Chronic posterior dislocation of the right hip treated with bipolar hemiarthroplasty in resource limited environment- a case report

Abstract

Introduction and importance

Chronic traumatic posterior dislocation of the hip is one of the uncommon conditions that surgeons in developing countries have to treat due to continued unvetted patronage of traditional bone setters by patients. It usually treatment challenges due to limitation in option available because resource constraints.

Case presentation

We present the case of 42-year-old male patient who presented to our hospital one and half years after sustaining road traffic accident. He had initial failed treatment with the traditional bone setters that left him with persistent right hip pain, limp, shortening and limitation of movement. He had initial heavy skeletal traction before an uneventful right bipolar hemiarthroplasty was done. His Harris hip score improved from 40.6 (preoperative) to 90.4 (postoperative).

Clinical discussion

Chronic posterior dislocation is a rarity in developed countries but is gradually becoming a common occurrence in developing countries. While total hip replacement is advocated in developed countries this may not be readily available due to financial constraints, poor access to the hospital, and fewer Orthopaedic surgeons to population ratios. This makes bipolar hemiarthroplasty used in this a readily available option that yielded a comparatively good outcome.

Conclusion

We propose that bipolar hemiarthroplasty is viable alternative to total Hip replacement in chronic posterior hip dislocation in resource limited environment where access to this procedure may not be easily available.

Highlights

• •Chronic posterior traumatic hip dislocation is one of the uncommon conditions that surgeons encounters in their Orthopaedic practice
• •A 42-year-old male with chronic traumatic posterior dislocation of the right hip. He had right bipolar hemiarthroplasty.
• •Harris Hip scores improved from 40.6 preoperatively to 90.4 postoperatively.

1. Introduction

A chronic dislocation of the hip is defined as one in the head of the femur that has stayed unreduced for more than six weeks [1]^, [2]^, [3]. It is not uncommon to have a few patients who present with this complication in developing countries due to delayed presentation to the hospital and seeking treatment from traditional bone setters [3]^, [4]. While a trial of reduction of neglected or unreduced hip dislocation can be attempted [5], it had been advocated that those with chronic posterior dislocation should be made to undergo total hip arthroplasty because of the increased likelihood of iatrogenic femoral shaft fracture, unstable reduction due to fibrous tissue overgrowth in the acetabulum and avascular necrosis of the head of the femur [3]. The longer head of the femur stayed unreduced, the greater the risk of the development of avascular necrosis of the head due to kinking of the retinacular artery of the medial circumflex femoral artery. This makes hip dislocation a surgical emergency. Posterior hip dislocation is the commonest form of dislocation in the hip and is very often secondary to high-energy injuries such as road traffic accidents. Chronic hip dislocation which is a rarity in developed countries is becoming a common occurrence in developing countries [1]. Decision-making can be challenging for surgeons practicing in developing countries when confronted with this kind of case because of the limitation of options available. While total hip replacement is usually the first line of treatment for such cases in developed countries; this may not be readily available due to the scarcity of needed expertise, ill-equipped hospitals, and few Orthopaedic Surgeon to population ratios. This makes it imperative for the few available surgeons to know alternative options for handling such cases in the face of resource constraints. Furthermore, a PubMed search revealed only a single paper that used hemiarthroplasty as a treatment option for chronic hip dislocation showing a paucity of its use [1]. The combination of these factors emphasizes the importance of this case report. We report a case of chronic dislocation of the right hip that was initially treated by the traditional bone setters but presented in our facility due to pain in the hip, difficulty with walking, and limitation of the activity of daily living. This case report is written in compliance with SCARE guideline [6].

2. Presentation of case

A 42-year-old male peasant farmer had a road traffic accident one and half years before presentation in our facility in April 2019 which resulted in injury to the right hip and femur. He was managed initially by the traditional bone setter but presented with persistent right hip pain, limping difficulty with walking, and limitation of the activity of daily living. Examination revealed a short limb antalgic gait and decreased range of motion of his hip. The limb was shortened (limb length discrepancy of 5 cm), fixed in adduction, and internal rotation with a Harris hip score of 40.6 %. Radiographs confirmed a dislocated right hip with false acetabulum in the right supra acetabular region with a united ipsilateral mid-diaphyseal femoral fracture [Figs. 1]. Patient could not afford a CT scan. He was initially put on heavy trans-tibial skeletal traction for 2 weeks before undergoing bipolar hemiarthroplasty using the modified Hardinge's direct lateral approach [5]. Operative findings were false acetabulum in the supra-acetabular region, the femoral head cartilage was yellowish with multiple erosion, and the acetabulum filled with fibrous tissue [Fig. 2, Fig. 3]. Femoral neck was made to retain part of the calcar and the acetabular floor was cleared of fibrous tissue. A cementless bipolar right hemiarthroplasty was done. The post-operative radiograph is shown in Fig. 4, Fig. 5. The patient had an uneventful recovery and was discharged 2 weeks postoperatively on partial weight-bearing with bilateral axillary crutches. The patient had a residual LLD of 1 cm. He was seen at 6 weeks, 3 months, and 6 months postoperatively with a Harris hip Score of 90.8 %, at the last, follow-up.

Fig. 1.

preoperative radiograph showing posterior dislocation of the right hip.

Fig. 2.

intraoperative image showing femoral head delivery into wound.

Fig. 3.

femoral head after the neck cut with irregular pitted head.

Fig. 4.

5 radiograph showing the bipolar prothesis.

Fig. 5.

Lateral view of the postoperative radiograph.

3. Discussion

Posterior dislocation of the hip is one of the Orthopaedic emergencies that warrant prompt intervention because the longer the hip remained dislocated, the greater the risk of avascular necrosis of the head of the femur. This risk increased from less than 10 % of reduction achieved within 6 h of injury to more than 50 % % if the reduction is done after 6 h post-injury [6]. However, in developing countries patients often failed to present within this time frame due to poor access to the hospital, lack of funds, and seeking alternative treatment from traditional bone setters [7]. Delayed presentation lead to further shortening of the affected limb, difficulty with walking, and inability to perform activities of daily living making treatment of neglected dislocation difficult to manage as time progresses. The acetabulum becomes filled with fibrous tissue and there is associated soft tissue contracture keeping the limb fixed in flexion, adducted, and internally rotated. Our patient presented one and half years after injury having had prior treatment at a local bone setter place. Due to this delayed presentation, initial heavy trans-tibia skeletal traction was done by a serial increase in traction weight over 2 weeks to stretch the contracted soft tissue. This was akin to the report by Kumar et al. where preoperative skeletal traction was done before operative treatment [4]. Similarly, Selimi et al. advocated for use of preoperative traction trans-tibia skeletal traction in patients whose dislocation was more than 12 months to stretch the taut and contracted hip muscles to facilitate reduction [1]. The incidence of avascular necrosis of the head of the femur increases with the duration of unreduced posterior dislocation, so is the incidence of post-traumatic arthritis even after successful reduction of neglected posterior dislocation of the hip, therefore Garret et al. advocated and recommended total hip replacement for hip dislocation with the duration of more than 3 months [3]. Previous reports on the outcome of THA for neglected posterior dislocation of the hip showed outcomes were graded as good to excellent function.

This was further corroborated by Jain et al. in their case series as evidenced by the increase in the preoperative Harris hip score from 27 to 42 to 81–91 in their three patients. In our patient, bipolar hemiarthroplasty was done for the patient due to cost constraints and lack of instrumentation for THR in the institution. The preoperative Harris Hip scores rose from 40.6 % to postoperative scores of 90.8 % similar to the report by Jain et al. [7] Also, the patient was relatively young, doing total hip replacement might warrant early revision later in life because the average expected implant life does not exceed 20 to 25 years in an actively mobile patient [8]. This is the high point of this case report. We, therefore, recommend that a bipolar hemiarthroplasty is a reasonable alternative for the patient presenting with a similar clinical scenario.

4. Conclusion

We opined a bipolar hemiarthroplasty is a viable option for surgeons practicing in a resource-limited environment when confronted with chronic posterior dislocation of the hip where facilities for a total hip replacement may not readily available.

Patient consent

Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical approval was waived for this article.

Funding

This case report did not receive any specific grant from funding agencies in public, commercial, or not for profit sectors.

Author contribution

AAO who operated the patient is a practicing Orthopaedic Surgeon with 22 years' experience in the field, wrote the draft of the manuscript. FAA assisted the surgeon at operation. He wrote the presentation of the case. AAO wrote the first draft. KSO helped in editing of final manuscript. All authors read and approved the final version to be published.

Guarantor

Dr. Anthony Ayotunde Olasinde is the guarantor for this publication.

Conflict of interest statement

None to declare.