Neglected traumatic anterior dislocation of the hip. Open reduction using the Bernese trochanter flip approach — a case report

© 2017 The Author(s). Published by Taylor & Francis on behalf of the Nordic Orthopedic Federation. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Non-Commercial License (https://creativecommons.org/licenses/by-nc/3.0) DOI 10.1080/17453674.2016.1272375 Neglected traumatic dislocations of the hip are rarely seen in high-income countries, and the modern literature is limited on the subject. Reports on neglected anterior hip dislocations are especially scarce. At Kamuzu Central Hospital, in Lilongwe, Malawi, we have treated 4 patients for neglected traumatic dislocation of the hip over the last 3 years. Open reduction is diffi cult in these cases using traditional approaches, and this has resulted in the recommendation of salvage procedures such as intertrochanteric osteotomy (Hamada 1957, Aggarwal and Singh 1967) or modifi ed excision arthroplasty (Nagi et al. 1992). In 2013, we saw a 50-year-old builder who had fallen from a roof of a house and landed on his feet with an extended hip. According to the patient, a radiograph was obtained at a district hospital, but it was described as normal and he was sent home. He was seen at Kamuzu Central Hospital 4 months later with a painful right hip that was held in extension and external rotation. A pelvic radiograph revealed an anterior pubic hip dislocation. Open reduction was attempted with an anterior approach, but it was not possible for us to get good exposure of the acetabulum with the dislocated femoral head and neck covering the acetabulum, without substantial soft tissue release. We therefore ended up opting for a modifi ed excision arthroplasty as recommended by Nagi et al. (1992). When seen at follow-up approximately 3 months after surgery, the patient was still using 2 crutches and had pain and instability of the hip if he tried to walk without support. As is so often the case in our setting (Young et al. 2013), the patient was lost to follow-up after this. In September 2014, SY heard Dr Duane Anderson present his experiences from Ethiopia using the Bernese trochanteric fl ip osteotomy (Ganz et al. 2001) for neglected traumatic posterior hip dislocations. We have since used this method successfully on 2 male patients with neglected posterior hip dislocations (3 and 4 months after trauma), and we have become convinced that this is the approach of choice for open reduction of neglected traumatic hip dislocations. In both of these cases, the approach gave the necessary exposure of the acetabulum to remove all the fi rm scar tissue that fi lled it. In the fi rst case, the labrum was inverted into the acetabulum and needed to be cut and everted to allow reduction. The approach preserves the blood supply to the femoral head, if it is not already damaged at the time of injury. By drilling a small hole in the femoral head at the border of the joint cartilage, one can assess whether there is a viable blood supply to the head and whether this changes after reduction. In these 2 cases, reduction was possible without undue force. In the fi rst case, there was no bleeding from the drill hole in the femoral head. The patient quickly recovered and was discharged after a few days with partial weight bearing axilla crutches. The patient unfortunately never came back for review. The second patient had good bleeding from the drill hole before and after reduction. He was reviewed 3 and 8 months later and made a full recovery. Radiographs showed no sign of avascular necrosis or osteoarthritis at the last review. When we received a 51-year-old man with a 6-week-old neglected anterior pubic dislocation in November 2015, we thought that the approach would be worth using in this case also. The injury had happened as he was walking home in the dark and fell into a well, falling backwards with hyperextension of the hip. He was bedridden at home without being able to look after himself and was brought in by family members. At this point, the hospital had not had a working X-ray machine for 4 months, but the patient had a radiograph from a district hospital confi rming the diagnosis and showing some small bone fragments in the acetabulum (Figure). Our CT machine was still working at the time, and a CT scan confi rmed that there were several small fragments from the anterior lip lying in the acetabulum. 3D reconstructions showed how the dislocated proximal femur lay in the way of good exposure of the acetabulum with traditional anterior and lateral approaches. We worried that the external rotation of the hip would make the trochanteric fl ip osteotomy impossible, but after the spinal anesthesia was administered, the leg could be internally rotated to almost the neutral position and this turned out not to be a problem. The patient was placed in the lateral position and a digastric trochanteric fl ip osteotomy as described by Ganz was performed (Ganz et al. 2001). A 2.5-mm drill hole at the edge of the femoral head cartilage confi rmed that the circulation of the femoral head was intact. Good exposure of the acetabulum revealed several fragments from the anterior lip still attached to an almost totally detached anterolateral labrum. The totally avulsed anterolateral labrum and fragments were removed along with some soft, immature scar tissue that fi lled the acetabulum, and the acetabulum was irrigated to remove any remaining debris. The anteromedial labrum was better preserved and included another small acetabular edge fragment that was retained. Reduction was easily