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I Rarely Scope After a Hip Dislocation: Wait and See I (and/or my - - PowerPoint PPT Presentation
I Rarely Scope After a Hip Dislocation: Wait and See I (and/or my - - PowerPoint PPT Presentation
I Rarely Scope After a Hip Dislocation: Wait and See I (and/or my co-authors) have something to disclose. Detailed disclosure information is available via: Printed Final Agenda AAOS Orthopaedic Disclosure Program on the AAOS website at
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Case Example
- 18 year old male playing football
who sustained a right hip injury four days ago.
- The patient states that he was
running to catch passes diving on to the ground and somebody stepped on his heel as he was diving to catch the pass.
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Plain Radiographs
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Plain Radiographs
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MRI
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MRI
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Follow Up
- After PWB for 6-8 weeks, he
underwent 4 phase PT program
- Repeat MRI showed no evidence
- f AVN
- He was able to return to football
after 4 months
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Management of Acute Hip Dislocations
History and physical exam
- Hip fixed in flexion, adduction,
internal rotation
- Neurovascular exam
Radiographs: AP & lateral views & Judet views Acute management: closed reduction < 6 hrs
- AVN 1-17%
- CT scan after reduction
- Controversial: indication for acute
arthroscopy with retained fragment
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Hip Instability
Traumatic hip subluxations
- MRI
- Moorman et al. (JBJS 2003) traumatic
posterior hip subluxation have triad of posterior acetabular lip fracture, iliofemoral ligament disruption, and hemarthrosis
- Fluoroscopic aspiration to decrease
intracapsular pressure
- PWB for 6 wks
- Repeat MRI to determine presence of AV
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Traumatic Hip Instability
- Traumatic Hip Dislocations
(Philippon et al. Arthroscopy 2009)
- All 14 RTP in professional athletes
- 9 of 14 with FAI
- FAI – Induced Hip Instability (Krych
et al. CORR 2012.)
- 20 of 22 patients RTP
- 18 of 22 with FAI
- MOI
- No FAI: posterior directed force
with hip in flexion – adduction (ie, dashboard)
- FAI: torsion and hyperflexion
Krych et al. CORR 2012. CAM, Femoral Retroversion, Acetabular Retroversion
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- 151 Patients from 31 studies
- Age: 25.2 yrs (range, 8-54 yrs)
- Mechanism:
- MVA 57%
- Sports 43%
- Direction:
- Posterior 94.5%
- Antero-inferior 4.5%
- Arthroscopic findings
- Labrum: 87.8% tear (9 incarcerated
tears)
- Lig teres: 96.4% torn or injured
- Loose bodies: 89.4%
- Cartilage or osteochondral injury: 60%
femoral head and 40% acetabulum
- Capsule injury: 8 cases
- FAIS: 16 cases
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Time of Arthroscopy
< 1 month: 24.5% > 1 month: 75.5%
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Outcomes
- Excellent outcomes in 84% of
reported cases (about 50%)
- Complications
- 1, Scrotal edema
- 3, Revision hip arthroscopy
- Frequent, Transient fluid
extravasation
- No intra-abdominal fluid
extravasation
- Post-traumatic OA: 4%
- Avascular necrosis: 2.7%
Ilizalturri et al. AJSM 2011.
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Management
- Acute Dislocation
- Fracture-dislocation
- ORIF Femoral Head
- ORIF Acetabulum
- Non-concentric reduction
- Loose body
- Incarcerated labrum
- If neither of the above criteria
has been met, then proceed with non-operative management
Ilizalturri et al. AJSM 2011.
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Management
- There are considerable risks with
early surgical intervention
- Intra-abdominal fluid
extravasation: Bartlett et al. described a case report of loose body removal after both column acetabulum fracture that lead to cardiac arrest
- Avascular necrosis risk high if
greater than 6 hr delay in reduction: Avoid surgery in cases where AVN is already a possibility
- Post-traumatic OA: If there is a
large chondral injury, the patient may be at increased risk of post- traumatic osteoarthitis
- 25% Simple Dislocations
- 89% Fracture Dislocations
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Recommendations
Wait and See Approach:
- Unless there is an absolute
indication for acute surgical intervention
- Protected WB with crutches for
6 wks
- Repeat MRI
- 4 Phase PT protocol to return to
sport
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