A STUDY OF 
SHORTENING OF THE 
TIBIA AND FEMUR 
IN FIFTY GASES OF TUBERCULOUS 
DISEASE OF THE HIP JOINT. 
BT 
RUSSELL A. HIBBS, M.D., 
Surgeon to the New York Orthopaedic Hospital 
Fellow of the New York Academy of Medicine 
REPRINTED FROM THE 
Ncto Iforfe J&etucal 
for December 16, 1899. Reprinted from the New Yorlc Medical Journal 
.JozJOecember 16, 1899. 
A STUDY OF 
SHORTENING OF THE TIBIA AND FEMUR 
IN FIFTY CASES OF 
TUBERCULOUS DISEASE OF THE HIF JOINT.* 
SURGEON TO THE NEW YORK ORTHOPEDIC HOSPITAL ; 
FELLOW OF THE NEW YORK ACADEMY OF MEDICINE. 
BUSSELL A. HIBBS, M. D., 
In studying the question of the causes of shortening 
of the limb in connection with tuberculous disease at the 
hip, from the writings upon this subject, one receives 
the impression that the principal cause is considered to 
be the destruction of bone. 
This is probably due to the fact that suppuration, a 
conspicuous evidence of the destruction of tissue, occurs 
so frequently, which, with the shortening of the tibia 
obscured by the usual method of measuring the limb 
from the anterior superior spine of the ilium to the in- 
ternal malleolus, suggests that the femur is chiefly 
affected and that bone is destroyed. It does not follow 
necessarily, however, that suppuration is evidence of the 
destruction of bone, as in many eases in which it is pro- 
fuse the destruction of hone is slight, while in others 
* Read by invitation before the American Orthopaedic Association at 
its thirteenth annual meeting, New York, June 2, 1899. 
Copyright, 1899, by D. Appleton and Company. 2 
SHORTENING OF THE TIBIA AND FEMUR. 
that have no suppuration it is considerable. Of one 
hundred and six cases of hip-joint disease reported by 
the writer, the greatest amount of shortening was found, 
as a rule, in those of the non-suppurative variety (New 
York Medical Journal, November 5, 1898). The im- 
portance of recognizing the amount of shortening of the 
tibia is obvious, since it, in not being due to the destruc- 
tion of tissue, would serve to indicate to what extent 
shortening was due to other causes. 
For the purposes of this discussion it would seem to 
simplify the matter to consider the causes of short- 
ening of two varieties: First, the direct, that due to 
the destruction of tissue; second, the indirect, that 
due to a trophoneurotic affection which causes diminu- 
tion in thickness as well as length of the hones and 
the interference with the growth of the limb by the 
impairment of function. The first of these causes 
would be effective only while the inflammatory process 
was active, and the same would probably be true of the 
second, so far as the trophoneurotic disturbances were 
concerned; but in the matter of interference with 
growth from impairment of function, this would con- 
tinue effective so long as growth was possible and in 
proportion to the extent of such impairment, which 
will he greater or less, depending upon many considera- 
tions which it is not my purpose to discuss here, though 
in most cases there will result some impairment of 
function, as you will have observed. The fact that im- 
pairment of function and interference with growth 
incident to it will continue until growth has been 
attained renders the consideration of this cause in 
cases that have not attained their growth of less value, 
but the difficulties in reporting a large number of cases SHORTENING OF THE TIBIA AND FEMUR. 
3 
that have attained their growth is obvious. The dis- 
placement of the head of the femnr would have an im- 
portant bearing upon the amount of shortening, but 
not being pertinent to this discussion it will not he 
considered, and no case has been included in this report 
in which it could be detected. 
The fifty cases studied were observed in the New 
York Orthopaedic Dispensary and Hospital, and are 
arranged in the accompanying table. Their treatment 
was by the traction method as applied by the long trac- 
tion hip splint, and the greater part of the time as dis- 
pensary patients. 
The measurement of the femnr was taken from the 
anterior superior spine of the ilium to the line of articu- 
lation between the femur and the tibia on the inner side 
of the knee joint, and the tibia from this point to the 
internal malleolus. This I believe to be a more accurate 
method of measuring these bones than to use the tuber- 
cle of the tibia as a fixed point, though this also was 
done in most instances. I am indebted to Dr. E. J. 
Parish, the assistant resident surgeon of the hospital, 
for assisting me in measuring most of these cases. 
In thirty-three cases, or sixty-six per cent., there was 
shortening of both the tibia and femur. In one the dis- 
ease had existed less than one year, and there was a quar- 
ter of an inch shortening of the tibia and three quarters 
of an inch shortening of the femur. In eleven cases the 
disease had existed from two to four years, and the 
average shortening of the tibia was .23 of an inch; of 
the femur, .43 of an inch. In two of the latter the 
shortening of the tibia was greater than that of the 
femur, in two it was equal, and in the remaining seven 
the shortening of the femur was greatest. Case 
No. 
Duration of 
disease. 
Suppu- 
rative. 
Non-suppu- 
rative. 
SHORTENING. 
LENGTHENING. 
Duration of 
Sex. 
Age. 
Disease. 
Tibia. 
Femur. 
Limb. 
Tibia. 
Femur. 
Limb. 
treatment by 
traction. 
1 
F. 
10 
L. H. 
34 years. 
1 
In. 
4 
In. 
In. 
In. 
In. 
4 
In. 
3 years. 
2 
M. 
10 
R. H. 
34 years. 
1 
i 
i 
3 years. 
3 
F. 
10 
L. H. 
6 years. 
1 
3 
4 
i 
1 
5 years. 
4 
M. 
13 
L. H. 
7 years. 
1 
4 
i* 
If 
2 years. 
5. . . . 
M. 
14 
L. H. 
7 years. 
1 
if 
24 
2 years. 
6 
F. 
11 
L. H. 
34 years. 
1 
i 
f 
i 
3 years. 
7 
M. 
8 
R. H. 
34 years. 
1 
i 
\ 
3 years. 
8 
M. 
12 
R. H. 
7 years. 
1 
i 
t 
i 
years. 
9 
M. 
5 
R. H. 
2f years. 
1 
i 
i 
4 
2 years. 
10 
M. 
4 
L. H. 
34 years. 
1 
i 
4 
3 years. 
11.... 
F. 
5 
R. H. 
24 years. 
1 
i 
i 
i 
2 years. 
12 
F. 
5 
R. H. 
2 years. 
1 
i 
i 
2 years. 
13 
M. 
9 
R. H. 
11 years. 
1 
i 
i 
1 year. 
14 
M. 
11 
R. H. 
2| years. 
1 
i 
i 
2 years. 
15.... 
M. 
6 
R. H. 
3| years. 
1 
i 
i 
i 
3 years. 
16 
M. 
8 
L. H. 
3 years. 
1 
i 
i 
f 
2 years. 
17. . .. 
M. 
6 
R. H. 
5 years. 
1 
4 
i. 
i 
44 years. 
18 
M. 
9 
R. H. 
3 years. 
1 
i 
i 
f 
2 5 years. 
19 
M. 
14 
R. H. 
10 years. 
1 
4 
if 
2i 
4 years. 
20 
F. 
19 
R. H. 
7 years. 
1 
4 
i 
H 
5 years. 
21 
M. 
5 
L. H. 
4 years. 
1 
4 
i 
4 
34 years. 
22 
F. 
11 
R. H. 
34 years. 
1 
i 
i 
n 
3 years. 
23 
M. 
17 
R. H. 
7 years. 
1 
i 
if 
H 
54 years 
24 
F. 
25 
L. H. 
12 years. 
] 
1 
if 
2| 
8 years. 25 
26 
27 
28 
F. 
M. 
F. 
F. 
16 
11 
10 
9 
R. H. 
L. H. 
L. H. 
L. H. 
11 years. 
8 years. 
2 years. 
14 years. 
1 
1 
1 
1 
1 
5 
1 
4 
4 
2 
14 
24 
24 
’i 
4 
5 years. 
5 years. 
14 year. 
1 year. 
29.. . . 
30 
31.. 
32 
33 
34 
35 
36 
SI 
88 
39 
M. 
M. 
M. 
F. 
F. 
F. 
F. 
M. 
M. 
F. 
M. 
10 
5 
7 
10 
12 
8 
13 
11 
8 
lu 
13 
L H. 
R. H. 
L. H. 
R. H. 
R. H. 
L. H. 
L. H. 
R. H. 
R. H. 
L. H. 
R. H. 
3-| years. 
years. 
3 years. 
24 years. 
7 years, 
3 years. 
7 years. 
14 years. 
6 years. 
7 years. 
11 years. 
i 
1 
1 
1 
1 
1 
1 
1 
1 
i 
1 
4 
4 
4 
4 
4 
4 
f 
-I 
i 
if 
4 
'i 
4 
4 
4 
4 
u 
24 
i 
it 
1 
’f 
4 
4 
1 
f 
24 
2f 
4 
2f 
1 
4 
1 
3 years. 
24 years. 
3 years. 
2 years. 
5 years, 
2 years. 
5 years. 
6 years. 
6 years. 
4 years. 
6 months. 
40. . . . 
41 
42 
43 
44 
45 
F. 
M. 
F. 
M. 
F. 
M. 
9 
17 
6 
5 
16 
6 
R. R. 
R. H. 
L. H. 
L. H. 
R. H. 
R. H. 
34 years. 
7 years. 
3 years. 
3 years. 
5 years. 
8 months. 
i 
i 
1 
1 
1 
i 
1 
’l 
i 
i 
f 
’i 
i 
4 
14 
1 
7 
¥ 
4 
8 years. 
6 years. 
14 year. 
3 years. 
5 years. 
2 months. 
46.... 
47 
48 
49 
50 
F. 
F. 
M. 
M. 
M. 
8 
13 
5 
10 
7 
L. H. 
R. H. 
L. H. 
L. H. 
R. H. 
4 years. 
5 years. 
24 years. 
6 years. 
44 years. 
i 
1 
i 
1 
1 
f 
4 
4 
4 
i 
i 
i 
i 
14 
1 
1 
4 
• • 
3 years. 
4 years. 
2 years. 
5 years. 
4 years. 6 
SHORTENING OF THE TIBIA AND FEMUR. 
In four cases the disease had existed from four to 
six years and the average shortening of the tibia was 
.43 of an inch; of the femur, .47 of an inch; the shorten- 
ing of the tibia being the greatest in one, the shortening 
equal in one, and the shortening of the femur greater 
in two. In eleven cases the disease had existed from 
six to eight years and the average shortening of the 
tibia was .54 of an inch; that of the femur, .94 of an 
inch. In one the shortening of the tibia was greater 
than that of the femur, in two the shortening was equal, 
and in eight the shortening of the femur was greatest. 
In one case the disease had existed eight years, and 
the shortening of the tibia was an inch, and that of the 
femur, an inch and a quarter. 
In the five remaining cases of this group the dis- 
ease had existed from ten to fourteen years, and the 
average shortening of the tibia was .57, and that of the 
femur, 1.9 inch. This group presents the conditions 
that would be expected in most cases—shortening of 
both bones. Note that the greatest amount of shorten- 
ing of the femur is found in those cases in which the 
duration of treatment by traction is shortest in com- 
parison with the duration of the disease. Instance Case 
36—the duration of the disease was fourteen years, while 
the duration of treatment by traction was six years ; 
also Cases 25 and 19 are similar. Of course, these are 
the most conspicuous, but this will be found compara- 
tively true of most of the cases. It is reasonable that 
such should be the case, as when traction is applied the 
effect of traumatism, an important element in increas- 
ing the activity of the disease, is minimized to the great- 
est degree. 
There were two cases in which there was shortening SHORTENING OF THE TIBIA AND FEMUR. 
of neither bone (43 and 50); the disease had existed in 
the former three years, in the latter four years and a 
half. And in two cases there was shortening only of 
the femur (Cases 2 and 45); the disease having existed 
in the former three years and a half, in the latter only 
eight months. 
It is difficult to explain the non-existence of short- 
ening of the tibia in three of the last four cases men- 
tioned. There might have been a congenital differ- 
ence between the lengths of the tibiae, the one of the 
diseased limb being the longer. In one instance the 
short duration (eight months) of the disease explains 
its absence. 
In two cases, Nos. 10 and 13, there was shortening 
of the tibia only; in the former the disease had existed 
three years and a half and in the latter a year and a 
third. 
In the remaining eleven cases there was shortening 
of the tibia and lengthening of the femur. In four 
cases of this group, Nos. 1, 7, 14, and 27, in which 
the disease had existed, respectively, three years and a 
half, three years and a half, two years and a half, and 
two years, the lengthening of the femur was equal to 
the shortening of the tibia, thus showing the limbs of 
equal length; while in the remaining seven cases the 
lengthening of the femur was greater than the shorten- 
ing of the tibia, thus showing lengthening of the limb, 
the amount varying from an eighth to half an inch. 
The duration of the disease in six cases was from two 
to three years and a half, and in one ease seven years. 
Thus it may be seen from the conditions found in 
a group of cases how a measurement of the limb as a 
whole would give an incorrect impression of the effect of 8 
SHORTENING OF THE TIBIA AND FEMUR. 
the disease, and emphasizes the importance of measuring 
these bones separately. I have no doubt that many of 
the cases reported as having no shortening or even 
lengthening of the limb are such as these, and if meas- 
ured in the same way would present a similar condi- 
tion. 
The cause of this undoubtedly is a congestion of 
the epiphysis of the femur which is due to the inflam- 
matory action of the disease, when in proximity to 
it, increasing the activity of its growth. 
A similar condition is often seen in the course of 
knee-joint disease where there is lengthening of either 
or both bones. An increased activity of the growth of 
the femur at this point may be sufficient to prevent 
shortening of the limb, or even produce lengthening 
for a time in the course of the disease, as was true in 
these cases; in one the disease had existed seven years 
(Case 8); but it is doubtful if this activity of growth 
will be sufficient to counterbalance the more con- 
stant causes of shortening and prevent their appear- 
ing ultimately some shortening of the limb. Measure- 
ments taken of the ease just mentioned (No. 8) eight- 
een months previous showed three quarters of an inch 
lengthening of the limb, while now there is only an 
eighth of an inch lengthening. This patient will un- 
questionably have a certain amount of shortening when 
he has attained his growth. 
The important relation that exists between func- 
tion and nutrition, and the well-known fact that short- 
ening increases somewhat after the disease has become 
inactive, suggest the probability that this increase will 
continue as long as growth is possible. As the less 
active growth of the diseased limb is due to impaired SHORTENING OF THE TIBIA AND FEMUR. 
9 
function, a condition found as a result of this disease 
in most instances and one which is, as a rule, perma- 
nent, the increase of shortening will be proportionate 
to such impairment and to the years of growth to he 
attained. 
I do not take the position that patients with tubercu- 
lous disease at the hip have not recovered with limbs of 
equal length after growth has been attained; but I 
think they arc exceedingly rare, and are only such as 
have recovered from the disease very early in child- 
hood, the treatment having been of short duration, 
with the normal function of the joint restored. 
While shortening of both the tibia and femur is 
present in the large percentage of these cases, it would 
seem desirable, in order to arrive at some general con- 
clusion as to the proportionate responsibility of these 
bones for the shortening of the limb, which would rep- 
resent as truly the ultimate condition as possible, to 
consider only those cases in which the disease had 
existed longest, which are as well those nearest the 
end of the period of growth. There are thirteen such 
cases, the disease having existed from seven to four- 
teen years, their ages varying from ten to twenty-five 
years. The average shortening of the tibia was .70 
of an inch, while that of the femur was 1.47 inch, 
thus showing the shortening of the femur about twice 
as great as that of the tibia. Whether this proportion 
will exist at a future period in the history of these cases 
it is impossible to say, though it is probable it will, in 
view of their age, the duration of the disease, and the 
inactivity of the disease in most instances. I would 
emphasize the importance of this fact, however, namely, 
that the knowledge of this proportion, whatever it may 10 
SHORTENING OF THE TIBIA AND FEMUR. 
be in any case, furnishes a means by which a fairly 
correct estimate may be placed upon the causes of short- 
ening as to their comparative responsibility for it. It is 
obvious that the destruction of tissue can play no part in 
the cause of shortening of the tibia, though one half of 
Fig. I.—Case 5. Right tibia and 
fibula. 
Fig. 2.—Case 5. Left tibia and 
fibula (diseased hip). 
the entire shortening of the limb is represented by that 
bone in these eases. If the indirect causes of shortening, 
the trophoneurotic affection caused by this disease, and 
the interference with growth by impairment of func- 
tion, produce this effect upon the tibia, it is fair to SHORTENING OF THE TIBIA AND FEMUR. 
11 
assume that the femur will also be affected in this way 
to as great a degree, which fact suggests that destruc- 
tion of tissue, the direct cause of shortening, is of less 
importance than the indirect causes, probably pro- 
ducing not more than one third of the total amount. 
Fig. 3.—Case 38. Tibia and fibula 
of limb of diseased hip (left). 
Pig. 4.—Case 38. Tibia and fibula 
of healthy limb (right). 
In all of these cases in which the disease had existed 
any considerable length of time the foot of the affected 
limb was smaller. That the diminution in the thick- 
ness of the tibia might be appreciated, radiographs of 
the tibiae were made in many instances, those of two 12 
SHORTENING OF THE TIBIA AND FEMUR. 
cases only accompanying this report, being sufficient 
to illustrate what was true of all that were examined 
in this way. These cases are fSTos. 5 and 38, the dis- 
ease having existed seven years in both instances. It is 
probable that radiographs will show diminution in the 
thickness of this bone as well as that of the femur 
earlier than shortening can be detected by measure- 
ments. Physicians 
who desire to keep au courant with the advances 
of medicine and surgery should read 
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