HIP DISLOCATIONS *, Study notes of Medicine

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HIP DISLOCATIONS *

Payam

Tabrizi, MD

and Associated Injuries

“Could Today’s Medicine Have Done Anything Differently?”

Baltimore

Monday Night Football 1988 *

J a n 1 3 1 9 9 1

“ … wait and see how well his injuries heal over the next several months before judging whether the athlete would be able to play again ”

Dr. James R. Andrews

• Release by the Royals

Dr. Steven Joyce

“Jackson’s prognosis for returning to competitive athletics is uncertain….”

“ Would not be able to play baseball this season ”

• Picked up by the White Sox, but his natural hip deteriorated rapidly after only 23 more games in 1991
• Lead to THR in spring of 1992

• In his 1 st^ game back in 1993, Jackson pinch-hit a home run off the Yankees Neal Heaton - Although he hit 16 home runs that year, he batted just. - White Sox released him
• He then hit a career-high .279 with 13 home runs in 201 at-bats for the Angels in 1994 - His career ended all too quietly when season cut short by a player’s strike

“If the blood supply is cut off to the area, there’s nothing you can do about it .... whenever you lose blood flow to your hip, you’re going to develop AVN. Everyone that has a hip injury doesn’t need a replacement or need to end their careers. I know a lot of people that have dislocated their hips and come back and been fine.”

“One of my teammates, (running back) Lionel James dislocated his hip his sophomore year at Auburn and kept playing.” James states that he did develop AVN but was able to keep playing with the Chargers from 1984-88. He was able to build up the muscles around his hip & take meds that over the years caused him a serious attack of pancreatisis. He received a THR a few years ago.

Epidemiology of Hip Dislocations

• Increasingly common injury - 1% bilateral
• Orthopaedic emergency - Resuscitation of life threatening injuries - Identification & Rx of associated injuries
• Mechanism often secondary to major forces
• 83.9% traffic accidents *
• MVA
• MCA
• Peds vs car
• Falls

• Sahin et al, J Trauma, 2003

Epidemiology

• Yes, medically, football is like a car crash
• Professional Football is terrifying

• Don’t know about his boney anatomy, but certainly his legs as strong as anyone ever in the history of professional sports - Congenital ABNL may predispose to instability - People with less anteversion more prone to posterior dislocation

Upadhyah et al, JBJS(B), 1985

Direction, magnitude & point of application of force determines exact injury pattern

Force Vector Can Predict # Pattern *

Intersection “T- bone” crash or Falls in elderly

Head on crash * (knee vs. dashboard)

Force Vector

• Early relocation

most important factor in prognosis

Time to Reduction

• Bo stated that he felt his hip go and then

popped it back in (instant reduction?)

• Despite his observed mythos, reduction of a pure hip dislocation has to be impossible
• A mortal human being, can’t do that
  • More likely partial dislocation or subluxation which slid back into place

Did Jackson actually dislocate his hip?

Or did Bo have a Femoral head #

Incidence

• 7-15%

Rx of Femoral Head #’s

Trans-Chondral

• Excision if small & not involving w.b surface
• ORIF if > 1/
  • Buried screws

Indentation

• No surgical Rx
• Traction & early ROM after CR

Long Term Outcome of Fem. Head #

• 32 pts (24 MVA; 23 with ass. injuries)
  • 28 with postero-superior dislocation
  • 1 postero-inferior 3 anterior

Dreinhofer et al, Unfallchirurg, 1996

6

4 7 11

• All C.R. by 4 hours (mean = 105 min)
  • 11 pts: no further Rx
  • 10 removal of fragments head
  • 7 ORIF femoral head
  • 3 ORIF acetabulum
  • 1 THR (Pipkin III)
• OA
  • Mild : 4 Mod OA: 2
• AVN
  • Partial: 4 / Subchondral collapse: 1
• H.O.: 8
• 15/26 pts with fair / poor results

F/U = 5 years (26 pts)

1. Stress test to assess need for operative

Rx in small & indeterminate size

fragments of posterior wall

2. If stable, early mobilization

3. If unstable, early ORIF

4. Undiagnosed: can lead to OA

Dynamic instability of hip

14 year old morbidly obese pt Fell off bicycle

AVN Rates:

• 4.8% if hip reduced < 6 h
• 52.9% if reduced > 6 h

Hougaard & Thomsen, Arch Orthop Trauma Surg, 1986

Prevention = First line of defense *

• When Bo’s injury occurred in 1991, the possible complications of # / dislocations of the hip were known
• Methods of diagnosing AVN established, but the process was still unrefined
• If Jackson was playing today, that period immediately following injury is when modern medicine could have possibly saved his hip / prolonged his career

Best chance today’s medical community could have given Bo for a full career would’ve been:

• Prevention of sequelae of AVN (collapse) & OA thru improved imaging techniques & early medical & surgical Rx

Hip aspiration urgently in locker room?

Protocol

• 6 wk regimen of toe-touch w.b / crutches
  • Repeat MRI at 6 wks:
    • If no early AVN: gradual return to sports
    • If AVN: risk for collapse & OA: advised against return to sports
• 6/8 returned to previous level competition
  • Remaining 2 severe AVN -> THR Moorman, Warren et al, JBJS(A), 2003

Cody Ross of Arizona Diamondbacks

Brian Pitta of Baltimore Ravens

Frank Gore of San Francisco 49’ers

WHAT ABOUT BO JACKSON?

Jackson states his THR affords him a fairly NL life

I have no problems with my hips. I can still do the things that I used to do. I can run, I’m just not the fastest person on the field anymore.

CONCLUSION