Reprinted from University Medical Magazine, March, 1894. 
WHAT SHALL WE DO FOR HIP-JOINT DISEASE? 
By A. M. Phelps, M.D., 
New York, 
Professor of Orthopedic Surgery in the University of New York, the New York Post-Graduate 
School and Hospital; Professor of Surgery in the University of Vermont; President 
of the American Orthopedic Association, etc. 
It is not a difficult thing to say what should be done in any given 
case, provided we decide on general and valid principles. Usually the 
cases which come to the clinic at the Post-Graduate and the University 
Dispensary are managed in the following manner : (i) We aim to over- 
come the existing deformity, and (2) we open abscesses ; and, when this 
has been done, the finger is used to carefully explore the joint. If dead 
bone is found, it is removed; if the head and neck of the bone have 
been destroyed, a complete excision is performed. Patients coming to 
us with a marked degree of angular deformity are placed in bed with 
the body and "well ' ' leg fixed in plaster of Paris, and with traction in the 
line of the deformity, and at right angles to that line, or, in other words, 
traction in the line of the axis of the neck; and day by day the limb 
is dropped until it is parallel to its fellow, or the deformity is entirely 
overcome. After this, suitable splints are adjusted, and the patient 
allowed to go on crutches and exercise in the open air. 
The splints which we use in the care of this class of cases are 
known as Phelps's lateral traction splints. They are so constructed as 
to fix the patient exactly as he was fixed in bed, and to apply traction 
in the same manner; that is, in the line of the axis of the neck. 
Fig. 1 conveys a correct idea of the splint. The steel ring catch- 
ing the tuberosity acts as a point for counter-extension. The limb is 
well buckled down into the splint by means of straps on the foot-piece, 
which are buckled into adhesive plasters attached to the limb. Lateral 
traction is made by buckling the limb firmly to the lateral traction- 
bar a. A cheaper splint is illustrated in Figs. 2 and 3, which answers 
the same purpose, lateral traction being made by lashing the limb firmly 2 
A. M. Phelps. 
to the bar a. It is much cheaper than the splint shown in Fig. i, and is 
used almost exclusively in our dispensary' work. 
The patients are now placed upon crutches, and are never allowed 
to step upon the splint until they are cured. (See Fig. 4.) This varies 
in time from one year to three or four. It will be observed that these 
splints, extending from below the heel to the axilla, prevent the limb 
from assuming an angle with the body. This is the reason why none of 
our cases recover with angular deformity. It will also be seen that, 
seizing the pelvis, as it does, with the pelvic band and steel ring, it fixes 
the joint, and this fixation is continued without motion from the com- 
mencement of the treatment until the patient is cured. This is the reason 
Fig. i. 
Fig. 2. 
why our patients never recover with bony ankylosis. All degrees of limit 
of motion are seen in these cases,-varying from never less than io° up 
to perfect motion. The reason for this is that, holding the joint at perfect 
rest, Nature goes on in her effort at cure uninterrupted by the trauma of 
motion. The constant stepping on a splint, as is allowed in the splints 
used by Sayre, Taylor, and others, produces a constant trauma of the 
joint; new material is thrown out, and, when finally the patient is 
cured, the contraction of this new material produces the limit of 
motion and ankylosis seen almost always in cases treated by the long 
traction splint. The splint extending below the foot has a decided What Shall we do for Hip-joint Disease? 
3 
advantage over Thomas' s-splint, because that splint stops at the calf of the 
leg. If the patient gets a slip, he must necessarily step on the foot, and this 
drives the head of the bone into the socket, producing a trauma; and, then, 
small children will step on their limb. The splint stopping at the calf does 
not protect the joint. Traction is not employed in the Thomas splint. 
Lateral traction is absolutely necessary to overcome the traction of the 
glutei muscles and the adductor groups. These muscles act in a line 
corresponding to the axis of the neck of the bone, and not of the shaft; 
Fig. 3. 
Fig. 4. 
Fig. 5. 
and to relieve intra-articular pressure, it is necessary that lateral traction 
should be applied, or traction in the line of the axis of the neck, as is done 
in the splint illustrated. 
Fig. 5 is my double hip-joint splint: it is simply two splints, like 
those shown in Fig. 2, joined together in the centre. 
Now, in the use of these splints, as I have already said, I never see 
bony ankylosis; no case recovers with angular deformity; and it is the A. M. Phelps. 
4 
exception to see a case with less than 10° of motion. That shortening of 
half an inch, which is almost always seen in cases treated by other splints, 
which shortening is due to intra-articular pressure, the result of muscular 
action, I do not see in my cases. The shortening in my cases is only 
produced by extensive disease of the bone,-the result of pathological 
changes, and not of pressure. 
If abscesses develop, they are immediately operated upon, and 
certainly no diagnostician can determine exactly the extent and 
location of the disease in the suppurating joint without intelligently 
exploring it with his finger; hence, when these abscesses have been once 
opened, the finger is introduced. Very frequently the head of the bone is 
found separated from the neck, the acetabulum perforated, with masses 
of diseased bone lying as sequestra in the cavity. These, of course, 
are removed, or a complete excision performed. The wound is packed 
and allowed to heal by granulation. Within four weeks after these 
operations are performed, and frequently much sooner, the patient is 
allowed to be up and about, on crutches, with the splint illustrated. 
The fear of opening abscesses, and the exaggerated reports of the un- 
favorable results from so doing, are all mythological. I would as soon 
cut open a healthy joint as I would look at one's tonsils, so far as danger 
to either is concerned. If suppuration is going on within the joint, and 
there is also an open sinus, it is no longer a joint, but a compound 
suppurating fracture. It is, in my opinion, extremely bad practice to 
allow these abscesses to burrow through the tissues and find their exit 
on different parts of the surface of the body. It is just as bad practice 
to curette and scrape sinuses with dead bone which cannot be removed, 
at the bottom of them, for, unless you can remove the bone, you only leave 
an abraded surface, which simply facilitates absorption. By early opera- 
tion on abscesses, life is frequently saved, and, inasmuch as cases in which 
abscesses occur do so much better after the abscesses have been properly 
treated, I believe that we should incise all abscesses. 
It is taught that the treatment of these abscesses, by allowing nature 
to take care of them, is conservative. This may be conservative, but, to 
my mind, it is extremely unscientific. Conservative surgery is doing the 
right thing at the wrong time ; scientific surgery is doing the right thing 
at the right time. The terms conservative surgery, alteratives in medicine, 
or scrofula are the breast-work behind which ignorance skulks. To illus- 
trate : A patient, fourteen years of age, came to the clinic from the 
New York Orthopedic Dispensary. She had been growing rapidly 
worse, notwithstanding she had been wearing the long-traction splint 
for a long time. When first seen, she had an abscess; the leg was 
flexed 450 or more; there was the characteristic deformity of the 
third stage of hip-joint disease, with one and a half inches of shorten- What Shall we do for Hip-joint Disease ? 
5 
ing. We adopted our almost invariable plan, and operated upon the 
abscess. On opening into the joint, we found extensive destruction 
of the bone, and the joint filled with pus, which was burrowing in 
all directions about the thigh. There were also pieces of bone loose 
in the acetabulum. These fragments and all disease were removed, 
and the wound packed daily during the healing process. She has 
worn the lateral-traction fixation splint, extending from below the 
foot to the axilla. This splint was worn for four years, or until 
about four weeks ago, when the thoracic band was cut off. There is 
one and one-half inches shortening ; in other words, exactly the same 
as when she came to us. Abduction and flexion have disappeared, 
and, although the joint was not moved for four years, she has good motion 
in it. The limb can be flexed to 15°, abducted and adducted 8° or io°, 
and these last motions are increasing. Hence, the fallacy of prolonged 
rest of a joint producing ankylosis, as taiight by Sayre and others, should 
be a thing of the past. Fixation does not cause ankylosis, as they teach. 
Fixation has no more to do with ankylosis as a cause, than plug-hats 
and suspenders have to do with civilization. I am sure this patient is 
cured, and I will tell you why, because, after removing all apparatus, the 
limit of motion has been steadily increasing. 
It is urged that the patients wearing the lateral-traction fixation 
splint cannot sit down. They sit on chairs as comfortably as with the 
long-traction or any other hip splint. It is further stated that the 
lateral traction applied produces intra-articular pressure by pressing 
upon the adductor group of muscles. 
Ridlon1 offers this criticism, and exhibits diagrams showing press- 
ure made in the " upper third" of the thigh : Lateral traction is made 
in the lower third of the thigh below the attachment of the adductor group ; 
hence no pressure is made on that group, and the argument must come to 
naught, being based on a false assumption. 
1 International Medical Clinic, 1893.