Review Article

Hip Dislocation: Evaluation and Management

Abstract
David M. Foulk, MD Brian H. Mullis, MD

A simple hip dislocation is one without fracture of the proximal femur or acetabulum. Complex fracture-dislocations involve the acetabulum, femoral head, or femoral neck. The incidence of posttraumatic arthritis is much lower in simple dislocations than in fracture-dislocations. The most common mechanism of injury is a high-energy motor vehicle accident, which is usually associated with other systemic and musculoskeletal injuries. The hip should be reduced emergently in an atraumatic fashion. For acetabular fracture, intraoperative stress views may be necessary to evaluate for instability and to determine whether surgical xation is required. The appearance of a concentric reduction on plain radiographs and CT does not rule out intra-articular hip pathology; such injury may contribute to long-term degenerative changes. Other complications of hip dislocation include osteoarthritis, osteonecrosis, and sciatic nerve injury. Indications for surgical management include nonconcentric reduction, associated proximal femur fracture (including hip, femoral neck, and femoral head), and associated acetabular fracture producing instability. Surgical management ranges from formal open arthrotomy to minimally invasive hip arthroscopy. Hip arthroscopy has become popular for treating intraarticular hip pathology, including loose bodies, chondral defects, and labral tears.

From the Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN. Dr. Mullis or an immediate family member serves as a board member, owner, officer, or committee member of Wishard Hospital and Orthopaedic Trauma Association, and has received research or institutional support from Wyeth, Synthes, and Amgen. Neither Dr. Foulk nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article. J Am Acad Orthop Surg 2010;18: 199-209 Copyright 2010 by the American Academy of Orthopaedic Surgeons.

he hip is a diarthrodial joint that maintains its stability with a combination of bony and soft-tissue constraints. Incidence of hip dislocations and fracture-dislocations is increasing, with most occurring in young adults as the result of highenergy motor vehicle accidents. Substantial force is required to dislocate the native hip joint. This damaging force coupled with young age at disease onset may lead to prolonged disability and dysfunction from complications such as osteoarthritis (OA) and osteonecrosis. The rate of coxarthrosis following hip dislocation is between 24% for simple dislocations and 88% for

those associated with acetabular fracture.1 Associated morbidity is compounded by the presence of other systemic injuries, which occur in approximately 40% to 75% of cases.2 One half of multiply injured patients are likely to have an unsatisfactory long-term outcome.3 Timely reduction may be essential to the survival of the femoral head and should be considered on an emergent basis. Subsequent treatment is based on the ability to achieve a concentric reduction as well as on the presence of intraarticular loose bodies and associated fractures (ie, acetabulum, femoral neck, femoral head). Management is contingent on the postreduction clinical and

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Table 1 Classication Systems for Hip Dislocation Classication Thompson and Epstein4 Type I II III Description Dislocation with or without minor fracture Posterior fracture-dislocation with a single, signicant fragment Dislocation in which the posterior wall contains comminuted fragments with or without a major fragment Dislocation with a large segment of posterior wall that extends into the acetabular oor Dislocation with fracture of the femoral head Simple dislocation with no fracture or with an insignicant fracture Dislocation in a stable hip that has a signicant single or comminuted element of the posterior wall Dislocation with a grossly unstable hip resulting from loss of bony support Dislocation associated with femoral head fracture

Classication
Hip injury is classified based on the direction of displacement of the femoral head in relation to the acetabulum, whether anterior or posterior. The most widely used classifications are those of Thompson and Epstein4 and Stewart and Milford5 (Table 1). Anterior dislocations, which make up <10% of hip dislocations, can be divided into three types: obturator, pubic, and iliac.4 In obturator dislocations, the femoral head can be seen overlying the obturator foramen on an AP pelvic radiograph. The position of the femoral head determines whether the anterior dislocation is termed pubic or iliac. Here, we focus on the management of simple hip dislocations and dislocations associated with acetabular wall fractures that are deemed insignificant (<20% posterior wall involvement) and that do not produce instability on intraoperative stress fluoroscopy.6

IV V I II

Stewart and Milford5

III IV

radiographic findings and may range from nonsurgical care with limited weight bearing to open procedures, such as formal arthrotomy with surgical dislocation, or hip arthroscopy. Advances in arthroscopy have led to a high rate of early identification and management of intra-articular pathology.

cur much less frequently. This injury pattern can be produced by an external rotation and abduction moment.

Anatomy Diagnosis
The stability of the hip joint is dependent on the bony architecture and its soft-tissue constraints. The primary blood supply to the femoral head is derived from the medial femoral circumflex artery through the retinacular arteries, originating from an extracapsular ring at the base of the femoral neck. Other contributions arise from the lateral femoral circumflex artery, the obturator artery (through the ligamentum teres), and the inferior and superior gluteal arteries. The sciatic nerve lies in close proximity to the hip joint and can be injured in traumatic dislocation or with surgical dissection. In most patients, the nerve exits the greater sciatic notch anterior to the piriformis muscle belly; however, anatomic variation does exist, and the surgeon should take care to identify and protect the nerve. Because of the high-energy mechanism of injury, a thorough clinical examination should be performed in the emergency department, beginning with airway, breathing, and circulation evaluation and following standard Advanced Trauma Life Support protocols. The position of the involved extremity portends the diagnosis. Posterior dislocation results in a flexed, adducted, and internally rotated leg. Anterior dislocation results in an externally rotated posture in combination with slight flexion and abduction. A meticulous, well-documented physical examination should be undertaken, highlighting the presence of neurologic or vascular injury. The entire extremity should be examined to rule out other bony or soft-tissue injuries. Plain radiographs are essential in

Mechanism of Injury
The hip joint is inherently stable, and substantial force is required to displace the femoral head from the acetabulum. The most common mechanism of injury is a dashboard injury in a motor vehicle accident. Other mechanisms include a fall from a height, automobile-pedestrian accidents, and athletic injuries. The main determinants of the type of hip injury incurred are the amount and direction of applied load and the position of the hip at the time the load is sustained. For the typical dashboard injury, the hip is positioned in flexion and adduction, with the resultant load directed along the long axis of the femur. Anterior dislocations oc-

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Figure 1

AP pelvis radiographs demonstrating posterior hip dislocation (A) and anterior hip dislocation (B). (Panel B courtesy of Samir Mehta, MD, Philadelphia, PA.)

the workup. An AP pelvic radiograph should be obtained when hip injury is suspected. With posterior hip dislocation, the femoral head will appear smaller than that of the contralateral side and will be incongruent with the acetabulum. With such injury, internal rotation of the femur is noted because the lesser trochanter is poorly visualized (Figure 1, A). In anterior dislocation, the femoral head appears to be slightly larger than on the contralateral side, and the lesser trochanter is in full profile (Figure 1, B). Visualization of the femoral head and neck in question is important because the presence of an occult fracture of the femoral neck would mandate a change in treatment plan. In general, CT is not needed prior to emergent reduction unless there is a high level of suspicion for a nondisplaced femoral neck fracture. If it can be obtained easily and fairly quickly, the surgeon may consider obtaining a CT scan before reduction if a reduction is planned in the surgical suite and if there is strong suspicion that open reduction with possible internal fixation may be required
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to manage an associated fracture of the femoral head or acetabulum.

Associated Injuries
Hip dislocations typically present after high-energy motor vehicle accidents and have a very high likelihood of associated injuries,7 either systemic or musculoskeletal. Ipsilateral knee injuries are quite common. Schmidt et al8 reported that 89% of patients had visible evidence of softtissue injury about the ipsilateral knee. MRI revealed acute meniscal tear in 22% of patients, bone bruise in 33%, effusion in 37%, cruciate ligament injuries in 25%, collateral ligament injuries in 21%, and periarticular fracture in 15%. Sciatic nerve injury is another associated injury, occurring in 10% to 15% of hip dislocations.1,2,5 The peroneal division is affected more frequently than the tibial branch. The peroneal branch is tethered at the pelvis and at the fibular neck; thus, it has a lower capability of dissipating stress. Additionally, the fascicles of the peroneal division are fewer in

number, larger in size, and protected by less connective tissue. Partial return of function of sciatic nerve palsy can be expected in more than half of affected patients.

Management Closed Reduction

Closed reduction should be considered emergently to reduce the period of avascularity to the hip; however, adequate radiographic imaging is needed prior to any reduction maneuver so as to exclude the presence of an associated femoral neck fracture. Osteonecrosis has been reported in 11% to >34% of hip dislocations, depending on the severity of the injury.1,2,7 Regardless whether successful early reduction is achieved, the patient should be counseled about osteonecrosis as a potential complication. Early reduction may assist in returning normal blood flow to the hip, thus reducing the duration of ischemia to the femoral head. Ideally, the hip should be reduced in the operating room under general anesthesia in an attempt to minimize further damage to the articular carti-

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Figure 2

The Allis maneuver for reduction of posterior hip dislocation. A, Anteriorly directed traction is applied to the affected limb. B, A combination of counterpressure and gentle internal and external rotation is applied to assist in an atraumatic reduction. C, Limb adduction and inline traction may further aid a successful reduction. (Reproduced with permission from Levin P: Hip dislocations, in Browner BD, Jupiter JB, Levine AM, Trafton PG, eds: Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, p 1732.)

lage. Alternatively, some surgeons prefer to perform reduction in the emergency department if deep conscious sedation and good muscle relaxation can be achieved. There are advantages to reduction attempts in the emergency department. If the attempt is unsuccessful under adequate deep sedation, a CT scan can be obtained before reduction is attempted in the operating room; if the attempt is successful, the reduction is achieved sooner after injury. A potential disadvantage to a reduction attempt in the emergency department is that adequate sedation or paralysis may not be achieved, which could lead to further damage to the articular cartilage or to nondisplaced associated fractures. Closed reduction is usually accomplished via traction in line with the deformity. Many reduction techniques have been described for posterior dislocation. The Allis maneuver was first described in 1896.2 The patient is positioned supine on the op-

erating table, and traction is applied in line with the deformity while an assistant applies counterpressure to the pelvis. The hip is slowly flexed and is internally and externally rotated until reduction is achieved (Figure 2). The Bigelow reduction technique, described in 1870, also provides traction in line with the deformity, coupled with an adduction moment and internal rotation.7 Another reduction maneuver is the East Baltimore Lift, in which three persons produce a controlled traction maneuver without standing on the patients gurney9 (Figure 3). In each of these techniques, an audible and a palpable clunk may be noticed, signifying reduction. A repeat AP pelvis radiograph should be obtained to confirm the reduction. Although controversial, a CT scan is usually performed with 2-mm cuts through the acetabulum to evaluate for a concentric reduction and for the presence of intra-articular fragments or

injury to the femoral head and/or acetabulum. Once a successful reduction is obtained, hip stability can be assessed clinically by gently moving the hip through its range of motion. If there is no associated fracture on postreduction films, the leg should be extended and externally rotated, and a knee immobilizer should be placed to prevent inadvertent flexion at the hip. Evidence suggests that CT may allow the physician to augment the clinical examination with radiographic criteria for stability in the patient with an associated posterior wall acetabulum fracture. Keith et al10 used a cadaver model to determine the size of posterior wall fragment that resulted in an unstable hip. They concluded that when <20% of the posterior wall was fractured, the hip was stable. On the contrary, the hip was unstable when >40% of the wall was disrupted. Moed et al11 recently offered an alternative for measuring the percentage of posterior

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Figure 3

The East Baltimore Lift reduction maneuver for correction of posterior hip dislocation. A, The patients knee and hip are placed in 90 of exion. The surgeon rests one arm under the calf of the patient, with the surgeons hand positioned on the shoulder of the assistant across the table. The other hand is used to control rotation. B, The assistant positions his or her arm in a similar fashion as that of the surgeon. A second assistant is useful for stabilizing the pelvis. Anteriorly directed traction is applied by the surgeon and the assistant. (Reproduced with permission from Schafer SJ, Anglen JO: The East Baltimore Lift: A simple and effective method for reduction of posterior hip dislocations. J Orthop Trauma 1999;13:56-57.)

wall involvement. With this method, fractures involving <20% of the wall are considered to be stable, but the authors stressed the need for intraoperative stress testing. In the presence of an associated wall fracture, stability should be fluoroscopically evaluated in the surgical suite by placing the hip in 90 of flexion, 20 of adduction, and slight internal rotation, and then applying a posteriorly directed force. For other acetabular fractures, force should be applied in the direction of displacement for the given fracture pattern. Intraoperative radiographic analysis is performed with iliac/ obturator oblique views and an AP pelvis view. If there is no evidence of subluxation or dislocation, then the hip is determined to be stable. Treatment may include continued nonsurgical management with follow-up radiographs or hip arthroscopy to evaluate for chondral injury and loose bodies. If subluxation occurs, the hip is considered to be unstaApril 2010, Vol 18, No 4

ble, and surgical fixation of the fracture should be performed to prevent the development of premature arthritis. Tornetta6 described the aforementioned dynamic stress view to determine whether an acetabular fracture mandated surgical fixation. In fact, 3 of 41 fractures that met previous radiographic criteria for nonsurgical management were determined to be unstable on dynamic stress views and required fixation. This finding reinforces the need for stability testing. Any incongruity on radiographs or CT scan could signify the presence of bony or chondral fragments or softtissue interposition. Frick and Sims12 concluded that CT was not beneficial after closed reduction in a simple dislocation because no loose bodies were found on 3-mm CT cuts; therefore, the findings did not alter their treatment plan. However, a negative CT scan does not rule out the presence of intra-articular pathology.

Mullis and Dahners13 and Yamamoto et al14 have shown that there is a high prevalence of intra-articular loose bodies despite negative plain radiographs and thin-cut CT scan. Thus, several patients may have debris within the joint that goes unrecognized and untreated. Direct arthroscopic visualization is the best means of evaluating for such debris. MRI studies may be useful to diagnose the presence of chondral injury or soft-tissue interposition; however, MRI is rarely used in clinical practice and likely is not as sensitive as CT in evaluating for retained bony fragments. A nonconcentric reduction is a surgical emergency because of the pressure on the articular cartilage, even in the presence of restored blood supply to the femoral head. Whether skeletal traction emergently placed is adequate to relieve this pressure, as opposed to emergent open removal

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of loose bodies, is controversial. There are no clinical studies to guide this decision, but the size and location of the fragment and amount of displacement may be of value. A dislocation should be considered irreducible when a senior member of the orthopaedic team fails to obtain reduction despite the administration of an anesthetic that achieves deep sedation and good muscle relaxation. Irreducible dislocations may be the result of bony or soft-tissue interposition, and several structures have the potential to impede successful reduction, including the labrum, capsule, iliopsoas, rectus femoris, piriformis, gluteus maximus, ligamentum teres, or bone fragments from the acetabular wall or femoral head. In the setting of an irreducible dislocation, emergent open reduction should be considered to restore blood flow to the femoral head. A CT scan might be considered before proceeding to the operating room if the scan can be obtained without undue delay. The CT scan may help in identifying the offending structure, such as incarcerated bone fragments from a femoral head or a posterior wall fracture, or soft-tissue interposition.

Open Reduction
Historically, it was felt that open reduction of a hip dislocation should proceed from the direction of the dislocation. Epstein15 felt strongly that the hip should be approached in the direction of the dislocation, stating that the opposite-side approach is contraindicated for fear of complete embarrassment of the blood supply to the hip. In contrast, Swiontkowski et al16 reported no cases of osteonecrosis of the femoral head or difference in functional outcomes in 24 femoral head fracture-dislocations treated by either an anterior or a posterior approach. One relative in-

dication for an anterior approach may be the presence of a femoral head or neck fracture. Approaching the hip from a posterior direction may be more familiar to most surgeons and may provide easy access to fractures of the posterior wall. Regardless of the approach chosen, the joint should be cleared of all debris and thoroughly irrigated before reduction. The cartilage of the femoral head and acetabulum should be evaluated, and every attempt should be made to anatomically repair avulsed soft tissue and labral tears. Following reduction, the hip should be assessed for stability, especially in the presence of a posterior wall fracture. Traditionally, fragments of bone within the fovea centralis have not mandated removal. In the absence of other surgical needs (eg, large posterior wall fragment, femoral head fracture), there was no clear indication for surgical intervention. Typically, this fragment represented a chondral or osteochondral fragment pulled off by the ligamentum teres and was not thought to be prone to migration into the articular surface of the joint. This remains a topic of controversy.17 However, fragments that are incarcerated between the articular surfaces of the femoral head and acetabulum mandate removal to reduce the probability of chondral injury and subsequent OA. Open arthrotomy is the standard method for removal of incarcerated fragments. If the fragment originates from the posterior wall, is large enough for hardware fixation, and causes instability on an intraoperative stress test, then it should be fixed with open reduction and internal fixation. If the size of the fragment does not cause instability and if the fragment is too small for surgical fixation, then it can be confidently excised. Surgical dislocation as described by Siebenrock et al18 can be performed if needed, although it may

incur an additional risk to the femoral head, which would have already suffered a period of avascularity. However, Ntzli et al19 showed prompt return to normal femoral head blood supply after surgical dislocation with subsequent reduction.

Arthroscopy
Hip arthroscopy technique has advanced greatly in the past decade. Byrd and Jones20 performed hip arthroscopy for persistent hip pain in 15 traumatic injuries, of which 6 were dislocations. Thirteen of the 15 hips had associated findings at the time of arthroscopy, including labral tears, chondral damage, and loose bodies. Neglected labral pathology may be sufficient to incur more damage. Specifically, an inverted labrum can lead to premature OA.21 Degenerative changes may also be perpetuated, such as with third-body wear caused by retention of loose bodies. Evans et al22 provided basic science evidence in rabbits that cartilage debris causes effusion, synovitis, and degradation as well as histologic changes to the intact articular cartilage. Epstein2 reported absence of loose bodies in only 9% of hips managed with open procedures for fracture/dislocation. McCarthy and Busconi23 determined that 76% of loose bodies were not diagnosed on conventional radiographs. Mullis and Dahners13 performed arthroscopy on 39 hips after posterior dislocation or fracture/dislocation and found loose bodies in 92% (Figure 4). There were five simple dislocations, all of which were found to have loose bodies at the time of arthroscopy. The authors also determined that the presence of a concentric reduction on plain radiographs and no evidence of loose bodies on CT did not correspond with a clean joint. In fact, they found loose bodies in seven of nine cases (78%) that

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Figure 4

Figure 5

Arthroscopic view of a typical loose body seen following hip dislocation. (Reproduced with permission from Mullis BH, Dahners LE: Hip arthroscopy to remove loose bodies after traumatic hip dislocation. J Orthop Trauma 2006;20:22-26.)

Typical axial CT scan of a simple hip dislocation with a subtle nonconcentric reduction in the left hip. No loose body is seen, but its presence is indicated by the nonconcentric reduction.

were predicted to be free of intraarticular pathology by both radiographs and thin-cut (2- to 3-mm) CT scan. A typical axial CT scan that might be seen with a hip dislocation with a subtle nonconcentric reduction is shown in Figure 5. Yamamoto et al14 reported similar findings in 11 cases of hip dislocation. In eight cases, they found loose bodies that had not been visualized on preoperative radiographs or CT scan. Philippon et al24 recently performed a retrospective review of 14 professional athletes who sustained simple hip dislocation during active competition. All 14 patients had arthroscopic evidence of labral tears and chondral injuries, and 11 had loose osteochondral lesions. None of these retrospective studies has determined whether loose body removal improves patient outcome with decreasing incidence of resultant OA; however, animal evidence suggests that the presence of chondral debris may lead to premature arthritis.22 Although there is basic science evidence to suggest that hip arthroscopy may be beneficial for patients beApril 2010, Vol 18, No 4

cause it enables detection of loose bodies, no clinical evidence supports this. If arthroscopy is being considered to evacuate loose bodies from the joint, the senior author prefers to proceed with arthroscopy within 72 hours of injury to prevent further damage to the articular cartilage. Interim bed rest or skeletal traction may be indicated if a small loose body resides within the weightbearing portion of the joint. The congruency of the reduction and the size of the intra-articular fragment may influence the timing of surgical intervention (Figure 6). Arthroscopy is a safe alternative to arthrotomy for addressing intra-articular pathology,25 and it has several advantages over arthrotomy, including less disruption of the capsuloligamentous structures of the hip, less blood loss, reduced potential for neurovascular injury, and decreased recovery time. Relative indications for arthroscopy are listed in Table 2. Complications of hip arthroscopy include traction neurapraxia (sciatic and femoral), direct injury of nearby neurovascular structures (eg, lateral femoral

cutaneous nerve), portal hematoma/ bleeding, osteonecrosis, and iatrogenic articular cartilage injuries. There is one case report of extravasation of fluid with intra-abdominal compartment syndrome and subsequent cardiopulmonary arrest in a patient with a bothcolumn acetabulum fracture treated with hip arthroscopy.26 The reported overall complication rate is 1% to 6%;27,28 however, meticulous attention to surgical technique and decreased surgical time (ie, time in traction) can aid in minimizing these complications.

Rehabilitation
Rehabilitation after reduction and/or surgical intervention is controversial. Many suggest a short period of skeletal traction until pain is improved. Early gentle range of motion and patient mobilization should be instituted. Weight-bearing status is also a source of debate. Some advocate nonweight bearing for days to months, with the intent of reducing the likelihood of femoral head collapse in patients who develop os-

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Figure 6

Treatment algorithm for hip dislocation. ORIF = open reduction and internal xation

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teonecrosis. Several authors have reported that prolonged nonweight bearing has no significant impact on the incidence of osteonecrosis.4,5 Sahin et al7 retrospectively reviewed 62 cases of hip dislocation, 50 of which were managed with closed reduction. Neither the type of postreduction treatment (traction or bed rest) nor the time to full weight bearing influenced outcomes significantly. Given the lack of evidence to support a routine postdislocation protocol, return to weight bearing should be left to the surgeons discretion.

tions managed with rapid reduction.29 Dreinhfer3 reported fair to poor objective results in 16 of 30 posterior dislocations and in 3 of 12 anterior dislocations (53% versus 25%, respectively). Parameters such as time to reduction, postreduction management and rehabilitation, asTable 2

sociated injuries, and duration of follow-up vary by study, which makes it difficult to compare results (Table 3). Associated injuries may play a role in the patients outcome. Dreinhfer et al3 found that five of seven patients with multiple injuries had fair results, and six of seven

Relative Indications for Hip Arthroscopy Alternative to open arthrotomy for a simple dislocation with a nonconcentric reduction Alternative to open arthrotomy for a fracture-dislocation with a nonconcentric reduction associated with a stable acetabulum fracture not otherwise requiring open reduction and internal xation* Relative indication for a simple dislocation or a fracture-dislocation with a concentric reduction and without radiographic abnormality to evaluate for small loose bodies or a labral tear (weak clinical evidence to support if this changes patient outcome).
* If the fragment is seen on radiographic studies and originates from the posterior wall, uoroscopic stress views are recommended in the operating room. If the hip is unstable, open reduction and internal xation is required. If the hip is stable, consider arthroscopic removal of small loose bodies.

Outcomes
Good to excellent long-term outcomes are reported in half to nearly all patients with simple hip dislocaTable 3

Outcomes in Stewart-Milford Type I and Type II Dislocations* Study Armstrong32 Thompson and Epstein4 Paus33 Stewart and Milford5 Morton34 Brav30 Hunter35 Reigstad36 Upadhyay et al29 Hougaard and Thomsen31 Yang et al37 Anterior Posterior Schlickewei et al38 Dreinhfer et al3 Anterior Posterior Sahin et al7 Year 1948 1951 1951 1954 1959 1962 1969 1980 1983 1987 1991 83 87 94 75 48 71 NA NA 0 0 19 10 NA 19 10 11 26 16 NA 4 NA NA 5 NA Good or Excellent Results (%) 76 67 71 57 76 77 95 83 75 87 Osteonecrosis (%) 2 10 2 19 NA 22 4 3 NA 5 Osteoarthritis (%) 13 7 20 48 NA 26 NA 3 24 31 Sciatic Nerve Injury (%) 7 13 NA 13 NA 7 10 7 NA 6

1993 1994

2003

* Data extrapolated from original text and tables NA = specic data not available Adapted from Tornetta P III, Mostafavi HR: Hip dislocation: Current treatment regimens. J Am Acad Orthop Surg 1997;5:27-36.

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with isolated hip injuries had good results. Other factors that influence outcome include osteonecrosis and OA.

Complications
Time to reduction of the femoral head is one of the most important factors in deciding outcome. A timely reduction decreases the time of ischemia, theoretically improving the chances of survival of the femoral head.39 The critical time to reduction is controversial. Brav30 reviewed 262 patients, of whom 22% underwent reduction within 12 hours and subsequently developed osteonecrosis. In comparison, 52% of patients who had a delay in reduction >12 hours developed osteonecrosis. Hougaard and Thomsen31 retrospectively evaluated 100 hip dislocations after a minimum 5-year follow-up and found that 4% of patients reduced within 6 hours developed osteonecrosis and 58% of hips that were reduced later than 6 hours developed osteonecrosis. Dreinhfer et al3 retrospectively evaluated 50 patients who underwent reduction within 6 hours for simple hip dislocation. They found no difference between reduction performed within 60 minutes and reduction performed between 1 and 6 hours, with osteonecrosis occurring in 12% of all hips managed within 6 hours. The ultimate goal of management is to restore blood flow to the femoral head. The risk of osteonecrosis is substantial and may occur in up to one third of dislocations, depending on the severity of injury. Thus, the initial damage incurred at the time of injury is another important factor in determining treatment outcome. Higher-energy injuries with more damage to the surrounding blood supply tend to result in a higher incidence of osteonecrosis.7 Osteonecrosis appears within 2 years

of injury in nearly all cases.30 However, Cash and Nolan39 proposed that longer-term follow-up may be needed. They reported a case of osteonecrosis 8 years after simple dislocation in a hip without previous evidence of radiographic changes. Posttraumatic coxarthrosis is the most common complication after hip dislocation. It is thought to arise from catabolic effects induced by the traumatic impact sustained in the dislocation because small amounts of strain may have deleterious effects on the articular cartilage. Upadhyay et al29 reported a 16% incidence of posttraumatic coxarthrosis and an 8% incidence of coxarthrosis secondary to osteonecrosis. The natural history of symptomatic osteonecrosis has been documented to lead to collapse and subsequent OA. The rate of both posttraumatic coxarthrosis and osteonecrosis is much higher for posterior fracture-dislocation, with an incidence of up to 70%.5 Sciatic nerve palsy occurs in approximately 10% to 15% of persons with hip dislocation.5 The peroneal division is most commonly affected, likely because of the anatomy and composition of the peroneal division, the length of which is somewhat restricted, and in which bundles are larger and less cushioned by connective tissue. Partial nerve recovery can be expected in more than half of patients; however, the severity of the injury may play a role in functional return. Rehabilitation is important because skin complications and contractures can arise. The mainstays are protective skin barriers and dorsiflexion splints, with the latter used to maintain a plantigrade foot. Some authors propose exploration when nerve function does not return within 1 to 3 weeks.5 However, others suggest a much longer period of observation. Tendon transfers can be performed in recalcitrant cases.

Summary
Simple hip dislocation is a severe injury that requires prompt attention. A whole-body evaluation should be done because of the high degree of association with other injuries. Emergent reduction should be performed and subsequently confirmed by radiography and CT scan. Multiple modalities exist for treatment of this patient population. Hip arthroscopy has shown substantial improvement over the past 10 years and warrants consideration in the treatment algorithm because a high incidence of loose bodies and other intraarticular pathology can be found and addressed arthroscopically. Arthroscopy is an especially attractive option for simple hip dislocation with a nonconcentric reduction. The complication rate following arthroscopy is low when performed by an experienced surgeon. Outcomes range from poor to excellent, with no prospective evidence to guide us. Continued research is needed to determine whether long-term results are better with arthroscopy than with traditional methods.

References
Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, reference 17 is level V expert opinion, and all other references are level IV studies. Citation numbers printed in bold type indicate references published within the past 5 years.
1. Upadhyay SS, Moulton A: The long-term results of traumatic posterior dislocation of the hip. J Bone Joint Surg Br 1981;63: 548-551. Epstein HC: Traumatic dislocations of the hip. Clin Orthop Relat Res 1973;92: 116-142. Dreinhfer KE, Schwarzkopf SR, Haas NP, Tscherne H: Isolated traumatic dislocation of the hip: Long-term results in 50 patients. J Bone Joint Surg Br 1994;76:6-12.

2.

3.

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