UNREDUCED ANTERIOR DISLOCATION OF THE HIP

Introduction

Traumatic anterior dislocation of the hip is uncommon as compared to the posterior dislocation and unreduced anterior dislocation is rare. Thompson and Epstein [1] reported 204 cases of dislocation of hip from a Los Angeles hospital record of 21 years and only 18 were anterior. Hamada [2] from Middle East, reported 7 cases of unreduced anterior dislocation of the hip for the duration of 10 years. Brav [3] reported 66 cases of anterior dislocation of the hip out of 523 hip dislocation, whereas Aggarwal [4] reported 7 cases of unreduced anterior hip dislocation.

The orthopaedic surgeons in the west are not likely to come across unreduced mismanaged anterior dislocation of the hip because of well organised health services in their countries. It often reflects failure of organised health-services and one such case is presented.

Case Report

A 16-year-old boy was admitted with the complaints of pain and stiffness of left hip following a scooter accident 4 months back. He was initially treated for fracture left calcaneum following the same accident, while the hip dislocation was missed. He complained of pain and stiffness in right hip and right sided limp. Examination of left hip revealed wasting of thigh and gluteal muscles. He was walking with the help of a stick. There was compensatory scoliosis towards the left. The limb was in flexion, abduction and lateral rotation at the hip. All movements of hip were absent except flexion and abduction which were markedly restricted. There was lengthening of limb by one inch. Radiogram of left hip (Fig 1) revealed anterior dislocation of the hip (obturator type).

Fig. 1.

Shows left anterior dislocation of the hip (obturator type).

He was given skeletal traction for 2 weeks pre-operatively. Open reduction of anterior dislocation was done by anterior Smith Peterson approach. Head and neck of femur were freed of fibrous tissue by combination of sharp and blunt dissection. Acetabulum was cleared by excision of fibrous tissue. Articular cartilage was healthy and intact. The head was relocated in the acetabulum with difficulty. Post-operatively he was given POP hip spica for 4 weeks followed by traction for six weeks alongwith active movements of left hip. The patient was followed up for 11 months. A repeat radiogram 11 months later (Fig 2) revealed no evidence of recurrence or avascular necrosis. He had achieved almost full pain-free movement of left hip. Patient was even able to squat (Fig 3).

Fig. 2.

Shows radiogram of same hip 11 months after operation.

Fig. 3.

Shows patient squatting, having almost full movements of the left hip.

Discussion

Management of old unreduced anterior dislocation of the hip is a taxing and difficult problem. The aim of any operative intervention is to correct the deformity and improve body mechanics and balance. Huckstep [5] in his series of 37 patients with neglected unreduced dislocation of the hip, managed 11 patients by closed reduction, 11 patients whose hip was painless with corrective inter trochanteric osteotomy and 12 patients with painful hips with excision arthroplasty of the hip with results ranging from excellent to poor. Arthrodesis was advocated for young patients in developing countries. Hamada [2] reported 4 cases and Aggarwal [4] reported 7 cases of the unreduced anterior dislocation of the hip. All cases were managed by trochanteric osteotomy with good results. Only one case by Aggarwal [4] was treated by open reduction and patient had painful hip during walking and reduction of joint space radiologically. Our patient has shown good functional results in terms of painless hip movements. This may be because this patient was young and dislocation was of only 5 months duration. Late complications like degenerative arthritis and avascular necrosis of femoral head cannot be ruled out as the period of post operative follow up has been only one year.