These methods of operation have been developed by the author during his experience of the past ten years, beginning at a time when, as far as he knows, he had no outside help except the suggestion of Dr. Albee that a wedge from the tibia might be used to hold down and strengthen the upper portion of the acetabulum. To this surgeon modern bone plastic surgery owes largely its inspiration.
Stability of the hip is assured in all cases. Freedom from pain is also almost constant. Mobility is always good in type one, usually satisfactory in type two, and quite variable in type three. The author's efforts are still being directed to improvement in the technique of operation and in the after-care to secure better and more uniform function in this last group of cases. He believes that the greater hindrances to motion lie in the soft structures of the joint and about it, rather than in the bone elements. The latter under the influence of Wolff's law are transformed more and more toward the normal, though they may be far removed from this in the beginning.
These operations are designed to relieve a group of patients who are already very seriously disabled or promise to become so as they grow older. An arthrodesis, or ankylosis, of the hip, which is the worst surgical result that may be obtained in these cases is a vast improvement over the preceding condition of the patient, as weakness, tire, and pain are removed. A patient with a stiff hip is able to work hard and to enjoy many pleasures in life. Her most serious handicap may be an inability to lace her shoe. Satisfactory motion, which may be obtained in the great majority of cases, may from this point of view be looked upon as an added blessing. But good motion in the other hip is, of course, essential. The author has been obliged at times to defer operation on the second hip in cases of bilateral dislocation because good motion has not been obtained in the one already operated on. For this reason, if for no other, it is desirable to press our efforts in securing satisfactory mobility in all cases, so that one may be able to guarantee it as well as stability.
The author attempts bloodless reduction on all cases under six years of age. If he is unable to secure it without the use of severe violence he does not hesitate to advise open operation. These cases fall into group one or group two, in which eminently satisfactory results may be secured.
If the hip can be replaced bloodlessly but, because of the shallowness and weakness of the acetabulum, shows a tendency to relapse after six months in plaster as the extremity is gradually brought down to a normal position, open operation is advised. These cases belong in group one. If relapse occurs as late as two or three years after bloodless reduction, open operation should be done as in type one. It seems to the author needless and unwise to subject these patients to many months and even years of plaster treatment when a splendid hip may be secured in three months by open operation.
When open operation is necessary, the earlier it is done the better. The younger the patient, the better the result. Eighteen of the author's cases had had futile bloodless reductions.
The orthopaedic surgeon will add tremendously to his armamentarium, if he will add open methods of reduction to his bloodless method. He will then bring his cures from an average of sixty-five per cent., approximately, up to one hundred per cent. in all patients under six years of age and he will be able to afford some measure of relief to those older cases, which until within recent years were regarded by all as hopeless.
The author has not tried the Lorenz bifurcation operation, as he has believed it sounder surgery to continue his efforts along the lines outlined in this paper.
Experience gained in operations upon congenital dislocation has been of great assistance in cases of pathological dislocation which present much the same features and difficulties as the difficult cases of congenital dislocation.