POSTGRAD. MED. J. (I96I), 37, 201

A REASSESSMENT OF THE SURGICALTREATMENT OF SEVERE CONTRACTURES

OF THE HIP JOINTSFOLLOWING POLIOMYELITIS

With a Review of Cases Treated at the Nuffield OrthopaFdic Centre, Oxford, 1953 to I960G. CARRERI, M.D.

Nuffield Orthopadic Centre, Oxford*

THE orthopledic problems of poliomyelitis havealready begun to disappear as the incidence of theinfection decreases following widespread use ofvaccination. Far from losing interest in thesurgical management of the deformities resultingfrom poliomyelitis, it seems to us that it is time tore-examine some of the case material which in thepast has presented particular difficulties intreatment.

In this country severely affected cases are stillseen, most of them referred from distant parts ofthe world. Unless the vast experience of a previousgeneration of orthop2dic surgeons with polio-myelitis problems is constantly re-examined, thenthere exists the danger that the small group ofpatients referred to above will come to be neg-lected. With this in mind, we have undertaken areview of the cases of flexion contractures of thehips in poliomyelitis.

Flexion deformities of the hip joints followingpoliomyelitis are not common. However, thesedeformities occur with varying degrees of severityand this paper is concerned with those caseswhich require surgical operations for theircorrection.

In a severe case, with irreducible flexion con-tractures of the hips, there may be associateddeformities. Flexed knock knees, external torsionof the tibix and valgus deformities of the feetcontribute to the enormous difficulties that thesepatients have in walking. In addition, obliquityof the pelvis and an exaggerated lumbar lordosisare other clinical features of note (Fig. i). Notonly do these patients have great difficulty inwalking, because of their inability to stand upstraight, but they may also be troubled with severelow back pain.The mechanisms responsible for the develop-

ment of this deformity will be discussed brieflyand the previously applied methods of treatment

*Present address: Centro Traumatologico Ortopedico,Via San Nemesio 21, Rome.

. . . - .5 ..x .-

FIG. i.-Drawing of the human skeleton seen from theside, showing 450 flexion deformity at the hipjoints, compensated partially by an exaggeration ofthe normal lumbar lordosis.

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POSTGRADUATE MEDICAL JOURNAL

will be reviewed. However, this paper is primarilyconcerned with a critical analysis of those cases offlexion contracture of the hips which have beentreated surgically at the Nuffield OrthopaedicCentre over the last 7 years.The causes of this deformity were studied in

great detail in the period from I920 to I930 andmany interesting papers were produced duringthis time, especially those by Yount (1926),Forbes (I928) and Fitchet (1933) and morerecently by Irwin (1949), Barr (1950), Merled'Aubigne and Scholder (I956).

Flexion contractures of the hips are very likelyto develop in severely paralysed cases who areallowed to sit in chairs for prolonged periods-orwho are nursed in bed with the hips kept con-stantly flexed. This tendency is even moremarked where there is also muscular imbalance inopposing groups.

In severe deformities of this type, the con-tracture involves all the soft tissues from the skinto the tendons, ligaments, joint capsule and evento the perivascular and perineural tissues.The development of the flexion contracture

depends on the slow progressive fibrous meta-plasia of the interstitial tissues involving also theparalysed muscular fibres leading to shorteningand contracture of the intermuscular fascix andfascia lata. The tensor fascia lata plays a specialrole in the development of this deformity.Whitman (1923) noted that this muscle was

rarely paralysed following poliomyelitis. Thishas been confirmed by Sharrard (1955) who, in hisinvestigation of the distribution of poliomyelitisparalysis among the muscles of the lower limbs,found that out of 962 severely paralysed cases,only 38 had paralysis of the tensor fascia lata.The tensor fascia lata arises from the anterior

5 centimetres of the outer lip of the iliac crest,from the outer surface of the anterior iliac spineand part of the outer border of the notch below it,between the gluteus medius and sartorius, andfrom the deep surface of the fascia lata. It isinserted between two layers of the ilio-tibial tractof the fascia lata about the junction of the middlewith the upper one-third of the thigh. Distally,the fascia lata fuses with the fascia femoris andforms a stout band which is inserted into atubercle on the antero-lateral aspect of the lateraltibial condyle. This muscle, therefore, is a flexorof the hip joint and it assists in extension of theknee and also in abduction and in medial rotationof the thigh. Further, it flexes the pelvis towardsthe same side. The tensor fascia lata acts in syner-gism with the gluteus maximus in abduction ofthe hip. (The gluteus maximus is not only anextensor of the thigh but also a tensor of thefascia lata.)

Having examined the various actions of thismuscle in the movements of the hip joint, it isclear that it can play an important role in thedevelopment of contractures at this joint (Fig. 2).

Occasionally, contracture of the tensor fascialata, associated with fibrosis and shortening ofadjacent intermuscular fascial septa, constitutesthe major deforming factor at the hip joint. Insuch cases, correction of the deformity may beachieved by conservative means or by minoroperations dividing only the tensor fascia lata andthe contracted fascia as reported by Lange (1924),Yount (1926), Irwin (I949) and Fitchet (I933).Recently, Allbrook and Lunn (I960) have reportedthe results of multiple transverse incisions in the

FIG. z.-Clinical photograph showing the compensatorylumbar lordosis which accompanies flexion defor-mities at the hip joints.

April I96 I202

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April I96I CARRERI: Contractures of the Hip Joints Following Poliomnyelitis 203

ilio-tibial tract for correction of severe paralytichip contractures.From a surgical point of view, the correction of

flexion contractures of the hips becomes progres-sively more difficult when the pathological pro-cesses involve, in addition, structures other thanthe tensor fascia lata and the ilio-tibial tract.Simple procedures like those mentioned above arethen no longer effective.Legg (I923) recommended transposition of the

tensor fascia lata posteriorly so that it could act asan abductor but not as a flexor of the hip joint.

Mezzari (1946) divided the contracted struc-tures attached to the anterior superior iliac spine.Then he passed the detached muscles through asubcutaneous tunnel to anchor them to the pubicspine. This operation corrected the flexionabduction and external rotation deformities at thehip joint.

Barr (I950) described a rather extensive pro-cedure for the transplanting of the distal end of theerector spine muscle into the detached ilio-tibialband which is brought under the vastus lateralisand passed deep to the gluteal aponeurosis. Addedto this, other contracted soft tissues in front of thehip joint are divided. In this way the flexion con-

tracture of the hip is corrected and along with it,the associated lumbar lordosis.

Other authors have recommended even moreradical procedures. Hallock (1950) reported theuse of arthrodesis of the hip joint. Campbell(1923) reported successful results following trans-position of the anterior superior iliac spine asso-ciated with release of the hip abductors and therectus femoris muscle.However, one of the most useful operations that

has been devised for the surgical treatment of thiscondition was described by Soutter in I926. Hewrote: 'When the cases are of long standing, theymay not yield to tenotomies of the tendons and ofthe tensor fascia femoris, and myotomies arenecessary'. In this operation the fascia lata isincised transversely from the level of the anteriorsuperior iliac spine, anteriorly, to the greatertrochanter posteriorly. Then, by means of anosteotome, the attached muscles and fascia areremoved from the anterior superior spine sub-periosteally on the inside, on the outside andbelow; they are pushed downwards. With thismethod, the muscles are not cut across. Theirperiosteal attachment is simply moved downwards.The method of surgical treatment to be

TABLE I

A SUMMARY OF THE FINDINGS IN 13 Hips

t Date of OnsetCases of Degree of Flexion Deformity Date of Hip Post-operative Results Assessed

Poliomyelitis of Hips Operation in June, I960

H.F.N. July I950 R. hip 300 flexion April 1953 The patient walks satisfactorily.L. hip IO0 flexion Bilateral No lordosis. Left hip full

extension. Right 5O flexion.

A.K.F. Nov. 1950 L. hip 250 flexion, 200 abduction May 1953 The patient is able to walk a little.Slight lumbar lordosis persists.Hip extension full.

A.F. May 1944 R. hip 400 flexion Feb. 1954 The patient walks well. No lumbarL. hip 4o0 flexion lordosis. Hip extension full.

C.A.P. May 1953 R. hip 400 flexion, abduction I May I955 The patient walks well. Slightlumbar lordosis persists. Hipextension full.

S.D. June 1953 R. hip 300 flexion Dec. 1958 The patient walks well. There is noexcessive lumbar lordosis. Hipextension full.

W.A. Sept. I955 R. hip 350 flexion Feb. 1958 The patient walks satisfactorily.L. hip 250 flexion April 1958 A little lumbar lordosis persists.

R. hip 50 flexion contracture.L. hip extension full.

H.J. June 1957 R. hip 40° flexion, I5° abduction Sept. 1959 The patient walks well. No lumbarL. hip 300 flexion, I00 abduction Dec. 1959 lordosis. Hip extension full.

D.T. Aug. I954 R. hip 450 flexion Feb. I960 The patient walks well withoutL. hip 450 flexion March I960 compensatory lumbar lordosis.

Hip extension full.

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FIG. 3.-Clinical photograph showing the healed skin incisions over both hip joints, and thecorrection of the hip and spine deformities which has been achieved by operation.

described in this paper is based on Soutter'sapproach to the problem, though it differs insome details.

Analysis of ResultsThis paper is based on the examination of

results in i3 hips operated upon in eight cases.The findings in each case are remarkably similar;consequently, only one of these will be presentedin detail. Notes on each case, relevant to hipdeformities, will be found in the accompanyingtable (Table i).

Case Report. D.T., born 2I.6.54.August 1954. Contracted poliomyelitis. He developed

gross muscle weakness in both lower limbs. A chart ofhis muscle power at the time showed strengths rangingfrom o to 2 in the lower limb groups; from 2 to 3 in theabdominal muscles and strengths of 3 in both of thequadratus lumborum muscles.January I958. He had developed flexion contractures

of 450 in both hip joints, with contractures of thetensor fascia lata muscles. He had a very pronouncedcompensatory lumbar lordosis which added greatly tohis difficulties in walking. After observation over thecourse of a year, it became evident that his walking wasdeteriorating.

February I960. Operations for release of the flexioncontractures of the hips.

3.2.60. Left hip operation. The skin incision beganjust below the level of the iliac crest, about two fingersbreadth behind the anterior superior iliac spine; passingforwards it was carried down on to the thigh for about5 inches, along the line between the anterior superiorand anterior inferior iliac spines.The tensor fascia lata muscle and the anterior fibres

of the gluteus medius were incised transversely justbelow the level of the iliac crest. The attachments ofthe sartorius and straight head of the rectus femorismuscles were then disinserted from the ilium. Divisionof these structures alone allowed the hip to extend fully.The wound was closed and a plaster spica applied to theleft leg in full extension.

24.2.60. Right hip operation. The procedure wasidentical with that described above. However, the hip

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April I96I CARRERI: Contractures of the Hip Joints Following Poliomyelitis 205

did not extend fully. The tendon of the ilio-psoasmuscle appeared to be responsible for the remaining100 of flexion contracture. This was not divided becauseof the gross weakness of all the other hip muscles. Theright hip was then included in plaster in extension tomake a double hip spica.

Post-operative care. Both hips were immobilised forsix weeks after the respective dates of operation.

Rehabilitation began with pool-therapy. He wasdischarged walking in calipers just over two monthsafter his second operation.

Result. When seen four months after operation hewas walking well in calipers. The unsightly lumbarlordosis had been corrected. The left hip could befully extended but a io° flexion contracture persistedin the right hip (Fig. 3).

DiscussionContractures of the hip joints occur in a small

group of patients in whom the lower limbs areseverely paralysed following poliomyelitis. Whenflexion deformities are of the order of 40°, it maybecome impossible for the patient to walk, despitethe use of calipers and crutches, if there is anassociated weakness of the lumbar spinal muscles

including, in particular, the quadratus lumborumgroups.Dame Agnes Hunt used to obtain correction of

these deformities by conservative means-usinga hip spica on one side combined with fixedtraction on a Thomas's splint applied to theaffected leg (quoted by Powell in 1953). Thisproven-effective method is simple in principle,but its successful application requires a highdegree of nursing skill.From an examination of the cases treated at this

Centre in the past 7 years, it appears that good,lasting results can be achieved in correcting theprimary contractures and some of the associateddisabling deformities by the use of a simple surgicalprocedure, combined with adequate post-operativecare.When considering the surgical approach to this

condition, it is useful to refer back to the normalanatomy of the hip joint in the child. If oneviews a dissection of this joint from the side(Fig. 4). with the pelvis in the standing position,

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FIG. 4.-A dissection of the hip joint of a child viewedfrom the side. The pelvis is in the anatomicalstanding position. The femoral head is in theacetabulum and the femoral neck is showndivided transversely. The structures on theright of the vertical line drawn on the photographof the specimen are those which may becomeinvolved in the process of contractures at thehip joint. x, Anterior superior iliac spine.2, Sartorius muscle. 3, Tensor fascia latamuscle.4, Gluteal aponeurosis. 5, Gluteus mediusmuscle. 6, Gluteus maximus muscle. 7, Gluteusminimus muscle. 8, Capsule of the hip joint.9, Straight head of the rectus femoris muscle.io, Tendon of the psoas major muscle andfibres of the iliacus muscle. i I, Femoral head.I2, The femoral neck cut transversely.

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206 POSTGRADUATE MEDICAL JOURNAL April I96I

the orientation of the deforming factors that have]been mentioned can be appreciated at once.4.Clearly then, with an exposure such as the one wehave described, it is possible to divide eachresponsible deforming element in turn, down toand including the hip joint capsule itself, until alltight structures have been released, allowing thehip to extend fully.

It is necessary to respect the integrity of theilio-psoas muscle in some of these cases whenthere is marked weakness of the quadratus lum-borum muscle on the same side. In such instancesthe ilio-psoas attachment to the femur must beleft intact, even at the expense of a full correctionof the flexion deformity. Its integrity will be vitalbecause without it the patient will be unable tocarry a caliper when walking.This relatively simple surgical approach com-

pares satisfactorily with the variety of surgicalprocedures that have been reviewed in this paper,many of which appear to us to be too complex.The operation must be followed by an adequateperiod of immobilisation of the hip joints in thecorrected position. Six weeks in a hip spica hasbeen shown to be sufficient. The patient can thenbe taught to walk again within a few weeks,rehabilitation being aided significantly by pooltherapy if this is available.We consider that correct, intensive rehabilita-

tion avoids severe flexion deformity in mostcases, but patients with progressive deformity,despite good treatment, respond best to the type

of management that has been outlined. It assures a

quick and satisfactory result without any tendencyfor the deformity to recur. Most of the casesreported here were able to walk satisfactorilywithin two months of their operation and fromthe point of view of the patient's psychologicalattitude to his disability, the results have beengratifying.

Summaryi. A review is presented of I3 operations based on

Soutter's method for the correction of flexiondeformities of the hip joints following polio-myelitis.

2. The literature dealing with other surgicalmethods is discussed.

3. It is pointed out that conservative measuressuch as those taught by Dame Agnes Huntshould not be forgotten; with the generalshortage of nurses these methods, which aretime-consuming and require a high degree ofskill, are now rarely used.

I should like to thank Professor J. Trueta for hiskindness in encouraging me to write this paper. Iam indebted to the consultant surgeons at the NuffieldOrthopsedic Centre for permitting me to examine their.cases. Mr. H. V. Crock provided me with Fig. 4, aphotograph of a specimen dissected by him, now in themuseum of the Anatomy Department in the Universityof Melbourne.

I have also to thank Miss P. Philpott and Mr. P.Sladen of the photographic department for their help.

REFERENCESALLBROOK, D., and FLETCHER LUNN, H. (I960): Surgical Relief of Severe Paralytic Hip Contracture, Lancet, i, 459.BARR, J. S. (1950): La Deformation de la Hanche d'Origine Poliomyelitique et la Transplantation de la Masse Sacro-

lombaire, J. Amer. med. Ass., I44, 813.CAMPBELL, W. (1923): Transference of the Crest of the Ilium for a Flexion Contracture of the Hip, Sth. med. J. (Bgham,

Ala.), x6, 289.FITCHET, S. M. (1933): Flexion Deformity of the Hip and the Lateral Intramuscular Septum, New Engl. J. Med.,

209, 74-FoRBIES, A. MCKENZIE (1928): The Tensor Fascia Femoris as a Cause of Deformity, J. Bone Jt. Surg., XO, 579.GRAY's ANATOMY (1949): Thirtieth Edition. London: Longmans, Green and Company.HALLOCK, H. (1950): Arthrodesis of the Hip for Instability and Pain in Poliomyelitis, 7. Bnet. Surg., 32A, 904.IRWIN, C. E. (1949): The Iliotibial Band, its Role in Producing Deformity in Poliomyelitis, Ibid., 3zA, I4I.LANGE, F. (1924): Quoted in Z. orthop. Chir., 45, 83.LEGG, A. T. (1923): Transplantation of the Tensor Fascia Femoris in Cases of Weakened Gluteus Maximus, 3. Amer.

med. Ass., 80, 242.(1933): Tensor Fascia Femoris Transplantation in Cases of Weakened Gluteus Medius, New Eng. 3. Med., 209, 6i.

MERLE D'AUBIGNh, R., and SCHOLDER, C. D. (1956): Traitement du Flexion du Genou et de la Hanche chez les Polio-myelitiques, Rev. Chir. Orthop., xlii, 591.

MEZZARI, A. (1946): Sulla Cura dell'auca Flessa Abdotta Poliomielitica, Chir. Organi Mov., xxx, 383.POWELL, M. (1953): Orthoptedic Nursing, Third Edition. Edinburgh: E. & S. Livingstone.SHARRARD, W. J. W. (1955): The Distribution of the Permanent Paralysis in the Lower Limbs in Poliomyelitis, Y. BoneYt. Surg., 37B, 540.SOUTTER, R. (1926): A New Operation for Hip Contracture in Poliomyelitis, Boston med. Soc. Y., 170, 380.WHITMAN, A. (1923): Observations on the Correction of Deformities of Long Standing, ?. Amer. med. Ass., 80, I8.YOUNT, C. C. (I926): The Role of the Tensor Fascia Femoris in Certain Deformities of the Lower Extremities, Y. BoneJt. Surg., 8, 171.

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