Surgical Dislocation Approach Research Articles

Application direct anterior approach in pediatric femoral head and neck lesions

BackgroundFemoral neck is one of the high-risk areas for benign tumors and tumor-like lesions. Small range of lesions may also lead to pathological fracture, femoral head necrosis and other serious problems.PurposeTo investigate a new minimally invasive surgical approach to resect femoral head and neck lesions in children.Patients and methodsRetrospective study of 20 patients with femoral neck and femoral head lesions from February 2019 to March 2023 in our hospital. Among them, 14 were boys and 6 were girls, 17 were femoral neck lesions and 3 were femoral head lesions. The age of the patients ranged from 3.2 to 12.6 years, with a mean of 7.1 years. The patients were divided into group A and group B according to different surgical approaches; group A used the Smith-Peterson approach, Watson-Jones approach or surgical dislocation approach and group B used the DAA. Intra-operatively, incision length, operative time and blood loss were recorded in both groups. Group A consisted of 1 femoral head lesion and 8 femoral neck lesions, including 5 cases of bone cyst and 4 cases of eosinophilic granuloma. Group B consisted of 2 femoral head lesion and 9 femoral neck lesions. A total of 11 patients with different types of disease were included in group B, including bone cysts (3 cases), aneurysmal bone cysts (1 case), eosinophilic granulomas (6 cases), Kaposi's sarcoma (1 case).ResultsThe two groups of patients differed in terms of incision length (P < 0.05), operative blood loss (P < 0.05) and operative time (P < 0.05). At 6–48 months post-operatively, there were no significant differences in function and all patients had good hip function.ConclusionThe direct anterior approach is effective for resection of paediatric femoral head and neck lesions. It provides clear exposure of the surgical site, minimal trauma and does not compromise the integrity of the anterior musculature.Level of evidence: III.

Functional outcome of type 4 Pipkin classification of femoral head fracture operated by open reduction internal fixation by ganz safe surgical dislocation approach management: a case report

Fracture of the femoral head is a severe, relatively uncommon injury; typically, it may have associated with traumatic posterior dislocation of the hip joint with or without acetabulum fracture. The Pipkin classification is the most commonly used classification system. Controversies include the preferred surgical approach (anterior versus posterior) versus ganz safe surgical dislocation approach and whether to perform femoral head fragment excision or internal fixation. Presenting a case report of 28 years old young male with a motor vehicle road traffic accident and suffered a head of femur fracture on right hip joint with posterior wall of right acetabulum fracture with Judet-Letournel type posterior wall and type 4 Pipkin’s classification of femoral head fracture. This patient was undergone for emergency surgical intervention of open reduction, internal fixation through Ganz approach and insertion of Herbert screws for femoral head and interfragmentary screw for trochanteric osteotomy. The patient was followed up for 1 year and have a complete range of motion at hip joint with painless daily lifestyle. Type 4 Pipkin classification of femoral head fracture managed timely and with surgical intervention by ganz safe surgical dislocation approach provides visualization to femoral head and whole acetabulum with internal fixation of femur head by herbert screw which preserves normal anatomic contour of femoral head shows appropriate reduction of fracture fragments and it may also avoid hemiarthroplasty surgeries. Fracture of the femoral head has been associated with a relatively poor functional outcome and requires timely management and surgical intervention. Specially type 4 Pipkin classification of femoral head fracture treated by ganz safe surgical dislocation approach with internal fixation of femur head by herbert screw shows better outcome and avoid risk of AVN of femoral head. Complications associated with fracture of the femoral head and subsequent treatment include osteonecrosis, post-traumatic osteoarthritis, heterotopic ossification and implant failure.

Hip Joint Instability After Surgery Performed Through the Surgical Dislocation Approach.

Safe surgical dislocation of the hip is a versatile approach to the hip joint with a low complication rate. Hip joint instability is a devastating complication with poor prognosis. All hips treated surgically through the safe surgical dislocation approach were entered in a database and the complication of hip joint instability was studied prospectively from 2000 to 2021. Instability was diagnosed by intraoperative stress examination and on postoperative radiographs. The initial deformities treated, type of instability, presumed causes, treatment provided, response to the treatment, and final result were recorded as they happened during the course of the treatment. We considered patient's age, sex, body mass index (BMI), and initial diagnosis as risk factors. We evaluated the radiographs for femoral neck shortening, lack of greater trochanteric advancement, acetabular deformity, and incongruity of the hip joint. Anterior hip precautions were initiated in the middle of the study period. 22/459 hips developed hip joint instability after surgical dislocation approach performed for hip preservation. Acetabular deficiency, coxa breva, coxa valga, posterior impingement, increased anteversion, lax soft tissues, medial thigh obesity and lack of postoperative precautions seemed to contribute to instability. 50% of the hips became normal. Chondrolysis and residual subluxation were common in the others. Surgical dislocation approach disrupts the soft tissue restraints of the hip and joint stability depends on bony morphology, abductor muscle tension, and postoperative precautions. Several risk factors were subjective and speculative, but awareness of all the potential risk factors and prevention and treatment options should decrease this complication. IV Case series.

Surgical Elbow Dislocation: Technique and Comparative Outcomes

Introduction: Surgical access to lateral column fractures of the distal humerus is difficult via traditional approaches due to limited anterior articular exposure for direct reduction and fixation. We have refined a surgical elbow dislocation approach to the articular surface of the distal humerus for fixation of lateral column injuries, which may permit improved access for operative fixation. Materials and Methods: We performed a retrospective review of lateral column fractures treated with open reduction internal fixation at our institution between 2009 and 2019. We divided patients into 3 cohorts based on surgical approach: surgical dislocation (n=10), lateral (n=17), and posterior (n=9). Surgical reports, radiographs, and patient records were reviewed for hardware positioning, tourniquet time, estimated blood loss, postoperative reduction quality, and patient outcomes including range of motion, neurovascular injury, development of heterotopic ossification, and pain on a visual analog scale. Results: With the numbers available, we were unable to detect a significant difference in outcomes including pain, range of motion, or blood loss. No patients treated with this approach experienced neurovascular injury, instability, or nonunion at follow-up. Conclusions: The surgical elbow dislocation is a powerful tool to aid reduction and osteosynthesis of intra-articular fractures of the lateral distal humerus. It may enable greater articular access for complex distal humerus patterns without deleterious effects on surgical or patient reported outcomes.

English

BACKGROUND High velocity motor vehicle injuries are associated with hip fracture dislocations especially dash board injuries. Most commonly posterior hip dislocations are associated with occasional femoral head fractures. Computerized tomographic imaging is done to look at the congruency of the hip joint. Safe surgical dislocation or Ganz approach was described in 2001 for exposing the hip in a 360-degree view without damaging the vascularity of the femoral head. In this study, we wanted to evaluate the radiological and functional outcome using modified Merle d' Aubigne-Postel and Harris hip scoring. METHODS The current study is a prospective study in a tertiary referral centre where 8 young adult males were followed up for a period of 2 years 6 months from August 2018 to February 2021 after safe surgical dislocation and reduction with headless Herbert screws to maintain congruent hip surface. RESULTS We had 1 patient with associated chest injury requiring intercostal tube placement, while none of them had developed avascular necrosis or early arthritis. We had used modified Merle d'Aubigne-Postel and Harris hip scoring to assess the functional outcome. We had six patients with excellent results and two patients with good outcome due to occasional pain. We followed all the patients for more than 2 years. We evaluated the radiological and functional outcomes. The results are comparable to other researcher’s studies. CONCLUSIONS Safe surgical dislocation is a very good choice for fixation of femoral head fractures where the complications like early arthritis of femoral head and acetabulum are less along with preserving the vascularity of the femoral head and preventing the chances of avascular necrosis of femoral head. It also provides a good intraoperative view for handling the fracture reduction. KEYWORDS Pipkin Fracture, Ganz Approach, Safe Surgical Dislocation Hip, Herbert Screw

Surgical Elbow Dislocation Approach to the Distal Humerus for Apparent Capitellar and Lateral Condyle Fractures in Adults

Access to fractures of the distal humeral capitellum, trochlea, and lateral condyle is difficult through traditional approaches due to limited anterior articular exposure for direct reduction and fixation. The purpose of this study is to evaluate the relative articular exposure of a surgical dislocation (SD) approach to the distal humerus compared with olecranon osteotomy (OO). Eight paired elbows from 4 cadavers underwent either SD or OO approach. Methylene blue staining demarcated visualized articular surface before disarticulation of the elbows. The main outcome measures were average visualized total distal humeral articular surface and anterior and posterior surface, and capitellar surface relative to the total surfaces was compared for each surgical approach using unpaired parametric t-tests. Intraclass correlation between raters was 0.995. The median exposed articular surface for SD and OO approaches was 90.0% and 62.8%, respectively. The overall exposure was significantly greater for the dislocation technique (P = 0.0003). With respect to specific regions of the distal humeral articular surface, SD allowed significantly greater visualization of the anterior surface (95.9% vs. 48.9%, P < 0.0001) and capitellum (100% vs. 40.4%, P < 0.0001). The surgical elbow dislocation approach to the distal humerus permits near total exposure of the anterior articular surface and the entire capitellum. Our data support this approach for anterior articular fractures of the distal humerus, to include those fractures that extend to the medial surface of the trochlea.

Morscher Osteotomy Through Surgical Dislocation Approach for True Femoral Neck Lengthening with Greater Trochanter Transposition.

Young adults presenting with hip pain can be affected by proximal femoral growth disturbances as seen in Legg-Calvé-Perthes disease (LCPD) or as a complication of surgical treatment of developmental dysplasia of the hip (DDH). In 1988, Morscher proposed a novel femoral neck lengthening osteotomy to address these issues. The purpose of this study was to evaluate the effectiveness and safety of the Morscher osteotomy as a procedure to complement the well-documented surgical hip dislocation, to increase femoral offset, to distalize the greater trochanter, and to increase the overall limb length. This study was a retrospective case series from 3 hip-preservation-expert surgeons. Morscher osteotomies performed through a surgical dislocation approach by 3 surgeons between January 2008 and September 2019 were reviewed. Fifteen patients with a median age at surgery of 17 years (range, 13 to 28 years) and a minimum follow-up of 3 months (until union) were included. Surgical indications, clinical findings, comparative radiographic analyses including the change in horizontal femoral offset and the position of the greater trochanter, and complications were assessed. Surgical indications included DDH and LCPD. The horizontal femoral offset improved in all patients, to a median of 32.5 mm (range, 4 to 46.4 mm). The articular-trochanteric distance increased to >5 mm in all patients. Limb length improved by a median of 11.5 mm (range, 3 to 30 mm). Complementary periacetabular osteotomy was performed in 14 patients. The lateral center-edge angle and the acetabular index improved in patients with an associated periacetabular osteotomy, to a median of 28.2° (range, 9° to 37.7°) and 7.9° (range, 0° to 20°), respectively. Two patients demonstrated osteoarthritis progression from Tönnis stage 0 to stage 1, and 6 patients had a decrease of the joint space. Complications included 1 pulmonary embolism, 1 case of asymptomatic fibrous union of the greater trochanter, and 1 transient sciatic nerve palsy. The time-tested Morscher osteotomy indicated for complex proximal femoral reconstruction is effective in increasing horizontal femoral offset, distalization of the greater trochanter, and limb length. Combining the Morscher osteotomy with the versatility of surgical hip dislocation and the improved coverage capacity of periacetabular osteotomy proved complementary in the arsenal of hip preservation. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Impingement-free hip range of motion after osteochondroplasty and relative neck lengthening in adults with healed Perthes disease

ObjectiveOur main objective is to assess the efficiency of the osteochondroplasty with relative neck lengthening in adults with healed Perthes clinically (through assessment of impingement-free hip ROM, functional scores) and radiographically.Patients and methodsThis was a prospective case series study included 30 hips of 30 patients who underwent osteochondroplasty and RNL due to symptomatic healed LCPD. This study included 16 males (53.3%) and 14 females (46.7%). The age of patients ranged from 19 to 40 years with mean age 26.4 years at the date of surgery (SD 6.4).ResultsMedian time of follow-up was 27.7 months after surgery (range 12–60 months). Two patients (6.6%) developed avascular necrosis (AVN) and needing total hip replacement; none of our patients developed nerve injury, detachment of the trochanteric fragment, and wound infection needing treatment. Preoperative Stulberg classes II and III improved more than preoperative Stulberg classes IV and V, although not statistically significant (P = 0.1104, n = 30). The mean HHS and WOMAC score values for each patient were higher in the Stulberg II and III groups compared to the Stulberg IV and V groupsConclusionHead and neck osteochondroplasty performed through the surgical dislocation approach, combined with RFNL, relieved pain and restored function in most of the patients with reasonable complications.Level of evidenceIV

Surgical Hip Dislocation for Small Posterior Wall Fracture After Hip Subluxation.

This case demonstrates a recognized association between an acetabular injury pattern and underlying morphology of the hip. In the patient discussed, hyperflexion of the hip results in the engagement of the present CAM lesion, and the resulting subluxation leads to a fracture of the posterior wall and instability of the hip. This combination of pathologies was addressed with a surgical dislocation approach to address both the CAM lesion and fix the posterior wall.

Combined Imhauser osteotomy and osteochondroplasty in slipped capital femoral epiphysis through surgical hip dislocation approach.

PurposeTreatment of moderate to severe stable slipped capital femoral epiphysis (SCFE) remains a challenging problem. Open reduction by modified Dunn procedure carries a considerable risk of osteonecrosis (ON). Imhauser osteotomy is capable of realigning the deformity without the risk of ON, but the remaining metaphyseal bump is implicated with significant chondro-labral lesions and accelerated osteoarthritis. We conducted this study to evaluate the efficacy and safety of Imhauser osteotomy combined with osteochondroplasty (OCP) through the surgical hip dislocation (SHD) approach.MethodsA prospective series of 23 patients with moderate-severe stable SCFE underwent Imhauser osteotomy and OCP through SHD. The mean age was 14.4 years (13 to 20) and the mean follow-up period was 45 months (24 to 66). The outcome measures included clinical and radiological parameters and Harris hip score (HHS) was used as a functional score.ResultsThe mean HHS improved significantly from 65.39 to 93.3. The limb length discrepancy improved by a mean of 1.72 cm. The mean flexion and abduction arcs showed a significant improvement (mean increase of 37.5° and 18.5°, respectively). The mean internal rotation demonstrated the most significant improvement (mean increase of 38.5°). All the radiographic parameters improved significantly; including anterior and lateral slip angles (mean improvement 37.52° and 44.37°, respectively). The mean alpha angle decreased by 39.19°. The articulo-trochanteric distance significantly increased to a mean of 23.26 mm. No cases of ON or chondrolysis were identified.ConclusionCombined Imhauser osteotomy and OCP through the surgical dislocation approach provide a comprehensive and safe management of moderate to severe stable SCFE.Level of evidenceIV

Surgical Correction of Healed Legg-Calve-Perthes Deformity

Healed Legg-Calve-Perthes disease is a complex problem to manage for the treating orthopaedic surgeon. Legg-Calve-Perthes disease begins as a pediatric disorder characterized by osteonecrosis of the femoral head. Once the initial osteonecrotic insult resolves, the patient is left with a complex deformity of the proximal femur and acetabulum leading to symptomatic femoroacetabular impingement and, potentially, hip instability. Throughout this review, we will highlight the relevant patient evaluation, radiographic parameters, and surgical algorithm to aid in the management of this difficult problem. Treatment of this condition is best achieved through a surgical dislocation approach to thoroughly address the intra- and extra-articular sources of femoroacetabular impingement, with the occasional patient requiring a redirective acetabular osteotomy to further improve morphology and function.

Management of nontraumatic osteonecrosis of the femoral head using impaction bone grafting via a light bulb window through a safe surgical dislocation approach

Purpose The aim was to appreciate the clinical and radiological results of impacted bone graft via bone window on the head-neck junction for treatment of nontraumatic avascular necrosis of femoral head through a safe surgical dislocation approach. Patients and methods A total of 33 hips in 26 patients were managed with femoral head osteonecrosis by impaction of autogenous iliac bone graft via bone window on the head-neck junction (light bulb) through a safe surgical dislocation approach. There were eight females and 18 males, with a mean age of 29.06 years (ranging from 14 to 46 years) with stage II and III avascular necrosis of the femoral head according to Association Research Circulation Osseous (ARCO). The results were studied based on variations in the Harris hip score and progress in radiographic stages. Results These 26 patients were followed up from 24 to 48 months (mean: 33.9 months). The mean Harris hip score was 82.78 (range from 66 to 95) after last follow-up when compared with 60.45 (range from 41 to 85) preoperatively. The clinical success for ARCO stage II was 75% (100% in stage IIA, 83.3% in stage IIB, and 50% in stage IIC) and for ARCO stage III was 43.5% (70% in stage IIIA, 60% in stage IIIB, and 0% in stage IIIC), whereas the overall radiographic progression was found in 15 of 33 hips (45.4%), where nine of them (27.3%) progressed to radiographic failure (femoral head collapse) and required total hip arthroplasty. Conclusions Impaction of autogenous bone graft through a safe surgical dislocation via a bone window creates a mechanical and biological condition for graft incorporation, and therefore, it may be the treatment of choice in nontraumatic osteonecrosis of the femoral head at the precollapse stage (stage II and early III), especially with a small-sized lesion, with a better outcome in idiopathic type.

Management of femoroacetabular impingement syndrome: current insights.

Since the description of femoroacetabular impingement (FAI) by Ganz in 2003, our understanding of the pathophysiology, management options, and outcomes has evolved and literature continues to be generated on this condition at a rapid rate. FAI has been identified as a primary source of hip pain as well as a generator of secondary osteoarthritis. Improvements in the radiographic detection of cam and pincer morphologies as well as a better understanding of the structural impact of these morphologies have led to improved preoperative planning. Advancements in hip arthroscopy techniques have also led to a higher rate of arthroscopic management of this condition over the initially described open surgical dislocation technique. While arthroscopic management of this condition has become the most common form of surgical management for FAI, inadequate bony resection has been shown to be a frequent source of revision surgery. Therefore, roles for open surgical dislocation and combined mini-open approaches remain, particularly in cases where concern for the inability to fully access the morphology arthroscopically exists.

Modified trapdoor procedures by surgical dislocation approach to treat chondroblastoma of the femoral head.

The aim of this study was to evaluate the efficacy of the surgical dislocation approach and modified trapdoor procedure for the treatment of chondroblastoma of the femoral head. A total of 17 patients (ten boys, seven girls; mean age 16.4 years (11 to 26)) diagnosed with chondroblastoma of the femoral head who underwent surgical dislocation of the hip joint, modified trapdoor procedure, curettage, and bone grafting were enrolled in this study and were followed-up for a mean of 35.9 months (12 to 76). Healing and any local recurrence were assessed via clinical and radiological tests. Functional outcome was evaluated using the Musculoskeletal Tumour Society scoring system (MSTS). Patterns of bone destruction were evaluated using the Lodwick classification. Secondary osteoarthritis was classified via radiological analysis following the Kellgren-Lawrence grading system. Steinberg classification was used to evaluate osteonecrosis of the femoral head. The epiphyseal plate was open, closing, and closed in five, five, and seven patients, respectively. In total, eight, six, and three patients were classified as having Lodwick classification IA, IB, and IC, respectively. Allogeneic and autogenous bone grafting was used in 13 and four patients, respectively. All patients had good bone healing and no local recurrence was observed. One patient developed osteonecrosis of the femoral head (Steinberg IA) and one developed secondary osteoarthritis of the hip joint (Kellgren-Lawrence Grade II). The mean postoperative MSTS functional score was 27.7 (24 to 30). Surgical dislocation and modified trapdoor procedures are safe and effective techniques for treating chondroblastoma in the femoral head. Cite this article: Bone Joint J 2019;101-B:732-738.

Safe Surgical Dislocation Approach for Open Reduction Internal Fixation of Femoral Head Fractures

Safe Surgical Dislocation Approach for Open Reduction Internal Fixation of Femoral Head Fractures

Utilization of the Safe Surgical Dislocation Approach in the Surgical Management of Early Hip Tuberculosis

Utilization of the Safe Surgical Dislocation Approach in the Surgical Management of Early Hip Tuberculosis

Indications for Hip Arthroscopy

Context:Hip arthroscopy is gaining popularity within the field of orthopaedic surgery. The development and innovation of hip-specific arthroscopic instrumentation and improved techniques has resulted in improved access to the hip joint and ability to treat various hip pathologies.Evidence Acquisition:Electronic databases, including PubMed and MEDLINE, were queried for articles relating to hip arthroscopy indications (1930-2017).Study Design:Clinical review.Level of Evidence:Level 4.Results:Initially used as a technique for loose body removal, drainage/debridement of septic arthritis, and treatment of pediatric hip disorders, hip arthroscopy is currently used to treat various hip conditions. The recognition of femoroacetabular impingement (FAI) as a source of hip pain in young adults has rapidly expanded hip arthroscopy by applying the principles of osseous correction that were previously described and demonstrated via an open surgical dislocation approach. Hip pathologies can be divided into central compartment, peripheral compartment, peritrochanteric space, and subgluteal space disorders.Conclusion:Although hip arthroscopy is a minimally invasive procedure that may offer decreased morbidity, diminished risk of neurovascular injury, and shorter recovery periods compared with traditional open exposures to the hip, it is important to understand the appropriate patient selection and indications.

Treatment of Unstable Versus Stable Slipped Capital Femoral Epiphysis Using the Modified Dunn Procedure.

The modified Dunn procedure (open subcapital realignment via a surgical dislocation approach) has been shown to be a safe and effective way of treating acute, unstable slipped capital femoral epiphysis (SCFE). There is a paucity of literature comparing the modified Dunn procedure in stable SCFE. The purpose of this study was to compare acute, unstable versus chronic, stable SCFE managed with the modified Dunn procedure. A retrospective chart review was performed on 44 skeletally immature patients who underwent the modified Dunn procedure for SCFE. Patients were divided into stable or unstable based on clinical presentation and intraoperative findings. Demographics, radiographic measurements, and complications were recorded and compared. χ and t tests were used to compare variables. In total, 31 consecutive hips (29 patients) with acute, unstable slips, and 17 consecutive hips (15 patients) with chronic, stable slips were reviewed. Average age was 12.5 and 13.8 years for acute and chronic, respectively (P=0.05). Mean follow-up was 27.9 months (unstable) and 35.5 months (stable). Average postoperative Southwick angle was 14.2 degrees; (unstable) and 25.3 degrees (stable) (P=0.001). Greater trochanteric height averaged 6.2 mm below the center of the femoral head in the acute group and 6.2 mm above center in the chronic group (P<0.001). Average femoral neck length measured 34.1 mm (unstable) and 27.1 mm (stable) (P<0.001). Two patients (6%) developed avascular necrosis (AVN) in the unstable group, with 5 patients (29.4%) in the stable group (P=0.027). All patients with hip instability (N=3) developed AVN. Although both acute, unstable and chronic, stable SCFE can be successfully treated with the modified Dunn procedure, the complication rate is statistically higher in patients with stable SCFE, specifically both AVN rate and postoperative instability. In addition, it is more difficult to establish normal anatomic indexes with regard to greater trochanteric height and femoral neck length. This procedure has great utility in the correction of the anatomic deformity associated with SCFE, but should be used with caution in patients with chronic, stable SCFE. Level III-retrospective review.

Iatrogenic Hip Instability Is a Devastating Complication After the Modified Dunn Procedure for Severe Slipped Capital Femoral Epiphysis.

The modified Dunn procedure facilitates femoral capital realignment for slipped capital femoral epiphysis (SCFE) through a surgical hip dislocation approach. Iatrogenic postoperative hip instability after this procedure has not been studied previously; however, we were concerned when we observed several instances of this serious complication, and we wished to study it further. The purpose of this study was to evaluate the frequency, timing, and clinical presentation (including complications) associated with iatrogenic instability after the modified Dunn procedure for SCFE. Between 2007 and 2014, eight international institutions performed the modified Dunn procedure through a surgical dislocation approach in 406 patients. During the period in question, indications varied at those sites, but the procedure was used only in a minority of their patients treated surgically for SCFE (31% [406 of 1331]) with the majority treated with in situ fixation. It generally was performed for patients with severe deformity with a slip angle greater than 40°. Institutional databases were searched for all patients with SCFE who developed postoperative hip instability defined as hip subluxation or dislocation of the involved hip during the postoperative period. We reviewed in detail the clinical notes and operative records of those who presented with instability. We obtained demographic information, time from slip to surgery, type of fixation, operative details, and clinical course including the incidence of complications. Followup on those patients with instability was at a mean of 2 years (range, 1-5 years) after the index procedure. Complications were graded according to the modified Dindo-Clavien classification. Radiographic images were reviewed to measure the preoperative slip angle and the presence of osteonecrosis. A total of 4% of patients treated with the modified Dunn procedure developed postoperative hip instability (17 of 406). Mean age of the patients was 13 years (range, 9-16 years). Instability presented as persistent hip pain in the postoperative period or was incidentally identified radiographically during the postoperative visit and occurred at a median of 3 weeks (range, 1 day to 2 months) after the modified Dunn procedure. Eight patients underwent revision surgery to address the postoperative instability. Fourteen of 17 patients developed femoral head avascular necrosis and three of 17 patients underwent THA during this short-term followup. Anterolateral hip instability after the modified Dunn procedure for severe, chronic SCFE is an uncommon yet potentially devastating complication. Future studies might evaluate the effectiveness of maintaining anterior hip precautions for several weeks postoperatively in an abduction brace or broomstick cast to prevent this complication. Level IV, therapeutic study.

Surgical Dislocation of the Hip in the Treatment of Complex Osteochondral Injury to the Femoral Head.

The optimal treatment for osteochondral fracture of the femoral head associated with posterior dislocation remains unclear. A case can be made to treat small fragments and those that concentrically reduce nonoperatively. On the other end of the spectrum are those where significant size and residual displacement warrant consideration of operative fixation. This video demonstrates the treatment of a large complex multifragmentary osteochondral femoral head fracture with surgical dislocation. With the patient in lateral decubitus position, the trochanter is approached through lateral incision. The trochanter is cut and capsulotomy performed taking care to preserve the critical medial femoral circumflex artery. Fixation with headless screws is performed from the small comminuted fragments into the dominant section of intact femoral head. Experience suggests that anatomic fixation through surgical dislocation can be carried out with low incidence of subsequent avascular necrosis and degenerative articular change. Given the degree of local osseous and muscular trauma, consideration should be given to prophylaxis of heterotopic bone. Although small osteochondral fragments restricted to the acetabular fossa can be treated nonoperatively, the size and displacement of the presented fragment mandated operative reduction. Given the predicted complexity of repair, the surgical dislocation approach was chosen to provide maximum exposure optimizing the chances for successful fixation.