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Stabilizes pelvis Surgeon: Flexes hip to 90 degrees, applies traction and adduction

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Hip Dislocations and Femoral Head Fractures Fernando Serna, MD John T. Gorczyca, MD University of Rochester Medical Center Created March 2004; First Revision January 2006 Second Revision July 2009
Introduction Hip dislocations caused by significant force: – Association with other fractures – Damage to vascular supply to femoral head Thus, high chance of complications
Anatomy: Hip Joint Ball and socket joint. Femoral head: slightly asymmetric, forms 2/3 sphere. Acetabulum: inverted “U” shaped articular surface. Ligamentum teres, with artery to femoral head, passes through middle of inverted “U”.
Joint Contact Area Throughout ROM: • 40% of femoral head is in contact with acetabular articular cartilage. • 10% of femoral head is in contact with labrum.
Acetabular Labrum Strong fibrous ring Increases femoral head coverage Contributes to hip joint stability
Hip Joint Capsule • Extends from intertrochanteric ridge of proximal femur to bony perimeter of acetabulum • Has several thick bands of fibrous tissue Iliofemoral ligament • Upside-down “Y” • Blocks hip hyperextension • Allows muscle relaxation with standing
Femoral Neck Anteversion • Averages 70 in Caucasian males. • Slightly higher in females. • Asian males and females have been noted to have anteversion of 140 and 160 respectively.
Blood Supply to Femoral Head 1. Artery of Ligamentum Teres • Most important in children. • Its contribution decreases with age, and is probably insignificant in elderly patients.
Blood Supply to Femoral Head 2. Ascending Cervical Branches • Arise from ring at base of neck. • Ring is formed by branches of medial and lateral circumflex femoral arteries. • Penetrate capsule near its femoral attachment and ascend along neck. • Perforate bone just distal to articular cartilage. • Highly susceptible to injury with hip dislocation.
Sciatic Nerve Composed from roots of L4 to S3. Peroneal and tibial components differentiate early, sometimes as proximal as in pelvis. Passes posterior to posterior wall of acetabulum. Generally passes inferior to piriformis muscle, but occasionally the piriformis will split the peroneal and tibial components
Posterior Hip Dislocation: Mechanism of Injury Almost always due to high-energy trauma. Most commonly involve unrestrained occupants in MVAs. Can also occur in pedestrian-MVAs, falls from heights, industrial accidents and sporting injuries.
Posterior Dislocation • Generally results from axial load applied to femur, while hip is flexed. • Most commonly caused by impact of dashboard on knee.
Type of Posterior Dislocation depends on: Direction of applied force. Position of hip. Strength of patient’s bone.
Hip Position vs. Type of Posterior Dislocation In General, Abduction: acetabulum fracture-dislocation Adduction: pure dislocation Extension: femoral head fracture-dislocation Flexion: pure dislocation
Anterior Dislocation 7-10% of hip dislocations Mechanism: • Forced abduction with external rotation of hip. • Anterior hip capsule is torn or avulsed. • Femoral head is levered out anteriorly.
Effect of Dislocation on Femoral Head Circulation Posterior dislocation of cadaveric hips results in statistically significant filling defects in the common femoral and circumflex arteries on cine- fluoroscopic vessel examination. • In some cases, collateral circulation maintained intraosseous blood flow. • Posited that AVN results from immediate ischemia at time of injury and from progressive and delayed arterial damage. Yue et al (J Orthop Trauma 1996)
Effect of Dislocation on Femoral Head Circulation • Injury to ascending cervical branches associated with damage to capsule during dislocation. • Dislocation disrupts artery of ligamentum teres. • Dislocated hip may kink or compress acending cervical branches until the hip is reduced. Thus, early reduction of the dislocated hip can improve blood flow to femoral head.
Associated Injuries Mechanism: high-energy, unrestrained vehicle occupants. Sahin et al reported 71% associated injuries in patients with traumatic hip dislocations and fracture-dislocations. (J Trauma 2003) Hak and Goulet reported 95% associated injuries in patients with hip dislocations. • Only 33% had isolated orthopaedic injuries. • 24% head, 21% craniofacial, and 21% thoracic injuries. • General Surgery/Trauma evaluation warranted in all hip dislocation patients. (J Trauma 1999)
Associated Injuries Mechanism: knee vs. dashboard Contusions of distal femur Patella fractures Foot fractures, if knee extended
Associated Knee Injuries 25% (46 of 187) of hip injury patients had knee injury. • 27 acetabulum fractures without dislocation, 10 pure hip dislocation, and 9 acetabulum fx-dislocations. • 85% had symptoms or clinical findings of knee injury. • 13 fractures (7 patella, 5 supracondylar femur or tibial plateau, 1 osteochondral), 9 ligamentous injury (2 knee dislocations, 1 MCL, 1 LCL, 5 combined), 1 patellar tendon tear, and multiple wounds and contusions • 75% had other injuries •Underscores the need for vigilance in detecting these injuries. Tabuenca and Truan (CORR 2000)
Associated Injuries Sciatic nerve injuries occur in 10% of adult and 5% of pediatric hip dislocations. Most commonly, these resolve with reduction of hip and passage of time. Stretching or contusion most common. Piercing or transection of nerve by bone can occur.
Classification Multiple systems exist. Many reflect outmoded evaluation and treatment methods.
Thompson and Epstein Classification of Hip Dislocations (Most well-known) Type I Pure dislocation with at most a small posterior wall fragment. Type II Dislocation with large posterior wall fragment. Type III Dislocation with comminuted posterior wall. Type IV Dislocation with “acetabular floor” fracture (probably transverse + post. wall acetabulum fracture-dislocation). Type V Dislocation with femoral head fracture. Thompson and Epstein, J Bone and Joint Surg, 1951
Epstein Classification of Anterior Hip Dislocations Type I Superior (pubic and subspinous) Type II Inferior (obturator and perineal) A No associated fracture B Associated fracture of the femoral head/neck C Associated fracture of the acetabulum i.e, Type IA, IIB, etc. Epstein, Clin Orthop Relat Res, 1973.
AO/OTA Classification • Most thorough. • Best for reporting data, to allow comparison of patients from different studies. • 30-D10 Anterior Hip Dislocation • 30-D11 Posterior Hip Dislocation • 30-D30 Obturator (Anterior-Inferior) Hip Dislocation
Evaluation: History Significant trauma, usually MVA. Awake, alert patients have severe pain in hip region.
Physical Examination: Classical Appearance Posterior Dislocation: Hip flexed, internally rotated, adducted.
Physical Examination: Classical Appearance Anterior Dislocation: Extreme external rotation, less-pronounced abduction and flexion.
Unclassical presentation (posture) if: • femoral head or neck fracture • femoral shaft fracture • obtunded patient
Physical Examination • Pain to palpation of hip. • Pain with attempted motion of hip. • Possible neurological impairment: Thorough exam essential!
Radiographs: AP Pelvis X-Ray • In primary survey of ATLS Protocol. • Should allow diagnosis and show direction of dislocation. – Femoral head not centered in acetabulum. – Femoral head appears larger (anterior) or smaller (posterior). • Usually provides enough information to proceed with closed reduction.
Reasons to Obtain More X-Rays Before Hip Reduction • View of femoral neck inadequate to rule out fracture. • Patient requires CT scan of abdomen/pelvis for hemodynamic instability – and additional time to obtain 2-3 mm cuts through acetabulum + femoral head/neck would be minimal.
X-rays after Hip Reduction: • AP pelvis, Lateral Hip x-ray. • Judet views of pelvis. • CT scan with 2-3 mm cuts.
CT Scan Most helpful after hip reduction. Reveals: Non-displaced fractures. Congruity of reduction. Intra-articular fragments. Size of bony fragments.
MRI Scan • Will reveal labral tear and soft-tissue anatomy. • Has not been shown to be of benefit in acute evaluation and treatment of hip dislocations.
Clinical Management: Emergent Treatment • Dislocated hip is an emergency. • Goal is to reduce risk of AVN and DJD. • Evaluation and treatment must be streamlined.
Emergent Reduction • Allows restoration of flow through occluded or compressed vessels. • Requires proper anesthesia. • Requires “team” (i.e. more than one person).
Time to reduction • Controversy in the literature regarding appropriate timing to reduction • Marchetti, Steinberg, and Coumas (J Orthop Trauma 1996) found no statistically significant difference in outcomes in posterior fracture-dislocations when reduced greater or less than 6 hrs from time of injury • Mehlman et al (CORR 2000) demonstrated a 20X greater risk of AVN in pediatric traumatic hip dislocations if reduction delayed > 6 hrs • Sahin et al (J Trauma 2003) demonstrated better prognosis in hip dislocations and fracture-dislocations reduced within 12 hrs • Universally agreed that the earlier the better
Anesthesia • General anesthesia with muscle relaxation facilitates reduction, but is not necessary. • Conscious sedation is acceptable. • Attempts at reduction with inadequate analgesia/ sedation will cause unnecessary pain, create muscle spasm, and make subsequent attempts at reduction more difficult.
General Anesthesia if: • Patient is to be intubated emergently in Emergency Room. • Patient is being transported to Operating Room for emergent head, abdominal or chest surgery. • Take advantage of opportunity.
Reduction Maneuvers Allis: Patient supine. Requires at least two people. Stimson: Patient prone, hip flexed and leg off stretcher. Requires one person. Impractical in trauma (i.e. most patients).
Allis Maneuver • Assistant: Stabilizes pelvis • Posterior-directed force on both ASIS’s • Surgeon: Stands on stretcher • Gently flexes hip to 900 • Applies progressively increasing traction to the extremity • Applies adduction with internal rotation • Reduction can often be seen and felt
Allis Maneuver
Reduced Hip • Moves more freely • Patient more comfortable • Requires testing of stability • Simply flexing hip to 900 does not sufficiently test stability
Stability Test 1. Hip flexed to 90 o 2. If hip remains stable, apply internal rotation, adduction and posterior force. 3. The amount of flexion, adduction and internal rotation that is necessary to cause hip dislocation should be documented. 4. Caution!: Large posterior wall fractures may make appreciation of dislocation difficult.
Irreducible Hip Requires emergent reduction in O.R. Pre-op CT obtained if it will not cause delay. One more attempt at closed reduction in O.R. with anesthesia. – Repeated efforts not likely to be successful and may create harm to the neurovascular structures, articular cartilage, or even cause iatrogenic fracture. Stannard et al, Clin Orthop Relat Res, 2000 Surgical approach from side of dislocation.
Hip Dislocation: Nonoperative Treatment • If hip stable after reduction, and reduction congruent. • Maintain patient comfort. • ROM precautions (No Adduction, Internal Rotation). • No flexion > 60 o . • Early mobilization. • Touch down weight-bearing for 4-6 weeks. • Repeat x-rays before allowing weight-bearing.
Hip Dislocation: Indications for Operative Treatment 1. Irreducible hip dislocation 2. Hip dislocation with femoral neck fracture 3. Incarcerated fragment in joint 4. Incongruent reduction 5. Unstable hip after reduction
1. Irreducible Hip Dislocation: Anterior Smith-Peterson approach • Watson-Jones is an alternate approach 1. Allows visualization and retraction of interposed tissue. 2. Placement of Schanz pin in intertrochanteric region of femur will assist in manipulation of the proximal femur. 3. Repair capsule, if this can be accomplished without further dissection.
1. Kocher-Langenbeck approach. 1.Remove interposed tissue, or release buttonhole. 1.Repair posterior wall of acetabulum if fractured and amenable to fixation. 1. Irreducible Hip Dislocation: Posterior
Irreducible Posterior Dislocation with Large Femoral Head Fracture Fortunately, these are rare. Difficult to fix femoral head fracture from posterior approach without transecting ligamentum teres.
Three Options 1. Detach femoral head from ligamentum teres, repair femoral head fracture with hip dislocated, reduce hip. 2. Reduce hip through posterior incision, close posterior wound, fix femoral head fracture from anterior approach (either now or later). 3. Ganz trochanteric “flip” osteotomy. Best option not known: Damage to blood supply from anterior capsulotomy vs. damage to blood supply from transecting ligamentum teres. These will be discussed in detail in femoral head fracture section.
2. Hip Dislocation with Femoral Neck Fracture Attempts at closed reduction potentiate chance of fracture displacement with consequent increased risk of AVN. If femoral neck fracture is already displaced, then the ability to reduce the head by closed means is markedly compromised. Thus, closed reduction should not be attempted.
2. Hip Dislocation with Femoral Neck Fracture Usually the dislocation is posterior. Thus, Kocher-Langenbeck approach. If fracture is non-displaced, stabilize fracture with parallel lag screws first. If fracture is displaced, open reduction of femoral head into acetabulum, reduction of femoral neck fracture, and stabilization of femoral neck fracture.
3. Incarcerated Fragment Can be detected on x-ray or CT scan. Surgical removal necessary to prevent abrasive wear of the articular cartilage. Posterior approach allows best visualization of acetabulum (with distraction or intra-op dislocation). Anterior approach only if: dislocation was anterior and,
4. Incongruent Reduction Caused By: • Acetabulum Fracture (weight-bearing portion). • Femoral Head Fracture (any portion). • Interposed tissue. Goal: achieve congruence by removing interposed tissue and/or reducing and stabilizing fracture.
• 25% (9/35) of pediatric patients with traumatic hip dislocation required surgery to remove interposed soft tissue and/or osteochondral fragments to achieve congruent hip reduction. Vialle et al, J Pediatric Orthop 2005 • 92% (33/36) of adults had loose bodies detected arthroscopically. • 21% (7/33) had normal x-rays and CT. –Clinical significance of soft-tissue interposition is not clear if joint congruent. –? Benefit of routine arthroscopy. Mullis and Dahner, J Orthop Trauma, 2006 Incongruent Reduction: Interposed Tissue
5. Unstable Hip after Reduction • Due to posterior wall and/or femoral head fracture. • Requires reduction and stabilization fracture. • Labral detachment or tear – Highly uncommon cause of instability. – Its presence in the unstable hip would justify surgical repair. – MRI may be helpful in establishing diagnosis.
Results of Treatment • Large range: from normal to severe pain and degeneration. • In general, dislocations with associated femoral head or acetabulum fractures fare worse. • Dislocations with fractures of both the femoral head and the acetabulum have a strong association with poor results. • Irreducible hip dislocations have a strong association with poor results. – 13/23 (61%) poor and 3/23 (13%) fair results. McKee, Garay, Schemitsch, Kreder, Stephen. Irreducible fracture-dislocation of the hip: a severe injury with a poor prognosis. J Orthop Trauma. 1998.
Complications of Hip Dislocation • Avascular Necrosis (AVN): 1-20% – Several authors have shown a positive correlation between duration of dislocation and rate of AVN. – Results are best if hip reduced within six hours. • Mehlman et al (CORR 2000) demonstrated a 20X greater risk of AVN in pediatric traumatic hip dislocations if reduction delayed > 6 hrs • Also demonstrated that bone scan results can be misleading, and thus routine screening is not recommended
Post-traumatic Osteoarthritis • Can occur with or without AVN • May be unavoidable in cases with severe cartilaginous injury. • Incidence increases with associated femoral head or acetabulum fractures. 16% osteoarthritis in uncomplicated hip dislocations and up to 88% in dislocations associated with severe acetabular fractures • Upudhyay et al, J Bone Joint Surg. (Br.), 1983. • Efforts to minimize osteoarthritis are best directed at achieving anatomic reduction of injury and preventing abrasive wear between articular carrtilage and sharp bone edges.
Recurrent Dislocation Rare, unless an underlying bony instability has not been surgically corrected (e.g. excision of large posterior wall fragment instead of ORIF). Some cases involve pure dislocation with inadequate soft-tissue healing – may benefit from surgical imbrication (rare). Can occur from detached labrum, which would benefit from repair (rare).
Recurrent Dislocation Caused by Defect in Posterior Wall and/or Femoral Head Can occur after excision of fractured fragment. Pelvic and/or intertrochanteric osteotomy could alter the alignment of the hip to improve stability. Bony block could also provide stability.
Delayed Diagnosis of Hip Dislocation Increased incidence in multiple trauma patients. More common if patient has altered sensorium. Results in: more difficult closed reduction. higher incidence of AVN. In NO Case should a hip dislocation be treated without reduction.
Sciatic Nerve Injury Occurs in up to 20% of adult and 5% of pediatric patients with hip dislocation. Peroneal nerve affected more commonly than tibial Nerve stretched, compressed or transected. With reduction: 40% complete resolution 25-35% partial resolution
Sciatic Nerve Palsy: If No Improvement after 3–4 Weeks EMG and Nerve Conduction Studies for baseline information and for prognosis. Allows localization of injury in the event that surgery is required.
Foot Drop Splinting (i.e. ankle-foot-orthosis): • Improves gait • Prevents contracture
Infection Incidence 1-5% Lowest with prophylactic antibiotics and limited surgical approaches
Infection: Treatment Principles Maintenance of joint stability. Debridement of devitalized tissue. Intravenous antibiotics. Hardware removed only when fracture healed.
Iatrogenic Sciatic Nerve Injury Most common with posterior approach to hip. Results from prolonged retraction on nerve.
Iatrogenic Sciatic Nerve Injury Prevention: Maintain hip in full extension Maintain knee in flexion Avoid retractors in lesser sciatic notch ? Intra-operative nerve monitoring (SSEP, motor monitoring)
Thromboembolism Hip dislocation = high risk patient. Prophylactic treatment with: • low molecular weight heparin, or • coumadin Early postoperative mobilization. Discontinue prophylaxis after 2-6 weeks (if patient mobile).
Femoral Head Fractures Treatment principles similar to those listed for hip dislocations.
Femoral Head Fractures – Mechanism • Fracture occurs by shear as femoral head dislocates. • With less hip flexion, femoral head fracture tends to be larger.
History and Physical Examination Similar to patient with hip dislocation. Patient posture may be less extreme due to femoral head fracture.
Classification of Femoral Head Fractures Thompson and Epstein Type V • Posterior hip dislocation with femoral head fracture Epstein Type IB • Anterosuperior dislocation with femoral head and/or neck fracture Epstein Type IIB • Anteroinferior dislocation with femoral head and/or neck fracture
AO/OTA Classification
Pipkin Classification I Fracture inferior to fovea II Fracture superior to fovea III Fracture of femoral head with fracture of femoral neck IV Fracture of femoral head with acetabulum fracture
Pipkin, JBJS, 1957
Pipkin I AO/OTA 31-C1.2
Pipkin II AO/OTA 31-C1.3
Pipkin III • Femoral head fracture with femoral neck fracture.
Pipkin IV • Femoral head fracture with acetabulum fracture. • High incidence of post-traumatic AVN.
Pipkin Prognostic Value • 33 patients with posterior fracture-dislocations of the hip. • Pipkin Types I/II had statistically significant better outcomes than Types III/IV. Marchetti, Steinberg, and Coumas, J Orthop Trauma, 1996 • 46 patients • Better outcomes in Pipkin Types I >II > IV > III Lederer et al, Unfallchirurg, 2007
Femoral Head Fracture: Radiographic Evaluation • AP Pelvis X-Ray • Lateral Hip X-Ray • Judet views • Post-reduction CT Scan
CT Scan Essential to evaluate quality of reduction of femoral head fracture (congruence), as well as intra-articular fragments.
Nonoperative Treatment If: Infra-foveal Fracture and Anatomically Reduced
Displaced Infra-foveal Fractures Can be reduced and stabilized, or excised. ORIF preferred if possible. Anterior approach allows best visualization.
Posterior vs Anterior Approach • Support for Posterior Approach – Sarmiento, CORR 1973 – Epstein, JBJS 1974 (0 good results with ant. approach) • Support for Anterior Approach – Swiontkowski, Thorpe, Seiler, Hansen, J Orthop Trauma 1992: • 12 anterior, 12 posterior. • Less blood loss and operative time with anterior approach. • Improved visualization anteriorly. • Increased H.O. anteriorly. • 67% good and excellent in each group. – Nork, Routt et al, OTA 2001: 21 cases, ? one AVN
Supra-foveal Fractures ORIF through: 1. anterior approach. 2. posterior approach. 3. posterior approach with Ganz trochanteric “flip” osteotomy. Excision of large fragment(s) will create instability, and thus is contraindicated.
Reconstruct Head Whenever Possible
Biomechanical Consequences of Femoral Head Fragment Excision • Excision of Pipkin I fragments caused no significant change in joint contact area and pressures. • Excision of Pipkin II fragment shifted loading patterns from periphery toward center of acetabulum, reduced joint contact area, and increased mean pressure on cartilage. • Posited that this may contribute the poorer outcomes seen with excision of larger fragments. Holmes et al, presented at OTA, 1999
Surgical Dislocation of the Hip for Fractures of the Femoral Head Helfet, Lorich et al, J Orthop Trauma, 2005
Pipkin III Fractures High incidence of AVN and degeneration with displaced fractures. – Relative indication for hemiarthroplasty in older patient due to this risk – Attempt at ORIF warranted in active, younger patients If femoral neck fracture is non-displaced, do not attempt manipulative reduction of hip until femoral neck is stabilized.
Femoral Head Fracture-Dislocation with Displaced Femoral Neck Fracture • Closed reduction attempts are futile. • ORIF in young: open reduction of hip, then reduction and stabilization of femoral neck and head. • Arthroplasty in middle-aged and elderly (No good results with ORIF reported in literature).
Femoral Head Fracture-Dislocation with Non-Displaced Femoral Neck Fracture Must consider stabilizing femoral neck fracture before performing reduction of hip.
Irreducible Femoral Head Fracture- Dislocation without Posterior Wall Fracture • 72 femoral head fractures treated in 6 years • 7 (10%) failed routine closed reduction. • Radiographic findings in these 7: • posterosuperior disclocations • sagittal plane femoral head fractures • intact posterior wall of acetabulum • close apposition of proximal femur to the supra-acetabular ilium. • All had slight, but fixed hip flexion with knee flexion and leg length discrepancy. Mehta and Routt, J Orthop Trauma, 2008
Irreducible Femoral Head Fracture- Dislocation without Posterior Wall Fracture • One patient sustained iatrogenic femoral neck fracture. • Two patients had AVN after delayed open reduction (14-32hrs). • The authors recommend early identification based on clinical and radiograhic findings, and emergent open reduction through anterior approach (i.e. DO NOT attempt at closed reduction) Mehta and Routt, J Orthop Trauma, 2008
What if Reduction Maneuver Results in Displaced Femoral Neck Fracture?
Reduction Maneuver Results in Displaced Femoral Neck Fracture • Emergent open reduction of hip from side of dislocation. • Reduction and stabilization of femoral neck fracture. • Assessment of femoral head fracture for surgical indications. • In elderly, perform arthroplasty.
Proximal Femoral Epiphysiolysis During Reduction of Adolescent Hip Dislocation • 5 patients sustained proximal femoral epiphysiolysis during closed reduction of hip dislocation under conscious sedation • Age 12-16 years Herrera-Soto et al, J Pediatr Orthop 2006
Proximal Femoral Epiphysiolysis During Reduction of Adolescent Hip Dislocation • 100% developed AVN • Recommend gentle reduction, with general anesthesia and manipulation under fluoroscopy, if available • Any indication of physeal injury should prompt reduction and pinning of the physeal injury prior to hip reduction Herrera-Soto et al, J Pediatr Orthop 2006
Pipkin IV Fractures Require appropriate treatment of femoral head and acetabulum fractures. Combination of fractures necessitates critical assessment of stability. Have high incidence of post-traumatic osteoarthritis.
Many Options for Approach:
Femoral Head Fracture with Acetabulum Fractures Kregor, AAOS, 2004 • 10 cases followed 28 months • All had ORIF of both femoral head and acetabulum • 6 Ganz trochanteric flip osteotomy, 3 anterior + posterior, 1 posterior. • Results: 3 excellent, 6 good, 1 poor. • “The Ganz Trochanteric Flip Osteotomy combined with surgical dislocation of the hip allows for optimal visualization and fixation of both injuries, controlled reduction of the hip, and thorough debridement of the hip joint.”
Questions? Return to Lower Extremity Index If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@ota.org

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L01_Hip-dislocatinos-femoral-head.ppt

  • 1.
    Hip Dislocations andFemoral Head Fractures Fernando Serna, MD John T. Gorczyca, MD University of Rochester Medical Center Created March 2004; First Revision January 2006 Second Revision July 2009
  • 2.
    Introduction Hip dislocations causedby significant force: – Association with other fractures – Damage to vascular supply to femoral head Thus, high chance of complications
  • 3.
    Anatomy: Hip Joint Ball andsocket joint. Femoral head: slightly asymmetric, forms 2/3 sphere. Acetabulum: inverted “U” shaped articular surface. Ligamentum teres, with artery to femoral head, passes through middle of inverted “U”.
  • 4.
    Joint Contact Area ThroughoutROM: • 40% of femoral head is in contact with acetabular articular cartilage. • 10% of femoral head is in contact with labrum.
  • 5.
    Acetabular Labrum Strong fibrousring Increases femoral head coverage Contributes to hip joint stability
  • 6.
    Hip Joint Capsule •Extends from intertrochanteric ridge of proximal femur to bony perimeter of acetabulum • Has several thick bands of fibrous tissue Iliofemoral ligament • Upside-down “Y” • Blocks hip hyperextension • Allows muscle relaxation with standing
  • 7.
    Femoral Neck Anteversion •Averages 70 in Caucasian males. • Slightly higher in females. • Asian males and females have been noted to have anteversion of 140 and 160 respectively.
  • 8.
    Blood Supply toFemoral Head 1. Artery of Ligamentum Teres • Most important in children. • Its contribution decreases with age, and is probably insignificant in elderly patients.
  • 9.
    Blood Supply toFemoral Head 2. Ascending Cervical Branches • Arise from ring at base of neck. • Ring is formed by branches of medial and lateral circumflex femoral arteries. • Penetrate capsule near its femoral attachment and ascend along neck. • Perforate bone just distal to articular cartilage. • Highly susceptible to injury with hip dislocation.
  • 10.
    Sciatic Nerve Composed fromroots of L4 to S3. Peroneal and tibial components differentiate early, sometimes as proximal as in pelvis. Passes posterior to posterior wall of acetabulum. Generally passes inferior to piriformis muscle, but occasionally the piriformis will split the peroneal and tibial components
  • 11.
    Posterior Hip Dislocation:Mechanism of Injury Almost always due to high-energy trauma. Most commonly involve unrestrained occupants in MVAs. Can also occur in pedestrian-MVAs, falls from heights, industrial accidents and sporting injuries.
  • 12.
    Posterior Dislocation • Generallyresults from axial load applied to femur, while hip is flexed. • Most commonly caused by impact of dashboard on knee.
  • 13.
    Type of PosteriorDislocation depends on: Direction of applied force. Position of hip. Strength of patient’s bone.
  • 14.
    Hip Position vs.Type of Posterior Dislocation In General, Abduction: acetabulum fracture-dislocation Adduction: pure dislocation Extension: femoral head fracture-dislocation Flexion: pure dislocation
  • 15.
    Anterior Dislocation 7-10% ofhip dislocations Mechanism: • Forced abduction with external rotation of hip. • Anterior hip capsule is torn or avulsed. • Femoral head is levered out anteriorly.
  • 16.
    Effect of Dislocationon Femoral Head Circulation Posterior dislocation of cadaveric hips results in statistically significant filling defects in the common femoral and circumflex arteries on cine- fluoroscopic vessel examination. • In some cases, collateral circulation maintained intraosseous blood flow. • Posited that AVN results from immediate ischemia at time of injury and from progressive and delayed arterial damage. Yue et al (J Orthop Trauma 1996)
  • 17.
    Effect of Dislocationon Femoral Head Circulation • Injury to ascending cervical branches associated with damage to capsule during dislocation. • Dislocation disrupts artery of ligamentum teres. • Dislocated hip may kink or compress acending cervical branches until the hip is reduced. Thus, early reduction of the dislocated hip can improve blood flow to femoral head.
  • 18.
    Associated Injuries Mechanism: high-energy,unrestrained vehicle occupants. Sahin et al reported 71% associated injuries in patients with traumatic hip dislocations and fracture-dislocations. (J Trauma 2003) Hak and Goulet reported 95% associated injuries in patients with hip dislocations. • Only 33% had isolated orthopaedic injuries. • 24% head, 21% craniofacial, and 21% thoracic injuries. • General Surgery/Trauma evaluation warranted in all hip dislocation patients. (J Trauma 1999)
  • 19.
    Associated Injuries Mechanism: kneevs. dashboard Contusions of distal femur Patella fractures Foot fractures, if knee extended
  • 20.
    Associated Knee Injuries 25%(46 of 187) of hip injury patients had knee injury. • 27 acetabulum fractures without dislocation, 10 pure hip dislocation, and 9 acetabulum fx-dislocations. • 85% had symptoms or clinical findings of knee injury. • 13 fractures (7 patella, 5 supracondylar femur or tibial plateau, 1 osteochondral), 9 ligamentous injury (2 knee dislocations, 1 MCL, 1 LCL, 5 combined), 1 patellar tendon tear, and multiple wounds and contusions • 75% had other injuries •Underscores the need for vigilance in detecting these injuries. Tabuenca and Truan (CORR 2000)
  • 21.
    Associated Injuries Sciatic nerveinjuries occur in 10% of adult and 5% of pediatric hip dislocations. Most commonly, these resolve with reduction of hip and passage of time. Stretching or contusion most common. Piercing or transection of nerve by bone can occur.
  • 22.
    Classification Multiple systems exist. Manyreflect outmoded evaluation and treatment methods.
  • 23.
    Thompson and EpsteinClassification of Hip Dislocations (Most well-known) Type I Pure dislocation with at most a small posterior wall fragment. Type II Dislocation with large posterior wall fragment. Type III Dislocation with comminuted posterior wall. Type IV Dislocation with “acetabular floor” fracture (probably transverse + post. wall acetabulum fracture-dislocation). Type V Dislocation with femoral head fracture. Thompson and Epstein, J Bone and Joint Surg, 1951
  • 24.
    Epstein Classification of AnteriorHip Dislocations Type I Superior (pubic and subspinous) Type II Inferior (obturator and perineal) A No associated fracture B Associated fracture of the femoral head/neck C Associated fracture of the acetabulum i.e, Type IA, IIB, etc. Epstein, Clin Orthop Relat Res, 1973.
  • 25.
    AO/OTA Classification • Mostthorough. • Best for reporting data, to allow comparison of patients from different studies. • 30-D10 Anterior Hip Dislocation • 30-D11 Posterior Hip Dislocation • 30-D30 Obturator (Anterior-Inferior) Hip Dislocation
  • 26.
    Evaluation: History Significant trauma,usually MVA. Awake, alert patients have severe pain in hip region.
  • 27.
    Physical Examination: Classical Appearance PosteriorDislocation: Hip flexed, internally rotated, adducted.
  • 28.
    Physical Examination: Classical Appearance AnteriorDislocation: Extreme external rotation, less-pronounced abduction and flexion.
  • 29.
    Unclassical presentation (posture) if: •femoral head or neck fracture • femoral shaft fracture • obtunded patient
  • 30.
    Physical Examination • Painto palpation of hip. • Pain with attempted motion of hip. • Possible neurological impairment: Thorough exam essential!
  • 31.
    Radiographs: AP PelvisX-Ray • In primary survey of ATLS Protocol. • Should allow diagnosis and show direction of dislocation. – Femoral head not centered in acetabulum. – Femoral head appears larger (anterior) or smaller (posterior). • Usually provides enough information to proceed with closed reduction.
  • 32.
    Reasons to ObtainMore X-Rays Before Hip Reduction • View of femoral neck inadequate to rule out fracture. • Patient requires CT scan of abdomen/pelvis for hemodynamic instability – and additional time to obtain 2-3 mm cuts through acetabulum + femoral head/neck would be minimal.
  • 33.
    X-rays after HipReduction: • AP pelvis, Lateral Hip x-ray. • Judet views of pelvis. • CT scan with 2-3 mm cuts.
  • 34.
    CT Scan Most helpfulafter hip reduction. Reveals: Non-displaced fractures. Congruity of reduction. Intra-articular fragments. Size of bony fragments.
  • 35.
    MRI Scan • Willreveal labral tear and soft-tissue anatomy. • Has not been shown to be of benefit in acute evaluation and treatment of hip dislocations.
  • 36.
    Clinical Management: Emergent Treatment •Dislocated hip is an emergency. • Goal is to reduce risk of AVN and DJD. • Evaluation and treatment must be streamlined.
  • 37.
    Emergent Reduction • Allowsrestoration of flow through occluded or compressed vessels. • Requires proper anesthesia. • Requires “team” (i.e. more than one person).
  • 38.
    Time to reduction •Controversy in the literature regarding appropriate timing to reduction • Marchetti, Steinberg, and Coumas (J Orthop Trauma 1996) found no statistically significant difference in outcomes in posterior fracture-dislocations when reduced greater or less than 6 hrs from time of injury • Mehlman et al (CORR 2000) demonstrated a 20X greater risk of AVN in pediatric traumatic hip dislocations if reduction delayed > 6 hrs • Sahin et al (J Trauma 2003) demonstrated better prognosis in hip dislocations and fracture-dislocations reduced within 12 hrs • Universally agreed that the earlier the better
  • 39.
    Anesthesia • General anesthesiawith muscle relaxation facilitates reduction, but is not necessary. • Conscious sedation is acceptable. • Attempts at reduction with inadequate analgesia/ sedation will cause unnecessary pain, create muscle spasm, and make subsequent attempts at reduction more difficult.
  • 40.
    General Anesthesia if: •Patient is to be intubated emergently in Emergency Room. • Patient is being transported to Operating Room for emergent head, abdominal or chest surgery. • Take advantage of opportunity.
  • 41.
    Reduction Maneuvers Allis: Patientsupine. Requires at least two people. Stimson: Patient prone, hip flexed and leg off stretcher. Requires one person. Impractical in trauma (i.e. most patients).
  • 42.
    Allis Maneuver • Assistant:Stabilizes pelvis • Posterior-directed force on both ASIS’s • Surgeon: Stands on stretcher • Gently flexes hip to 900 • Applies progressively increasing traction to the extremity • Applies adduction with internal rotation • Reduction can often be seen and felt
  • 43.
  • 44.
    Reduced Hip • Movesmore freely • Patient more comfortable • Requires testing of stability • Simply flexing hip to 900 does not sufficiently test stability
  • 45.
    Stability Test 1. Hipflexed to 90 o 2. If hip remains stable, apply internal rotation, adduction and posterior force. 3. The amount of flexion, adduction and internal rotation that is necessary to cause hip dislocation should be documented. 4. Caution!: Large posterior wall fractures may make appreciation of dislocation difficult.
  • 46.
    Irreducible Hip Requires emergentreduction in O.R. Pre-op CT obtained if it will not cause delay. One more attempt at closed reduction in O.R. with anesthesia. – Repeated efforts not likely to be successful and may create harm to the neurovascular structures, articular cartilage, or even cause iatrogenic fracture. Stannard et al, Clin Orthop Relat Res, 2000 Surgical approach from side of dislocation.
  • 47.
    Hip Dislocation: Nonoperative Treatment •If hip stable after reduction, and reduction congruent. • Maintain patient comfort. • ROM precautions (No Adduction, Internal Rotation). • No flexion > 60 o . • Early mobilization. • Touch down weight-bearing for 4-6 weeks. • Repeat x-rays before allowing weight-bearing.
  • 48.
    Hip Dislocation: Indications forOperative Treatment 1. Irreducible hip dislocation 2. Hip dislocation with femoral neck fracture 3. Incarcerated fragment in joint 4. Incongruent reduction 5. Unstable hip after reduction
  • 49.
    1. Irreducible HipDislocation: Anterior Smith-Peterson approach • Watson-Jones is an alternate approach 1. Allows visualization and retraction of interposed tissue. 2. Placement of Schanz pin in intertrochanteric region of femur will assist in manipulation of the proximal femur. 3. Repair capsule, if this can be accomplished without further dissection.
  • 50.
    1. Kocher-Langenbeck approach. 1.Removeinterposed tissue, or release buttonhole. 1.Repair posterior wall of acetabulum if fractured and amenable to fixation. 1. Irreducible Hip Dislocation: Posterior
  • 51.
    Irreducible Posterior Dislocation withLarge Femoral Head Fracture Fortunately, these are rare. Difficult to fix femoral head fracture from posterior approach without transecting ligamentum teres.
  • 52.
    Three Options 1. Detachfemoral head from ligamentum teres, repair femoral head fracture with hip dislocated, reduce hip. 2. Reduce hip through posterior incision, close posterior wound, fix femoral head fracture from anterior approach (either now or later). 3. Ganz trochanteric “flip” osteotomy. Best option not known: Damage to blood supply from anterior capsulotomy vs. damage to blood supply from transecting ligamentum teres. These will be discussed in detail in femoral head fracture section.
  • 53.
    2. Hip Dislocationwith Femoral Neck Fracture Attempts at closed reduction potentiate chance of fracture displacement with consequent increased risk of AVN. If femoral neck fracture is already displaced, then the ability to reduce the head by closed means is markedly compromised. Thus, closed reduction should not be attempted.
  • 54.
    2. Hip Dislocationwith Femoral Neck Fracture Usually the dislocation is posterior. Thus, Kocher-Langenbeck approach. If fracture is non-displaced, stabilize fracture with parallel lag screws first. If fracture is displaced, open reduction of femoral head into acetabulum, reduction of femoral neck fracture, and stabilization of femoral neck fracture.
  • 55.
    3. Incarcerated Fragment Can bedetected on x-ray or CT scan. Surgical removal necessary to prevent abrasive wear of the articular cartilage. Posterior approach allows best visualization of acetabulum (with distraction or intra-op dislocation). Anterior approach only if: dislocation was anterior and,
  • 56.
    4. Incongruent Reduction CausedBy: • Acetabulum Fracture (weight-bearing portion). • Femoral Head Fracture (any portion). • Interposed tissue. Goal: achieve congruence by removing interposed tissue and/or reducing and stabilizing fracture.
  • 57.
    • 25% (9/35)of pediatric patients with traumatic hip dislocation required surgery to remove interposed soft tissue and/or osteochondral fragments to achieve congruent hip reduction. Vialle et al, J Pediatric Orthop 2005 • 92% (33/36) of adults had loose bodies detected arthroscopically. • 21% (7/33) had normal x-rays and CT. –Clinical significance of soft-tissue interposition is not clear if joint congruent. –? Benefit of routine arthroscopy. Mullis and Dahner, J Orthop Trauma, 2006 Incongruent Reduction: Interposed Tissue
  • 58.
    5. Unstable Hipafter Reduction • Due to posterior wall and/or femoral head fracture. • Requires reduction and stabilization fracture. • Labral detachment or tear – Highly uncommon cause of instability. – Its presence in the unstable hip would justify surgical repair. – MRI may be helpful in establishing diagnosis.
  • 59.
    Results of Treatment •Large range: from normal to severe pain and degeneration. • In general, dislocations with associated femoral head or acetabulum fractures fare worse. • Dislocations with fractures of both the femoral head and the acetabulum have a strong association with poor results. • Irreducible hip dislocations have a strong association with poor results. – 13/23 (61%) poor and 3/23 (13%) fair results. McKee, Garay, Schemitsch, Kreder, Stephen. Irreducible fracture-dislocation of the hip: a severe injury with a poor prognosis. J Orthop Trauma. 1998.
  • 60.
    Complications of HipDislocation • Avascular Necrosis (AVN): 1-20% – Several authors have shown a positive correlation between duration of dislocation and rate of AVN. – Results are best if hip reduced within six hours. • Mehlman et al (CORR 2000) demonstrated a 20X greater risk of AVN in pediatric traumatic hip dislocations if reduction delayed > 6 hrs • Also demonstrated that bone scan results can be misleading, and thus routine screening is not recommended
  • 61.
    Post-traumatic Osteoarthritis • Canoccur with or without AVN • May be unavoidable in cases with severe cartilaginous injury. • Incidence increases with associated femoral head or acetabulum fractures. 16% osteoarthritis in uncomplicated hip dislocations and up to 88% in dislocations associated with severe acetabular fractures • Upudhyay et al, J Bone Joint Surg. (Br.), 1983. • Efforts to minimize osteoarthritis are best directed at achieving anatomic reduction of injury and preventing abrasive wear between articular carrtilage and sharp bone edges.
  • 62.
    Recurrent Dislocation Rare, unlessan underlying bony instability has not been surgically corrected (e.g. excision of large posterior wall fragment instead of ORIF). Some cases involve pure dislocation with inadequate soft-tissue healing – may benefit from surgical imbrication (rare). Can occur from detached labrum, which would benefit from repair (rare).
  • 63.
    Recurrent Dislocation Causedby Defect in Posterior Wall and/or Femoral Head Can occur after excision of fractured fragment. Pelvic and/or intertrochanteric osteotomy could alter the alignment of the hip to improve stability. Bony block could also provide stability.
  • 64.
    Delayed Diagnosis ofHip Dislocation Increased incidence in multiple trauma patients. More common if patient has altered sensorium. Results in: more difficult closed reduction. higher incidence of AVN. In NO Case should a hip dislocation be treated without reduction.
  • 65.
    Sciatic Nerve Injury Occursin up to 20% of adult and 5% of pediatric patients with hip dislocation. Peroneal nerve affected more commonly than tibial Nerve stretched, compressed or transected. With reduction: 40% complete resolution 25-35% partial resolution
  • 66.
    Sciatic Nerve Palsy: IfNo Improvement after 3–4 Weeks EMG and Nerve Conduction Studies for baseline information and for prognosis. Allows localization of injury in the event that surgery is required.
  • 67.
    Foot Drop Splinting (i.e.ankle-foot-orthosis): • Improves gait • Prevents contracture
  • 68.
    Infection Incidence 1-5% Lowest withprophylactic antibiotics and limited surgical approaches
  • 69.
    Infection: Treatment Principles Maintenanceof joint stability. Debridement of devitalized tissue. Intravenous antibiotics. Hardware removed only when fracture healed.
  • 70.
    Iatrogenic Sciatic NerveInjury Most common with posterior approach to hip. Results from prolonged retraction on nerve.
  • 71.
    Iatrogenic Sciatic NerveInjury Prevention: Maintain hip in full extension Maintain knee in flexion Avoid retractors in lesser sciatic notch ? Intra-operative nerve monitoring (SSEP, motor monitoring)
  • 72.
    Thromboembolism Hip dislocation =high risk patient. Prophylactic treatment with: • low molecular weight heparin, or • coumadin Early postoperative mobilization. Discontinue prophylaxis after 2-6 weeks (if patient mobile).
  • 73.
    Femoral Head Fractures Treatmentprinciples similar to those listed for hip dislocations.
  • 74.
    Femoral Head Fractures– Mechanism • Fracture occurs by shear as femoral head dislocates. • With less hip flexion, femoral head fracture tends to be larger.
  • 75.
    History and PhysicalExamination Similar to patient with hip dislocation. Patient posture may be less extreme due to femoral head fracture.
  • 76.
    Classification of FemoralHead Fractures Thompson and Epstein Type V • Posterior hip dislocation with femoral head fracture Epstein Type IB • Anterosuperior dislocation with femoral head and/or neck fracture Epstein Type IIB • Anteroinferior dislocation with femoral head and/or neck fracture
  • 77.
  • 78.
    Pipkin Classification I Fractureinferior to fovea II Fracture superior to fovea III Fracture of femoral head with fracture of femoral neck IV Fracture of femoral head with acetabulum fracture
  • 79.
  • 80.
  • 81.
  • 82.
    Pipkin III • Femoralhead fracture with femoral neck fracture.
  • 83.
    Pipkin IV • Femoralhead fracture with acetabulum fracture. • High incidence of post-traumatic AVN.
  • 84.
    Pipkin Prognostic Value •33 patients with posterior fracture-dislocations of the hip. • Pipkin Types I/II had statistically significant better outcomes than Types III/IV. Marchetti, Steinberg, and Coumas, J Orthop Trauma, 1996 • 46 patients • Better outcomes in Pipkin Types I >II > IV > III Lederer et al, Unfallchirurg, 2007
  • 85.
    Femoral Head Fracture: RadiographicEvaluation • AP Pelvis X-Ray • Lateral Hip X-Ray • Judet views • Post-reduction CT Scan
  • 86.
    CT Scan Essential toevaluate quality of reduction of femoral head fracture (congruence), as well as intra-articular fragments.
  • 87.
    Nonoperative Treatment If: Infra-fovealFracture and Anatomically Reduced
  • 88.
    Displaced Infra-foveal Fractures Canbe reduced and stabilized, or excised. ORIF preferred if possible. Anterior approach allows best visualization.
  • 89.
    Posterior vs AnteriorApproach • Support for Posterior Approach – Sarmiento, CORR 1973 – Epstein, JBJS 1974 (0 good results with ant. approach) • Support for Anterior Approach – Swiontkowski, Thorpe, Seiler, Hansen, J Orthop Trauma 1992: • 12 anterior, 12 posterior. • Less blood loss and operative time with anterior approach. • Improved visualization anteriorly. • Increased H.O. anteriorly. • 67% good and excellent in each group. – Nork, Routt et al, OTA 2001: 21 cases, ? one AVN
  • 90.
    Supra-foveal Fractures ORIF through: 1.anterior approach. 2. posterior approach. 3. posterior approach with Ganz trochanteric “flip” osteotomy. Excision of large fragment(s) will create instability, and thus is contraindicated.
  • 91.
  • 92.
    Biomechanical Consequences of FemoralHead Fragment Excision • Excision of Pipkin I fragments caused no significant change in joint contact area and pressures. • Excision of Pipkin II fragment shifted loading patterns from periphery toward center of acetabulum, reduced joint contact area, and increased mean pressure on cartilage. • Posited that this may contribute the poorer outcomes seen with excision of larger fragments. Holmes et al, presented at OTA, 1999
  • 93.
    Surgical Dislocation ofthe Hip for Fractures of the Femoral Head Helfet, Lorich et al, J Orthop Trauma, 2005
  • 97.
    Pipkin III Fractures Highincidence of AVN and degeneration with displaced fractures. – Relative indication for hemiarthroplasty in older patient due to this risk – Attempt at ORIF warranted in active, younger patients If femoral neck fracture is non-displaced, do not attempt manipulative reduction of hip until femoral neck is stabilized.
  • 98.
    Femoral Head Fracture-Dislocationwith Displaced Femoral Neck Fracture • Closed reduction attempts are futile. • ORIF in young: open reduction of hip, then reduction and stabilization of femoral neck and head. • Arthroplasty in middle-aged and elderly (No good results with ORIF reported in literature).
  • 99.
    Femoral Head Fracture-Dislocationwith Non-Displaced Femoral Neck Fracture Must consider stabilizing femoral neck fracture before performing reduction of hip.
  • 100.
    Irreducible Femoral HeadFracture- Dislocation without Posterior Wall Fracture • 72 femoral head fractures treated in 6 years • 7 (10%) failed routine closed reduction. • Radiographic findings in these 7: • posterosuperior disclocations • sagittal plane femoral head fractures • intact posterior wall of acetabulum • close apposition of proximal femur to the supra-acetabular ilium. • All had slight, but fixed hip flexion with knee flexion and leg length discrepancy. Mehta and Routt, J Orthop Trauma, 2008
  • 101.
    Irreducible Femoral HeadFracture- Dislocation without Posterior Wall Fracture • One patient sustained iatrogenic femoral neck fracture. • Two patients had AVN after delayed open reduction (14-32hrs). • The authors recommend early identification based on clinical and radiograhic findings, and emergent open reduction through anterior approach (i.e. DO NOT attempt at closed reduction) Mehta and Routt, J Orthop Trauma, 2008
  • 102.
    What if ReductionManeuver Results in Displaced Femoral Neck Fracture?
  • 103.
    Reduction Maneuver Resultsin Displaced Femoral Neck Fracture • Emergent open reduction of hip from side of dislocation. • Reduction and stabilization of femoral neck fracture. • Assessment of femoral head fracture for surgical indications. • In elderly, perform arthroplasty.
  • 104.
    Proximal Femoral EpiphysiolysisDuring Reduction of Adolescent Hip Dislocation • 5 patients sustained proximal femoral epiphysiolysis during closed reduction of hip dislocation under conscious sedation • Age 12-16 years Herrera-Soto et al, J Pediatr Orthop 2006
  • 105.
    Proximal Femoral EpiphysiolysisDuring Reduction of Adolescent Hip Dislocation • 100% developed AVN • Recommend gentle reduction, with general anesthesia and manipulation under fluoroscopy, if available • Any indication of physeal injury should prompt reduction and pinning of the physeal injury prior to hip reduction Herrera-Soto et al, J Pediatr Orthop 2006
  • 106.
    Pipkin IV Fractures Requireappropriate treatment of femoral head and acetabulum fractures. Combination of fractures necessitates critical assessment of stability. Have high incidence of post-traumatic osteoarthritis.
  • 107.
  • 108.
    Femoral Head Fracturewith Acetabulum Fractures Kregor, AAOS, 2004 • 10 cases followed 28 months • All had ORIF of both femoral head and acetabulum • 6 Ganz trochanteric flip osteotomy, 3 anterior + posterior, 1 posterior. • Results: 3 excellent, 6 good, 1 poor. • “The Ganz Trochanteric Flip Osteotomy combined with surgical dislocation of the hip allows for optimal visualization and fixation of both injuries, controlled reduction of the hip, and thorough debridement of the hip joint.”
  • 109.
    Questions? Return to Lower Extremity Index Ifyou would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@ota.org