Hip Dislocation: Evaluation and

Management
Abstract
A simple hip dislocation is one without fracture of the proximal
femur or acetabulum. Complex fracture-dislocations involve the
acetabulum, femoral head, or femoral neck. The incidence of
posttraumatic arthritis is much lower in simple dislocations than in
fracture-dislocations. The most common mechanism of injury is a
high-energy motor vehicle accident, which is usually associated
with other systemic and musculoskeletal injuries. The hip should be
reduced emergently in an atraumatic fashion. For acetabular
fracture, intraoperative stress views may be necessary to evaluate
for instability and to determine whether surgical xation is required.
The appearance of a concentric reduction on plain radiographs and
CT does not rule out intra-articular hip pathology; such injury may
contribute to long-term degenerative changes. Other complications
of hip dislocation include osteoarthritis, osteonecrosis, and sciatic
nerve injury. Indications for surgical management include
nonconcentric reduction, associated proximal femur fracture
(including hip, femoral neck, and femoral head), and associated
acetabular fracture producing instability. Surgical management
ranges from formal open arthrotomy to minimally invasive hip
arthroscopy. Hip arthroscopy has become popular for treating intra-
articular hip pathology, including loose bodies, chondral defects,
and labral tears.
T
he hip is a diarthrodial joint that
maintains its stability with a
combination of bony and soft-tissue
constraints. Incidence of hip disloca-
tions and fracture-dislocations is in-
creasing, with most occurring in
young adults as the result of high-
energy motor vehicle accidents. Sub-
stantial force is required to dislocate
the native hip joint. This damaging
force coupled with young age at dis-
ease onset may lead to prolonged
disability and dysfunction from com-
plications such as osteoarthritis (OA)
and osteonecrosis.
The rate of coxarthrosis following
hip dislocation is between 24% for
simple dislocations and 88% for
those associated with acetabular
fracture.
1
Associated morbidity is
compounded by the presence of
other systemic injuries, which occur
in approximately 40% to 75% of
cases.
2
One half of multiply injured
patients are likely to have an unsatis-
factory long-term outcome.
3
Timely reduction may be essential to
the survival of the femoral head and
should be considered on an emergent
basis. Subsequent treatment is based on
the ability to achieve a concentric reduc-
tion as well as on the presence of intra-
articular loose bodies and associated
fractures (ie, acetabulum, femoral neck,
femoral head). Management is contin-
gent on the postreduction clinical and
David M. Foulk, MD
Brian H. Mullis, MD
From the Department of
Orthopaedic Surgery, Indiana
University School of Medicine,
Indianapolis, IN.
Dr. Mullis or an immediate family
member serves as a board member,
owner, officer, or committee member
of Wishard Hospital and
Orthopaedic Trauma Association,
and has received research or
institutional support from Wyeth,
Synthes, and Amgen. Neither
Dr. Foulk nor any immediate family
member has received anything of
value from or owns stock in a
commercial company or institution
related directly or indirectly to the
subject of this article.
J Am Acad Orthop Surg 2010;18:
199-209
Copyright 2010 by the American
Academy of Orthopaedic Surgeons.
Review Article
April 2010, Vol 18, No 4 199
radiographic findings and may range
from nonsurgical care with limited
weight bearing to open procedures,
such as formal arthrotomy with surgi-
cal dislocation, or hip arthroscopy. Ad-
vances in arthroscopy have led to a high
rate of early identification and manage-
ment of intra-articular pathology.
Mechanism of Injury
The hip joint is inherently stable, and
substantial force is required to dis-
place the femoral head from the ace-
tabulum. The most common mech-
anism of injury is a dashboard injury
in a motor vehicle accident. Other
mechanisms include a fall from a
height, automobile-pedestrian acci-
dents, and athletic injuries. The main
determinants of the type of hip in-
jury incurred are the amount and di-
rection of applied load and the posi-
tion of the hip at the time the load is
sustained. For the typical dashboard
injury, the hip is positioned in flex-
ion and adduction, with the resultant
load directed along the long axis of
the femur. Anterior dislocations oc-
cur much less frequently. This injury
pattern can be produced by an exter-
nal rotation and abduction moment.
Anatomy
The stability of the hip joint is de-
pendent on the bony architecture
and its soft-tissue constraints. The
primary blood supply to the femoral
head is derived from the medial fem-
oral circumflex artery through the
retinacular arteries, originating from
an extracapsular ring at the base of
the femoral neck. Other contribu-
tions arise from the lateral femoral
circumflex artery, the obturator ar-
tery (through the ligamentum teres),
and the inferior and superior gluteal
arteries. The sciatic nerve lies in close
proximity to the hip joint and can be
injured in traumatic dislocation or
with surgical dissection. In most
patients, the nerve exits the greater
sciatic notch anterior to the pirifor-
mis muscle belly; however, anatomic
variation does exist, and the surgeon
should take care to identify and pro-
tect the nerve.
Classication
Hip injury is classified based on the
direction of displacement of the fem-
oral head in relation to the acetabu-
lum, whether anterior or posterior.
The most widely used classifications
are those of Thompson and Epstein
4
and Stewart and Milford
5
(Table 1).
Anterior dislocations, which make
up <10% of hip dislocations, can be
divided into three types: obturator,
pubic, and iliac.
4
In obturator dislo-
cations, the femoral head can be seen
overlying the obturator foramen on
an AP pelvic radiograph. The posi-
tion of the femoral head determines
whether the anterior dislocation is
termed pubic or iliac. Here, we
focus on the management of simple
hip dislocations and dislocations as-
sociated with acetabular wall frac-
tures that are deemed insignificant
(<20% posterior wall involvement)
and that do not produce instability
on intraoperative stress fluoroscopy.
6
Diagnosis
Because of the high-energy mechan-
ism of injury, a thorough clinical ex-
amination should be performed in
the emergency department, begin-
ning with airway, breathing, and cir-
culation evaluation and following
standard Advanced Trauma Life
Support protocols. The position of
the involved extremity portends the
diagnosis. Posterior dislocation re-
sults in a flexed, adducted, and inter-
nally rotated leg. Anterior disloca-
tion results in an externally rotated
posture in combination with slight
flexion and abduction. A meticulous,
well-documented physical examina-
tion should be undertaken, highlight-
ing the presence of neurologic or vas-
cular injury. The entire extremity
should be examined to rule out other
bony or soft-tissue injuries.
Plain radiographs are essential in
Table 1
Classication Systems for Hip Dislocation
Classication Type Description
Thompson and Epstein
4
I Dislocation with or without minor fracture
II Posterior fracture-dislocation with a single,
signicant fragment
III Dislocation in which the posterior wall
contains comminuted fragments with or
without a major fragment
IV Dislocation with a large segment of posterior
wall that extends into the acetabular oor
V Dislocation with fracture of the femoral head
Stewart and Milford
5
I Simple dislocation with no fracture or with an
insignicant fracture
II Dislocation in a stable hip that has a signi-
cant single or comminuted element of the
posterior wall
III Dislocation with a grossly unstable hip result-
ing from loss of bony support
IV Dislocation associated with femoral head
fracture
Hip Dislocation: Evaluation and Management
200 Journal of the American Academy of Orthopaedic Surgeons
the workup. An AP pelvic radio-
graph should be obtained when hip
injury is suspected. With posterior
hip dislocation, the femoral head will
appear smaller than that of the con-
tralateral side and will be incongru-
ent with the acetabulum. With such
injury, internal rotation of the femur
is noted because the lesser trochanter
is poorly visualized (Figure 1, A). In
anterior dislocation, the femoral
head appears to be slightly larger
than on the contralateral side, and
the lesser trochanter is in full profile
(Figure 1, B). Visualization of the
femoral head and neck in question is
important because the presence of an
occult fracture of the femoral neck
would mandate a change in treat-
ment plan.
In general, CT is not needed prior
to emergent reduction unless there is
a high level of suspicion for a non-
displaced femoral neck fracture. If it
can be obtained easily and fairly
quickly, the surgeon may consider
obtaining a CT scan before reduction
if a reduction is planned in the surgi-
cal suite and if there is strong suspi-
cion that open reduction with possi-
ble internal fixation may be required
to manage an associated fracture of
the femoral head or acetabulum.
Associated Injuries
Hip dislocations typically present af-
ter high-energy motor vehicle acci-
dents and have a very high likelihood
of associated injuries,
7
either sys-
temic or musculoskeletal. Ipsilateral
knee injuries are quite common.
Schmidt et al
8
reported that 89% of
patients had visible evidence of soft-
tissue injury about the ipsilateral
knee. MRI revealed acute meniscal
tear in 22% of patients, bone bruise
in 33%, effusion in 37%, cruciate
ligament injuries in 25%, collateral
ligament injuries in 21%, and periar-
ticular fracture in 15%.
Sciatic nerve injury is another asso-
ciated injury, occurring in 10% to
15% of hip dislocations.
1,2,5
The per-
oneal division is affected more fre-
quently than the tibial branch. The
peroneal branch is tethered at the
pelvis and at the fibular neck; thus, it
has a lower capability of dissipating
stress. Additionally, the fascicles of
the peroneal division are fewer in
number, larger in size, and protected
by less connective tissue. Partial re-
turn of function of sciatic nerve palsy
can be expected in more than half of
affected patients.
Management
Closed Reduction
Closed reduction should be considered
emergently to reduce the period of avas-
cularity to the hip; however, adequate
radiographic imaging is needed prior to
any reduction maneuver so as to ex-
clude the presence of an associated fem-
oral neck fracture. Osteonecrosis has
been reported in 11% to >34% of hip
dislocations, depending on the severity
of the injury.
1,2,7
Regardless whether suc-
cessful early reduction is achieved, the
patient should be counseled about os-
teonecrosis as a potential complication.
Early reduction may assist in returning
normal blood flow to the hip, thus re-
ducing the duration of ischemia to the
femoral head.
Ideally, the hip should be reduced
in the operating room under general
anesthesia in an attempt to minimize
further damage to the articular carti-
AP pelvis radiographs demonstrating posterior hip dislocation (A) and anterior hip dislocation (B). (Panel B courtesy of
Samir Mehta, MD, Philadelphia, PA.)
Figure 1
David M. Foulk, MD, and Brian H. Mullis, MD
April 2010, Vol 18, No 4 201
lage. Alternatively, some surgeons
prefer to perform reduction in the
emergency department if deep con-
scious sedation and good muscle re-
laxation can be achieved. There are
advantages to reduction attempts in
the emergency department. If the at-
tempt is unsuccessful under adequate
deep sedation, a CT scan can be ob-
tained before reduction is attempted
in the operating room; if the attempt
is successful, the reduction is
achieved sooner after injury. A po-
tential disadvantage to a reduction
attempt in the emergency department
is that adequate sedation or paralysis
may not be achieved, which could
lead to further damage to the articu-
lar cartilage or to nondisplaced asso-
ciated fractures.
Closed reduction is usually accom-
plished via traction in line with the
deformity. Many reduction tech-
niques have been described for poste-
rior dislocation. The Allis maneuver
was first described in 1896.
2
The pa-
tient is positioned supine on the op-
erating table, and traction is applied
in line with the deformity while an
assistant applies counterpressure to
the pelvis. The hip is slowly flexed
and is internally and externally ro-
tated until reduction is achieved (Fig-
ure 2). The Bigelow reduction tech-
nique, described in 1870, also
provides traction in line with the de-
formity, coupled with an adduction
moment and internal rotation.
7
An-
other reduction maneuver is the East
Baltimore Lift, in which three per-
sons produce a controlled traction
maneuver without standing on the
patients gurney
9
(Figure 3). In each
of these techniques, an audible and a
palpable clunk may be noticed, signi-
fying reduction. A repeat AP pelvis
radiograph should be obtained to
confirm the reduction. Although
controversial, a CT scan is usually
performed with 2-mm cuts through
the acetabulum to evaluate for a con-
centric reduction and for the pres-
ence of intra-articular fragments or
injury to the femoral head and/or ac-
etabulum.
Once a successful reduction is ob-
tained, hip stability can be assessed
clinically by gently moving the hip
through its range of motion. If there
is no associated fracture on postre-
duction films, the leg should be ex-
tended and externally rotated, and a
knee immobilizer should be placed to
prevent inadvertent flexion at the
hip. Evidence suggests that CT may
allow the physician to augment the
clinical examination with radio-
graphic criteria for stability in the
patient with an associated posterior
wall acetabulum fracture. Keith
et al
10
used a cadaver model to deter-
mine the size of posterior wall frag-
ment that resulted in an unstable hip.
They concluded that when <20% of
the posterior wall was fractured, the
hip was stable. On the contrary, the
hip was unstable when >40% of the
wall was disrupted. Moed et al
11
re-
cently offered an alternative for mea-
suring the percentage of posterior
The Allis maneuver for reduction of posterior hip dislocation. A, Anteriorly directed traction is applied to the affected
limb. B, A combination of counterpressure and gentle internal and external rotation is applied to assist in an atraumatic
reduction. C, Limb adduction and inline traction may further aid a successful reduction. (Reproduced with permission
from Levin P: Hip dislocations, in Browner BD, Jupiter JB, Levine AM, Trafton PG, eds: Skeletal Trauma, ed 2.
Philadelphia, PA, WB Saunders, 1998, p 1732.)
Figure 2
Hip Dislocation: Evaluation and Management
202 Journal of the American Academy of Orthopaedic Surgeons
wall involvement. With this method,
fractures involving <20% of the wall
are considered to be stable, but the
authors stressed the need for intraop-
erative stress testing.
In the presence of an associated wall
fracture, stability should be fluoroscop-
ically evaluated in the surgical suite by
placing the hip in 90 of flexion, 20 of
adduction, and slight internal rotation,
and then applying a posteriorly directed
force. For other acetabular fractures,
force should be applied in the direction
of displacement for the given fracture
pattern. Intraoperative radiographic
analysis is performed with iliac/
obturator oblique views and an AP pel-
vis view. If there is no evidence of sub-
luxation or dislocation, then the hip is
determined to be stable. Treatment may
include continued nonsurgical manage-
ment with follow-up radiographs or hip
arthroscopy to evaluate for chondral in-
jury and loose bodies. If subluxation oc-
curs, the hip is considered to be unsta-
ble, and surgical fixation of the fracture
should be performed to prevent the de-
velopment of premature arthritis.
Tornetta
6
described the aforemen-
tioned dynamic stress view to deter-
mine whether an acetabular fracture
mandated surgical fixation. In fact, 3
of 41 fractures that met previous ra-
diographic criteria for nonsurgical
management were determined to be
unstable on dynamic stress views and
required fixation. This finding rein-
forces the need for stability testing.
Any incongruity on radiographs or
CT scan could signify the presence of
bony or chondral fragments or soft-
tissue interposition. Frick and Sims
12
concluded that CT was not beneficial
after closed reduction in a simple dis-
location because no loose bodies
were found on 3-mm CT cuts; there-
fore, the findings did not alter their
treatment plan. However, a negative
CT scan does not rule out the pres-
ence of intra-articular pathology.
Mullis and Dahners
13
and Yamamoto
et al
14
have shown that there is a
high prevalence of intra-articular
loose bodies despite negative plain
radiographs and thin-cut CT scan.
Thus, several patients may have de-
bris within the joint that goes unrec-
ognized and untreated. Direct ar-
throscopic visualization is the best
means of evaluating for such debris.
MRI studies may be useful to diag-
nose the presence of chondral injury
or soft-tissue interposition; however,
MRI is rarely used in clinical practice
and likely is not as sensitive as CT in
evaluating for retained bony frag-
ments.
A nonconcentric reduction is a sur-
gical emergency because of the pres-
sure on the articular cartilage, even
in the presence of restored blood
supply to the femoral head. Whether
skeletal traction emergently placed is
adequate to relieve this pressure, as
opposed to emergent open removal
The East Baltimore Lift reduction maneuver for correction of posterior hip dislocation. A, The patients knee and hip
are placed in 90 of exion. The surgeon rests one arm under the calf of the patient, with the surgeons hand
positioned on the shoulder of the assistant across the table. The other hand is used to control rotation. B, The
assistant positions his or her arm in a similar fashion as that of the surgeon. A second assistant is useful for stabilizing
the pelvis. Anteriorly directed traction is applied by the surgeon and the assistant. (Reproduced with permission from
Schafer SJ, Anglen JO: The East Baltimore Lift: A simple and effective method for reduction of posterior hip
dislocations. J Orthop Trauma 1999;13:56-57.)
Figure 3
David M. Foulk, MD, and Brian H. Mullis, MD
April 2010, Vol 18, No 4 203
of loose bodies, is controversial.
There are no clinical studies to guide
this decision, but the size and loca-
tion of the fragment and amount of
displacement may be of value.
A dislocation should be considered
irreducible when a senior member of
the orthopaedic team fails to obtain
reduction despite the administration
of an anesthetic that achieves deep
sedation and good muscle relax-
ation. Irreducible dislocations may
be the result of bony or soft-tissue
interposition, and several structures
have the potential to impede success-
ful reduction, including the labrum,
capsule, iliopsoas, rectus femoris,
piriformis, gluteus maximus, liga-
mentum teres, or bone fragments
from the acetabular wall or femoral
head. In the setting of an irreducible
dislocation, emergent open reduction
should be considered to restore
blood flow to the femoral head. A
CT scan might be considered before
proceeding to the operating room if
the scan can be obtained without un-
due delay. The CT scan may help in
identifying the offending structure,
such as incarcerated bone fragments
from a femoral head or a posterior
wall fracture, or soft-tissue interposi-
tion.
Open Reduction
Historically, it was felt that open re-
duction of a hip dislocation should
proceed from the direction of the dis-
location. Epstein
15
felt strongly that
the hip should be approached in the
direction of the dislocation, stating
that the opposite-side approach is
contraindicated for fear of complete
embarrassment of the blood supply
to the hip. In contrast, Swiontkowski
et al
16
reported no cases of osteone-
crosis of the femoral head or differ-
ence in functional outcomes in 24
femoral head fracture-dislocations
treated by either an anterior or a
posterior approach. One relative in-
dication for an anterior approach
may be the presence of a femoral
head or neck fracture. Approaching
the hip from a posterior direction
may be more familiar to most sur-
geons and may provide easy access
to fractures of the posterior wall. Re-
gardless of the approach chosen, the
joint should be cleared of all debris
and thoroughly irrigated before re-
duction. The cartilage of the femoral
head and acetabulum should be eval-
uated, and every attempt should be
made to anatomically repair avulsed
soft tissue and labral tears. Follow-
ing reduction, the hip should be as-
sessed for stability, especially in the
presence of a posterior wall fracture.
Traditionally, fragments of bone
within the fovea centralis have not
mandated removal. In the absence of
other surgical needs (eg, large poste-
rior wall fragment, femoral head
fracture), there was no clear indica-
tion for surgical intervention. Typi-
cally, this fragment represented a
chondral or osteochondral fragment
pulled off by the ligamentum teres
and was not thought to be prone to
migration into the articular surface
of the joint. This remains a topic of
controversy.
17
However, fragments
that are incarcerated between the ar-
ticular surfaces of the femoral head
and acetabulum mandate removal to
reduce the probability of chondral
injury and subsequent OA.
Open arthrotomy is the standard
method for removal of incarcerated
fragments. If the fragment originates
from the posterior wall, is large
enough for hardware fixation, and
causes instability on an intraopera-
tive stress test, then it should be
fixed with open reduction and inter-
nal fixation. If the size of the frag-
ment does not cause instability and if
the fragment is too small for surgical
fixation, then it can be confidently
excised. Surgical dislocation as de-
scribed by Siebenrock et al
18
can be
performed if needed, although it may
incur an additional risk to the femo-
ral head, which would have already
suffered a period of avascularity.
However, Ntzli et al
19
showed
prompt return to normal femoral
head blood supply after surgical dis-
location with subsequent reduction.
Arthroscopy
Hip arthroscopy technique has ad-
vanced greatly in the past decade.
Byrd and Jones
20
performed hip ar-
throscopy for persistent hip pain in
15 traumatic injuries, of which 6
were dislocations. Thirteen of the 15
hips had associated findings at the
time of arthroscopy, including labral
tears, chondral damage, and loose
bodies. Neglected labral pathology
may be sufficient to incur more dam-
age. Specifically, an inverted labrum
can lead to premature OA.
21
Degen-
erative changes may also be perpetu-
ated, such as with third-body wear
caused by retention of loose bodies.
Evans et al
22
provided basic science
evidence in rabbits that cartilage de-
bris causes effusion, synovitis, and
degradation as well as histologic
changes to the intact articular carti-
lage. Epstein
2
reported absence of
loose bodies in only 9% of hips man-
aged with open procedures for
fracture/dislocation. McCarthy and
Busconi
23
determined that 76% of
loose bodies were not diagnosed on
conventional radiographs. Mullis
and Dahners
13
performed arthros-
copy on 39 hips after posterior dislo-
cation or fracture/dislocation and
found loose bodies in 92% (Figure
4). There were five simple disloca-
tions, all of which were found to
have loose bodies at the time of ar-
throscopy. The authors also deter-
mined that the presence of a concen-
tric reduction on plain radiographs
and no evidence of loose bodies on
CT did not correspond with a clean
joint. In fact, they found loose bodies
in seven of nine cases (78%) that
Hip Dislocation: Evaluation and Management
204 Journal of the American Academy of Orthopaedic Surgeons
were predicted to be free of intra-
articular pathology by both radio-
graphs and thin-cut (2- to 3-mm) CT
scan. A typical axial CT scan that
might be seen with a hip dislocation
with a subtle nonconcentric reduc-
tion is shown in Figure 5.
Yamamoto et al
14
reported similar
findings in 11 cases of hip disloca-
tion. In eight cases, they found loose
bodies that had not been visualized
on preoperative radiographs or CT
scan. Philippon et al
24
recently per-
formed a retrospective review of 14
professional athletes who sustained
simple hip dislocation during active
competition. All 14 patients had ar-
throscopic evidence of labral tears
and chondral injuries, and 11 had
loose osteochondral lesions. None of
these retrospective studies has deter-
mined whether loose body removal
improves patient outcome with de-
creasing incidence of resultant OA;
however, animal evidence suggests
that the presence of chondral debris
may lead to premature arthritis.
22
Although there is basic science evi-
dence to suggest that hip arthroscopy
may be beneficial for patients be-
cause it enables detection of loose
bodies, no clinical evidence supports
this. If arthroscopy is being consid-
ered to evacuate loose bodies from
the joint, the senior author prefers to
proceed with arthroscopy within 72
hours of injury to prevent further
damage to the articular cartilage. In-
terim bed rest or skeletal traction
may be indicated if a small loose
body resides within the weight-
bearing portion of the joint. The
congruency of the reduction and the
size of the intra-articular fragment
may influence the timing of surgical
intervention (Figure 6).
Arthroscopy is a safe alternative to ar-
throtomy for addressing intra-articular
pathology,
25
and it has several advan-
tages over arthrotomy, including less
disruption of the capsuloligamentous
structures of the hip, less blood loss,
reduced potential for neurovascular
injury, and decreased recovery time.
Relative indications for arthroscopy
are listed in Table 2.
Complications of hip arthroscopy in-
clude traction neurapraxia (sciatic and
femoral), direct injury of nearby neu-
rovascular structures (eg, lateral femoral
cutaneous nerve), portal hematoma/
bleeding, osteonecrosis, and iatrogenic
articular cartilage injuries. There is one
case report of extravasation of fluid
with intra-abdominal compartment
syndrome and subsequent cardiopul-
monary arrest in a patient with a both-
column acetabulum fracture treated
with hip arthroscopy.
26
The reported
overall complication rate is 1% to
6%;
27,28
however, meticulous atten-
tion to surgical technique and de-
creased surgical time (ie, time in trac-
tion) can aid in minimizing these
complications.
Rehabilitation
Rehabilitation after reduction and/or
surgical intervention is controversial.
Many suggest a short period of skel-
etal traction until pain is improved.
Early gentle range of motion and pa-
tient mobilization should be insti-
tuted. Weight-bearing status is also a
source of debate. Some advocate
nonweight bearing for days to
months, with the intent of reducing
the likelihood of femoral head col-
lapse in patients who develop os-
Arthroscopic view of a typical loose
body seen following hip dislocation.
(Reproduced with permission from
Mullis BH, Dahners LE: Hip
arthroscopy to remove loose
bodies after traumatic hip
dislocation. J Orthop Trauma
2006;20:22-26.)
Figure 4
Typical axial CT scan of a simple hip dislocation with a subtle nonconcentric
reduction in the left hip. No loose body is seen, but its presence is indicated
by the nonconcentric reduction.
Figure 5
David M. Foulk, MD, and Brian H. Mullis, MD
April 2010, Vol 18, No 4 205
Treatment algorithm for hip dislocation. ORIF = open reduction and internal xation
Figure 6
Hip Dislocation: Evaluation and Management
206 Journal of the American Academy of Orthopaedic Surgeons
teonecrosis. Several authors have re-
ported that prolonged nonweight
bearing has no significant impact on
the incidence of osteonecrosis.
4,5
Sa-
hin et al
7
retrospectively reviewed 62
cases of hip dislocation, 50 of which
were managed with closed reduction.
Neither the type of postreduction
treatment (traction or bed rest) nor
the time to full weight bearing influ-
enced outcomes significantly. Given
the lack of evidence to support a
routine postdislocation protocol, re-
turn to weight bearing should be left
to the surgeons discretion.
Outcomes
Good to excellent long-term out-
comes are reported in half to nearly
all patients with simple hip disloca-
tions managed with rapid reduc-
tion.
29
Dreinhfer
3
reported fair to
poor objective results in 16 of 30
posterior dislocations and in 3 of 12
anterior dislocations (53% versus
25%, respectively). Parameters such
as time to reduction, postreduction
management and rehabilitation, as-
sociated injuries, and duration of
follow-up vary by study, which
makes it difficult to compare results
(Table 3). Associated injuries may
play a role in the patients outcome.
Dreinhfer et al
3
found that five of
seven patients with multiple injuries
had fair results, and six of seven
Table 3
Outcomes in Stewart-Milford Type I and Type II Dislocations*
Study Year
Good or Excellent
Results (%)
Osteonecrosis
(%)
Osteoarthritis
(%)
Sciatic Nerve
Injury (%)
Armstrong
32
1948 76 2 13 7
Thompson and
Epstein
4
1951 67 10 7 13
Paus
33
1951 71 2 20 NA
Stewart and
Milford
5
1954 57 19 48 13
Morton
34
1959 76 NA NA NA
Brav
30
1962 77 22 26 7
Hunter
35
1969 95 4 NA 10
Reigstad
36
1980 83 3 3 7
Upadhyay et al
29
1983 75 NA 24 NA
Hougaard and
Thomsen
31
1987 87 5 31 6
Yang et al
37
1991
Anterior 83 NA NA NA
Posterior 87 NA 19 4
Schlickewei et al
38
1993 94 0 10 NA
Dreinhfer et al
3
1994
Anterior 75 0 11 NA
Posterior 48 19 26 5
Sahin et al
7
2003 71 10 16 NA
* Data extrapolated from original text and tables
NA = specic data not available
Adapted from Tornetta P III, Mostafavi HR: Hip dislocation: Current treatment regimens. J Am Acad Orthop Surg 1997;5:27-36.
Table 2
Relative Indications for Hip Arthroscopy
Alternative to open arthrotomy for a simple dislocation with a nonconcentric reduction
Alternative to open arthrotomy for a fracture-dislocation with a nonconcentric reduction
associated with a stable acetabulum fracture not otherwise requiring open reduction
and internal xation*
Relative indication for a simple dislocation or a fracture-dislocation with a concentric
reduction and without radiographic abnormality to evaluate for small loose bodies or
a labral tear (weak clinical evidence to support if this changes patient outcome).
* If the fragment is seen on radiographic studies and originates from the posterior wall,
uoroscopic stress views are recommended in the operating room. If the hip is unstable,
open reduction and internal xation is required. If the hip is stable, consider arthroscopic
removal of small loose bodies.
David M. Foulk, MD, and Brian H. Mullis, MD
April 2010, Vol 18, No 4 207
with isolated hip injuries had good
results. Other factors that influence
outcome include osteonecrosis and
OA.
Complications
Time to reduction of the femoral
head is one of the most important
factors in deciding outcome. A
timely reduction decreases the time
of ischemia, theoretically improving
the chances of survival of the femo-
ral head.
39
The critical time to reduc-
tion is controversial.
Brav
30
reviewed 262 patients, of
whom 22% underwent reduction
within 12 hours and subsequently de-
veloped osteonecrosis. In comparison,
52% of patients who had a delay in
reduction >12 hours developed osteone-
crosis. Hougaard and Thomsen
31
ret-
rospectively evaluated 100 hip dis-
locations after a minimum 5-year
follow-up and found that 4% of pa-
tients reduced within 6 hours devel-
oped osteonecrosis and 58% of hips
that were reduced later than 6 hours
developed osteonecrosis. Dreinhfer
et al
3
retrospectively evaluated 50
patients who underwent reduction
within 6 hours for simple hip dislo-
cation. They found no difference be-
tween reduction performed within
60 minutes and reduction performed
between 1 and 6 hours, with os-
teonecrosis occurring in 12% of all
hips managed within 6 hours.
The ultimate goal of management is
to restore blood flow to the femoral
head. The risk of osteonecrosis is sub-
stantial and may occur in up to one
third of dislocations, depending on the
severity of injury. Thus, the initial dam-
age incurred at the time of injury is an-
other important factor in determining
treatment outcome. Higher-energy in-
juries with more damage to the sur-
rounding blood supply tend to result in
a higher incidence of osteonecrosis.
7
Osteonecrosis appears within 2 years
of injury in nearly all cases.
30
How-
ever, Cash and Nolan
39
proposed
that longer-term follow-up may be
needed. They reported a case of os-
teonecrosis 8 years after simple dislo-
cation in a hip without previous evi-
dence of radiographic changes.
Posttraumatic coxarthrosis is the
most common complication after hip
dislocation. It is thought to arise
from catabolic effects induced by the
traumatic impact sustained in the
dislocation because small amounts of
strain may have deleterious effects
on the articular cartilage. Upadhyay
et al
29
reported a 16% incidence of
posttraumatic coxarthrosis and an
8% incidence of coxarthrosis sec-
ondary to osteonecrosis. The natural
history of symptomatic osteonecrosis
has been documented to lead to col-
lapse and subsequent OA. The rate
of both posttraumatic coxarthrosis
and osteonecrosis is much higher for
posterior fracture-dislocation, with
an incidence of up to 70%.
5
Sciatic nerve palsy occurs in approx-
imately 10% to 15% of persons with
hip dislocation.
5
The peroneal divi-
sion is most commonly affected,
likely because of the anatomy and
composition of the peroneal division,
the length of which is somewhat re-
stricted, and in which bundles are
larger and less cushioned by connec-
tive tissue. Partial nerve recovery can
be expected in more than half of pa-
tients; however, the severity of the in-
jury may play a role in functional re-
turn. Rehabilitation is important
because skin complications and con-
tractures can arise. The mainstays
are protective skin barriers and dor-
siflexion splints, with the latter used
to maintain a plantigrade foot. Some
authors propose exploration when
nerve function does not return
within 1 to 3 weeks.
5
However, oth-
ers suggest a much longer period of
observation. Tendon transfers can be
performed in recalcitrant cases.
Summary
Simple hip dislocation is a severe injury
that requires prompt attention. A
whole-body evaluation should be done
because of the high degree of associa-
tion with other injuries. Emergent re-
duction should be performed and sub-
sequently confirmed by radiography
and CT scan. Multiple modalities ex-
ist for treatment of this patient popu-
lation. Hip arthroscopy has shown sub-
stantial improvement over the past 10
years and warrants consideration in the
treatment algorithmbecause a high in-
cidence of loose bodies and other intra-
articular pathology can be found and
addressedarthroscopically. Arthroscopy
is an especially attractive option for sim-
ple hip dislocation with a nonconcen-
tric reduction. The complication rate
following arthroscopy is lowwhen per-
formed by an experienced surgeon.
Outcomes range frompoor to excellent,
with no prospective evidence to guide
us. Continued research is needed to de-
termine whether long-term results are
better with arthroscopy than with tra-
ditional methods.
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April 2010, Vol 18, No 4 209