Traumatic dislocations of the hip

Irreducible posterior fracture-dislocation of the hip associated with an ipsilateral femoral shaft fracture: A case report and review of the literature

INTRODUCTION

Ipsilateral fractures of the shaft of the femur combined with hip dislocations are extremely rare injuries, presenting a difficult diagnostic and therapeutic challenge. Diagnosis of hip dislocation is often delayed, due to the focus on femoral fracture.

CASE PRESENTATION

This article presents a case never described before of a 19-year-old patient who sustained this unusual combination of injuries as a result of a road traffic accident. The patient had an irreducible posterior hip fracture-dislocation associated with an ipsilateral femoral shaft fracture. Closed reduction attempts were unsuccessful, leading to the requirement for open reduction, via the posterolateral approach of the hip, which revealed that the femoral head buttonholed through the capsule. We proceeded to the reduction of the left hip with the osteosynthesis of the posterior wall acetabular fragment, and then the femur shaft fracture was fixed using an intramedullary nail. After 19 months postoperative follow-up, the patient had full range motion of the affected hip without any pain.

DISCUSSION

Closed reduction techniques, including various external devices, have been explored, with some success in specific cases. However, open reduction remains a crucial option, especially in irreducible dislocations. Complications, such as avascular necrosis of the femoral head and neurovascular injury, illustrate the importance of accurate diagnosis and appropriate treatment.

CONCLUSIONS

In conclusion, ipsilateral femoral shaft fractures combined with hip dislocations represent a rare and challenging orthopedic emergency. Timely diagnosis, careful assessment, and consideration of both closed and open reduction techniques are essential in managing these complex injuries.

Treatment and clinical outcome in patients with femoral head fractures: a long-term follow-up

INTRODUCTION

A femoral head fracture (Pipkin fracture) is a rare but severe injury. The optimal treatment is controversial, and there is a lack of research focusing on treatment strategies. The study aimed to analyze the treatment strategies in comparison to the outcome in patients after traumatic hip joint dislocation (THD) with concomitant femoral head fractures.

MATERIALS AND METHODS

A retrospective multicenter study at three Level I Trauma Centers was performed over a 12 year period from January 2009 to January 2021. Epidemiological data, associated injuries, and treatment were recorded. Patients were followed up for further treatment, re-operations, complications, and long-term functional outcomes using patient-reported outcome measures (PROMs), specifically the modified Harris Hip Score (mHHS) and the Tegner Activity Scale (TAS).

RESULTS

45 patients with a mean age of 44 ± 16.11 years were finally evaluated. The majority of 38 patients (84%) were treated surgically. The mean follow-up time was 5.75 years (range 2-12 years). 8 patients (31%) developed post-traumatic osteoarthritis and 4 patients (15%) developed osteonecrosis of the femoral head. 7 patients (27%) underwent total hip arthroplasty (THA). Fixation of the Pipkin fracture was more common in younger patients but had no statistically significant impact on PROMs. Patients with a higher BMI were significantly less likely to undergo fragment fixation (p < 0.05). TAS was significantly worse in patients who underwent THA (p < 0.05).

CONCLUSIONS

A femoral head fracture is a severe injury with overall limitations in activities of daily living and a high rate of post-traumatic osteoarthritis and osteonecrosis of the femoral head. Fragment fixation had no statistically significant impact on the outcome and PROMs. Treatment strategies should be guided by the fracture type, the patient's condition, and associated injuries. However, concomitant and life-threatening injuries may affect the treatment and limit the outcome.

Traumatic Hip Dislocation: Pediatric and Adult Evaluation and Management

Traumatic hip dislocation of a native hip joint represents an orthopaedic emergency that should be treated promptly. Dislocations can be classified based on the associated injuries and the direction of dislocation. Expeditious evaluation, reduction, and management of associated injuries are required to optimize short and long-term function of the hip. There are several important differences between the blood supply and ossification of the pediatric hip that necessitate different strategies for the evaluation and management of traumatic hip dislocations in pediatric patients. Appropriate treatment is dictated by the direction and type of dislocation as well as associated injuries. In addition to closed reduction, arthroscopy, open reduction (potentially with fracture fixation and/or soft-tissue repair), osteotomy, and total hip arthroplasty all have roles in treatment. Consensus on optimal postreduction activity protocols after simple hip dislocation remain unestablished. Short and long-term outcomes are largely driven by the amount of time from injury to reduction and associated injuries.

Traumatic Native Hip Dislocations: An Audit at a Major Trauma Centre and Assessment of Clinical Practice at Centres Across the United Kingdom

INTRODUCTION

Native hip dislocations are defined as traumatic dislocations of the hip, typically high-energy and associated with polytrauma. The majority of these injuries occur following motor vehicle accidents (MVAs). Due to the inherent stability of the hip joint, a significant force is required to cause dislocation. It is critical that such injuries are managed and reduced in a timely manner. We evaluated the current practice in a major trauma centre (MTC) in Cardiff and gathered information from emergency departments (EDs) in Wales and MTCs around the United Kingdom (UK).

METHODS

We did an evaluation of the current practice with a retrospective audit of all traumatic native hip dislocations presenting to the MTC at Cardiff from August 2018 to February 2021. Data was obtained from Trauma Audit and Research Network (TARN), medical records, radiology and theatre management systems. An online survey was developed and disseminated to EDs in Wales and MTCs across the UK.

RESULTS

There were 15 traumatic hip dislocation cases over the period evaluated. Sixty percent of cases were due to MVA. Eighty-six percent of patients had an associated fracture, with one Pipkin type IV fracture dislocation. The mean time to reduction from injury was 532 minutes (240-804 minutes), with 28.6% reduced within 6 hours and 71.4% reduced within 12 hours. Two patients had reduction performed in the ED (mean time to reduction, 275 minutes). There was one occurrence of avascular necrosis (AVN) and one of chondrolysis at the follow-up. The response rate to the survey was 80% and 83% in Wales and MTCs nationally, respectively. The majority (82%) of departments did not have an established pathway in place for managing traumatic native hip dislocations with a preference for reduction in the operating theatre.

CONCLUSION

Native hip dislocations are rare, high-energy injuries associated with significant morbidity. The available evidence suggests time to reduction is imperative in reducing the risk of future complications. The establishment of a pathway to guide management and having a mechanism to perform reductions in the ED may produce significant reductions in this time, impacting outcomes.

Clinical Outcomes and Associated Pathologies Following Pediatric Traumatic Hip Dislocations: A Systematic Review of the Literature

INTRODUCTION

Pediatric traumatic hip dislocations are a rare condition that can have devastating short and/or long-term outcomes and associated pathologies (APs), including associated injuries (AIs) and long-term adverse events (LTAEs), with negative long-term sequelae. Currently, there are little data that exist on the rate of APs, with the most notable being avascular necrosis (AVN), for pediatric traumatic hip dislocations. The purpose of this systematic review is to evaluate the outcome relative frequency of dislocation direction, reduction type, and rate of APs for traumatic hip dislocations in the pediatric population.

METHODS

A systematic review on the topic of traumatic hip dislocations in the pediatric population was performed using PubMed, ScienceDirect, Web of Science, CINAHL, and MEDLINE databases from database inception to March 30, 2023. Inclusion criteria was full-text English articles, addressed traumatic hip dislocations, and pediatric patients (<18 y old).

RESULTS

A total of 24 articles (n=575 patients) met final inclusion criteria from a total of 219 articles retrieved from the initial search. For the average age of the included patients with reported age (n=433 patients), the frequency weighted mean was 9.50 years±1.75 years with a frequency weighted mean follow-up time of 74.05 months ±45.97 months (n=399 patients). The most common dislocation direction was posterior (86.4%), the most common treatment type was closed reduction (84.5%), AVN was the most common type of LTAEs (15.5% of APs), and labral/capsular injuries and acetabular fractures were the most common type of AIs (14.0% and 9.4% of APs, respectively). There were a combined total of 414 APs (72%) out of 575 total patients.

CONCLUSION

Pediatric traumatic hip dislocations are associated with a high rate of AIs and LTAEs (72%, 414 APs out of 575 patients). AVN, labral/capsular injuries, and acetabular fractures are the most common APs after pediatric traumatic hip dislocations. Pediatric hip dislocations are usually posterior and commonly managed through closed reduction.

LEVEL OF EVIDENCE

III, Systematic Review.

Prognostic and therapeutic interest of a new classification in inferior hip dislocation: a systematic review of the literature

INTRODUCTION

Reported cases of inferior dislocation in the literature are found under several names (inferior, anteroinferior, obturator, or erecta), which may be source of confusion. The purpose of this comprehensive review of the literature is to collect as many cases of inferior dislocation as possible to determine better therapeutic strategies, outcome after reduction, complications, and prognostic factors.

METHODS

In April 2020, a literature search was performed in Pubmed, Medline, Scopus, Cochrane, and Embase databases. The MeSH keywords were "OBTURATOR DISLOCATION HIP" or "ANTERIOR DISLOCATION HIP" or "INFERIOR DISLOCATION HIP." Authors independently selected articles that met the selection criteria, with no time limit.

RESULTS

Out of the 97 articles selected, there were 119 cases of primary inferior hip dislocations. This review of the literature has allowed us to differentiate 3 radiographic subtypes of inferior dislocations, which correspond to 3 different anatomical positions of the femoral head: "obturator" dislocation, "proximal anterior-inferior" dislocation, and "distal anterior-inferior" dislocation. Our subtype classification yielded 39 obturator subtype inferior dislocations (32.8%), 66 proximal anteroinferior subtypes (55.4%), and 14 distal anteroinferior (11.8%). The obturator subtype is at risk of reduction failure and femoral neck fracture during the reduction manoeuver.

CONCLUSIONS

Our study identified 3 subtypes with different prognosis, with obturator and distal anteroinferior dislocations having a poorer prognosis because of their pre- and post-reduction complications. We were unable to determine the correct manoeuver to reduce inferior dislocations without taking the risk of femoral neck fracture, but each of these subtypes may require a different manoeuver.

Obturator dislocations of the hip associated with pelvic ring injuries: Case report and review of the literature

Case

An obturator hip dislocation with an associated open book pelvic ring injury is an extremely rare injury pattern. This case report will discuss challenges to closed reduction, acute management strategies and review the literature on combined hip dislocations and open book pelvic ring injuries.

Conclusion

This injury pattern presents unique reduction challenges that should be recognized early in order to provide effective resuscitation and preserve the femoral head blood supply. Failing to close reduce the hip delays reducing the pelvic ring volume because sheets and binders are precluded from working effectively.

Using Spinal Anesthesia and a Fracture Table for Closed Reduction of an Obturator Foramen Hip Dislocation: A Case Report

CASE

A 37-year-old man with a right obturator foramen hip dislocation underwent closed reduction under spinal anesthesia with the use of a fracture traction table.

CONCLUSION

This novel technique provides surgeons and anesthesiologists an alternative method of treating obturator foramen hip dislocations that provides a more controlled reduction and less need for assistants.

Traumatic Anterior Hip Dislocation in the Elderly: Description and Review of a Rare Trauma

Background

Traumatic hip dislocation (THD) is an orthopaedic emergency that requires rapid reduction. THD is generally encountered in high-energy trauma. THD with low-energy trauma is extremely rare, even more so in the elderly. Methods/Results. We report the case of a 72-year-old woman who presented to the emergency department with anterior superior left hip dislocation after a low-energy trauma.

Results

The patient was initially treated with closed reduction. Because of recurring dislocation, closed reduction was performed a second time. Magnetic resonance imaging showed no soft tissue interposition. At 12 week follow-up, the patient complained of intractable hip pain and was treated with total hip arthroplasty. The post-operative course was uneventful with a return to pre-injury functional mobility. We also conducted a review of the literature with regard to anterior hip dislocation in the population aged 70 years or more.

Conclusion

THD can be associated with significant morbidity. Time to reduction is considered essential in improving functional outcomes. In the case of poor functional outcomes, total hip arthroplasty should be considered.

Surgical treatment and functional outcome of bilateral symmetrical hip dislocation and Pipkin type II femoral head fracture: a 5-year follow-up case report and literature review

Background

Bilateral posterior hip dislocation and femoral head fracture are rare injuries, which may be the earliest case report that focuses on treatment with open reduction via the direct anterior approach (DAA) for bilateral symmetrical Pipkin type II fracture within 5 years of the follow-up period.

Case report

We present a case of bilateral posterior dislocation with a femoral head fracture (Pipkin II) of the hip in 47-year-old woman caused by a high-velocity accident. The dislocation was successfully reduced under general anesthesia at a local hospital and transferred to a tertiary center for surgical management. She was surgically treated with internal fixation using three Herbert screws on the bilateral hips. The DAA was used during surgery. Follow-up for 5 years was performed, and functional outcomes were evaluated using the D'Aubigné range of motion and modified Harris hip score. The range of motion in the bilateral hip was satisfactory, with no signs of post-traumatic arthritis, heterotopic ossification, or avascular necrosis of the femoral head.

Conclusion

Surgical management of bilateral Pipkin type II fractures was performed successfully with open reduction and internal fixation using a safe and reliable direct anterior approach, with good functional outcomes at 5-year follow-up.

Management of femoral head fracture by Ganz surgical dislocation of the hip

INTRODUCTION

Posterior hip dislocation is the commonest type of hip dislocation. It is associated with femoral head fracture in 7% of cases. Urgent and congruent hip reduction is mandatory to improve clinical outcomes and avoid irreversible complications. The purpose of this study is to assess the safety and functional and radiological outcomes of surgical hip dislocation by Ganz technique for treatment of femoral head fracture.

PATIENTS AND METHODS

In this retrospective study, 18 cases of femoral head fracture were included. Six cases had Pipkin type I and 12 had Pipkin type II fracture. They were treated through surgical hip dislocation. All cases were followed up for at least 24 months. Matta's criteria were used for radiological evaluation (plain radiographs). Functional evaluation was done using Harris Hip Score and modified Merle d'Aubigne and Postel score at final follow-up.

RESULTS

No patients were lost during the follow-up period. No signs of infection or wound dehiscence were noted in this study. There was one case of osteonecrosis. All cases had labral injury, which was debrided. None of our cases needed suture anchor repair of the labrum. Radiographical evaluation according to Matta's criteria yielded anatomic fracture reduction in 17 patients but imperfect in 1 patient. According to Harris Hip Score, four Pipkin type I cases were rated as excellent and two as good. Among cases of Pipkin type II fracture, six were rated as excellent, four as good, one as fair, and one as poor. According to modified Merle d'Aubigne and Postel score, 11 cases had excellent results, 5 cases were rated as good, one as fair, while one case had poor results.

CONCLUSION

Open reduction and internal fixation of femoral head fracture using surgical hip dislocation through Ganz approach is a viable treatment option and provides satisfactory results with low complication rate.

Traumatic Hip Dislocations in Major Trauma Patients: Epidemiology, Injury Mechanisms, and Concomitant Injuries

Introduction: Traumatic hip dislocations (THDs) are severe injuries associated with considerable morbidity. Delayed recognition of fracture dislocations and neurovascular deficits have been proposed to cause deleterious long-term clinical outcomes. Therefore, in this study, we aimed to identify characteristics of epidemiology, injury mechanisms, and associated injuries to identify patients at risk. Methods: For this study based on the TraumaRegister DGU^® (January 2002–December 2017), the inclusion criterion was an Injury Severity Score (ISS) ≥9 points. Exclusion criteria were an isolated head injury and early transfer to another hospital. The THD group was compared to a control group without hip dislocation. The ISS and New ISS were used for injury severity and the Abbreviated Injury Scale for associated injuries classification. Univariate and logistic regression analyses were performed. Results: The final study cohort comprised n = 170,934 major trauma patients. We identified 1359 individuals (0.8%) with THD; 12 patients had sustained bilateral hip dislocations. Patients with THD were predominantly male (79.5%, mean age 43 years, mean ISS 22.4 points). Aortic injuries (2.1% vs. 0.9%, p ≤ 0.001) were observed more frequently in the THD group. Among the predictors for THDs were specific injury mechanisms, including motor vehicle accidents (odds ratio (OR) 2.98, 95% confidence interval (CI) 2.57–3.45, p ≤ 0.001), motorcycle accidents (OR 1.99, 95% CI 1.66–2.39, p ≤ 0.001), and suicide attempts (OR 1.36, 95% CI 1.06–1.75, p = 0.016). Despite a lower rate of head injuries and a comparable level of care measured by trauma center admission, both intensive care unit and total hospital stay were prolonged in patients with THD. Conclusions: Since early diagnosis, as well as timely and sufficient treatment, of THDs are of high relevance for long-term outcomes of severely injured individuals, knowledge of patients at risk for this injury pattern is of utmost importance. THDs are frequently related to high-energy mechanisms and associated with severe concomitant injuries in major trauma patients.

Medium-term outcome and classification of traumatic anterior hip dislocations

INTRODUCTION

Traumatic anterior hip dislocations are subdivided to obturator (inferior) and pubic (superior) dislocations by Epstein's descriptive classification. This rare injury is thought to have favourable clinical outcomes. The incidence of associated femoral head and acetabular injuries has been low in past case series. We sought to revisit this injury and classification in the era of advanced imaging and contemporary surgical techniques.

MATERIALS AND METHODS

A retrospective study of 15 patients treated for anterior hip dislocation was performed. Medical records were reviewed for demographic and surgical data. Imaging studies were revisited to determine direction of dislocation and associated fractures. Patients were assessed for pain, hip function using the modified Harris Hip Score (mHHS), hip range of motion and radiographic changes. Mean follow-up time was 3 years.

RESULTS

Anterior dislocation occurred in an obturator (inferior), pubic (superior) or central direction. 9 patients had concomitant femoral head impaction and 7 patients suffered from acetabular fractures. 8 patients with an anterior hip dislocation underwent surgical treatment. This therapy, along with early range of motion and weight bearing, produced favourable clinical outcomes with 9 patients reporting no pain and an average mHHS of 83.8. 6 patients had heterotopic ossification at latest follow-up.

CONCLUSIONS

Traumatic anterior hip dislocation is commonly associated with femoral head impaction and acetabular injuries which should be addressed operatively when appropriate to produce favourable results. In this paper, we propose a revision to the commonly used descriptive classification system.

Femoral neck fracture combined with anterior dislocation of the femoral head: injury mechanism and proposed novel classification

BACKGROUND

Femoral neck fracture combined with anterior dislocation of the femoral head is very rare. To our knowledge, there is no classification system yet for this rare form of injury, and the injury mechanism of femoral neck fracture combined with obturator head dislocation has not been described in the literature. In this study, we systematically reviewed the literature and the cases treated in our hospital, and identified and classified all injury types according to the injury mechanism of femoral neck fracture combined with anterior dislocation of the femoral head. Further, based on the experience of treating a patient with femoral neck fracture and obturator dislocation of the femoral head, a theoretical hypothesis was proposed for the injury mechanism of this rare type of injury.

METHODS

A comprehensive search was conducted on PubMed, WOS, CNKI database. These fractures were classified according to the dislocation site and injury mechanism (one injury or two injuries).

RESULTS

1891 articles were initially identified through PubMed and other databases, and after bibliographic research, study screening, and removing duplicates, 1455 articles were selected. After applying the exclusion criteria, a total of 18 full-text articles describing femoral neck fractures combined with anterior dislocation of the femoral head. Different dislocation sites have different injury mechanisms. Our classification system, to the best of the authors' knowledge, allowed us to include all types of femoral neck fractures combined with anterior dislocation of the femoral head from the literature. According to the proposed classification system, the morphological features of femoral neck fracture combined with anterior dislocation of the femoral head can be accurately conveyed between doctors.

CONCLUSIONS

All injury patterns can likely be identified using the proposed classification system. This can help avoid confusion in the nomenclature of femoral neck fractures combined with anterior dislocation of the femoral head and help surgeons to more accurately detect lesions, thereby guiding surgical treatment.

Anterior Hip Dislocation: Characterization of a Rare Injury and Predictors of Functional Outcome

BACKGROUND

Anterior native hip dislocation remains poorly studied due to the rarity of the injury. The aim of this study was to describe injury characteristics of anterior hip dislocation, detail its initial treatment, and determine the intermediate term outcomes including the rate of conversion to total hip arthroplasty (THA).

METHODS

A cross-sectional study was performed at a single urban academic Level 1 trauma center for patients who sustained traumatic anterior hip dislocations from 2010-2017. Baseline demographic, injury, and treatment data were recorded. Patients were contacted to inquire about subsequent surgery and complete functional outcome questionnaires. Available post-operative radiographs were also reviewed.

RESULTS

Thirty-two anterior hip dislocations met inclusion criteria and were included in the study. 69% of dislocations were obturator dislocations and 31% iliac dislocations. Only 22% were simple dislocations with the remainder having an associated femoral head fracture and/or acetabular fracture. Iliac dislocations were more likely to be associated with acetabular fractures and require surgical treatment while obturator dislocations were more likely to be simple dislocations or have femoral head fractures. Excluding two patients treated with acute THA at the time of injury, follow-up information was available for 16 patients at a minimum of eighteen months from the time of injury. Only one required subsequent conversion to THA. For the remaining fifteen patients, modified Harris hip scores (mHHS) averaged 82.6, PROMIS global physical health averaged 51.9, and PROMIS global mental health averaged 48.3 with mean follow-up of 4.2 years. mHHS was significantly higher for obturator dislocations and a negative association was seen with age.

CONCLUSIONS

Obturator dislocations occurred twice as frequently as iliac dislocations. Associated acetabular or femoral head fractures are common. Conversion to THA was low, occurring in only 1 of 16 patients not treated with acute arthroplasty. Obturator dislocations and age less than 45 years old at the time of injury were associated with better functional outcome at intermediate term follow-up.

Decoding the behaviour of extracapsular proximal femur fracture- dislocation - A systematic review of a rare fracture pattern

PURPOSE

Proximal femoral extracapsular fractures with associated ipsilateral hip dislocation is an extremely rare pattern of injury. These fractures may be associated with a spectrum of severity from isolated trochanteric fractures to comminuted intertrochanteric and subtrochanteric fractures with hip dislocation. To date, this pattern of injury is not described in any injury classification system and no clear cut guidelines for the same are available. The aim of this review is to provide an evidence based pooled analysis of the existing literature and develop guidelines that help surgeons tackle this rare injury pattern.

METHODS

A comprehensive review of the literature was undertaken using the PRISMA. Case reports and series of Extracapsular proximal femoral fracture dislocations published in PubMed, EMBASE, Springer, OvidSP, ScienceDirect, Web of Science and Google scholar between inception of journals to May 2020 were included in the review. A pooled analysis comparing the demography, pattern of the fracture, mode and mechanism of injury with the clinical and radiological outcome and complications was performed.

RESULTS

52 cases from 46 case studies were included in the pooled analysis. There was a near significant association between avascular necrosis and mean time to reduction (p = 0.0865). Individuals with compound injury had 10.12 times higher risk of avascular necrosis (p = 0.009). No significant association between the pattern of proximal femur fracture and incidence of avascular necrosis (p = 0.116, chi-square). There was no significant association between polytrauma and poor clinical outcomes. (p = 0.231).

CONCLUSIONS

Principles of damage control orthopaedics should be followed in unstable patients with this rare fracture dislocation. Percutaneous Schanz screw reduction manoeuvre can be attempted gently with a low threshold to perform an open reduction. Every attempt at salvaging the fractured hip must be performed in young individuals with an arthroplasty standby for comminuted and unreconstructable cases.

Treatment of Pipkin type I fracture using safe surgical hip dislocation: A case report

We report the clinical and radiological outcomes of a 30-year-old female with femoral head fracture following a posterior hip dislocation. The patient was managed using safe surgical hip dislocation. She had a pain free range of motion of the hip at 1 year postinjury.

Management of Neglected Traumatic Hip Dislocation in Children

BACKGROUND

Neglected traumatic hip dislocation in children is uncommon and there is no consensus on appropriate management. Previous studies report varied operative management with high rates of avascular necrosis and postoperative subluxation/dislocation. We report a series of 7 consecutive cases who underwent operative reduction after neglected hip dislocation and describe our technique for treatment.

METHODS

All 7 children sustained posterior dislocations and had no treatment before presentation at our institution. An associated marginal acetabular fracture was present in 2 cases. One additional patient was excluded from the study due to complete loss of articular cartilage that precluded open reduction. The mean time before surgical intervention was 13.1 months (4 to 36 mo) with a mean age of 7 years (5.3 to 10.8 y). All children underwent preoperative skeletal traction for 10 to 14 days. A postero-lateral approach was used in all cases. The acetabulum was cleared of scar tissue and a femoral shortening performed as required (5 cases). Minor erosion of the articular cartilage of the posterior aspect of the femoral head was noted in 3/6 cases. After reduction, a posterior capsulorrhaphy was performed and the patient immobilized in a hip spica for 6 to 12 weeks.

RESULTS

The mean follow-up was 44 months (33 to 56 mo). The majority of children (86%) could walk and run without a limp, could squat, and had no pain. One child had mild pain and a limp. Mean Harris Hip Score was 98.9. No hip subluxed or dislocated postoperatively. The radiographs at latest follow-up showed no evidence of growth disturbance in 29% of cases, coxa magna in 57%, and partial femoral head collapse in 1 case (14%). Of note, those patients managed within 8 months of injury had none or minimal evidence of growth disturbance.

CONCLUSIONS

At medium-term follow-up, open reduction with a postero-lateral approach, posterior capsulorrhaphy, and femoral shortening (as required) produces a satisfactory outcome with a stable, congruent reduction. Good clinical function can be expected with a low incidence of avascular necrosis.

LEVEL OF EVIDENCE

Level IV.

Modified Ludloff's medial approach for management of Pipkin's type I femoral head fracture

INTRODUCTION

Numerous approaches were described for the management of Pipkin's type I fracture with no consensus on the "standard of care". The strategic thinking of the ideal access is through the medial approach.

MATERIAL AND METHODS

Using Ferguson intermuscular interval, prospective study was done (January 2014-2019) to evaluate radiological and functional outcomes using HHS and Thompson-Epstein criteria. Fracture patterns were subclassified: anterior and posterior-inferior (AI/PI) requiring different reduction positions.

RESULTS

Twenty-one patients (mean FU = 24.3 months (range, 12-48)) were divided into 14 (67.7%) AI and seven PI. Excision was performed in five (23.8%) (AI = 3 (14.3%) and PI = 2) and ORIF in 16 (AI = 11 (52.4%) and PI = 5). At the last follow-up, two (9.5%) were graded as excellent, 11 (52.4%) as good, three (14.3%) as fair, and five as poor.

CONCLUSION

Modified Ludloff's approach provides safe easy direct access to fracture allowing easy excision or direct anatomical reduction, perpendicular compression, and rigid fixation with minimal complications.

Transfer of osteochondral shell autografts to salvage femoral head impaction injuries in hip trauma patients

INTRODUCTION

Femoral head impaction defects are observed with variable severity, as a result of traumatic hip dislocations which can be caused by traffic accidents or seen in professional athletes amongst other mechanisms. Compression of the articular cartilage and the subchondral bone into the femoral head results in irregular articular surfaces influencing the outcome with predisposition to osteoarthritis, and being predictive for the need for delayed total hip replacement. This study reports the outcome after a minimum follow-up (FU) of five years in a consecutive series treated with transfer of osteochondral shell autografts in hips (TOSAH) from the head-neck junction into the defect using surgical hip dislocation.

PATIENTS AND METHODS

Between 06/2007 and 03/2014 a series of twelve consecutive patients (mean age: 35yrs, range 18-53; median Injury Severity Score: 12, range 9-27) sustained a traumatic posterior hip dislocation in combination with acetabular and/or Pipkin fractures and were inter alia treated using TOSAH using surgical hip dislocation. Conversion to total hip replacement (THR) during FU was noted as failure. Patients were clinically (Merle d'Aubigné score) and radiographically assessed for occurrence of osteoarthritis (OA), avascular necrosis (AVN) and/or heterotopic ossification (HO) at a minimal follow-up of five years.

RESULTS

Mean follow-up was 6.9 years (5.0-11.6). At five-year follow-up, we found a survivorship of 57.1% (95% Confidence interval {CI}, 46.7-100%). Four patients required conversion to a total hip replacement at 11, 16, 28 and 44 months respectively after the TOSAH procedure due to osteoarthritis progression. One patient required conversion to a total hip replacement 12 months after TOSAH procedure due to AVN. One patient was lost to follow-up after 2.7 years. The remaining six patients with preserved hips presented with a median Merle-d'Aubigné score of 16 points (range: 14-18) and no AVN. Two patients showed asymptomatic grade I osteoarthritis according to Tönnis at latest follow-up and three patients showed mild asymptomatic HO according to Brooker (Grade I-II).

CONCLUSION

The presented technique can be used as a salvage procedure for severely injured hip joints and to preserve the hip joint at midterm with satisfying clinical and radiological outcomes.

Understanding a Rare Injury: An Observational Study of Anterior-Superior Hip Dislocations

OBJECTIVE. The goals of this study were to assess the prevalence of anterior hip dislocation and to highlight the distinctive imaging features of anterior-superior hip dislocation. MATERIALS AND METHODS. A retrospective chart review was conducted of all hip dislocations seen at one university hospital from January 2005 to January 2019. The radiology database was queried for all reports of hip or pelvis radiographs with the word "dislocation." Cases of developmental dysplasia of the hip, infection, tumor, arthroplasty, Girdlestone procedure, surgical dislocation, and prior hip surgery were excluded, leaving 237 traumatic hip dislocations. Electronic medical records of the 18 cases of anterior hip dislocation were reviewed to determine the mechanism of injury, treatment, and subsequent outcomes. RESULTS. Among 237 traumatic hip dislocations, 18 (7.6%) were anterior hip dislocations. Among the 18 were three (17%) anterior-superior dislocations and 15 (83%) anterior-inferior dislocations. All anterior-superior dislocations had poor outcomes. One patient had persistent hip pain and instability and underwent follow-up imaging. In one case, MRI performed at the time of injury and 11 months later showed tears of the superior capsule, iliofemoral ligament, and ligamentum teres. The iliofemoral ligament tear did not heal, resulting in a persistent anterior capsule defect, a finding previously associated with instability in patients who have undergone arthroscopic surgery. CONCLUSION. The incidence of anterior hip dislocation was lower than some studies have suggested. Anterior-superior hip dislocation is a rare injury in which ligamentous defects are visualized at MRI and possibly contribute to anterior hip instability and pain.

Intrapelvic Femoral Head Dislocation without Associated Proximal Femur Fracture: A Case Report and Description of Closed Reduction Technique

Traumatic hip dislocations are potentially devastating injuries, especially in young patients, and require emergent orthopedic treatment. Given the significant amount of energy required to cause these injuries, a high index of suspicion is necessary to identify related injuries. The associated injuries, direction of dislocation, and time between injury and reduction represent the known prognostic factors, based on limited available research. Intrapelvic hip dislocations represent an uncommon variant of the traumatic hip dislocation, with all previously reported cases involving ipsilateral proximal femur fractures. We present a case of intrapelvic femoral head dislocation without an associated proximal femur fracture, as well as the maneuvers used to treat the patient via a closed reduction.

3D printing-based Ganz approach for treatment of femoral head fractures: a prospective analysis

BACKGROUND

Femoral head fractures are uncommon injuries. Open reduction and internal fixation (ORIF) of femoral head fracture is the preferred treatment for most patients. There are several surgical approaches and treatments for this difficult fracture. However, the optimal surgical approach for the treatment of femoral head fracture remains controversial. Meanwhile, the operation is difficult and the complications are numerous. We prospectively reviewed patients with femoral head fractures managed surgically through the 3D printing-based Ganz approach to define a better approach with the least morbidity.

PATIENTS AND METHODS

Between 2012 and 2017, a total of 17 patients were included in this study. An exact 1:1 3D printing model of the injured hip side was fabricated for each patient and simulated surgery was finished preoperative. The surgical approach was performed as described by Ganz. Functional assessment was performed using the modified Merle d'Aubigne scores. The reduction of the fracture was evaluated according to Matta's criteria. The incidence of complications, such as heterotopic ossification (HO) and avascular necrosis (AVN), and the need for additional surgery were also documented.

RESULTS

Twelve of 17 patients (four females and eight males) were available for 2 years follow-up. The mean follow-up was 35 months (25-48 months). Average age for the 12 patients was 39.9 ± 12.2 years. According to the Pipkin classification, four patients were type I fracture, three patients were type II fracture, and five patients were type IV fracture. The mean operative time was 124.2 ± 22.1 min, and the estimated blood loss was 437.5 ± 113.1 ml. According to Merle d' Aubigne scores, excellent results were achieved in six of the 12 patients; four good and two poor results occurred in the rest of the patients. On the radiograph evaluation, fracture reduction was defined as anatomical in eight patients, and imperfect in four. Most patients had good outcomes and satisfactory hip function at last follow-up. Almost all great trochanteric osteectomy healed uneventfully. One patient developed symptomatic AVN of the femoral head and underwent THA at 3 years. After THA, she regained a good hip function with the ability to return to work and almost no reduction in sports activities. Heterotopic ossification was found in four cases (type I-1, type II-2, and type III-1).

CONCLUSIONS

The 3D printing-based Ganz approach provides a safe and reliable approach and satisfactory results of treatment in femoral head fractures. Using 3D printed model for the fracture of the femoral head, the fracture can be viewed in every direction to provide an accurate description of fracture characteristics, which contributes to make a reasonable surgical plan for patients. In addition, the 3D printing-based Ganz approach can obtain excellent surgical exposure and protection of the femoral head blood supply, reduce the operation time and intraoperative blood loss, make the precise osteotomy, anatomically fix the intra-articular fragments, and effectively reduce postoperative complications.

TRIAL REGISTRATION

We register our research at http://www.researchregistry.com . The Unique Identifying Number (UIN) from the Research Registry of the study is researchregistry4847 .

Novel Treatment for Recurrent Posttraumatic Hip Instability: A Case Report

CASE

A 26-year-old woman sustained a traumatic right hip dislocation with posterior wall component in a motor vehicle collision. Initial treatment consisted of open reduction internal fixation of her posterior wall fracture. Six years later, she developed low-energy recurrent hip instability. Imaging demonstrated posterior capsular insufficiency and femoral retrotorsion. The patient underwent intertrochanteric femoral rotational osteotomy. Nine years postoperatively, the patient has returned to activity without restriction or subsequent dislocations.

CONCLUSIONS

Recurrent posttraumatic hip instability requires careful identification of the etiology of instability. This case provides long-term follow-up after successful treatment with intertrochanteric femoral rotational osteotomy.

Obturator dislocation of the femoral head combined with ipsilateral femoral neck and pubic fractures: A rare case report

RATIONALE

Obturator dislocation of the femoral head combined with ipsilateral femoral neck and pubic fracture is a rare injury. We used cannulated screws combined with a femoral neck medial plate for the first time to treat this type of injury and achieved good follow-up results.

PATIENT CONCERNS

The patient was hospitalized due to an accident resulting in swelling and deformity accompanied by limited mobility of the right hip and left knee.

DIAGNOSES

X-ray examination and computed tomography confirmed that the patient suffered from right hip obturator dislocation, femoral head and neck fracture, pubic fracture, as well as open fracture of the left femoral shaft.

INTERVENTIONS

Open reduction and internal fixation with cannulated screws and a medial support plate of the femoral neck were performed for the right hip obturator dislocation, femoral head and neck fracture, and the pubic fracture. Artificial bone grafting was performed to support the femoral head defect. Debridement and the second phase of internal fixation were executed to cure the open fracture of the left femoral shaft.

OUTCOMES

The patient was followed-up for 6 months and showed good hip function. X-ray examination and computed tomography indicated that the fractures healed well without fracture displacement or loosening of the implants. Meanwhile, there were no signs of femoral neck valgus and femoral head necrosis observed.

LESSONS

The combination of cannulated screws and medial support plate was suggested for the treatment of hip obturator dislocation and femoral head and neck fracture. Furthermore, partial weight loading exercise should be performed promptly to reduce the risk of muscular atrophy and myasthenia.

Cortical Impaction in Posterior Wall Acetabular Fractures

OBJECTIVES

To report the incidence of patients with extra-articular posterosuperior acetabular cortical impaction associated with a posterior wall acetabular fracture-dislocation.

DESIGN

Retrospective case series.

SETTING

Regional Level 1 trauma center.

PATIENTS/PARTICIPANTS

Ninety-seven patients who sustained an isolated posterior wall acetabular fracture-dislocation from July 2007 until July 2017.

INTERVENTION

The medical record and the computed tomography (CT) scan of the abdomen and pelvis were reviewed including axial, coronal, and sagittal reconstruction images and 3D surface renderings.

MAIN OUTCOME MEASUREMENTS

Each pelvic CT scan was evaluated for impaction of the extra-articular posterosuperior acetabular cortical surface associated with posterior wall acetabular fracture-dislocations. The reduction accuracy was assessed for each patient with cortical impaction using postoperative CT scans. The final attending radiology report was reviewed to see whether the cortical impaction was noted.

RESULTS

Four of the 99 patients (4.12%) had identifiable areas of cortical impaction on preoperative CT imaging. Reduction accuracy demonstrated 1 anatomical reduction, 2 imperfect reductions, and 1 poor reduction. The final attending radiologist report did not comment on any patient with cortical impaction.

CONCLUSIONS

Our study demonstrates that a small number of patients sustain cortical impaction of the posterosuperior acetabular cortical surface along with their posterior wall acetabular fracture-dislocation. Although uncommon, preoperative imaging should be scrutinized to identify this clinical entity. As part of the preoperative plan, the surgeon can anticipate the cortex available for reduction verification and whether any additional steps or altered surgical approaches are needed to achieve an anatomical reduction.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

An Unusual Presentation of Pubic-type Anterior Hip Dislocation with Concomitant Anterior and Posterior Acetabular Wall Fracture

Anterior hip dislocation is uncommon, comprising only 5%-15% of hip dislocations. It usually occurs following a severe external rotation and abduction injury. These injuries are occasionally associated with acetabular fractures, which generally occur in the direction of dislocation. We describe a rare case of pubic-type anterior hip dislocation with concomitant anterior and posterior acetabular wall fractures in a young male following a road traffic accident. The dislocation could not be reduced by closed means and open reduction had to be performed. Reduction of the hip allowed the wall fragments to fall back to their place and the hip remained stable. At the one-year follow-up, the clinical and radiological results were excellent. This case also emphasizes the importance of early diagnosis and prompt reduction in the successful management of these types of injury.

Asymmetric bilateral hip dislocation in young man: a case report

Bilateral hip dislocation is a rare event, asymmetric dislocation is even rarer. Due to the intrinsic stability of the hip joint this lesions usually follow a high energy trauma. Because of the common associated lesions, the initial clinical assessment should be performed thoroughly. CT scan rather than x-rays offers a complete survey of these possible associated injuries such as thoracic or abdominal bleedings, neurologic lesions or fractures directly associated with the hips dislocations. The first goal should be reduction of the dislocation to prevent avascular necrosis (AVN) of the femoral head and arthritis. We report a case of a young man with right anterior hip dislocation and left posterior hip dislocation with associated fracture of the posterior wall. (www.actabiomedica.it)

Hip dislocations and concurrent injuries in motor vehicle collisions

INTRODUCTION

Motor Vehicle Collisions (MVC) can cause high energy hip dislocations associated with serious injury profiles impacting triage. Changes in safety and regulation of restraint devices have likely lowered serious injuries from what was previously reported in the 1990s. This study aims to describe modern-day injury profile of patients with traumatic hip dislocations, with special attention to aortic injury.

METHODS

Retrospective review of a prospectively maintained trauma database at an urban level 1 trauma center was conducted. Patients with hip dislocation following MVC between January 2005 and December 2015 were grouped based on seatbelt use and airbag deployment. Patients with unknown restraint use were excluded. Multiple logistic regression was used to identify risk of injury profile between groups.

RESULTS

Of 204 patients with hip dislocation after MVC, nearly 57% were unrestrained. Seatbelt alone was used in 36 (17.7%), airbag deployed in 14 (6.9%), and 38 (18.6%) with both. Gender and number of injuries were similar between groups. The most common concomitant injury was acetabular fracture (53.92%) and the abdominopelvic region was the most injured. Use of a seatbelt with airbag deployment was protective of concomitant pelvic ring injury (OR = 0.22). Airbag deployment was significantly protective of lumbar fracture (OR = 0.15) while increasing the likelihood of radial and ulnar fracture or dislocation (OR = 3.27), acetabular fracture (OR = 5.19), and abdominopelvic injury (OR = 5.07). The no restraint group had one patient (0.80%) with an intimal tear of the thoracic aorta identified on CT chest that was successfully medically managed.

DISCUSSION AND CONCLUSION

Hip dislocations are high energy injuries with severe associated injuries despite upgrades in restraint devices. These patients require careful examination and heightened awareness when evaluating for concomitant injuries.

Posterior hip dislocation in a non-professional football player: a case report and review of the literature

The majority of injuries during a football game are contusions, sprains and/or strains in the thigh, knee and ankle. Hip dislocations account for 2-5% of total hip dislocations, and they can be posterior or anterior. Major complications of traumatic hip dislocation include avascular necrosis of femoral head, secondary osteoarthritis, sciatic nerve injury and heterotopic ossification. On the occasion of a case of a 33-year-old football player, who suffered a posterior hip dislocation, associated with a posterior wall fracture of the acetabulum, while playing football, we review the literature and analyze the various mechanisms of injury, the possible complications and the management including surgery and rehabilitation.

Asymmetrical traumatic bilateral hip dislocations with hemodynamic instability and an unstable pelvic ring: Case report and review of literature

Simultaneous anterior and posterior traumatic dislocations of both hips are very rare. Only 33 cases have been previously reported in the English language literature. Although they were all due to high-energy injuries, they were hemodynamically stable and had a stable pelvic ring. We report a unique case of asymmetrical hip dislocations with an unstable pelvic ring and hemodynamic instability. A 40-year-old man was injured in a high-energy motor vehicle accident. He was hemodynamically unstable when he presented in the emergency department. Radiolographs showed asymmetrical dislocations of both hips with an unstable pelvic ring. Under general anesthesia, he had closed reduction of the dislocations of both hips, followed by temporary stabilization with an external fixator. Transcatheter arterial embolization was performed to stop active pelvic bleeding. Delayed open reduction and internal fixation was performed 12 d later with anterior and posterior plates. The patient recovered well with an uneventful post-operative course. Asymmetrical bilateral hip dislocations with pelvic ring instability caused by trauma, as presented in this case, is very rare and potentially life threatening. Prompt treatment can give a good outcome.

Conscious sedation versus rapid sequence intubation for the reduction of native traumatic hip dislocation

BACKGROUND

Traumatic hip dislocations (THD) are a medical emergency. There is debate whether the painful reduction of a dislocated hip should be first attempted using primary conscious sedation (PCS) or primary general anesthesia (PGA) METHODS: All cases of native THD from 2006 to 2015 in the trauma registry of a level 1 trauma center were reviewed. The primary outcome was successful reduction of the THD.

RESULTS

67 patients had a native, meaning not a hip prosthesis, THD. 34 (50.7%) patients had successful PCS, 12 (17.9%) failed PCS and underwent reduction following PGA. 21 (31.3%) underwent PGA. Patients in the PGA group were more severely injured. Time to reduction greater than 6 h was associated with PCS failure (Odds ratio (95% confidence interval) 19.75 (2.06,189.10) p = 0.01).

CONCLUSION

Clinicians treating patients with a THD can utilize either PCS or PGA with many patients safely reduced under PCS. However, patients whose hip have been dislocated for more than 6 h are at risk for failure with PCS, and are good candidates for PGA.

Safe Positioning for Sexual Intercourse After Proximal Femoral Replacement

Hip arthroplasty is a common procedure used for the treatment of fractures and degenerative processes affecting the hip. Proximal femoral replacement is an uncommon type of hip arthroplasty used for reconstruction after extensive bone loss. Proximal femoral replacement is used most commonly after the resection of the proximal femur for malignancies and for extensive bone loss encountered in revision hip arthroplasty and occasionally for extensive bone loss after fractures. The authors present a case of a female patient who sustained a prosthetic dislocation of her proximal femoral replacement during sexual intercourse. Standard hip arthroplasty itself can pose a risk factor for dislocation associated with certain sexual positions. Proximal femoral replacement surgery likely carries an increased risk for dislocation, given the magnitude of soft tissue loss at the time of resection. The authors believe that routine perioperative conversations for sexually active patients with proximal femur replacements should include this potential risk and discuss appropriate positioning to prevent a potential dislocation. [Orthopedics. 2018; 41(2):e292-e294.].

Acetabular Fractures in Children and Adolescents: Comparison of Isolated Acetabular Fractures and Acetabular Fractures Associated With Pelvic Ring Injuries

OBJECTIVES

To compare mechanism of injury, fracture pattern, displacement, clinical, and radiographic outcome of isolated acetabular fractures (group 1) versus acetabular fractures associated with a pelvic ring injury (group 2).

DESIGN

Retrospective cohort comparative analysis.

SETTING

Private orthopaedic practice associated with a level one teaching trauma center.

MAIN OUTCOME MEASUREMENTS

Mechanism of injury, fracture pattern, displacement and treatment, Glasgow Coma Scale, Injury Severity Score, leg length discrepancy (LLD), and hip dysplasia.

PATIENTS

Thirty-two children (group 1: 12 fractures; group 2: 25) were classified as 9 A1, 21 A3, 3 B1, 3 B2, and 1 B3 OTA/AO types. Eighteen children (22 fractures) were included with average follow-up of 33.3 months (6-84). The average age was 12.8 years (4-16).

RESULTS

Main fracture pattern (75%) in group 1 was a posterior wall fracture (A1) caused by falls and sports in 50%. Six socket injuries had a hip dislocation, present only in group 1 (P < 0.001). The majority (84%) in group 2 had anterior wall/column (A3) fractures, caused by traffic accidents (88%). Fracture displacement in group 1 was higher than in group 2 (3.8 vs. 0.8 mm; P = 0.009). Group 2 had a lower Glasgow Coma Scale (P = 0.031) and a higher Injury Severity Score (P < 0.001). Nine (24%) fractures were treated operatively, significantly more were in group 1 (P < 0.001). Three (14%) children had complications including (LLD) (2) or hip dysplasia (2).

CONCLUSION

Compared with isolated pediatric acetabular fractures, fractures associated with pelvic ring injuries have less displacement and are less likely to require operative treatment, but they show more associated injuries. Because of potential hip joint growth disturbance, LLD and hip dysplasia can occur.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Traumatic Obturator Dislocation Following Total Hip Arthroplasty Managed with Closed Reduction: A Case Report and Review of the Literature

CASE

A 30-year-old man sustained an obturator dislocation of a left total hip prosthesis with a concomitant ipsilateral fracture of the greater trochanter following a high-energy motor-vehicle accident. With the patient under general anesthesia, the hip was successfully treated with closed reduction, as confirmed with intraoperative fluoroscopy and postoperative radiographs. Postreduction, the patient was able to mobilize with abduction restrictions and had no additional instability. Short-term follow-up showed evidence of healing of the greater trochanter.

CONCLUSION

Obturator dislocation of a total hip prosthesis is an exceedingly rare injury. Closed reduction can be considered as a treatment option in the appropriate patient, with a satisfactory short-term outcome.

Late versus early reduction in traumatic hip dislocations: a meta-analysis

AIMS

Traumatic hip dislocations are considered orthopaedic emergencies that are treated with urgent reduction to decrease the rate of osteonecrosis of the femoral head. The aim of our study was to systematically review the literature that compares late (>6 h from the time of injury) to early (<6 h from the time of injury) reduction in all traumatic hip dislocations.

MATERIALS AND METHODS

We searched five databases from 1951 to 2016 for studies that evaluated timing of reduction and osteonecrosis of the femoral head in all traumatic hip dislocations. We performed a meta-analysis using a random-effects model to pool odds ratios (ORs) for a comparison of osteonecrosis of the femoral head between patients undergoing late versus early hip reduction. We also investigated the osteonecrosis rate in low- and high-grade traumatic hip dislocations. Descriptive, quantitative and qualitative data were extracted.

RESULTS

Of the 13 articles identified, five studies (retrospective cohort studies) were eligible for the meta-analysis, encompassing a total of 236 traumatic hip dislocations. The pooled odds ratio for osteonecrosis of the femoral head between late and early reduction was in favour of early hip reduction and statistically significant (OR = 5.00, 95% CI: 1.30, 19.29). No significant difference in the rate of osteonecrosis of the femoral head was detected between low- and high-grade traumatic hip dislocations according to the time threshold (OR = 1.71, 95% CI: 0.22, 13.22).

CONCLUSIONS

The cumulative evidence at present does indicate an association between late hip reduction and higher rate of osteonecrosis of the femoral head in all traumatic hip dislocations. Hence, all traumatic hip dislocations should be reduced as soon as possible to decrease the rate of osteonecrosis of the femoral head. However, the evidence does not indicate an association between the grade of dislocation and rate of osteonecrosis of the femoral head.

LEVEL OF EVIDENCE

III.

An unusual case of traumatic bilateral hip dislocation without fracture

Bilateral traumatic hip dislocations are extremely rare. Most of these are related to acetabular or proximal femoral fractures, consisting of complex lesions, and are rarely pure ligamentous injuries. Posterior dislocation is the most frequent. Some dislocations are accompanied by sciatic nerve palsy. The present case is a posterior bilateral hip dislocation with no other associated lesions, there are very few reports published with this clinical setting. The patient had good functional outcome.

Results of 167 consecutive cases of acetabular fractures using the Kocher-Langenbeck approach: a case series

Background

Acetabular fractures are quite challenging injuries for the orthopedic surgeon because of their low incidence and their deep and complex anatomy. The objective of this study was to evaluate surgeon-independent parameters that might influence radiographic outcome and early complication rates of high-energy acetabular fractures treated by open reduction and internal fixation via the Kocher-Langenbeck approach, the golden standard for posterior access.

Methods

One hundred sixty-seven consecutive patients (111 males and 56 females) with a mean age of 41.8 years and a mean follow-up period of 10 months were surgically treated by one experienced surgeon at a level I trauma center within 10 years. To quantify the radiographic outcome, the Matta, Brooker, and Epstein grades were used. Posttraumatic arthritis and avascular necrosis of the femoral head (defined as Helfet grades 3 or 4 and Ficat/Arlet stages 3 or 4, respectively) were evaluated. Furthermore, subgroup analyses according to fracture type, age, and gender were performed for each outcome measure and complication (infection, hemorrhagic shock, revision surgery, nerve damage, and need of a total hip arthroplasty).

Results

65 A1, 34 A2, 51 B1, and 17 B2 fractures were identified according to the AO/ASIF classification. Of all patients, reduction was rated anatomic in 63.5%, imperfect in 22.2%, and poor in 14.4%. Degenerative changes were observed in 49.7%; 37.9% were affected by heterotopic ossification, 21.6% by posttraumatic arthritis, and 5.4% by avascular necrosis of the femoral head. Fifteen percent were diagnosed with a nerve damage, and 4.8% sustained an infection. Total hip arthroplasty was performed in 10.2%. Revision surgery due to secondary loss of reduction, seroma/hematoma, and wound infection was indicated in 6.0%.

Conclusions

Fracture type, age, and gender are prognostic factors for the surgical outcome after ORIF of high-energy acetabular fractures.

Electronic supplementary material

The online version of this article (doi:10.1186/s13018-017-0563-6) contains supplementary material, which is available to authorized users.

Bilateral asymmetrical hip dislocation with one side obturator intra-pelvic dislocation. Case report

•

Hip dislocation is considered an orthopedic emergency and should be reduced as soon as possible to decrease rate of complications.

•

Bilateral hip dislocation is very rare and usually results from high energy trauma mostly motor vehicle collisions.

•

Asymmetrical bilateral simultaneous hip dislocation with one hip dislocated intra-pelvic through the obturator foramen is rare.

•

Complex dislocation might better be reduced in the theatre.

Introduction

Hip dislocations usually occur as a result of motor vehicle accidents and require high energy trauma. Bilateral hip dislocations are rare compared to unilateral ones. Most reported cases are asymmetrical simultaneous bilateral anterior and posterior dislocations.

Case presentation

This case report describes a 32years female passenger who was involved in road traffic accident and had bilateral asymmetrical hip dislocations with one side posterior and the other side obturator intra-pelvic dislocation. Concentric reduction was achieved by closed reduction of both sides under general anesthesia but the patient required skeletal traction applied to the unstable side for three weeks.

Discussion

Hip dislocation is considered an orthopedic emergency and should be reduced as soon as possible to decrease rate of complications. Since hip dislocation usually occurs with high energy trauma so looking for associated injuries is of paramount importance and assessing such patients should be done according to advanced trauma life support.

Conclusion

Obturator intra-pelvic hip dislocation is challenging case and can be treated by closed reduction.

Surgical dislocation of the hip without trochanteric osteotomy

BACKGROUND

Surgical dislocation of the hip remains an important alternative in hip preservation surgery, especially when a dynamic access to the hip is needed and arthroscopy is not a suitable option. We describe a novel technique for operative dislocation of the hip without trochanteric osteotomy and the clinical results of our patients.

METHODS

Surgical dislocation of the hip without trochanteric osteotomy was done through a modified lateral approach in all of the cases. A review of demographic, clinical, and radiological data was done in all of the patients operated with this technique between 2010 and 2015. Complications, walking aids, weight-bearing status, and modified Harris Hip Score (mHHS) were also recorded.

RESULTS

Six surgical dislocations of the hip were carried out. Indications were tumor resection in five and bulletectomy in one hip. There were two women (four hips) and two men. Mean age was 19 ± 3.8 years. Median follow-up was 2.5 years (range 2-4.5 years). Median mHHS was 92 (90-96). There were no intraoperative nor postoperative complications.

CONCLUSIONS

Surgical dislocation of the hip without trochanteric osteotomy through a modified lateral approach appears to be a safe, simpler, and effective alternative.

Ipsilateral obturator type of hip dislocation with fracture shaft femur in a child: a case report and literature review

The incidence of traumatic hip dislocations in children is rising in this fast developing world along with increasing numbers of high-velocity road traffic accidents. Anterior dislocation of the hip has a lower incidence compared with posterior dislocation of the hip. We encountered a rare case of the obturator type of anteriorly dislocated hip associated with ipsilateral fracture of the shaft femur in an 11-year-old child. This is a highly unusual injury combination and the mechanism of injury is obscure. Only two similar cases have been reported in the English literature to date. Closed reduction of the hip using a hitherto undescribed technique and an intramedullary interlocking nail was performed in this case. At 6 months of follow-up, the fracture shaft femur has united and the child is bearing full weight on the limb.

Fixation of a fractured femoral head through a medial hip approach: an original approach to the femoral head

The decision to treat a femoral head fracture conservatively or surgically is the subject of ongoing debate. Several surgical approaches have been proposed for the open reduction and internal fixation of femoral head fractures. To our knowledge, fixation through a minimally invasive medial approach has not been described until now. The novel medial hip approach passes between the adductor muscle bellies posteriorly and their aponeuroses anteriorly. It provides direct access to the fracture site and allows for fixation by compression, without needing to dislocate the hip or detach the muscles. Any loose bodies in the joint that cannot be fixed can also be removed during the procedure. These features make the medial hip approach a clinically-relevant treatment option for the surgical management of femoral head fractures.

Treatment of Hip Dislocations and Associated Injuries: Current State of Care

Hip dislocations, most often caused by motor vehicle accidents or similar high-energy trauma, traverse a large subset of distinct injury patterns. Understanding these patterns and their associated injuries allows surgeons to provide optimal care for these patients both in the early and late postinjury periods. Nonoperative care requires surgeons to understand the indications. Surgical care requires the surgeon to understand the benefits and limitations of several surgical approaches. This article presents the current understanding of hip dislocation treatment, focusing on anatomy, injury classifications, nonoperative and operative management, and postinjury care.

Novel Technique for Femoral Head Reconstruction using Allograft following Obturator Hip Dislocation

Introduction:

Obturator hip dislocations with an associated osteochondral fracture of the femoral head are uncommon. The treatment of these injuries is challenging and the functional outcomes are poor. Though the injury pattern has been described previously in literature, there are few published reports regarding treatment options. This case report illustrates a novel technique for fixation and stabilization for an unusual injury involving an obturator hip dislocation and an osteochondral impaction fracture of the femoral head.

Case Presentation:

A 30-years old African American male, involved in a motor vehicle collision, sustained an obturator dislocation of the left hip with a large posterior osteochondral fracture of the femoral head. An emergency closed reduction procedure was performed followed by a computed tomography (CT) scan of the hip joint which demonstrated a large osteochondral defect (25 x 10 mm, depth: 5 mm) of the femoral head, visualized within the weight-bearing area. Surgical intervention was planned as a fracture of the femoral head with a defect deeper than four millimeters has been shown to be a risk factor for the development of post-traumatic arthritis, often with onset of symptoms within 5 years of the date of injury. Following surgical hip dislocation, the defect of the femoral head was reconstructed with implantation of a femoral head allograft and internal fixation. At the six months follow-up, the patient could ambulate with minimal pain and without assistive devices. Radiographs demonstrated maintenance of articular congruity with no evidence of implant failure, post-traumatic arthritis or avascular necrosis.

Conclusion:

Surgical hip dislocation and reconstruction using femoral head allograft used to treat obturator hip dislocations with concomitant femoral head impaction fractures can lead to satisfactory short term functional outcomes.

Ipsilateral Traumatic Posterior Hip Dislocation, Posterior Wall and Transverse Acetabular Fracture with Trochanteric Fracture in an adult: Report of First Case

Introduction:

Posterior dislocation of the hip joint with associated acetabular and intertrochanteric fracture is a complex injury. Early recognition, prompt and stable reduction is needed of successful outcome.

Case Report:

45 year old male patient presented with posterior dislocation of the hip with transverse fracture with posterior wall fracture of acetabulam and intertrochanteric fracture on the ipsilateral side. The complex fracture geometry was confirmed by CT scan. The patient was successfully managed by open reduction and internal fixation of intertrochanteric fracture was achieved with dynamic hip screw (DHS) plate fixation followed by fixation of acetabular fracture with reconstruction plate.

Conclusion:

Hip dislocation combined with acetabular fracture is an uncommon injury; this article presents a unique case of posterior wall and transverse fractures of ipsilateral acetabulum with intertrochanteric fracture in a patient who sustained traumatic posterior hip dislocation. Early surgical intervention is important for satisfactory outcomes of such complex fracture-dislocation injuries.

Transient epiphyseal lesion of the femoral head after traumatic hip dislocation: A case report

INTRODUCTION

We experienced a rare case in which magnetic resonance imaging (MRI) showed a transient epiphyseal lesion of the femoral head four months after traumatic hip dislocation. To our knowledge, there have been no previously published reports on the development of such transient lesions after traumatic hip dislocation involving no abnormalities just after dislocation.

PRESENTATION OF CASE

We report a 22-year-old man who showed a transient epiphyseal lesion of the femoral head after traumatic hip dislocation. On MRI performed two days after dislocation, no bony injuries were observed around the hip joint. Four months after dislocation, the patient suddenly experienced right hip pain without any new trauma or injury. A low-intensity band convex to the articular surface was apparent above the epiphyseal scar on T1-weighted imaging, and bone marrow edema was observed around the band lesion on short-tau inversion recovery imaging. Following a two-month period of non-surgical conservative therapy, the patient's hip pain resolved and the low-intensity band was no longer observed on follow-up MRI.

DISCUSSION

Although the detailed pathogenesis of this transient changes was unclear, we speculate that prolonged rest after traumatic hip dislocation may contribute to bone insufficiency, resulting in an insufficiency fracture of the femoral head.

CONCLUSION

This study suggests that transient epiphyseal lesions of the femoral head may occur in patients with a history of traumatic hip dislocation associated with an adapted long-term rest.

[Obturator hip dislocation: a rare injury in sport]

Les luxations antérieures traumatiques de la hanche sans fracture du cotyle ou de la tête fémorale sont rares. Elles sont souvent secondaires à des accidents de haute énergie cinétique. La prise en charge thérapeutique nécessite un chirurgien vigilant et prévenu du risque de complications. Nous rapportons le cas d'une luxation obturatrice (antéro-inférieure) chez un jeune de 18 ans pratiquant le roller