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Trochanteric Osteotomy for Incarcerated Hip Dislocation Due to Interposed Posterior Wall Fragments Jeffrey O

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Trochanteric Osteotomy for Incarcerated Hip Dislocation Due to Interposed Posterior Wall Fragments Jeffrey O 2ang.qxd 2/10/04 11:09 AM Page 213 FEATURE ARTICLE Trochanteric Osteotomy for Incarcerated Hip Dislocation Due to Interposed Posterior Wall Fragments Jeffrey O. Anglen, MD Michael Hughes Abstract A series of 12 patients was retrospectively reviewed to ly longer operations with more blood loss. Patients with evaluate the use of sliding trochanteric osteotomy for osteotomy tended toward a higher incidence of post- reduction of hip dislocations that were irreducible due to traumatic arthritis, but Harris hip scores at 2 years were interposed posterior wall fragments. Compared to simi- identical to matched comparisons. No adverse effects of lar patients who did not have irreducible dislocation or trochanteric osteotomy were identified. trochanteric osteotomy, the 12 patients had significant- Incarcerated hip dislocation is a severe ular fracture were identified through a gent operation (Figure 1). When they injury with poor prognosis. When the search of the Orthopaedic Trauma Service could not be taken directly to the operat- reduction is blocked by fragments of a database at the University of Missouri ing room, skeletal traction was applied. comminuted posterior wall, forceful Health Sciences Center, a level 1 trauma Trochanteric osteotomy was an intraoper- repeated attempts at reduction, pre- or center. All patients were operated on by a ative decision. intraoperatively, may further damage the single, fellowship-trained orthopedic With the early patients in this series, a articular surface. Trochanteric osteotomy traumatologist. Charts and radiographs variety of maneuvers were attempted during the surgical exposure of such cases were reviewed by a research assistant prior to osteotomy, including forceful has been found to facilitate reduction and who was uninvolved in the care of the manipulations of the leg, hip rotation with lessen trauma to the joint. patients, using a simple data collection distraction, and femoral distractor use. Due to reported complications and instrument designed to collect demo- However, substantial posterior wall frag- potentially detrimental effects of tro- graphic variables, operative findings and ments with attached capsule wedged chanteric osteotomy, a retrospective occurrences, follow-up complications, between the head and socket in the review of our experience with this tech- and outcomes. Charts were reviewed for acetabulum made the hip tight and pre- nique was performed to evaluate the injury severity score, operative time, time vented adequate access for fragment risks and benefits. from injury to surgery, estimated blood removal. Longitudinal distraction often loss, and outcome determinants such as increased the tension in abductor muscles MATERIALS AND METHODS degenerative joint disease, avascular and actually made the femoral head hard- Patients undergoing trochanteric necrosis, heterotopic bone, osteotomy er to extract from the acetabulum. It was osteotomy during exposure for an acetab- nonunion or other complication, average found by experience that trochanteric range of abduction, subsequent surgeries, osteotomy relaxed the muscular tension From the Department of Orthopedic Surgery, and Harris hip score, calculated from data enough to allow bone fragments to be University of Missouri Hospital and Clinics, in the chart. extracted. Later in this series, osteotomy Columbia, Mo. Attempted closed reduction was per- was performed early and routinely. Reprint requests: Jeffrey O. Anglen, MD, Boone Orthopaedic Associates, LLC, Broadway formed in the emergency department; The trochanteric osteotomy technique Medical Plaza, 1601 E Broadway, Ste 300, however, when the hip could not be used in this series is similar to that Columbia, MO 65201-8022. reduced, patients were posted for emer- described by Bray et al1 using a gigli saw www.orthobluejournal.com 213 2ang.qxd 2/10/04 11:09 AM Page 214 ORTHOPEDICS FEBRUARY 2004 VOL 27 NO 2 A B C Figure 1: AP pelvic radiograph of a posterior hip dislocation with associated posterior wall fracture (A). AP pelvic radiograph after failed attempt at closed reduction of the hip (B). CT revealing the cause of reduction failure—an interposed fragment of the posterior acetabular wall (C). matches were found for each index than for those who did not (mean: 3.2 patient. hours, range: 2-4.8 hours) (P=.024). Statistical analysis was performed Estimated blood loss was greater for using Systat for Windows (Systat Inc, patients with an osteotomy, 1280 cc ver- Evanston, Ill). A one-tailed t test was sus 720 cc (P=.037). Approximately 40% used to analyze continuous variables, of both groups had visible injury to the such as injury to surgery time, operative femoral head at surgery, and similar per- time, and blood loss. centages suffered marginal impaction of Figure 2: AP pelvic radiograph of the same acetabular cartilage (40% for the osteoto- patient after open reduction and internal RESULTS my group and 27% for the comparison fixation with trochanteric osteotomy. Twelve patients (2 women and 10 group, P=.42). men) with acetabular fractures who Heterotopic ossification was absent in underwent trochanteric osteotomy were 60% of patients in both groups. No in the interval between the abductors and identified. All osteotomies were per- patient developed Brooker grade 4 (anky- hip capsule. The vastus lateralis origin on formed for reduction of an incarcerated losis) heterotopic ossification, but 4 the lateralis ridge of the femur was kept dislocation during open reduction inter- patients (1 osteotomy, 3 comparison) intact in connection to the trochanteric nal fixation procedures. Average patient developed grade 3 heterotopic ossifica- fragment, in a “trochanteric flip,” as age was 46 years, and average weight tion, which did not require excision. This described by Siebenrock et al.2 It was was 95.5 kg. Average patient age of the difference was not statistically signifi- believed that this technique would allow comparison group was 43 years and aver- cant. more secure fixation of the trochanter age weight was 90.2 kg, which were not Of the osteotomy patients, 50% devel- and preserve trochanteric blood supply. statistically significantly different (P=.32 oped significant degenerative joint dis- The osteotomy was fixed with two large and P=.26, respectively). ease based on radiographic signs (sclero- fragment cancellous screws (Figure 2). Average injury severity score of sis, joint narrowing, osteophytes) and All patients received prophylactic treat- osteotomized patients was 19.1, and 16.8 clinical criteria (pain, stiffness, limitation ment against heterotopic ossification, for comparison patients (P=.35). The of range) compared to only 23% of the either single-dose postoperative radiation osteotomy group consisted of 5 posterior comparison patients; however, this differ- or 6 weeks of indomethacin (75 mg oral- wall fractures, 4 transverse and posterior ence was not statistically significant ly twice daily), according to a random- wall fractures, and 3 posterior column (P=.217). Two patients in each group ization protocol. and posterior wall fractures. The compar- developed radiographic signs of avascu- To evaluate patient outcomes, a com- ison group consisted of 12 posterior wall lar necrosis with pain and restricted range parison group of patients (without incar- fractures, 7 transverse and posterior wall of motion. cerated hip dislocation or trochanteric fractures, and 3 posterior column and The average Harris hip score was osteotomy) matched for gender, age posterior wall fractures. essentially identical between the two (within 5 years), weight (within 20 kg), Average time from injury to surgery groups (82 and 83) at final follow-up, and fracture type (including dislocation) was shorter for patients who required an which averaged 27 months (range: 12-62 were selected and reviewed. These osteotomy, 47 hours (range: 5-113 hours) months) for the osteotomy group and 22 patients were not intended to be a “con- versus 83 hours (range: 4-240 hours) months (range: 12-66 months) for the trol” group, but rather to provide a con- (P=.038). Operative time was longer for comparison group. Data for both groups text in which to place the outcome of patients who required an osteotomy is shown in the Table. these patients. From one to four adequate (mean: 4.5 hours, range: 2.3-8.3 hours) All trochanteric osteotomies united 214 www.orthobluejournal.com 2ang.qxd 2/10/04 11:09 AM Page 215 ANGLEN & HUGHES TROCHANTERIC OSTEOTOMY FOR HIP DISLOCATION without migration or hardware complica- tions. Seven (58%) of 12 patients had a TABLE positive Trendelenburg sign. In the com- Study Population Demographics parison group, 7 (32%) of 22 patients had a positive Trendelenburg sign, a differ- Osteotomy Comparison Demographic Patients Group ence that was not statistically significant (P=.244, Fisher exact test). One patient Age (y)* 46 (19-70) 43 (17-71) Weight (kg)* 95.5 (61-129) 90.2 (52-140) had elective screw removal for mild Injury severity score* 19 (10-34) 17 (9-41) symptoms of bursal irritation. Fracture type Posterior wall 5 12 Transverse and posterior wall 4 7 DISCUSSION Posterior column and posterior wall 3 3 As noted by McKee et al3 in 1998, Injury to surgery time (hr)* 47 (5-113) 83 (4-240) irreducible fracture dislocation of the Operative time (hr)* 3.9 (2.3-8.3) 2.2 (2-4.8) Estimated blood loss (mL)* 1167 (350-3000) 690 (350-1200) hip is a severe injury with a poor prog- Marginal impaction (%) 42 (5/12) 27 (6/22) nosis. Only 6 of 23 patients in their Injury to femoral head (%) 42 (5/12) 36 (8/22) study had a satisfactory outcome due to Heterotopic ossification (%) 42 (5/12) 32 (7/22) Degenerative joint disease (%) 50 (6/12) 23 (5/22) a variety of problems including avascu- Avascular necrosis (%) 17 (2/12) 9 (2/22) lar necrosis, rapid chondrolysis, sciatic Trendelenburg sign positive (%) 60 (7/12) 32 (7/22) nerve palsy, heterotopic ossification, Harris hip score* 81 (40-97) 83 (60-95) Follow-up (mos)* 27 (12-62) 22 (6-66) and severe ipsilateral lower extremity injuries. Approximately one third (7/23) *Represented as mean (range).
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