Surgical Dislocation of the Adult Hip.

A Technique
for the Treatment of Articular Pathology of the Hip
Martin Beck,* Shannon Puloski,* Michael Leunig,† Klaus-Arno Siebenrock,* and
Reinhold Ganz†

Surgical dislocation of the femoral head with trochanteric osteotomy is a safe and effective
approach for the treatment of articular pathology, including femoro-acetabular impinge-
ment, periarticular tumors, femoral head fractures, and some acetabular fractures. It now
allows the safe execution of subcapital reorientation procedures, femoral neck osteotomy,
and even femoral head osteotomy. It affords visualization of both the femoral head and the
acetabulum. Articular reduction can be visually confirmed rather than inferred from the
reduction of the retroacetabular surface. An understanding of the anatomy of the medial
femoral circumflex vessel is the key to avoiding complications with this approach. With the
experience of more than 1000 cases of surgical dislocation, no cases of osteonecrosis have
occurred.
Semin Arthro 16:38-44 © 2005 Elsevier Inc. All rights reserved.

KEYWORDS hip, intraarticular, surgical dislocation, trauma, impingement

S urgical dislocation of the hip affords the most complete

evaluation of the joint in the treatment of intraarticular
pathology but is rarely undertaken for reasons other than
total hip arthroplasty. Traditionally, the hip was dislocated
for the treatment of rheumatoid synovitis,1,2 synovial chon-
dromatosis,3 pigmented villonodular synovitis,4 labral tears,5
and joint debridement.6-9 However, concerns about the de-
velopment of avascular necrosis prevented surgeons from
performing surgical dislocation routinely. A surgical disloca-
tion of the hip can be performed through an anterior, lateral,
or posterior approach. Epstein and coworkers10 reported an
incidence of AVN of 5.3% for a posterior approach as op-
posed to 18% with the anterior approach. He argued that the
latter approach should not be used, stating that ligation of the
ascending branch of the lateral femoral circumflex artery
risks further disturbance of the femoral head perfusion.
However, Trueta and Harrison11 have shown that there is
little or no blood supply to the femoral head epiphysis from
the lateral femoral circumflex artery. Sevitt and Thompson12
were able to show that the principal vascular supply of the
*Department of Orthopaedic Surgery, University of Bern, Inselspital, CH-
3010 Bern, Switzerland.
†Department of Orthopaedic Surgery, Balgrist University Hospital,
CH-8008 Zürich, Switzerland.
Address reprint requests to Martin Beck, MD, Department of Orthopaedic
Surgery, University of Bern, Inselspital, CH-3010 Bern, Switzerland.
E-mail: martin.beck@insel.ch
femoral head epiphysis is the deep branch of the medial
femoral circumflex artery, which has been confirmed in other
anatomic studies.13 In the treatment of femoral head frac-
tures, Swiontkowski and coworkers14 compared the anterior
and posterior approaches and concluded that there was no
difference in the incidence of iatrogenic avascular necrosis.
Surgical Principles
The main perfusion to the femoral head in adults is from the
deep branch of the medial femoral circumflex artery
(MFCA).11-13,15 The artery of the ligamentum teres only sup-
plies the perifoveal area,12 and the lateral femoral circumflex
artery and the metaphyseal blood supply do not provide any
blood to the epiphysis of the femoral head.11,12
The surgical anatomy of the medial femoral circumflex
vessel has been described in detail.13 After its origin from the
deep femoral artery, the MCFA runs in a lateral direction
between the psoas and pectineus muscles and continues
along the inferior border of the obturator externus muscle at
the superior border of the quadratus femoris muscle toward
the greater trochanter. A constant trochanteric branch of the
vessel marks this level. After crossing the obturator externus
tendon dorsally, the vessel courses anterior to the triceps
coxae and perforates the hip joint capsule just proximal to the
superior gemellus muscle and takes a course as lateral epiph-
yseal vessels in a layer of connective tissue along the postero-

38 1045-4527/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.

doi:10.1053/j.sart.2004.12.004
Surgical dislocation of the adult hip 39

Figure 1 Diagram with the line of

the osteotomy of the greater tro-
chanter. Cranially, the osteotomy
exits just anterior to the most pos-
terior fibers of the gluteus medius
tendon. Distally, the origin of the
vastus lateralis remains on the tro-
chanteric fragment. (GMED: glu-
teus medius; PI: piriformis; OI:
obturator internus; Q: quadratus
femoris; VLAT: vastus lateralis.)
Reproduced with permission and
copyright © of the British Edito-
rial Society of Bone and Joint Sur-
gery.16

superior femoral neck. It penetrates the femoral head pos-
tero-superiorly on the epiphyseal side of the physeal scar.
Operative Technique
The surgical approach has been previously described in detail.16
Surgery is done in the lateral position. Initially we used a
Kocher–Langenbeck incision and the gluteus maximus muscle
and fascia lata were split in line with their fibers. With increasing
experience, we switched to a Gibson approach.17 The straighter
incision provides a cosmetically better result as there is less
“saddleback deformity” of the subcutaneous tissue (especially in
females). Because the gluteus maximus is detached in its integ-
rity, no denervation of the proximal portion occurs. The straight
incision is centered over the greater trochanter and the interval
between the gluteus medius and maximus muscle is developed
as the gluteus maximus is retracted posteriorly. The leg is then
internally rotated and the posterior border of the gluteus medius
is identified. At this stage no attempt is made to mobilize the
gluteus medius or to identify the piriformis tendon. A trochan-
teric osteotomy with an oscillating saw is performed, originating
from the posterosuperior edge of the greater trochanter to the
posterior border of the vastus lateralis ridge (Fig. 1). At its prox-
imal limit, the osteotomy should exit just anterior to the most
posterior insertion of the gluteus medius. This preserves and
protects the deep branch of the MFCA. The osteotomized
greater trochanter with the attached vastus lateralis is mobilized

Figure 2 In flexion and external rota-

tion of the femur, the trochanteric
fragment, including the tendon of
gluteus minimus, is turned over ante-
riorly. The interval between gluteus
minimus and the tendon of piriformis
is then developed and the gluteus
minimus is retracted superiorly to ex-
pose the capsule. (GMIN: gluteus
minimus; C: capsule; GMED: gluteus
medius; PI: piriformis; OI: obturator
internus.) Reproduced with permis-
sion and copyright © of the British
Editorial Society of Bone and Joint
Surgery.16
40
anteriorly. The vastus lateralis is released from the femoral origin
and the most posterior fibers of the gluteus medius often need to
be released from the stable trochanter. By retracting the gluteus
medius superiorly, the insertion of the piriformis tendon is iden-
tified and usually the most superior fibers have to be released
from the trochanteric fragment. With the leg flexed and exter-
nally rotated, the vastus lateralis and intermedius are further
released from the anterior and lateral aspect of the proximal
femur. The gluteus medius is retraced superiorly and the piri-
formis tendon becomes visible. The interval between piriformis
and gluteus minimus is opened and the gluteus minimus is
separated from the postero-superior acetabulum and joint cap-
sule (Fig. 2). The anastomosis between the inferior gluteal artery
and the deep branch of the MFCA, which runs along the inferior
Figure 4 Schematic showing
that for dislocation of the fem-
oral head the hip is flexed and
externally rotated. The leg is
brought over the front of the
operating table and placed in a
sterile bag. Reproduced with
permission and copyright © of
the British Editorial Society of
Bone and Joint Surgery.16
M. Beck et al.
Figure 3 For the Z-shaped capsulot-
omy, the femur is flexed and exter-
nally rotated further (arrows). The ex-
ternal rotators are left intact.
Reproduced with permission and
copyright © of the British Editorial
Society of Bone and Joint Surgery.16
border of the piriformis, should be preserved.13,16 The trochan-
teric fragment is mobilized anteriorly, and the superior and an-
terior capsule is exposed. A Z-shaped capsulotomy is performed
to access the hip joint (Fig. 3). The anterolateral capsular inci-
sion is made along the femoral neck to prevent iatrogenic injury
to the lateral epiphyseal vessels of the MFCA. The vessels lie
more posterior in a synovial fold. Exposure of the head is com-
pleted with an anteroinferior capsulotomy, leaving a caudal por-
tion of capsule intact and a posterosuperior capsulotomy along
the acetabular rim. The posterior capsulotomy should avoid the
labrum. For exposure of the retroacetabular surface, the pirifor-
mis tendon and triceps coxae tendons can be cut 2 cm from their
insertion onto the greater trochanter.13 The obturator externus
tendon and the quadratus femoris should be left intact to protect
Surgical dislocation of the adult hip 41

Figure 5 For inspection of the acetabulum

one retractor is impacted above the acetabu-
lum. One retractor hooks on the anterior rim
and a third retractor is placed in the incisura
acetabuli levering against the calcar of the
femoral neck. For inspection of the femoral
head, no retractors are needed; the knee is
lowered and with rotation of the leg different
surfaces of the head can be visualized. Re-
produced with permission and copyright ©
of the British Editorial Society of Bone and
Joint Surgery.16

the medial circumflex artery. The superior border of the latter

muscle is identified by the constant trochanteric branch of the
medial femoral circumflex vessel that is located at the cephalad
border of the quadratus femoris muscle. This branch also indi-
cates the location of the obturator externus tendon insertion.
The femoral head is dislocated anteriorly by flexing and
externally rotating the leg (Fig. 4). The ligamentum teres may
need to be transected to improve exposure. Once the hip is
dislocated, the femoral head and acetabular articular surface
are visualized (Fig. 5). Perfusion of the femoral head can be
documented by bleeding from a 2-mm drill hole into the
femoral head.18 Alternatively, bleeding can be confirmed
from the foveal area around the resected ligamentum teres.
During exposure, the cartilage should be frequently irrigated
to prevent drying and damage to the articular surface.19
With the head dislocated and positioned into the posterior
aspect of the surgical field, the acetabulum can be well visu-
alized. Placement of curved retractors will help facilitate ex-
posure. Evaluation and treatment of acetabular pathology
can commence. Addressing femoral head issues usually fol-
lows the acetabular procedure.
Reduction of the hip is easily done by traction on the flexed
knee and internal rotation. The capsule is repaired loosely Figure 6 With translucent templates the sphericity of the femoral
since a tight closure can diminish femoral head perfusion.20 head–neck junction is assessed in a hip with a cam-impingement.
The greater trochanter is reattached using two or three The aspheric part then is removed, until sphericity is achieved,
3.5-mm cortical screws. Prophylaxis against heterotopic os- which is the case when the template remains in complete contact
sification is not routinely used. Patients should be taught with the surface of the femoral head.
42 M. Beck et al.

Figure 7 (A, B, C) The torn labrum can be detached circumferentially

from the acetabular rim, as shown in this intraoperative photograph
(A). Thereafter the acetabular rim is trimmed back as needed (B) and
the labrum is sutured back to the rim with four to eight bone
anchors (C).

touch weight bearing (5 to 10 kg) for 8 weeks and then
progress to full weight bearing. Hip abductor strengthening
and range of motion exercises are initiated when full weight
bearing is initiated.
Surgical Indications
The technique of surgical dislocation is a very versatile ap-
proach and can be used for a variety of procedures. It gives
full access to the entire femoral head and acetabulum and
allows unrestricted inspection of the joint.
Our most common current indication is for the treatment of
femoro-acetabular impingement.21-23 Both impingement-re-
lated problems of the head–neck junction as well as problems of
the acetabular rim can be addressed. With translucent tem-
plates, the sphericity of the femoral head is assessed and the
aspheric section at the margin is removed (Fig. 6). On the ace-
tabular side, labral tears can be reattached with bone anchors.
Any excessive acetabular rim can be resected, particularly if
there is anterior overcoverage. In these cases the labrum is de-
tached from the acetabular rim and then reattached after resec-
tion of the excess bony rim (Fig. 7). Dislocation is also useful for
the treatment of chondromatosis, where arthroscopic treatment
often is not possible.
This approach also is useful in selected trauma cases includ-
ing transverse, T-shaped, and posterior wall fractures of the
acetabulum,24 femoral head fractures (Fig. 8), and combined
femoral head/posterior wall fractures. It affords exposure of the
articular surface of the acetabulum, retroacetabular surface, and
femoral head without risk of avascular necrosis. This is most
useful in assessing the joint reduction (Fig. 9) with the addi-
tional benefit of ensuring extraarticular placement of hardware.
Complications
Complications of this approach include heterotopic ossifica-
tion, trochanteric nonunion, and injury to the sciatic nerve.
In a previous review of 213 patients undergoing dislocation
for femero-acetabular impingement, 79 patients (37%) de-
veloped heterotopic ossification, of which 68 cases (32%)
were Brooker grade I, mostly involving the tip of the greater
trochanter. Only two patients (⬍1%) developed Grade III
ossification and ultimately required surgical resection.16
Avascular necrosis is avoidable, as long the technique is
Surgical dislocation of the adult hip 43

nacular vessels as the vessel courses along the posteroinferior

neck.
Iatrogenic injury to the sciatic nerve is rare, but can
occur after previous pelvic surgery, when the nerve is
tethered by scarring from previous dissection or fracture
hematoma. We observed three cases of transient sciatic
nerve palsy that were due to an aberrant course of the
sciatic nerve. During subsequent nerve exploration, the
peroneal and the tibial branches appeared separated and
the peroneal portion developed a transpirifomis course in
two cases and in one case the nerve coursed between the
superior gemellus and obturator internus. It is likely that

Figure 8 (A, B) Pipkin-II fracture in a 35-year-old male. After dislo-

cation of the hip, the ligamentum capitis femoris was sectioned. The
blood supply to the fragment is secured by the vessels in the inferior
retinaculum (Weitbrecht’s retinaculum). Figure 8B shows the situ-
ation after reduction and fixation of the fragment. To verify correct
fracture reduction, the sphericity of the femoral head was checked
with the translucent templates.

performed correctly. The trochanteric osteotomy should exit

just anterior to the most posterior insertion of the gluteus
medius tendon. This will prevent accidental injury to the
medial femoral circumflex vessel with the saw. During the
development of the interval between gluteus minimus and
piriformis, the dissection should remain strictly proximal to
the piriformis to protect the medial femoral circumflex ar-
tery. If the approach has to be extended to gain access to the
retroacetabular area, the piriformis, oburator internus, and
gemelli muscles should be transected at least 2 cm from their
insertion onto the proximal femur.13 The obturator externus
tendon and the quadratus femoris muscle should never be
transected since the vessel is protected by the obturator ex-
ternus tendon and enters the field at the superior border of Figure 9 (A, B) Transverse fracture of the acetabulum. The separa-
the quadratus femoris muscle.13 Finally, a Z-shaped capsu- tion of the fracture is easily visualized (A). After reduction and
lotomy with the anterior limb inferior and the posterior limb posterior plate fixation, the quality of the intraarticular reduction is
adjacent to the acetabular rim minimizes injury to the reti- assessed. Anatomic reduction of the fracture (B).
44
the nerve was tethered by its abnormal course and during
dislocation of the hip excessive traction or compression
was placed on the nerve.
Summary
Surgical dislocation of the femoral head is a safe and effective
approach for the treatment of articular pathology, including
femoro-acetabular impingement, periarticular tumors, fem-
oral head fractures, and selected acetabular fractures. If per-
formed correctly, it allows the safe execution of subcapital
reorientation procedures, femoral neck osteotomy, and even
femoral head osteotomy. It affords complete visualization of
both the femoral head and the acetabulum, thereby minimiz-
ing potential iatrogenic damage inherent to procedures such
as hip arthroscopy and arthrotomy without dislocation.
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