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Comment ary Ganz safe surgical dislocation of hip : an overview Jacob PJ1, Sreeganesh K2 www.kjoonline.o rg Govt. Medical College Thrissur, Kerala, India 1 Additional Professor of Or th opae di cs 2 Resident in Or th opae di cs Correspondence should be sent to: [email protected] Available online at www.kjoonline.o rg Quick response code 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 10 7 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 10 8 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 Announcement • Are you moving to a new address ? • Have you changed your email id or contact number recently ? • Do you have a query or suggestion regarding this journal? Kindly intimate the details, quoting your KOA membership number, current mailing address, email id and contact number to one of the following addresses :Kerala Orthopaedic Association Reg. no : ER-275/1992 Flat no. 505, Easland Enclave, Kochi 682020, Kerala, India Phone +91 484 2320175 e mail: [email protected] Editor, Kerala Journal of Orthopaedics [email protected] Kerala Journal of Orthopaedics Volume 26 | Issue 2 | July 2013 10 9