Displacement of the Hip in Childhood: Aetiology, Management and Sequelae

207 Pages·1982·9.25 MB·English

by  Edgar W. Somerville MA, FRCS, FRCS(Ed) (auth.)

Edgar W. Somerville
Displacement
of the Hip
in Childhood
Aetiology, Management and Sequelae
With 262 Figures
Springer-Verlag
Berlin Heidelberg New York 1982
Edgar W. Somerville, MA, FRCS, FRCS(Ed)
Emeritus Consultant in Orthopaedics
The Nuffield Orthopaedic Centre
Oxford, England
ISBN-13:978-1-4471-1313-3 e-ISBN-13:978-1-4471-1311-9
DOl: 10.1007/978-1-4471-1311-9
Library of Congress Cataloging in Publication Data
Somerville, Edgar W. (Edgar William), 1913- Displacement of the Hip in Child
hood, Aetiology, Management, and Sequelae. Includes bibliographies and index. 1. Hip
joint-Dislocation. 2. Hip joint-Dislocation, Congenital. 3. Pediatric orthopedia.
I. Title. [DNLM: 1. Hip dislocation-In infancy and childhood. WE 860 S696d]
RD 772.S65 617'.39781-9355
ISBN-13:978-1-4471-1313-3 (U.S.) AACR2
This work is subject to copyright. All rights are reserved, whether the whole or part of
the material is concerned, specifically those of translation, reprinting, re-use of illustra
tions, broadcasting, reproduction by photocopying, machine or similar means, and
storage in data banks. Under § 54 ofthe German Copyright Law, where copies are made
for other than private use a fee is payable to 'Verwertungsgesellschaft Wort', Munich.
© by Springer-Verlag Berlin Heidelberg 1982
Softcover reprint of the hardcover 1st edition 1982
The use of registered names, trademarks, etc. in this publication does not imply, even in
the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
Typeset by Phoenix Photo setting Chatham
2128/3916-543210
I wish to dedicate this book
to my wife Margaret
Contents
Preface................................................ XI
1 Aetiology .............................•............. 1
Pathology ........................................... 1
Cause of Displacement ..••••.•••••.••.••••.••••••. 2
Acetabular Dysplasia ••.•••..•••••••.•••.••.... 2
Capsular Laxity ...•............•....••.•••.••• 2
Position ••.•.••.....•..••......•....••.•.•...• 3
Intrauterine Compression .......••••.•••••••.•. 4
Time of Displacement •.....•.••..•....••...••....• 4
Direction of Displacement ..••.•.••....•.••..•..•.• 4
Posterior •••..•.••..•..•.•..•...•.•.•....•...• 4
Inferior •..•........•..•....••.•.•.••..••••... 5
Anterior ..•..•......•.....••....••.•..•.•.... 6
Mechanism of Displacement ...••.•..•••..••...••.• 8
References .•..•........•••..••.•..••.•.....••.•••.• 11
2 Age 0-9 Months 13
Early Diagnosis .••••...•.•••••••..•••••••.•.••••...• 13
Examination .•••••••••••..••..•.••••••••.••..•••••.• 14
Treatment ..••••••••••••..•.•..••••.•.•.••••.••••••. 16
Complications ••..•..•••.•.•••••••••••...••.••••• 17
Tightness of the Adductor Muscles •••••.•••••••• 17
The Unreduced Hip .•.••.••••••••••..•..•••••• 18
Redisplacement .•.•.•••.••••.••••..••••••••.•• 19
Results of Early Diagnosis and Treatment .••••••••••..• 23
Results of Later Treatment .••....••...•••••••••••••.. 25
References •......•...•....••.••..•.•..•..•.••.••... 27
3 The Secondary Changes .......................•...... 29
Ossification •••••••...••••••••.••.•••.•.•••.••••••••. 29
Soft Tissues ••••••••••••••.•.•..•••••..••••••••••••• 32
Deformity of the Acetabulum •••••••••.•...•..•••••••• 33
VIII . Contents
Upper End of the Femur .••........•.....•..•........ 38
References ........................••..•....•....... 39
4 Nine Months to Three-and-a-HaIfYears ••••••.••••••••• 41
Diagnosis .•....•................................... 41
Treatment.......................................... 41
Reduction ........•.............................. 42
Arthrography •.....•.......................... 44
Subluxation •.•....•.......................... 49
Dislocation ...•.....••.•.•.....•.•.....••..... 50
Stabilisation .•..............................•.... 52
Technique ••...•.•.•.......................•.. 53
Bilateral Dislocations •.•.....•..••...•...........•... 59
The Parents .•.••..•.•••••...•...•...•.............. 60
Medium Long-term Review •...... ;................... 62
Functional Assessment •....................•...... 63
Radiological Assessment .............•............ 65
Acceptable •.•.•.............................. 65
Unacceptable ..•..................•........... 65
Unilateral Displacement .............••........ 65
Bilateral Displacement ........•................ 67
Secondary Operations ............•............ 67
Rotation Osteotomy with Varus................... 67
Progress after Treatment ...............•.......... 67
Sequelae .••....•••.•••.................•........ 68
CE Angle ....•.•............•....•........... 69
Discussion .......•..••......................•....... 77
References ......................................... 78
5 Development of the Hip ••••••.....•..•••••••••••••••.• 79
Normal •.........•.........•....................... 79
Normal Development of the Abnormal Hip .....•.... 79
After Early Treatment ......•.................. 79
After-Treatment 'of Established Displacement ........ 82
Abnormal Development of the Abnormal Hip ....... 89
Causes of Mechanical Failure ............•••....... 99
Abnormalities of Soft Tissues ................... 99
References ••••..•.................................. 120
6 Operations on the Pelvis •••••••.....••••.•.•.•.••.•.•• 121
Innominate Osteotomy (Salter) ....................... 121
The Pemberton Osteotomy ........................... 123
The Chiari Osteotomy ............................... 130
References .....•................................... 137
Contents IX
7 Some Iatrogenic Problems 139
Fracture of the Femur ....................•.......... 139
Extreme Anteversion ..•...................•.... ... . . . 142
8 Perthes' Disease ..................................... 147
Aetiology ..•••••••...•....•....••••....••••••..•••. 147
Pathology ......•..........•.•..•••.••...........••. 150
Subluxation .....•..•.....•....•...........•••..•• 153
Treatment ••..•.......•..•.••........•....••.••..•.. 155
Technique .•...................•....•......•.. 156
Follow-up ..•.••.....••...•........•......•.•....... 157
Factors Affecting the Prognosis ............ • . • . . . . . 157
Age ..................................•.••.•. 157
Extent of Involvement ..........•.......•••.•.. 159
Phase of the Lesion at Diagnosis •..•....•.••.•.• 165
Osteotomy .•...•...........•......•.......... 165
Severity of Symptoms ........•..........•••.••. 167
What Does Have an Effect on the Result? •......•.••..• 170
Comment ......•..•..•....•....•..................• 177
References •.............................•...•...••. 178
9 Persistent Foetal Alignment ........................... 179
Deformity ......•••..............••.•........•.•.•.. 179
Primary .........•................••...•....•.... 179
Secondary ......•..•....•....••....•••..•..••.... 181
Treatment ...........................•......•..•.•.. 181
Ra tionale ..................•.....••••.•••••..... 181
Function ..............•.•.....•.•..••••...... 182
Cosmesis ....•.........•..•....•.........•.... 182
Arthritis ......................•••............ 184
Techniques ............................••....•••• 184
Conservative ....... . . . . . . . . . • . . . . . . . . . . . • . • . • 184
Surgical ...............•... ;.................. 184
References ....................•••..........•....... 186
10 Development of the Upper End of the Femur ............ 187
Aetiology ...........•.........................•.... 187
Treatment ......................•...•................ 193
References ....................................•.... 195
Subject Index ........................................... 197
Preface
This book is concerned with the effect that displacement, whether
minimal or severe, may have on the hip joint. Although it is concerned
with the changes which take place in childhood and during growth,
when they are most common and most severe, it is also to a lesser
extent concerned with the way they will continue or even start long
after growth has ceased.
It is based on a series of about 450 cases of congenital displacement
of the hip treated when the deformity was established, together with
unstable hips drawn from 82000 children whose hips were examined
at the time of birth.
This study was carried out at the Nuffield Orthopaedic Centre in
Oxford. It was started in early 1949 by the author with Mr. J. C. Scott
and continued until mid-1977, since when it has continued in the
capable hands of Mr. J. W. Goodfellow and Mr. M. K. Benson.
The study was started at a time when the generally accepted view
was still that the displacement was part of the primary failure of
development of the acetabulum, which could not adequately contain
the femoral head. Conservative treatment with manipulative reduc
tion followed by a prolonged period of plaster immobilisation was the
method of choice. Few attempts had been made with surgery as a
primary procedure and these had not met with continuing success.
The concept on which this study was based was that the hip which
became displaced was basically normal and that the changes seen in
established displacement were all secondary to the displacement. The
displacement occurred at or about the time of birth as a result of
stresses applied to a temporarily softened capsule. The idea was that if
these secondary changes were corrected definitively by surgery· so that
normal mechanics were restored to the joint in time, the hip should be
able to develop normally while being used in a normal manner. The
method of treatmeQt described in this book has remained the same
throughout apart from two minor changes-division of the transverse
acetabular ligament routinely and the addition of 15° of varus to the
rotation osteotomy-both of which were included during the last 8 or 9
years. It was inevitable, since there was little previous work along these
lines to act as a gnide, that errors would be made. These were usually
the result of a mistaken urge to be more conservative. Operations were
delayed or were inadequate, leading to a number of failures which
necessitated second operations to do what should have been done
properly the first time.
In 1957, with the full co-operation of Dr. Victoria Smallpiece and
Dr. Hugh Ellis, the paediatricians at the Radcliffe Infirmary, routine
XII Preface
examination of the hips of all new-born children at the Oxford hospi
tals was started. This was later extended to the periphery through
lectures in hospitals and instruction to general practitioners and mid
wives.
Also in 1957, the minor displacement so often seen in Perthes'
disease seemed to take on a greater significance. It was found that this
could quite easily be reduced and the reduction maintained by a
suitable high femoral osteotomy, with a surprising degree of remodel
ling taking place over a period of many years. These cases have been
treated surgically ever since, and experience with the technique is
described.
Throughout the whole of these series it has become increasingly
apparent how readily the development of the hip joint can be
influenced, for better or for worse, by alterations in the mechanics.
While this is more obvious in young children, in whom the changes
take place rapidly, it also occurs in any age group, though more slowly
as age advances. It is this theme of the malleability of joints in the
presence of mechanical changes, even though they may be very small,
which is the basis of this book.
Oxford, June 1981 Edgar W. Somerville
Acknowledgements: I would like to acknowledge the great help and
support I received from Mr. J. C. Scott, who played a large part in the
early days and was responsible for the introduction of the frame as a
means of reducing the displacement without trauma, which did more
than anything else to reduce the incidence of osteochondritis.
I wish also to acknowledge the support of all my colleagues both at
the Nuffield Orthopaedic Centre and at the peripheral hospitals, who
did me the honour of referring their patients to me, and that of the
paediatricians at the Radcliffe Infirmary, with whom I had such a
happy and useful relationship in the early diagnosis of hip displace
ment.
For more than 28 years I was fortunate in having with me many
excellent residents, many of whom contributed to this concept, and
particularly Mr. G. P. Mitchell, now of Edinburgh, who was particu
larly involved in the early years and has added so much on his own
since.
The treatment of the cases referred to here cannot be undertaken
without a highly efficient nursing staff. I was indeed fortunate in having
the help first of Sister Martin for 15 years and then of Sister Howard for
13. Without their invaluable help I do not think this work could ever
have been done. At the same time I can never forget the help I received
from the after-care Sisters, the theatre staff, and all those concerned
with the outpatient clinics.
The follow-up of such.a large number of patients, all with visual and
written records maintained up to date all the time, involves a great deal
of work. I was most fortunate in having Mrs. Joan Anderson as my
Secretary for many years. I very much doubt whether such a follow-up
could have been achieved without her tremendous enthusiasm.
I would like to acknowledge the great help I received from all
Acknowledgements XIII
members of the Photographic Department under the care of Mr. Bob
Emmanuel, and I am most grateful to Mr. Anthony Rollason, the surgi
cal artist, for the drawings he did for me (Figs. 5.32, 5.52, and 8.9).
I am most grateful for the help I have received from Mr. J. Crawford
Adams in the writing of this book. I greatly appreciated his construc
tive and helpful advice.
Lastly I would like to thank the patients and their parents, who so
loyally continued to attend the special C.D.H. clinic, often at great
inconvenience to themselves, often long after they could see any good
reason for doing so; in doing so they made such a long follow-up a
practical possibility.
A great deal of what appears in this book has been previously
recorded in papers to journals, chiefly the Journal of Bone and Joint
Surgery (British edition), and I am grateful to the Editor for permis
sion to reproduce a number of the illustrations. I am also grateful to the
Editors of the Proceedings of the Royal Society of Medicine and the
Israeli Journal ofS urgery for permission to reproduce illustrations and
tables which have appeared in these journals, and to the Editor of
Acta Orthopaedica Belgica for permission to include illustrations in
the section on Perthes' disease which originally appeared in his
symposium.