Manual of Surgery Volume II Part 23

In cases of long standing, beginning in childhood, the shortening is still further added to by deficient growth in length of the femur, and it may be of all the bones of the limb; even the foot is smaller on the affected side.

The most reasonable explanation of the att.i.tudes a.s.sumed in hip disease is that given by Konig. If the patient walks without crutches, as he is usually able to do at an early stage of the disease, the att.i.tude of abduction, eversion, and slight flexion enables him to save the limb to the utmost extent; on the other hand, if he uses a crutch, as he is obliged to do at a more advanced stage, he no longer uses the limb for support, and therefore draws it upwards and medially into the position of adduction, inversion, and greater flexion.

Similarly, if he is confined to bed, he lies on the sound side, and the affected limb sinks by gravity so as to lie over the normal one in the position of adduction, inversion, and flexion. Konig's explanation accords with the fact that in the exceptional cases which begin with adduction and inversion we have usually to deal with a severe type of the disease, a.s.sociated with grave osseous lesions--precisely those cases in which the patient is compelled from the outset to lie up or to adopt the use of crutches. Further, the transition from the abducted to the adducted position usually follows upon such an aggravation of the symptoms that the patient is no longer able to walk without the a.s.sistance of a crutch.

During the third stage the other signs and symptoms become more p.r.o.nounced; the patient looks ill and thin, he is usually unable to leave his bed, his sleep is disturbed by startings of the limb, and the rigidity of the joint and the wasting of the muscles are well marked. The temperature may rise slightly after examination of the limb, or after a railway journey.

#Abscess Formation in Hip Disease.#--The formation of abscess is not related to any stage of the disease; it may occur before there is deformity, and it may be deferred until the disease is apparently cured. Its importance lies in the fact that if a mixed infection with pyogenic organisms occurs, the gravity of the condition is greatly increased.

An abscess may appear _in the thigh_ in front or behind the joint. The _anterior abscess_ emerges on one or other side of the psoas muscle; from the resistance offered by the fascia lata, the pus may gravitate down the thigh before perforating the fascia. It has occasionally happened that when such an abscess has been opened and become infected with pyogenic organisms, the femoral vessels have been eroded, and serious or even fatal haemorrhage has resulted. The _posterior abscess_ appears in the b.u.t.tock and may make its way to the surface through the gluteus maximus; more often it points at the lower border of this muscle in the region of the great trochanter, or it may gravitate down the thigh.

Abscesses which form _within the pelvis_ originate either in connection with the acetabulum or in relation to the psoas muscle where it pa.s.ses in front of the joint. Those that are directly connected with disease of the acetabulum may remain localised to the lateral wall of the pelvis, or may spread backwards towards the hollow of the sacrum. They may open into the bladder or r.e.c.t.u.m, or may ascend into the iliac fossa and point above Poupart's ligament (Fig. 115), or descend towards the ischio-rectal fossa. The abscess which develops in relation to the psoas muscle may be shaped like an hour-gla.s.s, one sac occupying the iliac fossa, the other filling up Scarpa's triangle, the two sacs communicating with each other through a narrow neck beneath Poupart's ligament.

So long as the skin is intact, the abscess is unattended with symptoms, and may escape notice. If it bursts externally, pyogenic infection is almost inevitable, and the patient gradually pa.s.ses into the condition of hectic fever or chronic toxaemia; he loses ground from day to day, may become the subject of waxy disease in the viscera, or may die of exhaustion, tuberculous meningitis, or general tuberculosis.

#Dislocation# is a rare complication of hip disease, and is most likely to occur during the stage of adduction with inversion. It has been known to take place during sleep, apparently from spasmodic contraction of muscles. In the dorsal dislocation, which is the most common form, adduction and inversion are exaggerated, the trochanter projects above and behind Nelaton's line, and the head of the bone may be felt on the dorsum ilii. It is a striking fact that after dislocation has occurred there is less complaint of pain or of startings than before, and pa.s.sive movements may be carried out which were previously impossible.

#Diagnosis of Hip Disease.#--The diagnosis is to be made not only from other affections of the joint, but also from morbid conditions in the vicinity of the hip, as in any of these the patient may seek advice on account of pain and a limp in walking. The patient should be stripped, and if able to walk, his gait should be observed. He is then examined lying on his back, and attention is directed to the comparative length of the limbs, to the att.i.tude of the limbs and pelvis, and to the movements at the hip-joint, especially those of rotation. When there is any doubt as to the diagnosis, the examination should be repeated at intervals of a few days. In children, there are three non-febrile conditions attended with a limp and with shortening of the limb, which may be mistaken for hip disease,--_congenital dislocation_, _c.o.xa vara_, and _paralysis following poliomyelitis_--but in all of these the movements are not nearly so restricted as they are in disease of the joint.

In tuberculous disease of the _sacro-iliac joint_, while the pelvis may be tilted, and the limb apparently lengthened, the movements at the hip are retained. In tuberculous disease of the _great trochanter_, or of either of the _bursae_ over it, while there may be abduction, eversion, impairment of mobility, and swelling in the region of the trochanter followed by abscess formation, the movements are less restricted than in disease of the joint.

In _psoas abscess_ a.s.sociated with spinal disease, or in _disease of the bursa underneath the psoas_, the limb is flexed and everted, there may be lordosis, and the patient may limp in walking, but the movements at the hip are restricted only in the directions of extension and inversion, while in hip disease they are restricted in all directions.

_New-growths_ in the vicinity of the hip--especially central sarcoma of the upper end of the femur--are difficult to differentiate from hip disease without the help of the X-rays.

Among other conditions which by interfering with the free mobility of the hip may simulate hip disease, are appendicitis, inflammation of the glands in the groin, staphylococcal disease of the upper end of the femur, and sciatica.

The diagnosis _from other diseases of the hip-joint_ is made by careful consideration of the history, symptoms, and X-ray appearances.

#Prognosis.#--The prognosis in hip disease is more serious than in tuberculosis of other joints, excepting only those of the spine, and it is most unfavourable when there are gross lesions of the bones and infected sinuses.

Whatever the stage of the disease, recovery is a slow process, and even in early and mild cases it seldom takes place in less than one or two years, and is liable to be attended with some impairment of function. During the process of cure, complications are liable to occur, and after apparent recovery relapses are not uncommon. When arrested during the initial stage, recovery may be complete; but when there has been destruction of the articular surfaces, there is apt to be ankylosis of the joint and shortening of the limb.

In cases which terminate fatally, death usually results from meningeal, pulmonary, or general tuberculosis, or from pyogenic complications and waxy degeneration.

#Treatment.#--A large proportion of cases recover under conservative treatment, and the functional results are so much better than those following operative interference that unless there are special indications to the contrary, conservative measures should always be adopted in the first instance.

_Conservative Treatment._--The first essential is to take the weight off the limb and secure its fixation in the att.i.tude of almost complete extension and moderate abduction. When the symptoms are well marked, the child is kept in bed and the limb is extended with a weight and pulley.

_Extension by Weight and Pulley_ (Fig. 116).--The weight employed varies from one to four pounds in children, to ten or more pounds in adolescents and adults, and must be adjusted to meet the requirements of each case. If pain returns after having been relieved, it is due to stretching of the ligaments, and the weight should be diminished or removed for a time. If there is deformity, the line of traction should be in the axis of the displaced limb until the deformity is got rid of. The extension should be continued until pain, tenderness, and muscular contraction have disappeared, and the limb has been brought into the desired att.i.tude.

[Ill.u.s.tration: FIG. 116.--Extension by adhesive plaster and Weight and Pulley.]

In restless children, in addition to the extension, a long splint is applied on the sound side and a sand-bag on the affected one; or, better still, a double long splint and cross-bar, the long splint on the affected side being furnished with a hinge opposite the hip to permit of varying the degree of abduction (Fig. 117).

[Ill.u.s.tration: FIG. 117.--Stiles' Double Long Splint to admit of abduction of diseased limb.]

When the deformed att.i.tude does not yield rapidly to extension, it should be corrected under an anaesthetic, and if the adductor tendons and fasciae are so contracted that this is difficult, they should be forcibly stretched or divided.

The immediate correction of deformed att.i.tudes under anaesthesia has largely replaced the more gradual method by extension with weight and pulley; and in hospital practice it is usually followed by the application of a plaster case. The plaster bandages are applied over a pair of knitted drawers; the pelvis and both thighs, the diseased one in the abducted position, are included. The case may be strengthened by strips of aluminium, and should be renewed every six weeks or two months.

_Ambulant Treatment._--When the patient is able to use crutches, the affected limb is prevented from touching the ground by fixing a patten on the sole of the boot on the sound side. This may suffice, or, in addition, the hip-joint is kept rigid by a Thomas' (Fig. 118) or a Taylor's splint. The Thomas' splint must be fitted to the patient under the supervision of the surgeon, who must make himself familiar with the construction of the splint, and its alteration by means of wrenches.

[Ill.u.s.tration: FIG. 118.--Thomas' Hip Splint applied for disease of Right Hip. Note patten under sound foot. The foot on the affected side is too near the ground.]

In children who are unable to use crutches, a double Thomas' splint is employed; the child thereby is converted into a rigid object, capable of being carried from one room to another and into the open air.

Personally we have obtained satisfaction from the double Thomas'

splint employed for spinal disease, which extends from the occiput to the soles of the feet.

The fixation of the hip-joint and the taking of the weight off the limb by one or other of the above methods, should, as a general rule, be continued for at least a year.

Should an abscess develop, it is treated on the usual lines.

_Operative Interference._--Widely diverse opinions are held on the question as to whether or not recourse should be had to operative interference.

Some surgeons are opposed to operative interference, on the grounds that however advanced the disease may be it will yield to conservative measures if judiciously and perseveringly carried out. Other surgeons advocate operative treatment in all cases which do not speedily show improvement under conservative treatment. An intermediate att.i.tude may be adopted which recommends operation in cases in which the disease progresses in spite of conservative treatment, and in which periodic examination with the X-rays shows that there are progressive lesions in the upper end of the femur or in the acetabulum.

It is claimed by those who advocate operation under these conditions that pain and suffering are at once got rid of, sleep is restored, appet.i.te returns, and there is a marked improvement in the general health, and that this result is obtained in months instead of years, and that the cure is more likely to be permanent. It is certainly unwise to delay operation until sinuses have formed, as such a course is largely responsible for the bad results which formerly followed excision of the joint.

_Amputation_ for tuberculous disease of the hip has become one of the rarest of operations, but is still required in cases which have continued to progress after excision, and when there is disease of the pelvis or of the shaft of the femur, with sinuses, alb.u.minuria, and hectic fever.

#The Correction of Deformity resulting from Antecedent Disease of the Hip.#--From neglect or from improper treatment, deformity may have been allowed to persist, while the disease has undergone cure. It is a.s.sociated with ankylosis of the joint, or contracture of the soft parts or both. The contracture of the soft parts involves specially the tendons, fasciae, and ligaments on the anterior and medial aspects of the joint, and is usually present to such a degree that, even if the joint were rendered mobile, these shortened structures would prevent correction of the deformity. The usual deformity is a combination of shortening, flexion, and adduction.

#Bilateral Hip Disease.#--Both hip-joints may become affected with tuberculous disease, either simultaneously or successively, and abscesses may form on both sides. The patient is necessarily confined to bed, and if the disease is recovered from, his capacity for walking may be seriously impaired, especially if the joints become fixed in an undesirable att.i.tude. The most striking deformity occurs when both limbs are adducted so that they cross each other--one variety of the "scissor-leg" or "crossed-leg" deformity--in which the patient, if able to walk at all, does so by forward movements from the knees. An attempt should be made by arthroplasty to secure a movable joint at least on one side.

OTHER DISEASES OF THE HIP-JOINT

#Pyogenic Diseases# are met with in childhood and youth as a result of infection with the common pyogenic organisms, gonococci, pneumococci, or typhoid bacilli. While the organisms usually gain access to the tissues of the joint through the blood stream, a direct infection is occasionally observed from suppuration in the femoral lymph glands or in the bursa under the ilio-psoas.

The _clinical features_ are sometimes remarkably latent and are much less striking than might be expected, especially when the hip affection occurs as a complication of an acute illness such as scarlet fever. It may even be entirely overlooked during the active stage, and only noticed when the head of the femur is found dislocated, or the joint ankylosed. In the acute arthritis of infants also, the clinical features may be comparatively mild, but as a rule they a.s.sume a type in which the suppurative element predominates. The limb usually becomes flexed and adducted, and a swelling forms in front of the joint at the upper part of Scarpa's triangle; the upper femoral epiphysis may be separated and furnish a sequestrum.

The flexion and adduction of the limb favour the occurrence of dislocation. A child who has recovered with dislocation on to the dorsum ilii is usually able to walk and run about, but with a limp or waddle which becomes more p.r.o.nounced as he grows up. The condition closely resembles a congenital dislocation, but the history, and the presence of gross alterations in the upper end of the femur as seen with the X-rays, should usually suffice to differentiate them.

_Treatment._--In the acute stage the limb is extended by means of the weight and pulley, and kept at rest with the single or double long splint, or by sand-bags. If there is suppuration, the joint should be aspirated or opened by an anterior incision, and Murphy's plan of filling the joint with formalin-glycerine may be adopted. In children, it is remarkable how completely the joint may recover.

If there is dislocation, the head of the femur should be reduced by manipulation with or without preliminary extension; it has been successful in about one-half of the cases in which it has been attempted. Preliminary tenotomy of the shortened tendons is required in some cases. When reduction by manipulation is impossible, the joint structures should be exposed by operation and the head of the bone replaced in the acetabulum. When the upper end of the femur has disappeared, the neck should be implanted in the acetabulum, and the limb placed in the abducted position.

#Arthritis Deformans.#--This disease is comparatively common at the hip, either as a mon-articular affection or simultaneously with other joints.

[Ill.u.s.tration: FIG. 119.--Arthritis Deformans, showing erosion of cartilage and lipping of articular edge of head of femur.]

_The changes in the joint_ are characteristic of the dry form of the disease, and affect chiefly the cartilage and bone. The atrophy and wearing away of the articular surfaces are accompanied by new formation of cartilage and bone around their margins. The head of the femur may acquire the shape of a helmet, a mushroom, or a limpet sh.e.l.l, and from absorption of the neck the head may come to be sessile at the base of the neck, and to occupy a level considerably below that of the great trochanter (Fig. 120). These changes sometimes extend to the upper part of the shaft, and result in curving of the shaft and neck, suggesting a resemblance to a point of interrogation (Fig. 121).

The acetabulum may "wander" backwards and upwards, as in tuberculous disease. It is usually deepened, and its floor projects on the pelvic aspect; its margins may form a projecting collar which overhangs the neck of the femur, or grasps it, so that even in the macerated condition the head is imprisoned in the socket and the joint locked.

There is eburnation of the articular surfaces in those areas most exposed to friction and pressure.

[Ill.u.s.tration: FIG. 120.--Upper End of Femur in advanced Arthritis Deformans of Hip. The shaft is curved and the head of the bone is at a lower level than the great trochanter.]

[Ill.u.s.tration: FIG. 121.--Femur in advanced Arthritis Deformans of Hip and Knee Joints. The upper end of the bone shows the condition of c.o.xa vara; the lower end shows enlargement of the medial condyle and alteration in the axis of the articular surface.]