OPEN REDUCTION IN CONGENITAL DISLOCATION OF THE HIP

There is a wide divergence of opinion on the merits and demerits of open reduction of the congenitally dislocated hip. The protagonists of conservative treatment are at least as dogmatic as those in favour of open reduction and, in spite of the favourable results described by the latter, open reduction has never met with widespread enthusiasm and is usually reserved for those hips in which closed reduction has failed. The reasons for this seem to be threefold : firstly, there is a belief that open reduction damages the hip joint and causes growth disturbance in the upper femoral epiphysis and possibly stiffness as well ; secondly, it is a big and, in a small child, dangerous operation ; and thirdly, the cause of obstruction is not always obvious even when the hip is open. These objections will be dealt with later but some comment must be made on them now. In the small series of twenty-three cases described here in which open reduction has been carried out, there has been no instance of growth change in the epiphysis. The longest time since operation is three years, and the shortest time is six months. The operation to be described is simple and quick, being unassociated with shock, and there has never been any necessity for a transfusion or other form of resuscitation. The third argument is perhaps more valid according to reports in the literature. Leveuf (1948) described constriction of the capsule, adherence of the capsule to the head below or to the floor of the acetabulum, hypertrophy of ligamentum teres, fibro-fatty tissue, inverted limbus, among others as being the causes of obstruction, and many other authors have described similar findings. Doubt about the actual cause of obstruction has often led to an unnecessarily wide exposure of the joint to determine which factor is responsible in any particular instance. On the other hand there seems to be little doubt that in the vast majority of congenitally dislocated hips there is some interposition of soft tissues at least in the early stages of the reduction whatever method is used to bring about the reduction. Opinions differ as to whether the soft tissue atrophies or is pushed out of the way by pressure of the head in the acetabulum, but the results of conservative treatment show that in about one-third of the hips treated the result is reasonably good, while in two-thirds it is unreasonably bad. This suggests that, although the obstruction is removed one way or another in a certain number of hips, yet in many, perhaps most, either it is incompletely removed or the damage done in the process leaves a permanently defective joint. The value of gradual reduction on the “Wingfleld” frame, and its advantages in reducing the incidence of osteochondrosis have been described by Scott,* but there seem still to be some missing factors which account for the remainder of indifferent results. This investigation has been carried out as a natural continuation of that work in an attempt to determine the nature of the obstruction that prevents immediate and complete reduction, and to devise an operation by which it can be removed with the least possible trauma.