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LONG-TERM
TRAUMATIC
RESULTS IN 50 PATIENTS
DISLOCATION
OF
THE
HIP
K. E. DREINHOFER, From
N. P. HAAS,
H. TSCHERNE
the Hannover
From 1974 to 1989, we treated 50 patients with a simple dislocation of the hip: 38 were posterior dislocations and 12 were anterior. All dislocations primarily treated at our hospital were reduced by closed methods within three hours (mean 85 minutes (10 to 180)) and 43 were reviewed after an average follow-up of 8 years (2 to 17). It is widely held that isolated hip dislocation reduced within six hours gives an excellent outcome, but we found a significant number of complications. There were radiological signs of partial avascular necrosis in two, mild osteoarthritis in seven, and moderate degeneration in two. Heterotopic ossification was seen in four patients, but 29 of 33 MIII examinations were normal. Objective evaluation according to the Thompson and Epstein (1951) criteria showed fair and poor results in 3 of 12 anterior dislocations, but in 16 of 30 posterior dislocations. In six of the seven patients with no other severe injury, the hip had an excellent or good result; in only three of the eight patients with severe multiple injuries was this the case. The important factors in the long-term prognosis appear to be the direction of the dislocation and the overall
severity
J BoneJoint
Received
Hip dislocation may be anterior or posterior. Classifications based on the severity of associated bone involvement have
been developed for both common anterior posterior dislocations displacement 1954).
simple
(Epstein There
(Thompson
dislocation
and Epstein 1951; Stewart and Milford reports of the long-term outcome after
fracture
prognosis
(type
has
I in all classifications),
been considered to be
but
good
(Nicoll
Reigstad avascular associated
1952;
Hunter
1969; Kristensen
and Stougaard
1974;
1980; Jacob, Rao and Ciccarelli 1987). Subsequent necrosis (AVN) of the femoral head has been with a long interval between injury and reduction McCarroll Rosenthal Hougaard reported and Mulhollan 1975; and Coker 1979; Epstein and Thomsen 1986), but the later development of
(Bray 1962; Stewart, Weigand Ct al 1978; 1980; Reigstad 1980; other authors have
osteoarthritis
Moulton
and Srikrishnamurthy 1983; Hougaard and Thomsen 1987). We have made a retrospective study of the treatment and long-term results in a series of patients with simple dislocation of the hip in respect of prognostic factors.
of injuries.
Surg
30 April
fBr/ /993;
1994;
Accepted
76-B:fs--12.
21 June
/993
PATIENTS From
dislocation
AND
METHODS a total
hip were
1972
to 1989
of the
of 421
admitted
patients
to the
with
traumatic
of
Department
Trauma excluded
(shear
Surgery, and
Hannover
Medical
Germany.
We
traumatic
I). There
women with a mean age of 29 years (5 to 62). The highest incidence was between 20 and 30 years (Fig. 1). The right
hip was
patients K. E. DreinhOfer, MD, Orthopaedic
Orthopaedic Surgery,
involved
had bilateral
in 27 patients,
dislocations.
Registrar
Registrar Universitht
S. R. Schwarzkopf, MD, Department of Orthopaedic D-89081 Ulm, Germany. N. P. Haas, MD, Professor
whom
Ulm, Oherer Eselsberg,
air-rescue Germany
Department Germany.
of
Trauma
Surgery,
Freie
Universitht,
D-13353
Berlin,
by a physician. The mean rescue from the accident until arrival at (15 to 150).
and of the
H. Tschernc,
Department Hannover, Correspondence 1994 British 0301-620X194/1695
MD, Professor
of Trauma Germany. should Editorial Surgery, be sent Society $2.00 Hannover Medical School, D-30625
was
43 minutes
primarily
Thirty-seven
treated accident at our
of the
hospital
diagnosed
and
of the
13 primarily
within 12
treated
hours
in another In four of
hospital, these
12 were
because of
transferred
additional
severe
injuries.
cases
the
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
ISOLATED
TRAUMATIC
DISLOCATION
OF
THE
HIP
Table
I. Details
of 50 patients
with
isolated
dislocations
Case
1
Sex M
Age (yr)
21
Treatment group
A
Direction Post-sup Post-sup Post-sup Post-sup Post-sup Ant-sup Post-sup Post-sup Post-sup Post-inf
Post-sup
Osteoarthritis
AVN (Stulberg)
Ossification (Brooker)
Subjective result 2
1 3 3 4 I I
Follow-up (mth) 37
42 53 137 111 149 99 128 45
2
3
4
M
F M
16
49 16
A
A A
I I
3 3
50 55
150
5
6 7
M
M M
18
31 20
A
A A A A A A
60
60 70
New
New New
8
9
M
M
38
3(1
Ila
3 3
1 3
10 11 12
13
M
F
32
21
60 70 50
90
Mild
2
1
104
126
New
New
F
M
31
21
A
A
Ant-inf
A.nt-inf
32
10
2 I Moderate 3
4 3 Mild Ila 3 1 4 3 3
75
56 129 122 93
New
New New New New
14 15 16 17 18 19
M F M F M M
59 47 26 19 58 20
A A A A A A
A A
5 2 6 8 12 53 34
6 47
80 150 180
70
2 2 2
2
I 3
187
129 177
New
New New
60 70 95
20
21 22
23
F
M F
M
21
55
1
I Mild II 2 3 2 2
I 1 3 1 1 1
139
58 91
New
New New New New
50
10 70 45
150
41
30
A
A
Ant-inf
Post-sup
15
5
106
35
24 25 26 27 28
29
F M F F F
M
50 57 46 21 62
32
A A A A A
A
Ant-inf
Post-sup Ant-inf Post-sup Post-sup Post-sup
15
11 6 18 6 20
2
1 1
84
65 63 67
New
New New New
120
110
50 80
240 I
2 2
2
1
1 1
81
160
48
New
New New
30 31 32
33 34
F M M
M M
19 5 50
40 20 16
B B C
C C C
Post-sup
Post-sup Post-sup
1
1 6
270 ha 2
1
1 3 1
46
126 121
New
New New New
Iha
I II
3
3
10 52 4 14 15
1 20
35
36 37
38
F
M M
F
3
3
100 58 159
51
16 21
59
C C
C
1 2
1
New New
New
3
2
4
39 40
41 42 43
M M
M M M
22 29
20 33 18
A A
A B D
47 28
Chart Chart
Post-sup
Post-sup Post-sup Post-sup
1
14 18 15
2 Moderate hIb
105
58 124
Chart Chart
Arthroplasty No No
Died Died Died Died
III
44 45 46 47 48 49 50
*
M M M M F M F
45 32 22 21 32 26 46
A A A A A B C at reporting
105 60
50
Post-sup
Post-sup Post-sup Post-sup Post-sup
15
43 66 69 64
90
110
150
Post-sup
hospital; months
53
treatment elsewhere, reduction at centre; C, reduction elsewhere, later treatment at centre;
Died
D, primary treatment
A, all treatment
B, primary
elsewhere,
arthroplasty
2, good;
after eight
3, fair;
4, poor
VOL. 76-B,
No. 1, JANUARY
1994
K.
E.
DRE1NHOFER,
5.
R. SCHWARZKOPF,
N.
P. HAAS.
H. TSCHERNE
Table
ofSO
isolated
25 15 passenger
passenger 5 5
4 10 1 3
I
Biking
Sledge
1
1
Falls
3 objects
accidents
Age in years
Fig. Age hip. and sex distribution of 50 patients 1
Falling
Rollover
1
3
with
traumatic
dislocation
of the
dislocation
within months at which ofthe after
was diagnosed
the accident radiographs protocol
after transfer,
One patient because showed includes
Associated
injuries
in 43
patients
with
isolated
hip
of the injury.
injury extremity
injury
37 fracture 22
20
every
( 37
severely
superior
injured
were
and one
or comatose
inferior) and
patient,
12 were
and therefore
were
anterior
no
(four
dislocations
overlooked.
Thirty-eight
posterior
Spinal
fracture
2
10 4 3
superior injuries,
Polytrauma maximum
2 I 12
5
The mean reduction time, defined as the interval from the accident until reduction was 70 minutes (10 to 180) in the 37 patients treated primarily at our hospital (treatment group A), one patient having reduction at the scene of the
Acetabular
5 and 2 2
Contralateral 33 Ipsilateral 1
accident. The mean reduction time in four of the patients treated primarily elsewhere and reduced at our hospital was
260 minutes whose hips (150 to 375) (group B). For had been reduced at another the eight patients hospital no exact
fracture fracture
timing
first
was available
to us during
the
5 2
1
3 4
closed reduction one patient had widening of the joint space; arthrotomy showed an interposed labrum. The patient with an unreduced dislocation at eight months had developed severe deformity of the displaced femoral head; this was treated by skeletal traction for four weeks followed by a total hip replacement. Further treatment varied according to the associated injuries. We did not use skeletal traction. Early mobilisation was advised with partial weight-bearing weeks. During any period of bed rest injuries, patients joint movement. had physiotherapy with for two to three required for other active and passive were
Malleolar fracture Talar fracture Calcaneal fracture Cuneiform fracture Metatarsal fracture
1 I 1
Follow-up. Five patients died from severe injuries; their average PTS was 59 (43 to 69). Six patients refused to
participate in the follow-up study, but for four of them we
had full clinical and radiological follow-up for 2.5 to 9 years (mean 4.5). The patient with very late reduction treated by hip replacement was also excluded. Thus, long-term available for results after a mean of 8 years (2 to 17) 42 patients, with a recent clinical and
THE
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BONE
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ISOLATED
TRAUMATIC
DISLOCATiON
OF
THE
HIP
radiological
examination
in
38
of
them.
The
latter
had two
Radiological patients
signs
(Stulberg changes
llb)
were
seen ha)
in in
clinical assessment and AP and lateral radiographs. We graded necrosis using the classification of Stulberg et al (1989) and heterotopic ossification on the grading of Brooker et al (1973). Thirty-three patients were also examined by MRI, with results classified according to Mitchell et al
and there
(Stulberg
four. Of the 33 MRI examinations, 29 were normal. Four hips showed pathological changes: one in Mitchell class A, two in class C and one in class D. All four hips also showed radiological The evaluated changes. objective according clinical to Thompson and radiological and Epstein data (1951): were 23 of systems good or in these
(1989). (1951)
judgement
We used Thompson and Epsteins to rate the clinical result and recorded
of the patients as excellent, good,
classification
the subjective
fair or poor.
42 hips had excellent or good results. By the scoring of Merle dAubign#{233} and Postel (1954), 37 were excellent and the Harris (1969) score gave 33 categories. The subjective opinions in 28 of the 38 seen for late review. factors on the outcome is given
RESULTS The objective clinical results were excellent or good in 23 of 42 patients; the subjective opinion was excellent or good in 28 of 38 patients. There was heterotopic ossification in 16 hips: 12 were in Brooker grade I, two in grade II, one in grade III and one in grade IV. The last two patients with severe ossification had had severe head injuries with subarachnoid on respirators. bleeding and spent 25 and 31 days respectively
in Table
Direction
of dislocation.
in only
one
quarter of the anterior dislocations, but in more than 50% of the posterior dislocations (p < 0.18). In the anterior group only one hip showed mild osteoarthritis and one low-grade heterotopic ossification (Brooker H).
Injury
severity.
The grade
of the initial
injury
affected
the
Table
IV.
Results
related
to various
Heterotopic
Number Direction of dislocation 4 8 30 1 (P1S score) 23
11
Excellent/Good
Poor
AVN
Osteoarthritis
ossification
Anterosuperior
3 6 15
1 2 12 1
1 3 6 1 7 1 3
13
7
9
2
1
2
4
2
2
4 2
6 2 time in minutes 12 15
6
2 I
4 I
1 1
7 9
4
5 4
2
2 1
1 1
1
3 3
1
1 1 1
241to360 Site of treatment All treatment at reporting hospital Primary treatment elsewhere, reduction at centre
Reduction elsewhere,
32 3 7
19 2 2
11
2 1
3 1 2
7 1 1
1 1 2
at centre
8 13
13 8 of follow-up (years) 14 14
14
4 8 5
4 4
1 2
1 1
7 1
1 I
4 1
4 2
5 10
8
7 4
5
2
1
3 1
2
4 3
2
2 2
Nine
patients
had
signs
of
osteoarthritis;
seven
had
final
outcome.
Five
of the seven
with
severe
multiple
injuries
irregular
femoral with
heads pronounced
and acetabula
with
mild
or moderate
narrowing
acetabula
VOL. 76-B.
of the joint
space,
heads
and
had only fair results; six of the seven patients with isolated dislocations had excellent or good results, while one had
mild pain and cystic changes on the radiograph. The
narrowing.
No. I, JANUARY
1994
10
K.
E.
DREINHOFER,
S. R. SCHWARZKOPF,
N. P. HAAS,
H. TSCHERNE
incidence
patients
of osteoarthritis
(7/18) than in
was
those
greater
with only
in multiply-injured
minor associated
had did
injuries
(2/23).
findings
were reported
severe injuries
by Yang
were
et al (1991). fractures
In
in
Time
under
patients cystic
from
six
injury
hours
Despite
and
hospital and two
the short
reduction
two hips
injury
at our
delay in all
developed
of 35
our
series
associated
more
the contralateral
leg: there
were
three ipsilateral
as
primarily changes
showed
subchondral
sequestrae,
the the
and
crescent
sign
(Stulberg
lib).
We
found
no
fractures, (15 of long bones This difference indicates in the two limbs.
statistical
between
minutes the seven
difference
results
those
(Fishers
in dislocations
which referred had after
exact
a delay
test two
reduced
tail;
in less
1.0) than 60
=
In the right-hand drive UK Upadhyay and Moulton found that the left hip was involved twice as often as
of 1 to 6 hours.
Five
of
(1992)
reported
that in automobile
drivers
patients
reduction
at another
had severe
hospital
associated
had
injuries.
only
fair
results,
but
all
these
there was a tendency for the left hip to dislocate and for the right hip to suffer posterior fractureor pure anterior between the cause dislocation. We of the dislocation,
others have reported
Age
more former
thritis;
of patient.
at the group,
this was
patients
excellent
aged 50 years
or good results,
or
dislocation correlation
site, and the
time
had
final
results,
but
compared
with
17 of the 34 younger
however,
already
patients.
time of the
Three
accident
of the
osteoarin
cause
of the that
long-term
evidence
at the
of bilateral
(Upadhyay reported
et al 1991). anteversion
two.
traumatic of follow-up. Patients with the shortest period of had the highest incidence of fair and poor results;
demonstrate no increase in incidence of post-
dislocation
(Upadhyay,
Moulton
and
Burwell
Duration follow-up
we could
1985; de la Caffini#{232}re and Ould Ouali 1989), not verify this in our patients when compared
A subchondral
volunteers (unpublished data). Long-term complications are generally believed to be caused by insufficient blood supply to the femoral head. In
crescent sign appeared in two femoral heads; one of these developed mild and one moderate osteoarthritis. One of the four hips with cystic changes developed mild signs of osteoarthritis, degenerative respectively. Correlation of clinical In 33 of the 42 patients radiological result. Seven and radiological the clinical status patients results (Table V). correlated with the clinical but changes the other after three follow-up showed no evidence of of 4, 10, and 1 1 years
rabbits,
supply hours
achieved
Duncan
and
Shim
(1977)
showed
that
the blood
12
hours
after
injury
did
not
improve
the
circulatory
Table
and
V.
Correlation
results
between
clinical
radiological
result
despite
a normal
radiograph,
usually
because
of pain.
hip with with mild
Radiology
Normal Abnormal
Clinical
result Fair/Poor 7 10
Good clinical results were associated in one moderate heterotopic ossification, and in another, osteoarthritis Correlation There objective than was and cystic between only findings. a weak The result changes objective correlation patients according own
Excellent/Good 23 2
in the femoral head. and subjective results. between evaluation in five. to Thompson subjective was and better recovery. tion is the
the objective
and Epstein
Clinical most
studies important
also
indicated initial
that
prompt
reducwith the
(1951)
management,
critical delay being reported by some authors to be 12 hours (Bray 1962; Epstein 1974). More recent articles recommend reduction within 6 hours (Weigand et al 1978; Hougaard and dislocation of the hip was once considered to be
Thomsen studies 1986; included Jaskulka enough et patients al 1991), with hips but none reduced of these
between
other
recent
series
(Hougaard
1987; was
Fischer and Fenzl 1991), a dashboard common mechanism in our cases. Most hip dislocations are said
severe concomitant injuries (Suraci
question,
hospital
treated
to be associated
1986;
Jaskulka
et al
1991), but the effect of the severity of general final outcome at the hip has not been addressed
difference
reduction within
between
We did
very
find
reduction
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
ISOLATED
TRAUMATIC
DISLOCATION
OF THE
HIP
11
worse information
results
reduced and
confirmed
to us within
and 3 of 12 anterior
Upadhyay et al (1983) found that the incidence of secondary osteoarthritis increased with time but both Epstein (1980) and Hougaard and Thomsen (1987) reported that this complication usually developed within five years of dislocation, as seen in our series. There rate ofdegeneration with increased authors have hips in older reported patients also seems to be a higher injury severity, and some
femoral head and arthritis may result from the initial injury and not from delay in reduction. It is difficult to compare our results with other reported series especially systems. The designed because of the use of different Merle dAubign#{233} and Harris of arthroplasties, while classification scores were the Thomp-
for evaluation
although this was not confirmed in other reports 1980; Hougaard and Thomsen 1986) or our series.
son and Epstein score primarily Their original criteria imply that of pain should of be all classified other explain studies regardless criteria; worse parameters.
assesses hip dislocations. all patients with any kind only We used a fair these result, rigid
as having
For many
period 1962;
years,
prolonged
immobilisation
were recommended and Weiss 1977),
and a long
(Bray but recent
the fact that our results were which either used another et al 1983; Schlickewei Jacob et al 1987; et al 1993) or a criteria
investigations have failed to show deleterious early mobilisation (Hougaard and Thomsen
classification Hougaard
different
et al 1991; Schlickewei et al 1993). Simple traumatic dislocation ofthe hip without fracture, rapidly reduced, has been considered to have few long-term complications, 100% (Stewart with excellent or good results in 85% to et al 1975; Weigand et al 1978; Hougaard
of the Thompson
and Epstein
(Jaskulka
et al 1991).
Conclusions.
that an isolated excellent
We do not agree
hip dislocations outcome: In our were we series found
held view
have of number (better
reduced
six hours
and
Thomsen
1987;
Jacob
et al 1987;
Niederwieser
and
complications.
the important
for long-
Primavesi 1991; Yang et al 1991; Schlickewei Ct al 1993), or in other series 75% (Lamke 1970; Epstein 1980; Upadhyay et al 1983; Jaskulka et al 1991). By contrast, W#{246}lfel et al
term prognosis
for anterior
to the patient.
the direction
dislocation)
severity
of all injuries
(1991),
dislocation
reviewing
treated
42 results
by traction
at 6 to 20 years
for four weeks found
after
and
isolated
and non2 poor
No benefits commercial in any form party related have been received directly or indirectly or will be received to the subject of this from article. a
weight-bearing
for 3 to 4 months,
15 fair
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