A Prospective Study of Management of Fracture Dislocation of Hip (PIPKIN) by Safe Surgical Dislocation (2 Years 6 Months Follow-Up in a Tertiary Hospital at Visakhapatnam)

BACKGROUND High velocity motor vehicle injuries are associated with hip fracture dislocations especially dash board injuries. Most commonly posterior hip dislocations are associated with occasional femoral head fractures. Computerized tomographic imaging is done to look at the congruency of the hip joint. Safe surgical dislocation or Ganz approach was described in 2001 for exposing the hip in a 360-degree view without damaging the vascularity of the femoral head. In this study, we wanted to evaluate the radiological and functional outcome using modified Merle d' Aubigne-Postel and Harris hip scoring. METHODS The current study is a prospective study in a tertiary referral centre where 8 young adult males were followed up for a period of 2 years 6 months from August 2018 to February 2021 after safe surgical dislocation and reduction with headless Herbert screws to maintain congruent hip surface. RESULTS We had 1 patient with associated chest injury requiring intercostal tube placement, while none of them had developed avascular necrosis or early arthritis. We had used modified Merle d'Aubigne-Postel and Harris hip scoring to assess the functional outcome. We had six patients with excellent results and two patients with good outcome due to occasional pain. We followed all the patients for more than 2 years. We evaluated the radiological and functional outcomes. The results are comparable to other researcher’s studies. CONCLUSIONS Safe surgical dislocation is a very good choice for fixation of femoral head fractures where the complications like early arthritis of femoral head and acetabulum are less along with preserving the vascularity of the femoral head and preventing the chances of avascular necrosis of femoral head. It also provides a good intraoperative view for handling the fracture reduction. KEYWORDS Pipkin Fracture, Ganz Approach, Safe Surgical Dislocation Hip, Herbert Screw

Reconstruction of the Hip in Multiple Hereditary Exostoses

The hip joint involvement in multiple hereditary exostoses (MHE) occurs in 30–90%, causing pain and limitation of motion by femoroacetabular impingement, coxa valga, acetabular dysplasia, hip joint subluxation, and osteoarthritis. The purpose of this study was to investigate the clinical and radiographic outcomes of ten hips in seven patients treated by surgical dislocation and corrective osteotomies between 2004 and 2009. Surgical dislocation and excision of the osteochondromas and varus intertrochanteric osteotomies were performed in all cases when the neck–shaft angle was > 150°. Common sites of osteochondromas were medial, posterior, and anterior neck of the femur. Neck–shaft angle of the femur was improved from a mean of 157° to 139°, postoperatively. On an average, the center-edge angle improved from 20° to 30° postoperatively. We believe that Ganz’s safe surgical dislocation technique is the preferred treatment of MHE. This safeguards the circulation of the femoral head and the osteochondromas can be resected under direct vision. It can be combined with additional corrective osteotomies because the hip affected by MHE is frequently associated with dysplastic changes which can result in premature osteoarthritis.

Bilateral femoral head reshaping and mosaicplasty in Legg–Calvé–Perthes disease residual deformity

Residual hip deformity secondary to Perthes disease may lead to early symptomatic joint degeneration. The altered anatomy results in biomechanical and biological problems that can be surgically addressed in adolescents or young adults with hip preservation procedures. This case report aims to demonstrate a customized surgical treatment performed on a 15-year-old male who developed painful hips with significant intra- and extra-articular impingement, secondary to bilateral Leg–Calvé–Perthes disease residual deformity. Intra-articular procedures were executed through a safe surgical dislocation of the hip, with a mosaicplasty using osteochondral autografts from the exceeding peripheral ipsilateral femoral head, a femoral head–neck osteochondroplasty and a labrum repair. A relative lengthening of the femoral neck was also carried out with a trochanteric advancement to solve the extra-articular issues. On follow-up, he referred to a substantial improvement in pain and function, being his radiographic studies satisfactory. At 4 and 5 years from surgery, the patient was able to exercise regularly with minimal complaints, with a Harris Hip Score of 85.85% and a Hip Outcome Score of 94.1% for activities of daily life and 86.1% for sports. In patients with hip deformity after healed Perthes disease, treatment strategies that address both the morphological disturbance of coxa magna, plana and breva, as well as the biological concerns arising from osteochondral injuries or labral tears, and mechanical dysfunctions lead to improvements in symptomatology, function and medium-term prognosis. Further procedures to address residual adaptative acetabular dysplasia would favor outcomes of conservative hip surgery in the sequelae of LCPD.

Historical analysis of the diagnosis and management of femoroacetabular impingement prior to the year 2000: a systematic review

This systematic review aims to assess the diagnosis, indications and treatment of femoroacetabular impingement (FAI) prior to the year 2000 and to determine if historical concepts remain applicable today. PUBMED, MEDLINE and EMBASE were searched for literature evaluating the diagnosis/treatment of FAI prior to 2000. Cadaver/non-human, non-English and review studies were excluded. Quality assessment was performed using the Methodological Index for Non-Randomized Studies. Nine studies comprising 307 patients [315 hips; mean age of 32.6 ± 2.4 years (range, 12–58)] were included. Patients reported groin pain. Magnetic resonance arthrography (MRA; n = 76) and the anterior impingement test (AIT) (n = 88) were used to diagnose impingement. Surgical dislocation with a trochanteric flip osteotomy (n = 237) and Bernese periacetabular osteotomy (n = 40) were common treatments. Pain and range of motion improved for patients. Overall complication rate was 35% (n = 99), with heterotopic ossification (n = 79) most commonly reported. Prior to 2000, there was low quantity and quality of research on the diagnosis/management of FAI. Diagnostic evaluation was primarily through clinical examination (i.e. groin pain and AIT). MRA was occasionally used to detect labral degeneration; however, utilization of computed tomography (CT) and diagnostic injections were not reported. Surgical dislocation and osteotomies of the acetabulum yielded desirable short-term clinical outcomes with a moderate complication rate. No study reported using arthroscopy for FAI management prior to 2000. Clinicians today can learn from historical principles (i.e. clinical diagnosis of FAI, management with surgical correction of femoral head–neck offset) while applying novel techniques (i.e. CT, injections, arthroscopic surgical techniques and rehabilitation) to improve patient outcomes. Level of Evidence: IV (systematic review of III and IV evidence).