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Logo of mjafiGuide for AuthorsAbout this journalExplore this journalMedical Journal, Armed Forces India
 
Med J Armed Forces India. 2015 July; 71(Suppl 1): S208–S210.
Published online 2014 April 26. doi:  10.1016/j.mjafi.2014.02.010
PMCID: PMC4529577

Arthroscopic removal of intraarticular fracture fragment after fracture dislocation of hip

B. Hari Krishnan, Col,a,* G.R. Joshi, Brig,b and Akshay Pushkar, Majc

Introduction

Hip arthroscopy has advanced dramatically since the 1990s. The techniques and indications have become better defined, instrumentation has improved, and results are showing early promise worldwide. The hip joint being a ball and socket joint is difficult to treat successfully arthroscopically.

The indications of hip arthroscopy are well defined but its scope is increasing. Arthroscopic removal of bullet fragments from the hip, extraction of intraarticular cement, and excision of impinging ligamentum tears have been reported. Contraindications are few and include ankylosis of the hip and superficial skin infections around the hip.

The use of arthroscopy for removal of intraarticular bony fragment after closed reduction of dislocation of hip promises to be a minimally invasive technique avoiding the morbidity of hip arthrotomy and damaging the important muscles, nerves & vessels, and thereby preserving the hip function. However, the procedure is technically demanding and a complete removal of intraarticular fragment is necessary for a good outcome.

Case report

A 21-years old male patient sustained pelvic fracture with fracture dislocation right hip, fracture posterior wall of right acetabulum, bilateral inferior pubic rami fracture and fracture superior pubic rami left in a motor cycle accident on 20 July 2012 (Fig. 1).

Fig. 1
Pre reduction X-ray showing dislocated RT hip.

The patient was managed by closed reduction of dislocated right hip on 20 July 2012 at a local hospital and discharged with an advice to seek further treatment from nearest Orthopaedic centre. He reported to Command Hospital (SC) on 24 July 2012 where a CT scan revealed an intraarticular loose body in right hip (Fig. 2 and and4).4). Arthroscopic removal of intraarticular loose body was done on 30 July 2012 and managed with post operative skeletal traction for 3 weeks (Fig. 3). The anterolateral portal was used for visualization and anterior portal was used as working portal for the extraction of loose fragment. Post operative recovery was uneventful. Patient was allowed partial weight bearing ambulation for the next six weeks.

Fig. 2
Post reduction CT scan showing intraarticular loose body in RT hip.
Fig. 3
Intra operative photograph showing the anterior and anterolateral arthroscopic portals.
Fig. 4
Intraarticular loose fracture fragment seen in arthroscopy.

On review after 6 weeks, he did not have any pain, swelling or deformity. The arthroscopic portals had healed well. There were no sinuses or local tenderness. Movements at hip joint were normal and pain free. He was able to ambulate without support with a normal gait.

Discussion

One of the earliest reports about hip arthroscopy was published in 1931 by Burman et al.1 Hip joint is a deep seated ball and socket joint. It has a thick capsular cover and muscles all around. The rigid instruments of arthroscope and the narrow joint space make hip arthroscopy a very challenging procedure. The femoral head is deeply recessed in the bony acetabulum and is convex in shape, unlike the more planar surface of the knee.2 Not only does arthrotomy of hip cause significant trauma to abductor apparatus and nearby neurovascular structures but it also predisposes the joint to subsequent dislocation, avascular necrosis of femoral head, heterotopic ossification and increased risk of infection. Hip arthroscopy has advanced dramatically since the 1990s. The techniques and indications have become better defined, instrumentation has improved, and results are showing early promise worldwide.3 Nonetheless, it is still early to determine all the direct benefits of arthroscopic hip surgery. The hip joint is difficult to treat successfully arthroscopically because of the sphericity of the head and the inaccessibility of certain areas and the flexible arthroscopes and operative instruments. Systematic arthroscopic examination of the hip can be performed through two portals: anterolateral and anterior.4 Arthropump and hypotensive anaesthesia may be used in selected patients for better visualization during the surgery.

The most common indications for arthroscopy of the hip include labral symptoms, buckling, locking, falling episodes, and persistent inguinal pain. Arthroscopic removal of bullet fragments from the hip, extraction of intraarticular cement, and excision of impinging ligamentum tears have been reported, and the arthroscope has been used in total hip replacement procedures. In adults, lavage and debridement for early-stage septic arthritis can be performed. In paediatric patients, the small size of the joint and the close proximity of neurovascular structures make the procedure difficult to perform safely and adequately. In addition, patients with long-standing, unresolved hip joint pain and positive physical findings may benefit from arthroscopic evaluation.5–10

Contraindications are few and include ankylosis of the hip and superficial skin infections around the hip. Relative contraindications include advanced osteonecrosis of the femoral head, advanced osteoarthritis, and congenital dislocation of the hip.

The use of arthroscopy for removal of intraarticular bony fragment after closed reduction of dislocated hip promises to be a minimally invasive technique. The procedure prevents the morbidity of arthrotomy such as damage of abductor muscles, nerves and vessels, thereby preserving the hip function. The post op rehabilitation is much easier and so is the outcome. However, the procedure is technically demanding and a complete removal of intraarticular fragment is necessary for a good outcome. Rigidity of the scopes makes manoeuvrability more difficult. Fracture table is required to distract the joint space. In our case, we managed to retrieve the loose fracture fragment with the help of rigid scopes used for knee arthroscopy (Fig. 4).

This procedure is, however, not free of complications. Breakage of scope and damage to the labrum and joint cartilage are commonly encountered. Cardiac arrest may result due to intraabdominal extravasation of fluid during arthroscopic removal of a loose body from the hip joint of a patient with an acetabular fracture.11

Conflicts of interest

All authors have none to declare.

References

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11. Bartlett C.S., DiFelice G.S., Buly R.L., Quinn T.J., Green D.S., Helfet D.L. Cardiac arrest as a result of intraabdominal extravasation of fluid during arthroscopic removal of a loose body from the hip joint of a patient with an acetabular fracture. J Orthop Trauma. 1998 May;12(4):294–299. [PubMed]

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