Bilateral  Simultaneous Traumatic Hip Dislocation In Opposite Direction At A Non Complient Patient

Savvas Lykoudis, Ioannis Koutroubas, Nikolaos Manidakis, George Tzoanos, Kyriakos Kakavelakis, Konstantinos Balalis, Pavlos G. Katonis.

Department of Orthopaedics and Traumatology,
Heraklion University Hospital Crete Greece.
Voutes Heraklion 71110

Address for Correspondence:
Savvas Lykoudis
Department of Orthopaedics and Traumatology,
Heraklion University Hospital Crete Greece.
Voutes Heraklion 71110

Abstract:

This case presents a bilateral simultaneous hip dislocation with left hip anterior dislocated and the right hip posterior dislocated accompanied by posterior wall fracture. The first try for reduction was made in the emergency room under sedation and a post reduction plain radiograph and C/T scan was applied. The left hip reduction was achieved but for the right hip an open reduction in the operating with posterior Kocher- Langebeck approach was applied with posterior wall fracture reconstruction and bony fragment from the hip joint removal. The patient was non-compliance and immediately after operation left the hospital, coming again to the emergency department after three months with loss of reduction from the right hip and fixation break down. The definitive treatment for the patient was cementless total hip replacement with metal cage in the acetabulum for posterior wall support. Traumatic hip dislocation is a true Orthopaedic emergency and it needs prompt diagnosis and immediate therapy.

J.Orthopaedics 2010;7(4)e3

Keywords:

Bilateral hip dislocation; acetabular fracture; closed reduction; open reduction; posterior wall reconstruction; total hip  arthroplasty; motor vechicle accident; patient compience.

Introduction:

Traumatic bilateral hip dislocation is a rare injury. It is caused by high-energy trauma and it accounts about (1-2)% of joint dislocations. [1] Even rare is the injury with bilateral total hip dislocation and the affected hips to be dislocated in opposite directions. [2,3,4]

A 47-years-old male is going to be presented at this case report . After a car accident he came to the hospital suffering from anterior dislocation of the left hip and posterior dislocation with posterior wall fracture in the right hip.

Case Report:

A 47-years-old male involved in a car accident was carried to the emergency department one hour after injury with his right hip flexed abducted and internally rotated whereas his left hip was moderately flexed abducted and externally rotated. The patient was conscious; he had no other associated injuries. His respiratory rate was normal; his peripheral pulses in arterial dorsalis pedis and arterial tibialis posterior were also normal. The patient had no other neurologic deficiency. Plain radiographs reveal an anterior dislocation in the left hip and posterior dislocation in the right hip associated with posterior wall fracture. There was also and a bone fragment in the right acetabular cavity. (Fig 1)At the emergency room and under sedation (iv. propofol and fentanyl) was made the first try for closed reduction. The left hip was reducted closely applying traction to the extremity while extending and internally rotated the hip. The reduction was checked with post reduction plain radiograph and C\T scan. It was also checked the stability and the range of motion of the hip. [fig.2] The right hip needed an open reduction in the operating room under general anesthaesia in order to remove the bony fragment of the joint and to reconstruct the injured acetabulum posterior Kocher-Langebeck approach was used. The bony fragment from the hip joint was removed and the posterior wall was reconstructed using screws and the right hip was reducted. There was no difference in the neurological status postoperatively. The patient was non-compliance he left the hospital immediately after the operation and he was applied full weight bearing since the first operation day. The patient came again to the hospital three months after the surgery at the emergency department with loss of fixation and the hip dislocated posteriorly again. [fig.3] As definite treatment in the right hip was applied cementless total hip arthroplasty with metal cage as posterior wall support. [Fig. 4]

Fig.1: AP radiograph of the pelvis at presentation showing anterior dislocation of the left hip and posterior dislocation with associated posterior wall fracture in the right hip.

Fig.2: C/T scan after first try for reduction showing that the left hip is reduced and a bony fragment in the right acetabulum and a posterior wall fracture.

Fig.3: AP radiograph showing a loss of reduction and reconstruction failure of the right hip.

Fig.4: A total hip Arthroplasty was applied with metal cage for posterior wall support.

Discussion :

The patient was in complete recovery. Traumatic hip dislocation is an injury that we rarely met. Represents  (2-5)% of all dislocated joints caused from trauma [3].  Bilateral simultaneous hip dislocations are even more unusual  [5]. The majority 90%, of hip dislocations is posterior whereas only 10% of incidences are anterior [6] The cause is the high-energy trauma such as motor vehicle accident [7] and depends on the position of the leg at the time of injury, posterior or anterior hip dislocation on associated posterior wall fracture will be present. (If the leg is flexed and adducted caused posterior hip dislocation). The patient should be examined for associated injuries carefully. These include femur fracture (about 4% of cases), vascular injury (external iliac or femoral vessels) especially in anterior hip dislocation [8], ligament knee injuries such as posterior curiae ligament injury or complete knee dislocation, sciatic nerve injury- predominately in posterior hip- dislocation, venous thrombosis and, as in our case, acetabular fracture. [9, 10] If the reduction is performed within the first six hours of injury, the risk of complications such as osteonecrosis of the femoral head, sciatic nerve injury is lower. [11] According to Thompson and Epstein classification, the left hip was type 1 and the right hip was type 4.The patient had dashboard injury and received direct trauma to both knees while his left hip was abducted, flexed and internally rotated and his right hip was abducted, flexed and externally rotated. [12]. The proper management for the patient was closed reduction for the left hip and open reduction with posterior approach reconstructing the posterior wall and removing the fracture fragment from the cavity, for the right hip. [13]. The patient postoperatively should avoid full weight bearing for the left hip four 6 to 8 weeks for capsular healing and at least 10 to 12 weeks for right hip until the fracture healing occurs. [14]. Unfortunatelly our patient left the hospital immediately after the operation and he beard his limbs coming three months later with complete loss of fixation and his right hip dislocated.

We considered the right hip was prolonged dislocated and the risk for avascular necrosis of the femoral head was very high. A total hip arthroplasty with metal cage for acetabular support was applied. For such injuries it is very important factor patients compliance and patients cooperation with his physician. Otherwise the outcomes are much less satisfactory than someone expects.

Reference:

1. Lam F, Walczak J, and Franklin A. Traumatic asymmetrical bilateral hip dislocation in an adult. Postgrad Med J2001; 18 : 506-507.

2. Speed K. Simultaneous bilateral traumatic dislocation of the hip. Am J Surg 1953;85:292.

3. Shukla PC, Cooke SE, Pollack Jr CV, Kolb JC. Simultaneous asymmetric bilateral traumatic hip dislocation. Ann Emerg Med 1993;22:1768—71.

4. Kerem BıLSEL, Bugra ALPAN, Ender UGUTMEN, Korhan OZKAN Bilateral simultaneous traumatic hip dislocation in opposite directions A case report Acta Orthop. Belg., 2009; 75: 270-272

5. Ozgur Sahin · Cagatay Ozturk · Ferit Dereboy · Oguz Karaeminogullari Asymmetrical bilateral traumatic hip dislocation in an adult with bilateral acetabular fracture Arch Orthop Trauma Surg 2007; 127:643–646.

6. KE Dreinhofer, Schwarzkopf, SR, NP Haas, and H Tscherne. Isolated traumatic dislocation of the hip. Long-term results in 50 patients. J Bone Joint Surg Br, Jan 1994; 76-B: 6 - 12.

7. Loupasis G, Morris EW. Asymetric bilateral traumatic hip dislocation. Arch Orthop Trauma Surg 1998; 118:179–180.

8. Holt GE, McCarty EC: Anterior hip dislocation with an associated vascular injuryrequiring amputation. J Trauma 2003; 55: 135-138.

9. Hillyard RF Fox J. Sciatic nerve injuries associated with traumatic posterior hip dislocations. Am J Emerg Med 2003; 21: 545-548.

10. Sanchez ML, Kovacs NK. Bilateral asymetric traumatic hip dislocation in an adult. J Emerg Med 2006 31:429–431.

11. Rodriguez-Merchan EC.Osteonecrosis of the femoral head  after traumatic hip disloctionin the adult. Clin Orthop Relat  Res 2000; 377:68-77.

12. Kaleli T, Alyuz N .Bilateral traumatic dislocation of the hip: simultaneously one hip anterior and the other posterior. Arch Orthop Trauma Surg 1998 117:479–480.

13. Rockwood and Green’s. Fractures in Adults sixth edition ; p.1742.

14. Rockwood and Green’s. Fractures in Adults sixth edition ; p.1740.

This is a peer reviewed paper 

Please cite as: Savvas LykoudisE: Bilateral  Simultaneous Traumatic Hip Dislocation In Opposite Direction At A Non Compience Patient.

J.Orthopaedics 2010;7(4)e3

URL: http://www.jortho.org/2010/7/4/e3

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