Treatment of Femoroacetabular Impingement with Surgical Dislocation

Background

The authors report the results of femoroacetabular impingement (FAI) treated with a surgical dislocation.

Methods

From April 2005 to May 2007, 15 FAI hips were treated with a surgical dislocation. The male/female ratio, mean age and mean symptom duration was 12/2, 35.8 years and 2.3 years, respectively. Radiographs and MR arthrograms were taken. The clinical evaluation involved changes in the pre- and postoperative Harris hip score (HHS).

Results

There were 12 hips (80%) with at least one structural abnormality in the radiographs, with 11 (79%) labral tears and 8 (73%) abnormally high angles in the MR arthrograms. We performed 15 osteochondroplasties, 12 labral repairs, 12 acetabuloplasty, and 3 debridements. The mean HHS improved from 76 to 93 points. Three non-unions of the trochanteric osteotomy sites were encountered as complications.

Conclusions

Radiographs and MR arthrograms are important for making a proper diagnosis of FAI and planning treatment. A surgical dislocation can be used to treat FAI but further technical improvements will be needed for fixation of the greater trochanteric osteotomy sites.     

成人先天性髋脱位(CDH)的手术治疗

目的：探讨成人先天性髋脱位的手术治疗。方法：对7例(9髋)成人先天性髋脱位病例应用股骨髁上牵引、髂剥及骨盆截骨加盖植骨术治疗，随访1～4a，按Muller和Seddon的评分标准进行主、客观评估临床疗效。结果：功能及步态满意率85．7％。结论：成年人先天性髋关节脱位单一的治疗方法难以取得满意的疗效，髂剥及骨盆截骨加盖植骨术治疗对功能的恢复有较好的效果。     

Caution Should be Taken in Performing Surgical Hip Dislocation for the Treatment of Femoroacetabular Impingement in Patients Over the Age of 40

Background

Open and arthroscopic procedures are treatment options for patients with femoroacetabular impingement (FAI). Age has been found to be a predictive factor in the outcome of patients undergoing periacetabular osteotomy (PAO) for hip dysplasia. It is unclear if older age contraindicates joint preservation through a surgical hip dislocation (SHD).

Questions/Purpose

The purpose of this retrospective case series was to evaluate the short-term outcomes of patients over 40 years of age without radiographic evidence of end-stage arthritis who underwent SHD for the treatment of FAI and to determine whether older age should be a contraindication for joint-preserving procedures in these patients. Our specific aims included (1) documenting the intraoperative findings and procedures, (2) assessing pain relief provided, and (3) assessing treatment failures and postoperative complications, noting the number of patients that ultimately required total hip arthroplasty (THA).

Patients and Methods

All patients at age 40 and older who had SHD for the treatment of FAI were identified from a series of patients treated with SHD. Clinical notes, radiographs, and operative reports were reviewed to determine clinical results, complications, and the need for additional procedures. The minimum follow-up was 1 year (mean 3.9 years; range 1–8 years).

Results

At final follow-up, 11/22 (50%) of hips had pain relief, while 11/22 (50%) either continued having significant symptoms or required THA. Five (23%) reported nontrochanteric pain symptoms that were the same or worse than before surgery, and six hips (27%) underwent subsequent THA). The average time between SHD and THA was 1.9 years (0.9–6.2). The average age of patients who went on to require THA was 45 (42–50) years.

Conclusions

Surgical hip dislocation can be used for the treatment of FAI in patients over age 40, but strict selection criteria should be adhered to, as only half of the patients experienced significant improvement in their hip pain. THA was required in one-third of hips for continued pain and radiographic progression of arthritis. SHD for treatment of pathology that is not amenable to hip arthroscopy should remain a surgical option in older patients with FAI only if joint degeneration is not present.     

大龄疑难先天性髋脱位的手术治疗

为进一步提高大龄疑难先天性髓脱位的治疗效果，降低术后严重并发症的发生率，我们总结了过去１０年间经手术治疗的２３８例３１７髋７岁以上学龄儿童及青少年先天性髋脱位，采用Ｍｃｋａｙ临床评定标准评价髋关节功能，优良率为７６．６％，术后股骨头缺血性坏死为１５．１％，髋关节运动受限为１７．７％。重点讨论了年龄因素、局部解剖畸形和病理改变特点与手术的选择，以及作者对预防和减少术后股骨头缺血性坏死和髋关节运动障碍     

High Offset Stems Are Protective of Dislocation in High-Risk Total Hip Arthroplasty

BackgroundSpinal stiffness has been shown to increase risk of dislocation due to impingement and instability. Increasing anteversion of the acetabular component has been suggested to prevent dislocation, but little has been discussed in terms of femoral or global offset restoration. The purpose of this study is to quantify dislocation rates after primary THA using standard versus high-offset femoral components and to determine how differences in offset affect impingement-free range of motion in a stiff spine cohort using a novel impingement model.MethodsA total of 12,365 patients undergoing THA from 2016 to 2018 were retrospectively reviewed to determine dislocation rates and utilization of standard- versus high-offset stems. For 50 consecutive patients with spinal stiffness, a CT-based computer software impingement modeling system assessed bony or prosthetic impingement during simulated range of motion. The model was run 5 times for each patient with varying offsets. Range of motion was simulated in each scenario to determine the degree at which impingement occurred.ResultsThere were 51 dislocations for a 0.41% dislocation rate. Total utilization of high-offset stems in the entire cohort was 49%. Of those patients who sustained a dislocation, 49 (96%) utilized a standard-offset stem. The impingement modeling demonstrated 5 degrees of added range of motion until impingement for every 1 mm offset increase.ConclusionIn the impingement model, high-offset stems facilitated greater ROM before bony impingement and resulted in lower dislocation rates. In the setting of high-risk THA due to spinal stiffness, surgeons should consider the use of high-offset stems and pay attention to offset restoration.     

Ferguson法治疗先天性髋脱位

目的：观察观察Ｆｅｒｇｕｓｏｎ法治疗小年龄髋脱位的效果。材料和方法：采用Ｆｅｒｇｕｓｏｎ法治疗先天性髋脱痊２１例２８髋。患儿平均年龄１８个月（１５￣２６个月）,平均随访时间５年（３￣７年）。结果：最终随访时９１％结果为优或良,５髋（１７．８５％）行二次骨性手术,５髋（１７．８５％）发生股骨头坏死。结论：作者认为该方法对２岁以下患儿是一种安全有效的治疗方法。     

The Role of Surgical Hip Dislocation in the Treatment of Acetabular and Femoral Head Fractures

Abstract Background and Purpose: Surgical hip dislocation by trochanteric flip osteotomy facilitates access to acetabular and femoral head fractures. Furthermore, it allows evaluation of cartilage damage and vascularity of the femoral head. In this study the potential benefits of this procedure for improved fracture management and for prognostic assessment were investigated. Patients and Methods: From July 1997 to October 1999, 20 selected patients with displaced acetabular fractures (n = 12), femoral head fractures (n = 7), or combined injuries (n = 1) were included. Inclusion criteria for acetabular fractures were either displaced posterior wall fragments with cranial extension or complex acetabular fractures involving a displaced transverse fracture line. Open reduction and fixation of either complex acetabular fractures or femoral head fractures were carried out through Kocher-Langenbeck approach, trochanteric flip osteotomy, and complete surgical hip dislocation. Additionally, the extent of cartilage destruction and femoral head perfusion were assessed. Results: Anatomic reduction ( 1 mm displacement) of acetabular fractures was achieved in 69% of patients and good reduction ( 3 mm) in 31%. In patients with acetabular fractures, severe cartilage destruction of the acetabulum was found in 38% and of the femoral head in 15%, while patients with isolated femoral head fractures revealed severe cartilage damage of the femoral head in 57%. Arterial bleeding from the femoral head, tested by drilling, was observed in all patients. Secondary dislocation of the trochanteric osteotomy occurred in one patient and made refixation necessary. Patients were reexamined at least 2 years after intervention. 77% of patients with acetabular fractures and all patients with femoral head fractures showed good or excellent results after 32.6 ± 6.1 months according to the functional score of DAubigné & Postel. Conclusion: Surgical hip dislocation allows adequate reconstruction of complex acetabular and femoral head fractures and intraoperative evaluation of local cartilage damage and femoral head perfusion.     

Acute Iatrogenic Dislocation Following Hip Impingement Arthroscopic Surgery

This is the first case report of an iatrogenic anterior hip dislocation after arthroscopic surgery for femoroacetabular impingement with over 1 year of follow-up. This case report describes the clinical course of a patient with symptomatic cam-pincer femoroacetabular impingement. She underwent arthroscopic rim trimming, labral debridement after a failed attempt at labral refixation from suture cut-through, and femoral head-neck resection osteoplasty. The procedure involved supranormal hip distraction for extraction of an iatrogenic loose body (detached metallic radiofrequency probe tip). The patient had an anterior hip dislocation in the recovery room. Immediate closed reduction under general anesthesia and bracing were performed but failed despite the ability to obtain a concentric but grossly unstable reduction. After 3 failed attempts, a mini-open capsulorrhaphy was performed that successfully restored stability. Her postoperative management and outcome are presented. All of the major static stabilizers of the hip (osseous, labral, and capsuloligamentous) were surgically altered, and a multifactorial causation is proposed. Lessons learned are discussed in hopes of minimizing the occurrence of this rare but dramatic complication.     

Total hip Replacement in Congenital Dislocation of the Hip

Twenty cases of congenital dislocation of the hip were treated with total hip replacement. the hips were completely dislocated with the femoral head supported by a nearthrosis proximal to the original acetabulum. the concept was to reconstruct the hip with an acetabular cup at the site of the original acetabulum even if a portion of the proximal end of the femur had to be sacrificed in the process. the Harris prosthesis appears, in most instances, to be the most suitable type of prosthesis but it was concluded that the surgeon needs a selection of prostheses for this procedure. Nine-tenths of the patients were improved by the procedure and the complications could mostly be successfully dealt with. This type of surgery is justified in cases with special indications.     

Traumatic Hip Dislocation in Childhood: A Report of Three Cases

Three cases of traumatic dislocation of the hip joint in children are presented. All were subjected to immediate closed reduction under general anesthesia, followed by immobilization by means of skin traction for 2 weeks. Weight-bearing was resumed 2-3 weeks after the injury, and at follow-up examinations 23 to 27 months later the hip joints were found to be normal both clinically and radiographically.     

Traumatic Hip Dislocation in Childhood: A Report of Three Cases

Three cases of traumatic dislocation of the hip joint in children are presented. All were subjected to immediate closed reduction under general anesthesia, followed by immobilization by means of skin traction for 2 weeks. Weight-bearing was resumed 2–3 weeks after the injury, and at follow-up examinations 23 to 27 months later the hip joints were found to be normal both clinically and radiographically.