The Classic: Congenital Dislocation of the Hip

Dr. Henry Ling Taylor, of New York, said that there were at least two classes of congenital luxations at the hip, viz., those in which the luxation is produced at the time of labor, and those in which the condition is caused by an arrest of the growth of the acetabulum. He had had a case in which the luxation was unilateral, and in which there was a history of version and forcible delivery by traction on the luxated extremity. About six years ago he had presented to the New York Pathological Society a specimen of congenital dislocation which he had removed from a middle-aged man. In this case, not only were the acetabula shallow and narrow, but the entire pelvis was very light, and portions of the bones were as thin as an eggshell. Beside these, there was a fissure of the sacrum, giving additional evidence of the imperfect development of the whole pelvis.

Dr. N. M. Shaffer, of New York, had had two cases of unilateral congenital dislocation in children, which he had treated by the straight traction splint until the maximum amount of lengthening had been obtained, when a modified apparatus with a joint at the knee and a perineal support was employed. The best result had been obtained in a case which he had seen with Dr. Sands, and in which an attempt was made under ether to reduce the dislocation. After using considerable force this plan of reduction was found not to be feasible, but the manipulation produced, so to speak, an adhesive inflammation which was beneficial, and at the end of two years there was only about half an inch of shortening and a very firm joint.

Dr. Charles C. Foster, of Cambridge, said that the best recorded result had been obtained in the case treated by Dr. Brown. He had assisted in the treatment of that case, and could speak very positively of the great amount of faithful, patient work which had been required to bring about this result. The child belonged to a family a number of whose members had loose joints. The femur could be rubbed all over the pelvis, and there was an acetabulum so slight as to be almost inappreciable. The child was put to bed and pressure applied to keep the bone in the acetabulum, and then by an arrangement of straps the limb was exercised in this position several times every day. As soon as there was evidence of deepening of the acetabulum these exercises were modified. No splint was used at any time, but when the child was removed from bed it was placed in a sort of go-cart, supported on a saddle, so that it could be allowed very gradually to bear more and more weight upon the foot.

Dr. Albert Hoffa, of Würzburg, said that the best that could be obtained by mechanical treatment was to pull down the head of the femur, and so improve the patient’s gait. He thought the best results would be obtained by operation. The chief impediment to reduction is the shortening of the muscles running from the pelvis to the leg, owing to the trochanter major being nearer to the iliac crest than in the normal subject. The posterior leg muscles are also shortened. The reduction in adult cases is so difficult that he would not advise attempting operative reduction in patients over eight or ten years of age. In children of from three to six years, the reduction is very easy. After cutting off the joint and separating all the soft parts from the upper end of the femur, it is very easy to pull down the femoral head until it is in the position of the old acetabulum. It is desirable next to enlarge this acetabulum. It has been said that it is impossible to do this, but by reference to the specimen exhibited by Dr. Phelps, it will be seen that the acetabulum is the thickest part of the pelvis, and there is no difficulty whatever in making a sufficiently deep acetabulum. In his first operations he used a periosteal flap which he sewed over the trochanter major, but subsequently he found that it was not necessary to make this flap, for, if the cavity be sufficiently deep, there is no danger of the head of the bone coming down. The chief feature of his operation consisted in saving the head, and thereby obtaining a healthy joint. His first operations were performed about two years ago, and about two months since he examined the first case and found a perfectly movable joint and the absence of the awkward gait characteristic of congenital dislocation. Even lordosis was absent. In all of his cases he had found a rudimentary acetabulum, which was triangular in shape. Some cases had been reported in France in which the site of the acetabulum was occupied by an exostosis, but no such condition had existed in any of his cases.

Dr. Howard Marsh, of London, England, called attention to the statement which had been made concerning the absence of any causal relation between these dislocations and heredity. He did not consider that this remark correctly represented the subject, for, many years ago, he had had a case of congenital dislocation of the hip brought to him whose mother also had the same condition with very free telescopic movement on the pelvic wall. The condition found in the child was exactly similar to that shown in the specimen just presented. The anterior position is the most favorable one because in these cases there is no lordosis, for the lordosis depends upon the extent to which the femur is displaced backward upon the walls of the pelvis. Congenital dislocations should be divided into (1) those in which the bone slips about on the walls of the pelvis, and (2) those in which it is fixed. In the majority of cases it is so fixed, and under these circumstances he did not think operative measures should be undertaken. Such measures were more properly applicable to cases where the head of the femur is high up and movable.

Dr. John Ridlon, of New York, had had an opportunity of seeing one of Dr. Phelps’s cases. He had also had two cases of this condition in his own practice, and he desired to direct attention to the uselessness of mechanical treatment. Dr. Brown’s case was a posterior one and the result was good, and this was what might be expected. In his own first case, after the use of traction by the Taylor splint in bed for a year, until the shortening had been reduced, on placing the head of the bone over the acetabulum the entire limb was rotated inward about 90 degrees. In: the process of growth from birth to the age of eleven years a distortion of the neck had occurred, and, therefore, simply replacing the bone only resulted in placing the feet at right angles—a worse condition than at the beginning. In these cases mechanical treatment is obviously of no benefit. He thought anterior dislocations more hopeless than posterior ones under mechanical treatment.

Dr. R. H. Sayre, of New York, had had a case of dislocation on the dorsum of the ilium. Here he had brought down the head on to the acetabulum, but it now had a tendency to become a pubic dislocation. He uses an instrument similar to the long traction splint, but with a joint at the pelvis, so that the head can, if desired, make movements at the hip joint with the idea of assisting in creating a new acetabulum. He thought with Dr. Foster that a grinding motion is an important factor in securing such a result, provided the head of the bone could be retained in the proper position. The iron ring in Dr. Phelps’s apparatus he did not think would prove as good in practice as a strap, which could be removed from time to time. The cases in which the bone remained in a fixed position were best let alone.

Dr. E. H. Bradford, of Boston, referred to a case which he had reported on a previous occasion in which he had been using a very light portable splint, which he desired to exhibit to the Association.

Dr. De Forest Willard, of Philadelphia, considered the movable cases the most hopeful ones for operation. In cases where there is slight movement it is better to combine operative and mechanical treatment, beginning first with rather forcible attempts at reduction in order to produce inflammation, and then making continuous horizontal traction, as well as employing systematic exercises with the idea of exciting sufficient inflammation to hold it in place. Lastly came the use of a retaining splint.

Dr. L. A. Weigel, of Rochester, during the past two years had seen three cases of congenital misplacement, two of them being unilateral, and in all of them, by simple traction upon the leg, the limb could be brought down to the normal length, and there was a perceptible play on striking the rudimentary acetabulum. In some cases the muscles on the affected side were rather imperfectly developed. He did not think that in old cases the shortening could be overcome.