Surgical Hip Dislocation Approach Research Articles

Femoral Head Fractures: Evaluation, Management, and Outcomes.

Fractures of the femoral head typically occur after high-energy trauma. Radiographs and cross-sectional imaging are used to appropriately classify and identify associated injuries or morphologic characteristics that may influence management. Identification of the radiographic and clinical hallmarks of an irreducible variant is critical to optimizing the patient's outcome. Nonsurgical treatment can be used in the setting of small, infrafoveal femoral head fractures without hip instability. When surgical treatment is indicated, an anterior (Smith-Petersen), posterior (Kocher-Langenbeck), or surgical hip dislocation approach may be used depending on injury details and surgeon preference. The purpose of this review was to summarize current evidence on femoral head fractures regarding indications, variant patterns, surgical approaches, and outcomes.

Outcomes of Intra-Articular Procedures through Safe Surgical Hip Dislocation Approach to Manage Residual Hip Deformities Secondary to Legg-Calv-Perthes Disease: A Systematic Review and Meta-Analysis

Abstract Background Legg-Calve-Perthes disease (LCPD) is a childhood condition characterized by femoral head osteonecrosis. The osteonecrotic lesion eventually heals, but persistent deformity to the proximal femur and acetabulum might induce hip discomfort and dysfunction following recovery. Previous reports have noted that between 30% and 50% of individuals affected by LCPD to have residual hip symptoms that persist and a frequent precursor to hip osteoarthritis in young adulthood. Aim of the Work The aim of the present study is to review the efficacy of intra-articular procedures through surgical hip dislocation approach to residual hip deformity secondary to Legg- Calve-perthes disease. Patients and Methods A Systematic Review and Meta-Analysis, We will include: Randomized control trails (RCTs), controlled clinical trials, retrospective cohort studies and we will exclude: case reports, case series studies, cross sectional studies and non English studies. Results The surgical hip dislocation approach allows the surgeon to dynamically evaluate the hip, identify sources of impingement, and treat intraarticular and extraarticular abnormalities. Conclusion Head and neck osteochondroplasty performed through the surgical dislocation approach, combined with other procedures such as FHRO, RFNL, ITO and acetubular osteotomies relieved pain, improved ROM and restored function in most patients with no major complications.

Comparison of Gait and Functional Outcomes Between Open and Arthroscopic Treatment of Adolescent and Young Adult Femoroacetabular Impingement.

Management of femoroacetabular impingement (FAI) through an arthroscopic or surgical hip dislocation (SHD) approach has been shown to have similar clinical success and patient-reported outcomes. However, there are limited data comparing functional outcomes. The purpose of this study was to compare gait and functional outcomes of adolescent/young adult patients with FAI treated by either an arthroscopic or open SHD approach. We identified prospectively enrolled adolescent/young adult patients (≤20 years old) who underwent surgical treatment for FAI through an SHD or arthroscopic approach. Participants were evaluated in a movement science lab preoperatively and postoperatively (minimum 8 months postoperatively) with barefoot walking and a 30-second single-limb balance trial on the affected side. Participants also completed the Harris Hip Score at the same timepoints. Differences from preoperative to postoperative were determined using a paired-samples t test for each surgical technique, and differences between the SHD and arthroscopic groups were determined using an independent samples t test (α=0.05). Fifty-five participants (42F, 16.2±1.4y) were tested and grouped by surgical intervention. The SHD and arthroscopy groups consisted of 28 and 27 participants, respectively, with no significant difference between the SHD and arthroscopic cohorts in age (16.4±1.2 vs. 15.9±1.5y, respectively, P=0.218) or sex distribution (78.6% vs. 74.1% females, respectively, P=0.75). Each group demonstrated significant postoperative improvement in Harris Hip Score (SHD: 64.8±16.4 to 81.8±17.8; arthroscopy: 57.0±16.7 to 84.7±19.7; preoperatively to postoperatively, respectively, both P<0.001). During gait, increased maximum hip flexion was observed following surgical intervention for the SHD group (32.3±5.7 vs. 36.1±5.2, P=0.003). No other clinically significant changes were detected in the SHD or arthroscopic groups preoperatively to postoperatively in trunk, pelvis, or hip kinematics in the coronal plane. During the balance task, neither cohort demonstrated markers of clinically significant abductor dysfunction. However, post operatively, the arthroscopy group was able to balance longer than the SHD group (18.8±7.8 vs. 14.2±2.7s, respectively, P=0.008), although no differences were detected in trunk or pelvis position in the coronal plane during balance. Both open SHD and arthroscopic treatment of FAI resulted in improved clinical outcomes with no clinically significant abductor dysfunction 1 year post operatively. However, further study is needed to determine whether more dynamic tasks can potentially elicit subtle differences between the groups. Level II-prospective study.

Clinical and radiological outcomes following surgical hip dislocation for paediatric hip pathologies, a prospective cohort study

BackgroundSurgical Hip Dislocation (SHD) is a powerful tool in the armamentarium of any surgeon treating conditions affecting the hips of children presenting with sequelae of a number of common conditions including Legg-CalvéPerthes disease (LCPD) and slipped capital femoral epiphysis (SCFE). Risks associated with the procedure are well described. We investigated to assess if SHD is associated with significant surgical risk and if it improved clinical outcomes for patients. MethodsWe conducted a prospective cohort study. We reviewed 18 (11 males and 7 females; mean age 13.7 years (6–17) with symptomatic hip pathology, secondary to femoroacetabular impingement (FAI) between 2017 and 2021. All patients underwent a surgical hip dislocation approach and femoral head-neck osteochondroplasty, Head Split osteotomy or both. Clinical improvement was assessed using the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index. The minimum follow-up was 6 months (mean, 22 months; range, 6–42 months). ResultsWOMAC scores improved at final follow-up from 10 to 3 for pain, 33 to 10 for function, and 4 to 2 for the stiffness subscales. All radiographic measures improved significantly of the postoperative X-rays. No patients developed osteonecrosis, implant failure, deep infection, or nonunion. ConclusionSurgical Hip Dislocation, in the short term, we found improvement in WOMAC scores and radiographic indices with a low complication rate.

Morscher's femoral neck lengthening osteotomy through surgical hip dislocation approach for preservation of Perthes and Perthes-like deformities.

Background:Typical sequelae of Perthes disease and Perthes-like deformities comprise a short femoral neck, aspherical femoral head, and greater trochanteric overgrowth. Morscher’s osteotomy aims at restoring the normal extra-articular anatomy, but incapable of restoring a normal head-neck contour with residual impingement. Femoral neck lengthening osteotomy combined with osteochondroplasty through surgical hip dislocation approach was not previously described in the literature. We hypothesized that this technique is capable of near-normal restoration of the proximal femoral anatomy, increasing limb length, restoring abductor power, and simultaneous management of intra-articular chondro-labral disease.Methods:A prospective series of 21 consecutive patients with sequelae of Perthes disease and Perthes-like deformity (Stulberg II and III) were treated by Morscher’s osteotomy through surgical hip dislocation approach. The mean age was 14.9 years (9–30 years) and the mean follow-up was 4.5 years (2–8 years).Results:The mean Harris hip score improved significantly from 66.5 to 89.5 points (p < 0.001), and the mean limb length discrepancy improved from 2.5 to 0.6 cm (p < 0.001). The mean alpha angle improved from 81.8° to 49.5°, the mean neck-shaft angle increased from 117.8° to 129.8°, and the articulo-trochanteric distance has improved from −6.7 to 20.8 mm. Six out of 21 patients required staged periacetabular osteotomy for residual acetabular dysplasia. No cases of chondrolysis or osteonecrosis were identified.Conclusion:Femoral neck lengthening osteotomy through surgical hip dislocation appraoch has proven to be safe and effective for preservation of symptomatic hips with Perthes and Perthes-like deformities and mild to moderate femoral head deformities (Stulberg II and III). A staged periacetabular osteotomy may be required in those patients with significant acetabular dysplasia.Level of evidence:Level IV.

Management of residual hip deformities secondary to Legg–Calve–Perthes disease in adults

Background The objective of this study is to systematically review the results of different studies related to the management of hip deformities secondary to Perthes’ disease in adults. Patients and methods Thirteen studies matching the inclusion and exclusion criteria, totaling 316 adults including 326 hips that underwent 119 surgical hip dislocation (SHD), 49 periacetabular osteotomy, 111 SHD with periacetabular osteotomy, 16 intertrochanteric osteotomy with acetabular roof plasty, and 31 adductor tenotomy with cheilectomy of the femoral head. Their age was in the range from 19 to 42 years with clinical follow-up range (16–135 months). The degree of pain, function, range of movements, and deformities were evaluated. Results The SHD approach has a 360° view allowing full dynamic evaluation of the hip joint, identification, and correction of the most common residual deformations, leading to functional improvement and pain relief with low complication rates. Harris hip score was a common clinical parameter in a lot of studies and showed improvement from the average range (60–68.5) before surgery to 72–95 after it. In all, 188 hips were reported to have reduction in pain at last follow-up, but adequate clinical follow-up were not available for 112 hips. However, 26 patients were reported as a failure (defined as total hip arthroplasty or persistent or increased pain). Onset osteoarthritis advancement cannot be prevented in hips. Conclusion SHD provides the opportunity to achieve any kind of simultaneous femoral and acetabular osteotomies leading to functional improvement and pain relief with low complication rates.

Surgical hip dislocation for treatment of femoral head chondroblastoma: efficacy and safety.

Femoral head chondroblastoma poses a surgical challenge. Anatomical limitations may lead to increased risk of local recurrence, damage to the articular cartilage, growth disturbances, and/or avascular necrosis (AVN). We are presenting our results with surgical hip dislocation approach with the aim to evaluate its efficacy in preventing recurrence and its safety, preserving a functional hip joint and avoiding complications. Ten patients were managed using surgical hip dislocation with direct access to femoral head lesions, extended curettage through a modified trapdoor approach, and cement reconstruction. These were six males and four females, with a mean age of 17 ± 2.7years (range: 14-20) and a mean follow-up of 34 ± 12months (range: 17-57). The lesion extended into the neck in 60% of patients with the physis being either closed in seven or closing in three patients. We had a single case (10%) of recurrence at the trochanters for which re-curettage was done. However, all patients had their hips preserved with good function at the latest follow-up, and no serious complications recorded. The Musculoskeletal Tumor Society score improved significantly from a pre-operative median of 23.5 (range: 16-28) to a post-operative median of 29 (range: 26-30) (P = 0.005). This report describes a safe reproducible approach to effectively manage these locally aggressive lesions with good short-term results. This is done while maintaining the integrity of the articular surface, growth plate, as well as preserving the femoral head blood supply.

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

BACKGROUNDFemoral head fractures (FHFs) are considered relatively uncommon injuries; however, open reduction and internal fixation is preferred for most displaced fractures. Several surgical approaches had been utilized with controversial results; surgical hip dislocation (SHD) is among these approaches, with the reputation of being demanding and leading to higher complication rates.AIMTo determine the efficacy and safety of SHD in managing FHFs by reviewing the results reported in the literature.METHODSMajor databases including PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched to identify studies reporting on outcomes of SHD utilized as an approach in treating FHFs. We extracted basic studies data, surgery-related data, functional outcomes, radiological outcomes, and postoperative complications. We calculated the mean differences for continuous data with 95% confidence intervals for each outcome and the odds ratio with 95% confidence intervals for binary outcomes. P < 0.05 was considered significant.RESULTSOur search retrieved nine studies meeting our inclusion criteria, with a total of 129 FHFs. The results of our analysis revealed that the average operation time was 123.74 min, while the average blood loss was 491.89 mL. After an average follow-up of 38.4 mo, a satisfactory clinical outcome was achieved in 85% of patients, with 74% obtained anatomical fracture reduction. Overall complication rate ranged from 30% to 86%, with avascular necrosis, heterotopic ossification, and osteoarthritis being the most common complications occurring at an incidence of 12%, 25%, and 16%, respectively. Trochanteric flip osteotomy nonunion and trochanteric bursitis as a unique complication of SHD occurred at an incidence of 3.4% and 3.8%, respectively.CONCLUSIONThe integration of SHD approach for dealing with FHFs offered acceptable functional and radiological outcomes with a wide range of safety in regards to the hip joint vascularity and the development of avascular necrosis, the formation of heterotopic ossification, and the development of posttraumatic osteoarthritis; however, it still carries its unique risk of trochanteric flip osteotomy nonunion and persistent lateral thigh pain.

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

Hip preservation experience of avascular necrosis of femoral head according to China-Japan Friendship Hospital classification

To sum up staging treatment experiences of hip preservation for avascular necrosis of the femoral head (ANFH) according to China-Japan Friendship Hospital Classification (CJFH Classification). The literature about hip preservation of ANFH was extensively reviewed, and a staging treatment method for ANFH was set up base on CJFH Classification and the 28 years of clinical experience in this research group. According to CJFH Classification, the ANFH can be rated as types M, C, and L. And the type L is rated as L1, L2, and L3 subtypes. The staging treatment method for ANFH based on CJFH Classification is set up. Conservative treatment was selected for CJFH-M patients because the necrotic area is small and in the medial non-weight-bearing area. Minimally invasive sequestrum clearance, impacting bone graft, and supporting allogenic fibular graft is selected for CJFH-C patients because the necrotic area is also small and in the lateral non-weight-bearing area. If patients are in CJFH-L1, normal bone area is less than 1/3 on hip abduction radiograph, the sequestrum clearance and impacting bone graft via surgical hip dislocation approach can be selected. If patients are in CJFH-L1, normal bone area is more than 1/3 on hip abduction radiograph, the transtrochanteric curved varus osteotomy can be selected. The rotational osteotomy on the base of femoral neck via surgical hip dislocation approach is for CJFH-L2 patients. Total hip arthroplasty via direct anterior approach is for CJFH-L3 patients. The staging treatment method for ANFH according to CJFH Classification has good short-term effectiveness. But the long-term effectiveness needs further follow-up.

Osteochondroplasty and relative neck lengthening in the treatment of late sequelae of Perthes disease

Purpose The goal was to evaluate the short-term results of femoral head osteochodroplasty and trochanteric advancement in the treatment of late sequelae of Perthes disease associated with aspherical head and hinged abduction. Patients and methods The authors carried out a prospective study to evaluate the clinical and radiological results of 15 patients with late sequelae of Perthes disease treated by osteochodroplasty of the head neck junction with distal advancement of the greater trochanter through a surgical hip dislocation approach. Results The mean age of the patients was 20 years, with a mean follow-up of 36 months. We achieved a mean improvement of harris hip scores (HHS) from 65.6 preoperatively to 87.6 postoperatively, with a marked improvement in range of motion, especially for abduction (from 13.8° preoperatively to 30.3° postoperatively) and internal rotation (from 16.4° preoperatively to 28.6° postoperatively). The mean center trochanteric distance (CTD) improved from −18 to 0.26 mm postoperatively. Seven cases progressed one grade of osteoarthritis (OA); two of them required total hip replacement. Conclusion Combined osteochondroplasty and distal advancement for the treatment of late sequel of Perthes disease improve hip function, decrease pain, and improve radiological parameters of the hip.

Impacting bone graft via surgical hip dislocation approach versus core decompression and bone graft for avascular necrosis of femoral head at ARCO stage Ⅲ

To compare the effectiveness of sequestrum clearance and impacting bone graft via surgical hip dislocation approach and core decompression and bone graft for avascular necrosis of the femoral head (ANFH) at Association Research Circulation Osseous (ARCO) stage Ⅲ. A clinical data of 60 patients (69 hips) of non-traumatic ANFH at ARCO stage Ⅲ, which met the inclusion criteria between October 2013 and April 2016, was retrospectively analyzed. Among them, 24 patients (28 hips) were treated with sequestrum clearance and impacting bone graft via surgical hip dislocation approach (group A); and 36 patients (41 hips) were treated with core decompression, sequestrum clearance, impacting bone graft, and nonvascular fibular allograft supporting (group B). There was no significant difference in gender, age, disease duration, affected side, type and stage of the ANFH, and preoperative Harris hip score and visual analogue scale (VAS) score between the two groups ( P>0.05). After operation, the function of the hip was evaluated by Harris hip score, imaging examination was performed to observe the femoral head shape and evaluate whether the hip preserving success. The incisions of two groups healed by first intention. All patients were followed up. The follow-up time was 12-48 month (mean, 25.8 months) in group A and 12-54 months (mean, 26.4 months) in group B. At last follow-up, 5 hips in group A were classified as clinical failure, femoral head survival rate was 82.1%, the median survival time was 43 months. While 19 hips in group B were classified as clinical failure, femoral head survival rate was 53.7%, the median survival time was 42 months. There was significant difference in survival curve distribution between the two groups ( χ 2= 4.123, P=0.042), and the surgical procedures of group A was superior to group B. In the two groups, the Harris hip scores at last follow-up were significantly higher than preoperative ones ( P<0.05), and VAS scores were significantly lower than preoperative ones ( P<0.05). There was no significant difference in Harris hip score and VAS score at last follow-up between the two groups ( P>0.05). All grafted bones got fusion according to the X-ray films, and there was no significant difference in the fusion time between the two groups ( t=0.752, P=0.456). In group A, greater trochanter bone cutting were healed well; and the heterotopic ossification around the hip joint occurred in 1 case. The surgery of impacting bone graft via surgical hip dislocation approach and core decompression and bone graft can be applied to treat ANFH at ARCO stage ⅢA which was mild collapse and satisfactory effectiveness can be obtained. While for the patients of ANFH at ARCO stage Ⅲ B with severe collapse, the hip survival rate of the former is better than that of the latter.

Effectiveness comparison between impacting bone graft and rotational osteotomy via surgical hip dislocation approach for avascular necrosis of femoral head at ARCO stage Ⅲ

To compare effectiveness between sequestrum clearance and impacting bone graft and rotational osteotomy on the base of femoral neck via surgical hip dislocation approach for avascular necrosis of femoral head (ANFH) at Association Research Circulation Osseous (ARCO ) stage Ⅲ. A clinical data of 24 patients (27 hips) with ANFH at ARCO stage Ⅲ, who met the inclusion criteria between June 2012 and November 2017, was retrospectively analysed. Of all patients, 12 patients (14 hips) were treated with sequestrum clearance and impacting bone graft via surgical hip dislocation approach (group A); and 12 patients (13 hips) were treated with rotational osteotomy on the base of femoral neck via surgical hip dislocation approach (group B). There was no significant difference in gender, age, disease duration, and affected side, type, and stage of the ANFH between 2 groups ( P>0.05). The operation time of each hip and hospitalization stays of each patient in 2 groups were recorded and compared. Imaging examination was performed to observe the blood supply around femoral head, healing of the osteotomy, and the femoral head collapsed. The function of the hip was evaluated by Harris score. There was no significant difference in operation time and hospitalization stays ( t=-0.262, P=0.797; t=-0.918, P=0.411). All patients were followed up, the follow-up time of group A was 12-28 months (mean, 19.7 months), and the follow-up time of group B was 14-24 months (mean, 17.8 months). The Harris score in groups A and B increased significantly at 6 months and 12 months after operation when compared with preoperative ones ( P<0.05). There was no significant difference between 2 groups at 6 months and 12 months ( P>0.05). At 12 months after operation, according to the Harris scoring, there were 3 hips of excellent, 7 hips of good, and 4 hips of poor, with the excellent and good rate of 71.4% in group A; there were 5 hips of excellent, 7 hips of good, and 1 hip of poor, with the excellent and good rate of 92.3% in group B. Digital substraction angiography was performed at 1 week after operation and indicated that the blood supply around the femoral head was not destroyed during the operation. Imaging examination after operation showed that the osteotomy of the greater trochanter all healed in 2 groups and the osteotomy of the femoral neck healed in group B. Hip collapse occurred in 2 patients (2 hips) of group A at 12 months after operation. No hip collapse occurred in group B. The rotational osteotomy on the base of femoral neck via surgical hip dislocation approach is superior to sequestrum clearance and impacting bone graft in delaying the collapse and improving the hip function for patients with ANFH at ARCO stage Ⅲ.

The pathological change of chondrocyte of the growth plate of the proximal femur in slipped capital femoral epiphysis

Objective To observe the pathological change of chondrocyte of the growth plate of the proximal femur in slipped capital femoral epiphysis (SCFE). Methods Modified Dunn osteotomy through surgical hip dislocation approach was used to treat 8 severe SCFE cases from June 2012 to June 2016. Proximal femoral growth plates and synovial tissue of 7 cases were prepared and sectioned for hematoxylin- eosin (HE) staining. Histomorphological changes were observed by microscope. Results Chondrocyte degeneration, necrosis and regeneration were noted at the growth plate of the proximal femur. Degeneration and necrosis were noted at the synovial tissue of hip joint. Conclusion It is more feasible for the surgical hip dislocation approach to obtain the specimens of the growth plate of the proximal femur in SCFE. Through observing the chondrocyte pathological change, it can play an important role in exploring the pathogenesis of SCFE. Key words: Slipped capital femoral epiphysis; Proximal femur; Growth plate

Treatment of chronic, stable slipped capital femoral epiphysis via surgical hip dislocation with combined osteochondroplasty and Imhauser osteotomy.

PurposeTreatment of slipped capital femoral epiphysis (SCFE), including the modified Dunn procedure, restores anatomy with significant risk for avascular necrosis (AVN), if performed in the setting of moderate to severe, stable SCFE. The Imhauser osteotomy has been shown to be an effective way to correct residual deformity without the risk of AVN. We sought to evaluate the effectiveness and safety of a combined Imhauser osteotomy and osteochondroplasty, performed via a surgical hip dislocation approach for the acute and delayed treatment of stable SCFE.MethodsA retrospective review was performed on a series of patients who underwent Imhauser osteotomy and osteochondroplasty via surgical hip dislocation for treatment of chronic, stable SCFE. Patients were divided into acute or delayed treatment groups based on whether osteotomy was performed as the initial slip treatment.ResultsIn total 19 patients (15 male, four female, average age 13.7 years) were reviewed. Six osteotomies were performed acutely in combination with in situ pinning, 13 were delayed at least six months after in situ pinning (average 21.7 months). Two hips had labral tears that required repair. The mean follow-up was 61 months (23 to 120) (delayed) and 53 months (27 to 61) (acute). The average improvement in slip angle was 40.7° (delayed) and 50.2° (acute) (p = 0.0916), final post-operative slip angle averaged 15.8° (delayed) and 17.8° (acute) (p = 0.544). Femoral neck length and greater trochanteric height were similar between both groups. Average alpha angle at final follow-up measured 55.8° (delayed) and 60.8° (acute) (p = 0.542). No cases of AVN were identified.ConclusionImhauser osteotomy combined with osteochondroplasty via surgical hip dislocation approach is a safe and effective treatment of moderate to severe, stable SCFE performed in both the acute and delayed setting.

Primary outcomes of femoral head reduction osteotomy for coxa magna or coxa plana

Objective To investigate the clinical efficiency and safety of femoral head reduction osteotomy for young patients with coxa magna or coxa plana. Methods Between June 2012 and September 2015, the clinical characteristics of 12 patients (13 hips) with coxa magna or coxa plana who underwent femoral head reduction osteotomy were analyzed retrospectively. There were 6 males (7 hips) and 6 females (6 hips) with average age 18.1 years (range, 10-25 years). The etiology of the femoral head deformity was multiple epiphyseal dysplasia in 6 hips and Legg-Calve-Perthes sequela in 7 hips. The head reduction osteotomy was conducted through the surgical hip dislocation approach combined with extended retinacular soft-tissue flap extending technique. All patients underwent simultaneous periacetabular osteotomy and relative lengthening of the femoral neck, of which four also underwent proximal femur derotational osteotomy. All patients received the standardized rehabilitation procedures. The postoperative complications, gaits, the range of motion (ROM) of the hip, Harris hip scores, iHOT scores and VAS were analyzed postoperatively. In addition, the lateral center-edge (LCE) angle, sphericity index and coverage rate of femoral head were assessed as well. Results The average follow-up duration was 28.8 months (range, 12-45 months). All patients achieved osteotomy healing of the femoral head and greater trochanter with average healing time 3.7 months (range, 3-7 months). Nine of 12 patients had significant gaits improvement. The Harris hip scores (81.08±12.36 vs. 88.38±8.96, t=2.41, P=0.033), iHOT score (51.90±15.07 vs. 67.69±8.70, t=3.63, P=0.003), LCE angle (-1.82°±16.57° vs. 36.02°±7.72°, t=10.52, P=0.000), sphericity index of anteroposterior pelvic radiographs (71.08%±10.32% vs. 81.22%±8.61%, t=7.17, P=0.000) and the coverage index (48.79%±11.85% vs. 87.46%±10.44%, t=8.56, P=0.000) were all significantly improved when compared to those preoperatively. The VAS score (4.46±2.37 vs. 1.23±0.93, t=4.25, P=0.001) was significantly decreased when compared with that preoperatively. However, for the sphericity index of 65° false profile (78.96%±10.39% vs. 80.36%±8.42%, t=0.411, P=0.688) and the average hip ROM (264.62°±32.05° vs. 255.00°±40.31°, t=0.89, P=0.391), they did not achieve statistical significant difference. One case of femoral head necrosis site was localized at the lateral-superior part of femoral head, and there was no progression after 3 years follow-up. Moreover, no revision or total hip arthroplasty were observed due to other complications (osteoarthritis, hip pain or non-union). Conclusion The femoral head reduction osteotomy can correct deformity, improve femoral head sphericity, relieve pain and improve gaits and hip function. This procedure leads to satisfied clinical outcomes for patients with coxa magna or coxa plana in early follow-up. Key words: Osteochondrodysplasias; Legg-Calve-Perthes disease; Reconstructive surgical procedures; Hip dislocation, congenital

Subcapital reorientation for moderate and severe slipped capital femoral epiphysis: early results of Ain Shams University Hospitals

Background Subcapital reorientation for severe slipped capital femoral epiphysis offers the double benefit of immediate restoration of range of motion (ROM), limb length discrepancy (LLD), and long-term hip preservation from premature osteoarthrosis. Patients and methods Modified Dunn’s technique through safe surgical hip dislocation was performed in 12 adolescents who presented with moderate-to-severe slipped capital femoral epiphysis. There were 10 males and only two females, with a mean age of 15 years. The mean Southwick’s slip angle was 47°. Only two slips were clinically unstable. Results After a mean follow-up of 23 months, the mean α angle measured 37°, and the mean slip angle decreased to 4.7°. The mean hip flexion range was 104°; the mean internal rotation in flexion was 33°; and the mean external rotation in flexion was 34°. The mean Harris hip score at the latest follow-up was 99.6. None of the cases developed chondrolysis or osteonecrosis. Conclusion It has been a long-standing orthopedic myth, believed by many surgeons, that the capital epiphysis cannot be realigned for fear of avascular necrosis. On the basis of the present study, we believe that subcapital reorientation through safe surgical hip dislocation approach restores close to normal the proximal femoral anatomy, and thus, presumably, would offer good long-term outcomes for a condition that can have serious lifelong consequences on young adults.

Surgical Hip Dislocation for the Treatment of Intra-Articular Injuries and Hip Instability Following Traumatic Posterior Dislocation in Children and Adolescents.

Traumatic posterior hip dislocation in children is a rare injury that typically is treated with closed reduction. Surgical treatment is typically recommended for nonconcentric reduction with joint space asymmetry with entrapped labrum or an osteochondral fragment. The surgical hip dislocation (SHD) approach allows for full assessment of the acetabulum and femoral head and has been our preferred surgical strategy. The purpose of this study was to (1) describe the intra-articular pathologic findings seen at the time of SHD; and (2) to investigate hip pain, function, and activity level of a cohort of children and adolescents after open treatment of a posterior hip dislocation using the SHD approach. Following IRB approval, 23 patients who sustained a traumatic posterior hip dislocation between January 2009 and December 2013 were identified. In 8/23 (34.8%) patients there was evidence of nonconcentric reduction after closed treatment and surgical treatment was performed using the SHD approach. Seven male and 1 female (mean age, 11.2 y; range, 6 to 14.6 y) were followed for an average of 28 months (range, 13 to 67 mo). The modified Harris Hip Score (mHHS) and the University of California Los Angeles activity score assessed clinical hip outcome and activity level at minimum of 1 year after surgery. Six patients were treated after an acute trauma, whereas 2 were treated after recurrent dislocations. Five patients were involved in motor vehicle accidents and 3 in sports-related injuries. Intraoperative findings include posterior labral avulsion in all patients, fracture of the cartilaginous posterior wall (n=3), and femoral head chondral injuries (n=5) and fracture (n=1). The labral root was repaired using suture anchor technique in 7/8 patients and resected in 1. In 2 patients, labral repair was complemented by screw fixation of the posterior wall. All but one patient (mHHS=94) reported maximum mHHS. The University of California Los Angeles activity score was 10 for 5/8 patients and 7 in 3 patients. No case of femoral head osteonecrosis was noted. One patient developed an asymptomatic heterotopic ossification. When open reduction is recommended for the treatment of intra-articular pathologies and hip instability following traumatic dislocation of the hip in children and adolescents, the SHD is an excellent approach that allows surgical correction of the damaged bony and soft-tissue structures including repair of the capsule-labral complex, and reduction and internal fixation of the cartilaginous posterior wall and femoral head fractures. Level IV.

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 hip dislocation approach for treatment of Pipkin type IV fractures

Objective To investigate clinical efficacy of surgical hip dislocation approach(Ganz approach)used in the treatment of Pipkin type Ⅳ fracture(combined fracture of femoral head and acetabulum). Methods We retrospectively reviewed 5 patients who had been treated for Pipkin type Ⅳ fracture through surgical hip dislocation approach between June 2010 and December 2014. They were 3 men and 2 women, with an average age of 38. 2 years(from 21 to 57 years). According to Pipkin classification, the fractures of femoral head were type I(2 cases)and type Ⅱ(3 ones). According to Letournel-Judet classification, the acetabular fractures were one posterior wall fracture, 2 posterior column and posterior wall fractures, and 2 posterior wall and hemitransverse fractures. All patients received reduction and supracondylar bone traction within 8 hours after injury, and surgery 5 to 12 days after injury. The Ganz approach was made. The trochanteric fragment was displaced anteriorly. After a Z-shaped capsulotomy, the visualized hip joint was dislocated. The acetabulum was fixated after the femoral head was reduced and fixated. Postoperative traction continued for 4 weeks. The outcomes were evaluated in terms of avascular necrosis of the femoral head, heterotopic ossification and Thompson-Epstein scores. Results All patients obtained fine radiographic reduction and union of the fractures of femoral head and acetabulum. The patients were followed up for an average of 18 months(from 6 to 36 months). Necrosis of the femoral head of stage Ib- Ⅱb(by International Bone Circulation Society Scale)without obvious symptoms occurred in one case. Necrosis of the femoral head of stage Ⅲb 1 occurred in another who was treated by total hip replacement. Heterotopic ossification occurred in one case. No infection, implant failure, or nonunion of fracture of femoral head or acetabulum happened. By the Thompson-Epstein score, 3 patients were excellent, one good and one fair. Conclusion The surgical hip dislocation approach(Ganz approach)is fine for the treatment of Pipkin type IV fracture, because it can not only protect the remaining vessels of the femoral head but also fully reveal the acetabulum and the femoral head. Key words: Femoral head; Acetabulum; Fractures, bone; Surgical approach