Surgical dislocation of the hip: evolving indications

Surgical Hip Dislocation in the Era of Hip Arthroscopy Demonstrates High Survivorship and Improvements in Patient-reported Outcomes for Complex Femoroacetabular Impingement

BACKGROUND

Over the past decade, hip arthroscopy has become more commonly used in the treatment of patients with femoroacetabular impingement (FAI) as well as those with many other intra-articular hip pathologies. As such, the indications for open surgical hip dislocation have narrowed to include complex intra-articular and extra-articular bony morphologies and revision hip preservation. Although surgical hip dislocation has been established as an effective approach, previous research using contemporary indications has been limited primarily to smaller cohorts with short-term follow-up. Furthermore, factors associated with reoperation, conversion arthroplasty, and not achieving clinical improvement remain ambiguous.

QUESTIONS/PURPOSES

At a minimum of 2 years of follow-up in patients treated for FAI with surgical hip dislocation, (1) how much did patient-reported outcome measures (PROMs) improve, and what percentage of patients achieved the minimum clinically important difference (MCID) and patient-acceptable symptom state (PASS)? (2) What was the survivorship free from reoperation of the hip for any reason? (3) What was the survivorship free from conversion to arthroplasty (THA or hip resurfacing)?

METHODS

Between February 2011 and April 2021, 211 patients were treated at one academic institution with surgical dislocation and osteoplasty of the femoral head-neck junction or greater trochanter for FAI. Of these, patients with concomitant diagnoses including Legg-Calvé-Perthes disease, slipped capital femoral epiphysis, osteochondritis dissecans, a benign tumor, or another neurologic or metabolic disorder were excluded. This yielded 74% (156 of 211) of patients as potentially eligible. A further 12% (18 of 156) of patients without postoperative PROMs were excluded, and another 13% (21 of 156) were lost before the minimum study follow-up of 2 years, leaving 75% (117) for analysis at a median of 4.9 years (range 2 to 12 years) in this retrospective study. A total of 88% of the patients were women (103 of 117), and 40% (47 patients) underwent the procedure as a revision. All patients underwent surgical hip dislocation. Intraoperatively, 66% (77 of 117) of patients demonstrated cam impingement, and the remainder had either pincer impingement or combined cam and pincer; 82% (96 of 117) had some component of extra-articular impingement. To answer our first research question, we obtained PROM scores for the modified Harris hip score (mHHS) and international hip outcome tool 12 (iHOT-12) before surgery and at the most-recent follow-up from our longitudinally maintained institutional database, and we determined the percentage of patients who achieved the MCID or PASS. To answer our second research question, we calculated Kaplan-Meier survivorship free from any reoperation on the hip at 5.8 years (mean follow-up) after the index procedure. To answer our third research question, we calculated the Kaplan-Meier survivorship free from conversion to arthroplasty at 5.8 years. Using univariate logistic regression analysis, factors associated with meeting these defined endpoints were identified.

RESULTS

At a mean of 6 ± 3 years, the mHHS of patients treated with surgical hip dislocation for FAI who had not had previous surgery on the hip improved from 53 ± 15 to 85 ± 13 (mean difference 31 [95% confidence interval 27 to 36]; p < 0.01) and the mean iHOT-12 score improved from 25 ± 14 to 74 ± 24 (mean difference 49 [95% CI 42 to 56]; p < 0.01). At a mean of 5 ± 3 years, for patients with prior hip surgery, mHHS improved from 55 ± 13 to 79 ± 15 (mean difference 24 [95% CI 18 to 30]; p < 0.01) and iHOT-12 scores improved from 25 ± 16 to 66 ± 26 (mean difference 41 [95% CI 31 to 50]; p < 0.01). The proportion of patients who achieved the MCID for the mHHS was 87% (55 of 63) and 83% (33 of 40), while the proportion who achieved the PASS for the mHHS was 66% (46 of 70) and 51% (24 of 47) for primary and revision surgery, respectively. The proportion of patients who achieved the MCID for the iHOT-12 was 87% (53 of 61) and 83% (33 of 40), while the proportion who achieved the PASS for iHOT-12 was 68% (47 of 69) and 57% (26 of 46) for primary and revision surgery, respectively. Higher lateral center-edge angles (odds ratio 1.2 per 1° [95% CI 1.1 to 1.3]; p < 0.01), a lower acetabular version at 2:00 (OR 0.92 per 1° [95% CI 0.85 to 0.99]; p = 0.05), the absence of a labral tear (OR 0.21 [95% CI 0.06 to 0.79]; p = 0.02), a higher preoperative mHHS (OR 1.1 per 1 point [95% CI 1.02 to 1.2]; p < 0.01), and a higher preoperative iHOT-12 score (OR 1.1 per 1 point [95% CI 1.01 to 1.1]; p = 0.01) were associated with not achieving the MCID. In patients without a history of ipsilateral hip surgery, survivorship free from reoperation at 5.8 years after surgical hip dislocation was 90% (95% CI 82% to 98%). In the setting of prior ipsilateral hip surgery, survivorship free from reoperation at 5.8 years after surgical hip dislocation was 75% (95% CI 60% to 95%). No patients for whom surgical hip dislocation was their primary hip procedure underwent conversion to arthroplasty. Among the revision patient cohort, survivorship free from conversion to arthroplasty at 5.8 years after surgical hip dislocation was 97% (95% CI 91% to 100%).

CONCLUSION

Surgical hip dislocation effectively improves hip pain and function with high survivorship (free of reoperation or conversion to arthroplasty) for complex intra-articular and extra-articular FAI that is deemed less suitable for arthroscopic treatment, but when the procedure is used in patients who have had prior hip surgery, they should be told that revision surgery is a realistic possibility. If insufficient acetabular coverage is anticipated, acetabular reorientation osteotomy should be considered. Future studies should evaluate long-term survivorship and PROMs in larger patient cohorts, as well as identify other factors associated with reoperation and conversion to arthroplasty.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The evolution of surgical hip dislocation utilization and indications over the past two decades: a scoping review

PURPOSE

To assess the evolution of surgical hip dislocation (SHD) utilization over the past 20 years, concentrating mainly on the patients' population (adults vs. paediatric), the hip conditions treated using this approach, and reporting on complications of this procedure.

METHODS

This scoping review was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. A PubMed database search was performed using specific search terms for articles related to SHD published between January 2001 and November 2022.

RESULTS

Initial search revealed 321 articles, of which 160 published in 66 journals from 28 countries were eligible for final analysis. The number of publications increased by 10.2 folds comparing the period from 2001 to 2005 with 2018 to 2022. USA and Switzerland contributed to more than 50% of the publications. Case series studies represented the majority of publications (65.6%). Articles including adult patients represented 73.1% of the publications while 10% were on paediatric patients; however, there was 14 folds increase in publications on paediatric patients comparing the first with the last five years. Managing non-traumatic conditions was reported in 77.5% of the articles, while traumatic conditions in 21.9%. Femoroacetabular impingement (FAI) was the most treated non-traumatic condition reported in 53 (33.1%) articles. In contrast, femoral head fractures (FHF) were the most treated traumatic condition, which was reported in 13 articles.

CONCLUSION

The publications on SHD and its usage for managing traumatic and non-traumatic hip conditions showed an increasing trend over the past two decades from worldwide countries. Its use in adult patients is well established, and its utilization in treating paediatric hip conditions is becoming more popular.

Surgical Approaches for Managing Femoral Head Fractures (FHFs); What and How to Choose from the Different Options?

Femoral head fractures (FHFs) are considered a relatively uncommon injury; however, they carry a challenge to the trauma surgeon. Choosing the appropriate management option, either conservatively or surgically, if the latter was chosen, should it be open reduction and internal fixation or simple excision of the fragment, or acute total hip arthroplasty. Furthermore, selecting the best surgical approach through which surgical management could be performed depends on the fracture classification, the familiarity of the surgeon, and the presence of associated injuries. All approaches to the hip, including hip arthroscopy, had been proposed for the management of FHFs; however, the difference among approaches is related to the complexity of the approach, the need for special training or equipment, the effect of the approach on the functional outcomes as well as the rate of postoperative complications. This review discussed the possible surgical approaches used to manage FHFs, advantages, and disadvantages for each, and offered a guideline for selecting the most appropriate surgical approach.

Safety and efficacy of surgical hip dislocation in managing femoral head fractures: A systematic review and meta-analysis

BACKGROUND

Femoral head fractures (FHFs) are considered relatively uncommon injuries; however, open reduction and internal fixation is preferred for most displaced fractures. Several surgical approaches had been utilized with controversial results; surgical hip dislocation (SHD) is among these approaches, with the reputation of being demanding and leading to higher complication rates.

AIM

To determine the efficacy and safety of SHD in managing FHFs by reviewing the results reported in the literature.

METHODS

Major databases including PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched to identify studies reporting on outcomes of SHD utilized as an approach in treating FHFs. We extracted basic studies data, surgery-related data, functional outcomes, radiological outcomes, and postoperative complications. We calculated the mean differences for continuous data with 95% confidence intervals for each outcome and the odds ratio with 95% confidence intervals for binary outcomes. P < 0.05 was considered significant.

RESULTS

Our search retrieved nine studies meeting our inclusion criteria, with a total of 129 FHFs. The results of our analysis revealed that the average operation time was 123.74 min, while the average blood loss was 491.89 mL. After an average follow-up of 38.4 mo, a satisfactory clinical outcome was achieved in 85% of patients, with 74% obtained anatomical fracture reduction. Overall complication rate ranged from 30% to 86%, with avascular necrosis, heterotopic ossification, and osteoarthritis being the most common complications occurring at an incidence of 12%, 25%, and 16%, respectively. Trochanteric flip osteotomy nonunion and trochanteric bursitis as a unique complication of SHD occurred at an incidence of 3.4% and 3.8%, respectively.

CONCLUSION

The integration of SHD approach for dealing with FHFs offered acceptable functional and radiological outcomes with a wide range of safety in regards to the hip joint vascularity and the development of avascular necrosis, the formation of heterotopic ossification, and the development of posttraumatic osteoarthritis; however, it still carries its unique risk of trochanteric flip osteotomy nonunion and persistent lateral thigh pain.

Hip arthroscopy for lateral cam morphology: how important are the vessels?

The purpose of this narrative review is to identify the anatomy and relevant blood supply to the femoral head as it pertains to hip arthroscopy and lateral cam morphology. The primary blood supply to the femoral head is the lateral ascending superior retinacular vessels, which are terminal branches of the medial femoral circumflex artery. These vessels penetrate the femoral head at the posterolateral head–neck junction. Surgeons performing posterolateral femoral osteoplasty must respect this vasculature to avoid iatrogenic avascular necrosis (AVN). Avoidance of excessive traction, avoidance of distal posterolateral capsulotomy and avoidance of disruption of the superior retinacular vessels should keep the risk for AVN low. Hip extension, internal rotation and distraction are useful in hip arthroscopy to better visualize lateral/posterolateral cam morphology to facilitate an accurate comprehensive cam correction and avoid vascular disruption.

External fixation-assisted reduction for the treatment of neglected hip dislocations with limb length discrepancy: a retrospective study of 13 cases

BACKGROUND

The purpose of this study was to evaluate a new method for treating neglected hip dislocation with limb length discrepancy by using external fixation-assisted pre-reduction.

METHODS

Thirteen patients admitted between January 2010 to February 2018 with a mean duration from injury to surgery of 5.0 ± 2.1 months and an average preoperative leg-length discrepancy of 7.7 ± 2.3 cm were enrolled in this study. The dislocation and associated acetabular fracture type, clinical outcomes and residual limb length discrepancy were evaluated.

RESULTS

All patients had posterior dislocations, and nine patients presented with acetabular fractures and were followed-up for at least 12 months. The average traction duration of external fixators was 28.8 ± 8.0 days and all patients received second-stage open reduction and internal fixation. Six patients showed residual limb length discrepancy within 2 cm. Patients showed significant improvement in hip function and pain relief. Complications including avascular femoral head necrosis and osteoarthritis occurred in three patients.

CONCLUSION

Effective correction of limb length discrepancy and improved function were observed in patients with neglected hip dislocations and limb equality using traction by external fixation combined with second-stage open reduction. Further follow-up is required to determine long-term outcomes.

Biomechanical Evaluation of the Depth of Resection During Femoral Neck Osteoplasty for Anterior Impingement Following Slipped Capital Femoral Epiphysis

BACKGROUND

Femoroacetabular impingement as a result of slipped capital femoral epiphysis (SCFE) has been treated traditionally with a proximal femoral osteotomy, but open and arthroscopic femoral osteoplasty is becoming increasingly popular. Cam lesions result from excess bone primarily at the anterolateral femoral head-neck junction. SCFEs result from posterior and inferior slippage of the femoral epiphysis, causing the metaphysis to move anteriorly. This study's purpose was to compare fourth-generation sawbones standard femurs with SCFE femurs to determine whether bone resection from the anterior metaphysis results in similar biomechanical properties.

METHODS

A custom fourth-generation composite SCFE sawbone was created with a 30-degree slip angle. Control group consisted of fourth-generation composite standard nondeformed medium femurs. The femoral neck at the head-neck junction was divided into 4 quadrants. All resections were done in the anterolateral quadrant. Twenty SCFE sawbones and 20 standard sawbones were divided into 4 subgroups based on resection depths of 0%, 10%, 30%, and 50% of the metaphysis at the head-neck junction. After resection, all proximal femurs were loaded to failure in an Instron testing machine to determine the ultimate load to failure, stiffness, and energy to failure.

RESULTS

The standard femurs were significantly stronger than the SCFE femurs (P<0.001) and the strength of the femurs decreased significantly as the resection amount increased (P<0.001). Similarly, the standard femurs withstood significantly more energy before failing than the SCFE femurs (P<0.001) and the energy to failure decreased significantly with varying resection amounts (P<0.001).

CONCLUSIONS

SCFE femurs demonstrate a significant reduction in strength and energy to failure after osteoplasty compared with nondeformed femurs in a sawbone model. Strength and energy to failure are inversely proportional to the depth of bone resection.

CLINICAL RELEVANCE

Aggressive femoral neck osteoplasty for treatment of a SCFE deformity may lead to increased risk of fracture. Further studies are necessary to determine the safe depth of resection in a clinical setting.

Surgical hip dislocation through a direct lateral approach: A cadaveric study of vascular danger zones

OBJECTIVE

There is limited information on the potential danger to the vascularity of the femoral head during surgical dislocation of the hip using the direct lateral approach. The objective of this study was to investigate the topographical anatomy of the medial femoral circumflex artery (MFCA), the primary source of blood supply to the femoral head, in relationship to the direct lateral approach.

METHODS

Seven unembalmed cadaver hips had dye injection into either the profunda femoris artery or the MFCA. Surgical hip dislocation was then performed through a direct lateral approach, noting the danger zones to the MFCA branches during each step of the exposure.

RESULTS

None of the MFCA branches were found to cross the anterior surgical field superficial to the capsule. The deep (main) branch of the MFCA pierced the inferior capsule at the level of the lesser trochanter after emerging posterior to iliopsoas tendon. Ascending branches up the medial femoral neck were identified at this level. The deep branch then coursed posteriorly terminating in a variable number of vessels ascending the posterior femoral neck. Dislocation of the femoral head did not stretch or alter the course of the deep branch of the MFCA.

CONCLUSION

Safe surgical hip dislocation preserving the MFCA can be performed though a direct lateral approach as long as the inferomedial portion of the anterior capsule is preserved (main branch of the MFCA pierces the capsule at this level). Extracapsular injury is possible from inadvertent dissection at the level of the lesser trochanter or aggressive retraction on the iliopsoas. The posterior capsule should be left intact and instrumentation around the posterior neck should be avoided.

Incidence and Complications of Open Hip Preservation Surgery: An ABOS Database Review

Hip preservation surgery encompasses various surgical procedures that have the goal of decreasing the progression of osteoarthritis, preserving normal hip function, and delaying the need for arthroplasty. These procedures can encompass arthroscopic, open, and combined techniques. This study investigated the trends and complications associated with open hip preservation surgery performed by candidates undergoing Part II of the American Board of Orthopaedic Surgery examination. The American Board of Orthopaedic Surgery Part II surgeon case database was queried from the years 2003 to 2013 for Current Procedural Terminology (CPT) codes related to open hip preservation surgery in patients 10 years and older. Patient demographics, fellowship training, geographic location, and complications were extracted from the database. These data were analyzed to determine the incidence by year of individual procedures and complications. During the study period, 644 cases (352 male, 292 female; mean age, 29.7 years) and 730 CPT codes were reported. The most commonly reported fellowship was pediatric orthopedics. No trend was observed in the overall incidence of these surgeries, but there was an increase in the number of cases performed in the Midwest. There were 212 reported complications, with a rate of 33% per case, or 29% per CPT code (range, 12.5%-100% per CPT code). Complications reported ranged from infection to death. The incidence of complications over time showed no discernible trend. Based on the results of this study, the yearly incidence and complications associated with open hip preservation surgery performed by surgeons undergoing board certification should continue at a predictable rate. [Orthopedics. 2017; 40(1):e109-e116.].

New perspectives on femoroacetabular impingement syndrome

Femoroacetabular impingement (FAI) is characterized by an abnormality in the shape of the femoral head-neck or acetabulum that results in impingement between these two structures. Arthroscopic treatment has become the preferred method of management of FAI owing to its minimally invasive approach. Surgical correction involves resection of impinging osseous structures as well as concurrent management of the associated chondral and labral pathology. Research from the past 5 years has shown that repair of the labrum results in a better anatomic correction and improved outcomes compared with labral debridement. Research is underway to improve cartilage assessment by using innovative imaging techniques and biochemical tests to inform predictions of prognosis. Several ongoing randomized controlled trials, including the Femoroacetabular Impingement Trial (FAIT) and the Femoroacetabular Impingement Randomized Controlled Trial (FIRST), will provide critical information regarding the diagnosis, management and prognosis of patients undergoing arthroscopic management of FAI.

The Hyperflexible Hip: Managing Hip Pain in the Dancer and Gymnast

Context:

Dance, gymnastics, figure skating, and competitive cheerleading require a high degree of hip range of motion. Athletes who participate in these sports use their hips in a mechanically complex manner.

Evidence Acquisition:

A search of the entire PubMed database (through December 2013) and additional searches of the reference lists of pertinent articles.

Study Design:

Systematic review.

Level of Evidence:

Level 3.

Results:

Whether innate or acquired, dancers and gymnasts have some hypermobility that allows their hips to be placed in potentially impinging or unstable positions required for their given activity. Such extremes of motion can result in both intra-articular and extra-articular impingement as well as compensatory osseous and muscular pathology. In addition, dancers and gymnasts are susceptible to impingement-induced instability. Dancers with innate generalized hyperlaxity are at increased risk of injury because of their activities and may require longer recovery times to return to play. Both nonoperative and operative treatments (arthroscopic and open) have an important role in returning flexibility athletes to their preoperative levels of sport and dance.

Conclusion:

Because of the extreme hip motion required and the compensatory soft tissue laxity in dancers and gymnasts, these athletes may develop instability, impingement, or combinations of both. This frequently occurs in the setting of subtle pathoanatomy or in patients with normal bony anatomy. With appropriate surgical indications and the correct operative technique, the treating surgeon can anticipate high levels of return to play for the gymnast and dancer with hip pain.

Can we predict femoral head vitality during surgical hip dislocation?

PURPOSE

Surgical hip dislocation is commonly performed in orthopaedic surgery for several pathologies that often present risk of avascular necrosis (AVN) of femoral head. Observation of blood spilling out from a drill hole, performed in the head after dislocation, has been proposed as a predictive test for AVN. No data have been published about test reliability. Study's aim was to evaluate the correlation between 'bleeding sign' and AVN in surgical dislocation for elective disease and for acetabular fractures.

METHODS

All patients meeting the indication for surgical dislocation were included in this prospective study. Patients with follow-up shorter than 8 months were excluded. Intra-operative assessment of head vascularity was performed in 44 patients through the 'bleeding sign': a 2.0-mm drill hole carried out on the head during surgery. A positive bleeding test was considered an immediate appearance of active bleeding. Development of AVN was considered the main outcome. Necrosis group criteria were detection of type II, III or IV X-ray according to Ficat classification.

RESULTS

Forty-four patients with selected acetabular fractures, slipped capital femoral epiphysis and femoral head deformity were enrolled. Mean age was 25 years and mean follow-up was 36 months. Thirty-eight patients presented positive intra-operative bleeding sign and six demonstrated no bleeding. Sensitivity for the 'bleeding sign' was 97%, specificity was 83%, positive predictive value was 97%, negative predictive value was 83% and accuracy was 95% (P < 0.001).

CONCLUSIONS

Bleeding after head drilling is a reliable test for AVN in patients who undergo a surgical hip dislocation.

Operative treatment of femoroacetabular impingement

Femoroacetabular impingement is a common pathologic disorder of the hip that causes pain and has been implicated in the development of early osteoarthritis in young adults. This disorder includes 2 different subtypes: cam impingement and pincer impingement. When nonsurgical treatment methods fail, surgical options are indicated. These options have been increasingly investigated over recent years and show promising results. Several surgical techniques have been described, including surgical dislocation of the hip, mini-open procedures, hip arthroscopy, and periacetabular osteotomies. Nevertheless, the preferred mode of surgical management of femoroacetabular impingement remains a source of controversy. Only short-term and midterm outcome data are available regarding the efficacy of these surgical techniques. This review details 5 approaches for surgical management of femoroacetabular impingement: open surgical dislocation, a combined arthroscopic and open approach, hip arthroscopy, a mini-open anterior approach, and periacetabular osteotomy. It focuses specifically on surgical technique, outcomes, and their efficacy in treatment of femoroacetabular impingement.

A less-invasive technique for capsular management during hip arthroscopy for femoroacetabular impingement

The aim of this work is to describe a new arthroscopic technique for the treatment of femoroacetabular impingement that allows a complete articular joint view with maximum protection of the capsuloligamentous complex. This arthroscopic technique avoids injury to the capsuloligamentous complex, preventing the risk of postoperative instability. The diagnosis of femoroacetabular impingement was based on clinical and radiographic grounds. An alpha angle greater than 50° was considered pathologic. In this technique, the use of intra-articular devices (retractors) allows us to separate the capsular tissue from the femoral head-neck junction and mobilize the capsule, achieving an adequate joint view without performing a capsulotomy and, consequently, avoiding the complications of capsular damage.

Trends in the surgical management of hip dysplasia

Hip dysplasia is a spectrum of disease. There are established screening programmes for its detection in childhood, but there is also increasing interest in its presentation and surgical treatment at skeletal maturity. This study was aimed at establishing patterns of operative treatment for hip dysplasia in the UK using the hospital episode statistics database over an 11-year period. From a total of 12 100 operations during this interval, there has been no significant change in the level of intervention in the paediatric population. There has, however, been a four-fold rise in procedures in the adult population over the same timeframe.