DISLOCATION OF TOTAL HIP DISLOCATION OF TOTAL HIP REPLACEMENT NEEDINGREPLACEMENT NEEDINGREPLACEMENT NEEDING REPLACEMENT NEEDING

OPEN REDUCTIONOPEN REDUCTIONOPEN REDUCTIONOPEN REDUCTION

VASU PAIVASU PAIHAWKE’S BAY DISTRICT HAWKE’S BAY DISTRICT

HOSPITALHOSPITAL

HASTINGSHASTINGSHASTINGSHASTINGS

IntroductionIntroductionIntroductionIntroduction

Dislocation following THRDislocation following THR 11--5%5%

In most, reduction is easy In most, reduction is easy

Irreducible dislocation is very rareIrreducible dislocation is very rareIrreducible dislocation is very rare Irreducible dislocation is very rare

CAUSES FOR IRREDUCIBLE CAUSES FOR IRREDUCIBLE DISLOCATIONDISLOCATION

1 Di i i f f d l h i1 Di i i f f d l h i1. Dissociation of components of modular prosthesis1. Dissociation of components of modular prosthesis

2 S ft ti tr pm t2 S ft ti tr pm t2. Soft tissue entrapment2. Soft tissue entrapment

3 Interposition of gentamicin beads or cement3 Interposition of gentamicin beads or cement3. Interposition of gentamicin beads or cement3. Interposition of gentamicin beads or cement

4. Stem displacement4. Stem displacement4. Stem displacement4. Stem displacement

Written up as case reports. No classification available.Written up as case reports. No classification available.p p fp p f

MaterialsMaterialsMaterialsMaterials

8 patients 8 patients Hastings NZ : 1995 and 2000.Hastings NZ : 1995 and 2000.Hastings, NZ : 1995 and 2000.Hastings, NZ : 1995 and 2000.

Mechanisms of injury: Mechanisms of injury:

Bending at the hip to put on shoesBending at the hip to put on shoesBending at the hip to put on shoes,Bending at the hip to put on shoes,Twisting injury whilst pivoting on the leg, Twisting injury whilst pivoting on the leg, Slipping in the shower.Slipping in the shower.

MaterialsMaterialsMaterialsMaterials

Primary RxPrimary Rx: : Different surgeons & hospitals; Different surgeons & hospitals; Various types of total hip prostheses.Various types of total hip prostheses.

Male : FemaleMale : Female:: 0:80:8Male : FemaleMale : Female: : 0:80:8

PresentationPresentation: : Pain, Limp, Shortening or Deformity. Pain, Limp, Shortening or Deformity.

Type I: Dislodgement of the stemType I: Dislodgement of the stemType I: Dislodgement of the stemType I: Dislodgement of the stem78 F l78 y; Female

Cemented Exeter for OA Hip

Post op X ray

F ll i h hFell in the shower

Post Dislocation 3/52

Closed reduction was t i d b j itried by a junior doctor under sedation

Dislodgment of the stem from the cement mantlecement mantle

Open reduction

St h d b k i t thStem was pushed back into the cement mantle

1 yr: showed no further problem

Proximal migration of the stemProximal migration of the stemProximal migration of the stemProximal migration of the stem

2 patients: 1 73 yr old Exeter Hip2 patients: 1 73 yr old Exeter Hip2. 64 yr old CPT total hip2. 64 yr old CPT total hip

Both Had open reductionBoth Had open reduction

One year followOne year follow--up: No further problemsup: No further problemsyy p pp p

Type II: Dislodgement of the cup at the Type II: Dislodgement of the cup at the cementcement--bone interfacebone interface

88 F l88yr Female

Severe OA with protrusio and psevere destruction of the head

Post op X rayPost op X ray

Reasonable fixation of the

tcomponents

Posterior dislocation #1:

Closed reduction

Presented with second dislocation 2/12

X ray: Dislodgment of the cup at cement bone interfacecement bone interface

Revision fixation of the cup with cement

Type II: Cup migrationType II: Cup migrationType II: Cup migrationType II: Cup migration

85/F85/F ExeterExeter 6 wks6 wks OR & Revision cupOR & Revision cup85/F85/F ExeterExeter 6 wks6 wks OR & Revision cupOR & Revision cup

//84/F 84/F CPT CPT 6M6M OR & Revision cupOR & Revision cup

82/F 82/F ExeterExeter 3M3M OR & Revision cup OR & Revision cup Excision arthroplasty Excision arthroplasty

Type III: Dissociation of the linerType III: Dissociation of the linerType III: Dissociation of the linerType III: Dissociation of the liner

66yr FemaleRevision HipRevision Hip

Noncemented, HG II acetabular component with a cemented stem 1994cemented stem 1994

1st dislocation in 1995: Reduced under II (G.A).

*6 months later: Pain in the left hip, radiating to her ankle.

*X ray: ? Normal by radiologist and the surgeon

Rxed for spinal disorder for next one year

Admitted with increasing hip and leg pain

X ray:

Head is eccentrically situated in relation to the cup

R d i i hReduction in the “visualized femoral head” measurement (Faranz)

LeftRight

measurement (Faranz)

Lateral view

Metal shell

Liner

Stem

Metallosis

Worn out metal shell due to metal on metal articulation

Revision of acetabular component to cementedcomponent to cemented cup

E i i f th lExcision of the granuloma caused by metallosis

Type IV: Soft tissue interpositionType IV: Soft tissue interposition

83 Female : THR through posterior approach for #NOF (1995)

Anterior dislocationAnterior dislocationAnterior dislocationAnterior dislocation

Presented with anterior dislocation following a trivial twist

TreatmentTreatmentTreatmentTreatment

CR under GA with complete muscle relaxationCR under GA with complete muscle relaxation1. Manual longitudinal traction with the hip1. Manual longitudinal traction with the hipg pg p

flexion as well as in extension;flexion as well as in extension;2 The Allis and Bigelow methods2 The Allis and Bigelow methods2. The Allis and Bigelow methods. 2. The Allis and Bigelow methods. 3. Direct pressure + axial traction. 3. Direct pressure + axial traction.

Failed CR Failed CR Open reductionOpen reduction

Type IVa: Soft tissue interpositionType IVa: Soft tissue interposition

*Lateral approach (Hardinge)

*The neck was pinched in aThe neck was pinched in a fork between iliopsoas and rectus.

*R i f f h k*Rectus in front of the neck was divided.

Open reductionOpen reductionOpen reductionOpen reduction

Type IVb: Extensive myositis ossificans Type IVb: Extensive myositis ossificans with cup migrationwith cup migration

81yr Female81yr FemalePrimary THR 1978 Primary THR 1978 yyRevision THR (Hybrid) Revision THR (Hybrid) 1994 1994 The patient was The patient was mobilised PWBmobilised PWBmobilised PWBmobilised PWB

6 Months: asymptomatic

Check X ray showed: Cup migration and extensive myositis ossificans

Clinically hip was stable

Patient declined further treatment

Classification of Dislocation of THR Classification of Dislocation of THR needing open treatmentneeding open treatmentneeding open treatment needing open treatment

II Dislodgement of the stemDislodgement of the stemIIII Dislodgement of the cup Dislodgement of the cup g pg p

IIIIII Disassociation of the liner or head Disassociation of the liner or head IVIV InterpositionInterposition a Soft tissuea Soft tissueIV IV Interposition Interposition a. Soft tissuea. Soft tissue

b. Myositisb. Myositisc. Bone cement or c. Bone cement or

gentamicin gentamicin d. Pseudoaneurysmd. Pseudoaneurysm

ConclusionConclusionConclusionConclusion

C f l i d d di l d THRC f l i d d di l d THRCareful assessment is needed dislocated THR:Careful assessment is needed dislocated THR:

The surgeon should be aware of possible types The surgeon should be aware of possible types of irreducible dislocationof irreducible dislocationd b dd b d

Need for open reduction or revision should be Need for open reduction or revision should be discussed while obtaining informed consentdiscussed while obtaining informed consentdiscussed while obtaining informed consentdiscussed while obtaining informed consent

ConclusionConclusionConclusionConclusion

A working classification of irreducible A working classification of irreducible dislocation of the THR has been proposeddislocation of the THR has been proposedp pp p