We used laser Doppler flowmetry (LDF) with a high energy (20 mW) laser to measure perfusion of the femoral head intraoperatively in 32 hips. The surgical procedure was joint debridement requiring dislocation or subluxation of the hip. The laser probe was placed within the anterosuperior quadrant of the femoral head. Blood flow was monitored in specific positions of the hip before and after dislocation or subluxation. With the femoral head reduced, external rotation, both in extension and flexion, caused a reduction of blood flow. During subluxation or dislocation, it was impaired when the posterosuperior femoral neck was allowed to rest on the posterior acetabular rim. A pulsatile signal returned when the hip was reduced, or was taken out of extreme positions when dislocated. After the final reduction, the signal amplitudes were first slightly lower (12%) compared with the initial value but tended to be restored to the initial levels within 30 minutes. Most of the changes in the signal can be explained by compromise of the extraosseous branches of the medial femoral circumflex artery and are reversible. Our study shows that LDF provides proof for the clinical observation that perfusion of the femoral head is maintained after dislocation if specific surgical precautions are followed.
We dissected 20 cadaver hips in order to investigate the anatomy and excursion of the trochanteric muscles in relation to the posterior approach for total hip replacement. String models of each muscle were created and their excursion measured while the femur was moved between its anatomical position and the dislocated position. The position of the hip was determined by computer navigation. In contrast to previous studies which showed a separate insertion of piriformis and obturator internus, our findings indicated that piriformis inserted onto the superior and anterior margins of the greater trochanter through a conjoint tendon with obturator internus, and had connections to gluteus medius posteriorly. Division of these connections allowed lateral mobilisation of gluteus medius with minimal retraction. Analysis of the excursion of these muscles revealed that positioning the thigh for preparation of the femur through this approach elongated piriformis to a maximum of 182%, obturator internus to 185% and obturator externus to 220% of their resting lengths, which are above the thresholds for rupture of these muscles. Our findings suggested that gluteus medius may be protected from overstretching by release of its connection with the conjoint tendon. In addition, failure to detach piriformis or the obturators during a posterior approach for total hip replacement could potentially produce damage to these muscles because of over-stretching, obturator externus being the most vulnerable.
Recently, femoroacetabular impingement has been recognised as a cause of early osteoarthritis. There are two mechanisms of impingement: 1) cam impingement caused by a non-spherical head and 2) pincer impingement caused by excessive acetabular cover. We hypothesised that both mechanisms result in different patterns of articular damage. Of 302 analysed hips only 26 had an isolated cam and 16 an isolated pincer impingement. Cam impingement caused damage to the anterosuperior acetabular cartilage with separation between the labrum and cartilage. During flexion, the cartilage was sheared off the bone by the non-spherical femoral head while the labrum remained untouched. In pincer impingement, the cartilage damage was located circumferentially and included only a narrow strip. During movement the labrum is crushed between the acetabular rim and the femoral neck causing degeneration and ossification. Both cam and pincer impingement lead to osteoarthritis of the hip. Labral damage indicates ongoing impingement and rarely occurs alone.
