Surgical dislocation technique for the treatment of acetabular fractures

Developing a core outcome set for acetabular fractures: a systematic review (part I)

BACKGROUND

There are indications that clinical studies investigating the surgical treatment of acetabular fractures assess different outcomes. This heterogeneity reduces the comparability of study results and, thus, limits the knowledge generated from research. Core outcome sets (COS) contain a minimum set of outcomes that should be measured in studies investigating a specific disease or injury. A COS for surgically treated acetabular fractures does not yet exist. Therefore, the aim of this study is to identify the reported outcomes in studies investigating the surgical treatment of acetabular fractures.

METHODS

Studies including skeletally mature individuals (≥ 16 years) with isolated acetabular fractures treated surgically were included. Studies with polytrauma patients, pathological fractures, additional pelvic fractures, exclusively non-surgical treatment, or juvenile individuals were excluded. Three databases and two clinical trial registries were searched on 15 November 2022. The identified outcomes were grouped and subsequently categorized according to the Core Outcome Measures in Effectiveness Trials Guidelines.

RESULTS

A total of 193 studies were included, which reported a cumulative total of 2581 outcomes. After grouping, 266 unique outcomes were identified. No outcome was examined in all studies. Pain, ability to walk independently, range of motion, quality of reduction, and heterotopic ossification were the most reported unique outcomes and assessed in at least 60% of included studies. A total of 105 outcomes were only assessed in one of the included studies. Outcomes of all five core areas and 25 outcome domains of the Core Outcome Measures in Effectiveness Trials taxonomy were examined. Furthermore, outcomes were named and defined differently, measured at different time points, and assessed using a variety of measurement instruments.

CONCLUSION

Overall, this systematic review shows that a wide range of outcomes are measured in studies examining surgical treatment of acetabular fractures. The results of this systematic review will be used in a subsequent study to develop the COS for surgically treated acetabular fractures by using the Delphi method.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42022357644; COMET: 2123.

Posterior approaches to the acetabulum

Posterior approaches, particularly the Kocher-Langenbeck approach, remain the workhorses in the treatment of acetabular fractures. Various modifications have been developed, each offering specific advantages depending on surgical requirements. The modified Gibson approach, for example, is suggested to provide enhanced visualization of the superior acetabulum, although recent cadaveric studies have not consistently substantiated this benefit. The Ganz approach, which involves bigastric trochanteric osteotomy with safe surgical hip dislocation, is particularly advantageous for managing complex and comminuted posterior acetabular fractures, as it enables a 360° view of the acetabulum and femoral head. Overall, posterior approaches are associated with low rates of complications, with heterotopic ossification being the most prevalent. The choice of surgical approach and patient positioning should be guided by the surgeon's preference and expertise, tailored to the specific fracture pattern and patient characteristics.

Arthroscopic assistance during open reduction and fixation for complex acetabular fractures

Achieving an anatomical reduction in acetabular fracture is essential but may also be challenging. Most of complex fractures are treated with anterior approaches without direct visualization of the acetabular surface. In this paper, we present the surgical technique for arthroscopic assistance during open reduction and fixation for complex acetabular fractures. To our knowledge, this technique has not been described in the literature yet.

The modified Hardinge approach is not inferior to trochanteric flip osteotomy for Pipkin type IV femoral head fractures: a comparative study in 40 patients

PURPOSE

To compare the modified Hardinge approach and trochanteric flip osteotomy for the treatment of Pipkin type IV femoral head fractures.

METHODS

 This retrospective study included 40 patients who underwent surgical treatment for Pipkin type IV femoral head fractures between 2011 and 2020 and completed at least 1 year of follow-up. The clinical outcome of the Merle d'Aubigné-Postel score and radiological outcomes, including the quality of the fracture reduction, osteonecrosis of the femoral head, posttraumatic osteoarthritis, and heterotopic ossification, were compared between the two groups. Conversion to total hip replacement was recorded as the main outcome measure, analyzed by Kaplan-Meier curve and log-rank test.

RESULTS

Nineteen and 21 patients were treated using the modified Hardinge approach (Group A) and trochanteric flip osteotomy (Group B), respectively. The estimated surgical blood loss was significantly higher in Group B (500.00 ± 315.44 mL vs. 246.32 ± 141.35 mL; P = 0.002). Two patients in Group B complained of discomfort caused by the trochanteric screws and requested implant removal. Radiographic outcomes did not differ significantly between the two groups. Clinical outcomes assessed using the Merle d'Aubigné-Postel score 1 year after injury were nearly identical (P = 0.836). Four (21.1%) patients in Group A and three (14.3%) patients in Group B underwent conversion to total hip replacement during the follow-up period; the log-rank test showed no significant difference (P = 0.796).

CONCLUSIONS

The modified Hardinge approach resulted in reduced blood loss, with clinical and radiological outcomes similar to those of trochanteric osteotomy; thus, it is an acceptable alternative to trochanteric flip osteotomy.

Functional Outcomes and Their Influencing Factors for the Surgical Management of T-type Acetabulum Fractures: A Prospective Single-Centre Study of 73 Patients

Introduction T-type fractures of the acetabulum are uncommon injuries, typically resulting in poorer long-term outcomes compared to other patterns of acetabular fractures. Our main purpose is to analyse the epidemiology, functional outcomes, and factors affecting the functional outcomes of patients with T-type acetabular fractures. Methods This prospective, single-centre study included 73 patients with T-type and T with posterior wall acetabular fractures. They underwent treatment with open reduction internal fixation using plating through the modified Stoppa, Kocher-Langenbeck (KL), or dual approach. The post-operative reduction was assessed according to Matta's criteria, and functional outcomes were evaluated using the modified Harris hip score. Results Between September 2017 and January 2023, 53 patients underwent surgery for T-type fractures (72.6%), and 20 patients were treated for T with posterior wall acetabular fractures (27.4%). The minimum follow-up period was one year, with a mean follow-up of 3.5 years. Anatomical reduction emerged as the major contributing factor towards good functional outcomes compared to satisfactory reduction according to Matta's criteria (P value: 0.006). Overall, 65 patients (89%) achieved excellent to good modified Harris hip scores, while eight patients (11%) obtained fair to poor scores. Patients with T-type fractures demonstrated better functional outcomes compared to T with posterior wall fractures (P value: 0.031). Conclusion Anatomical reduction, as assessed by Matta's reduction criteria, serves as a predictor of favourable functional outcomes. T with posterior wall fractures exhibit poor outcomes in comparison to T-type fractures. The surgical approach employed does not influence the reduction or the final functional outcome of the patient.

A systemic review and meta-analysis of pararectus versus ilioinguinal approach for the management of acetabular fractures

PURPOSE

The complex anatomy of acetabular fracture needs a surgical approach that can achieve anatomical reduction with fewer complications for the fixation of these fractures. Current literature suggests that both Pararectus (PR) approach and Ilioinguinal (IL) approach can be used for the fixation of these fractures safely. However, superiority of the PR approach over the IL approach is not established. Hence, this meta-analysis aimed to compare the PR versus IL approach.

METHODOLOGY

A literature search was performed on five databases Medline/PubMed, Scopus Embase, Cinhal, and Cochrane Library, from the inception to January 14, 2023. A qualitative and quantitative analysis was done for the five eligible studies from the literature search. Individual study characteristics data and outcomes were extracted, and Software version 5.4.1 of Review Manager was used for statistical analysis.

RESULTS

Five articles, one Randomized trial (RCT), and four retrospective articles were included and analyzed in this meta-analysis. PR approach has a shorter surgical time [mean difference (MD) -48.4 with 95% CI -74.49, -22.30; p = 0.0003], less intraoperative blood loss (MD -123.22 with 95% CI -212.28, -34.15; p = 0.007), and smaller surgical incision (MD -9.87 with 95% CI -15.21, -4.52; p = 0.0003) than the IL approach. However, the meta-analysis failed to show a difference between the two surgical approaches concerning the quality of reduction, overall complications, nerve injury, vascular injury, heterotopic ossification, deep vein thrombosis, and pulmonary embolism.

CONCLUSION

The PR approach has a shorter surgical duration, less blood loss, and a smaller surgical incision than the IL approach. However, both surgical approaches have equivocal results regarding fracture reduction quality, complication rates, and functional outcomes for acetabular fracture fixation. Hence, for acetabular fractures fixation, PR approach can be considered a safe and feasible alternative to the IL approach.

The fate of acetabular fracture fixation at 10 years: rates of conversion to arthroplasty

BACKGROUND

Post-traumatic arthritis, implant failure, non-union or avascular necrosis may result in a total hip arthroplasty (THA) after acetabular fracture fixation (AFF). The aim of this study was to report the occurrence of THA after AFF and analyse factors that predict its occurrence.

PATIENTS AND METHODS

All patients with AFF between 2010 and 2014, in a major trauma centre, were included. Patients treated conservatively or with acute THA were excluded. Data regarding classification of fracture, details of surgery and follow-up using EQ-5D and Oxford Hip Score (OHS) were recorded prospectively. Postoperative radiographs and CT scans were analysed for accuracy of reduction. The number of patients who underwent secondary THA and indications were recorded.

RESULTS

122 patients with a mean age of 42 years were included. At a mean follow-up of 10 years, the mean OHS was 39 (range 22-48) and EQ-5D was 22 (range 10-25). THA was performed in 10 patients (8%), 50% of which were performed between 2-5 years after AFF. Age >40 years, posterior dislocation and presence of posterior wall fracture, were the only factors associated with progression to THA. The survivorship of fixation at 5 years was 95% (95% CI, 91-98%) and at 10 years was 91% (95% CI, 86-96%).

CONCLUSIONS

Conversion to THA after AFF was 8%, with even anatomically reduced posterior wall fractures having a poor prognosis. A period of follow-up of at least 5 years is suggested in patients with risk factors.

Sciatic nerve injury after acetabular fractures: a meta-analysis of incidence and outcomes

PURPOSE

To investigate the incidence and the outcome of post-traumatic and iatrogenic sciatic nerve palsy (SNP) associated with fractures of the acetabulum. The results of sciatic nerve grafting for treatment were also investigated.

METHODS

PUBMED, SCOPUS and COCHRANE databases were searched for longitudinal observational studies reporting sciatic nerve palsy related to acetabular fractures in adult patients over the last 20 years. Data regarding patients demographics, type of acetabular fracture, rate of post traumatic and iatrogenic sciatic nerve palsies as well as recovery rate are reported. Studies were assessed for their quality. Random effects meta-analyses were carried out to pool overall proportions of SNP incidence and complete recovery. Variations in SNP incidence by main study characteristics were assessed by subgroup analysis and meta-regression. A narrative review of sciatic nerve grafting was also conducted.

RESULTS

Twenty studies reporting 44 post-operative and 18 iatrogenic SNPs in 651 patients were reviewed. The pooled incidence of posttraumatic SNP was 5.1% (95% CI 2.7-8.2%). The pooled incidence of iatrogenic SNP was 1.4% (95% CI 0.3-2.9%). Complete recovery of post-traumatic and iatrogenic SNP occurred in 64.7% (95% CI 41.7-85.4%) and 74.1% (95% CI 31.5-100%), respectively.

CONCLUSION

A favorable outcome of both post-traumatic and iatrogenic SNP related to acetabular fractures has been found. Due to the poor results of sciatic nerve grafting, a "wait and see" approach may be the best option, in cases of a contused but anatomically intact sciatic nerve.

Midterm results of digastric trochanteric flip osteotomy for high acetabular posterior wall fracture

PURPOSE

Kocher-Langenbeck (K-L) approach is widely used in surgery of posterior wall fracture of acetabulum. However, challenges are frequently encountered in fractures involving the superior dome due to its short of view. We aimed to evaluate the efficacy of digastric trochanteric flip osteotomy (DTFO) in the K-L approach for high posterior wall acetabular fracture (HPWF).

METHODS

From January 2014 to December 2016, 39 patients who suffered high posterior wall fracture (HPWF) were included in this retrospective study. All the patients were divided into two groups according to surgery type (17 standard K-L approach (control group), 22 with DTFO (DTFO group)). The Matta criterion was used to evaluate the accuracy of reduction according to post-operative CT image, while modified Harris hip score and 12-item short-form health survey (SF-12) were applied to measure the clinical outcomes.

RESULTS

The median follow-up period was 55 (45 to 62.5) months. Blood loss and operation time were similar between the two groups. DTFO group achieved much more anatomical reduction than the control group (54.6% vs. 35.3%; OR, 2.2; 95% CI, 0.6 ~ 8.08). Significantly better functional outcomes were found in the DTFO group (10% higher points than the control group, p < 0.05). All the patients receiving good-to-anatomical reduction ended with good or excellent outcomes. The total incidence of complications in the DTFO group was much lower than in the control group (40.9% vs. 70.6%, p = 0.07).

CONCLUSIONS

Compared with the traditional K-L approach, the intraoperative DTFO technique enabled better quality of reduction in patients with HPWF, thus ensuring superior clinical outcomes.

Clinical efficacy and its influencing factors of surgical treatment for T-shaped associated with posterior wall acetabular fractures using combined surgical approaches

BACKGROUND

The objective of this study was to evaluate the outcomes of surgical treatment for T-shaped associated with posterior wall acetabular fractures using combined surgical approaches and its influencing factors.

METHODS

Between January 2009 and June 2018, a total of 21 patients with T-shaped acetabular fractures involving posterior wall were treated with combined approaches. The combined approaches were a combination of the Kocher-Langenbeck (KL) approach and the anterior approach (Stoppa or Ilioinguinal). The acetabular fractures in this study were divided into two groups respectively according to surgical approach and surgical timing: KL + Ilioinguinal (IL) approaches and KL + Stoppa approaches, early surgery and late surgery.

RESULTS

13 cases were treated within 14 days of injury. 15 cases were treated using the KL + Stoppa approaches and remaining 6 cases were treated using the KL + IL approaches. Anatomical and imperfect reduction were achieved in 12 cases (57.1%) with excellent to good clinical outcome in 42.9% of cases. Early surgery had a statistically significant improvement over late surgery in terms of quality of reduction and clinical outcomes. In the early surgery, the incidence of preoperative chest and abdomen injuries and postoperative deep vein thrombosis was significantly lower than that of the late surgery. There was no statistical difference between the KL + IL approaches and KL + Stoppa approaches in the demographics, preoperative associated injuries, quality of reduction, clinical outcomes and postoperative complications.

CONCLUSIONS

The results of this study indicate that T-shaped associated with posterior wall acetabular fractures are difficult to treat surgically. Early surgery can improve the quality of fracture reduction, promote the recovery of hip function, and decrease the incidence of postoperative deep vein thrombosis. The main factor that affects surgical timing is the presence of preoperative chest and abdominal injuries. Compared with the KL + IL approaches, the KL combined with Stoppa approach can not significantly improve the clinical outcomes of such acetabular fractures.

Surgical hip dislocation in fixation of acetabular fractures: Extended indications and outcome

BACKGROUND

Surgical hip dislocation has been described as an excellent method for reduction and fixation of acetabular fractures. It allows a 360-degree access to the acetabulum and acetabular dome. However, reproducibility of this technique is still a concern. The primary outcome of this study was to investigate the short term functional and radiological outcome with the use of surgical hip dislocation in acetabular fractures. The secondary outcome was to describe different indications and methods of reduction using this technique.

METHODS

This is a retrospective consecutive case series for the use of surgical hip dislocation in acetabular fractures. Between July 2013 and February 2017, we used this technique to manage 36 cases of acetabular fractures. Two patients were lost to follow up leaving 34 patients eligible for the study. All surgeries were done by a 5-years and a 10-years' experience surgeons in pelvic and acetabular trauma surgeries. Through Gibson approach, we used the technique of surgical hip dislocation as described by the Bernese group. Different methods of fracture reduction were used. Intraoperative grading of cartilage injury was done using Disler's grading system. Postoperative fracture reduction was evaluated using the criteria described by Matta. Clinical evaluation was done using the modified Merle d'Aubigne ́ and Postel system.

RESULTS

The mean intra-operative blood loss was about 700 ± 35.4 ml. The mean units of blood transfused were 1 ± 0.1 unit. The mean surgical time was 135 ± 11.7 minutes. Anatomical reduction was achieved in 27 patients (79.4%). At a mean of 30 ± 16.8 months (median = 26 and IQR 22) follow up, the functional score was excellent in 5 (14.7 %), very good in 8 (23.5%), good in 9 (26.5%), fair in 2 (5.8%), and poor in 10 (29.4%) patients. Four patients (11.7%) developed AVN at a mean of 8 months postoperatively. Conversion to THA was done in 5 patients (14,7%). Trochanteric osteotomy showed osseous healing in all cases. No patient developed nerve injury or infection. One patient developed severe (grade III) heterotopic ossification.

CONCLUSIONS

Besides the indications of surgical hip dislocation mentioned before as reduction of the anterior column in T and Transverse fractures, associated femoral head fractures, intraarticular fragments, and labral injuries, it can be used in other indications as entrapped posterior wall, roof impaction, pure impaction injuries and cranial extension of the posterior wall fractures. The technique is reproducible; however, the learning curve is steep and needs to be performed by experienced acetabular trauma surgeons.

Comparison of Therapeutic Outcomes of Transabdominal Pararectus Approach and Modified Stoppa Approach in Treating Pelvic and Acetabular Fractures

OBJECTIVE

Pelvic and acetabular fractures are common orthopedic diseases, and this research was to investigate the therapeutic effects of pararectus and Stoppa approaches in treating complex pelvic acetabular fractures.

METHODS

The clinical information of patients with pelvic and acetabular fractures treated surgically in Lu'an Hospital of Chinese medicine, China from January 2016 to April 2020 was analyzed. There were 30 cases each in the transabdominal pararectus approach and modified Stoppa approach groups. The operation time, incision length, blood loss, and postoperative complications of both groups were recorded according to the Merle d'Aubigné-Postel hip score. The recovery of hip function was evaluated 6 months after surgery, and the clinical and therapeutic efficacies of the two groups were compared.

RESULTS

The patients were followed up for 6-7 months (average, 6.5 months). The average operation time, incision length, and blood loss in the pararectus and Stoppa approach groups were 180 ± 41.105 min, 8.667 ± 1.373 cm, 259.667 ± 382 mL and 202.667 ± 32.793 min, 11.600 ± 1.958 cm, and 353.667 ± 590 mL, respectively. The satisfactory rate of fracture reduction, excellent and good rate of hip function score, and incidence of complications were 28/30, 27/30, 1/30 and 25/30, 25/30, 3/30, respectively. There were significant differences in operation time, incision length, and blood loss between the two groups (p < 0.05). However, there was no significant difference in the excellent and good rate of hip function score, fracture reduction satisfaction, and complication rate between both groups (p > 0.05).

CONCLUSIONS

The pararectus approach can reveal the better anatomical structure of the pelvis and acetabulum, such as the corona mortis and quadrilateral plate, for conducive fracture reduction and fixation. It can also effectively shorten the length of the incision, reduce operative blood loss, and shorten the operation time. It is a better choice for the clinical treatment of complex pelvic and acetabular fractures.

Gluteus Minimus Debridement During Acetabular Fracture Surgery Does Not Prevent Heterotopic Ossification-A Comparative Study

OBJECTIVES

To compare rates of heterotopic ossification (HO) after acetabular fracture surgery, through a posterior approach, with and without gluteus minimus muscle (GMM) debridement.

DESIGN

Retrospective comparative study.

SETTING

Single academic Level I trauma center.

PATIENTS

Ninety-four patients in the GMM preserved group and 42 patients in the GMM debrided group met inclusion criteria.

INTERVENTION

GMM preservation or debridement during acetabular fracture surgery through a single-posterior approach.

MAIN OUTCOME MEASUREMENTS

Primary outcomes were incidence and severity of HO. Reoperation for HO excision was assessed. Other risk factors for severe HO (Brooker class III-IV) were secondarily assessed using multivariable logistic regression analyses. Odds ratios (ORs) with 95% confidence intervals were calculated. The significance was set at P-value ≤ 0.05.

RESULTS

There was no difference in the incidence or severity of HO between the debrided and preserved groups. Rates of reoperation for HO excision were comparable. American Society of Anesthesiologists physical status class (OR = 3.3), head injury (OR = 4.6), and abdominal injury (OR = 4.5) were associated with severe HO.

CONCLUSION

GMM debridement was not associated with a decreased incidence of HO after acetabular fracture surgery. American Society of Anesthesiologists class is a novel risk factor associated with severe HO formation.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Management of femoral head fractures through surgical hip dislocation (SHD): a demanding but safe technique

INTRODUCTION

Femoral head fractures considered to be rare injuries. Surgical intervention is indicated for major fragment displacement or in the presence of instability. Surgical management can be achieved through either Anterior, posterior, and trans-trochanteric surgical approaches. Surgical hip dislocation (SHD) has been advocated by many authors to be a safe and effective alternative way of management. The aim of this study was to report on the accuracy of fracture reduction, procedure safety, and outcomes of using SHD in the management of femoral head fractures.

PATIENTS AND METHODS

Between 2011 and 2017, 31 patients presented with femoral head fracture were treated through SHD. At a mean follow-up of 48 months, 27 patients were available for the study with a mean age of 33.8 years. Patient demographics, clinical evaluation according to modified Harris hip score and modified Merle d'Aubigne and Postel score, radiographic fracture reduction according to Matta's criteria, and any complications were reported.

RESULTS

Excellent and good clinical outcomes were reported in 25 (92.6%) and 24 (89%) patients according to the modified Harris hip and modified Merle d'Aubigne and Postel scores, respectively. Anatomic fracture reduction was achieved in 21 (77.8%) patients. Two (7.4%) patients developed AVN, one (3.6%) patient developed hip OA (grade 3 according to Tönnis classification), and five (18.5%) patients developed asymptomatic Brooker stage I heterotopic ossification. No infection or trochanteric flip osteotomy fragment non-union was reported.

CONCLUSIONS

SHD offers a safe and efficient approach for femoral head fractures management with acceptable clinical outcomes as well as complication rates. Giving the advantage of fully exposing the femoral head and the acetabulum which enables the surgeon to anatomically reduce the fracture and treat any associated injuries, SHD is recommended besides other approaches for the management of femoral head fractures.

The use of Verbrugge forceps for reduction of the posterior column element in displaced acetabular fractures: clinical and radiological evaluation

PURPOSE

Different reduction techniques and tools are described to facilitate anatomical reduction of acetabular fractures. However, maintenance of reduction, plate placement, and fracture fixation remain a challenge owing to the large surface area occupied by the available reduction tools. This study aims at radiological and functional assessment of the effectiveness of a novel reduction technique for the posterior column element in displaced acetabular fractures.

METHODS

A prospective study was conducted for evaluation of a novel reduction technique; the use of the conventional large holding Verbrugge forceps for reduction of posterior column and transverse, with or without posterior wall, fractures. Intra-operative safety and reduction time were evaluated. The immediate postoperative quality of reduction was assessed using Matta radiographic criteria. The functional outcome was evaluated at the latest follow-up visit using the modified Merle d'Aubigne and Postel (MDP) score.

RESULTS

Thirty patients with a mean follow-up of 18.1 months were included. Fifteen had transverse/posterior wall, ten had transverse, and five had posterior column fractures. All fractures were displaced ≥ 2 mm on anteroposterior and/or Judet views of the pelvis without traction. The average operative time was 100.4 min with 12.5 min reduction time. No intra-operative complications were encountered. Twenty-three patients (76.6%) had anatomical while seven (23.3%) had imperfect reduction. The functional outcome score was excellent in three patients, good in 18, fair in four, and poor in five patients at the latest follow-up.

CONCLUSION

The use of the conventional large Verbrugge bone-holding forceps for the reduction of the posterior column element in displaced acetabular fractures using the Kocher-Langenbeck approach is a safe, effective, time-saving, and technically undemanding procedure.

Surgical outcomes of transverse acetabular fractures and risk factors for poor outcomes

Background

Transverse acetabular fractures, although classified as elementary, have worse outcomes than other types of acetabular fractures. Prognostic factors for this fracture type are not clearly established. This study aimed to assess the surgical outcomes of transverse acetabular fractures and subtypes thereof and to investigate the prognostic factors.

Methods

Between 2014 and 2019, 39 patients (39 hips) had transverse fractures or subtypes thereof. We reviewed the surgical outcomes and evaluated patient factors, injury factors, and surgical factors in relation to osteoarthritis (OA) and conversion to total hip arthroplasty (THA). Additionally, we analyzed the cutoff values for postoperative residual gaps and steps.

Results

Twenty-three male patients and sixteen female with a mean age of 41.7 years (range, 18–78 years) were included. There were 29 satisfactory reductions (74.4%). Eleven hips (28.2%) developed OA, and five (12.8%) of them underwent THA. Dome impaction (odds ratio [OR], 41.173; 95% confidence interval [CI], 1.804–939.814; p = 0.020) and residual gaps (OR, 4.251; 95% CI, 1.248–14.479; p = 0.021) were correlated with poor outcomes. Residual gaps (≥3 mm) and residual steps (≥1 mm) were significantly associated with OA.

Conclusions

Relatively poor reduction was found for transverse acetabular fractures and subtypes thereof. However, the rates of OA and conversion to THA were not high. Dome impaction and wide residual gaps were identified as risk factors for poor outcomes. The development of OA significantly increased if residual gap and step were more than 3 mm and 1 mm, respectively.

Is non-operative management of acetabular fracture a viable option for older patients? A systematic review of the literature for indication, treatments, complications and outcome

There is no consensus about the best treatment for acetabular fracture in older patients. The purpose of this study was to review the current literature looking for indication, perioperative information and outcome of nonoperative management for acetabular fractures in elderly.A systematic review of literature was performed on different research database by using various combination of the keywords "acetabular fracture", "elderly patients", "60 years", "nonoperative", "nonsurgical" and "conservative treatment".Six articles met our inclusion criteria, 315 patients aged 60 or more treated nonoperatively for acetabular fracture were included in the analysis. The average age was 78.1 years, the average follow-up length was 48.7 months. The main criteria for indication of nonoperative management for acetabular fractures were, old age (75 years or more), two or more important medical comorbidities, and minimally or undisplaced fracture. The most frequent fracture pattern was anterior column in 25.3% of cases. Fall from standard height was the most frequent causative mechanism in 80% of patients. A conversion total hip arthroplasty was performed after 8.3% of cases. A 1-year mortality of 18% was reported, an overall mortality of 33.1% at last follow-up was reported.The management of acetabular fractur in elderly is a challenging problem and there is no consensus about the best treatment. Currently, multiple treatment options have been suggested, depending on fracture pattern and patients' general conditions. Although operatively treatment allow for an early recovery, there is not an high level of evidence about the superiority in terms or complications and mortality rate compared to nonoperative treatment.

An unusual pattern of posterior wall fracture of acetabulum

BACKGROUND

This study aims to describe an uncommon presentation of posterior wall acetabular fracture-dislocation with displacement of fracture fragment anterior to femoral head with its management and clinico-radiological outcome.

METHODS

This retrospective review was performed at a Level I trauma centre over a period of six years. Hospital records, radiological database, operative register and follow-up data identified 7 patients with anteriorly lying posterior wall fragment of acetabulum. Analysis was performed with 6 patients having complete follow-up ranging from 2 to 7 years. The patients were operated with standard Kocher-Langenbeck approach; modification of this approach with trochanteric flip osteotomy and safe surgical dislocation was performed based on the location of the anteriorly lying fragment. Final functional and radiographic outcome was analysed according to modified Merle D'Aubigné and Postel score, and Matta's grade, respectively.

RESULTS

This uncommon presentation was observed in 11.11% of patients out of 63 patients with isolated posterior wall acetabular fractures managed during the study period. Anteriorly displaced posterior wall fragment was located in anterosuperior (n, 3), anterocentral (n, 2) and anteroinferior (n, 1) quadrants anterior to the femoral head. Final clinical and radiographic outcome revealed good-to-excellent outcome in 5 (83.33%) patients, and poor in one. One patient developed progressive arthrosis of hip which required total hip arthroplasty within 2 years.

CONCLUSION

This unusual pattern of posterior wall fracture requires adequate pre-operative planning, careful handling of the fractured fragments along with its soft tissue attachments during surgery, and preferably a concomitant trochanteric flip osteotomy with/without surgical hip dislocation to achieve good results.

Fractures of the acetabulum: from yesterday to tomorrow

Purpose

The aim of this article is to present history, state of the art, and future trends in the treatment of acetabular fractures.

Methods

Review of recent and historical literature.

Results

Acetabular fractures are difficult to treat. The first descriptions of this injury already appeared in ancient Greek history, but intensive development started in the second half of the twentieth century after Judet and Letournel’s seminal work. Their classification is still the gold standard today. It is actually a pre-operative planning system and is used to determine the most appropriate surgical approach. The therapy of choice for dislocated fractures is open reduction and internal fixation. Recent modern techniques based on high-tech computerized planning systems and 3D printing have been successfully integrated into orthopaedic trauma practice.

Conclusion

There is no ideal surgical approach for acetabulum fracture treatment, so new approaches have been developed in recent decades. The best outcome series have shown good or excellent results, between 70 and 80%.

Trochanteric osteotomy for acetabular fracture fixation: a case series and literature review

PURPOSE

This study examined osteotomy union and heterotopic ossification (HO) after performing digastric trochanteric osteotomies during open reduction and internal fixation (ORIF) of acetabular and combined femoral head fractures. Femoral head osteonecrosis and trochanteric screw removal were secondarily assessed.

METHODS

Twenty-six patients treated at a Level I trauma center, from years 2003 to 2019, who received a digastric trochanteric osteotomy during acetabular and combined femoral head fracture ORIF through a posterior surgical approach were retrospectively identified. Osteotomies were fixed with two 3.5 mm cortical lag screws. Rates of osteotomy union, HO, femoral head osteonecrosis, and trochanteric screw removal were determined.

RESULTS

All osteotomies went onto union without displacement or failure of fixation. Only three (12%) patients developed severe HO (modified-Brooker class III-IV). There were no instances of femoral head osteonecrosis and only one (7%) patient required trochanteric screw removal.

CONCLUSIONS

The digastric trochanteric osteotomy heals reliably with low rates of severe HO, femoral head osteonecrosis, and screw removal for soft-tissue irritation. A review of the literature is presented and found comparable findings.

Current Uses of the Transtrochanteric Approach to the Hip: A Systematic Review

BACKGROUND

The indications and technique for the transtrochanteric approach to the hip have evolved greatly since its initial popularization in the 1960s. The purpose of this systematic review was to assess current uses of this approach on the basis of indications, osteotomy technique, trochanteric fixation method, complications, and functional outcome.

METHODS

A comprehensive search of MEDLINE and Embase databases from January 2000 to July 2017 was performed in accordance with the PRISMA guidelines. Articles were divided into 3 major categories on the basis of the type of hip surgery performed: (1) primary arthroplasty, (2) revision arthroplasty, and (3) joint-preserving procedures. Patient data were then analyzed according to these 3 categories.

RESULTS

Seventy-six studies (5,028 hips), mainly of Level-IV evidence, were included. Four types of osteotomy were reported for a variety of indications. Rates of nonunion were 6.0% (303 of 5,028) across all studies, 4.2% (39 of 921) for primary arthroplasty, 6.7% (114 of 1,690) for revision arthroplasty, and 4.4% (56 of 1,278) for joint-preserving procedures. Rates of dislocation were 1.5% (14 of 921) for primary arthroplasty and 4.6% (77 of 1,690) for revision arthroplasty. The rate of osteonecrosis after joint-preserving procedures was 1.1% (14 of 1,278). Rates of deep infection were 1.1% (55 of 5,028) across all studies, 0.1% (1 of 921) for primary arthroplasty, 2.1% (36 of 1,690) for revision arthroplasty, and 0.6% (8 of 1,278) for joint-preserving procedures.

CONCLUSIONS

The transtrochanteric approach remains useful in cases requiring extensile exposure of the acetabulum or femoral medullary canal. However, trochanteric complications continue to pose a clinical challenge.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Single versus double column fixation in transverse fractures of the acetabulum: A randomised controlled trial

INTRODUCTION

Biomechanical studies have compared fixation methods in transverse acetabular fractures, yet there is not enough clinical data to suggest an optimal fixation method. The aim of this randomized controlled trail was to compare fracture stability in posterior plating alone versus posterior plating and anterior column lag-screw fixation in treatment of transverse and transverse with posterior wall acetabular fractures.

METHODS

Thirty patients were randomized to one of two groups, either posterior fixation alone (single column group), or posterior plating and anterior fixation with percutaneous anterior column screw (double column group). Patients were followed up with serial radiographic assessments documenting any loss of reduction, utilizing Matta's radiological criteria, measuring the roof arc angles and by measuring any change in the femoral head offset.

RESULTS

Fifteen patients were randomized to each group. Mean patient age was 31 years, mean follow up period was 19 months (range 12-24). There was no significant differences between the two groups with regards the quality of post-operative reduction, blood loss, hospital stay and functional score using the modified Merle D'Aubinge and Postel score. The operative time was significantly longer in the double column fixation group (130 min versus 104 min). There was no loss of reduction observed in either of the two groups.

CONCLUSION

Single poster column fixation in transverse and transverse posterior wall fractures showed similar result to double column fixation, in terms of fractures stability in the follow up period, quality of reduction and early functional outcome.

Midterm results of trochanteric flip osteotomy technique for management of fractures around the hip

INTRODUCTION

In this study, we aimed to investigate safety and efficacy of the trochanteric flip osteotomy with surgical hip dislocation technique in selected displaced acetabular and femoral head fractures with clinico-radiological outcome and potential complications.

MATERIALS AND METHODS

We retrospectively reviewed 32 patients from January 2009 to June 2014. Selected displaced acetabular fractures with comminution and/or cranial extension of posterior wall, marginal impaction, intraarticular fragment, femoral head fractures and hip fracture-dislocations were operated by this modified approach of trochanteric flip osteotomy and surgical hip dislocation. Patients were evaluated for fracture reduction, femoral head viability, trochanteric union, abduction power, and functional evaluation was done by Merle d'Aubigné-Postel scoring system. Minimum follow-up was 24 months.

RESULTS

Reduction was judged to be anatomical in 84.38% of cases, and within 1-3 millimetres in 9.38% of cases. All osteotomies healed in an anatomical position. Heterotopic ossification was found in 2 patients limited to Brooker class I. Osteonecrosis developed in 1 patient. 2 patients developed arthritis of the hip as sequelae of poor reduction. Abduction power was MRC 5/5 in all except in 1 patient (4/5). Mean Merle d'Aubigné-Postel score was 16.18; overall good to excellent result was achieved in 87.5% of cases.

CONCLUSIONS

Trochanteric flip osteotomy with surgical dislocation allows better intraarticular assessment, control of intraarticular fragments, assists accurate reduction and the fixation of complex acetabular and femoral head fractures, without compromising femoral head vascularity and abductor strength. This technique has provided excellent midterm results in the management of complex injuries around the hip.

Contemporary acetabular fracture surgery

In the time since Letournel popularised the surgical treatment of acetabular fractures, more than 25 years ago, there have been many changes within the field, related to patients, surgical technique, implants and post-operative care. However, the long-term outcomes appear largely unchanged. Does this represent stasis or have the advances been mitigated by other negative factors? In this article we have attempted to document the recent changes within the surgery of patients with a fracture involving the acetabulum, outline contemporary management, and identify the major problem areas where further research is most needed.

Cite this article: Bone Joint J 2017;99-B:1125–31

Treatment of Transverse with or without Posterior Wall Fractures of Acetabulum Using a Modified Smith-Petersen Combined with Kocher-Langenbeck Approach

BACKGROUND The aim of this study was to explore the surgical treatment of transverse with or without posterior wall fractures of the acetabulum. MATERIAL AND METHODS We surgically treated 21 consecutive cases of pure transverse (7 cases) and with posterior wall (14 cases) fractures of the acetabulum. The anterior column fractures were firstly reduced, temporarily fixed through a modified Smith-Petersen small incision, and finally fixed after the fixation of the posterior column and wall fractures, which were reduced and fixed through a Kocher-Langenbeck approach. The operative time, intra-operative blood loss, quality of reduction (Matta criteria), perioperative complications, osseous union, subsequent complications, and hip function evaluation were recorded. RESULTS The mean operative time was 198.1 min and the mean intra-operative blood loss was 938.1 ml. Anatomic reduction of the anterior column was obtained in 20 cases and was imperfect in 1 case. All posterior column and wall fractures were anatomically reduced. We followed up 18 cases for a mean duration of 16.3 (8-30) months. All the fractures achieved osseous union. The mean Harris score was 85.1 points, with an excellent result in 7 cases, good in 8, fair in 2, and poor in 1. According to modified Merle d' Aubigne and Postel score system, the results were excellent in 2 cases, good in 15, and poor in 1. Avascular necrosis of the femoral head occurred in 1 case, heterotopic ossification in 3 cases, and numbness of the anterolateral thigh in 6 cases. CONCLUSIONS For transverse with or without posterior wall fractures of the acetabulum, reduction and fixation of anterior and posterior column should be done in sequence, and a modified Smith-Petersen small incision might be a good choice in reduction and fixation of the anterior column because it possesses advantages of direct visualization and minimal invasion.

Patients undergoing surgical hip dislocation for the treatment of acetabular fractures show favourable long-term outcome

Aims

The aims of this study were to determine the cumulative ten-year survivorship of hips treated for acetabular fractures using surgical hip dislocation and to identify factors predictive of an unfavourable outcome.

Patients and Methods

We followed up 60 consecutive patients (61 hips; mean age 36.3 years, standard deviation (sd) 15) who underwent open reduction and internal fixation for a displaced fracture of the acetabulum (24 posterior wall, 18 transverse and posterior wall, ten transverse, and nine others) with a mean follow-up of 12.4 years (sd 3).

Results

Clinical grading was assessed using the modified Merle d’Aubigné score. Radiographic osteoarthritis was graded according to Matta. Kaplan-Meier survivorship and a univariate Cox-regression analysis were carried out using the following endpoints: total hip arthroplasty, a Merle d’Aubigné score of < 15 and/or progression of osteoarthritis.

Conclusion

The ten-year cumulative survivorship was 82% (95% confidence interval 71 to 92). Predictors for the defined endpoints were femoral chondral lesions, marginal impaction, duration of surgery, and age of patient. Cite this article: Bone Joint J 2017;99-B:508–15.

Labral reconstruction with tendon allograft: histological findings show revascularization at 8 weeks from implantation

This description shows the histological findings of a peroneus brevis tendon allograft used for labral reconstruction, implanted 8 weeks before being retrieved due to a postoperative complication unrelated to the graft. As far as we have knowledge this is the first description about revascularization of an allograft used for hip labral reconstruction. The histological report of the removed peroneus brevis tendon allograft shows evidence of vascular ingrowth represented by small vessels with a thin muscular wall in all layers of the graft and cellular migration mainly represented by mature fibroblasts.

The efficacy of posterior plating and anterior column screw fixation in the management of T-shaped acetabular fractures - CART analysis of prospective cohort study

T-shaped acetabular fractures are challenging injuries. The goal of surgical treatment is to achieve a stable and a concentric reduction of the femoral head under the anatomically reduced weight-bearing dome. There is an ongoing debate about the ideal approach and fixation method for T-shaped fractures. In this study, a group of 34 patients with T-shaped acetabular fractures were treated by posterior plating and anterior column screw. All patients, were followed for at least two years or until hip replacement. The aim of this prospective cohort study was to report the rate of postoperative radiological results together with the early clinical outcome. Anatomical reduction was achieved in 62%, satisfactory reduction of the anterior column with restoration of hip congruency in 82% with excellent to good clinical outcome in 75% of cases. We used classification regression trees (CART) to select the important predictors and generate hypotheses on interaction among them. Residual anterior column displacement >3.5mm was associated with poor clinical results. In cases with residual displacement <3.5mm, the presence of a posterior wall fracture was an independent negative predictor.

Surgical hip dislocation through a direct lateral approach: A cadaveric study of vascular danger zones

OBJECTIVE

There is limited information on the potential danger to the vascularity of the femoral head during surgical dislocation of the hip using the direct lateral approach. The objective of this study was to investigate the topographical anatomy of the medial femoral circumflex artery (MFCA), the primary source of blood supply to the femoral head, in relationship to the direct lateral approach.

METHODS

Seven unembalmed cadaver hips had dye injection into either the profunda femoris artery or the MFCA. Surgical hip dislocation was then performed through a direct lateral approach, noting the danger zones to the MFCA branches during each step of the exposure.

RESULTS

None of the MFCA branches were found to cross the anterior surgical field superficial to the capsule. The deep (main) branch of the MFCA pierced the inferior capsule at the level of the lesser trochanter after emerging posterior to iliopsoas tendon. Ascending branches up the medial femoral neck were identified at this level. The deep branch then coursed posteriorly terminating in a variable number of vessels ascending the posterior femoral neck. Dislocation of the femoral head did not stretch or alter the course of the deep branch of the MFCA.

CONCLUSION

Safe surgical hip dislocation preserving the MFCA can be performed though a direct lateral approach as long as the inferomedial portion of the anterior capsule is preserved (main branch of the MFCA pierces the capsule at this level). Extracapsular injury is possible from inadvertent dissection at the level of the lesser trochanter or aggressive retraction on the iliopsoas. The posterior capsule should be left intact and instrumentation around the posterior neck should be avoided.

Surgical dislocation of the hip without trochanteric osteotomy

BACKGROUND

Surgical dislocation of the hip remains an important alternative in hip preservation surgery, especially when a dynamic access to the hip is needed and arthroscopy is not a suitable option. We describe a novel technique for operative dislocation of the hip without trochanteric osteotomy and the clinical results of our patients.

METHODS

Surgical dislocation of the hip without trochanteric osteotomy was done through a modified lateral approach in all of the cases. A review of demographic, clinical, and radiological data was done in all of the patients operated with this technique between 2010 and 2015. Complications, walking aids, weight-bearing status, and modified Harris Hip Score (mHHS) were also recorded.

RESULTS

Six surgical dislocations of the hip were carried out. Indications were tumor resection in five and bulletectomy in one hip. There were two women (four hips) and two men. Mean age was 19 ± 3.8 years. Median follow-up was 2.5 years (range 2-4.5 years). Median mHHS was 92 (90-96). There were no intraoperative nor postoperative complications.

CONCLUSIONS

Surgical dislocation of the hip without trochanteric osteotomy through a modified lateral approach appears to be a safe, simpler, and effective alternative.

Versatility of an Extended Posterior Approach for the Treatment of Acetabular Fractures With Reference to the Superior Gluteal Neurovascular Bundle

The superior gluteal neurovascular bundle is at risk of injury in certain types of acetabular fractures and the associated surgery. This article describes the versatility of an extended posterior approach, previously described for complex revision total hip replacement (the Adelaide approach) and for the treatment of acetabular fractures that allows a wide exposure of the ilium through identification, protection, and mobilization of the superior gluteal neurovascular bundle.

Surgical hip dislocation is a reliable approach for treatment of femoral head fractures

BACKGROUND

Femoral head fractures are rare injuries; incongruency and instability are indications for surgical intervention. Anterior, posterior, and transtrochanteric surgical approaches have been proposed, but the exposure is limited with classical approaches. Surgical hip dislocation allows for a 360° view of the head and may facilitate a reduction in selected head fractures, but to our knowledge, few studies have reported on the results with this technique. We therefore report on the (1) quality of fracture reduction; (2) modified Harris hip score at a minimum of 2 years (mean, 6 years, range, 26-122 months); and (3) frequency of complications, including avascular necrosis (AVN), arthritis development, and heterotopic ossification, in a case series of patients with femoral head fractures treated with this approach.

DESCRIPTION OF TECHNIQUE

The procedure involves digastric trochanteric flip osteotomy and safe dislocation of the femoral head, preserving its vessels. Using this technique we are able to reduce all displaced femoral head fractures under direct view. Definitive fixation is performed through this approach with 2.7-mm nonabsorbable screws. The same technique may be used also for Pipkin IV fractures to fix transverse, T-type, posterior wall, or posterior column acetabular fracture.

METHODS

Between 2004 and 2011, we used this approach to manage all displaced femoral head fractures in patients younger than 55 years old. A total of 17 patients were thus treated; of those three were lost to followup before 2 years, and one was excluded from study because of severe preoperative neurological impairment, leaving 13 for analysis here. Patient demographic, injury, and surgical variables as well as complications were recorded and retrospectively evaluated. Radiographic outcome was scored according to Matta's criteria on postoperative radiographs. Outcomes were evaluated with the modified Harris hip score. Minimum followup was 24 months (mean, 77 months; SD, 32.8 months).

RESULTS

Fracture reduction was anatomic in eight hips and imperfect in five. Mean clinical score was 82 points (SD, 7.7). One patient developed symptomatic femoral head AVN and underwent total hip arthroplasty 4 years after the index procedure; no other patient underwent arthroplasty. Besides this patient, signs of arthritis (Grade I according to Tönnis classification) were found in one patient and heterotopic ossification was recorded in two patients, but neither was symptomatic.

CONCLUSIONS

Our experience with surgical dislocation shows clinical results comparable to previously reported outcomes in femoral head fractures treated with common approaches; we also present a similar rate of AVN and a lower rate of posttraumatic arthritis, but a higher risk of heterotopic ossification. Further case-control studies are necessary to confirm these statements.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Rationale for more consistent choice of surgical approaches for acetabular fractures

OBJECTIVES

All acetabular fractures are difficult to treat surgically, but there are four types involving two columns that are particularly challenging. The choice of surgical approach is crucial. The purpose of the study was to determine and evaluate the factors influencing the choice of surgical approach for two-column acetabular fractures. We hypothesised that more accurate preoperative planning, sophisticated technical capabilities, and evolution of surgeon experience will result in more consistent use of non-extensile single surgical approaches. We also evaluated the outcomes of surgical treatment and the correlation with the surgical approach used.

DESIGN

Retrospective cohort study.

PATIENTS AND METHODS

A total of 156 patients with 157 acetabular fractures involving two columns (Letournel T-types and both-column) treated surgically in a 25-year period (1988-2013) were included in the study. The acetabular fractures in this study were divided into two groups according to the date of surgery: 81 in Group 1 (1998-2002) and 76 in Group 2 (2003-2013). All fractures were classified preoperatively according to the Judet and Letournel classification system and Matta's categorisation of surgical approach. Four surgical approaches were used: single Kocher-Langenbeck (KL), single ilioinguinal (II), combined Kocher-Langenbeck and ilioinguinal (KL+II), and extended iliofemoral (EIF). The efficacy of the surgical approach utilised was assessed using three parameters: anatomical reduction, surgical time and intraoperative complications.

RESULTS

There was no statistical difference between Group 1 and Group 2 in the distribution of T-type (p=0.424) and both-column (p=0.425) fractures. In Group 2 more acetabular fractures were treated through single non-extensile approaches compared with Group 1 (90.8% vs. 54.3%, p<0.001). Increase in single approach surgery resulted in shorter mean surgical time (p<0.001) and significant increase in anatomical reduction (p=0.039). The frequency of intraoperative complications was not statistically different (p=0.07) between the two groups, but there was a trend to fewer complications in Group 2.

CONCLUSIONS

The surgical approaches chosen for acetabular fractures that involve two columns (Letournel T-types and both-column) should become more consistent. The results of this study indicate that the majority of such acetabular fractures can be treated successfully through single surgical approaches.

Clinical and radiographic outcomes of femoral head fractures: excision vs. fixation of fragment in Pipkin type I: what is the optimal choice for femoral head fracture?

BACKGROUND

In this work, we present relatively long-term results of femoral head fractures with a specific focus on Pipkin type I fractures.

METHODS

Fifty-nine femoral head fractures were treated according to modified Pipkin's classification as follows: type I, small fragment distal to the fovea centralis (FC); type II, large fragment distal to the FC; type III, large fragment proximal to the FC; type IV, comminuted fracture. There were 15 cases of type I, 28 of type II, 9 of type III, and 7 of type IV fractures. Conservative treatment with skeletal traction was performed in 4 type II cases, excision of the fragment in 15 type I and 10 type II cases, fixation of the fragment in 14 type II and all 9 type III cases, and total hip replacement in all 7 type IV cases. The overall clinical and radiographic outcomes were evaluated using previously published criteria, focusing on the results in Pipkin type I fractures with relatively large fragments.

RESULTS

Based on Epstein criteria, in type II fractures, excellent or good clinical results were seen in 6 of 10 patients (60.0 %) treated by excision of the fragment and 12 of 14 patients (85.7 %) treated by internal fixation (p = 0.05). Also, excellent or good radiologic results were seen in 4 of 10 (40.0 %) patients treated by excision of the fragment and 12 of 14 (85.7 %) patients treated by internal fixation (p = 0.03).

CONCLUSIONS

Even in Pipkin type I fractures, if the fragment is large (modified Pipkin type II), early reduction and internal fixation can produce good results.

Surgical hip dislocation: techniques for success

Surgical hip dislocation (SHD) is a versatile approach used to address both intra-articular and extra-articular pathology around the hip joint in both pediatric and adult patients. It allows anterior dislocation of the femoral head for direct visualization of the hip joint while preserving femoral head vascularity and minimizing trauma to the abductor musculature. Previously described indications for SHD include femoroacetabular impingement, deformity resulting from Legg-Calve-Perthes disease, slipped capital femoral epiphysis, periarticular trauma, benign lesions of the hip joint, and osteochondral lesions. In this review, we will describe current surgical techniques, indications, and clinical outcomes for SHD.

Can we predict femoral head vitality during surgical hip dislocation?

PURPOSE

Surgical hip dislocation is commonly performed in orthopaedic surgery for several pathologies that often present risk of avascular necrosis (AVN) of femoral head. Observation of blood spilling out from a drill hole, performed in the head after dislocation, has been proposed as a predictive test for AVN. No data have been published about test reliability. Study's aim was to evaluate the correlation between 'bleeding sign' and AVN in surgical dislocation for elective disease and for acetabular fractures.

METHODS

All patients meeting the indication for surgical dislocation were included in this prospective study. Patients with follow-up shorter than 8 months were excluded. Intra-operative assessment of head vascularity was performed in 44 patients through the 'bleeding sign': a 2.0-mm drill hole carried out on the head during surgery. A positive bleeding test was considered an immediate appearance of active bleeding. Development of AVN was considered the main outcome. Necrosis group criteria were detection of type II, III or IV X-ray according to Ficat classification.

RESULTS

Forty-four patients with selected acetabular fractures, slipped capital femoral epiphysis and femoral head deformity were enrolled. Mean age was 25 years and mean follow-up was 36 months. Thirty-eight patients presented positive intra-operative bleeding sign and six demonstrated no bleeding. Sensitivity for the 'bleeding sign' was 97%, specificity was 83%, positive predictive value was 97%, negative predictive value was 83% and accuracy was 95% (P < 0.001).

CONCLUSIONS

Bleeding after head drilling is a reliable test for AVN in patients who undergo a surgical hip dislocation.

Surgical hip dislocation does not result in atrophy or fatty infiltration of periarticular hip muscles

Surgical hip dislocation is the gold standard for treatment of femoroacetabular impingement (FAI). It utilizes an intermuscular and internervous approach to the hip. Concerns have been expressed that this approach causes soft tissue trauma resulting in post-operative muscle weakness of patients undergoing this procedure. We therefore asked whether surgical hip dislocation leads to (i) atrophy (decreased muscle diameter or cross-sectional area [CSA]) and (ii) degeneration (fatty infiltration) of 18 evaluated periarticular hip muscles. We retrospectively evaluated 32 patients (34 hips) following surgical hip dislocation for the treatment of FAI using pre and post-operative magnetic resonance (MR) arthrography of the hip. We evaluated muscle diameter, CSA and degree of fatty infiltration according to Goutallier for 18 periarticular hip muscles on axial and sagittal views. The mean interval between pre and post-operative MR was 1.9 ± 1.5 years (range, 0.4–6.1 years). Pre and post-operative muscle diameter and CSA of all 18 evaluated hip muscles did not differ. There was no post-operative change in the Goutallier classification for any of the evaluated 18 muscles. No muscle had post-operative degeneration higher than Grade 1 according to Goutallier. No atrophy or degeneration of periarticular hip muscles could be found following surgical hip dislocation for treatment of FAI. Any raised concerns about the invasiveness and potential muscle trauma for this type of surgery are unfounded. Level III, retrospective comparative study. See guidelines for authors for a complete description of levels of evidence.