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Pros and Cons of Surgical Hip Dislocation for the Treatment of Femoroacetabular Impingement

Tibor, Lisa M. MD*; Sink, Ernest L. MD

Journal of Pediatric Orthopaedics: July/August 2013 - Volume 33 - Issue - p S131–S136
doi: 10.1097/BPO.0b013e318286006e
Hip Disorders Supplement

A more detailed understanding of the anatomy of the medial femoral circumflex artery enabled the development of the modern technique for surgical hip dislocation. Although the surgical hip dislocation is best known as an open method for treating femoroacetabular impingement, it allows the surgeon to address a variety of different hip pathologies, including femoral head and posterior wall acetabular fractures, chondral defects requiring cartilage restoration techniques, and excision of benign tumors. When the technique of an extended retinacular flap is added, surgeons are able to perform intra-articular osteotomies and open reduction of slipped capital femoral epiphysis while preserving the blood supply to the femoral head. The surgical hip dislocation allows direct observation of both intra-articular and extra-articular impingement and a means of correcting both during 1 procedure. The downsides of the surgical hip dislocation are largely related to the trochanteric flip osteotomy, with up to half of patients reporting mild residual lateral hip pain 1 year postoperatively. Trochanteric nonunion and residual abductor weakness are also potential complications of the surgical hip dislocation technique. Several studies have shown improved pain and functional outcomes in short-term and mid-term follow-up after treatment of femoroacetabular impingement. It has a low complication rate in the hands of experienced surgeons and is an important technique for addressing complex intra-articular hip pathology that would be technically challenging arthroscopically.

*Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI

Center for Hip Preservation, Hospital for Special Surgery, New York, NY

This work received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

The authors declare no conflict of interest.

Reprints: Ernest L. Sink, MD, Center for Hip Preservation, Hospital for Special Surgery, 535 E. 70th St., New York, NY 10021. E-mail:

The modern technique of safe surgical hip dislocation was developed by Ganz et al1 based on a more detailed understanding of the anatomy of the medial femoral circumflex artery (MFCA).2 Their technique modified previous methods of approaching the hip to preserve the MFCA and decrease the risk of femoral head avascular necrosis. In particular, the surgical hip dislocation differs from a Kocher-Langenback approach by at least 2 specific modifications1: a Gibson approach between the gluteus maximus and medius, and a trochanteric osteotomy with an anterior capsulotomy and dislocation. The Gibson modification was initially described in 19503 and has the advantages of improved hemostasis intraoperatively and better preservation of gluteal function postoperatively.1,3 The trochanteric osteotomy leaves the external rotator and obturator externus tendons intact, protecting the MFCA but enabling an anterior capsulotomy and dislocation (Fig. 1).



Although the surgical hip dislocation is best known as an open method for treating femoroacetabular impingement (FAI),5 it allows the surgeon to address a variety of different hip pathologies. It does have particular importance to the history of the concept of FAI because the ideas about the pathomechanics and treatment of FAI were developed from observations made during surgical hip dislocations.5 Subsequent to this, the arthroscopic technique for treating FAI was developed and published,6 leading to frequent comparisons of open versus arthroscopic management of FAI.7–9 These comparisons aside, the pros and cons specific to surgical hip dislocation are worth considering when contemplating hip preservation surgery in the young adult.

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First and foremost, surgical hip dislocation is a very versatile approach to the hip. It can be used to treat a wide variety of intra-articular pathology that would be extremely challenging or impossible arthroscopically, or with other common open approaches to the hip. Surgical hip dislocation has been used in the trauma setting for open reduction and internal fixation of femoral head fractures10–12 and posterior wall acetabular fractures that do not extend into the posterior column.11–13 It has been described in multiple case reports as part of the treatment of chondral or osteochondral defects14–19 and for excision of benign tumors including exostoses,20,21 osteoid osteomas,20,22 and pigmented villonodular synovitis.20 It has also been used as a surgical approach for femoral head resurfacing23 based on the idea that preservation of the blood supply to the femoral head during resurfacing will decrease the rates of postoperative avascular necrosis and bone resorption under the resurfacing.

When the technique of the extended retinacular flap is added to a surgical hip dislocation,24 intra-articular osteotomies can be performed to treat pediatric hip diseases. Because these diseases can be addressed at the site of the deformity, potentially powerful corrections are possible. This enables a safe open reduction of moderate and severe cases of slipped capital femoral epiphysis, which is otherwise known as the modified Dunn technique.24–31 For patients with the sequelae of Legg-Calvé-Perthes disease, FAI from the large femoral head can be treated with osteochondroplasty and extra-articular impingement from the prominent trochanter can be addressed with relative femoral neck lengthening in the same setting (Figs. 2 and 3).24,32–36





With a surgical hip dislocation, one can directly observe both intra-articular and extra-articular impingement intraoperatively. Intra-articular FAI resulting from cam or pincer mechanics has been well described.5,37–42 During a surgical dislocation, the osteochondroplasty is easy to visualize. In particular, addressing atypical and posterior rim and cam impingement can be extremely challenging arthroscopically and may be safer or more straightforward with a dislocation. Extra-articular FAI is an emerging concept, but largely occurs due to contact between a prominent facet of the greater trochanter and the ilium or ischium. The classic example of extra-articular impingement is that occurring from trochanteric overgrowth after growth arrest at the femoral capital epiphysis in the post-Perthes hip (Figs. 2 and 3)24 or after closed or open hip reduction in young children with dysplasia. Extra-articular impingement can also lead to hip dislocation after total hip arthroplasty.43,44 In the native hip, the senior author has seen it most often in females who have relatively short femoral necks, prominent trochanters, and subtle cam or rim pathoanatomy. The patient often has symptoms and pain from impingement testing like patients with intra-articular FAI, but has only minimal or partial pain relief with an intra-articular injection. Three main types of trochanteric-pelvic impingement have been observed intraoperatively:

  • Contact between a prominent anterior facet of the trochanter or intertrochanteric ridge and the anterior rim of the acetabulum or anterior-inferior iliac spine in flexion and internal rotation.
  • Contact between a prominent posterior trochanteric ridge and the ischium in flexion, abduction, and external rotation. This may be more likely to occur in patients with excessive femoral anteversion because the trochanter is positioned relatively posterior.
  • Contact between a prominent or “high-riding” trochanter and lateral acetabular rim when the hip is abducted.

To treat extra-articular impingement, a careful intraoperative examination is used to identify the specific sites of impingement—both intra-articular and extra-articular—and the specific bony anatomy causing the impingement. Intra-articular cam and rim impingement is generally addressed first followed by reexamination. Extra-articular impingent is treated by addressing the specific site(s) of impingement identified on the intraoperative examination, with osteoplasty for an impinging anterior trochanteric facet, inside-out removal of a prominent posterior trochanteric ridge, or relative femoral neck lengthening. After treating the sites of extra-articular impingement, there should be a substantial improvement in range of motion.

When compared with arthroscopy, the learning curve for surgical hip dislocation may not be as steep.45–47 There may be less risk of chondral injury as compared to arthroscopy, where the incidence of chondral scuff is likely underreported.46,48,49 In addition, surgical hip dislocation avoids the need for intraoperative traction, which is a significant cause of complications in hip arthroscopy.45,46,48,49 Overall, in the hands of experienced surgeons, surgical dislocation has a very low complication rate and is considered a safe procedure.47

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The biggest downside of a surgical hip dislocation is the trochanteric ostetomy. Mild residual trochanteric pain 1 year postoperatively was common in 1 series of surgical dislocation patients,50 although it did not affect the functional outcome. Trochanteric nonunion is a concern and the rates of this vary dramatically.23,47 Thus, to protect the healing trochanter, most surgeons have their patients use crutches for 4 to 6 weeks postoperatively. A residual “saddlebag” deformity due to subtle pull through of the fascial sutures in the thin gluteus fascia may also occur. Patients may report aching pain and dissatisfaction with the appearance of their leg.1 Similarly, residual abductor weakness after the trochanteric osteotomy is a concern. Qualitatively, patients do seem to recover full abductor function postoperatively,1 but to date, no quantitative studies of muscular function after surgical dislocation have been published.

Although the ability to directly observe impingement at the time of surgery is an advantage of the surgical dislocation, correct management of impingement requires that the surgeon is able to recognize the pathoanatomy causing impingement and knows how to address it safely. A surgical dislocation is more invasive than arthroscopy, so careful soft-tissue handling and hemostasis have a significant impact on the postoperative result. Similarly, postoperative physical therapy that includes appropriate progression of range of motion, strength, and incorporates soft-tissue release work is critical for good results and return to activity. Unlike arthroscopy, surgical dislocation generally involves a short inpatient stay. In addition there is some potential for painful postoperative adhesions that can be related to the intraoperative soft-tissue management or postoperative rehabilitation.51,52

One of the most serious potential complications of surgical hip dislocation is avascular necrosis of the femoral head. This is an important consideration because the treatment options for avascular necrosis consist primarily of total hip arthroplasty or hip fusion. Both of these procedures have considerable morbidity for young patients, who are the patients most commonly undergoing surgical hip dislocation. In 2 large series of surgical hip dislocation, however, there were no reported cases of avascular necrosis.1,47 It is important to note that 1 of these 2 series was from the developer of the technique1 and the other was a multicenter study from 11 experienced hip preservation surgeons.47 As such, it is imperative that the anatomy of the MFCA be well understood and protected at all times by the treating surgeon. With this consideration in mind, it seems that surgical hip dislocation can be consistently performed safely.

Other known potential complications include mild heterotopic ossification47,53 and, similar to arthroscopic management of FAI, poor results in older patients or patients with preexisting arthrosis.53,54 In addition, because surgical hip dislocation and FAI are both relatively new, there may be unknown or unintended future consequences of these procedures that are not currently apparent.

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The mid-term (minimum 2-y follow-up, mean 5-y follow-up) results of surgical hip dislocation have recently been published.53 Approximately 80% of patients were satisfied with the results of the procedure and reported normal or near-normal hip function. There was a 3% conversion rate to total hip arthroplasty and 8% of patients required either major or minor revision. The major revisions primarily consisted of subsequent arthroscopy, whereas the minor revisions were for trochanteric refixation and fascial, IT band, or other soft-tissue problems.53 Hardware removal is common in Switzerland, where this study was performed, and 64.4% of patients underwent removal of their trochanteric screws.

The return to play for athletes undergoing surgical hip dislocation was initially touted as being much longer than for athletes undergoing arthroscopy for FAI.8,9 However, that gap seems to have narrowed with the publication of more recent arthroscopic and open series, such that most series report a variable return to sport at 4 to 9 months postoperatively.55–57 Furthermore, the rates of good to excellent outcomes after surgical hip dislocation for FAI are comparable to those reported for arthroscopic management.9,58,59

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The surgical hip dislocation has numerous advantages, particularly because it is a versatile, potentially powerful approach for treating intra-articular and extra-articular hip pathology in the young patient. Furthermore, it has been shown to be safe, with a low complication rate in the hands of experienced surgeons. It is an important technique for addressing more complex intra-articular hip pathology that would be technically challenging arthroscopically. Several studies have shown improved pain and functional outcomes in short-term and mid-term follow-up, but as with all techniques for addressing FAI, the effect on the natural history of FAI and the progression to arthrosis is, as yet, unknown and awaits long-term results.

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    hip preservation; surgical hip dislocation; femoroacetabular impingement; FAI

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