlai atrophy. In the majorilx ol eases the 
llexion is possible only oblicpiclx outward, the decree ol rota 
lion and oblicpiitx ol llexion bciii” in accordance with the 
axis ol the nen lx shaped cxlinchical head. I he limp, pain, 
and restricted moxement in theearliei stages, to^ethei with 
the latei maniIestat ion ol musailtn alroblix max c ause eon 
lusion ol this condition with tuberculous coxitis ol a sub 



ac ute type. I lie clinical course varies with the strain and the 
amount ol irritation Irom use put upon the affected joint, 
the greatei the strain and irritation Irom lunction the more 
rapid is the progress ol the joint lesion. As has been stated, 
the motions of the hip are associated with little 01 no muscle 
spasm except when joint symptoms become acute. 

Differential Diagnosis. Careful scrutiny ol the history, 
proper interpretation of the symptoms, and physical signs, 
together with the v-ray picture, should make differentiation 
from tuberculous coxitis comparatively easy. The symptom- 
complex of this condition is so sharply differentiated Irom 
all other arthritides of the hip that an absolute diagnosis is 
not difficult (see Chap. VI). 

X-ray appearances of osteoarthritis differ greatly from the 
pictures of tuberculous or other types of arthritis. Contrasted 
with the rarefaction and disintegration of tuberculous ar¬ 
thritis, this condition shows marked increase of the densitv 
ol the elements of the joint from eburnation and the ac¬ 
cumulation of osteophytes around the superior, and usualh 
also the inferior, margin of the joint, associated with varying 
degrees of flattening of the head. 

Summary of Clinical Features. Briefly, the clinical mani¬ 
festations of osteoarthritis (arthritis deformans) of the hip 

t. Insidious onset. 

2. Symptoms manifested only during locomotion. 

g. Motions ol the hip change Irom those of a ball and 
socket joint to those ol a binge joint. 

|. The axis on movement ol this hinge joint in flexion is 
always obliquely outward, and varies in its obliquitv to the 
anteroposterior plane ol the pelvis in different cases. 

r ( . Muscle spasm, on passive motion, ma\ be entirely ab¬ 
sent . 

(i. Marked contrast ol the v-ray appearance to other concli 
i ions whic h simulate it < linic ally. 

y. The lrequenc\ ol trauma as an etiological factor. 




\s io ic'( <)\ci \ w ith .1 functional joint, the prognosis is mi 
laxorable. Oases that hecoim 1 adxaneed do not tend toward 
reeoxerx. Maltreated cases dexelop sex ere flexion adduct ion 
deformity, with increasing obslrnc tixe ankxlosis Irom tlie de 
|)osit of hone within the joint and around its margins, hut 
indent nnatelx actual bonx ankxlosis nexei oceans. I he hip. 
therefore. is always subject to joint strain and pain ol xaix 
ing intensity. As to prognosis alter operation, bony hxatioti 
bx the anlhoi s arthrodesis operation relieves the patient 
Ironi all pain and gives him a limb in laxorable relationship 
to the 1 pel\ is (idecrees llexion, yio decrees abduc tion) 
and Imnishes a xeix satislactoix limb, even in the case ol 
the laboring man. Artlnoplastx olFers a chance lor mobility, 
but the (lancet s ol associated pain and the long c onx alescone e 
m old subjects should be borne in mind in considering this 
pi ocednre. 

Tkl A t XI i \t 

\( )\ ( ) I * I K X I IX I I RI ATM I \ I 

Occasionally some rebel max be experienced in early cases 
bx regulation ol the patient’s habits and occupation, or bx 
local massage, Iriction and manipulation of the joint in ab¬ 
duction and extension in order to prevent contraction. 
Phxsiotherapx in the lorm ol heat and massage is indicated 
to <>\crcomc pain, contracture and limitation ol motion. A 
prolonged course ol treatment with thxinns and pitnitarx 
extracts is also indicated. Occasionally deformity max be 
counteracted bx traction, rest.oi reduction nuclei anesthesia 
billowed bx a hip splint to lake pressure or diction I rom 
motion oil the joint. 01 bx a short plastct ol Paris spica. 

I lowcxcr, it has long been well known that a large innnbei 
ol prog loss i\ e and adx ai ic ed cases ol ost coat t h ri l is ol the hip, 
w ith die ac conipanving delormitx and disability, fail to re¬ 
spond to the c onx out ional methods ol systematic hygienic 


rest 01 brace treatment, and progress toward complete in¬ 
validism. I Ids ( lass ol eases is met in adult life, and the 
length ol time rc(|itircd by the treatment heretofore em¬ 
ployed cannot be satisfactorily undertaken by the working 
man with a lamily dependent upon him, the chances for an 
ultimate recovery being extremely remote. 

W ith marked anatomical and pathological changes present, 
such as the wearing away ol the femoral head and ace¬ 
tabulum, ebttt nation, osteophytes, and the associated flexion 
and adduction deformity, satisfactory results can rarely be 
anticipated Irom expectant treatment. 

on RATI VI 1 Kt A I M I NT 

Resection of the upper extremity of the femur (an opera¬ 
tion which I believe has outlived its usefulness) was practiced 
by 1 folia and others with very unsatisfactory results. Holla 
was one ol the last to discard complete excision. Forcible 
manipulation under ether has produced disastrous results in 
both the hypertrophic and the atrophic types. In the hyper¬ 
trophic type, forcible manipulation of the parts produces 
further hypertrophy in many instances, more pain and ulti¬ 
mate deformity by the traumatization of the joint struc tures; 
and, in the atrophic condition, on account ol osseous rare¬ 
faction, further damage is likely to occur from the crushing 
ol this rarefied bone. When this disorganizing condition of 
the hip joint exists, with its accompanying adduction and 
flexion, with firm musculat contractures and a progressive 
bony obstructive ankylosis associated with pain, with the 
thigh in this faulty position, it is best to aim lor an im¬ 
mediate firm ankylosis by means of an arthrodesis operation. 

The limb is placed in a position of slight overcorrection to 
compensate for the existing practical shortening, there being 
but little lurthei actual bone shortening produced by the 
opet at ion. 

Jnl ra-arlieular Arthrodesis with Supplementary Extra- 
arliiulai draft. I he production ol surgical ankylosis ol the 



adult hip joint is indicated lot the lollowino conditions: (t) 
Marked pain: (2) librous ankylosis lollowinu, previous opera 
lion, trauma, or Irom otliet eanscs; (;;) rarelnction ol the 
femoral and nee k in tlie adult, with inevitable 01 actual 
crushing ol t It esc sti tie lures. 

lutlioi b I'rilnii(ilie. Since I Inst repotted the icchmipie 
ol arthrodesis I01 arthritis delormans ( 1 <)<><S), K I have modi 
lied the technique in several respects, principally by the ad 
dition of citlici 1 lit 1 a art ieular or c\t 1 a art i( ulai *»ra11s. 

I lie hip joint is reac hed hv the Smith I’etei sen approac h. 
I he capsule becomes visible and is incised. A pail ol the 

osteophytes about the acetabulum are turned upward with 
the soli tissues adherent to them, since it is considered ad 
v usable to preserve as main ol these as feasible on account 
ol their potential bone producing power. With the head ol 
the lemur in situ, approximately one-third ol its upper hemi¬ 
sphere is remov ed with a lont> osteotome or chisel. •"> s inch 
in width, in a plane nearly parallel with the lone, axis ol the 
neck ol the- femur. With the same instrument and a strong 
curette with a c ross handle, the ac etabulum is transformed 
into a llal sin lac cal rnol against whic h the Hat surfac e of the 
head is Imallv brought into linn contact In abduction ol the 

Access to the joint is much facilitated by a position ol 
adduction ol the limb. For the purpose ol orientation, an 
assistant is constantly kept in readiness to rotate the lenitti 
while the- operation is in progress. Ihe bone is removed in 
such a wav that the' flat pelvic surlace is tilted up somewhat 
mesiallv in order to produce a locking ol the parts and to 
prevent am possibility ol dislocation Irom weiyht-beai ill”. 

II the adductor muscles prevent the 1 required amount ol 
abduction, an open division of these musc les and tendons is 
made to permit the leu, to be brought into the* desired po 
sition. I he acetabular and lemmal head surfaces are brought 

r Albee. I II. Vnhiiiis dc'loimans ol ilic hip joint. Report ol a new opera 
lion. /. I. \ 1 . I., 1 iijoS. 



into lonliK l In simply abducting (lie* thigh. In my i<)i<) text 
hook, 1 lie inti .1 ;u l i( ular mortising operation supplemented 
In chip grails around the periphery of the joint was de¬ 
scribed. However, I was occasionally disappointed in the 
failnre ol arthrodesis or a delay in the occurrence ol the 
ankylosis. 1 his experience plus the realization that well- 
mortised massive grafts are more trustworthy induced me to 
modily the operation by sliding an inlay gralt Irom the outei 
table ol the ilium just above and inc luding the rim ol the 
acetabulum, downward into the cleft produced by the split 
ting in silu ol the trochanter from above downward and out¬ 
ward with a l lpk inc h osteotome, with a minimum amount of 
periosseous and solt parts separated. The superior surface ol 
the neck ol the femur is at the same time freshened by re¬ 
moving with an osteotome sullicient bone to make a flat 
surface against which is contacted the under surface of the 
iliac graft. 

Since changing the technique in this manner, the early 
fusion obtained and the absence of failure to sec tire ankvlosis 
have been most gratifying. The comparative experience with 
the old intra-articular arthrodesis supplemented with chip 
grafts as compared with the massive inlay graft bears upon 
all such operations performed upon any joint or location in 
the body; that is, it proves the untrustworthiness ol small 
chip grafts as to their osteogenesis and their ability to 1 use, 
and emphasizes the trustworthiness ol the massive grab well 
incorporated l>\ inlay ot mortise into the elements ol a joint 
to be fused. 

Soft tissues are sutured with continuous suture ol chromic 
catgut No. i; skin, with continuous suture No. t plain cat¬ 

A double plaster ol Paris spica c ast extending to the* toes 
on the operated side and to the* tuberc le ol the tibia on the 
other side is applied, which remains on lot a period ol eight 

Following the' removal of tlu' cast, il roentgenograms and 



phvsical examination reveal solid l)ony lusion ol the lii|). 
massart* is started and llu' patient is allowed to beat weight 
as soon as his strength permits, nsnall) at the end ol 11\e to 
sev en da\ s. 

(,l \ I l< \ 1 1)1 s( t ssl( )\ < )l VK I I IK< )l)l s| \ (, ()l’l KA 1 11 >\s 

In a n Is v losis I tom snppnral iv e artIn it is, 11 aitina ot l n hen it 
losis. il the* conditions <)I the joint and pet iat thrilic slrnctincs 
ate favorable, as well as the age ol the patient, lot Inlnre 
arthroplasty. I so plan i n\ arthrodesis that conditions are 
favorable lot an artlnoplastv at a later date. Ibis is pat 
ticnlarlv tine ol the knee and the hip. both joints being 
favorable to artlnoplastv, and the latter operation being ol 
great advantage to the patient. 

\t the hip. instead ol using local bone-gralt material. I 
prefer to use tibia] grafts so as not to destroy or impair the 
flit tire func tion ol the trochanteric musc les, whic h is essential 
to the success of an arthroplasty. And Irom a second stand 
point. I do a true extra-articnlai arthrodesis so that the grabs 
can easily be removed at the artlnoplastic procedure and 
will not interfere with the exec ution ol the operation. Fur¬ 
ther, a varying amount ol trochanter ends are left in place 
with the gluteal muscles into which they are inserted, at 
tac lied so that tlieii Innctional control ol the fennn will be 
accentuated, particularly in active abduction of the hip and 


In certain cases ol osteoarthritis, particularly those in 
voting and middle-aged patients in which the arthritis has 
come on following an adolescent slipping ol the femoral 
epiphysis, a partial artlnoplastv mav be clone to restore mo 
lion. I he indications lor the c hoice ol this procedure are 
\ ci v deli nit e, as lol lows: ( i ) I lie hip in list be almost can i i cl v 
painless with no evidence’ ol active i n Mammal ion, the - cliiel 
complaint being the limitation ol motion. (2) I lie patient's 



occupation must allow him to sit a great deal of the time 
while at work. (3) Ihe patient must littve the mental and 
Imam i a I resources to permit him to go through a Ion,” period 
ol massage j)ostoperati\ely. 

Ihe Smith-Peierscn incision is used and the capsule is 
opened widely. With the large gouge, used in arthroplasty 
ol the hip, the osteophytes surrounding the head of the lemur 
are removed and the head reduced to such si/e that it is 
able to move Ireely throughout its normal range of motion. 
The articular surface ol the acetabulum is not disturbed. 
The osteophytes surrounding the rim of the acetabulum are 
not removed unless they block the Iree range of motion of 
the newly formed head. The subcutaneous tissues are closed 
in layers with No. 1 chromic catgut and the skin sutured 
with No. o plain catgut. A double plaster-ol-Paris spica cast 
is applied extending to the toes on the operated side and to 
the tubercle of the tibia on the opposite side with the oper¬ 
ated hip in slight hyperextension, moderate internal rota¬ 
tion and abduction. At the end ol three weeks the cast is 
removed and daily massage and exerc ise given. I he patient 
begins to bear weight after a week or ten days. 

The results of this procedure in a large series of carefully 
selected cases has been most gratifying. I lie deformity re¬ 
mains collec ted. Alien four to six weeks of massage ai d exer¬ 
cise a good range of active, painless motion is secured. Many 
of these patients are able to resume active sports lollowing 
this procedure. 

Chapter XII 


i. Ni on. asms 

M AI l(,\AN I (,l« >U I I IS 

M U .K.'s \\ I owths lire very line in the upper 
end of the lemur. Carcinoma, when it occurs here, 
is almost always secondary to a primary growth 
el sew h ct e. Sail oma o I the round-eel 1 variet y is t he usual hum 
ol malignant neoplasm in this locality. It originates in the 
periosteum, is \ci\ uipid in its growth, and highly malignant. 
The tumor is very vascular, alvcolated, and olten pulsating. 
Local extension ol the growth takes place early. Spontaneous 
Iraeture of the hip is olten the Inst sign ol the disease. 

Clinical Features of Sarcoma. Adolescents are the usual 
victims. There is Irequenth a definite history oi trauma. 
Karlv swelling ol the hip-joint occurs with rapid inc rease ol 
its size .uid later elimination ol motion in the joint. The size 
ol the joint is olten enormous, with consequent stretching of 
the overlying skin. Lain is often absent or very slight, except 
in the c ase ol pressure oi stretching ol nerve trunks, elasticity 
occasionally oca ms in the tumor. Fluctuation, when present, 
is an indication ol disorganization ol the growth at its centei 
and the pressure ol 11 ce blood in its interstices, in whic h 
event pulsation ol the' tumor becomes more marked. 

Diagnosis. The diagnosis is based on the history ol the 
growth, ils outlines and physical properties. The most re 
liable evidence, however, is offered l>\ the \ ra\. II there is 
still doubt ol the nature ol the- lesion, an exploratory incision 
is justifiable loi removal ol a small piece of the suspected 




tissue and its microscopical examination. A pulsating sarcoma 
is sometimes mistaken lor an aneurysm. 

/ real incut. Unless a positive diagnosis is made and a radi¬ 
cal operation performed before extension of the process oc¬ 
curs. no treatment is ol any avail. In cases detected early, 
while the growth is limited to the head of the femur, am¬ 
putation or resection ol the hip-joint offers the only hope of 

Gordon Taylor and Wiles * have performed the “hind- 
quarter” amputation in 5 cases with death in 2 of them. 
There have been 20 ol these cases reported in the literature 
since 1910 with a mortality of jo per cent. They believe it 
probable that in the luture such an extensive surgical pro¬ 
cedure will be undertaken less and less frequently because 
of the more conservative irradiation therapy now possible. 

The amputation involves the entire gluteal mass, the os 
innominatum, and the entire lower extremity. It is per¬ 
formed under general anesthesia supplemented by spinal 
block. The incision is made along the crest to the antero 
superior spine, thence downward and inward 11/, inches 
below Poupart's ligament toward the middle of the origin 
of the abduc tor brevis. Poupart’s ligament is divided at each 
end and the spermatic cord retrac ted downward. The rectus 
abdominis muscle is then cut from its insertion on the pubic 
crest, the pubis denuded on both sides, and the svmphvsis 
divided. Next, a skin inc ision is made Irom the center ol the 
iliac crest to the gluteal fold and along this fold to meet the 
lower mesial end of the Inst incision. The ilium is sawed 
through into the sciatic notch. The innominate bone and 
lower extremity can then be drawn awa\ Irom the pehic 
peritoneum. The psoas muscle is sectioned above the pelvic 
brim, and all other muscles attached to the disengaged os 
innominatum are divided neat the bone. Alter hemostasis 
and injection of nerve trunks, the remains ol the muscles are 

* (tore Ion I a\ loi, C... and Wiles. I’. I ntei innomi no a bdominal (hi net-qua rich 
ampula!ion. Intermit. Ihst. Sing., (>i: uyli, i<)•{",. 



Mil in t'd lo reinforce I Ik* peritoneum and die skin llaps are 
sutured. I’dood transfusions should always he gi\en. 

( -i s i s (>i 1111 i i»i*i- i< im) or I I 11 I I Ml k 

C.\sts ol die ubbn end ol the Icm luu are usualh ol the 
nature ol a solid mass ol tissue in which the cvsls are etn 
hedded. (xsts ol that portion ol the lenun entering into the 
loimation ol the hip-joint (the head and neck) have been 
from time to time recorded in the literature. 

('.Unit nl H idol y. l-'ract tire is a yen cot muon symptom ol ten 
the initial sign ol the malady. Fracture is sometimes inconi 
plete. I here is Irequenth good union altei Iracture through 
a cyst. though bending and swelling ol the hone at its site 
mat occur, possibly on account ol the increased loimation 
ol fibrous or fibrocartilaginous tissue. Simple cysts are usually 
encountered in Noting children, while the cystic formation in 
solid masses o! fibrous or other tissue may occ ur at any age. 

In some instances the clinical course resembles that ol an 
osteoarthritis ol the hip. beginning with vague discomfort in 
the joint which gradualh becomes worse and is followed b\ 
limitation ol motion. 

A on I j/jx'tntiiK es. II the cyst has c aused considerable c\ 
pansion ol bone, the v-rav pic ture is characteristic. A shell ol 
cortical bone is seen surrounding the tumoi except where 
1 1 act lire ore ms. II this cortical shell ol bone is absent at am 
point, it should make one suspicious ol sarcoma. I lie rest 
is centrally placed, and there is absence of periosteal thick 
ening and ol sclerosis ol tlie sm rounding bone. In oilier c ases 
there is pi ne tic ally no expansion ol bone, the onl\ abnormal 
i> N m the' \-ra\ picture being the uniform density ol the 
bone, the cortical portion not being sharply delineated as in 
normal bone'. I rabeculae subdividing the 1 translucent area 
are ol common occurrence. 

1 )iIfocnl ml 1 )nt^ Siih/jIc I niuumlit finchuc can he 
eliminated b\ the v-ia\ Imdings. 



Sarcoma of the fenim. I lie clinical history is shorter in 
sarcoma, and the central position ol the cysts, the integrity 
ol the (ortical shell, and the absence ol periosteal changes in 
the \ ray appearance ol cystic disease will permit ol ready 
different iat ion. 

Pathology. Klmslic divides these cystic conditions ol the 
upper end ol the lemur into two types, viz.: 

1. Single c\sl, lound almost exclusively in young children, 
and resembling cysts ol the upper end ol the lemur both 
clinically and pathologically. Its walls consist of fibrous tissue 
in various stages ol organization, cartilage, bone (under¬ 
going both deposit and absorption), and blood clots. 

2. Ala. s.s of new growth containing one or more cysts, and 
occurring at till ages. The solid mass contains cartilage (hy¬ 
aline or fibrous), spieulae ol bone (in various stages ol de¬ 
posit and absorption), fibrous tissue of all sorts and in all 
stages of development, including myxomatous degeneration, 
the entite pathological picture being eery complex. 

One ol the varieties ol multiple cyst ol rare occ urrence is 
the echinococcus cyst. Very lew echinococcus cysts of bone 
are recorded in the literature, although they are relatively 
common in the viscera, particularly the liver. The author, a 
lew years ago, encountered one ol these echinococcus cysts 
of the head ol the lemur in a patient from New Zealand 
upon whom he operated. 

7 ’ tealnwnt. A cyst ol the upper end ol the lemur with de¬ 
generation and destruction ol the head, or head and neck, 
of the lemur presents a more formidable problem than when 
the disease is extra-articular. In the hitter instance, a tibial 
bone grab has been suecesslully employed to span the delect 
remaining al'tet the removal ol the cyst. I he grab is inlaid 
with one end into the lower Iragment and the other end 
contacted into tlm acetabular cavity. II destruction ol the 
acetabulum is sufficient to warrant immobilization, then the 
graft is mortised into the pelvis at a point above the 1 ace 
labulum as well as inlaid into the tippet end ol the femur. 



1 lie liml) should In- Itxed in .1 lout; plaslct spit a in slight 
abduction I01 ten 01 twchc weeks. In instances where the 
shall ol the lenun has heroine maikedly Lowed because ol 
1 he \ i cl ding «>1 l lie' weakened pot l ion ol l he lemurI he aul hoi 
has eorreeled the delormilN h\ a cnncilorm osteolotm (l>\ 
means ol his motor saw and an osteotome) and has then in 
laid a strong tihial ora11 through the r\stir area. II the how 
delormit\ is not loo great to leave. Inrthei progression ol the 
bending can he prevented h\ inlaving a tihial <*ra11 (same 
terhni(|ite as when hone is broken) through the weakened 

2 . ( )sl 1 OCMOXDRI 1 is Dr 1 or.maxs 1 1 \ 1 MI Is 
(1 .egg-(a 1 1 \ c Perthes Disease) 

Dc/ini/ion. Osteochondritis deformans juvenilis is a de¬ 
forming affection ol the lemotal head resulting Irotn a dis 
turhance ol growth ol the epiphyseal cartilage. 

A'/ iologx. A definite historv ol trauma of greater or less 
se\erit\ precedes a majority ol the cases. Hoffman* sum 
mari/es the rations opinions as to the exac t etiologic al lac ten 
responsible lor this condition and comes to the conclusion 
that the delormitr is due to deficient blood supply to the 
epiphysis and that weight hearing or trauma have no con¬ 
ned ion. 

I *\ iat dm greatet numbei ol c ases occurs iu males. I he 
commonest age ol incidence is the second (|nin<|nenninm. 
I lie- disease is almost invariably unilateral. It makes its ap¬ 
pearance without special warning in an individual in ap 
parenth good health and in those free Irotn tuberculous, 
syphilitic or other inlec tions. 

Ptilliolofry. I he essential lesion is a pec ttliai atroplo of 
the tippet epiphysis ol the- lemur. conse<|iient upon destruc¬ 
tion ol the subc hondral bom .substance ol the- lemotal head. 
I here- are prac 1 ic a 11 \ no data exist ing as to the gross 01 m i< 10 

IlnlliiDin. R I |ii|>h\sc;il pscudoi til >c* i < ulosis osi cot hond i ii is juvciidis, 
luh nial. Ibsl. S/// o., (ii up',",. 



st«»j)i( appearance <>l (lie diseased portion ol die femur. 
Perthes , s in his original connuunicat ion described the patho 
logical change as an overgrowth ol abnormal cartilage e\ 
tending down into lairly normal hone, [.egg, in his original 
observation on the condition, concluded that the pathological 
changes in the epiphysis and femoral neck were due to in 
terlerence with the blood-supply as a result of trauma of the 
epiphyseal line. 

X-ray A Jj/iearanees. There is an irregular defic iency of lime 
salts in the epiphysis, causing a laminated appearance. Ir 
regular atrophy ol die neck just below the epiphysis is ap¬ 
parent. 1 his atrophy, with absorption, reduces the epiphysis 
eventually to a lew segments ol bone which become com¬ 
pressed as a result ol pressure by the superimposed bodv- 
weiglit. Shortening of the atrophied neck takes place from 
the strain put upon it by the body-weight. During recovery 
from this pathological condition, calc ium salts are again de¬ 
posited in the head, whic h becomes flattened out against the 
acetabulum as the "mushroom'' type ol head, while the neck 
is thick and short. 

Clinical Features. Claudication in a previouslv healthy 
c hild is the first symptom. There is hesitancy in standing on 
the affected limb, and the child walks with a slight lurch 
(in a manner somewhat like the gait ol unilateral congenital 
dislocation) and tires easily. This phenomenon depends upon 
one or all of several factors, inc luding inefficiency ol the 
pelvitrochanterie muscle group, elevation ol the great tro¬ 
chanter, limitation ol abduction, or shortening ol the leg. 
The limp varies in amount, and. whether or not treatment 
is attempted, it continues a variable number ol months or 
years, when it disappears and recovery occurs with very slight 
derangement <>l the joint function. 

Shortening ol the leg occ urs as the result ol utrophv ol the 
femoral neck and epiphysis. Fain is slight 01 cm it i red \ ah 

IViilics, C.. I rlici C Isieoc liomli il is dcloi m.ins juvenilis. Iiiliiinill. il. 
(Irillscli. (•rsi llsi II. /. (till., | ‘J. |)l. l |u, i«) i •{. 



nc i11 . Exaggerated movements at the hip joint are ac c om 
panieil h\ pain ol slight debtee. No evidence ol infection 
can he ohtained, although some authors believe the < ondi 
lion to he dependent upon a lowparade locali/ed hematog 
etioiis inlection: while others, as her;”, believe the local in 
lection to be mcreh an accidental lactor. Slight muscular 
at robh y accompanies the condition. . I Ixl m I iou and external 
rotation are greatlv limited. I lexion at the hip is normal. 
I lie trochantn ma/oi is fnonuneut. 

I h II n an I ml Diagnosis. ()st eochondri t is del on nans j n veil i I is 
must be distinguished from epiphvseal and acetabulat tuber 
miosis, coxa vara, polvarticnlar rheumatism, juvenile de 
forming arthritis ol the hip, and osteomyelitis ol the hip. 

lrom t ti bn minus coxiti.s, dilferentiation is easy except in 
the verv earlv cases ol Perthes' disease. 

Extra-articular E ubereulosis (Tuberculous Coxa Vara): 
Lameness occurring in the morning alter a night’s rest is 
one of the first symptoms, with limitation ol llexion, rota 
tion, and abduction: pain is delmitely localized in the joint: 
swelling is usnallv absent. Dilferentiation is made by the 
presence ol muscle spasm and the other classical signs ol 
tuberculous hip disease, and the diagnosis can always be con¬ 
firmed bv v-rav examination. 

Infantile Coxa Vara: Both this and Perthes’ disease are ac¬ 
companied b\ limp, elevation ol the great trochanter, limita¬ 
tion ol abduction and internal rotation, and absenc e of pain: 
but shortening ol the limb and elevation of the great 
trochanter are always more marked in coxa vara. An v-ray 
examination is conc lusive. In congenital coxa vara the signs 
are positive. In rachitic coxa vara, olhei rachitic stigmata 
will aid in establishing the diagnosis. 

hair oi Chronic lilnular “Rheumatism": Ihe onset 
with level is different I torn that ol Perthes’ disease: likewise 
the ac c ompanv ing emaciation and the rebel afforded bv 
salic vlates and othei antii heumal ic drugs may be charactei 
ist ic ol "1 heumal ism. 



()stcoin\cl1 1 is of the Hij>: II the inlection is acute, no ion- 
lusion is likely. II the osteomyelitis is extra-articular or 
chronic, the absence ol the clinical signs ol Perthes’ disease 
and the \ ray appearances will permit differentiation to be 
readily made. 

Juvenile Deforming Irllnilis: The dilliculty in diagnosis 
arises horn the hut that a great many cases ol this affection 
are encountered in children undei twelve years of age having 
all the features ol Perthes’ disease. Points ol differentiation 
are crepitus, stiffness on movement, acute pain, such lame¬ 
ness as to prohibit walking (on account ol stiffness and pain), 
and the v rav appearances. The latter show the head to be 
thickened, flattened on its upper surface, irregular, and al¬ 
most plate-like, and with the presence of osteophytes. 

Ti eahnenl . In accordance with the confusion as to the 
etiology of this condition there are wide differences of opin¬ 
ion regarding the proper method of treatment. Danforth # 
and Pnailslorchf believing that the changes in the head and 
neck are due to crushing caused by weight-bearing, recom¬ 
mend rest until all evidences of bony change are gone. At 
the present time the majority of observers believe that the 
deformity is due to a lack of adequate blood-supply to the 
epiphysis. Ilo/an | recommends conveying a fresh blood 
supply to the epiphysis by means of multiple drill holes 
through the trochanter and neck. It has been my practice, in 
the cases with marked deformity, to place an autogenous 
bone peg through the neck and head by the same method 
used Id) intrac apsular fracture ol the neck ol the femur. 

The more mild cases are protected from weight-bearing 
for a lew weeks until all muscle spasm is gone, alter which 
they are permitted to resume cautious weight-bearing. These 
c ases are examined each week and il there is any ev idence of 

* 1 )an torih. VI. X. the trealiiK'nl ol I,egg-( '.al ve-I’eri lies' disease without 
weight heal ing. /. Hone i Join! Surg., i(>: 193.|. 

-| ltrailslord. |. t. Osteochondritis. Inlenuil. .Ibsl. Sing., (it: 50, 19;;-,. 

1 Bo/nii, K. |. A new treatment ol ini 1 ;n apsular fractures of llie neck of the 
femur and Oalved.egg-I’erthes - disease. /. Hone 6 - Joint Surg., 1 |: (iSp 1932. 



muscle spasm then activities air rcstiiclcd. Massage seems 
lo have a la\oial>le ellec I and shorten die pel iod ol con 
\ alescence. 

g. Snaimmno Hip 

Iiilni-mlinihn l \j>r. In children, the term snapping hip 
is applied to slight displacement ol the head ol the lennn 
ovci the superior or upper bordei ol the acet a I) 111 nm when 
the thighs are sharplv Hexed and adducted. Eh is inti a ai tit n 
lar t\pe is nint h less common than the extra-articular type. 
Ease ol displacement is increased l>\ habit, and is best pie 
\ented b\ a bandage about the hi]) to prevent llexion. 

Extra-m ticulm Exj/e. I>< >t 1 1 in adults and children snapping 
hi|i ol the extra art it nlar tvpe is encountered in cases ol arth¬ 
ritis 01 ol eflusion into the bursa between the gluteus maxi 
nuts and the lemur: or, again, it is due to Iriction between 
the anterior margin ol the gluteus maximus and the trochan¬ 
ter. or between some other tendon or lascial band and some 
bom prominence. The \-ra\ should always be employed to 
exclude such conditions as osteoma or osteochondritis. W ith 
the ley flexed at the knee, internal rotation causes a tendent \ 
lot the attachment ol the gluteus maximus to spring back- 
warti on the trochanter. These cases are rarely ol any clinical 
importance, anti usualh retpiire no treatment. Where the 
affet tioti is especdally annoying or is protlucetl by an osteoma, 
the- lattei should be chiselled awa\ and a bee or pedit led 
lascial lat graft interposed between its site and the "snap 
ping” tendon or muscle. 


Mention must be made of this neuropathic affec lion ol the 
hip inasmuch as it is 11 e<|iient 1 \ mistaken for tuberc ulous 
< ox it is. the symptoms and signs ol which can be t loseh simu¬ 
lated by the hysterical patient. I he signs most perfectly 
mimicked are lameness, llexion of the joint, lateral devia 
lion ol the- spine, lordosis. Handling ol the hip. and adduc 



lion and apparent shortening ol the leg. Detection of the 
subterfuge may best be accomplished by Hexing the normal 
leg forcibly at the hip; il the knee can then be brought down 
on the abdomen without raising the suspected limb from the 
examining table, tuberculous coxitis can be eliminated. 
Other evidences ol hysteria can usually be obtained from the 
personal history and by careful examination and scrutiny of 
the subject. Roentgenography and examination under anes¬ 
thesia will remove all further doubt. 

5. Hemophiliac Disease 

Children and adolescents ol hemophiliac tendenc ies occa¬ 
sionally stiller spontaneous hemorrhage into the joints. 

Pathologically, lollowing repeated hemorrhages, the svn- 
ovial membrane becomes thickened and reddish brown; de¬ 
generation and rarefaction ol the cartilages occur, resulting 
in irregular weakening ol these structures, and intra-artic ulai 
adhesions form. 

Clinically, the onset is with pain, swelling, and distention 
of the capsule. Reflex muscular contrac tion causes temporary 
deformity ol position; the knee, the commonest situation, 
becomes Hexed. Recurrence is usual. 

Differential diagnosis must be made from tuberculous 
and syphilitic arthritis; this is usually done by the family 
history (see (Tap. VI). 

Treatment. Prophylactic protection of the joints Irom 
trauma and strain should be carried out. Operative inter¬ 
ference is not indicated. 

For combating the hemophiliac tendency, calcium chlo¬ 
ride is ol less value than fresh animal serum or human serum 
given in the form ol small whole blood transfusions. 

(>. P1 tc ICC ) m 1 t 1 \ 

Phocomelia is a congenital absence ol the lemur or its 
proximal portion. No treatment has proven sat islaetory in 


these t .ist'v \n artihrial leg oilers the best solution to this 
most dillu nil | it oltie'll). 

-. I \ i r \ im i \ u .Pro I Kl Sl( )\ ( )l ini \< a i \ m I I M 

1 here ma\ he a non traumatic, chronic, progressive arth 
til is ol t he hip joint with ini i ape lx i( prot fusion o I 1 he acetal) 
ilium and head ol the' le'imu * (Otto pelxis; at tinokolady 
asis). I he - etiologx is unknown."j" 

I lie' ehie'l complaint in the' axerage ease is a slowly pro 
grossing painlul coxitis which has been present lor months 
01 xeais.'j W hen the deloi milx is great and the condition has 
he'e'ii present loi a 1 c> 11 o time, all movements ol die 1 hip aie' 
restrie te'd. 

Even in earl\ eases die' diagnosis may he made by roent 
oeii rax examination, l he protrusion ol the acetahidum 
varies from a lew millimeters to | or r } cm. As the acetab- 
ulum migrates, it inclines upward, inward and lorward, so 
that it max project above the ramus ol the pubie' bone and 
extend toward the obturator I ossa. 

\s it extends into the pelxis, a low-grade osteoplastic pro¬ 
cess is initiated and the yielding joint is splinted by the 
formation ol a dense wall on the inner aspect ol the acetal) 
ilium parallel with its projecting margin. The external mat 
gins ol the acetabulum project outward over the neck of 
the leinui as irreguhu serrated vegatative formations. 

In the t \ j jit a I delormitx the integritx of the femoral head 
is maintained. \s the head ol the lemur is submerged within 
the acetabulum the troc hanters approach the Literal margins 
ol the pelxis and incline posteriorlv. The greater trochanter 
impinges on the lateral margins of the ilium in the region 
ol the acetabulai shelf, and the lesser trochanter approaches 

I’omenm/, XI. XI. Intrapclvie pi ol nision ol lhe acetabulum (Otto pelxis). 
Inlmuil. Ihsl, Sill}’., |. 1 

'*■ ( aiv \i lliioplaslx ol die hip joint. /. Bom’ i loin I Sing., i.j: (is y. 

; Ktc-cl. I X. \ case ol anhrokoiad\sis ol the hip joint. /, Hour i- /o ini 
Sing., i-,: So i <|‘jli. 



tlie* is( Ilium. I his explains why the femur cannot be rotated 
outward or bac kward. 

In cases where the submerged hip-joint remains reason¬ 
ably intact, pain can be relieved and motion largely restored 
by radical removal ol the impinging bone about the rim of 
the acetabulum. In the more advanced cases with severe pain 
on weight-bearing, arthrodesis is the most satisfactory treat¬ 

Overgaard # reports another type of protrusion of the 
acetabulum whic h he calls juvenile osteoasthenic protrusion. 
1 his condition develops at the age of puberty in girls in 
the absence of signs of arthritic or traumatic changes in the 
hip-joint, probably as the result of weakness of the bone 
tissue. The treatment consists of guarded weight-bearing as 
long as there are any signs ol progression of the lesion. 

8. Coxa Magna 

Ferguson and Howard f have described a condition char¬ 
acterized by enlargement of the femoral head and neck in 
children. They suggested that the cause of this enlargement 
is a disturbance of circulation produced by sclerotic changes 
in the soft tissues about the femoral neck following infec¬ 
tious arthritis. There was a gradual onset ol pain and limp 
in all cases. Examination showed a varied amount of limi¬ 
tation of motion in different cases, each motion of the hip 
being subject to limitation. Tenderness, spasm and pain on 
motion are present in all cases. The treatment consists ol re- 
moval of loc i ol infection and rest ol the hip as long as there 
is musc le spasm. Deformities must be prevented by a plaster 
ol Paris spica cast. If, after all the acute signs have disap¬ 
peared, motion is limited, manipulation or arthroplasty must 
be clone. 

* Overt>aard, K. Otto's disease and other forms of protrnsio acetabuli. In 
hintil. Abst. Sttrir., (it: i<)- 

| I'Vruuson, It. 15 ., and Howard, M. 15 . Coxa niafpia: a condition of the hip 
related to coxa plana. /. /. 5 /. I . top 82S, 1 i)‘{y 


\ 11>iT. i ii.. i. -. M. i -. i11. 39. 

“S. (in, ~i). So. Sy. <)X. ioj. I |S. i nj. 
i |*>• i<>7. ai',. ai(i. 2|i!, a 13. |f,. 

-> |<*. 2 17. 2 |i). 230. 27,1. 272, 271 
Mlison, 117. 119 
\ndersoii. 2S 
\ndcison. R.. 2 1. 19. 32 
\nno\ ,i//i. 1 1 1 

Baet . \\. s.. 221 

Bai Ik-i . 2(> 

lU-i sit-in. 113. 119 

Bigelow, 131. 133. 137 

Bisi>ard. ). 1 )., 1S9 

Bo/.111. I- . |., 282 

Bi.iikcll. 1 . (.., 232. 233. 231 

111 adl'01 (1, S1. 93, 113, 119. 131 

Bniilsloril. |. I . 2S2 

Braudes. 109 

Buka. 1 iS 

Bin »liai d, 113 

(.alot. 97. 97. 9N. 100. 101, 103 
( ain|)l)('ll. \\ . ( .. 3 | 

( a 1 \. \.. 2S3 
( c< 1 1 . R. I .. 1 S3 

( I.11 ke. 113. Mi) 

( (Kill a lie. \V. \., 133 
(.odi \ i I la, i)7 
(olonna. I’. ( . 91, 128 
( 01 nei 113 
( 011 el, I’., 112 
( otlon. I . |.. 72 

1 tanloi ill. M S,, 2S2 
I >a\ is. (.. ( ... 1 o(i. 113, iii) 

I )ela”enicre. 119 

I )euts( Iilacndci. 119 

l)i(kson. I . I)., loti. 11S, ii(), 122, 132, 

23S, i/lio 

I)ixon. 21). 113, iii) 


> 11)a 1 iei . 1 1 (i 
) 111>u\ 11 en. 77 

ai 1 Bank, 91. 113. 119 
•ei mison. II. I!.. 2'S(> 

01 lies. \|.. 2B3 
reilict ”, | A.. SB 
1 el 1 nil. I . 7 |. 132 
• 1 i s( 11. 113, in) 

- rod i( Ii. 93 

(.aensslen, I |.. 117 
(.a I low a v. II. I’. II., 93. 1 1 3. 1 1 Ii. iii) 
(.am. 232, 233. 2 |o 
(.liormle\. R. K.. 1 S3 
(.ill. 111 lice. 93, IK). 127. 127 
(.onion I a\ lor. (... 27(1 
(.roves, I,. \V. Hex, 1)3, 1 iS, 12S, 27S, 

I lal lo|)eau, 119 
Hass, 1(17 

I lendci son. 3[. 203 

II ililts. 93. 1 •{ 1, 1(17. 1S 1 
I lolla, 111. 203, 270 

I loll man. R.. 279 
I low 011 Ii. M . B.. 1 1 (i. 2S(i 

I»ianni, 113 

(oliansson, 3 | 

|olnison. II. I .. 131) 

|olmson, R. \\ .. 7 
[ones, I 11 is, (ii) 

Jones. Sii Robert, S-j. 233 

K a | > | > i s, 1(17 

Keith, Si 1 \rt Ii in . 38, 71) 

Is in”, 3 1 

Koclier. 2(1, 2S, 29. 30, 2 11 



kreilcl. I,.. 230 
k i cum her, 237 
krida, A.. gg, ioS, mi) 
kulouski, ).. 132 

I agomaisino, 1 II., i id 
I ambcau, i ig 
I ambolIe. i 1 g, iii) 

I a net’, i 18 
1 ane, 2j 

I ant‘, m2. 237, i»r,i) 

I ail^cnbeck, all. 2i| 

I cailbel l ci. (.. M , -,1 
be Damanv. i i g, i 11) 

I egg. A. I .. 278. 251), 280, 281 
I cxei. g 1, 1 1 g, iii) 

I isiranc, 2(> 

Lorenz, 79, 8g, gg, 97, 108, 110, 111, 
112, 1 (> 1 

1 OVCt 1 , 8l, 82, gg 
1 in kc, 26 
1 udlolf, 1 ig, 1 ig 

Macausland, A. R., 243 
Mai \ 1 isla 1 nI, W. R., 1 15 
Mai Neal. 196 
Mallei, I ., no 
Mathicu, 1(17 
Main laire, 1 1 <) 

Ma\ei . I eo. g7, 2 g2. 238, 2.76, 277 
Mikulicz, 227 
M i 1 11)e1, I . | . ig8 
Moore, \11s1in, 76, 77, 78 
Murphy, |. lb, gi, gp gg, 207, 220. 

Narath, 112 
Nil hols, 201 
Novc |osseranil, 1(17 

Oher, 119 
On, 26 

Osborne, R. I’., 29, go 
Overgaard, k., 28G 

Pal sc like, 1 13, 119 
I’cn \. 2I) 

I‘ei l lies, (... 280 

I’oiiieran/. M. M., 287 

Pulli. V., 8(i, i)o, 92, 96, 110, 1 go 

Ransohoir, N. S., 7(1, 77 
Reed, I N„ 287 
Resclike. 197 
R ii'ha nl, 113 
Richardson, 201 
Roux. 2I) 

Sanli, E.. 190 
Santos. |. A'., 72 
Scaglielti. ().. 77 
Si lieile, 97, igi 
Sdnimm. 1(17 
Sell i I lot, 2!) 

Sherman, Manx \b. 113. 119 

Silver, 263 

Smi 1 h. 11 . \\ .. 1 i(i 

Smith-I’etersen. M. N„ 28, 77. Go 

Soulier. R., 97, 118, 277 

Speed, kellogg, 2 

Spit zv, 119 

Sprengel, 28 

SteiuiUer. A„ 132 

Swell, I’. I ., 119. 1 g 1, 132 

l av lor, 1 1 2 
l elson, I). R.. 7(>, 77 
I lioinas, 113, iii) 
bubbv , 113. 119, 22I) 

\ ance, 119 

Wallace, 119 
Wan. E. I .. 138 
M ai die. E. N ., 2 )o 

Whitman, R., 18, (17. 1 | p 22!). 229. 

232, 23C). 2|8 
Wiles. Ik, 27<* 

W ilkie, I). V. I).. 239 
Willis, 1 13, 1 19 
Wilson. 1(17 
Wilson, I’, lb. 133 
M 0I1 ol I, p gli 
Worn, iiiiius, 90 

Noiing, 263 
Voilllg, lx, 189 


\ 1 >< 111 (I ion: lorcible. and fixation in 
coxa \ a 1 a . 233 
• Iiiniled in ioxa \ ai a. 227 
metltod ul reduction ol liaclures. 
\V'hitman. |8 3 i 

\bduclion flexion conitaciurcs, i*33 
“ > / 

Xbsccss formation in tubetc nlosis, 

\uidents in reduction ol dislocation. 

i i 

\c clabulum: in dislocation. 78. 87 
11 ail me (>1. 777k 

- inlrapehic protrusion ol. 2S3 
\dduclion: coni rail tires. 277 2(17 

- ol leimn . 223 
\denii is. ai me. 1 7 | 

Age: factor in choice ol procedure, 
(|2. 1 17 

- in tract me ol tin k ol leimn. 33, 

:! 1 

lor reducing congenital dislocation, 

Age incidence: coxa vaia. 227. 211 

- osteoni\ el it is, 11| 1 

t uliei ( uloiis disease. 1 | | 

\lhec: arthroplastc technique. 212 
bone grail opeialion. 78 

- I’racttire- table. 7b 
motoi, 7 

-reconstruction operation lot Irac 
tine. 78. bo-by. (Ii) 

- shell opei at ion, 1 20. 1 pj 

\ meric an College ol Surgeons. 2 
Xmcrican Orthopaedic Association, 2, 

\mpiilai ion ol hip joint, 27b 
\ 111 \ loid disease, 1 77 
Anatomical t\pes ol coxa vara, 22 | 
Anatomy: hip joint. 23 2| 
-pathological, in congenital disloca 
1 ion, 78 8 | 

in 1 itheic 11 Ions 1 liseaxe, 1 | | 


Anderson method: ol countcriiai 
lion, 21 

- ol reduct ion ol 11 ad in e. 71 
-well leg 1111 n bin kle, 72 

Xnesthcsia. |8. 31, 7b, 77, <(-2. 03, i)ti, 
1117. 137. 1 |o. 1 bi), 270 

Ankylosis, 201 222 

in a 11 In it is ilcloi mans, 201 

— bonv. 201, 20 | 
diagnosis, 202 
et iologv, 21 )2 
fibrous, 201, 20 | 

following suppurative ait hi it is. 107 
in gonot 1 heaI ai I hi it is, 188 
prognosis, 203 
propin laxis, 202 
1 realment. 203 
Ixpcs, 201 

\nomalies, co existing, in congenital 
dislocat ion, 83 

\ppendic it is. 173 

\pproach. surgical. See Surgical ap 

\rmamentai ium. 2. Ii 22 

Arthritis : ai me, 13 | 
at 1 opltic. 1 3b 
delormans, 133, 201. 227 

— gonori heal, 18b 1 88 

— inlec lions or rheumatoid, 18318b 

— neurotrophic. ti)C| 200 

— pvogcnic, 188 

— siippurat i\e, 188 tcj8. See also Os 
teomvelii is. 

— ankclosis following. 017 
bac 1 et iophage in, 11)7 

— remoik ling ol hip joint in 
hea led < ases, 1 <|(i 

11 eat itirnl. 1 (| t 
s\ pin I i 1 i< . 11)8 

Arthrodesis, 1 3 

lor complete paralcsis ol hip inns 
ck-s. 1 13 



Arthrodesis: extra-articular, in 

I ubci c ulotis disease, i 63 
atn hoi 's let liniciue, i (iS 

— general discussion of, 273 
iin ra-arl ic ulai. i 63, 270 

Arthroplasty, 201-222 
a ill hoi's lei hni(|iie, 2 12 
Baet s lei linii|iie, 22 1 
Murphy's lechnique, 220 
panial. 250, 273 

— results, 209 

Aiihroiomv, lesions requiring, 27 
\spiralion ol hip, 187 
At rophic a 11 In ii is. 1 7(i 
\l roph\: bom. 71), 280 

— 111 list ular, 2(17, 281 

Bacleriemia. phage treatment of, 196 
Bacteriophage, 2(i. 193, 195, 19(1 
Baer's technique of arthroplasty, 221 
Bandage. See Dressing. 

Bifurcation operation for dislocation. 

Bigelow’s method of closed reduction 
of dislocation. 137 
Bipp. 193 

Blood supply: bone graft and. 3, 38 
- in fracture of neck ol femur, |, 35. 
:!<»• 7 1 

in transtrochanteric fractures of 
leintii. 73 

Blood transfusion, 191, 277, 28 | 
Blood vessels: encountered in hip 
joint surgery, 30 

— rupture ol, from manipulations, 
1 1 2 

Boils, 193 
Bone grafts, 3 

— for ailhrodesis, 207 

— anti blood supply, 3, 38 

— boiled, 17 

in evsis of femur. 278 

— in 1-11 is (ones’ technique for tin 
united fracture of neck of femur, 
7 " 

lot non union ol 11 at I tired lemur. 

peg, at t in at \ of fit of, |(i 
in t o\a \a 1 a. 2 18 
loi Mat tine ol femoral neck, 39, 

Bone peg: value ol autogenous, 71, 

— saline solution on, dining manipu¬ 
lations. 13 

— in tuberculous disease, 1O8, ifig, 
171. 172, 177. 178, 180 181, 182. 183 

Bone mill, electro-operative, 8-10 
Bones: atrophy in osteochondritis, 


in tuberculous tlisease, 1 13, 131, 
iliti, 1 Ii8 

Boiiv ankylosis, 201 
- 11 eat ment ol. 20 | 

Bowlegs, 89 

Braces, 8, 132, 138, 139. 163, 2it) 
Blackett s circular osteotomy. 233 

-modi lied. 23 | 

Bi adit )td hip splint. 1 62 
British Fracture Committee, 33 
But k A extension, 22 1 
Bunnell guide. 7. (3 
Bursae, diseases of, 136 

Callus formation: dependent on 
blood supply . 36 

— in fracture of neck of femur, p 3 
Capsule in congenital dislocation. 81 
('.a 1 buncles. 193 

Carrel Dakin treatment, 193 
Cartilage in tuberculous disease, 1 13 
Cartilaginous lining of acetabulum, 


Cast. See I’laster-ol I’aiis dressing. 
Cervical coxa vara, 221-232 
Charcot hip, 199 
Circular osteotomy, 233-236 
Clinical features. See also Symp¬ 

— congenital dislocation, 83 

— coxa vara, 227, 230 

— osteoarthritis. 267. 268 

— osteochondritis deformans juve¬ 
nilis, 280 

— sa 1 coma, 273 

College ol I’hvsicians and Surgeons. 

Colontia s operation I’m reduction ol 
dislocation, 128 

Complications: lollowing fracture. 32 
in reduction ol congenital clisloca 
1 ion. 1 1 2 

Congenital coxa valga, 272 



( ongeniial coxa vara. 227. 230 -3' 

( ongeniial (1 islotation <>l hip. Sec 
Disloi at ion. 

( onsi it in ional ilist tirbani cs in l nt >cm 
( IlllHIS disease. i | < > 

C outrai lures: abduction llexion. 27,7, 

aildtii iion. 2*17. 2(13 
( ,on\.descent iicaimcnt ol iiibcrcu 
Ioiin disease. i• >i2 
( on ill fit i ai l ion: \ndcrson s. 21 
wi'll leg used tor. |(). *,2 
Cmv horn pegs in tract in cs. 17 
('.ox a manna. 2S(i 
(oxa \ a 1 oa. 223. 27,2-27, | 

Coxa vara, 17,7,. 223-27,1 
acipiiicd, 22(i 
adolest fill. 2 |o 
anatomical 1 \ pcs. 22 | 
bilateral. 229 

— <ci \ it al. 22 |. 227. 232 

— 1 lassilkal ion ol. 22(5 

— clinical lea 1 in cs. 227 

— closed reduction ol. 2 (8 

— circulai osteoionn lor, 233 
— modifii ation ol. 23 | 

— congenital, 227. 230 

— cuneiform ostcotomv lor. 23(1 

— definition. 223 

dillcrcntial diagnosis, 89, 230 
cpiplnseal. 22|. 2 |o. 2 pS 

— eiiologv, 227, 

— forcible abduction and lixalion in, 

— general considerations, 223 

— infantile, 281 

— lineal osteoionn lot. 2 |o 

— open redui 1 ion ol, 2 |K 

— osteotonn lor, 233 

— partial aithroplastx for. 27,0 
SMiiptoms and signs, 228 

— 11 atonal ic, 1 *,ti. 2 pi 

— 11 eattnent of, 230 

— trochanteric a. 223. 227, 232 
unilatei al. 228 

( .OX i I is. 2S3 

tuberculous. 231, 21)7, 281, 1283 
(uinolin for plastcr-ol I’aiis dressing, 
lli. 18 

(aincilorm osleoiomv, 236 
(.x st. echinococcus, 278 
- ol upper end ol lemur. 277 

I tea ill. See also M oil al it v. 

Irom manipulations in induction 
of dislot at ion. 1 1 2 

Deformity: in congenital dislota 
l ion. Si> 

in osieoai 1 In it is. 2(17 
p.u a I x 1 ic. 27,7, 2(51 

in tuberculous disease. 197, 1-, |. 

1 (>3 

Diagnosis: ankvlosis. 202 
congenital dislocation. 8(5 
coxa \a l a. 2 ] 3 See I )iHerein ial tliag 

— I rai l ure of acetabul uni, 77 
gonon heal art hral is, 187 

isol.iied hat lure ol head ol leiiim. 
.‘I I 

— netirol rophii at I In ii is, 191) 
osieoai 1 In il is. 2O7 
sarcoma, 277, 

s\ no\ il is. 18 | 

sx phi I il ie a 11 In it is. 1911 

— traumatic dislocation. 133 

— 1 uben ulous disease. 1 92 
Dickson: operation I01 paralxsis ol 

glutei. 2lio 

— 1 eel u 1 ii pie of reduction ol dislota 
lion. 12H 

Diet in a 1 tin il is. 1877 
Differential diagnosis: congenital 
dislocation, 89, 90 
coxa \ara, 230 
i \ si s ol I cm in . 277 
hemophiIiai disease, 28 | 

— ustcourt h 1 iI is. 268 

— osteochondritis deformans jure 

ni I is, 281 

— luberi ulous hip disease. 1 *, | 
Diphthci ia, 1 *, |. 1 8 | 

Dislocation, congenital, 1. 2. 77 

' 33 - fV> 

accidents Irom reduction manipii 
Ial ions. 1 1 2 

— aielabuluni in. 78. 87 
- al I el 11 ea Imenl. 1 o | 

anomalies coexisting. 89 
bil 111 cal ion opci al ion loi. 170 
bilaiei al. 81, 8 |. 89 . mil 
in children ol live to six \ea 1 s, 

loll lOif 

— ol 1 wo lo tin ee \ e.u s, 1)7 



Dislocation, congenital: classilica 
i ion ol (ases. (| i 

— cl inical I cat urcs, 89 

• closed reduction, 96 imj 

- C.olonna’s operation for, 128 

— complications in reduction of, 112 
-correction of acute torsion in, 95 

and coxa vara, 231 
delinilion. 77 

— deform it \ in, 8(5 
diagnosis, 8(5 

Dickson operatise leclniicpte for, 

I 2(> 

— cl i llerent ia I diagnosis, 89, go 
end results in, 132 

— et iolog\, 8 | 

— extent, 87 

— (.allowat reduction 1 echnitjlie, 113 
(.ill's opera! ion for, 123, 1 2 | 
hereditary factor, 83 

history, 77 

- immohili/ation pet iod in, g(i, 102, 

IOC). 113, 121 , 128 

incidence, 77 

— obstacles to reduction, 91 

— open reduction. 93, 9], 112-133 

— pathological analoim, 78-SI 

— predislocation, 92 

— prognosis, go 

I’utti s operation, 12c) 

— retention of reduction, 012 

— septic disease resembling, 196 

— shelf operations for, 117, tig 

— Swell s icclniitpic for, 131 

— 1 i me lot red tic t ion, 91 

— treatment of, age factor in, 92, 117 
— non painful cases, cj(i 

— unilateral. 81. 8 |, 86, 97, 106 

— vat ieties, 8 | 

Dislocation from osteomyelitis, 191 
Dislocation, paralytic, ' |o 1 13. 261 

— closed reduction, t [o 

- inuuobi I i/at ion in, 1 j 2 
-keystone graft leclniicpte, 1 40 

shell opei at ion for, 1 p; 

Dislocation, pathological and con 
genital, dilleiontiation of, 89 
Dislocation, traumatic, 133-1.10 
-anterior, 131, 133. 137 
Bigelow's method ol reduction, 137 

— closed reduction of, 137 

diagnosis, 133 

Dislocation, traumatic: immobili 
/alien in, 133, 13c) 

— inc ideuce, 133 
-mechanism, 134 

— open reduction of. 138 

— pathology, 133 

— posterior. 13 j. 136, 138 

— prognosis, 139 

— D pes. 133 
Dixon approach, 29 
Doyen reamer, 12c) 

Dressings, 7. 92 

— in extra-articular arthrodesis, 175 

— following Albee reconstruction op¬ 
en a l ion, 67 

— On , 26, 191 

— in osteomyelitis. 191 
plaster-of-Paris, 13-22 

-appl icai ion of, 20 

-in closed reduction of disloca 

lion, 102 

-in dislocation, 12 1 

-method of preparing, 16 

-removal of, 2 1 

-requirements of, 18 

-saturation of, 19 

-storing, 17 

-traction snaps incorporated in, 

2 1 

-in tuberculous disease, 160, 161, 

l( > b '75 

-varnishing, 21 

Drill, motor, jo 

Dyspituitary type, coxa vara in, 243 

Echinococcus c\st. 278 
Electrically driven tools, 6, 8-10, 40 
Empyema atlieuli, 186 
Endocrine elistui bailees and coxa 
' ant, 2 13 

Epiphyseal coxa vara, 22 p 291 

— cause, 2(2 

— s\mptoms, 2 13 

11 eat ment. 117. 148 
Epiphyseal fracture, 136 
Epiphysis, femoral, in congenital dis¬ 
loca t ion, 87 
E piphy sit is. 184, 188 

— acute, 134 

Etiology: ankylosis, 202 

— congenital dislocation, 84 



Etiology: »oxa taiga, 27,2 
• - coxa vara. 223, 230. up. 232 

— osteochondritis deformans juve¬ 

lxanthcmata. 171 

f xtra articulai arthrodesis, 163, 168 

1 asciotomv, Soulier's, ay, 

Femur: tests of upper end, 277 

— fracture, in reduction of disloea 

ion. 1 o<). 1 12 
11 anst uk liantei ii. 7", 

— head, in congenital dislocation. 78, 
8 () 

— crushed in inanipulations. 11 a 
-neck, in congenital dislocation, 79 

— 1 1 ai t tue. Set I 1 act m e. 

— Hihbs' osteotome foi anlctor- 
sion. 1 3 1 

— resect ion of upper end for osteo¬ 
arthritis. 2 tip 

-sarcoma. 278 

lihi oiu ank\ losis, aot. 20 | 

fixation: dressings. .See Dressings. 

— matei ials, li 

fluid in hip joint. 17b. See also 
se not itis. 

— in joint cat its. 1 p-,. 1 3 1 

foreign bodies, nails acting as, 33, 

Fractures, .‘52-78 

— of acetabulum, 77-7(1 

— epipht seal, 1 -,(> 

11101 lalitt in. ‘52, ‘i‘{ 

of neck of femur, 2. 32-77,, 17,(1 
— Anderson method ol reduction, 


biophesiological factors, 33 
-blood supple in, p 37,, 36, 71 

-hone gi all in. 33 

- I ,C K‘ .‘ 5 ! I 17 

— callus I01 mat ion in, 3, 7 

— coxa e a 1 a I mm. 227 
-end results in. 33 

— fixation with kiischner wires, 
7 <i , 7 s 

Iresh, 39-7,8 

I eadhelter method ol reduction, 
'ji -53 

Iile ol 11 agments in, 72 
mortal lie in, 33 

— nonunion in, 32, 37, 7 | 


Fractures, of neck of femur: open 
e s. i losed redut 1 ion. 77 

Smith I’elersen opeiation, 73 7,7 
suhiapital, | 

ununiled, \lhee operation lot, 
(io (>7 

bone-graft peg operation for, 

(auscs ol non union. 72. 33. 71 
I 11 is (ones' techniipie I01. (ip 

7 ' 

pathology, 38 
t real nielli. 38-77, 

- weight heat ing in. r,p 
Whitman ret oust rut t ion op 
eration. (i7-<ip 

— weight hearing in. 3 | 

Whitman ahiluction method of 

redut t ion. |8-r, 1 

— 11 ansi rot ha til ei it, 73 
f in tint les. 11177 

(.ail, 83, 86, 177. 221) 

(.alloeeae techniipie of open retluc- 
t ion ol dislot al ion. 1 1 3 
(.ant s osteotome, 1 (i-, 

(.etui reciirealnm, 3 
(.ill's opera!ions, 123. 123 
Glutei, paralysis of, 27,8-263 
(.0110! rhea, 1 7 | 

Gonorrheal arthritis, 186-188 
(.rail: hone. See Bone graft. 

— extra-articular, and intra articular 
arthrodesis in osteoarthritis. 270 

(■lines, flee, operation lot paralysis 
of glutei, 262 
(■ t oee i ng pains. 1 33 

Hass procedure in tuberculosis, 17). 

I 8 1 

Heliotherapy, 1 31) 

I lemaloma, 26 
I lemophiIiac disease. 28 | 

I lemoi 1 liage. surgit a 1. 30 
lleredilate laitor in congenital tlislo 
t at ion, ,83 

Hernia from manipulations in redut 
lion ol 11 isiotalion. 112 
llibbs: osteotome lot anteversion ol 
net k ol lemin , 171 
procedure in tuberculosis, 173. 181 



Hip joint: anatomy. 23-24 

— biophvsiological requirements, 2 

— character, 1 

— diseases of. See names of various 

History: in congenital dislocation, 77 

— in c\sts, 277 

— in tuberculous disease, 152 
IIvdrops articuli, 18G 
Hysterical hip, 283 

Ichor pocket in tuberculosis, 145, 150, 

15 1 

Ilium: bone graft from, 177, 178, 182, 
183, 208 

— osteomyelitis of, 189 
Immobilization. See also Dressing. 

-in congenital dislocation, 96, 102, 
109, 115, 121, 125, 128 

— in coxa vara, 232, 238, 250 

— in cests of femur, 278 

— in gonorrheal arthritis, 188 

— in osteoarthritis, 272 

— in paralytic dislocation, 142 

— in traumatic dislocation, 133, 139 
Inanition, 243 

Incidence: congenital dislocation, 
/ 7 

— traumatic dislocation, 133 

— tuberculous disease, 144 
Incision. See Surgical approach. 
Infantile paralysis, 258 

— coxa valga from, 253 
Infection, control of, 25 
Infectious arthritis, 185 
Inflammation, phlegmonous, 18G 
Injttry. See Trauma. 

Instruments, 9. See also Tools. 
Irradiation in sarcoma, 276 
I\ory pegs in fractures, 47 

Jones: graft, 71 

— operation, 58 

— saw, 235 

Kahn test, 199 

Keystone bone graft in paralytic dis¬ 
location, 1 |o 

Kirst liner: method of traction, 117 

— wire, 38, 39, 7 | 

— fixation of fractured neck ol 
femur, 56-58 

Knee flexion, paraly/cd, 263 
Knee joint disease, 155 
Knock-knee, 3, 263 
Kocher approach, 28 
Ki ida's method of reducing disloca 
lion, 108 

l ameness: in coxa vara, 228 

— in tuberculous disease, 1 |(i. 1 |8 
I.andmarks, surgical, 23-24 

Lane bone elevator, 6 
Lange's position, 102 
Langc-Krcuschcr operation foi paral 
xsis of glutei, 259, 262 
Langenbeck approach, 2N, (19 
I angenbeck Kocher approach, 29 
I cadbettcr method ol closed reduc¬ 
tion, 39, 51-51 

Legs: crossing in coxa vara, 229 

— rotation in congenital dislocation, 

— shortening in congenital disloca 
lion, 88 

— in osteochondritis, 280 
Legg-Cahe-Perthes' disease, 279 
Legg's operation foi parahsis of 
glutei, 259, 262 

Lesions requiring arthrotomv, 27 
Ligaments of hip joint. 23, 24 
Ligamentum teres, 2| 

— blood stipple of, 37 

— in congenital dislocation, 82 
Linear osteotome, 2 |o 

Lordosis in congenital dislocation, 82, 

Lorenz bifurcation operation. 130 

Maggot treatment of osteomeelilis, 
1 1)5 

Massage. See also l’hvsical therapy. 

— of adductors during reduction of 
dislocation, 99 

Meyer's operation for abduction Ilex 
ion contractures. 255, 256 
Measurements in tuberculous disease, 

1 I!) 

Mec lianics of hip joint. 209 
Meningitis, tuberculous, 157 
Mercurial treatment of coxa vara, 

2 13 

Moot e nail, 7. 39 



Mottaliiv: in tinctures ol hip. 32. 33 
in tuberculous disease. 137 
M 1111> 1 1 \ gouge. - 1 2. 2 15 
nail. 37 

shoehorn 1 cl 1 at toi. 93 

skill. I 2 i) 

technique ol arlhroplaslv, 22 
Muscles: atrophv in osteoarthritis, 
2 (i 7 

in osteochondritis. 281 
in congenital dislocation. S2 S j 
spasm in coxa vara. 22;) 

in inhere ulous disease. 1 |(). 133 
M use iilatui e ol hip joint, 23 2 | 
and atthrotlesis, 210 

Nails, 6. 39 

-acting as foreign bodies, 13, |(i 

— object ions to, 38 

Neck ol Ictnui in dislocation. 79 
li.Kture. See Id act lire. 

Necrosis: following traumatic dislo- 
i at ion, 1 |o 

— ol head ol femur following frac- 
ime. 73, 7 | 

Neoplasms. 273-279 

Nerve ti links, rupture of, in reduc- 

I ion of dislot at ion. 1 1 2 
Neurotrophic arthritis. 199. 200 
N ight 11 ies, 1 |(i 

Non-union: in fracture ol femoral 
neck, 32. 33 

— c a uses of. 7 | 

Olrcr approach. 30 
Obesitv and coxa earn, 213 
<)< hsner c lamps, |2 
Ollier lateral approach, 31 
Olliei Mikulic/ incision, 221 
Operative treatment. See Reduction. 
On treatment of septicemia. 192 
C )sbot tie approat It. 29 
Osteoarthritis, 2(13 271 
clinical teat tn es, 2(18 

— diagnosis, 2(17 

— dillei cut iaI diagnosis. 2(18 

— ini 1 a at t ii ular arthrodesis with ex 

II a articula 1 gt at t, 270 

— nonopei alive treatment. 2(iq 

— operative treatment, 270 
pal 1 ial arthroplastv, 273 

— patliology, 2(13 

Osteoarthritis: prognosis, 2(19 
lesection ol tippet extremity ol 
Iciniii, 270 

— sv mptoms. 2(17 

\ 1 av appeal am e, 26H 
Osteochondritis deformans juve¬ 
nilis, 279-283 

— clinical leal in es. 280 
elillercniial diagnosis, 280 
el iologv. 270 

— t real incut, 282 

— v i av appeal ance. 280 
Osteomalacia, 227 
Osteomyelitis, 18 p 188 

— age incidence, 191 
bactei iophage in, 193 

— and coxa v at a, 227 

— end results in, 197 
ol ilium. 189 

— remodeling hip joint in, 19G 

— 11 eat ment, 191 

Osteophytes in osteoarthritis, 265 
Osteoporosis, senile. 227 
Osteotomy: circular, 233-236 
— modification of, 234 

— in coxa v at a. 233 

— cuneifoi nr, 236 

— (.ant's, 165 

— 11 i Oils’, 131 

— linear, 240 
OtLo pelv is, 283 

Pain: in osteoarthritis, 267 

— in osteochondritis, 280 

— sense, loss of. 199 

— in tuberculous disease, 146 
l’arallm vaseline treatment of ostco 

myelitis, 192 

Paralysis: complete, ol hip muscles, 
1 13 

— c 1 tit al. 112 

— of glutei, 258-263 

— of hip and knee flexion, 263 

— from nerve rupture in reduction of 
disl ocat ion, 112 

— pseudohv pet trophic, 89 
spast ic, 258 

Paralytic delot mities, 233 263 
l’atalvlic dislocation, 1 jo-i pj, 263 
Pathological anatomy in congenital 
disloc at ion, 78-8 | 



Pathology: cysts of femur, 278 

— osicoai 1 In i( is, 265 

— osteochondritis deformans juve¬ 
nilis, 270 

— traumatic dislocation, 135 

— tuberculous disease, 141 

- ununited fractures ol 



femur, 58 

’eg, bone-gralt. See Bone g 


’el v ic cav it y, pencil at ion 



femur, 7(1 
Pelvic disease, 156 
Pelvis, in congenital dislocation, St 
Periai liculai disease, 155 
Perinephritis, 155 
Perthes' disease, 34, 279, 281, 282 
Phage. See Bacteriophage. 

Phelps: brace, 152, 158, 159 

— traction hip splint, 161, 162. 1G3 
Phlegmons, 195 

Phlegmonous inflammation, 186 
Phocomelia, 284 

Physical signs in tuberculous disease, 
i -17 

Physical therapy, G7, 104, 10G. 121, 
128, 159, 185. 204, 269 
Plaster-of-Paris, 15 

— dressings. See Dressings. 

— impregnation of crinolin bandage 
with, 16, 18 

— strengtheners, 17, 20 

— technique, 7, 18 
Plimpton splint, 1G3 
Pneumonia, 154 
Poliomyelitis: anterior, 85, 154 

— paralysis of, 89 

Postoperative cate, 57, 121, 125, 128, 
1 7.7 

Postoperative check in fractures, 50 
Poll’s disease. Go, 89, 144, 155 
Preoperative treatment, 25-2G, 10G, 


Prognosis: ankylosis, 203 

— congenital dislocation, 90 

— gonorrheal arthritis, 187 

— osicoai I h 1 i I is, 2G9 

— traumatic dislocation, 139 

— tuberculous disease, 137 
Prophylaxis: ankylosis, 202 
Pseudoarthrosis in ununited fracture, 


Put 1 i s method of reduction of dislo¬ 
cation, 129 
Pyemia, 243 
Pyogenic a 11hritis, 188 

Rainey splint, 221 

Reconstruction operation for un¬ 
united fracture: Mhee. 60-67 
Whit man, 67-69 
Redislocat ion, 1 1G 

Reduction: of coxa vara, closed, 
2 1* 

open, 2)8 

— of dislocation, closed. 96, 137 
Bigelow's method, 137 
— C'.olonna’s operation, 128 
-maneuvers of, 99 

— open, 93, 94, 1 12-133, 138 
-results of, 110-1 1 2 

-retent ion of, 102 

- fractures, Vnderson method, 77 

— closed, abduction method, jS-yt 
— method of Leadbetter, 51-33 

— open vs. closed. 33 

- of paralytic dislocation, closed, 

1 jO 

of traumatic dislocation, closed, 

-open, 138 

Rheumatism, 155 

— articular, 281 
Rheumatoid art In it is. 185 
Rickets, 226, 227, 243 
Roentgenography. See A-rays. 

Sacroiliac disease. 156 
Saline solution in hone-graft opera¬ 
tion. 13 
Sarcoma. 275 

— of femur, 278 
Saw, twin, 9 

Sciatic nerve in traumatic dislocation, 
1 35 

Sc iat it paralysis. 1 1 2 
Sciatica, 267 
Screws, bone-gralt, i» 

— wood, 7 

8ctiny, 155. 2 13 
Sedation, pre-operative. 25 
Sept iccmia, 2 13 

genetali/ed, in osteomyelitis, 191 



Sex incidence: congenital tlisloca 
IHill. Sr, 
coxa xara. 223 
i iibct ( ulous disease, i ) | 

Shelf operation for dislocation, 

3- 11 :■ 1 1:1 

authors, 1 •_ 


( tilonna s. 

1 28 

Dicksons, 1 

1 2(i 

(.ill's, 123. 

12 | 

indie at ions 

loi . Ill) 

1 esnl 1s ol, 1 

2( > 

shot telling ol 

leg, 88. 

Skin folds in 

thigh in 

lot a l ion. 88 

Smith-Petersen: approach, 27. 28. 30, 
71. 120. 12;;. 12G. 138, 1 |<>, 19G, 212, 
2|S. 271. 271 

— met hod ol reduction of fracture ol 
femoral neck, 33. 39, 3 7 -", 7 

— nail. ti. 38. -, |. 33. 57 
Snapping hip. 283 
Soulier's lasciotoim. 257, 

Splint, Bradford hip. 1(12 

— convalescent. 1 (> 3 

— I’helps' traction hip, 1O2 
Rainex. 221 

— Tax lor t t at t ion. 1 f> | 

Sprengel approach, 27. 28. Go, 120 
Steinma 11 pin. y> 

St eri I i/a 1 ion of tools. 8 
St i I le s t nt ter. 18 
Surgical approach, 2(1-31 

— anterolateral, 28 

— in hone-graft peg operation. 39 

— I )i\Oll. 21) 

— goxct tied l)\ (ondition rcfiuiring 
arthroiomx, 27 

kochcr. 28 
I angenbeck. 28 

— lateial. 27, 31 
()hci. 30 

()lIiet. 3 1 
Oshoi 1 te. 2t) 

Smith I’elersen Sprengel, 28 
stit in e matei ia 1. 2ti. | | 

Swells open reduction of dislocation, 

13 1 

Symptoms: coxa xalga. 273 

— coxa \ara. 228 

— gonori heal aiilnitis, 186 

— inlet 1 ions at 1 licit is, 187 

Symptoms: osicoai tin i t is. 2(17 
osteomxelil is, 1 89 
s\ nox it is. 18 j 
I ohci 1 iiIons disease. 1 |(i 
Sx nox it is. 18 | 187 
sei oh I n i nous, 18(i 
Sx phi I is, 1 Sip 2 13 
Sx phi I it ic art In it is, 198 
Sx 1 ingonix el ia, 199 

I .1 lies dot sal is. 1 <)<) 

lable, fraet lire orthopedic operating, 
10-1 7 

lax lor 11 action splint. 1 ti |. 2 19 
l et hnicpte, surgical. See names ol 
\ a 1 ions proccdtu es. 

I elson-Ransoholl Maxei nail. 7, 77 
l emperat 111 e sense, loss ol. 199 
I emit 111 inn. ti. hi 

I enotomx of atldut loi tenclons. 278 
I ensoi lastiae fcmoi is, transplanla 
lion ol, 279, 2G0, 2(12 
I liomas: In ace, 8 

— hip splint, 1G1, 163, 232 
knee I trace, 2 11) 

ring, it>2 

— test for must iiktr spasm. 1 |t) 

I iltia. hone graft from, p, 169 
Tonsillitis, t8| 

Tools: lot artbioplasts, 213 

— motor ill i\ en. (i, 8 10. |o 
Traction: lollowing arthrodesis, 219 

— in shell operation, 121. 128 

— straps incorporated in dressing. 21 

— in inhere•ulous disease, 139 

I 1 ansl usion. hlood. 191. 277. 28 | 

I ranst roc hanterit 1 1 aft 11 res ol Iciimi. 
7 .a 

Trauma: aiilnitis following, t88 

— coxa \ alga I rom. 233 

— coxa vara from, 22(1. 227 

— dillcreniial ion from congenital tlis 
lot at ion, 8t) 

lotah and tuberculous disease tlil 

lei eni iatetl, 13 | 

opei al ixe. 27 

s\ nox it is lol loxx ing, 18 | 

I 1 au 111a (ie tlislot al ion, 1 33 1 |o 
I rentlelenhiirg sign, liy. 83 
I rot hanterit tttxa x ara. 221 232 
I ubereuloxis: extia articular, 281 



Tuberculosis: miliary. 15- 

— |)ulinon;n \. 1 57 

1 uherculous coxitis, 231. 267, 281, 

Tuberculous disease of hip: age 
inc idence, 1 | | 

— ambulatory ireatmeui. itii 
-- arthroplastv in. 205 

— author's technique of extra-articu¬ 
lar arthrodesis in, 1 (i,S 

— convtilescertt treatment of, 1G2 

— ck'linilion, i | | 

— diagnosis, 1 -,2 

— dilfcrcntial, 154 

— et iology, 1 | | 

— general treatment, 137 

— history, 152 

— incidence, 1 | | 

— indications for operation, 165 

— leading to coxa vara, 227 
local treatment, 158-1(12 

— morbid anatomy, 1 | | 

— operative treatment, 165-183 

— pathology, 1 |[ 

— phvsical signs, 137 

— prognosis, 157 

— recumbent treatment, 160 
repair by natural process, 145 

— surgical procedures, 165 

— s\ mpioms, 1 )6 

— treatment of acute stage, 160 

— — of deformities, 163 

— v-rays in, 151, 158 
Typhoid, 154 

1 retinitis, gonorrheal, 186 

Vaginitis. 154 

Vail: guide, 13 

— nail. 6, 39. 57 

Varnishing cast. 21 

Vaseline: irradiated, 19 | 

— treatment of osteomyelitis, 192 

Wassermann lest. 199 

Wedge in cuneiform osteotomv, 236, 

‘> 0*7 

Weight-bearing in ununited fracture 
ol netk ol Ictniu. 59, 73 

Whitman: abduction method of 

closed reduction, 39, 48-51, 75 

— position, 75 

— reconstruction operation for tin 
united fracture ol femoral neck, 58, 

\-ra\ theraps in sarcoma, 27(1 

X-rays: in congenital dislocation, 86 

— in coxa \aia. 230. 236, 2 11 

— in cWs, 277 

— following reduction of congenital 
dislocation, 132 

— following removal of spica in coxa 
vara, 232 

— in intrapelvic protrusion of ace¬ 
tabulum. 285 

— in osteoarthritis, 268 

— in osteochondritis deformans juve¬ 
nilis, 280 

— in tuberculous disease, 151, 154, 

— - postoperative, 50, 53 

— during surgical manipulation, 52, 

r>r>. ,■)•>. !i:i 

I * \ 111 It. 1 lot in u, Inc., 19 hast 33rd Si.. New York 
Medical Hook Department ol llatpei N Brothers