THE

DIRECT

APPROACH
E. W.

TO

CONGENITAL
and

DISLOCATION
OXFORD,
Centre, Oxford

OF

THE

HIP*

SOMERVILLE
From the

J. C. Scorr,
Orthopaedic

ENGLAND

Nuffleld

There congenital

is an old dislocation

saying that of the hip

we plant it is our

trees for successors new

posterity. Equally in the who will judge our results to the problem problem are

treatment rather necessary

of than to

ourselves. Even so, periodic reviews of any assess its apparent value. In the past six years we have developed dislocation of the must be corrected we have corrected
time known and nature abnormalities

approach approach

a direct

to the

of congenital

hip based on the belief that there are certain structural if the hip is to develop normally (Somerville 1953b). by operation rather than by leaving the correction
alone. that It is only their by observing in the the results etiology of and such significance prognosis

abnormalities which These abnormalities to the uncertainty of

deliberate of correction the condition of

can

really This

be assessed. programme is placed

is based on each stage,

upon and the

our that

interpretation they should for each

of the be carried step and

mechanics out how

of the

dislocation. The out, purpose and to

Emphasis of this comment

separately. it is carried

paper is to describe briefly on the interim progress. refers only to in which they

reason

TREATMENT

the

This paper critical age

typical congenital dislocation are commonly brought for

of

the

hip

in

children

at

treatment-that

is,

from

the

beginning of walking, or just before, are also applicable to patients outside The programme of treatment may of full medial rotation and removal 3) correction of anteversion by means
Reduction-It is necessary for the

to five years. Some of the procedures described here these limits, but such cases will not be considered here. be divided into four stages: I) reduction; 2) establishment of an intra-acetabular of a rotation osteotomy obstruction when of the femur; and this is present; 4) mobilisation. with the frame tissue,

femoral

least

possible

trauma.

This

has

been

head achieved reduction weeks.

to be reduced into by the use of the with progressive

the acetabulum double abduction stretching

(Scott 1953). The method a process that is usually Establishment of medial

permits completed rotation,

gradual in four and

of soft the

removal

of acetabular

obsfruction-After

reduction

of the femoral head into the acetabulum it is necessary to obtain full medial hip, but when the limbus of the acetabulum is inverted sufficiently to cause it must first be excised (Somerville 1953a). On the other hand, if the limbus sufficiently to cause a real obstruction all that is necessary is to place general of medial the hip rotation. This is best hip in about 40 degrees obtained without two weeks, when rotation quite force. it will and done by applying a plaster spica under of abduction and the greatest degree If this is insufficient be found that the in this position hip

rotation of the an obstruction is not inverted in full medial with the that can be

anaesthesia rotation

it will be necessary to repeat the process after will seemingly go into 90 degrees of medial for a further two weeks. We say rotated, indeed, rotated

easily,

it is immobilised

seemingly 90 degrees the hip will be much unless the posterior at all. and
*

of medial rotation because, whereas the leg will be 90 degrees less rotated on account of the anteversion of the femoral neck; structures are adequately stretched the hip may not be medially

If the limbus has been excised the leg is immobilised extension, and about 40 degrees of abduction. This
Based on a paper read at a meeting 1957 of the British Orthopaedic

in a hip spica in full medial rotation spica is left on for one month.
Association at Gleneagles in May 1956. 623

VOL.

39 B. NO. 4, NOVEMBER

624

E. W.

SOMERVILLE

AND

J.

C.

SCOTT

Correction
is performed

of anteversion-The
just below the lesser

spica

is removed trochanter. The

and

an

adequate are

lateral fixed

rotation with a plate

osteotomy and four

fragments

screws. depending

Experience on the

has shown that the degree of rotation required is 60 to 90 degrees, anteversion and the amount of medial rotation obtained at the previous to angle remains

stage of the the osteotomy

is to allow

treatment. If the neck of the femur is in a valgus position it is advisable into varus. The fragments unite in six weeks. Mobilisation-Up to this point treatment has taken about fourteen weeks, and all that the first for removed hip to become spasm, if present, mobile and for can be avoided the child to begin by applying skin walking. traction

When the plaster is with I to 2 lb. weight be

a week When encouraged tends to be

while the movements of the hip are begun by the childs movements in bed. free, the child should be kept by day sitting in a chair rather than lying, and to crawl and walk as soon as possible. We have found that progress in mobilisation more rapid at home than in hospital.
THE
THE

RATIONALE
OBSTRUCTION

OF
TO

THIS
FULL

TREATMENT
REDUCFION

Extra-articular
these can be

obstacles-The
stretched by

first
manipulative

obstacle

to reduction
manoeuvres in

is the
which

shortened
the head

muscles.
is reduced

Certainly
into the

acetabulum done, must causes the femoral

with the hips cause great head

flexed, pressure The

the legs being abducted and extended. This, on the femoral head, which is probably soft tissues Most must of the be stretched stretching must gradually be done before

however carefully one of the chief leverage head on enters the

of osteochondritis.

to reduce

to a minimum.

the acetabulum. Gradual has shown that it is wise, to elapse before proceeding. subluxation, even a minor Intra-articular obstruction-At

reduction on a once the head This ensures one, in this way this point

frame fulfils these criteria admirably. Experience is opposite the acetabulum, to allow several days that the stretching is complete. It is wise to treat as well as complete dislocation. in treatment the hips must be differentiated into obstruction
to these two

two types: those in which there is in the acetabulum no mechanical and those in which an obstruction is present. In this paper we refer are only stages in the same condition) as subluxation and dislocation. to differentiate between these types without the aid of arthrography.
ARTHROGRAPHY

to reduction,
types (which

It is not

always

possible

we this

It is wise to undertake arthrography also obtained arthrographs before in order to reduce the number Arthrography is carried out

after the initial frame reduction. treatment was begun, but we have anaesthesia, and the skin

In the earlier cases now discontinued receives the usual

of anaesthetics. under general

pre-operative preparation. A 17 per cent solution of diodone is injected into the hip joint by the anterior route until the joint is full but not tense. If the 35 per cent solution (as supplied in ampoules)is used it will be found to be too dense and may obscure the soft-tissue outlines. If too little fluid is injected the joint may be inadequately filled, with consequent fallacious appearance. On the other hand, if the tension is too with exaggeration of the displacement. fluid is sufficient. It is not easy to direct the needle into great, the In a child the joint, head may of eighteen which, be blown out of the joint, months about 4 millilitres of being empty, is only a potential

space. to the While

The needle is pushed into the femoral head just below the inguinal ligament and lateral femoral artery. The leg is moved to make sure that the needle is in the femoral head. gentle pressure is applied to the plunger of the syringe, the needle is gently withdrawn plunger that it may
THE JOURNAL

until the fluid runs in freely. When the pressure on the run back into the syringe; this is the only sure indication arthrography is done before reduction of the dislocation

is released the fluid should the fluid is in the joint. If be made easier by applying
OF BONE AND JOINT SURGERY

THE

DIRECT

APPROACH

TO

CONGENITAL

DISLOCATION

OF

THE

HIP

625

traction otherwise In tendency

to the leg, the sharp all to

thus relaxing outlines will

the capsule. The radiographs be lost by absorption of the shadows There are

must fluid.

be taken

without

delay, a for:

arthrographs read too

there are many much into them.

to be seen, two principal

and there features

is consequently to be looked

FIG. Figure l-Arthrograph pooling. The Iimbus to which the acetabular

1
of a normal hip showing the head fitting accurately

FIG.

2
acetabulum without

in the

can

be clearly
roof into

seen.

Figure

2-Arthrograph

showing

a subluxation.
head does

The
not

is cartilaginous the joint, and

is well demonstrated. the limbus is somewhat

The femoral pressed up.

extent fit well

FIG.

FIG.

Figure 3-Arthrograph of a dislocated hip. This makes an interesting comparison with Figures 1 and 2. The limbus is grossly deformed and turned into the joint. Figure 4-Arthrograph after the head of the femur has been pulled down to the acetabulum. The limbus is forming an obstruction which prevents the femoral head from sinking into the acetabulum, and it permits pooling of the fluid.

the

position

and

shape

of

the

limbus;

and

pooling

of the

contrast

medium

in the

floor

of the

acetabulum. The head

VOL.
B

limbus tapers
NO.

in a normal to a sharp

hip point
1957

(Fig. with

1) is easily a notch

distinguishable. distal to it.

It fits closely In a subluxation

to the femoral the limbus and

and 39 B,

4, NOVEMBER

626 roof and of the apparently

In

E.

W.

SOMERVILLE

AND

J.

C.

SCOTT

acetabulum deficient,
the

are but

displaced otherwise

upwards the general

is totally

so that
different

the

roof
(Fig.

becomes remains
3). The

elongated unchanged
limbus is

upwards (Fig.
seen as

conformation The
constriction.

2).
a is

a dislocation

appearance

globular
up, which

tag turned
gives the

into

the cavity
of

of the
an

acetabulum.

lower

part
The

of the
apparent

capsule

is drawn

appearance

hour-glass

constriction

FIG.

5 (scale in centimetres

typical

limbus

after

excision

and

inches).

due to the redundant capsules which it normally clings closely. it becomes adherent, as it may
After the head has been

being drawn up by the displaced The capsule forms no obstruction in older children.
into the acetabulum the limbus

anteverted femoral neck to to reduction except when

is seen to be compressed

reduced

against the cartilaginous been described elsewhere

roof. Its size, shape (Somerville 1953a).

and

significance

under

these

circumstances

have

FIG. Figure

FIG.

FIG.

8
head has has sunk extent it

been
into

6-Diagrammatic representation of a dislocation showing the inverted limbus. Figure 7-The pulled down and the limbus is turned into the joint. Figure 8-With time the femoral head the floor of the acetabulum by compressing the limbus into the acetabular roof, and to some has itself become flattened.

Pooling

of

the

contrast

medium

in the

lower

part

of

the

acetabulum

is evidence

that

the femoral head does not fit accurately into the acetabulum in subluxations and dislocations (Figs. 2 and 3) and no pooling If the arthrograph shows that an obstruction is present proceeded to remove
it under the same anaesthetic. The

(Fig. 4). This is quite different is seen in the normal hip (Fig. I). we have, in almost all instances,
at present
OF BONE

evidence
THE JOURNAL

available
AND JOINT

suggests
SURGERY

THE

DIRECT

APPROACH

TO

CONGENITAL

DISLOCATION

OF

THE

HIP

627

that
arises: problem

it is usually does is to every

advantageous inverted inverted no determine if the

so

to limbus which pooling

remove need to be

the be or in the removed,

inverted removed? and if it does arthrograph,

limbus,
The which
not

but
answer may
prevent

the
safely
easy

question
is probably be left left. it in complete

undoubtedly
no. Our position; reduction but The policy

must limbus

has
without

been

that
delay

is small, is seen

that

we

have

FIG. Case I-Hip after treatment osteotomy at the time of 60 degrees

9 mobilisation had been was started. performed. A rotation

FIG.

10
the hip has dislocated: of 40 degrees was done, derotation and three

FIG.

11 Figure is stable. Il-A

Case I.

Figure further

10-Six rotation

weeks later osteotomy

had been inadequate. years later the hip

in all other dislocation other

cases

except

three a sizable

the

limbus was

has

been deliberately

excised. left

These in one structure

three hip

were but (Fig. child,

cases removed 5) which it has

of bilateral from will little the stand chance

in which

limbus

so that progress could be compared. The inverted limbus is a substantial of the head
NOVEMBER

fibrocartilaginous
it is soft,
as in

up to the pressure
VOL.

and,

unless

a very

young

39 B,

NO.

4,

1957

628

E. W.

SOMERVILLE

AND

J.

C.

SCOTT

FIG.

12 a rotation-adduction osteotomy.
more valgus.

FIG.

13

Case

2.

Figure

12-After

Figure

13-Three

years

later.

The

neck

is much

FIG.

14

FIG.

15

Case

Figure 14-An adduction osteotomy was done some years previously. Although the plate is on the lateral aspect of the femur, with the leg in the functional position, it lies posteriorly because the anteversion was uncorrected. Figure 15-The same plate was reapplied after a 70 degrees rotation osteotomy.

3.

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

THE

DIRECT

APPROACH

TO

CONGENITAL

DISLOCATION

OF

THE

HIP

629 roof and any attempt an

of being of the

pressed acetabulum

out

of the where

way.

Instead a deep

it becomes groove, the

pressed producing size of the

into

the

soft

cartilaginous acetabulum, so that

it forms

a deficient acetabulum

irregularity of the head (Figs. Furthermore the inverted

6 to 8). limbus reduces

to force a reduction may cause considerable compression is prolonged it may cause flattening and malformation a factor in the development of osteochondritis.
ROTATION OSTEOTOMY

of the femoral of the femoral

head. If the pressure head, and may well be

Persistent cause process, has of

anteversion

necessitates This is taken results a last

prolonged

immobilisation

and

is

the

commonest insidious result. when to have it

recurrent and by the fair used the ensure

subluxation. time action the than

late redisplacement it is often too late of rotation osteotomy salvage

may be to produce in such How it is our

a gradual, a satisfactory circumstances, much practice better

It is scarcely been prevented To

to assess

as no more recurrence a stable

desperate

operation. mobilisation

from ever taking place. reduction and to allow early in the course and whether

to perform whether We base

a rotation osteotomy of subluxation or this and

means

as early dislocation,

of treatment as is practicable in all cases, or not the limbus has been excised.

policy on the evidence that stable it seems logical to leave the hip
of an osteotomy. We have

reduction is obtained in this stable position

that it is best to do

with the hip fully rotated medially, but to turn the leg to the front by
the osteotomy immediately below

found

the lesser trochanter, and that the fragments must be fixed prevent loss of position (Somerville 1957). Experience has also shown that the degree of rotation depending Attempts osteotomy same time The varus Some corrected, be desired. alone and, plate was while was

with must

a plate be from

and

four

screws

to

60 to 90 degrees

on the amount of anteversion and degree of medial rotation obtained beforehand. to do less have led to failure which has been corrected by a further rotation (Figs. 9 to 11). Excessive valgus of the femoral neck should be corrected at the by bending the four-hole plate, provided osteotomy is as high tends to become corrected spontaneously as growth proceeds surgeons believe that the valgus deformity of the femoral but despite the improvement afforded by adduction osteotomy In one done reapplied the varus child-not 14). was without in this Some maintained, altering series, but from fragment of angulation an older persisted. was rotated (Fig. group-an The 15). (Fig. degree the of subluxation the lower degree
MOBILISATION

as possible (Fig. 13). neck alone it leaves adduction osteotomy

(Fig. need much osteotomy was

12). be to

revised original

70 degrees.

The

Six aim up

weeks to this

after point and varies

the has

osteotomy been

the

plaster the

is removed mechanics

and

mobilisation The success. within

is started. rapidity The period six months,

Our of and

to correct

of the joint. of our regained

of recovery

of movement mobilisation

normal joint considerably.

development is a measure Full movement is usually

in no case has the child regained less than 90 degrees of flexion within this period. Occasionally it will be found that after removal of the plaster the hip is at first a little irritable, and becomes flexed and rotated laterally. Any attempt at movement is resented, and a radiograph suggests

that the hip is subluxating.

hanging and over the end of the mobilisation In some lateral rotation out. out,
VOL.

In such bed for

circumstances seven to ten

we apply skin traction days, by which time the

with a 1-lb. hip will have

weight settled

may be resumed safely. cases it will be found that although there during mobilisation, and the radiograph there is no obstruction, policy is to get the child
4, NOVEMBER 1957

is no spasm the hip tends to lie in suggests that the head is standing rotation or, if this osteotomy has been carried is not immediately possible,

Provided the best 39 B,

NO.

and an adequate up and walking,

630 crawling
and the temptation

E. W.

SOMERVILLE

AND

J. C.

SCOTT

or sitting
best course to treat turn

in a chair.
is to the hip foot send will to

It is unwise
the not the child arise. front,

to delay
home Children

weight
with regain the head

bearing
movement

by putting
to better this

the effect,

child so The

to bed, that the reason

instructions

at home.

for
will

encouraging
always

weight
the

bearing

in such

circumstances
forcing

is that
of

in the
the

upright
femur

position
backwards

the
into

child
the

20

acetabulum. even sits

and 5 placed the

If the child in bed, the leg

condition

lies supine in bed, or lies in lateral rotation

is aggravated. no restrictions believe that once are the the likely form or

Once on

the child is walking the activities. We the the joint hip

10

mechanics of more normally it is to develop

have been corrected, is used the more and in be some unnecessary. that any

normally, particularly should

of

restraint, position,

unnatural

bizarre
I

234cYRS
FIG.

PROGRESS This
16
time of diagnosis.

paper
hips

is

based

on

study

of

fifty
and hip

Graph

showing

ages

at

the

dislocated consecutively.
two

in forty-four There were twenty-eight

patients-treated forty-two girls patients the left

boys.

In

was
years,

affected,
and the

in ten the right,

was present in the three shortest

and
other years.

in six both.
hip. The age The

In four
longest at diagnosis

patients
period is shown

with

dislocation

on one
and

side
a half

subluxation

of follow-up in Figure

is seven

that only no
femur

most two

dislocations below the age

were

diagnosed year

between (both at nine

the

ages months). there Five

the

of one

and

a half

16. It will be seen to two years, and sepsis which in a fracture of the

of one

Few complications way interfered with

during the period

have arisen. the course

of mobilisation,

In two cases of treatment.

or during

was some superficial children sustained

subsequent year.

FIG.

Case

4. Figure

17-Initial

17 radiograph

FIG.

showing
was

dislocated
clinically

hip.
normal.

Figure

18-Eight

18 months

later.

The

hip

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OF

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AND

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SURGERY

THE

DIRECT

APPROACH

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CONGENITAL

DISLOCATION

OF

THE

HIP

631

FIG. Case 5. Figure 19-Dislocated

19 hip in a child months later, aged when two years mobilisation three was months. begun.

FIG. Figure

20
20-Four and a half

FIG. Case 5. Figure 21-Ten

21
months later still.

There

still defective.

Figure

22-After

a further

FIG. 22 is clinically normal function, but ossification year the ossification of the acetabulum is much

of the ilium improved.

is

VOL.

39

B,

NO.

4,

NOVEMBER

1957

632 In four cases the hips

E. W.

SOMERVILLE

AND

J. C.

SCOTT

presented

some

problem

after

mobilisation been
less

had

begun,

but with
considered

in three results
in

of these this was the In the remaining

which are clinically

result of a deliberate forty-six hips the

normal. Radiologically

variation in technique. course of treatment has

the results are

uneventful,
when

good

detail, place

but a characteristic with growth. This

feature has been is not a feature ofhips

the progressive which have been oftreatment

improvement which has taken treated by the more conventional to consider the development

methods. It seems to us that in estimating the results of each individual component of the joint.

it is best

The acetabulum-We
with the development

were aware of the of the acetabulum. limbus seems subsequently

possibility This to assist develop

that excision has not proved acetabular a normal

of the limbus might interfere to be the case ; indeed the though Figure this does 17 shows not the

removal of the inverted mean that all hips will

development, acetabulum.

dislocated hip of a child in which the ossification of the acetabulum is defective. The limbus was excised, and eight months later the radiographs showed that rapid development had taken place in the ossification (Fig. 18). By the time some hips come to treatment ossification may be retarded

Figure very
that deficient. time head limb

to such an extent 19 shows the hip The limbus showed radiographs

that full recovery of a child of two excised a bony and acetabular

is not possible. in whom ossification was seemingly begun roof

of the three insufficient

acetabulum months to later. prevent

was At the

was

mobilisation

femoral use the year but two On

from riding up (Fig. 20). Despite this, the child normally as soon as possible without restraint. an appearance of deficiency the radiological if the limbus (Fig. 21) although appearance was much remains in the inverted in the ossification and Figures

was encouraged Radiographs the hip was improved position (Fig. it may

to walk and after a further normal, into 22). be pressed

showed

clinically

years later still the other hand,

the acetabular Figures 6 to

roof, with consequent delay 8 show this diagrammatically,

and 23 to

development of this region. 25 show how deceptive an a

arthrograph may be after this has happened. In this instance, after a well shaped acetabulum had developed, as seen radiologically, the hip remained unstable. The hip was explored and large limbus was excised; since then the hip has developed well. The femoral head-The development of the femoral head is one of the main factors affecting the results of treatment methods of manipulative from interference variously ascribed the head by twisting of congenital reduction dislocation has been the of the hip. development One big problem of osteochondritis, in all accepted presumably

with the to injury the

blood supply at the time and muscles. not encountered and

to the ossific nucleus. The of reduction, to compression to extensive a hip the pressure in which on the the head

cause for this has been of the vessels supplying after reduction, from

capsule,

tightness of the shortened In our series we have with head osteochondritis has, on the

radiological ossific

changes nucleus

associated femoral

have appeared, whole, been good.

development

of the

of the

The factors so far as possible, factor that has

mentioned above as being responsible by the use of the frame (Scott 1953). been eliminated and in this programme the femoral pressure may

for osteochondritis It may be that The is normal to interfere

there

have been eliminated, is another causative limbus reduces the to may is forced into the circulation acetabulum,

of treatment.

inverted in size, with

the size of the acetabulum, acetabulum. The consequent the ossific nucleus. prevent this pressure grows is due With the rapidly. to rapid A second recovery Usually growth, nucleus

head, which be sufficient

Excision of the from interfering of function, the outline which often suggests develops

limbus, by increasing with the circulation and when the mechanics becomes a little shaggy that in the there medial

the size of the to the head. are normal, and irregular. insufficiency. head,
OF

the ossific nucleus This appearance the

AND

is no vascular part of the

THE

giving
BONE

whole
JOINT

ossific
SURGERY

JOURNAL

THE

DIRECT

APPROACH

TO

CONGENITAL

DISLOCATION

OF

THE

HIP

633

nucleus and the

a somewhat whole

elongated

appearance increases

(Figs. in size.

26 and In some

27).
hips

The
the

two
primary

nuclei
centre

soon

fuse
placed

(Fig.
laterally

28)

progressively

FIG. Case 6-Plain radiograph

23
hip after reduction before

of the arthrography.

FIG.

24
after four reduced but instability years after the the

FIG. position had been maintained because the head stands out. limbus was excised.

25
for Figure three months, 25-Condition

Case
showing

6.

Figure 24-Arthrograph the well shaped acetabulum,

in the
valgus.
VOL.

head

grows

more

rapidly

than

the

medial

centre,

producing

a progressively

increasing

39 B,

NO.

4,

NOVEMBER

1957

634

E. W.

SOMERVILLE

AND

J.

C.

SCOTT

FIG.

Case

7.

Figure
and

26 26-Hip

FIG.

27

at completion
Figure 27-A

of treatment
second ossific years later. The

is visible

it is round.

FIG. 28 about to begin mobilisation. Only one ossific centre nucleus is visible medial to the original one. Figure 28-Two

and

two

centres

are

fusing.

two
perhaps

It seems likely from these observations ossific nuclei which, when they develop but in congenital
altogether,

that the normal femoral head simultaneously, are not usually development
reduction

is formed from seen as separate is delayed, or

to It is interesting

entities,

dislocation
unless

the
a stable

of

the

medial
early.

centre

suppressed

is obtained

FIG.

29

A case

of Perthes

disease.

The
medial

lateral
part

part

of the head

is defective,

but the

is normal.

compare this with Perthes disease one is often preserved (Fig. 29).

in which
method

the
of

lateral
treatment

centre

degenerates,
well

whereas
defined

the
Harriss

medial
lines

The upper
which show

end of the femur-This

clearly the way

produces

in which

growth

takes

place
THE

in the
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AND

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femur
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HIP

635

FIG.

30

FIG.

31

Case

8.

Figure

30-Radiograph
femoral neck.

a year
Figure

and

a half
years

after
later,

completion
showing

of treatment,
well shaped head

showing
and

a varus
neck.

and

short

31-Four

FIG. Case with 9. the

32

Figure
rotation

32-In
at the

this

exceptional

case
Figure

it was necessary

to combine

FIG. 33 an exaggerated later the coxa

degree
vara

of adduction
less and

osteotomy.

33-Only eighteen months the hip remains stable.

is much

voi.

39 B,

NO.

4,

NOVEMBER

1957

636 (Somerville the

seems

E. W.

SOMERVILLE

AND

J.

C.

SCOTT

1953b). side of the

measurements

There greater

is a continuous trochanter
that equal growth

metaphysis (Trueta
takes

from and
at place

the in the
the

medial early
ends two

side stages
of

of the at any
the

head rate

to it
but

outer
from

1957), the rate

femur;

when

two

separate

epiphysial

nuclei

develop

of growth

at the

upper

end

is reduced.

With this arrangement of two epiphyses any inequality of growth between them will result in alterations of the anteversion or of the valgus or varus angle, and that these two angles can progressively alter to the detriment of the joint is undoubted. There has been a tendency in all the hips treated When the hip but cause varus when the impairment at the site for the neck to become progressively was varus to begin with this tendency angle is at first when normal, or even mentioned even to of development. of osteotomy As already necessary, more valgus. does not matter a little the we have extent valgus, (Figs. further 30 and valgus 31), may

neck-shaft

not hesitated of creating

to produce considerable

deformity, which will either become corrected spontaneously or can be corrected at a later date, if necessary, after the joint has developed (Figs. 32 and 33). In the same way, if the angle of anteversion has been inadequately corrected, or if the hip remains unstable, the anteversion will recur. A child aged two years was treated for a congenital dislocation year. Some time after anteversion still was was unsatisfactory, carried out. and At the with she manipulation had been free A rotation and immobilisation it was found that the in the frog position hip was subluxating,

for

one

and hip

that was

excessive.

osteotomy

of 90 degrees

was

carried

out.

The

three years later a further lateral age of eighteen years the hip, which

rotation osteotomy of 90 degrees was dislocated, was causing pain,

and a Charnley central dislocation stabilisation was carried out. In order to do this it was found necessary to perform a lateral rotation osteotomy of 90 degrees. Thus this girls femur had been rotated by osteotomies through 270 degrees in one direction, and finally lay in the neutral position. In our series it is not uncommon to find that after rotation osteotomy there is some
excessive lateral rotation for a while, but

that

this

progressively

diminishes

and

medial

rotation

correspondingly increases. It is, therefore, seem to be necessary on purely theoretical

wise to produce more lateral rotation than might considerations, and we have never regretted doing so. DISCUSSION

It is impossible the hip with even though

to compare

the

results

of one

series

of treated

congenital

dislocations

of

another because of the remarkable the methods used may have been

variation similar.

in results recorded in the literature, Many authors have commented on

this feature, and Hass summarised it well thus: In a collective German review begun by Deutschlander and continued by Reiner, including thousands of cases, the percentage of cures reported by various surgeons in unilateral dislocations varies from 8 per cent to 78 per cent, and in bilateral dislocations from nil to 75 per cent. This speaks for itself, but there must be some reason other than over-optimism or over-pessimism to account for such remarkable variations. so very much better than the functional result much into account Among these reasons anatomical ones and either the taken result. are, firstly, the fact that therefore very misleading, as the criterion In actual fact functional results are and in some instances

has been in assessing

of success or has been taken too the functional result in the early

stages is of little significance, and in assessing the benefit of treatment it is better to judge from the anatomical result. In our series, apart from minor degrees of limitation in range of movement outside the normal functional range to be found in a few children, there are three children who limp-one because she subsequently developed poliomyelitis and has paralysis below the knee, the hip being stable and developing well; a second child with bilateral dislocation, is negative, who in spite first seen at the age of four has a dip when walking; and of the radiological and a half years, who, although the child whose hips are illustrated has only a slight
THE

the Trendelenburg test in Figures 32 and 33, walking,

BONE AND

appearance

dip
JOURNAL

when
OF

and
JOINT

this
SURGERY

is

THE

DIRECT

APPROACH

TO

CONGENITAL

DISLOCATION

OF

THE

HIP

637

improving
acetabulum, be corrected

steadily.
and by once

In this
the operation.

case
hip has

the

varus

was

produced
if it has not

deliberately
been corrected

to

keep

the

head

in the
it may

developed,

spontaneously,

The
sufficiently show worthless Thirdly, whether much

second
into better

cause
account. results

for

the
than

discrepancy
a series a series the stage in

is that
in which at which to

the

age
the

of the
age at The

patients
diagnosis average were

is not
is low age at

always
diagnosis

taken
to is is,

Clearly, this. instances, or

which

is likely

it is high. the with

in estimating in many it is a subluxation

dislocations inverted between limbus,

encountered-that is with two few important exceptions stages

a full impossible

dislocation

ensured. without
hips in

It is, in fact, often the use of arthrography.

which dislocation was

differentiate

these

In our
complete,

series
and

we have
that the

confined
limbus

ourselves
was turned

to fifty
into

consecutive
the joint was

FIG. Figure 34-A case of proved

34
synovial tuberculosis. Figure 35-The same hip

FIG. six

35 years later. Function is

normal,

but there

is an obvious

subluxation

due to overgrowth

of the head

and

a valgus

neck.

proved,

first

by arthrography

and

then

by exploration.

We

have

only

mentioned

subluxation

for comparison in diagnosis and treatment. Since subluxation is an earlier stage in the condition its treatment is easier, though the final result is still largely dependent on the degree of damage that has been done, and the capacity of the tissues to reconstitute themselves when the mechanics of the joint have been corrected. A feature of almost every published series is that the effectiveness of treatment is estimated solely on the percentage of good results obtained, such as 25 per cent normal or near normal, 15 per
figures

cent
quoted

functionally
for one

satisfactory
series. When

for
we

a while,
consider

and
that

60
we

per
are

cent
treating

failures,
a condition

which produce

are
which,

the
if

left
better
VOL.

untreated, becomes
still,

will
eliminates

not

result
them 1957

in pain and
altogether

for

very

many
well

years,
have more

even which
to

if it does reduces
be said

lameness, or, with

a failure

a tragedy,

a method
might

of treatment

such
for

misfortunes, it than one

39 B,

NO.

4,

NOVEMBER

638

E. W.

SOMERVILLE

AND

J.

C.

SCOTT

FIG.

36

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

THE

DIRECT

APPROACH

TO

CONGENITAL

DISLOCATION

OF

THE

HIP

639

FIG.

Twenty-four
described.
VOL.

hips,
The NO.

in which

a complete
are

dislocation

36 was present

in the

first
time

place,
varies

treated
from

by the
seven and

method
a half

illustrations

in chronological years

order, and the follow-up to four and a half years.

39 B,

4,

NOVEMBER

1957

640 a slightly we have

E. W.

SOMERVILLE

AND

J. C.

SCOTT

higher percentage of good results but no child, other than the three mentioned all the valgus

a higher (one

percentage of failures. because of poliomyelitis),

In our series who limps. in of

This does not mean that we consider which we consider some degreeofanatomical the femoral head or from increasing

hips to be satisfactory. instability to be present, This overgrowth

There are eleven hips either from overgrowth of the head and valgus

of the neck.

of the neck is by no means confined to this method of treatment ; in fact it seems to occur almost less commonly with this method. The cause is presumably hyperaemia of the capital epiphysis resulting from stimulation of the head in consequence of its being in the acetabulum, and subjected to normal stress for the first time after being inactive so long. It is not confined to congenital Rather produce the whole the dislocation than divide interim (Fig. series 36). but the The may occur, for example, results into good and of the first twenty-four follow-up in synovial tuberculosis bad according to our hips treated, which are (Figs. 34 and own judgment, representative and the 35). we of

results

A feature

of most

methods

is between seven and a half and four of treatment is the length of time for which We have based our method be so altered that full normal without fourteen any form of restraint. though it could weeks,

a half years. hip must be on and taken be

protected after reduction for the concept that the mechanics use of the hip the can be allowed so to adjust reduced of our mechanics

it to become stable. of the joint can at an early of the hip date is about

of treatment movement The time sometimes

to a little uncertainty

less than this. In some as to what would happen,

of our early cases this time was exceeded because and in some other cases delay has occurred from diseases. and relieves or more, consider

unforeseen The the

with

circumstances short period from

ever

such as the development of colds and other infectious of treatment is clearly a tremendous advantage to the child, burden
uncertainty

parents
the

the

of looking
that

present

that

two

comparatively

small

after the child in splints or plaster for a year operation may still be necessary. Most parents operations are a small price to pay as an alternative. CONCLUSIONS

1.
2.

A method
The rationale

of treatment
of the

of the
treatment

congenitally
is considered.

dislocated generally,

hip is described.
and of its individual and of this components, method is is not

3. The described.

subsequent

development

of

the

hip

4. Comparison between the results of other methods attempted for reasons stated. 5. The advantages of a shortened period of splintage 6. The state of a follow-up
We wish to thank

of treatment are discussed.

of fifty period
our

completely of from
who

dislocated hips treated three to seven and a half

by sending us their patients

consecutively years.
have helped

is described

at the

end

colleagues

in the

carrying

out

of this

work.

REFERENCES HAss, Scorr, 35-B,

J. (1951):
372.

Congenital J. C. (1953): Frame

E. W. (l953a):

Dislocation of the Hip. Springfield, Reduction in Congenital Dislocation Open Reduction in Congenital of Congenital Alignment
Anatomy

Illinois:

Charles

C. Thomas.

of the Hip.

Journal

of Bone and Joint Surgery, Journal Journal of Bone and Joint of Bone and Joint 39-B,
Journal

SOMERVILLE,

Dislocation Dislocation

of the Hip. of the

Hip.

Surgery,
SOMERVILLE,

35-B,
35-B,

363.

E. W. (l953b): Development 568. SOMERVILLE,E. W. (1957); Persistent Foetal TRUETA, J. (1957): The Normal Vascular Bone and Joint Surgery, 39-B, 358. Surgery,

of the Hip.
of the Human

Journal
Femoral

of Bone and Joint Surgery,

Head during Growth.

106.
of

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY