Brisetnent fore(' must be entirely condemned (Dollinger). Even in the apparently healed cases we can find infectious foci which can light up the process again. (Formation of an abscess!) By increasing the extension with weights, dependent on the general health, and by changing over at times to casts, we will be able to over come even the most rigid contractures of the soft parts.
In cases in which we have reason to suspect bony or fibrous union, we prefer the subtrochanteric para-articular osteotomy according to Gant or Volkmann to the conservative treatment (Fig. 124). This avoids disturb ing the affected joint and may be done easily and without the least danger.
Should abscesses appear in the course of the disease, these should be punctured under aseptic precautions, emptied and injected with iodoform-glyeerine (or camphor naphthol, according to Calot), but they should never, under any circumstances, be opened widely, because a secondary infection might easily set in during the long-continued treat ment and this would give the disease a very serious aspect.
We may also aspirate the joint itself if we can prove that it contains pus (protrusion of the femoral artery, skiagram). This is best done, according to Calot, a little to the outside of the femoral artery at the typical point for the head. The canula when inserted at this place may easily be pushed down to the bone without any other injury; should it be closed by detritus it could be cleaned with a wire (Kirmisson) or by the injection of iodoform-glycerine.
Other surgical measures during the active stage would only be justified by a vital indication in progressive and profuse suppuration with high fever, but even then we should be satisfied with the most conservative surgery.
Of the resections we could consider in children only the total ones, the extra-articular elimination of the focus together with the joint (Lorenz, Reiner); but we would always hesitate before submitting a child to so serious an operation in the beginning, knowing as we do the splendid results of conservative treatment and being aware also of the fact that even thus we are not certain that we can remove the primary focus in its entirety.
When we can see on the skiagram that the head is loose and that it lies in the acetabulum like a scquestrum, then only may we remove it and thereby shorten the process materially (Fig. 50, Plate 5).
For opening the joint we make use of the bloody operations which we have described for congenital luxation, those devised by Lorenz and by Hofia, and especially that of Kocher, which is best adapted to the anatomical conditions.
Curved incision from behind the trochanter major upwards to its apex and from there following the fibres of the &tams muscle, curved upwards and backwards. Then splitting the fascia, working clown between the fibres of the Outwits maximus, then at the lower edge of the gluticus medius, between the Outwits minions and the pyriformis down to the capsule. The insertions of the tendons of these muscles may be loosened subperiosteally and then the whole joint will be free before our eyes; we now remove only as inu•h as we eonsider neces sary to insure prompt healing. In progressive cases we cannot con sider a radical cleaning out of the joint, because the resection of the head would have to be followed by a more or less extensive resection of the pelvis.
The mortality of resection is always large, perhaps because we use this only as the last resort in desperate cases.
(e) Tuberculosis of the Sacro-iliar Synrhondrosis (Sarro-iliac Disease, Sarroroxitis) This is a seat of the infection which we have observed only rareiy.
find the same pictures of destruction and casea tion; abscesses form as a rule and these frequently arc the first indication of the disease.
After breaking through the capsule the pus appears at the surface through several openings in the region of the sacrum, or it collects at the anterior surface of the sacrum and follows the psoas muscle, filling the iliac fossa, to appear as a psoas abscess in the groin. In rarer cases it will follow the traction of the pelvio-trochanterie muscles, leave the pelvis through the foramen isehiadicum and appear near the trochante• major. Occasionally the pus will follow the sacrum and coccyx and appear as periproctitic abscess, bulging the rectum forwards.