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 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, reuse of illustrations, broadcasting, reproduction by photocopying machine or similar means, and storage in data banks. Under § 54 of the German Copyright Law where copies are made for other than private use a fee is payable to 'Verwertungsgesellschaft Wort', Munich. © Springer-Verlag Berlin Heidelberg 1987 Sotlcover reprint of the hardcover I st edition 1987 The use of registered names, trademarks, etc. in the 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. Product Liability. The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. 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