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.

Traumatic hip dislocation is a rare injury in orthopaedic practice and typically occures in high energy trauma. The goal of this study was to analyze hip morphology in patients with low energy traumatic hip dislocations and to compare it with a control group.

We performed a retrospective comparative study. The study group included 45 patients with 45 traumatic posterior hip dislocation. Inclusion criteria were traumatic hip dislocation with simple acetabular rim or Pipkin I or II fracture. Traumatic dislocations combined with other acetabular or femoral fractures were excluded. The control group consisted of 90 patients (180 hips) that underwent radiographic examination for urogenital indication and had no history of hip pain. Hip morphology was assessed on antero-posterior and axial views.

The study group showed significantly increased incidence (p<0.001) of positive cross-over sign (82% vs. 27%) with a increased retroversion index (26 ± 17 [0–56] vs. 6 ± 12 [0–53]), positive ischial spine sign (70% vs. 34%), and positive posterior wall sign (79% vs. 21).

Hips that underwent an low energy posterior traumatic hip dislocation show significanly more radiographic signs for acetabular retroversion compared to a control group. Therefore, acetabular retroversion seems to be a contributing factor for posterior traumatic hip dislocation.

The Bernese Periacetabular Osteotomy (PAO) has become the established method for treating developmental dysplasia of the hip. In the 1990s, the surgical technique was modified to avoid postoperative cam impingement due to uncorrected head neck offset or pincer impingement due to acetabular retroversion after reorientation. The goal of the study was to compare the survivorship of two series of PAOs with and without the modifications of the surgical technique and to calculate predictive factors for a poor outcome.

A retrospective, comparative study of two consecutive series of PAOs with a minimum follow-up of 10 years was carried out. Series A included 75 PAOs performed between 1984 and 1987 and represent the first cases of PAO. Series B included 90 hips that underwent PAO between 1997 and 2000. In this series, emphasis was put on an optimal acetabular version next to the correction of the lateral coverage. Additionally, a concomitant arthrotomy was performed in every hip to check impingement-free range of motion after reorientation and in 50 hips (56%) an additional offset correction was performed. Survivorship analyses according to Kaplan and Meier were carried out and the endpoint was defined as conversion to a total hip arthroplasty, progression of osteoarthritis, or a Merle d'Aubign score 14. Predictive factors for poor outcome were calculated using the Cox-regression analysis.

The cumulative 10-year survivorship of Series A was significantly decreased (77%; 95%-confidence interval [CI] 72–82%) compared to Series B (86%; 95%-CI 82–89%, p=0.005). Hips with an aspherical head showed a significantly increased survivorship if a concomitant offset correction was performed intraoperatively (90% [95%-CI 86–94%] versus 77% [95%-CI 71–82%], p=0.003). Preoperative factors predicting poor outcome included a high age at surgery, a Merle d'Aubign score 14, a positive impingement test, a positive Trendelenburg sign, limp, an increased grade of osteoarthritis according to Tönnis, and (sub-) luxation of the femoral head (Severin > 3). In addition, predictive factors related to the three dimensional orientation of the acetabular fragment were identified. These included total, anterior, and posterior acetabular over-coverage or under-coverage, acetabular retroversion or excessive anteversion, a lateral center edge angle < 22 °, an acetabular index > 14 °, and no offset correction in aspherical femoral heads.

A good long term result after PAO mainly depends on optimal three-dimensional orientation of the acetabulum and impingement-free range of motion with correction of an aspherical head neck junction if necessary.

Femoroacetabular impingement (FAI) is a pathologic condition of the hip that leads to osteoarthrosis. The goal of the surgical hip dislocation is to correct the bony malformations to prevent the progression of osteoarthrosis. We investigated the topographical cartilage thickness variation in patients with FAI and early stage osteoarthrosis using an ultrasonic probe during surgical hip dislocation.

We performed a prospective case-series of 38 patients (41 hips) that underwent surgical hip dislocation. The mean age at operation was 30.6 (range, 18–48) years. Indication for surgery was symptomatic FAI with 4 hips (10%) with pincer-type, 7 hips (17%) with cam-type, and 20 hips (73%) with mixed-type of FAI. Cartilage thickness was measured intraoperatively using an A-mode 22 MHz ultrasonic probe at 8 locations on the acetabular cartilage.

The thickest acetabular cartilage was found in the weight bearing zone (range 2.8–3.5mm), whereas the thinnest cartilage was in the posterior acetabular horn (1.0–2.2 mm). In all hips, cartilage was thicker in the periphery area compared to the central area. In the anterior and posterior acetabular horn, the anterior area, and the superior area (central parts) a significantly decreased cartilage thickness in pincer-type compared to cam-type of FAI was found (p<0.05).

Cartilage thickness shows topographical differences in all types of FAI with pincer-type of FAI having generally thinner cartilage than cam-type FAI. This is the first study measuring in vivo cartilage thickness in the human hip.

Surgical dislocation of the hip in the treatment of acetabular fractures allows the femoral head to be safely displaced from the acetabulum. This permits full intra-articular acetabular and femoral inspection for the evaluation and potential treatment of cartilage lesions of the labrum and femoral head, reduction of the fracture under direct vision and avoidance of intra-articular penetration with hardware. We report 60 patients with selected types of acetabular fracture who were treated using this approach. Six were lost to follow-up and the remaining 54 were available for clinical and radiological review at a mean follow-up of 4.4 years (2 to 9).

Substantial damage to the intra-articular cartilage was found in the anteromedial portion of the femoral head and the posterosuperior aspect of the acetabulum. Labral lesions were predominantly seen in the posterior acetabular area. Anatomical reduction was achieved in 50 hips (93%) which was considerably higher than that seen in previous reports. There were no cases of avascular necrosis. Four patients subsequently required total hip replacement. Good or excellent results were achieved in 44 hips (81.5%). The cumulative eight-year survivorship was 89.0% (95% confidence interval 84.5 to 94.1). Significant predictors of poor outcome were involvement of the acetabular dome and lesions of the femoral cartilage greater than grade 2. The functional mid-term results were better than those of previous reports.

Surgical dislocation of the hip allows accurate reduction and a predictable mid-term outcome in the management of these difficult injuries without the risk of the development of avascular necrosis.