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Ganz safe surgical dislocation of hip : an overview
Jacob PJ1, Sreeganesh K2
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Govt. Medical College
Thrissur, Kerala, India
1
Additional Professor of
Or th opae di cs
2
Resident in
Or th opae di cs
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Kerala Journal of
Orthopaedics 2013 ;26:
10 7- 10 9
© Kerala Journal of Orthopaedics
INTRODUCTION
Internus and Gemelli anteriorly and then perforates
Surgical dislocation of hip has been indicated the capsule to continue its intracapsular course.
for many pathological conditions in adults and
children. One common complication of this
Gautier et al. proposed that the relation
procedure is avascular necrosis of femoral head.
between the deep branch of MFCA and that of
Obturator Externus is surgically important because
Ganz et al. described a technique of surgical the tendon protects the branch from being disrupted
dislocation of hip involving trochanteric flip or stretched during dislocation of hip traumatically
osteotomy and anterior capsulotomy preserving or surgically.
the blood supply to femoral head. The technique
is based on extensive study of blood supply to the
It is found that the risk of AVN in an
proximal femur. This technique allows us to uncomplicated hip dislocation treated conservatively
completely dislocate the joint creating a space of is 11% as compared to 31% in a surgically treated
up to 11cm which allows complete access to intra fracture dislocation. Ganz et al. postulates that this
articular pathology. This technique has also been difference may be due to the rupture of Obturator
used for hip arthroplasties.
Externus and the resultant damage of deep branch
of MCFA.
Blood supply to femoral head
Based on cadaveric studies on twenty four
Gautier et al. also studied the average distance
hips, Gautier et al. have postulated that the blood of deep branch of MFCA from trochanteric crest
supply of femoral head is mainly based on medial which can be considered as a useful guide for the
circumflex femoral artery (MFCA). The course of surgeon while operating the hip. The average distance
MFCA in its extracapsular division is relatively was 18.2 mm from the lesser trochanter, 8.8 mm at
constant. This extracapsular ring gives inferior, the level of Obturator Externus tendon and 12.4
posterior and superior retinacular vessels. Damage mm at the level of Obturator Internus tendon.
to short external rotators can interfere with the
perfusion of femoral head.
This shows that the artery is always farthest
from lesser trochanter and always closest to the
The blood supply to the weight bearing trochanteric crest at the level of Obturator Externus.
portion is mainly derived from the superior Gautier also found on their detailed dissection that
retinacular vessels. The inferior retinacular, the ascending branch of lateral circumflex artery
metaphyseal, lateral circumflex femoral and the (LCFA) contributes very little to the blood supply of
artery of ligamentum teres contribute very little the femoral head and the anastamosis between
to the blood supply of head of femur.
MFCA and LFCA undergoes involution after one
year of age.
In all cases they found a consistent relation
between the attachment of Obturator externus
There is an always constant anastamosis
tendon and the deep branch of MCFA, that the between deep branch of MFCA and a branch of
tendon is crossed posteriorly by the deep branch inferior gluteal artery along the piriformis. This might
of MFCA as it winds around the base of neck compensate for the reduction in blood supply after
posteriorly. After this, the artery passes superiorly injury to the former vessel.
crossing the conjoint tendon of Obturator
Indications
Kerala Journal Of Orthopaedics Volume 26| Issue 2 | July 2013
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Comment ary
Jacob et al .: Ganz safe surgical dislocation of hip : overview
Paediatric population
1.
Femoral head impingement in deformed head
due to Legg - Calve - Perthes disease.
2.
Correction of intra articular deformity in Slipped
capital femoral epiphysis.
Adult population
1.
Femoral head fractures
2.
To remove intra articular fracture fragments in
fracture dislocation of femoral head
3.
Re fixation of labral tears under vision
4.
Correction of femoro acetabular impingement
5.
As an approach for surface replacement
arthroplasty
6.
As an approach for acetabular fractures
7.
To approach intra articular pathologies like
synovial chondromatosis, pigmented
villonodular synovitis and in joint debridement
Steps of safe surgical dislocation
Exposure: The patient in positioned in the lateral
decubitus position. A Kocher- Langenbeck approach is used
and fascia is split accordingly in the superior portion and gluteus
maximus fibres split along the inferior portion. An alternative
approach is the Gibson approach. The leg is internally rotated
and the posterior border of gluteus medius is identified
Trochanteric flip osteotomy
An incision is done from the postero superior trochanteric
edge to the posterior border of ridge of vastus lateralis.
Trochanteric osteotomy is done with a maximal thickness of 1.5
cm and the trochanteric fragment is mobilised anteriorly with
the fibres of vastus lateralis. A successful osteotomy means the
upper edge of the osteotomy passes just anterior to the most
posterior border of gluteus medius and only a part of fibres of
the tendon of piriformis need to be released for the mobilisation
of the greater trochanteric fragment.
Capsular exposure
The leg is then flexed and slightly rotated externally and
vastus lateralis and intermedius are elevated from the lateral and
anterior aspects of the proximal femur.
· The tendon of piriformis can be carefully dissected by
anterosuperior retraction of the posterior border of gluteus
medius. The inferior border of gluteus minimus is separated
from the relaxed piriformis and underlying capsule. The constant
anastamosis between the inferior gluteal artery and MFCA, which
runs along the distal border of the piriformis muscle and tendon,
is preserved. Care has to be taken to avoid injury to the sciatic
nerve, which passes inferior to the piriformis muscle into the
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pelvis.
The entire flap, including gluteus minimus, is retracted
anteriorly and superiorly to expose the superior capsule, facilitated
by further flexion and external rotation of the hip. This exposes
the anterior, superior and postero superior capsule
Capsulotomy
An anterolateral incision on the capsule along the axis of
the femoral neck is done. An antero inferior incision along the
intertrochanteric line ending just anterior to the lesser trochanter
to avoid damage to the main branch of the MFCA, which lies
posterosuperior to lesser trochanter
Elevation of the antero inferior flap allows visualisation
of the labrum. The first capsular incision is then extended towards
the acetabular rim where it is sharply turned posteriorly parallel
to the labrum reaching the retracted tendon of piriformis. Care
must be taken not to damage the labrum.
Hip dislocation
Hip can be anteriorly dislocated by flexing and externally
rotating the leg, which can be completed by incising the
ligamentum teres.
This allows a gap of up to 11 cm between the head and
the acetabulum, giving a view of the femoral head of about
360° and a full 360° view of the acetabulum. For a complete
inspection of acetabulum three retractors are needed.
To check the vascular status of femoral head intra
operatively, Ganz has proposed three techniques
1.
A 2.0 mm drill hole in the dislocated femoral head
2.
Active bleeding while removing the osteophytes
3.
Laser flow Doppler study
Hip can be reduced by minimal traction and internal
rotation. Ganz recommends that the capsule should be sutured
without tension and the greater trochanter is reattached using
two to three 3.5 mm cortical screws.
Post operatively active abduction of hip and active flexion
beyond 70 degrees is allowed after 8 weeks and passive range of
motion exercises can be advised one week after the procedure.
Ganz et al. carried out this procedure in 213 hips between
1992 to 1999 excluding hips which had a pre-existing avascular
necrosis and those hips converted to total hip replacement. The
mean operating time in their study was 25 to 45 minutes and
mean blood loss was around 300 ml. The follow up period
Kerala Journal of Orthopaedics Volume 26 | Issue 2 | July 2013
Comment ary
Jacob et al .: Ganz safe surgical dislocation of hip : overview
ranged from 2 to 7 years and no hip had developed avascular
necrosis.
Complications
1.
Sciatic nerve damage. This can be prevented if
the surgical landmarks are closely followed.
2.
Trochanteric non-union is rare.
3.
Heterotopic ossification is reported in 37 % (79
of 213 hips) cases by Ganz et al. The commonest
site of ossification was at the tip of greater
trochanter and this can be prevented by careful
retraction of gluteus medius.
REFERENCES
1.
2.
Ganz R, Gill T, Gautier E, et al. Surgical dislocation of
the adult hip a technique with full access to the femoral
head and acetabulum without the risk of avascular
necrosis. J Bone Joint Surg Br, 2001. 83B: 1119-24.
Gautier E, Ganz K, Krugel N, et al. Anatomy of the
medial femoral circumflex artery and its surgical
implications. J Bone Joint Surg Br, 2000. 82B: 679-83.
CONCLUSION
Ganz safe surgical dislocation of hip is a very useful
procedure for the exposure of intra articular pathologies of hip
It does not compromise the blood supply of the head of the
femur. Hence there is no risk of avascular necrosis. By this
technique the hip preserving surgeries can be easily performed
with a good exposure to intra articular and peri articular tissues.
Source of funding: Nil; Conflict of interest: Nil
Cite this article as:
Jacob PJ, Sreeganesh K., Ganz safe surgical dislocation of hip : overview. Kerala Journal of Orthopaedics 2013; 107-109
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