Surgical Hip Dislocation Approach Research Articles

Current Practice in the Management of Slipped Capital Femoral Epiphysis.

The most widely used treatment for slipped capital femoral epiphysis (SCFE) is in situ fixation. In an attempt to reduce the chances of impingement, osteoarthritis, and osteonecrosis, surgeons have started adopting newer surgical techniques. The purpose of this study was to determine the current pattern of treating SCFE. A questionnaire was sent electronically to all of the members of the Pediatric Orthopaedic Society of North America. The data were analyzed dividing surgeons into academic versus private practice, years of practice, and number of SCFEs treated per year. Of 990 members, 277 (28%) responded to the survey.Type of practice (academic, n=181 vs. private, n=51): For unstable severe SCFE, surgeons in academic practice use the surgical hip dislocation (SHD) approach significantly more frequently (35.7% vs. 14.9%; P=0.02). A radiolucent table is used significantly more frequently in academic practice for both stable (50.6% vs. 29.8%; P=0.01) and unstable (39.6% vs. 15.2%; P=0.002) SCFE. Fully threaded cannulated screws (44.4% vs. 27.1%; P=0.03), open capsular decompression (63.9% vs. 32.4%; P=0.001), contralateral pinning (79% vs. 58.7%; P=0.005), and postoperative magnetic resonance imaging (MRI) (15.5% vs. 3.9%; P=0.03) are significantly more frequent in academic practice.Years of practice (≤15 y, n=124 vs. >15 y, n=140): For severe stable SCFE, surgeons practicing for ≤15 years do acute osteotomies significantly less frequently (1.8% vs. 9%; P=0.004) and perform SHD significantly more frequently (20.2% vs. 8.2%; P=0.004). For unstable moderate SCFE, SHD is utilized significantly more frequently by surgeons ≤15 years in practice (29.8% vs. 16.5%; P=0.04). Bilateral frog-leg lateral views (86.4% vs. 73.7%; P=0.04), preoperative MRI (36.1% vs. 20.6%; P=0.006), open capsular decompression (69.3% vs. 51.7%; P=0.01) are significantly more frequent among surgeons ≤15 years in practice.Number of SCFE treated per year (<10, n=129 vs. ≥10, n=136): For unstable severe SCFE, surgeons treating ≥10/y perform SHD significantly more frequently (38.6% vs. 26.1%; P=0.02) and do in situ fixation with manual reduction significantly less frequently (11.8% vs. 21.8%; P=0.02). Radiolucent table (54.3% vs. 38%; P=0.01), 7.5 mm screw versus 6.5 mm (62% vs. 45.4%; P=0.01), contralateral pinning (78.9% vs. 67.8%; P=0.04), postoperative MRI (17.6% vs. 9.3%; P=0.04), and postoperative computed tomography (14.7% vs. 7%; 0.04) are significantly more frequent among surgeons doing ≥10/y. Elective implant removal is more common among surgeons treating <10/y (16.2% vs. 6.9%; P=0.02). Treatment of SCFE varies significantly depending on the surgeon's type of practice, years in practice, and numbers treated per year. Surgeons in academic practice, surgeons with ≤15 years in practice, and surgeons treating greater number of SCFEs are more likely to use SHD to acutely reduce the slip.

Surgical Hip Dislocation is Safe and Effective Following Acute Traumatic Hip Instability in the Adolescent.

A traumatic hip dislocation in the pediatric patient is a rare but potentially catastrophic injury. The purpose of this study was to review our early clinical results and radiographic morphology of hips treated with a surgical hip dislocation (SHD) approach for intra-articular hip pathology resulting from traumatic instability in pediatric and adolescent patients. This is a retrospective analysis of a consecutive series of patients presenting with nonconcentric reduction after traumatic hip instability. All patients were treated with a transtrochanteric SHD with concomitant procedures based on intra-articular findings. Radiographic evaluations and Harris Hip Scores were completed at final follow-up. Eleven male patients, mean age of 12.3 years (range, 9.3 to 16.1 y) and mean body mass index 19.6 kg/m (range, 15.4 to 28.0 kg/m). Intraoperative findings included: labral tear (8), femoral cartilage injury (5), acetabular rim fracture (4), acetabular cartilage delamination (3), loose body (2), and femoral head osteochondral fracture (1). Postoperatively, 1 patient developed a transient peroneal nerve palsy. At a mean 24.5 months (range, 12.0 to 48.1 mo) postoperatively, no hips have radiographic evidence of osteonecrosis. The mean lateral center edge angle was 20 degrees (range, 9 to 38 degrees) with 6 hips of <20 degrees; mean acetabular index 9 degrees (range, -2 to 23 degrees) with 5 hips of >10 degrees; mean α-angle 56 degrees (range, 48 to 62 degrees) with 6 hips of >55 degrees; mean acetabular version 12 degrees (range, 8 to 16 degrees) with 8 hips of <15 degrees. At 1-year follow-up, the mean Harris Hip Score was 95.8 (range, 84.7 to 100). Early results suggest that SHD is a safe approach to treat an incomplete reduction following posterior hip instability and is effective for identification and treatment of acute intra-articular pathology. Acetabular dysplasia, relative acetabular retroversion, and/or decreased femoral offset may be risk factors for posterior hip instability in adolescents. Level IV.

Application of the Surgical Dislocation Approach to Residual Hip Deformity Secondary to Legg-Calvé-Perthes Disease

Long-term prognosis after Legg-Calvé-Perthes disease (LCPD) depends on the severity of residual hip deformities including a nonspherical femoral head, a short and wide femoral neck, a high riding greater trochanter, and secondary changes in the acetabulum. Hip deformity after healed LCPD may lead to abnormal hip mechanics including femoroacetabular impingement and hip instability secondary to acetabular dysplasia. The surgical dislocation approach has recently been applied to LCPD hip deformity with encouraging short-term results. This approach allows complete dynamic evaluation of the hip joint, identification, and correction of the most common residual deformities. The purpose of this paper is to describe the application of the surgical hip dislocation approach to LCPD deformity and to evaluate the current available literature on the results of this approach to the healed LCPD hip.

Results of Treatment of Femoroacetabular Impingement in Adolescents with a Surgical Hip Dislocation Approach

The literature contains few studies of open treatment with an open surgical hip dislocation approach for treatment of femoroacetabular impingement (FAI) in adolescents. The average age and associated disorders in adolescents with FAI reveal a critical need to study younger patients whose hip disorder has not had time to progress. We assessed (1) how validated measures of patient-oriented assessment of hip function and quality of life change after surgical hip dislocation; (2) whether any patient-related or technique variables correlated with changes in the outcome scores; and (3) what the complications of treatment are and how many reoperations we performed on these patients. We retrospectively reviewed a consecutive series of 71 hips in adolescents younger than 21 years who underwent surgical hip dislocation for FAI. The final cohort consisted of 44 patients (52 hips) with a mean age of 16 years. We analyzed changes in outcome variables after surgical hip dislocation and recorded reoperations during the study period. The minimum followup was 12 months (average, 27 months; range, 12-60 months). Modified Harris hip scores increased from a mean of 57.7 preoperatively to a mean of 85.8 postoperatively. Mean SF-12 scores increased from 42.3 to 50.6. Mean preoperative hip flexion increased from 97.5° to 106.2°. Mean internal rotation of the affected hip at 90° flexion increased from 18.19° to 34°. Early results revealed improvements in hip function, patient quality of life, and ROM after surgical hip dislocation for the majority of this group of adolescents with FAI. However, 10% of the patients did not improve, and an additional 15% improved but still did not consider their hips good or excellent. This points toward the need for further studies in this population of patients.

Slipped Capital Femoral Epiphysis: Prevalence, Pathogenesis, and Natural History

Obesity is a risk factor for developing slipped capital femoral epiphysis (SCFE). The long-term outcome after SCFE treatment depends on the severity of residual hip deformity and the occurrence of complications, mainly avascular necrosis (AVN). Femoroacetabular impingement (FAI) is associated with SCFE-related deformity and dysfunction in both short and long term. We examined obesity prevention, early diagnosis, reducing AVN and hip deformity as strategies to reduce SCFE prevalence, and the long-term outcomes after treatment. A search of the literature using the PubMed database for the key concepts SCFE and treatment, natural history, obesity, and prevalence identified 218, 15, 26, and 49 abstracts, respectively. WHERE ARE WE NOW?: A correlation between rising childhood obesity and increasing incidence of SCFE has been recently reported. Residual abnormal morphology of the proximal femur is currently believed to be the mechanical cause of FAI and early articular cartilage damage in SCFE. WHERE DO WE NEED TO GO?: Reducing the increasing prevalence rate of SCFE is important. Treatment of SCFE should aim to reduce AVN rates and residual deformities that lead to FAI to improve the long-term functional and clinical outcomes. HOW DO WE GET THERE?: Implementing public health policies to reduce childhood obesity should allow for SCFE prevalence to drop. Clinical trials will evaluate whether restoring the femoral head-neck offset to avoid FAI along with SCFE fixation allows for cartilage damage prevention and lower rates of osteoarthritis. The recently described surgical hip dislocation approach is a promising technique that allows anatomic reduction with potential lower AVN rates in the treatment of SCFE.

Low Early Failure Rates Using a Surgical Dislocation Approach in Healed Legg-Calvé-Perthes Disease

Hip deformity secondary to Legg-Calvé Perthes disease (LCPD) may result in femoroacetabular impingement (FAI) and ultimately osteoarthritis. Observations made with the surgical hip dislocation approach have improved our understanding of the pathologic mechanics of FAI. However, owing to concerns about complications related to the vascularity, the role of surgical hip dislocation in the treatment of healed LCPD remains controversial. We present an algorithm to treat deformities associated with healed LCPD and asked (1) whether femoral head-neck osteochondroplasty and other procedures performed with the surgical hip dislocation approach provide short-term clinical improvement; and (2) is the complication rate low enough to be acceptable. We retrospectively reviewed 29 patients (19 males, 10 females; mean age, 17 years; range, 9-35 years) with symptomatic LCPD between 2001 and 2009. All patients underwent a surgical hip dislocation approach and femoral head-neck osteochondroplasty and 26 patients had 37 additional procedures performed. Clinical improvement was assessed using the WOMAC index. The minimum followup was 12 months (mean, 3 years; range, 12-70 months). WOMAC scores improved at final followup (8 to 4 for pain, 21 to 13 for function, and 4 to 2 for the stiffness subscales). No patients had osteonecrosis, implant failure, deep infection, or nonunion. Three patients underwent THA at 1, 3, and 6 years after their index procedure. Using the surgical hip dislocation approach as a tool to dynamically inspect the hip for causes of FAI, we were able to perform a variety of procedures to treat the complex deformities of healed LCPD. In the short term, we found improvement in WOMAC scores with a low complication rate.

Surgical Management of the Problematic Hip in Adolescent and Young Adult Patients

Surgical management of the problematic hip in adolescent and young adult patients can be challenging. In many of these patients, hip arthrosis and pain occur secondary to hip dysplasia associated with chronic instability, whether the result of prior treatment or chronic unmanaged acetabular dysplasia. Surgical techniques such as the Bernese periacetabular osteotomy are performed to correct acetabular deficiency, restore hip joint stability, and eliminate pain. Patients with previous Legg-Calvé-Perthes disease or slipped capital femoral epiphysis frequently note onset of symptomatic hip arthrosis and pain in adolescence or young adulthood. Pain occurs secondary to pathologic impingement of the deformed proximal femur against the anterolateral acetabulum (ie, femoroacetabular impingement). The recent successful innovation of the transtrochanteric surgical hip dislocation approach provides complete access to the hip and offers the potential for comprehensive correction of both the often severe proximal femoral deformity and associated labral chondral disease secondary to Legg-Calvé-Perthes disease and slipped capital femoral epiphysis. Restoration of more normal proximal femoral morphology results in marked improvement in functional outcome. Effective orthopaedic management requires an understanding of the mechanisms of hip disease as well as surgical expertise.

Utilization of the Safe Surgical Dislocation Approach of the Hip to Retrieve a Bullet from the Femoral Head

Retained intra-articular missiles from low-velocity handguns can lead to mechanical arthritis, synovitis, and lead toxicity. Various surgical approaches have been described to extract such foreign bodies from the hip joint. We present the case of a 17-year-old male in which the surgical dislocation approach was utilized to retrieve a bullet from the femoral head with a good short-term outcome. This case represents a rare application of the surgical hip dislocation approach for an unusual trauma.

Die operative Behandlung der Azetabulum-T-Fraktur über eine chirurgische Hüftluxation oder einen Stoppa-Zugang

Anatomic reduction and stable fixation by means of tissue- preserving surgical approaches. INDICATIONS Displaced acetabular fractures. Surgical hip dislocation approach with larger displacement of the posterior column in comparison to the anterior column, transtectal fractures, additional intraarticular fragments, marginal impaction. Stoppa approach with larger displacement of the anterior column in comparison to the posterior column. A combined approach might be necessary with difficult reduction. CONTRAINDICATIONS Fractures > 15 days (then ilioinguinal or extended iliofemoral approaches). Suprapubic catheters and abdominal problems (e.g., previous laparotomy due to visceral injuries) with Stoppa approach (then switch to classic ilioinguinal approach).Surgical hip dislocation: lateral decubitus position. Straight lateral incision centered over the greater trochanter. Entering of the Gibson interval. Digastric trochanteric osteotomy with protection of the medial circumflex femoral artery. Opening of the interval between the piriformis and the gluteus minimus muscle. Z-shaped capsulotomy. Dislocation of the femoral head. Reduction and fixation of the posterior column with plate and screws. Fixation of the anterior column with a lag screw in direction of the superior pubic ramus. Stoppa approach: supine position. Incision according to Pfannenstiel. Longitudinal splitting of the anterior portion of the rectus sheet and the rectus abdominis muscle. Blunt dissection of the space of Retzius. Ligation of the corona mortis, if present. Blunt dissection of the quadrilateral plate and the anterior column. Reduction of the anterior column and fixation with a reconstruction plate. Fixation of the posterior column with lag screws. If necessary, the first window of the ilioinguinal approach can be used for reduction and fixation of the posterior column.During hospital stay, intensive mobilization of the hip joint using a continuous passive motion machine with a maximum flexion of 90 degrees . No active abduction and passive adduction over the body's midline, if a surgical dislocation was performed. Maximum weight bearing 10-15 kg for 8 weeks. Then, first clinical and radiographic follow-up. Deep venous thrombosis prophylaxis for 8 weeks postoperatively.17 patients with a mean follow-up of 3.2 years. Ten patients were operated via surgical hip dislocation, two patients with a Stoppa approach, and five using a combined or alternative approach. Anatomic reduction was achieved in ten of the twelve patients (83%) without primary total hip arthroplasty. Mean operation time 3.3 h for surgical hip dislocation and 4.2 h for the Stoppa approach. Complications comprised one delayed trochanteric union, one heterotopic ossification, and one loss of reduction. There were no cases of avascular necrosis. In two patients, a total hip arthroplasty was performed due to the development of secondary hip osteoarthritis.

Surgical Technique: Open Reduction and Internal Fixation for Unstable Slipped Capital Femoral Epiphysis

Failure to reduce displacement of the epiphysis after an unstable slipped capital femoral epiphysis (SCFE) can lead to femoroacetabular impingement, labral damage, and early degeneration of articular cartilage. Surgical dislocation of the hip has provided us with a safe means to reduce and fix the epiphysis after an unstable slip. This article details the surgical technique for open reduction and internal fixation of the unstable SCFE, using the surgical hip dislocation approach. Early results are promising and demonstrate the safety of surgical hip dislocation used for the unstable SCFE, reproducing the safety of the procedure for elective applications. This method should be considered for any unstable SCFE, especially as surgeon experience improves.

Application of Ganz Surgical Hip Dislocation Approach in Pediatric Hip Diseases

BackgroundGanz surgical hip dislocation is useful in the management of severe hip diseases, providing an unobstructed view of the femoral head and acetabulum. We present our early experience with this approach in pediatric hip diseases.MethodsTwenty-three hips of 21 patients with pediatric hip diseases treated using the Ganz surgical hip dislocation approach were the subjects of this study. The average age at the time of surgery was 15.7 years. There were 15 male and 6 female patients who were followed for an average of 15.1 months (range, 6 to 29 months). Diagnoses included hereditary multiple exostoses in 9 hips, slipped capital femoral epiphysis in 7, Legg-Calvé-Perthes disease in 4, osteoid osteoma in 1, pigmented villonodular synovitis in 1, and neonatal septic hip sequelae in 1. Medical records were reviewed to record diagnoses, principal surgical procedures, operative time, blood loss, postoperative rehabilitation, changes in the range of hip joint motion, and complications.ResultsFemoral head-neck osteochondroplasty was performed in 17 patients, proximal femoral realignment osteotomy in 6, open reduction and subcapital osteotomy for slipped capital femoral epiphysis (SCFE) in 2, core decompression and bone grafting in 2, hip distraction arthroplasty in 2, and synovectomy in 2. Operative time averaged 168.6 minutes when only osteochondroplasty and/or synovectomy were performed. Hip flexion range improved from a preoperative mean of 84.7° to a mean of 115.0° at the latest follow-up visit. Early continuous passive motion and ambulation were stressed in rehabilitation. No avascular necrosis of the femoral head was noted up to the time of the latest follow-up visit, except for in one SCFE patient whose surgical intervention was delayed for medical reasons.ConclusionsGanz surgical hip dislocation provides wide exposure of the femoral head and neck, which enables complete and precise evaluation of the femoral head and neck contour. Hence, the extensive impinging bump can be excised meticulously, and the circulation of the femoral head can be monitored during surgery. The Ganz procedure was useful in severe pediatric hip diseases and allowed for quick rehabilitation with fewer complications.