“I don’t understand why you’re in such a mood with me!” Fao exclaimed, exasperated. Ely had been off with him since he’d come in late the night before, and he’d finally lost it with her.
“Oh, I don’t know, maybe it’s because you’ve done close to an 80 hour week this week! I hardly see you, and you’re supposed to be taking things easy! You’re not long after major surgery, or had you forgotten that bit?”
“I’m recovered, I’m fine! I got the all clear to come back to work.”
“You got the all clear to take it easy at work! You’re so bullheaded!”
“It’s not my fault the department is down two surgeons. I have to work otherwise we’d have no trauma cover! You know what it’s like.”
“Not to the point of working yourself to death. They can get locums in, you’re going to end up hurting yourself Fao!”
“I’m not going to hurt myself.” He snapped. “I’m fine. You can’t wrap me in cotton wool forever, let me life my fucking life!” He turned away from his girlfriend, grabbing his boots. “I’m taking the dog for a walk, I’m not having this conversation anymore.”
“Oh, so we’re just going to ignore it, then. Sounds about right, you ignore everything else.” Ely retorted sarcastically.
“Oh, charming.” He muttered, resting his leg on the edge of the bed to tie his laces.
Finn had been standing outside his brother's door for most of the argument. He'd been about to knock before the raised voices, and he'd hesitated. His stomach was still flipping though, and he knew he couldn't leave it. He couldn't risk being alone.
He knocked gently. "Fao? Ely?"
Ely frowned. “Finn? What’s wrong?” She called.
"Can I come in?"
Ignoring Fao, Ely crossed the room to open the door. “Are you alright?”
He shook his head. "Feel all wrong. Didn't want to be alone."
Leg still up on the bed, Fao twisted to look at his brother, concerned. “Finn?”
"I need help."
“Why don’t you sit down?” Ely said gently.
"Can't."
“Sit on the bed.” Ely told him.
She didn't get it. "Can't."
Fao twisted further, trying to work out what the hell was going on. Really, he should have known better, but he wasn’t thinking. Finn was always his priority. That was, until pain overwhelmed him, and he struggled to stay upright. “Fuck.’
Finn was too distracted to pay attention to Fao, grabbing at Ely to stop himself falling.
“Oh, you have got to be kidding me.” Ely muttered, struggling to help Finn. “Fao, what’s going on?”
“Uh, I, fuck. Think I’ve done my hip.”
“The fuck do you mean done?!”
“Well, uh, it hurts.” He said weakly. “I think it’s dislocated. I’ll live. How’s Finn?”
"Ely." Finn managed between absences and myos. "'s Fao?"
Desperately trying not to keel over, Fao grabbed at the bed and tried to sit. “Ely, there’s midaz in my bedside drawer.”
“Why can’t the two of you just take it in turns?” She grumbled, grabbing Finn’s meds. “Fao, are you going to be alright?”
“I need help getting on the bed.” He whimpered.
Finn finally lost his fight against the seizure, slipping under and convulsing.
Keeping an eye on the time, Ely swore as Finn started to seize. But there wasn't a lot she could do, and so rushed to help Fao.
“You've got to be kidding me.” Fao groaned. The pain was immense, but he was more worried about Finn. He couldn't help manage the seizure, couldn't do much of anything. He was settled enough, and then pushed his girlfriend's hands off of him. “Sort Finn, not me.” He snapped.
Ely knew better than to argue with him, and wordlessly crouched next to Finn. They at least had pillows to protect him a little, but really it was a waiting game until they could give Midaz. She just hoped he resolved before then.
It did, thankfully. It still left him unconscious and out of breath, his tongue bleeding and running down his cheek. Finn didn't move, taking his time to come round.
Worried, Ely took a quick set of obs (as many as she could, anyway, and then left Finn to come round in his own time, propped up on his side. She turned her attention to her boyfriend, but one look told her all she needed to know.
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I'm in so much pain from my job but I can't stop working, because I have literally just enough money for rent next month, not enough for food, or school, just rent. So I'm working with a shredded ligament in my dominant hand, a hip that dislocates on the reg, and terrifying neurologic symptoms that I don't know what they are because doctors cost money. I hate my body. I hate my genes. I hate my job. I hate everything. I hate pain.
Hip dislocation often causes severe pain and limits mobility, necessitating immediate medical attention to realign the joint and prevent fur
Hip dislocation often causes severe pain and limits mobility, necessitating immediate medical attention to realign the joint and prevent further complications.
Well, Hip Dislocation can also occur in newborns and the condition is congenital hip dislocation, and this is what we will discuss in the post. Let us start with a brief introduction to the condition.
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What do You Need to Know About Congenital Hip Dislocation?
Hip dislocation is a debilitating condition that makes it difficult for the person to walk, stand, or sit. Dislocation often occurs because of traumatic conditions in adults, and in the elderly, routine activities may dislocate their hip. However, hip dislocation may also occur at birth and such a condition is called congenital hip dislocation. In this post, we will discuss it in detail.
Hip dislocation is a condition characterized by the displacement of the femoral head from its socket. In other words, when the ball (femoral head) moves out of the socket (acetabulum), the condition is called hip dislocation. Now, depending on the severity of the condition, the dislocation could be complete or partial. Let us see it in detail.
The Role of Surgical Hip Dislocation in the Management of Selected Traumatic Injuries: A Case Series by Thiago SB
Abstract
Objective: We aimed to report our initial experience with hip surgical dislocation in a series of cases of different traumatic injuries. We have reviewed the relevant literature. Ganz initially described the surgical hip dislocation as a technique for treating femoroacetabular impingement through a safe hip dislocation. The method was later described as an auxiliary tool for managing specific patterns of acetabular and femoral head fractures.
Methods: We retrospectively analyzed 10 cases of traumatic injuries treated at our institution using the controlled Ganz dislocation from 2013 to 2015.
Results: The main indication found was an acetabular fracture. Other indications were fractures of the femoral head in two cases and two cases of withdrawal of an intra-articular firearm projectile. The average age was 37.2 years, all individuals were male, with a follow-up of 23.5 months. At the endpoint, all osteotomies healed, and there was no case of avascular necrosis of the femoral head. The results found in this study were similar to those in the literature.
Conclusion: In our experience with the Ganz technique applied to selected trauma cases, there was clinical and radiographic healing of the trochanteric osteotomy in all cases. There was no episode of aseptic necrosis of the femoral head until the mean follow-up of 23.5 months.
Keywords: Hip Dislocation; Ganz; Femoral Head Fracture; Acetabular Fractues
Introduction
The treatment of specific traumatic injuries to the hip and acetabulum in young adults represents a challenge for the orthopedic surgeon. In addition to the initial trauma, usually of high energy, there is the risk of secondary complications such as post-traumatic arthritis or avascular necrosis of the femoral head (AVN), among others, aggravated by the surgical trauma itself and also by the inherent difficulties in the treatment of these injuries. Based on previous anatomical studies, described in 2001 a technique of surgical hip dislocation with no case of AVN reported in their series [1,2]. Firstly conceived for the treatment of femoral-acetabular impingement, later its use was also expanded for traumatic injuries of the hip [3]. In this way, it became an ancillary tool for the treatment of selected patterns of joint fractures, allowing a more significant reach, including a 360-degree direct view of the femoral head's articular surface and acetabulum [4]. The main indications for its use in trauma are acetabular fractures [5-8]: high transverse or associated with fracture of the posterior wall, juxtatectal, "T" fractures, in addition to aged fractures [9] or simply when there is a need for better, direct control of the reduction. Other indications include: femoral head fractures [10-12], irreducible posterior dislocations13 or removal of intra-articular foreign bodies [14]. The objectives of this study are to evaluate the safety of Ganz's surgical dislocation concerning the consolidation of trochanteric osteotomy and the presence or absence of avascular necrosis of the femoral head in our initial series with this technique applied to the selected traumatic injuries of the hip.
Materials and Methods
From the hospital records and through the digital image file, all the first 10 cases treated at our service were identified and analyzed retrospectively. Ganz controlled dislocation was used to treat traumatic hip injuries. All cases were treated by the main author, between the years 2013 to 2015. Medical records and radiological images were evaluated.
For radiological analysis, the radiographic anteroposterior, alar, and obturator views were initially evaluated alongside the computed tomography studies to classify the lesions. In addition to the preoperative radiological images, records of surgical description and medical records were also considered for the characterization of lesions. Follow-up images were evaluated radiographically in anteroposterior and frog views. All postoperative images were scrutinized for radiographic signs of avascular necrosis of the femoral head or the greater trochanter's nonunion.
Surgical Technique
The technique described by Ganz2 consists of positioning in lateral decubitus, Gibson or Kocher-Langenbeck (KL) access, fasciotomy between the gluteus maximus muscles, and tensor fascia lata (Gibson) or divulsion of the gluteus maximus muscle (KL). KL access is used in the traditional way when posterior fixation to the wall or acetabular column is required. When this is not necessary, Gibson access is used. Next, the osteotomy line of the greater trochanter (GT) is identified, connecting the posterior edge of the vastus lateralis muscle with the posterior border of the trochanteric insertion of the middle gluteal muscle. In this stage, the GT can be pre-drilled to facilitate its fixation at the end of the procedure. The osteotomy is performed with a saw, leaving the trochanteric fragment with about 1 cm to 1.5 cm in its greatest thickness. In this way, the fragment is then elevated anteriorly, the capsular insertions are previously detached, while the lower limb is rotated laterally. A figure in "Z" capsulotomy is performed, with the anterior section of the capsulotomy towards the neck and the posterior section following the acetabular ridge, taking care not to injure the acetabular labrum. The ligament teres is sectioned, and the femoral head is elevated from the acetabulum (dislocation). The femoral head is perforated with a Kirschner wire or 2.0mm drill to ensure its viability (through the presence of active bleeding through the orifice). Maneuvers with the lower limb allow full exposure of the femoral head and the acetabulum's articular surface. The femoral head must be irrigated continuously with physiological saline to prevent chondral dryness. After the desired repair, the joint is reduced and the capsulotomy is sutured. The digastric osteotomy is fixed using two or three 3.5mm bi-cortical traction screws, directed to the calcar. The surgical wound is then closed in layers in the usual manner. We evaluated all patients radiologically for the healing of trochanteric osteotomy and the presence of NACF. The study was approved by the Research Ethics Committee of our institution and is registered on Plataforma Brasil.
Results
Table 1 shows the complete description of the studied population. Of the ten patients who underwent this technique, all were male. Age ranged from 21 to 54 years, with an average of 37.2 years. Follow-up ranged from 12 to 37 months, with an average of 23.5 months. The main indication for the use of controlled dislocation was an acetabular fracture, in three cases, juxtatectal transverse fractures and one case associated with the posterior wall. Other indications were a "T" fracture in two cases, fractures of the femoral head in two cases (one associated with the posterior wall of the acetabulum), and two intra-articular firearm projectiles removal. All patients presented consolidation of the trochanteric osteotomy and absence of signs of NACF in the last follow-up, through radiographic evaluation.
The complications observed were as follows: According to family members, case 2 had a history of psychiatric illness and walked without crutches at home since the first days after surgery due to a mental crisis for refusing to use his routine medications. He returned to the outpatient clinic thirty days after surgery, with loss of reduction of the acetabular fracture. Total hip arthroplasty was indicated after the control of the psychiatric condition and fracture healing. In definitive surgery, four months after the fracture, there was a regular extoscopic aspect of the femoral head medulla, which was then particulate and used as a graft. The trochanteric osteotomy was healed. It evolved satisfactorily after arthroplasty until the last follow-up. Case 4 presented Grade 1 heterotopic ossification, according to Brooker, without complaints or functional limitations. Case 6 presented the loosening of the trochanteric fixation in the week following the surgery. It was found that he was walking without crutches, jumping on the contralateral side. It was surgically reopened, and the osteotomy was re-fixed, using 4.5mm screws, evolving satisfactorily with GT consolidation and without NACF until the last follow-up.
The analysis of complications in cases 2 and 6 highlights the need for a meticulous preoperative selection. The lack of adherence to the postoperative protocol may have precipitated the need for reoperation. Case 9, with a diagnosis of irreducible posterior dislocation associated with a femoral head fracture, was referred to our service with five days of evolution. In the intraoperative period, the viability of the femoral head (bleeding) was verified. Total traumatic avulsion of the tendons of the gluteus medius and minimum of their insertions in the greater trochanter was also found reinserted to the footprint with titanium anchors at the end of the procedure. In this case, trochanteric osteotomy was not performed, given that the abductor system was no longer an obstacle due to its traumatic disinsertion, but the same technique of anterior "Z" arthrotomy and anterior dislocation was performed. This case was the subject of a case report by this team due to the rarity of the associated injuries.
Discussion
Ganz's technique, initially described for the treatment of femoral-acetabular impingement in 2001, with a series of 213 patients and a seven-year follow-up, proved the possibility of addressing the hip joint surface in its full range, without the risk of osteonecrosis [2-4].
The technique, initially developed to allow total joint access in elective cases, was later described for the treatment of acetabular fractures5-8 and femoral head.10-12 Siebenrock reported a series of 12 patients treated for traumatic pathologies with no evidence of NACF in a 35-month follow-up.3 Tannast published a series of 60 cases of acetabular fractures using controlled dislocation with no occurrence of NACF in eight years of follow-up.8 He also stressed the usefulness of intra-articular control in reducing and preventing intra-articular synthesis material. Haverkamp [9] demonstrated the utility of Ganz's dislocation for the treatment of acetabular pseudoarthrosis. According, the traumatic fracture-dislocation of the femoral head presented a better prognosis when treated using the Ganz technique, when compared to other accesses [12]. Keel et al. reached similar conclusions [13] Maqungoa [14] described firearm projectile removal cases using the Ganz technique with satisfactory results.
We had two possibly preventable complications (cases 2 and 6). The lack of adherence to postoperative care seems to have led to the need for a re-operation, but which did not present AVN and culminated in osteotomy healing. Case 4 showed grade 1 heterotopic calcification of Brooker, which was reported as the most frequent complication in this access, but without any clinical repercussions.
Conclusion
In our experience with Ganz controlled dislocation applied to trauma, there was clinical and radiographic consolidation of trochanteric osteotomy in all cases, and there was no episode of aseptic necrosis of the femoral head until the mean follow-up of 23.5 months.
