Congenital Dysplasia and Dislocation of the Hip in Children and Adults

558 Pages·1987·25.75 MB·English

by  Professor Dr. Dietrich Tönnis (auth.)

Dietrich T6nnis
Congenital Dysplasia
and
Dislocation of the Hip
in Children and Adults
With Collaboration of Helmut Legal and Reinhard Graf
Translated by Terry C. Telger
With 389 Figures in 952 Separate Illustrations
Springer-Verlag
Berlin Heidelberg New York
London Paris Tokyo
Autor
Professor Dr. Dietrich Tonnis
Direktor der orthopadischen Klinik
Stadtische Kliniken Dortmund
Beurhausstrasse 40, 4600 Dortmund, FRG
Collaborators
Professor Dr. Helmut Legal
Orthopadische U niversiHitsklinik
Rathsberger Strasse 57, 8520 Erlangen, FRG
Univ.-Doz. Dr. Reinhard Graf
Landessonderkrankenhaus Stolzalpe
8852 Stolzalpe, Austria
Translator
Terry C. Telger
6112 Waco Way WY, Fort Worth, TX 76133, USA
Title of the original German edition:
Die angeborene Huftdysplasie und Huftluxation
im Kindes-und Erwachsenenalter
© Springer-Verlag Berlin Heidelberg 1984
ISBN 3-540-13015-2/0-387-13015-2
ISBN-13: 978-3-642-71040-7 e-ISBN-13: 978-3-642-71038-4
001: 10.1007/978-3-642-71038-4
Library of Congress Cataloging-in-Publication Data. Tonnis, D. (Dietrich)
Congenital dysplasia and dislocation of the hip in children and adults. Translation of:
Die angeborene Hiiftdysplasie und Hiiftluxation im Kindes-und Erwachsenenalter.
Includes bibliographies and index. 1. Hip joint-Dislocation, Congenital. I. Legal,
Helmut. II. Graf, Reinhard, 1946-. III. Title. [DNLM: 1. Hip Dislocation, Congenital.
WE 860T666aj RD 772. T6213 1987 617'.376 86-15582
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© Springer-Verlag Berlin Heidelberg 1987
Sotlcover reprint of the hardcover I st edition 1987
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2124/3140-543210
Historical Dedication
This book is dedicated to a man who, more than a century ago, correct
ly described the etiology of congenital hip dislocation1 and advocated
an approach to neonatal diagnosis and treatment similar to that prac
ticed today:
Wilhelm Roser (1817 -1888)
In 1879 he wrote the following lines:
"Fifteen years ago I suggested the idea that congenital dislocation of
the hip may result from an abnormal adducted position of the leg dur
ing fetal life, a crowding of the fetus in a uterus that contains a scant
volume of amniotic fluid. I based this belief on observations in chil
dren whose flail hips could be dislocated by adduction of the leg and
then reduced again by abduction. At that time I asked my obstetric col
leagues to consider this mechanism and to test my theory clinically.
There has been no response to this request. Neither is there any appar
ent notice of my theory in the literature, even though it appears to rest
upon sound anatomical and mechanical concepts, and so for the pre
sent I remain its sole possessor. Nevertheless, I believe I am justified in
commending it once again to the attention of my colleagues, as I re
view the basis of the theory and offer new evidence on its behalf ..."
"And thus I take the liberty of asking my surgical colleagues to bring
my theory, forgotten for 15 years, to the attention of the obstetric com
munity so that it may be properly tested and investigated. I do not
solicit agreement with my theory; I ask only that its merits be tested,
and that children no longer be allowed to reach the age of two years
before their hip dislocations are diagnosed."2
Despite this renewed request, Roser's suggestions were forgotten.
Many other theories on the etiology of congenital hip dislocation were
advanced, but no progress was made toward the early diagnosis and
treatment of the condition in newborns. Many children suffered from
poor results and disability because of late diagnosis and treatment,
until finally Ortolani described the "snapping sign" in 1937, and von
Rosen introduced the routine screening of newborns for hip disloca
tion in Sweden in 1957. But even today, congenital hip dislocation is
diagnosed much too late in a large percentage of patients, and so it
seems appropriate to recall Roser's admonitions at the beginning of
this book.
1 Archiv fUr Heilkunde (1984) 5: 543-545.
2 Langenbecks Archiv fUr klinische Chirurgie (1879) 24: 309-313.
Preface to the German Edition
For more than 100 years, congenital dislocation of the hip has been an
area of concern in orthopedics. This publications on the subject are al
most too numerous to count. Yet our knowledge of the basic principles
of congenital hip dislocation and its management is constantly being
expanded by new research. In Germanspeaking countries, Kaiser pub
lished the last comprehensive textbook on congenital hip dislocation
in 1958, and Schlegel followed with a comprehensive handbook in
1961. In the Angloamerican world, Coleman's monograph was pub
lished in 1978, Somerville's in 1982, and Wilkinson's in 1985. In 1982
Tachdjian compiled a volume on congenital hip dislocation that con
tained contributions from 44 authorities.
The purpose of the present book is to provide an overview of our pre
sent state of knowledge of congenital hip dislocation, covering basic
principles, diagnosis, methods of closed and open treatment, and indi
cations. In the process, an attempt is made to trace progress in the field
from its beginnings to the present time.
Many authors describe the diagnosis and treatment of congenital hip
dysplasia and dislocation in terms of specific age groups. We believe it
is more prudent to take an individualized approach based on arthro
graphic findings and the degree of severity of pathologic changes. Less
emphasis is placed here on the management of patients by age
group.
Today congenital dislocation of the hip is an area of interest to ortho
pedists, pediatricians, radiologists, and family practitioners. While
some readers will be content with an introduction, more experienced
colleages will expect more detailed and explicit discussions, and those
active in research will want a survey of the literature. The subject mat
ter of the book has been subdivided accordingly, and separate chapters
are devoted to subjects of interest to pediatricians, radiologists, and or
thopedists concerned with conservative as well as operative treatment
of congenital hip disease. For the researcher, separate chapters have
been written to survey the literature on topics of special interest.
The final chapter of the book presents a series of illustrative cases in
tended to supplement theoretical discussions. In recognition of the
practical difficulties inherent in the interpretation of individual radio
graphs, we address such questions as what is normal, what is patholog
ic, and how therapeutic decisions are made on the basis of specific ra
diographic presentations.
In grouping our subject matter for readers with different areas of inter
est and different levels of expertise, it was inevitable that there would
be a certain amount of repetition from one chapter to the next. But it is
unlikely that such an extensive text will be read from cover to cover.
VIII Preface to the German Edition
On the one hand, this volume covers all current standard methods of
treatment and presents conflicting opinions where appropriate. At the
same time, it contains the features characteristic of a monograph:
Knowledge is critically appraised, personal experience is related, and
personal recommendations are offered together with corroborative
statistical data.
The goal of treatment must be a normal hip joint; this is the standard
by which all results are judged. The decision for or against a particular
treatment method requires a knowledge of the normal and pathologic
hip joint and the way in which it changes over time. This is why we de
vote space to techniques of radiographic measurement and to the nor
mal values of the hip. We also present suggestions for a standardized
evaluation system based on tables of normal values and degrees of de
viation from the norm.
In conclusion, I wish to express deep appreciation to all those who
contributed to the success of this book. First I express thanks to my ac
ademic teachers, Prof. Dr. A. N. Witt and Prof. Dr. H. Mittelmeier, who
introduced me to the field. I thank my coauthor, H. Legal of Erlangen,
for writing the chapter on Biomechanics and providing such a detailed
account of the practical application of biomechanics to hip operations.
I am indebted to Prof. Dr. W. Psaar (Dortmund) and Dr. K. Kalch
schmidt for their assistance in checking the manuscript, and to Mr.
L. Picht of Springer-Verlag for his editorial support. I thank my secre
tary, Mrs. Tiemann, for typing the manuscript and the lengthy bibliog
raphy. The drawings were done by Mr. R. Henkel (Heidelberg), and
the photographs were provided by our clinical photographers, Mrs.
Wirth and Mr. Kuhn. The quality of their work speaks for itself.
I am very grateful to Springer-Verlag for their great courtesy and coop
eration in the production of the book, especially with regard to the
handling of photographic materials.
I extend very special thanks to my wife and children. Without their pa
tience and understanding during the past several years, this book
would not have been possible.
Dortmund, February, 1984 Dietrich Tonnis
Preface to the English Translation
Different languages are trenches that separate peoples and individuals
from one another. A common language creates a bridge for mutual un
derstanding. That is why I am pleased that Springer Verlag decided to
have this book translated into English, so that the work of many Euro
pean authors now can become known in other parts of the world. Eu
ropeans in particular have long been concerned with congenital dys
plasia and dislocation of the hip because of the prevalence of those
conditions on the Continent.
The English edition is the first to include a comprehensive chapter on
the sonographic evaluation of the hip. Dr. R. Graf, who is largely re
sponsible for making sonography of the pediatric hip an established
method of early diagnosis, was kind enough to furnish the chapter,
which Dr. F. J. Lang of our clinic helped supplement with clinical ex
amples. A number of other additions and revisions have been made in
the text and bibliography since the German edition. I am grateful to
the authors for the time and effort they put into their contributions.
I express special thanks to Mr. T. C. Telger of the United States for the
very capable work he did in the translation of this volume.
Finally, I wish to thank the staff of Springer Verlag, who made the
translation possible and enabled this book to be so generously illus
trated.
Dortmund, September 1986 Dietrich Tonnis
Table of Contents
1 Anatomic Aspects ..... 1
1.1 Anatomy of the Hip Joint. 1
1.1.1 The Acetabulum . . . . . . 1
1.1.2 Position of the Acetabulum. 3
1.1.3 The Femoral Head. . . . . 3
1.1.4 The Femoral Neck ..... . 3
1.1.5 Angle of Femoral Torsion . . 4
1.1.6 Femoral Shaft Axis, Mechanical Axis, and Knee Joint
Axis ........................... . 5
1.1.7 Tibial Torsion . . . . . . . . . . . . . . . . . . . . . . 5
1.1.8 The Role of the Acetabular Labrum and Atmospheric
Pressure in Stabilizing the Hip ..... 6
1.1.9 The Capsule and Ligaments of the Hip 6
1.1.10 The Muscles of the Hip .. 7
1.2 Vascular Supply of the Hip 9
1.2.1 Vascular Supply of the Femoral Head and Femoral Neck 9
1.2.2 Vascular Supply of the Acetabulum 10
1.3 Innervation of the Hip Joint .... 12
2 Development ofthe Hip Joint . . . . . . . . . . . . . . .. 13
2.1 Development of the Acetabulum . . . . . . . . . . . . .. 13
2.2 Principles of Pelvic Growth . . . . . . . . . . . . . . . .. 14
2.2.1 External Apposition (Perichondrial and Periosteal). . .. 14
2.2.2 Internal, Proportional Resorption in the Pelvic Aperture. 14
2.2.3 Chondral Growth Principle. . . . . . 14
2.2.4 Details of Growth . . . . . . . . . . . 15
2.3 Development of the Proximal Femur. 16
2.4 Factors Influencing the Growth and Shape
of the Proximal Femur ................... 17
2.4.1 StaticForces ......................... 17
2.4.2 Muscular Forces. . . . . . . . . . . . . . . . . . . . . .. 19
2.5 Shape and Position of the Hip Joint During Development 20
2.6 Growth of the Juvenile Hip Joint as Established from
Planimetric Measurements . . . . . . . . . . . . . . . .. 21
XII Table of Contents
3 Development of the Vascular System of the Hip Joint
and Its Variations with Reference to Ischemia . 23
3.1 Vascular Pattern at Birth ........... 23
3.2 Infantile Phase (from About Four Months to Four Years) 24
3.3 Intermediate Phase from About Four to Seven Years 24
3.4 Preadolescent Phase from 9 to 10 Years 24
3.5 Adolescent Phase . . . . . . . . . 24
3.6 Variations of the Vascular Pattern 24
3.7 Clinical Implications . . . . . . . 25
4 Introduction to the Biomechanics of the Hip ........ 26
(H. Legal)
4.1 General. . . . . . . . . . . . . . . . . . . . . . . . . 26
4.2 Loads and Stresses on the Hip .. . . . . . . . . . . 26
4.3 Current Knowledge on the Biomechanics of the Hip
(Literature Survey). . . 27
4.4 Anatomic Aspects . . . . . . . . . . . 28
4.5 Radiographic Aspects . . . . . . . . . 32
4.6 Principles of Biomechanical Analysis 35
4.7 The Load on the Hip ......... 36
4.7.1 Load Model . . . . . . . . . . . . . . 36
4.7.2 Discussion of Geometric Parameters Used to Determine
the Hip Load . . . . . . . . . . . . . . . . 38
4.7.3 Procedure for Calculating the Hip Load . 40
4.7.4 Remarks on Load Calculations. . . . 41
4.8 The Stress on the Hip . . . . . . . . . . . 41
4.8.1 Model for Calculating Joint Pressure
(Maximum Pressure, Equal Pressure Distribution) 41
4.8.2 Correction of the Pressure Calculation (Position of the
Femoral Head Center C, Acetabular Anteversion) . 44
4.8.3 Calculation of Weight-Bearing Area with Allowance
for the "Mean Inlet Plane" . . . . . . 45
4.8.4 Pressure Distribution
(Linear Pressure Rise, Hooke's Law) . 45
4.9 Explicit Calculation of Load and Stress 46
4.9.1 The Normal Hip. . . . . . . . . . . . . 46
4.9.2 Illustrative Case . . . . . . . . . . . . . 50
4.9.3 Published Reports on Biomechanical Data in the Normal
Hip .............................. 50
4.10 Standard Treatments of Hip Dysplasia in Adults
and Their Biomechanical Efficacy 51
4.10.1 Intertrochanteric Osteotomies 51
4.10.2 Trochanteric Transfer . . . . . . . 53
4.10.3 Pelvic Operations . . . . . . . . . 54
4.11 Questions Relating to the Planning of Operative Tactics 55
4.12 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . 56
Table of Contents XIII
5 Etiology of Congenital Dislocation of the Hip 58
5.1 Older Causation Theories . . . . . . . . . 58
5.2 Anatomic and Racial Predisposition . . . 58
5.3 Prevalence and Geographic Distribution 59
5.4 Sex Incidence and Ratio of Mfected Sides. 59
5.5 Inheritance . . . . . . . . . . . . . . . . . . 61
5.6 Exogenous, Mechanical Causative Factors 62
5.7 The Study of P. M. Dunn ......... . 62
5.8 Further Studies on Mechanical Causative Factors 64
5.9 Hormonal Effects on the Hip Capsule 66
5.10 Capsular and Ligament Laxity 67
5.11 Seasonal Influences . . . . 68
5.12 Summary and Conclusion .. 69
6 Pathologic Anatomy of Congenital Dislocation of the Hip. 71
6.1 Grade 1 Dislocation of the Hip. 71
6.2 Grade 2 Dislocation of the Hip. 71
6.3 Grade 3 Dislocation of the Hip. 73
6.4 Direction of Dislocation and Orientation
of the Acetabulum . . 76
6.5 The Proximal Femur 77
6.5.1 Coxa Valga ..... . 77
6.5.2 Femoral Antetorsion 77
6.5.3 The Femoral Head. . 78
6.6 Vascular Supply in High Dislocations 79
6.7 The Muscles in Congential Dislocation of the Hip 79
7 Nomenclature and Classification of Congenital Hip
Dislocation . . 80
7.1 Nomenclature 80
7.2 Classification of Congenital Hip Dislocation
and Anatomic Findings . . . . . . . . . . . . 80
7.3 Grades of Dislocation According to Howorth and Dunn. 81
7.4 Grades of Dislocation According to the CSHD . . 83
7.5 Graf's Classification by Sonographic Appearance . . .. 83
8 Clinical Examination of the Hip . 84
8.1 History .......... . 84
8.1.1 Newborns and Infants .. . 84
8.1.2 Older Children and Adults 84
8.2 Examination During Walking and Standing . 84
8.2.1 Limp with a Positive Trendelenburg Sign 84
8.2.2 Limp Due to Shortening 85
8.2.3 Limp Due to Pain . . . 85
8.2.4 Limp Due to Ankylosis 85
8.2.5 Examination in Stance 85