Neglected Hip Fracture -Dislocation in 21 Years old Young.
Neglected Hip Fracture-Dislocation in 21 Years-Old Young
Male
A Case Series
dr. Melissa Pingkan Johana Tungka
dr. Cok Gde Oka Dharmayuda, SpOT(K)
PROGRAM PENDIDIKAN DOKTER SPESIALIS I
BAGIAN/SMF ORTHOPAEDI DAN TRAUMATOLOGI
UNIVERSITAS UDAYANA
2014
Neglected Hip Fracture-Dislocation in 21 Years-Old Young Male
A Case Series
Melissa Pingkan Johana Tungka*Cok Gde Oka Dharmayuda**
*Resident of Orthopedic and Trauma, Faculty of Medicine Udayana University, Sanglah
Hospital
**Staff of Orthopedic and Trauma, Faculty of Medicine Udayana University, Sanglah
Hospital
ABSTRACT
Introduction
Neglected fracture-dislocation of the hip is common in developing countries due to various
factors. However the incidence percentage has not been determined yet. This condition causes
several complications of the bone and soft tissue and has poor functional outcome. Different
options including arthrodesis, Girdlestone arthroplasty and total hip replacement (THR) are used
for its treatment. Till date, arthrodesis in youngsters and resection arthroplasty in the elders has
been the treatment of choice. THR, however, is being done by a few, but the experience has not
been published. Proper treatment was mandatory to prevent complications.
Methods
We are reporting two cases; of 21 years old man with neglected posterior fracture dislocation of
the hip with acetabulum fracture and subtrochanteric fracture of femur. The leg discrepancy was
8 cm and there’s already contracture. The second patient was 21 years old male with neglected
dislocation of right hip, with 6 cm leg discrepancy, and there’s atrophy of quadriceps muscle.
Result
For the first patient, we performed soft tissue release, hip arthrodesis, and plating of the femur.
The patient planned for THR in the next surgery. Recently, patient walked with 2 crutches. For
the second patient, we performed open reduction and arthrodesis.
Conclusion
Different options are present for treating old unreduced acetabulum fracture-dislocations.
Traction and soft tissue release is essential in management of neglected hip dislocation that
present for more than 1 year and heavy skeletal traction should be considered. Total hip
replacement with reconstruction of the acetabulum has good functional results.
Keywords: Neglected hip dislocation, Soft tissue release, Hip arthrodesis, Plating.
REFERENCES
1. Brumback RJ, Kenzora JE, Levitt LE, Burgess AR, Poka A. Fractures of the femoral
head. In: Proceedings of the Hip Society. St. Louis: CV Mosby, 1987:181- 206.
2. Butler JE. Pipkin type-II fractures of the femoral head. J Bone Joint Surg Am
1981;63:1292-1296.
3. Chakraborti SS, Miller IM. Dislocation of the hip associated with fracture of the femoral
head. Injury 1975;7:134-142.
4. Epstein HC, Wiss DA, Cozen L. Posterior fracture dislocation of the hip with fractures of
the femoral head. Clin Orthop 1985;201:9-17.
5. Marchetti ME, Steinberg GG, Coumas JM. Intermedi- ate-term experience of Pipkin
fracture-dislocations of the hip. J Orthop Trauma 1995;10455-461.
6. Yue JJ, Wilber JH, Lipuma JP, Posterior hip dislocations: a cadaveric angiographic study.
J Orthop Trauma 1996;10:447-454.
7. Brav EA. Traumatic dislocation of the hip: army experience and results over twelve-year
period. J Bone Joint Surg Am 1962;44:1115-1134.
8. Garrett JC, Epstein HC, Harris WH, Harvey JP Jr, Nickel VL. Treatment of unreduced
traumatic posterior dislocations of the hip. J Bone Joint Surg Am 1979; 61: 2-6.
9. Zippel H, Palme E. Neglected hip dislocation fractures. Zentralbl Chir 1981; 106: 674-82.
10. Malkin C, Tauber C. Total hip arthroplasty and acetabular bone grafting for unreduced
fracture-dislocation of the hip. Clin Orthop Relat Res 1985; 201: 57-9
11. Ilyas I, Rabbani SA. Total hip arthroplasty in chronic unreduced hip fracture-dislocation.
J Arthroplasty 2009; 24: 903-8.
12. Hansen E, Shearer D, Ries MD. Does a cemented cage improve revision THA for severe
acetabular defects? Clin Orthop Relat Res 2011; 469: 494-502.
13. Stuck WG, Vaughan WH: Prevention of disability after traumatic dislocation of the hip.
South Surg 1949;15:659-675.
14. Brav EA: Traumatic dislocation of the hip: Army experience and results over a twelveyear period. J Bone Joint Surg Am 1962;44:1115-1134.
15. Stewart MJ, Milford LW: Fracture-dislocation of the hip: An end-result study. J Bone
Joint Surg Am 1954;36:315-342.
16. Thompson VP, Epstein HC: Traumatic dislocation of the hip: A survey of two hundred
and four cases covering a period of twenty-one years. J Bone Joint Surg Am
1951;33:746-778.
17. Paus B: Traumatic dislocations of the hip Late results in 76 cases. Acta Orthop Scand
1951;21:99-112.
18. Dreinhofer KE, Schwarzkopf SR, Haas NP, et al: Isolated traumatic dislocation of the
hip: Long-term results in 50 patients. J Bone Joint Surg Br 1994;76:6-12.
19. Urist MR: Injuries to the hip joint: Traumatic dislocations incurred chiefly in jeep
accidents in World War II. Am J Surg 1947;74:586-597.
20. Leenen LPH, van der Werken C: Traumatic posterior luxation of the hip. Neth J Surg
1990;42:136-139.
21. Jacob JR, Rao JP, Ciccarelli C: Traumatic dislocation and fracture dislocation of the hip:
A long-term follow-up study. Clin Orthop 1987 214:249-263.
22. Schlickewei W, Elsässer B, Mullaji AB et al: Hip dislocation without fracture: Traction
or mobilization after reduction? Injury 1993;24:27-31.
23. Tornetta P, Mostafavi HR. Hip Dislocation: Current Treatment Regiement. J Am Acad
Orthop Surg 1997;5:27-36
24. Miyamoto RG, Kaplan KM, Levine BR, Egol KA, Zuckerman JD. Surgical Management
of Hip Fractures: An Evidence-based Review of the Literature. I: Femoral Neck
Fractures. J Am Acad Orthop Surg 2008;16:596- 607
25. Kuzyk PRT, Dhotar HS, Sternheim A, Gross AE, Oleg S, Backstein D. Two-stage
Revision Arthroplasty for Management of Chronic Periprosthetic Hip and Knee
Infection: Techniques, Controversies, and Outcomes. J Am Acad Orthop Surg 2014;22:
153-164
26. Tornetta P. Displaced Acetabular Fractures: Indications for Operative and Nonoperative
Management. J Am Acad Orthop Surg 2001;9:18-28
27. Pike J, Davidson D, Garbuz D, Duncan CP, O’Brien PJ, Masri BA.Principles of
Treatment for Periprosthetic Femoral Shaft Fractures Around Well-fixed Total Hip
Arthroplasty. J Am Acad Orthop Surg 2009;17: 677-688
28. Herrra-Soto JA, Price CT. Traumatic Hip Dislocations in Children and Adolescents:
Pitfalls and Complications. J Am Acad Orthop Surg 2009;17: 15-21
29. Schoenecker PL, Clohisy JC, Millis MB, Wenger DR.Surgical Management of the
Problematic Hip in Adolescent and Young Adult Patients. J Am Acad Orthop Surg
2011;19: 275-286
30. Rafael RJ, Trousdale RT, Ganz R, Leunig M. Hip Disease in the Young, Active Patient:
Evaluation and Nonarthroplasty Surgical Options. J Am Acad Orthop Surg 2008;16:689703
31. Boykin RE, Anz AW, Bushnell BD, Kocher MS, Stubbs AJ. Hip Instability. J Am Acad
Orthop Surg 2011;19: 340-349
32. Beaule PE, Matta JM, Mast JW. Hip Arthrodesis: Current Indications and Techniques. J
Am Acad Orthop Surg 2002;10:249-258
Neglected Hip Fracture-Dislocation in 21 Years-Old Young Male
A Case Series
INTRODUCTION
Neglected traumatic posterior fracture-dislocation of the hip in young people who present sith
delayed treatment beyond 3 month has a poor prognosis and outcome. It has several
complications which involved soft tissue (i.e: contractures of muscles, ligaments, and joint
capsules) and hard tissue (i.e delayed/non-union, malunion, osteoporosis, AVN of femoral head,
and chondrolysis). We are reporting a case of 21 years old man with neglected posterior fracture
dislocation of the hip with acetabulum fracture and subtrochanteric fracture of femur. In clinical
examination, the leg discrepancy was 8 cm and there’s already contracture.
CASE REPORT
CASE 1
A healthy 21 year-old man reported painful motion of his right hip and femur for 3.5 years. He
had been involved in motor vehicle accident 3.5 years earlier and went to local district hospital in
Sumba and advised for amputation but the patient refused and then he attended local bone setter.
He only consumed traditional medicine. Three years later he came to outpatient clinic and
planned for staged surgery.
A physical examination of the right hip showed that there’s external rotation, shortening with 8
centimeters leg discrepancy, atrophy of quadricep muscle and also false movement of right
proximal femur
Roentgenographic images and computed tomography scans revealed fracture of proximal third of
femur and posterior dislocation of right hip (Figs. 1, 2)
A
B
C
D
Fig 1. A-D.A. clinical picture showing the leg discrepancy, the left lower limb was 8 cm shorter
than the left. B-C.Initial radiograph of pelvis taken 3.5 after the accident. There’s posterior
dislocation of right hip with damage of the femoral head and acetabulum D. radiograph of right
femur taken 3.5 after skeletal traction. There’s athropic non union of proximal shaft of the femur.
A
B
C
Fig 2 A-C. 3D reconstruction of computed tomography, showing damage of right acetabulum
with its rim, and damage of femoral head and non union of proximal femoral shaft.
Patient was admitted for 8 kgs skeletal traction for 23 days. After 23 days, the leg discrepancy
was 6cm. Patient underwent soft tissue release surgery of right hip, hip arthrodesis, soft tissue
release of right femur and plating of the femur. The surgery performed with lateral approach in
supine position. The fragment of the proximal femoral shaft and acetabulum were exposed and
there’s minimal callus. The acetabulum and femoral head was damaged and filled with fibrous
tissue. There’s also chondrolysis of the hip joint. Refreshment of bone fragments was performed,
the fragment was reduced and fixed with broad LCP with bone graft (fig 3). The hip joint was
fixed with 2 parallel Kirschner wires. The roentgenograph after surgery was taken (fig 4)
A
C
B
D
Fig 3. A. intraoperative picture showing the damage of acetabulum and femoral head which is
filled with fibrous tissue and B. showing the head of femur after soft tissue release and proximal
shaft of femur. C. Picture showing the femoral head and acetabulum after reduction and D.
Plating of the femoral shaft after the fragment refreshed.
A
B
Fig 4A-B. Postoperative roentgenograph after the second surgery. The hip joint was fixed with 2
parallel Kirscner wires (A) and the femur was fixed with broad LCP and bone graft (B).
On one month follow up after surgery, the K-wires were removed, patient complained minor hip
pain and Non weight bearing with 2 crutches.
CASE 2
A healthy 21 year-old man reported painful motion of his right hip and femur for 2 years. He had
been involved in motor vehicle accident 2 years earlier and went to local bone setter.. Three
years later he came to outpatient clinic and planned for staged surgery.
A physical examination of the right hip showed that there’s shortening with 6 centimeters leg
discrepancy, atrophy of quadriceps muscle.
Rontgenographic images and computed tomography scans revealed posterior dislocation of right
hip (Figs. 5A-D)
Fig 5A. Clinical picture showing leg discrepancy and skeletal traction
Fig 5B. Initial X-Ray of the hip before skeletal traction
Fig 5C. X-ray after 12 kgs skeletal traction
Patient was admitted for 12 kgs skeletal traction. After traction the leg discrepancy was 2 cm.
Patient underwent soft tissue release surgery of right hip and hip arthrodesis. The surgery
performed with lateral approach in supine position. The acetabulum and femoral head was
damaged and filled with fibrous tissue.
6A. clinical picture showing post-operative after arthrodesis of hip.
6B. Pelvic AP view of the hip, showing pin placement in the hip joint.
DISCUSSION
Dislocation of the hip and ipsilateral fracture of femur is associated with a poor outcome.1-5This
may be a consequence of the greater energy transmission through the hip.which has implication
for the degree of chondral damage suffered. This chondral damage may be responsible for
subsequent rapid chondrolysis and early osteoarthritis.
The distortion of local anatomy, especially the proximity of sciatic nerve, caused by the
persistent posterior dislocation of the femoral head has been well described by Yue et al. 6This
deformation contributes to the difficulty of intraoperative repair. The extent of operative
dissection required to facilitate open hip reduction may also have detrimental effect on the blood
supply to the femoral head and may thus contribute to the high incidence of AVN 7
Unreduced fracture-dislocation of the hip for more than 3 months is considered an old neglected
dislocation. Conservative treatment becomes impossible to achieve stable concentric reduction 8
due to unreduced wall fracture leading to instability and fibrous tissue filling the spaces and
covering the fracture. The operative treatment remains the only chance to reduce the hip or
reconstruct with arthroplasty. Various investigators use different methods for operative treatment
of old unreduced fracture-dislocations including8,32:
Girdlestone procedure: The procedure exposes the head section of the femur bone and then the
head is removed Rarely both sides are done in one operation,most times one side is done and
allowed to heal before the other side is done. Unlike most other hip surgeries, the head of the
femur is not replaced, but is allowed to heal and develop its own fibrous scar tissue so that the
joint is no longer bone−to-bone, a pseudoarthrosis. The neck of the femur is usually removed at
the same time as the head. This prevents the post operative complication of bone rubbing on
bone and continued pain.
Arthrodesis.
Cobra Head Plate Technique
The technique involves stripping the abductor muscles from the iliac crest to accommodate
the cobra head of the plate together with a pelvic oste- otomy to enlarge the area of contact
between femur and pelvis. Fusion rates from 94% to 100% have been reported.
Anterior Plating Technique
The original motivation for the anterior approach was to create a technique that provides
fixation to both the pelvis and femur while sparing the hip abductor muscles. In addition, with
the patient supineand the pelvis level during the surgery, positioning of the hip is facilitated.
With the screws in- serted in an anteroposterior direction, excellent purchase is achieved in
this area of thick bone, making this technique advantageous when there is loss of acetabular
or proximal femoral bone stock. The insertion of a lag screw from the trochanteric area
through the supra-acetabular bone into the center of the femoral head provides additional
compression because of a lateral tension band effect. As with other internal fixation
techniques, no external fixation (casting) is required unless the patient is expected to be
noncompliant. The anterior plating technique can also be effective in the presence of loss of
bone stock
The patient is placed in the supine position on a standard fracture table or, optimally, on a
Judet table. On a Judet table, the hip is placed in the desired position before preparing the
patient. An intraoperative radiograph verifies the range of abduction-adduction. The modified
Smith-Petersen approach involves elevating the abdominal muscles from the iliac crest
through their fascial attachment without violating the abductor musculature. The distal
extension is within the tensor fascia muscular sheet, with detach- ment of both the sartorius
and rectus femoris muscles. To expose the femur, the vastus lateralis is elevated from a lateral
to medial direction to avoid denervation. With the hip joint exposed and denuded of cartilage, the lag screw is inserted first, followed by the 12- to 14-hole low-contact broad dynamic
compression plate. Viewed anteriorly, the plate has a 10° concave bend to match the internal
iliac fossa, a 50° convex bend crossing the anterior acetabular rim, and a 35° concavity in the
intertrochanteric area. Usually the plate is fixed to the pelvis first, fol- lowed by a tensioning
device applied to the distal end of the plate. The plate may have to be undercon- toured to
avoid increasing hip flexion as the plate is being tensioned. Iliaccrest bone graft from the
inner table may be used if necessary. Postoperatively, patients are usually restricted to 30
pounds of weight-bearing for 8 to 10 weeks. After 12 weeks, if radiographic consolidation is
present, full weight-bearing is allowed.
Fig 5. Anterior Plating Technique for arthrodesis
Double Plating technique
The first stage is the preparation of the head and the acetabulum for fusion, usually with local
fixation and an intertrochanteric osteotomy to remove the lever arm acting on the desired site
of fusion. In the second stage, 6 to 8 weeks later, the intertrochanteric area is stabilized. By
removing the lever arm of the femur, the fusion site may heal with greater predictability. With
the patient in the lateral position, a modified lateral approach is used; the gluteus medius and
minimus muscles are elevated with a part of the greater trochanter. The exposure is continued
anteriorly in the plane between the sartorius and tensor, with the hip flexed and exter- nally
rotated. The lateral plate (broad 4.5 mm) is first applied and contoured over the trochanteric
bed and placed anterior to the greater sciatic notch and along the lateral aspect of the femur.
The plate is then secured proximally with a tension device applied distally. After removal of
the anterior-inferior iliac spine, the anterior plate (narrow 4.5 mm) is applied along the
femoral shaft, and a second tensioning device is applied with the plate fixed proximally. Both
tensioning devices are then tightened; the plates tend to lift off the bone but are reapproximated with the insertion of screws. Postoperatively, patients are limited to 30 pounds of
weight-bearing for 8 to 12 weeks and allowed full weight-bearing when consolidation is
evident on radiographs
Fig 6. Double Plating Technique for Hip arthrodesis
The advantages of this technique in this case are diminished pain and patient can mobilize early
and later this procedure can be converted to hip arthroplasty. The disadvantages are the ROM is
diminished and can cause discomfort for the patient.
Endoprosthetic replacement and total hip replacement. This technique consists of total hip
replacement with acetabular reconstruction (acetabuloplasty) and re-alignment of femoral
component by using subtrochanteric osteotomy.
The advantages of this procedure are diminished pain, early ROM mobilization so the patient can
perform daily life activity comfortly. The disadvantages are difficulty in adjusting the proper
acetabular and femoral component due to pathological conditions of acetabulum and femur also
the already damaged soft tissue surrounding the joint making the implant less stable unless using
the more advanced prosthesis.
All these procedures have their merits and demerits and give different outcomes. The result can
be further altered by avascular necrosis of the femoral head which occurs in more than 50 % of
the cases. Garrett et al8 and Zippel et al9 have recommended total hip arthroplasty for hips with
posterior dislocations categorised as type IV (fracture of the acetabular rim andfloor) or type V
(fracture of the femoral head with or without other fractures) that have remained dislocated for
more than 3 months. Malkin et al,10 Ilyas et al11 and others have shown good functional
outcome with THR for old unreduced fracture-dislocation of the hip. Similar to our case with
posterosuperior acetabulum wall deficiency due to old unreduced dislocation, the investigators
recommend acetabulum reconstruction prior to acetabulum cup fixation. They used either bone
graft augmentation for the deficient wall or a cage for stability. Hansen E and colleagues used
cemented cage with allograft for reconstruction of acetabular defect, and they found favourable
results in total hip arthroplasty.12
In our case,patients has already presented 3.5 years and the other one 2 years after injury which
makes the reduction difficult due to soft tissue tightening. We decided to perform soft tissue
release of the hip and femur on the first patient soft tissue release and hip arthrodesis on the
second patient to facilitate the reduction and later range of motion exercise. Later, the patient
planned for arthroplasty of the hip.Many recommendations exist for the postreduction treatment
of simple hip dislocations.15-18,19-22 In this case we choose THA, because compared to arthrodesis
it has several advantages;
The patient is active young age, so after the THA procedure the patient can get back to
daily living activity which.
There’s subtrochanteric fracture which can cause difficulty if only the arthrodesis is
performed because the end of subtrochanteric fragment has been refreshed so the rotation
difficult to be achieved properly if only the arthrodesis performed
In general, THA gives good functional outcome according to Harris hip score in many
studies.
Strict immobilization leads to intraarticular adhesions and arthritis and should be avoided. Most
surgeons recommend a temporary period of traction or balanced suspension until the patient’s
initial pain has subsided. This rarely takes longer than several days.After this, controlled passive
range-of-motion exercises with a continuous-passive-motion machine and early mobilization are
thought to benefit the patient’s overall condition. Extremes of motion should be avoided for 4 to
6 weeks to allow capsular and softtissuehealing. 24-26
The most controversial point regarding aftercare is the length of time that weight bearing should
be prohibited. Time from several days to 1 year have been proposed.The theoretical advantages
of a prolonged non-weight-bearing period apply to patients who have had an ischemic insult
severe enough to lead to late collapse. Although early weight bearing has not been shown to add
to the initial ischemic insult, it is believed that the amount of collapse in patients who develop
AVN may be diminished if weight bearing is delayed. 13 This hypothesis has not been tested
prospectively, but does have merit on historical grounds.14
A delay in full weight bearing for 8 to 12 weeks for patients who are at high risk of collapse may
be reasonable. This applies when reduction of the hip was delayed for more than 6 hours.
Patients who show radiologic signs (on plain radiography or MR imaging) of AVN early in their
followup course may also be treated with protected weight bearing and passive ROM
exercises.26,27For other patients, partial weight bearing can begin when comfortable and be
advanced as tolerated, with full weight bearing usually becoming possible after 2 to 4 weeks.
The ability of the patient to control the leg in space is a good indicator that he is ready to
progress to full weight bearing. Rehabilitation should include specific strengthening exercises for
the musculature about the hip.28-31
Consequently, primary arthroplasty has been recommended by a number of authors. However, it
appears reasonable to suggest, that open repair followed by a short period of skeletal traction
should be considered as an alternative treatment for young adults, given the tenuous efficacy of
total hip replacement, as determined by long-term results, and their poor tolerance of hip
arthrodesis or traction alone.
CONCLUSION
Different options are present for treating old unreduced acetabulum fracture-dislocations.
Traction and soft tissue release is essential in management of neglected hip dislocation that
present for more than 1 year and heavy skeletal traction should be considered. Total hip
replacement with reconstruction of the acetabulum has good functional results.
REFERENCES
1. Brumback RJ, Kenzora JE, Levitt LE, Burgess AR, Poka A. Fractures of the femoral
head. In: Proceedings of the Hip Society. St. Louis: CV Mosby, 1987:181- 206.
2. Butler JE. Pipkin type-II fractures of the femoral head. J Bone Joint Surg Am
1981;63:1292-1296.
3. Chakraborti SS, Miller IM. Dislocation of the hip associated with fracture of the femoral
head. Injury 1975;7:134-142.
4. Epstein HC, Wiss DA, Cozen L. Posterior fracture dislocation of the hip with fractures of
the femoral head. Clin Orthop 1985;201:9-17.
5. Marchetti ME, Steinberg GG, Coumas JM. Intermedi- ate-term experience of Pipkin
fracture-dislocations of the hip. J Orthop Trauma 1995;10455-461.
6. Yue JJ, Wilber JH, Lipuma JP, Posterior hip dislocations: a cadaveric angiographic study.
J Orthop Trauma 1996;10:447-454.
7. Brav EA. Traumatic dislocation of the hip: army experience and results over twelve-year
period. J Bone Joint Surg Am 1962;44:1115-1134.
8. Garrett JC, Epstein HC, Harris WH, Harvey JP Jr, Nickel VL. Treatment of unreduced
traumatic posterior dislocations of the hip. J Bone Joint Surg Am 1979; 61: 2-6.
9. Zippel H, Palme E. Neglected hip dislocation fractures. Zentralbl Chir 1981; 106: 674-82.
10. Malkin C, Tauber C. Total hip arthroplasty and acetabular bone grafting for unreduced
fracture-dislocation of the hip. Clin Orthop Relat Res 1985; 201: 57-9.
11. Ilyas I, Rabbani SA. Total hip arthroplasty in chronic unreduced hip fracture-dislocation.
J Arthroplasty 2009; 24: 903-8.
12. Hansen E, Shearer D, Ries MD. Does a cemented cage improve revision THA for severe
acetabular defects? Clin Orthop Relat Res 2011; 469: 494-502.
13. Stuck WG, Vaughan WH: Prevention of disability after traumatic dislocation of the hip.
South Surg 1949;15:659-675.
14. Brav EA: Traumatic dislocation of the hip: Army experience and results over a twelveyear period. J Bone Joint Surg Am 1962;44:1115-1134.
15. Stewart MJ, Milford LW: Fracture-dislocation of the hip: An end-result study. J Bone
Joint Surg Am 1954;36:315-342.
16. Thompson VP, Epstein HC: Traumatic dislocation of the hip: A survey of two hundred
and four cases covering a period of twenty-one years. J Bone Joint Surg Am
1951;33:746-778.
17. Paus B: Traumatic dislocations of the hip Late results in 76 cases. Acta Orthop Scand
1951;21:99-112.
18. Dreinhofer KE, Schwarzkopf SR, Haas NP, et al: Isolated traumatic dislocation of the
hip: Long-term results in 50 patients. J Bone Joint Surg Br 1994;76:6-12.
19. Urist MR: Injuries to the hip joint: Traumatic dislocations incurred chiefly in jeep
accidents in World War II. Am J Surg 1947;74:586-597.
20. Leenen LPH, van der Werken C: Traumatic posterior luxation of the hip. Neth J Surg
1990;42:136-139.
21. Jacob JR, Rao JP, Ciccarelli C: Traumatic dislocation and fracture dislocation of the hip:
A long-term follow-up study. Clin Orthop 1987 214:249-263.
22. Schlickewei W, Elsässer B, Mullaji AB et al: Hip dislocation without fracture: Traction
or mobilization after reduction? Injury 1993;24:27-31.
23. Tornetta P, Mostafavi HR. Hip Dislocation: Current Treatment Regiement. J Am Acad
Orthop Surg 1997;5:27-36.
24. Miyamoto RG, Kaplan KM, Levine BR, Egol KA, Zuckerman JD. Surgical Management
of Hip Fractures: An Evidence-based Review of the Literature. I: Femoral Neck
Fractures. J Am Acad Orthop Surg 2008;16:596- 607.
25. Kuzyk PRT, Dhotar HS, Sternheim A, Gross AE, Oleg S, Backstein D. Two-stage
Revision Arthroplasty for Management of Chronic Periprosthetic Hip and Knee
Infection: Techniques, Controversies, and Outcomes. J Am Acad Orthop Surg 2014;22:
153-164.
26. Tornetta P. Displaced Acetabular Fractures: Indications for Operative and Nonoperative
Management. J Am Acad Orthop Surg 2001;9:18-28.
27. Pike J, Davidson D, Garbuz D, Duncan CP, O’Brien PJ, Masri BA.Principles of
Treatment for Periprosthetic Femoral Shaft Fractures Around Well-fixed Total Hip
Arthroplasty. J Am Acad Orthop Surg 2009;17: 677-688.
28. Herrra-Soto JA, Price CT. Traumatic Hip Dislocations in Children and Adolescents:
Pitfalls and Complications. J Am Acad Orthop Surg 2009;17: 15-21.
29. Schoenecker PL, Clohisy JC, Millis MB, Wenger DR.Surgical Management of the
Problematic Hip in Adolescent and Young Adult Patients. J Am Acad Orthop Surg
2011;19: 275-286.
30. Rafael RJ, Trousdale RT, Ganz R, Leunig M. Hip Disease in the Young, Active Patient:
Evaluation and Nonarthroplasty Surgical Options. J Am Acad Orthop Surg 2008;16:689703.
31. Boykin RE, Anz AW, Bushnell BD, Kocher MS, Stubbs AJ. Hip Instability. J Am Acad
Orthop Surg 2011;19: 340-349.
32. Beaule PE, Matta JM, Mast JW. Hip Arthrodesis: Current Indications and Techniques. J
Am Acad Orthop Surg 2002;10:249-258.
Male
A Case Series
dr. Melissa Pingkan Johana Tungka
dr. Cok Gde Oka Dharmayuda, SpOT(K)
PROGRAM PENDIDIKAN DOKTER SPESIALIS I
BAGIAN/SMF ORTHOPAEDI DAN TRAUMATOLOGI
UNIVERSITAS UDAYANA
2014
Neglected Hip Fracture-Dislocation in 21 Years-Old Young Male
A Case Series
Melissa Pingkan Johana Tungka*Cok Gde Oka Dharmayuda**
*Resident of Orthopedic and Trauma, Faculty of Medicine Udayana University, Sanglah
Hospital
**Staff of Orthopedic and Trauma, Faculty of Medicine Udayana University, Sanglah
Hospital
ABSTRACT
Introduction
Neglected fracture-dislocation of the hip is common in developing countries due to various
factors. However the incidence percentage has not been determined yet. This condition causes
several complications of the bone and soft tissue and has poor functional outcome. Different
options including arthrodesis, Girdlestone arthroplasty and total hip replacement (THR) are used
for its treatment. Till date, arthrodesis in youngsters and resection arthroplasty in the elders has
been the treatment of choice. THR, however, is being done by a few, but the experience has not
been published. Proper treatment was mandatory to prevent complications.
Methods
We are reporting two cases; of 21 years old man with neglected posterior fracture dislocation of
the hip with acetabulum fracture and subtrochanteric fracture of femur. The leg discrepancy was
8 cm and there’s already contracture. The second patient was 21 years old male with neglected
dislocation of right hip, with 6 cm leg discrepancy, and there’s atrophy of quadriceps muscle.
Result
For the first patient, we performed soft tissue release, hip arthrodesis, and plating of the femur.
The patient planned for THR in the next surgery. Recently, patient walked with 2 crutches. For
the second patient, we performed open reduction and arthrodesis.
Conclusion
Different options are present for treating old unreduced acetabulum fracture-dislocations.
Traction and soft tissue release is essential in management of neglected hip dislocation that
present for more than 1 year and heavy skeletal traction should be considered. Total hip
replacement with reconstruction of the acetabulum has good functional results.
Keywords: Neglected hip dislocation, Soft tissue release, Hip arthrodesis, Plating.
REFERENCES
1. Brumback RJ, Kenzora JE, Levitt LE, Burgess AR, Poka A. Fractures of the femoral
head. In: Proceedings of the Hip Society. St. Louis: CV Mosby, 1987:181- 206.
2. Butler JE. Pipkin type-II fractures of the femoral head. J Bone Joint Surg Am
1981;63:1292-1296.
3. Chakraborti SS, Miller IM. Dislocation of the hip associated with fracture of the femoral
head. Injury 1975;7:134-142.
4. Epstein HC, Wiss DA, Cozen L. Posterior fracture dislocation of the hip with fractures of
the femoral head. Clin Orthop 1985;201:9-17.
5. Marchetti ME, Steinberg GG, Coumas JM. Intermedi- ate-term experience of Pipkin
fracture-dislocations of the hip. J Orthop Trauma 1995;10455-461.
6. Yue JJ, Wilber JH, Lipuma JP, Posterior hip dislocations: a cadaveric angiographic study.
J Orthop Trauma 1996;10:447-454.
7. Brav EA. Traumatic dislocation of the hip: army experience and results over twelve-year
period. J Bone Joint Surg Am 1962;44:1115-1134.
8. Garrett JC, Epstein HC, Harris WH, Harvey JP Jr, Nickel VL. Treatment of unreduced
traumatic posterior dislocations of the hip. J Bone Joint Surg Am 1979; 61: 2-6.
9. Zippel H, Palme E. Neglected hip dislocation fractures. Zentralbl Chir 1981; 106: 674-82.
10. Malkin C, Tauber C. Total hip arthroplasty and acetabular bone grafting for unreduced
fracture-dislocation of the hip. Clin Orthop Relat Res 1985; 201: 57-9
11. Ilyas I, Rabbani SA. Total hip arthroplasty in chronic unreduced hip fracture-dislocation.
J Arthroplasty 2009; 24: 903-8.
12. Hansen E, Shearer D, Ries MD. Does a cemented cage improve revision THA for severe
acetabular defects? Clin Orthop Relat Res 2011; 469: 494-502.
13. Stuck WG, Vaughan WH: Prevention of disability after traumatic dislocation of the hip.
South Surg 1949;15:659-675.
14. Brav EA: Traumatic dislocation of the hip: Army experience and results over a twelveyear period. J Bone Joint Surg Am 1962;44:1115-1134.
15. Stewart MJ, Milford LW: Fracture-dislocation of the hip: An end-result study. J Bone
Joint Surg Am 1954;36:315-342.
16. Thompson VP, Epstein HC: Traumatic dislocation of the hip: A survey of two hundred
and four cases covering a period of twenty-one years. J Bone Joint Surg Am
1951;33:746-778.
17. Paus B: Traumatic dislocations of the hip Late results in 76 cases. Acta Orthop Scand
1951;21:99-112.
18. Dreinhofer KE, Schwarzkopf SR, Haas NP, et al: Isolated traumatic dislocation of the
hip: Long-term results in 50 patients. J Bone Joint Surg Br 1994;76:6-12.
19. Urist MR: Injuries to the hip joint: Traumatic dislocations incurred chiefly in jeep
accidents in World War II. Am J Surg 1947;74:586-597.
20. Leenen LPH, van der Werken C: Traumatic posterior luxation of the hip. Neth J Surg
1990;42:136-139.
21. Jacob JR, Rao JP, Ciccarelli C: Traumatic dislocation and fracture dislocation of the hip:
A long-term follow-up study. Clin Orthop 1987 214:249-263.
22. Schlickewei W, Elsässer B, Mullaji AB et al: Hip dislocation without fracture: Traction
or mobilization after reduction? Injury 1993;24:27-31.
23. Tornetta P, Mostafavi HR. Hip Dislocation: Current Treatment Regiement. J Am Acad
Orthop Surg 1997;5:27-36
24. Miyamoto RG, Kaplan KM, Levine BR, Egol KA, Zuckerman JD. Surgical Management
of Hip Fractures: An Evidence-based Review of the Literature. I: Femoral Neck
Fractures. J Am Acad Orthop Surg 2008;16:596- 607
25. Kuzyk PRT, Dhotar HS, Sternheim A, Gross AE, Oleg S, Backstein D. Two-stage
Revision Arthroplasty for Management of Chronic Periprosthetic Hip and Knee
Infection: Techniques, Controversies, and Outcomes. J Am Acad Orthop Surg 2014;22:
153-164
26. Tornetta P. Displaced Acetabular Fractures: Indications for Operative and Nonoperative
Management. J Am Acad Orthop Surg 2001;9:18-28
27. Pike J, Davidson D, Garbuz D, Duncan CP, O’Brien PJ, Masri BA.Principles of
Treatment for Periprosthetic Femoral Shaft Fractures Around Well-fixed Total Hip
Arthroplasty. J Am Acad Orthop Surg 2009;17: 677-688
28. Herrra-Soto JA, Price CT. Traumatic Hip Dislocations in Children and Adolescents:
Pitfalls and Complications. J Am Acad Orthop Surg 2009;17: 15-21
29. Schoenecker PL, Clohisy JC, Millis MB, Wenger DR.Surgical Management of the
Problematic Hip in Adolescent and Young Adult Patients. J Am Acad Orthop Surg
2011;19: 275-286
30. Rafael RJ, Trousdale RT, Ganz R, Leunig M. Hip Disease in the Young, Active Patient:
Evaluation and Nonarthroplasty Surgical Options. J Am Acad Orthop Surg 2008;16:689703
31. Boykin RE, Anz AW, Bushnell BD, Kocher MS, Stubbs AJ. Hip Instability. J Am Acad
Orthop Surg 2011;19: 340-349
32. Beaule PE, Matta JM, Mast JW. Hip Arthrodesis: Current Indications and Techniques. J
Am Acad Orthop Surg 2002;10:249-258
Neglected Hip Fracture-Dislocation in 21 Years-Old Young Male
A Case Series
INTRODUCTION
Neglected traumatic posterior fracture-dislocation of the hip in young people who present sith
delayed treatment beyond 3 month has a poor prognosis and outcome. It has several
complications which involved soft tissue (i.e: contractures of muscles, ligaments, and joint
capsules) and hard tissue (i.e delayed/non-union, malunion, osteoporosis, AVN of femoral head,
and chondrolysis). We are reporting a case of 21 years old man with neglected posterior fracture
dislocation of the hip with acetabulum fracture and subtrochanteric fracture of femur. In clinical
examination, the leg discrepancy was 8 cm and there’s already contracture.
CASE REPORT
CASE 1
A healthy 21 year-old man reported painful motion of his right hip and femur for 3.5 years. He
had been involved in motor vehicle accident 3.5 years earlier and went to local district hospital in
Sumba and advised for amputation but the patient refused and then he attended local bone setter.
He only consumed traditional medicine. Three years later he came to outpatient clinic and
planned for staged surgery.
A physical examination of the right hip showed that there’s external rotation, shortening with 8
centimeters leg discrepancy, atrophy of quadricep muscle and also false movement of right
proximal femur
Roentgenographic images and computed tomography scans revealed fracture of proximal third of
femur and posterior dislocation of right hip (Figs. 1, 2)
A
B
C
D
Fig 1. A-D.A. clinical picture showing the leg discrepancy, the left lower limb was 8 cm shorter
than the left. B-C.Initial radiograph of pelvis taken 3.5 after the accident. There’s posterior
dislocation of right hip with damage of the femoral head and acetabulum D. radiograph of right
femur taken 3.5 after skeletal traction. There’s athropic non union of proximal shaft of the femur.
A
B
C
Fig 2 A-C. 3D reconstruction of computed tomography, showing damage of right acetabulum
with its rim, and damage of femoral head and non union of proximal femoral shaft.
Patient was admitted for 8 kgs skeletal traction for 23 days. After 23 days, the leg discrepancy
was 6cm. Patient underwent soft tissue release surgery of right hip, hip arthrodesis, soft tissue
release of right femur and plating of the femur. The surgery performed with lateral approach in
supine position. The fragment of the proximal femoral shaft and acetabulum were exposed and
there’s minimal callus. The acetabulum and femoral head was damaged and filled with fibrous
tissue. There’s also chondrolysis of the hip joint. Refreshment of bone fragments was performed,
the fragment was reduced and fixed with broad LCP with bone graft (fig 3). The hip joint was
fixed with 2 parallel Kirschner wires. The roentgenograph after surgery was taken (fig 4)
A
C
B
D
Fig 3. A. intraoperative picture showing the damage of acetabulum and femoral head which is
filled with fibrous tissue and B. showing the head of femur after soft tissue release and proximal
shaft of femur. C. Picture showing the femoral head and acetabulum after reduction and D.
Plating of the femoral shaft after the fragment refreshed.
A
B
Fig 4A-B. Postoperative roentgenograph after the second surgery. The hip joint was fixed with 2
parallel Kirscner wires (A) and the femur was fixed with broad LCP and bone graft (B).
On one month follow up after surgery, the K-wires were removed, patient complained minor hip
pain and Non weight bearing with 2 crutches.
CASE 2
A healthy 21 year-old man reported painful motion of his right hip and femur for 2 years. He had
been involved in motor vehicle accident 2 years earlier and went to local bone setter.. Three
years later he came to outpatient clinic and planned for staged surgery.
A physical examination of the right hip showed that there’s shortening with 6 centimeters leg
discrepancy, atrophy of quadriceps muscle.
Rontgenographic images and computed tomography scans revealed posterior dislocation of right
hip (Figs. 5A-D)
Fig 5A. Clinical picture showing leg discrepancy and skeletal traction
Fig 5B. Initial X-Ray of the hip before skeletal traction
Fig 5C. X-ray after 12 kgs skeletal traction
Patient was admitted for 12 kgs skeletal traction. After traction the leg discrepancy was 2 cm.
Patient underwent soft tissue release surgery of right hip and hip arthrodesis. The surgery
performed with lateral approach in supine position. The acetabulum and femoral head was
damaged and filled with fibrous tissue.
6A. clinical picture showing post-operative after arthrodesis of hip.
6B. Pelvic AP view of the hip, showing pin placement in the hip joint.
DISCUSSION
Dislocation of the hip and ipsilateral fracture of femur is associated with a poor outcome.1-5This
may be a consequence of the greater energy transmission through the hip.which has implication
for the degree of chondral damage suffered. This chondral damage may be responsible for
subsequent rapid chondrolysis and early osteoarthritis.
The distortion of local anatomy, especially the proximity of sciatic nerve, caused by the
persistent posterior dislocation of the femoral head has been well described by Yue et al. 6This
deformation contributes to the difficulty of intraoperative repair. The extent of operative
dissection required to facilitate open hip reduction may also have detrimental effect on the blood
supply to the femoral head and may thus contribute to the high incidence of AVN 7
Unreduced fracture-dislocation of the hip for more than 3 months is considered an old neglected
dislocation. Conservative treatment becomes impossible to achieve stable concentric reduction 8
due to unreduced wall fracture leading to instability and fibrous tissue filling the spaces and
covering the fracture. The operative treatment remains the only chance to reduce the hip or
reconstruct with arthroplasty. Various investigators use different methods for operative treatment
of old unreduced fracture-dislocations including8,32:
Girdlestone procedure: The procedure exposes the head section of the femur bone and then the
head is removed Rarely both sides are done in one operation,most times one side is done and
allowed to heal before the other side is done. Unlike most other hip surgeries, the head of the
femur is not replaced, but is allowed to heal and develop its own fibrous scar tissue so that the
joint is no longer bone−to-bone, a pseudoarthrosis. The neck of the femur is usually removed at
the same time as the head. This prevents the post operative complication of bone rubbing on
bone and continued pain.
Arthrodesis.
Cobra Head Plate Technique
The technique involves stripping the abductor muscles from the iliac crest to accommodate
the cobra head of the plate together with a pelvic oste- otomy to enlarge the area of contact
between femur and pelvis. Fusion rates from 94% to 100% have been reported.
Anterior Plating Technique
The original motivation for the anterior approach was to create a technique that provides
fixation to both the pelvis and femur while sparing the hip abductor muscles. In addition, with
the patient supineand the pelvis level during the surgery, positioning of the hip is facilitated.
With the screws in- serted in an anteroposterior direction, excellent purchase is achieved in
this area of thick bone, making this technique advantageous when there is loss of acetabular
or proximal femoral bone stock. The insertion of a lag screw from the trochanteric area
through the supra-acetabular bone into the center of the femoral head provides additional
compression because of a lateral tension band effect. As with other internal fixation
techniques, no external fixation (casting) is required unless the patient is expected to be
noncompliant. The anterior plating technique can also be effective in the presence of loss of
bone stock
The patient is placed in the supine position on a standard fracture table or, optimally, on a
Judet table. On a Judet table, the hip is placed in the desired position before preparing the
patient. An intraoperative radiograph verifies the range of abduction-adduction. The modified
Smith-Petersen approach involves elevating the abdominal muscles from the iliac crest
through their fascial attachment without violating the abductor musculature. The distal
extension is within the tensor fascia muscular sheet, with detach- ment of both the sartorius
and rectus femoris muscles. To expose the femur, the vastus lateralis is elevated from a lateral
to medial direction to avoid denervation. With the hip joint exposed and denuded of cartilage, the lag screw is inserted first, followed by the 12- to 14-hole low-contact broad dynamic
compression plate. Viewed anteriorly, the plate has a 10° concave bend to match the internal
iliac fossa, a 50° convex bend crossing the anterior acetabular rim, and a 35° concavity in the
intertrochanteric area. Usually the plate is fixed to the pelvis first, fol- lowed by a tensioning
device applied to the distal end of the plate. The plate may have to be undercon- toured to
avoid increasing hip flexion as the plate is being tensioned. Iliaccrest bone graft from the
inner table may be used if necessary. Postoperatively, patients are usually restricted to 30
pounds of weight-bearing for 8 to 10 weeks. After 12 weeks, if radiographic consolidation is
present, full weight-bearing is allowed.
Fig 5. Anterior Plating Technique for arthrodesis
Double Plating technique
The first stage is the preparation of the head and the acetabulum for fusion, usually with local
fixation and an intertrochanteric osteotomy to remove the lever arm acting on the desired site
of fusion. In the second stage, 6 to 8 weeks later, the intertrochanteric area is stabilized. By
removing the lever arm of the femur, the fusion site may heal with greater predictability. With
the patient in the lateral position, a modified lateral approach is used; the gluteus medius and
minimus muscles are elevated with a part of the greater trochanter. The exposure is continued
anteriorly in the plane between the sartorius and tensor, with the hip flexed and exter- nally
rotated. The lateral plate (broad 4.5 mm) is first applied and contoured over the trochanteric
bed and placed anterior to the greater sciatic notch and along the lateral aspect of the femur.
The plate is then secured proximally with a tension device applied distally. After removal of
the anterior-inferior iliac spine, the anterior plate (narrow 4.5 mm) is applied along the
femoral shaft, and a second tensioning device is applied with the plate fixed proximally. Both
tensioning devices are then tightened; the plates tend to lift off the bone but are reapproximated with the insertion of screws. Postoperatively, patients are limited to 30 pounds of
weight-bearing for 8 to 12 weeks and allowed full weight-bearing when consolidation is
evident on radiographs
Fig 6. Double Plating Technique for Hip arthrodesis
The advantages of this technique in this case are diminished pain and patient can mobilize early
and later this procedure can be converted to hip arthroplasty. The disadvantages are the ROM is
diminished and can cause discomfort for the patient.
Endoprosthetic replacement and total hip replacement. This technique consists of total hip
replacement with acetabular reconstruction (acetabuloplasty) and re-alignment of femoral
component by using subtrochanteric osteotomy.
The advantages of this procedure are diminished pain, early ROM mobilization so the patient can
perform daily life activity comfortly. The disadvantages are difficulty in adjusting the proper
acetabular and femoral component due to pathological conditions of acetabulum and femur also
the already damaged soft tissue surrounding the joint making the implant less stable unless using
the more advanced prosthesis.
All these procedures have their merits and demerits and give different outcomes. The result can
be further altered by avascular necrosis of the femoral head which occurs in more than 50 % of
the cases. Garrett et al8 and Zippel et al9 have recommended total hip arthroplasty for hips with
posterior dislocations categorised as type IV (fracture of the acetabular rim andfloor) or type V
(fracture of the femoral head with or without other fractures) that have remained dislocated for
more than 3 months. Malkin et al,10 Ilyas et al11 and others have shown good functional
outcome with THR for old unreduced fracture-dislocation of the hip. Similar to our case with
posterosuperior acetabulum wall deficiency due to old unreduced dislocation, the investigators
recommend acetabulum reconstruction prior to acetabulum cup fixation. They used either bone
graft augmentation for the deficient wall or a cage for stability. Hansen E and colleagues used
cemented cage with allograft for reconstruction of acetabular defect, and they found favourable
results in total hip arthroplasty.12
In our case,patients has already presented 3.5 years and the other one 2 years after injury which
makes the reduction difficult due to soft tissue tightening. We decided to perform soft tissue
release of the hip and femur on the first patient soft tissue release and hip arthrodesis on the
second patient to facilitate the reduction and later range of motion exercise. Later, the patient
planned for arthroplasty of the hip.Many recommendations exist for the postreduction treatment
of simple hip dislocations.15-18,19-22 In this case we choose THA, because compared to arthrodesis
it has several advantages;
The patient is active young age, so after the THA procedure the patient can get back to
daily living activity which.
There’s subtrochanteric fracture which can cause difficulty if only the arthrodesis is
performed because the end of subtrochanteric fragment has been refreshed so the rotation
difficult to be achieved properly if only the arthrodesis performed
In general, THA gives good functional outcome according to Harris hip score in many
studies.
Strict immobilization leads to intraarticular adhesions and arthritis and should be avoided. Most
surgeons recommend a temporary period of traction or balanced suspension until the patient’s
initial pain has subsided. This rarely takes longer than several days.After this, controlled passive
range-of-motion exercises with a continuous-passive-motion machine and early mobilization are
thought to benefit the patient’s overall condition. Extremes of motion should be avoided for 4 to
6 weeks to allow capsular and softtissuehealing. 24-26
The most controversial point regarding aftercare is the length of time that weight bearing should
be prohibited. Time from several days to 1 year have been proposed.The theoretical advantages
of a prolonged non-weight-bearing period apply to patients who have had an ischemic insult
severe enough to lead to late collapse. Although early weight bearing has not been shown to add
to the initial ischemic insult, it is believed that the amount of collapse in patients who develop
AVN may be diminished if weight bearing is delayed. 13 This hypothesis has not been tested
prospectively, but does have merit on historical grounds.14
A delay in full weight bearing for 8 to 12 weeks for patients who are at high risk of collapse may
be reasonable. This applies when reduction of the hip was delayed for more than 6 hours.
Patients who show radiologic signs (on plain radiography or MR imaging) of AVN early in their
followup course may also be treated with protected weight bearing and passive ROM
exercises.26,27For other patients, partial weight bearing can begin when comfortable and be
advanced as tolerated, with full weight bearing usually becoming possible after 2 to 4 weeks.
The ability of the patient to control the leg in space is a good indicator that he is ready to
progress to full weight bearing. Rehabilitation should include specific strengthening exercises for
the musculature about the hip.28-31
Consequently, primary arthroplasty has been recommended by a number of authors. However, it
appears reasonable to suggest, that open repair followed by a short period of skeletal traction
should be considered as an alternative treatment for young adults, given the tenuous efficacy of
total hip replacement, as determined by long-term results, and their poor tolerance of hip
arthrodesis or traction alone.
CONCLUSION
Different options are present for treating old unreduced acetabulum fracture-dislocations.
Traction and soft tissue release is essential in management of neglected hip dislocation that
present for more than 1 year and heavy skeletal traction should be considered. Total hip
replacement with reconstruction of the acetabulum has good functional results.
REFERENCES
1. Brumback RJ, Kenzora JE, Levitt LE, Burgess AR, Poka A. Fractures of the femoral
head. In: Proceedings of the Hip Society. St. Louis: CV Mosby, 1987:181- 206.
2. Butler JE. Pipkin type-II fractures of the femoral head. J Bone Joint Surg Am
1981;63:1292-1296.
3. Chakraborti SS, Miller IM. Dislocation of the hip associated with fracture of the femoral
head. Injury 1975;7:134-142.
4. Epstein HC, Wiss DA, Cozen L. Posterior fracture dislocation of the hip with fractures of
the femoral head. Clin Orthop 1985;201:9-17.
5. Marchetti ME, Steinberg GG, Coumas JM. Intermedi- ate-term experience of Pipkin
fracture-dislocations of the hip. J Orthop Trauma 1995;10455-461.
6. Yue JJ, Wilber JH, Lipuma JP, Posterior hip dislocations: a cadaveric angiographic study.
J Orthop Trauma 1996;10:447-454.
7. Brav EA. Traumatic dislocation of the hip: army experience and results over twelve-year
period. J Bone Joint Surg Am 1962;44:1115-1134.
8. Garrett JC, Epstein HC, Harris WH, Harvey JP Jr, Nickel VL. Treatment of unreduced
traumatic posterior dislocations of the hip. J Bone Joint Surg Am 1979; 61: 2-6.
9. Zippel H, Palme E. Neglected hip dislocation fractures. Zentralbl Chir 1981; 106: 674-82.
10. Malkin C, Tauber C. Total hip arthroplasty and acetabular bone grafting for unreduced
fracture-dislocation of the hip. Clin Orthop Relat Res 1985; 201: 57-9.
11. Ilyas I, Rabbani SA. Total hip arthroplasty in chronic unreduced hip fracture-dislocation.
J Arthroplasty 2009; 24: 903-8.
12. Hansen E, Shearer D, Ries MD. Does a cemented cage improve revision THA for severe
acetabular defects? Clin Orthop Relat Res 2011; 469: 494-502.
13. Stuck WG, Vaughan WH: Prevention of disability after traumatic dislocation of the hip.
South Surg 1949;15:659-675.
14. Brav EA: Traumatic dislocation of the hip: Army experience and results over a twelveyear period. J Bone Joint Surg Am 1962;44:1115-1134.
15. Stewart MJ, Milford LW: Fracture-dislocation of the hip: An end-result study. J Bone
Joint Surg Am 1954;36:315-342.
16. Thompson VP, Epstein HC: Traumatic dislocation of the hip: A survey of two hundred
and four cases covering a period of twenty-one years. J Bone Joint Surg Am
1951;33:746-778.
17. Paus B: Traumatic dislocations of the hip Late results in 76 cases. Acta Orthop Scand
1951;21:99-112.
18. Dreinhofer KE, Schwarzkopf SR, Haas NP, et al: Isolated traumatic dislocation of the
hip: Long-term results in 50 patients. J Bone Joint Surg Br 1994;76:6-12.
19. Urist MR: Injuries to the hip joint: Traumatic dislocations incurred chiefly in jeep
accidents in World War II. Am J Surg 1947;74:586-597.
20. Leenen LPH, van der Werken C: Traumatic posterior luxation of the hip. Neth J Surg
1990;42:136-139.
21. Jacob JR, Rao JP, Ciccarelli C: Traumatic dislocation and fracture dislocation of the hip:
A long-term follow-up study. Clin Orthop 1987 214:249-263.
22. Schlickewei W, Elsässer B, Mullaji AB et al: Hip dislocation without fracture: Traction
or mobilization after reduction? Injury 1993;24:27-31.
23. Tornetta P, Mostafavi HR. Hip Dislocation: Current Treatment Regiement. J Am Acad
Orthop Surg 1997;5:27-36.
24. Miyamoto RG, Kaplan KM, Levine BR, Egol KA, Zuckerman JD. Surgical Management
of Hip Fractures: An Evidence-based Review of the Literature. I: Femoral Neck
Fractures. J Am Acad Orthop Surg 2008;16:596- 607.
25. Kuzyk PRT, Dhotar HS, Sternheim A, Gross AE, Oleg S, Backstein D. Two-stage
Revision Arthroplasty for Management of Chronic Periprosthetic Hip and Knee
Infection: Techniques, Controversies, and Outcomes. J Am Acad Orthop Surg 2014;22:
153-164.
26. Tornetta P. Displaced Acetabular Fractures: Indications for Operative and Nonoperative
Management. J Am Acad Orthop Surg 2001;9:18-28.
27. Pike J, Davidson D, Garbuz D, Duncan CP, O’Brien PJ, Masri BA.Principles of
Treatment for Periprosthetic Femoral Shaft Fractures Around Well-fixed Total Hip
Arthroplasty. J Am Acad Orthop Surg 2009;17: 677-688.
28. Herrra-Soto JA, Price CT. Traumatic Hip Dislocations in Children and Adolescents:
Pitfalls and Complications. J Am Acad Orthop Surg 2009;17: 15-21.
29. Schoenecker PL, Clohisy JC, Millis MB, Wenger DR.Surgical Management of the
Problematic Hip in Adolescent and Young Adult Patients. J Am Acad Orthop Surg
2011;19: 275-286.
30. Rafael RJ, Trousdale RT, Ganz R, Leunig M. Hip Disease in the Young, Active Patient:
Evaluation and Nonarthroplasty Surgical Options. J Am Acad Orthop Surg 2008;16:689703.
31. Boykin RE, Anz AW, Bushnell BD, Kocher MS, Stubbs AJ. Hip Instability. J Am Acad
Orthop Surg 2011;19: 340-349.
32. Beaule PE, Matta JM, Mast JW. Hip Arthrodesis: Current Indications and Techniques. J
Am Acad Orthop Surg 2002;10:249-258.