International Orthopaedic s (SICOT) (1992) 16:136-139
International
Orthopaedics © Springer-Verlag 1992
The management of unreduced traumatic dislocation of the hip in developing countries V. S. Pai Arrowe Park Hospital, Arrowe Park Road, Upton, Wirral, Merseyside L49 5PE, UK
Summary. Traumatic dislocation of the hip often remains untreated in developing countries. This paper reports the outcome of twenty nine patients with neglected dislocations (3 anterior and 26posterior). We have outlined the indications for five different methods of treatment. An attempt has been made to explain the causes of poor results.
to reduction are subtrochanteric osteotomy, excision arthroplasty, replacement arthroplasty or arthrodesis [ 1 , 2 , 4 , 7 , 9 , 12, 13]. W e report our experience in treating neglected dislocation o f the hip. W e define neglect as a delay in treatment of m o r e than 72 h [7].
R~sum~. Les luxations traumatiques de la hanche
Materials and methods
sont souvent ndglig6es dans les pays en voie de d6veloppement. Nous prdsentons ici les r6sultats d'une s~rie de 29 cas (3 luxations antdrieures et 26 postdrieures ndglig~es). Nous avons essayd de d6finir les indications de cinq mdthodes diff6rentes de traitement et d' expliquer les causes des mauvais rdsultats.
Twenty-nine cases of neglected dislocations were seen in the Orthopaedic Department of Kasturba Medical Hospital, India, between 1981 and 1984. There were 26 posterior and three anterior dislocations. Table 1 summarises the relevant information on these patients. There were eighteen males and eleven females ranging in age from 3 to 64, with a mean of 29 years. All presented with more than one of pain, limp, shortening or deformity. In three patients there was an associated injury, an ipsilateral femoral fracture in one, an ipsilateral tibial fracture in the second and a pelvic fracture and head injury in the third patient. We have used two classifications: 1) The Thompson and Epstein [16] classification to describe the type of injury (Table 2). 2) A modified Garrett's [6] classification to describe the length of time the hip remained dislocated (Table 3). Five methods of treatment were used, according to the delay in treatment and the severity of the injury (Table 4).
Introduction Little has been written about neglected traumatic dislocation because of its rarity. H o w e v e r , in developing countries it is not u n c o m m o n . Neglected cases pose a problem, for they are not seen often enough to give an individual orthopaedic surgeon enough experience to draw conclusions [1]. W a t s o n Jones [19] experienced the difficulties of open reduction and suggested arthrodesis for unreduced dislocation of the hip. D e l a y in reduction results in a greatly increased incidence of avascular necrosis and joint degeneration. H o w e v e r , Buchanan [3], N i x o n [14] and V a r m a [18] treated hips which had remained dislocated for periods of up to 1 year b y operative reduction and had reasonably good results. H e a v y traction and abduction was successful in reducing s o m e neglected dislocations. Alternatives
Shoe raise In seven patients with dislocations present for more than 1 year (Group IV), the dislocated hip was not reduced. Four had stable hips due to the formation of a pseudoacetabulum and were happy with a shoe raise. In three the hip was left unreduced for socioeconomic reasons. This group is not considered in the analysis of the results.
Closed reduction In three cases where the delay was less than three weeks (Group I), closed reduction under general anaesthesia was employed successfully.
137
V. S. Pai: Traumatic dislocation of the hip Table 1. Summary of 29 cases of neglected dislocation of the hip Case No.
Sex
Age
Mode of Injury
Type a
Neglect period
Associated injuries
Treatment
F.U.
Result
1 2 3 4 5 6 7 8 9 10
M M M M F M F F M F
64 22 5 4 3 5 30 3 12 3
Fail from tree Road accident Fall on stairs Fall from wall Fall while playing Fail on ground Road accident Roof collapse Road accident Smack by object
Ant. Post Post Post Post Post Post Post Post Post
Gp.1 Gp.1 Gp.1 Gp.III Gp.III Gp.II Gp.lI Gp.II Gp.IV Gp.II
#Femur #Pelvis/Head -
3 5 4 5 3 4 3 2 3
Satis. Satis. Saris. Satis. Saris Saris Satis. Unsat. Unsat.
11
M
25
Fall while playing
Post I
Gp.III
-
12
F
35
Fall while playing
Ant.
Gp.III
-
13 14 15 16 17 18 19 20 21 22
M F F F F M M M F F
26 60 25 48 16 16 28 16 22 19
Auto-accident Road accident Dashboard injury Fall from tree Fall from tree Fall from stairs Step in manhole Fall from ladder Fall from tree Fall from stairs
Post III Post V Post V Ant. Post I Post I Post I Post I Post I Post I
Gp. 1 Gp. 1 Gp. 1 Gp.IV Gp.IV Gp.IV Gp.IV Gp.IV Gp.IV Gp.IV
# Tibia -
C.R. C.R. C.R. HT-A HT-A HT-A HT-A Failed HT-A Failed HT-A Failed HT-A + O.R. Failed HT-A + O.R. Failed HT-A + O.R. Failed C/OR Failed C/OR Hemiarth. Girdlestone SO SO SO SO SO SO
23-29
Were treated with shoe raise only. All had posterior dislocations over one year previously. Four had formed a pseudoacetabulum and three could not be treated for socio-economic reasons
1 1 1 1 1 1 In Ill I
Yr Yr Yr Yr Yr Yr Yr Yr Yr
3 Yr
Satis.
3 Yr
Satis.
3 2 2 3 4 3 5 2 2 3 4
Satis. Saris. Saris. Unsat. Unsat. Saris. Satis. Satis. Satis. Satis. Saris.
Yr Yr Yr Yr Yr Yr Yr Yr Yr Yr Yr
a Thompson and Epstein [5]: Type 1 Type II Type III Type IV Type V Neglect
Dislocation without fracture or with no more than minor fracture. With large single fracture of the posterior acetabular rim. With a comminuted fracture of the posterior rim or without major fracture of the acetabulum. With a fracture of both the acetabular rim and floor. With a fracture of the femoral head, with or without other fractures. Group I (3 days to 3 weeks) Group II (3 weeks to 3 months) Group III (3 months to 1 year) Group IV (more than a year)
CR = Closed reduction, OR = Open reduction, HT-A = Heavy traction abduction method, C/OR = closed and open reduction, SO = Shanz osteotomy
o major trauma. (Thompson and Epstein Type III & V). Open reduction and fixation of the acetabular fragment was carried out in one patient and excision of a small piece of bone from the inferior aspect of the femoral head in the other. (Cases 13 and 14)
Heavy traction and abduction [15] Skeletal traction was applied for a period of two to three weeks. Reduction was accomplished by abducting the limb and reducing the traction to 5 - 7 Ibs for 3 weeks. This method was tried in eight posterior dislocations and one anterior dislocation. The period of neglect in all but one patient, who was untreated for over 1 year, was between 3 weeks and 1 year (Groups III and IV). Four out of nine patients had a concentric reduction. In three traction failed to achieve concentric reduction and an open reduction was performed. In the remaining two a nonconcentric reduction was accepted as the patients refused further surgical intervention.
Reconstructive procedures Eight patients underwent primary reconstructive procedures. One patient (Case 15), who had a comminuted fracture of the head of the femur, had a replacement arthroplasty. Six patients (Group IV) were treated by subtrochanteric, medial displacement osteotomy and one by excision arthroplasty. The postoperative follow up ranged from 2 to 6 years. The patients were assessed from the point of view of pain, movement, limp and radiologicai findings,
Primary open reduction Two patients (Group I) had an open reduction without any preliminary heavy traction. Both these patients had been subjected t
V. S. Pal: Traumatic dislocation of the hip
138 Table 2. Type of dislocation in 29 cases. (Thompson VP and Epstein HC)
Anterior dislocation: Posterior dislocation:
3 19 2 3 0 2
Type I Type II Type III Type IV Type V
Table 3. Time elapsed between the injury and reporting to the hospital
Group
Length of neglect
No. of patients
I II III IV
3 days to 3 weeks 3 weeks to 3 months 3 months to 1 year More than a year
6 4 4 15
reduction and the results were satisfactory. In the eighth patient, in whom a non-concentric reduction was accepted, post-traumatic arthritis developed within six months of the injury. In Group IV (over 1 year), six patients underwent reconstruction in the form of subtrochanteric valgus osteotomy. All six patients were happy with the outcome. Case 9 was a twelve year old boy who presented two years after injury. He had a fracture dislocation with a large acetabular fragment. A non-concentric reduction was obtained after heavy traction abduction, but as the patient refused further operative treatment the reduction was held in a hip spica. Subsequently redislocation occurred. The remaining patient in this group had a neglected anterior dislocation. As the head was badly deformed, excision arthroplasty was undertaken. The average of period of follow up was 3.3 years.
Discussion Table 4. Treatment of unreduced dislocation in 29 patients
Type of treatment Closed reduction Heavy tractionabduction Open reduction Reconstruction Left dislocated
Group I
II
III
IV
Total
3 -
4
4
1
3 9
2 1 -
-
-
7 7
2 8 7
It has been well documented that delayed reduction of traumatic dislocation of the hip increases the risk of avascular necrosis and arthritis. In view of these poor results, Garrett [7] suggested total hip replacement as the treatment of choice. However, this management was not appropriate in our series. We therefore suggest alternative methods of treatment to achieve painless, mobile and stable hips in these cases. Because treatment for neglected dislocation has been somewhat empirical, we have attempted to answer a number of key questions:
Results
In Group I (less than 3 weeks), closed reduction under general anaesthesia was successful in three out of six cases. Of the three unsuccessful cases, one had a fracture of the acetabulum which required open reduction and internal fixation. The second patient had a fracture of the inferior portion of the head which was obstructing reduction. This nonweightbearing portion of the head was excised to achieve reduction. These two patients did reasonably well. In the third patient the dislocation was associated with a comminuted fracture of the head of the femur. An Austin Moore hemiarthroplasty was performed in this patient but postoperatively she had a sciatic nerve palsy which has not recovered at two years. Analysis of the results in Groups II and III (3 weeks to 1 year), showed no significant difference. All eight patients were initially subjected to the heavy traction-abduction method. In four cases concentric reduction was achieved. In three patients open reduction was required to obtain concentric
1) Which patients with neglected dislocation require reduction ? Dislocation up to one year can be managed by either closed or open reduction provided the head of the femur is spherical. Generally reduction by manipulation under anaesthesia should be attempted up to 3 weeks. Over 3 weeks but under 1 year, heavy traction-abduction or open reduction give good results.
2) How successful is reduction by heavy traction? How should failed cases be managed? In contrast to Gupta's series [8], we were successful in achieving concentric reduction in 4 out of 9 cases. In two, a non-concentric reduction was accepted but had a poor clinical result. Therefore, we feel that the prognosis after closed or open reduction depends on the concentricity of reduction. Any widening of the medial joint space indicates interposition of soft
V. S. Pai: Traumatic dislocation of the hip
tissue or bony fragments and then we strongly recommend open reduction.
3) What is the advantage of using a heavy tractionabduction in neglected dislocations? It has been suggested that traction produces significantly less trauma to the femoral head, soft tissues are stretched and less pressure is exerted on the articular cartilage of the acetabulum [8]. It has also been reported that avascular necrosis is less common [15].
4) When is subtrochanteric osteotomy indicated? A subtrochanteric osteotomy is indicated for very old dislocations, when limp and instability are the presenting symptoms. Though a mild limp persists after the procedure, the preoperative range of movement is maintained.
5) What factors are responsible for the poor results in neglected dislocation ? a) Severity of injury. Brav [2] related the incidence of avascular necrosis to the degree of initial trauma. In our series the low incidence of avascular necrosis (3 out of 22) would appear to support this (Table 1). b) Duration of dislocation. Hougaard [10] reported an incidence of avascular necrosis of 4.8% when the dislocation was reduced within six hours and 52.9% in hips reduced more than 6 h after injury. In contrast Gupta [8], Pai [15] and Varma [18] showed that delay did not j eopardise the end result. c) Type of dislocation. Hougaard [11] and Epstein [6] reported poor results with Type III fracture dislocations. In our series, among three patients with Type III injuries, the two treated conservatively had a poor result. d) Type of reduction. We agree with Epstein that the main factor influencing the result is the concentricity of reduction. Our follow up is relatively short and it remains to be seen whether late post-traumatic arthritis will occur. Upadhyay and Moulton [17] reported that the frequency of arthritis increases with time after the dislocation. However, Hougaard [1 l] concluded that in the majority of patients, osteoarthritis developed within five years of the initial injury and in most of
139
the patients who had a poor result, symptoms developed within one year of the dislocation. Acknowledgements. I wish to thank Mr A J M Simison, Consultant Orthopaedic Surgeon, Arrowe Park Hospital, for his help in preparing the manuscript.
References 1. Agarwal ND, Singh H (1967) Unreduced anterior dislocation of the hip. J Bone Joint Surg 49-B: 288-292 2. Bray ES (1962) Traumatic dislocation of the hip. Army experience and results over a twelve year period. J Bone Joint Surg 44-A: 1115-1134 3. Buchanan JJ (1962) Open reduction of old dislocation of the hip. Surg Gynaecol Obstet 31:462-471 4. Coventry MB (1974) The treatment of fracture dislocation of the hip by total hip arthroplasty. J Bone Joint Surg 56-A: 1128-1134 5. Epstein HC (1980) Traumatic dislocation of the hip. Williams & Wilkins, Baltimore London 6. Epstein HC (1974) Posterior fracture dislocations of the hip, Long term follow up. J Bone Joint Surg 56-A: 1103-1127 7. Garret JC, Epstein HC, Harris WH, Harvey JP, Nickel VL (1979) Treatment of unreduced traumatic posterior dislocations of the hip. J Bone Joint Surg 61-A: 2 - 6 8. Gupta RC, Shravat BP (1977) Uureduced posterior dislocation of the hip. J Bone Joint Surg 59-A: 249-251 9. Hamada (1957) Unreduced anterior dislocation of the hip. J Bone Joint Surg 39-B: 471-476 10. Hougaard KL, Thomsen PB (1987) Coxarthrosis following traumatic posterior dislocation of the hip. J Bone Joint Surg 69-A: 679-683 11. Hougaard KL, Thomsen PB (1988) Traumatic posterior fracture dislocation of the hip with fracture of the femoral head or neck or both. J Bone Joint Surg 70-A: 233-239 12. Huckstep RC (1971) Neglected traumatic dislocations of the hip. J Bone Joint Surg 53-B: 355 13. Moore J (1953) Old traumatic dislocation of the hip with mahinited fractures of the acetabulum. Surg Clin North Am 33:1551-1569 14. Nixon JR (1976) Open reduction of traumatic dislocation of the hip. Report of three cases. J Bone Joint Surg 58-B: 41 15. Pai VS, Kumar B (1990) Management of unreduced traumatic posterior dislocation of the hip: heavy traction abduction method. Injury 21:223 16. Thompson VP, Epstein HC (1951) Traumatic dislocation of the hip: A survey of 204 cases covering a period of 21 years. J Bone Joint Surg 33A: 746 17. Upadhyay SS, Moulton A (1981) The long term results of traumatic posterior dislocation of the hip. J Bone Joint Surg 63-B: 548-551 18. Varma BP (1975) Management of old unreduced traumatic dislocations of the hip. Ind J Orthop 9 : 6 9 - 7 9 19. Watson-Jones Sir R (1982) Fractures and joint injuries, 6th edn, vol II. Churchill Livingstone, Edinburgh London, pp 917-921
International
Orthopaedics © Springer-Verlag 1992
The management of unreduced traumatic dislocation of the hip in developing countries V. S. Pai Arrowe Park Hospital, Arrowe Park Road, Upton, Wirral, Merseyside L49 5PE, UK
Summary. Traumatic dislocation of the hip often remains untreated in developing countries. This paper reports the outcome of twenty nine patients with neglected dislocations (3 anterior and 26posterior). We have outlined the indications for five different methods of treatment. An attempt has been made to explain the causes of poor results.
to reduction are subtrochanteric osteotomy, excision arthroplasty, replacement arthroplasty or arthrodesis [ 1 , 2 , 4 , 7 , 9 , 12, 13]. W e report our experience in treating neglected dislocation o f the hip. W e define neglect as a delay in treatment of m o r e than 72 h [7].
R~sum~. Les luxations traumatiques de la hanche
Materials and methods
sont souvent ndglig6es dans les pays en voie de d6veloppement. Nous prdsentons ici les r6sultats d'une s~rie de 29 cas (3 luxations antdrieures et 26 postdrieures ndglig~es). Nous avons essayd de d6finir les indications de cinq mdthodes diff6rentes de traitement et d' expliquer les causes des mauvais rdsultats.
Twenty-nine cases of neglected dislocations were seen in the Orthopaedic Department of Kasturba Medical Hospital, India, between 1981 and 1984. There were 26 posterior and three anterior dislocations. Table 1 summarises the relevant information on these patients. There were eighteen males and eleven females ranging in age from 3 to 64, with a mean of 29 years. All presented with more than one of pain, limp, shortening or deformity. In three patients there was an associated injury, an ipsilateral femoral fracture in one, an ipsilateral tibial fracture in the second and a pelvic fracture and head injury in the third patient. We have used two classifications: 1) The Thompson and Epstein [16] classification to describe the type of injury (Table 2). 2) A modified Garrett's [6] classification to describe the length of time the hip remained dislocated (Table 3). Five methods of treatment were used, according to the delay in treatment and the severity of the injury (Table 4).
Introduction Little has been written about neglected traumatic dislocation because of its rarity. H o w e v e r , in developing countries it is not u n c o m m o n . Neglected cases pose a problem, for they are not seen often enough to give an individual orthopaedic surgeon enough experience to draw conclusions [1]. W a t s o n Jones [19] experienced the difficulties of open reduction and suggested arthrodesis for unreduced dislocation of the hip. D e l a y in reduction results in a greatly increased incidence of avascular necrosis and joint degeneration. H o w e v e r , Buchanan [3], N i x o n [14] and V a r m a [18] treated hips which had remained dislocated for periods of up to 1 year b y operative reduction and had reasonably good results. H e a v y traction and abduction was successful in reducing s o m e neglected dislocations. Alternatives
Shoe raise In seven patients with dislocations present for more than 1 year (Group IV), the dislocated hip was not reduced. Four had stable hips due to the formation of a pseudoacetabulum and were happy with a shoe raise. In three the hip was left unreduced for socioeconomic reasons. This group is not considered in the analysis of the results.
Closed reduction In three cases where the delay was less than three weeks (Group I), closed reduction under general anaesthesia was employed successfully.
137
V. S. Pai: Traumatic dislocation of the hip Table 1. Summary of 29 cases of neglected dislocation of the hip Case No.
Sex
Age
Mode of Injury
Type a
Neglect period
Associated injuries
Treatment
F.U.
Result
1 2 3 4 5 6 7 8 9 10
M M M M F M F F M F
64 22 5 4 3 5 30 3 12 3
Fail from tree Road accident Fall on stairs Fall from wall Fall while playing Fail on ground Road accident Roof collapse Road accident Smack by object
Ant. Post Post Post Post Post Post Post Post Post
Gp.1 Gp.1 Gp.1 Gp.III Gp.III Gp.II Gp.lI Gp.II Gp.IV Gp.II
#Femur #Pelvis/Head -
3 5 4 5 3 4 3 2 3
Satis. Satis. Saris. Satis. Saris Saris Satis. Unsat. Unsat.
11
M
25
Fall while playing
Post I
Gp.III
-
12
F
35
Fall while playing
Ant.
Gp.III
-
13 14 15 16 17 18 19 20 21 22
M F F F F M M M F F
26 60 25 48 16 16 28 16 22 19
Auto-accident Road accident Dashboard injury Fall from tree Fall from tree Fall from stairs Step in manhole Fall from ladder Fall from tree Fall from stairs
Post III Post V Post V Ant. Post I Post I Post I Post I Post I Post I
Gp. 1 Gp. 1 Gp. 1 Gp.IV Gp.IV Gp.IV Gp.IV Gp.IV Gp.IV Gp.IV
# Tibia -
C.R. C.R. C.R. HT-A HT-A HT-A HT-A Failed HT-A Failed HT-A Failed HT-A + O.R. Failed HT-A + O.R. Failed HT-A + O.R. Failed C/OR Failed C/OR Hemiarth. Girdlestone SO SO SO SO SO SO
23-29
Were treated with shoe raise only. All had posterior dislocations over one year previously. Four had formed a pseudoacetabulum and three could not be treated for socio-economic reasons
1 1 1 1 1 1 In Ill I
Yr Yr Yr Yr Yr Yr Yr Yr Yr
3 Yr
Satis.
3 Yr
Satis.
3 2 2 3 4 3 5 2 2 3 4
Satis. Saris. Saris. Unsat. Unsat. Saris. Satis. Satis. Satis. Satis. Saris.
Yr Yr Yr Yr Yr Yr Yr Yr Yr Yr Yr
a Thompson and Epstein [5]: Type 1 Type II Type III Type IV Type V Neglect
Dislocation without fracture or with no more than minor fracture. With large single fracture of the posterior acetabular rim. With a comminuted fracture of the posterior rim or without major fracture of the acetabulum. With a fracture of both the acetabular rim and floor. With a fracture of the femoral head, with or without other fractures. Group I (3 days to 3 weeks) Group II (3 weeks to 3 months) Group III (3 months to 1 year) Group IV (more than a year)
CR = Closed reduction, OR = Open reduction, HT-A = Heavy traction abduction method, C/OR = closed and open reduction, SO = Shanz osteotomy
o major trauma. (Thompson and Epstein Type III & V). Open reduction and fixation of the acetabular fragment was carried out in one patient and excision of a small piece of bone from the inferior aspect of the femoral head in the other. (Cases 13 and 14)
Heavy traction and abduction [15] Skeletal traction was applied for a period of two to three weeks. Reduction was accomplished by abducting the limb and reducing the traction to 5 - 7 Ibs for 3 weeks. This method was tried in eight posterior dislocations and one anterior dislocation. The period of neglect in all but one patient, who was untreated for over 1 year, was between 3 weeks and 1 year (Groups III and IV). Four out of nine patients had a concentric reduction. In three traction failed to achieve concentric reduction and an open reduction was performed. In the remaining two a nonconcentric reduction was accepted as the patients refused further surgical intervention.
Reconstructive procedures Eight patients underwent primary reconstructive procedures. One patient (Case 15), who had a comminuted fracture of the head of the femur, had a replacement arthroplasty. Six patients (Group IV) were treated by subtrochanteric, medial displacement osteotomy and one by excision arthroplasty. The postoperative follow up ranged from 2 to 6 years. The patients were assessed from the point of view of pain, movement, limp and radiologicai findings,
Primary open reduction Two patients (Group I) had an open reduction without any preliminary heavy traction. Both these patients had been subjected t
V. S. Pal: Traumatic dislocation of the hip
138 Table 2. Type of dislocation in 29 cases. (Thompson VP and Epstein HC)
Anterior dislocation: Posterior dislocation:
3 19 2 3 0 2
Type I Type II Type III Type IV Type V
Table 3. Time elapsed between the injury and reporting to the hospital
Group
Length of neglect
No. of patients
I II III IV
3 days to 3 weeks 3 weeks to 3 months 3 months to 1 year More than a year
6 4 4 15
reduction and the results were satisfactory. In the eighth patient, in whom a non-concentric reduction was accepted, post-traumatic arthritis developed within six months of the injury. In Group IV (over 1 year), six patients underwent reconstruction in the form of subtrochanteric valgus osteotomy. All six patients were happy with the outcome. Case 9 was a twelve year old boy who presented two years after injury. He had a fracture dislocation with a large acetabular fragment. A non-concentric reduction was obtained after heavy traction abduction, but as the patient refused further operative treatment the reduction was held in a hip spica. Subsequently redislocation occurred. The remaining patient in this group had a neglected anterior dislocation. As the head was badly deformed, excision arthroplasty was undertaken. The average of period of follow up was 3.3 years.
Discussion Table 4. Treatment of unreduced dislocation in 29 patients
Type of treatment Closed reduction Heavy tractionabduction Open reduction Reconstruction Left dislocated
Group I
II
III
IV
Total
3 -
4
4
1
3 9
2 1 -
-
-
7 7
2 8 7
It has been well documented that delayed reduction of traumatic dislocation of the hip increases the risk of avascular necrosis and arthritis. In view of these poor results, Garrett [7] suggested total hip replacement as the treatment of choice. However, this management was not appropriate in our series. We therefore suggest alternative methods of treatment to achieve painless, mobile and stable hips in these cases. Because treatment for neglected dislocation has been somewhat empirical, we have attempted to answer a number of key questions:
Results
In Group I (less than 3 weeks), closed reduction under general anaesthesia was successful in three out of six cases. Of the three unsuccessful cases, one had a fracture of the acetabulum which required open reduction and internal fixation. The second patient had a fracture of the inferior portion of the head which was obstructing reduction. This nonweightbearing portion of the head was excised to achieve reduction. These two patients did reasonably well. In the third patient the dislocation was associated with a comminuted fracture of the head of the femur. An Austin Moore hemiarthroplasty was performed in this patient but postoperatively she had a sciatic nerve palsy which has not recovered at two years. Analysis of the results in Groups II and III (3 weeks to 1 year), showed no significant difference. All eight patients were initially subjected to the heavy traction-abduction method. In four cases concentric reduction was achieved. In three patients open reduction was required to obtain concentric
1) Which patients with neglected dislocation require reduction ? Dislocation up to one year can be managed by either closed or open reduction provided the head of the femur is spherical. Generally reduction by manipulation under anaesthesia should be attempted up to 3 weeks. Over 3 weeks but under 1 year, heavy traction-abduction or open reduction give good results.
2) How successful is reduction by heavy traction? How should failed cases be managed? In contrast to Gupta's series [8], we were successful in achieving concentric reduction in 4 out of 9 cases. In two, a non-concentric reduction was accepted but had a poor clinical result. Therefore, we feel that the prognosis after closed or open reduction depends on the concentricity of reduction. Any widening of the medial joint space indicates interposition of soft
V. S. Pai: Traumatic dislocation of the hip
tissue or bony fragments and then we strongly recommend open reduction.
3) What is the advantage of using a heavy tractionabduction in neglected dislocations? It has been suggested that traction produces significantly less trauma to the femoral head, soft tissues are stretched and less pressure is exerted on the articular cartilage of the acetabulum [8]. It has also been reported that avascular necrosis is less common [15].
4) When is subtrochanteric osteotomy indicated? A subtrochanteric osteotomy is indicated for very old dislocations, when limp and instability are the presenting symptoms. Though a mild limp persists after the procedure, the preoperative range of movement is maintained.
5) What factors are responsible for the poor results in neglected dislocation ? a) Severity of injury. Brav [2] related the incidence of avascular necrosis to the degree of initial trauma. In our series the low incidence of avascular necrosis (3 out of 22) would appear to support this (Table 1). b) Duration of dislocation. Hougaard [10] reported an incidence of avascular necrosis of 4.8% when the dislocation was reduced within six hours and 52.9% in hips reduced more than 6 h after injury. In contrast Gupta [8], Pai [15] and Varma [18] showed that delay did not j eopardise the end result. c) Type of dislocation. Hougaard [11] and Epstein [6] reported poor results with Type III fracture dislocations. In our series, among three patients with Type III injuries, the two treated conservatively had a poor result. d) Type of reduction. We agree with Epstein that the main factor influencing the result is the concentricity of reduction. Our follow up is relatively short and it remains to be seen whether late post-traumatic arthritis will occur. Upadhyay and Moulton [17] reported that the frequency of arthritis increases with time after the dislocation. However, Hougaard [1 l] concluded that in the majority of patients, osteoarthritis developed within five years of the initial injury and in most of
139
the patients who had a poor result, symptoms developed within one year of the dislocation. Acknowledgements. I wish to thank Mr A J M Simison, Consultant Orthopaedic Surgeon, Arrowe Park Hospital, for his help in preparing the manuscript.
References 1. Agarwal ND, Singh H (1967) Unreduced anterior dislocation of the hip. J Bone Joint Surg 49-B: 288-292 2. Bray ES (1962) Traumatic dislocation of the hip. Army experience and results over a twelve year period. J Bone Joint Surg 44-A: 1115-1134 3. Buchanan JJ (1962) Open reduction of old dislocation of the hip. Surg Gynaecol Obstet 31:462-471 4. Coventry MB (1974) The treatment of fracture dislocation of the hip by total hip arthroplasty. J Bone Joint Surg 56-A: 1128-1134 5. Epstein HC (1980) Traumatic dislocation of the hip. Williams & Wilkins, Baltimore London 6. Epstein HC (1974) Posterior fracture dislocations of the hip, Long term follow up. J Bone Joint Surg 56-A: 1103-1127 7. Garret JC, Epstein HC, Harris WH, Harvey JP, Nickel VL (1979) Treatment of unreduced traumatic posterior dislocations of the hip. J Bone Joint Surg 61-A: 2 - 6 8. Gupta RC, Shravat BP (1977) Uureduced posterior dislocation of the hip. J Bone Joint Surg 59-A: 249-251 9. Hamada (1957) Unreduced anterior dislocation of the hip. J Bone Joint Surg 39-B: 471-476 10. Hougaard KL, Thomsen PB (1987) Coxarthrosis following traumatic posterior dislocation of the hip. J Bone Joint Surg 69-A: 679-683 11. Hougaard KL, Thomsen PB (1988) Traumatic posterior fracture dislocation of the hip with fracture of the femoral head or neck or both. J Bone Joint Surg 70-A: 233-239 12. Huckstep RC (1971) Neglected traumatic dislocations of the hip. J Bone Joint Surg 53-B: 355 13. Moore J (1953) Old traumatic dislocation of the hip with mahinited fractures of the acetabulum. Surg Clin North Am 33:1551-1569 14. Nixon JR (1976) Open reduction of traumatic dislocation of the hip. Report of three cases. J Bone Joint Surg 58-B: 41 15. Pai VS, Kumar B (1990) Management of unreduced traumatic posterior dislocation of the hip: heavy traction abduction method. Injury 21:223 16. Thompson VP, Epstein HC (1951) Traumatic dislocation of the hip: A survey of 204 cases covering a period of 21 years. J Bone Joint Surg 33A: 746 17. Upadhyay SS, Moulton A (1981) The long term results of traumatic posterior dislocation of the hip. J Bone Joint Surg 63-B: 548-551 18. Varma BP (1975) Management of old unreduced traumatic dislocations of the hip. Ind J Orthop 9 : 6 9 - 7 9 19. Watson-Jones Sir R (1982) Fractures and joint injuries, 6th edn, vol II. Churchill Livingstone, Edinburgh London, pp 917-921
