Luxaia traumatic a oldului

Gheorghevici T. tefan, MD
sub coord. Sef lucr.Dr. Cozma Tudor

Universitatea de Medicin i Farmacie Gr. T. Popa Iai
Spitalul Clinic de Recuperare Iai

2011
Definiie
Urgenta ortopedica caracterizata prin
parasirea permanenta a cotilului de catre
capului femural fractura
Anatomia
articulatiei oldului
enartroza, cu grad mare de stabilitate
capul femural usor asimetric, 2/3 de sfera
conducere ligamentara
acetabulum: suprafata articulara in forma de U inversat
labrum (2/3 ale circumferintei) + ligamentul
transvers acetabular (1/3 ale circumferintei) inel
fibros cu rol in cresterea acoperirii capului femural
capsula (mai subtire in portiunea inferioara), cu forma
de butoi
ligamente
ilio-femural (in Y, a lui
Bertin/Bigelow) cu 2
fascicole: - ilio-
pertrohanterian lim. E, RE,
ABD,
- ilio-pretrohantenian lim.
E, rezista la 3.5- 6 kN,

ischiofemural
pubofemural (cel mai slab)
ligamentul rotund al capului
femural
musculatura: - coaptoare ms.
pelvitrohanterieni scurti posteriori, fesier
mijlociu si micul fesier in opozitie cu m.
abductoare si flexoare.
Anteversia colului femural
7
0
in medie la barbatii caucazieni
mai mare la sexul feminin
orientali pot avea un unghi de anteversie intre 14
0
si
16
0

Vascularizatia
capului femural
1. A. ligamentului rotund
din sistemul obturator
A. iliaca interna

Vascularizatia
capului femural
2. Ramuri cervicale ascendente
artere cicumflexe
artera femurala profunda
artera femurala comuna
artera iliaca externa
aorta
risc foarte mare de lezare in luxatia traumatica a
soldului
Nervul sciatic
format din radacinile L4 - S3.
trece posterior de peretele
posterior acetabular
trece inferior de m. piriformis,
cu variatii
FRECVENTA
5% din totalul luxatiilor
sex masculin > sex feminin,
20-45 ani, rar copii si exceptional batrani.
ETIOLOGIE
consecutiva unui traumatism de inalta energie
(accidente rutiere, cadere de la mare inaltime, accidente
miniere).
low-energy trauma copii <6 ani, datorita laxitatii
ligamentare si batrani cu proteza de sold (10%)

Mecanism de producere
indirect - accidente rutiere - sindromul tabloului
de bord, accidente industriale
direct traumatismul actioneaza asupra partii
superioare a femurului, fortandu-l sa paraseasca
articulatia printr-o bresa capsulara
F+ADD+RIdeplasarea posterioara a capului femural in
FIE (85-90%) fractura sprancenei cotiloide
F+ABD luxatie anterioara (10-15%)
F+ usoara ABDluxatie centrala/intrapelvina protuzia
capului femural in bazin, cu fractura acetabulului; rezulta 2
fragmente: superior si inferior care incarcereaza capul
femural asemeni uni cioc de pasare
E+RE luxatie antero-superioara (pubiana)
Leziuni asociate
leziuni ale capului si ale fetei
leziuni ale toracelui
leziuni intra-abdominale
fracturi ale extremitatilor si luxatii
ANATOMIE PATOLOGICA
lig. rotund rupt/ smuls fragment osos
capul sfasie capsula + lig. inferioare (ischio-
femural, pubo-femural)
in portiunea inferioara grosimea capsulei=2-3mm,
in portiunea superioara=8-12 mm
lig. Bertin intactluxatie tipica (regulata), lig.
Bertin ruptluxatie atipica(neregulata)
m. pelvitrohanterieni pot fi rupt /desirati; in luxatiile
posterioare m. gemeni, obturatorul intern si patratul
crural pot si dilacerati, in luxatiile anterioare pot fi lezati
m. pectineu, micul si mijlociul adductor
frecvent sunt asociate leziuni osoase: fracturi ale
sprancenei cotiloide posterioare,
fracturi ale femurului: cap, col, masiv trohanterian,
diafiza.
leziuni vasculare (foarte rar), cu hematom foarte mare
compresiv
elongarea/compresiunea n.sciatic
Efectele luxatiei asupra circulatiei
capului femural
arterele cervicale ascendente sunt intinse/rupte
artera ligementului rotund este rupta
unele artere cervicale sunt comprimate
reducerea rapida poate imbunatati fluxul sanguin al
capului femural
SIMPTOMATOLOGIE
dureri vii in regiunea soldului
impotenta functionala totala a membrului inferior
la indivizii slabi - diformitati ale soldului luxat
atitudine vicioasa in raport cu forma
anatomopatologica
in luxatiile tipice:
LUXATIILE POSTERO-SUPERIOARA (ILIACA)
F coapsei pe bazin (poate fi mascata de lordoza
compensatoare); E aproape completa
RI mica genunchiul se sprijina pe celalalt genunchi, halucele
se sprijina pe fata dorsala a piciorului sanatos
largirea transversala a soldului (dizlocatia + tumefierea locala)
in triunghiul lui Scarpa se constata o depresiune
scurtarea poate atinge 6-7 cm
la palpare: capul femural este in FIE,
marele trohanter este ascensionat
Luxatiile postero-inferioare (ischiatica)
ADD importanta a coapsei cu F a genunchiului si RI
picior peste picior
scurtarea MI luxat la flexia 90
0
pe bazin 3-5cm
la palpare capul femural se simte inapoia tuberozitatii
ischiatice formatiune dura, mobila la mobilizarea pasiva
a genunchiului
ABD, RE si E sunt imposibile, dureroase

Luxatiile antero-superioare (pubiene)
MI luxat in E, ADB si RE
la palpare: capul femural este in reg. inghinala sau
in triunghiul lui Scarpa
capul femural rupe capsula antero-superior
lig. pubo-femural plasandu-se inaintea ramurii
orizontale a pubisului
se fixeaza sub m. ileaopsoas
intinde n. femural
ADD, RI, si F sunt imposibile
scurtarea este de 1-2 cm
Luxatiile antero-
inferioare (obturatorii)
F exagerata, ADB si RE importanta
sold sters, turtit
capul femural se poate palpa in dreptul gaurii
obturatorii
coarda m. adductori in tensiune
MI alungit cu 1-2 cm
cand este bilaterala, pozitia clasica de batracian
compresiuni ale n. obturator
Luxatiile atipice
Luxatia Capul femural Observatii
supracotiloidiana deasupra cotilului
capsula rupta in portiunea
superioara+fractura
sprancenei cotiloide. fascicolul
extern al lig. in Y este rupt
subspinoasa sub SIAI
suprapubiana
in partea mijlocie a arcadei
femurale
perineala
placat pe ramura ascendenta
a ischionului
poate ajunge in reg. scrotala
subischiatica la nivelul spinei ischiatice
intrapelviana in micul bazin
luxatie centrala/protuzie
acetabulara de cap femural
EXPLORARI PARACLINICE
Examen radiografic
Examen CT
Examen IRM
Examen scintigrafic
Examen radiografic
fata si profil de bazin
incidenta alara/
obturatorie
incidenta Jutet

Examen CT
sectiuni de 2-3 mm;
deceleaza fracturi de cotil/cap femural
reconstructie 3D, util in reducerile
sangerande
prezenta bulelor de gazsubluxatie
redusa spontan

Examen IRM
T
1
NACF, corp liber intraarticular, rupturi
labrale, leziuni condrale, flebita vaselor
bazinului, fracturi oculte;
T
2
edemul sprancenei acetabulare, nu e
folosit curent
Examen scintigrafic
permite aprecierea vitalitatii capului
femural
Diagnostic diferential
entorsa de sold dureri mai putin intense si
difuze, miscarile pasive sunt posibile, nefiind
blocate in pozitii vicioase
contuzia de sold durri difuze, moderate, permit
miscarile pasive, absent pozitiilor vicioase, marele
trohanter nu este ascensionat
fractura de col femural cu deplasare RE si
scurtare, nu apare ADD
fracturi acetabulare sau ale bazinului
fractura de cap femural
NACF
CLASIFICARE
Clasificarea Epstein
Clasificarea Thompson si Epstein
Clasificarea Pipkin
Clasificarea Levin
Clasificarea Stewart and Milfords
Clasificare AO/OTA
Clasificarea Epstein


Tip I: Luxatii superioare inclusiv pubiene sau
suprapubiene
Tip IA: Fara fracturi asociate
Tip IB: Fracturi asociate sau tasari ale capului
femural
Tip IC: Fracturi asociate ale acetabulului
Tip II: Luxatii inferioare inclusiv obturatorii si
perinale
Tip IIA: Fara fracturi asociate
Tip IIB: Fracturi asociate sau tasari ale capului
femural
Tip IIC: Fracturi asociate ale acetabulului

Clasificarea Thompson si Epstein
Tip I: Luxatie cu/fara fractura minora
Tip II: Luxatie cu un singur fragment major
al peretului posterior acetabular
Tip III: Luxatie cu cominutia peretului
posterior acetabular cu/fara fragment major
Tip IV: Luxatie cu fractura tavanului
acetabular
Tip V: Luxatie cu fractura capului femural

Clasificarea Pipkin
Tip I: Luxatie posterioara a soldului cu fractura
capului femural caudal de fovea capitis
Tip II: Luxatie posterioara a soldului cu fractura
capului femural proximal de fovea capitis
Tip III: Tip I sau II luxatie posterioara cu fracura
de col femural asociata
Tip IV: Tip I, II, sau III luxatie posterioara cu
fractura acetabulara

Clasificarea Levin
Tip I
Fra fracturi importante, fara afectarea stabilitatii
postreductionale
Tip II
Luxatie ireductibila fara fractura/tasare a capului femural/
acetabulara
Tip III
Luxatie incoercibila sau fagmente osteocondrale incarcerate
Tip IV
Fractura acetabulara asociata ce necesita reconstructie pentru
restabilirea congruentei articulare
Tip V
Leziune asociata capului femural (fractura sau tasare)

Clasificarea Stewart si Milfords
Tip I luxatie cu /fara fracturi insignifiante
acetabulare
Tip II luxatie asociata fie cu fractura simpla sau
cominutiva a peretelui posterior acetabular, fara
pierderea stabilitatii soldului
Tip III fractura-dizlocatie cu pierderea stabilitatii
soldului consecutiv pierderii suportului structural
Tip IV luxatie asociata cu fractura capului femural
Clasificarea AO/OTA
30-D10 Luxatie anterioara a soldului
30-D11 Luxatie posterioara a soldului
30-D30 Luxatie obturatorie a soldului
EVOLUTIE SI PROGNOSTIC
sunt mai favorabile in luxatiile simple decat
in cele asociate cu fracturi
precocitatea reducerii amelioreaza
prognosticul (luxatii simple reduse
>24hcomplicatii 66%, luxatii+ fracturi
acetabulare reduse >24hcomplicatii
100%)
nu trebuie sa treaca nici un rasarit sau
apus de soare

COMPLICATII
Complicatii generale
intretinerea/accentuarea tulb. circulatorii
cerebrale(frecv. la pacienti cu TCC)
leziune socogenatrombogena
risc de TVPEP grava, necesita
trombopreventia cu HGMM


B. Complicatii locale imediate
compresiunea n. obturator, n. crural
elongarea n. sciatic
comprimarea vaselor femurale
ruperea a. femurale
luxatia deschisa
luxatia deschisa
retentia de urina
leziunile osoase
tromboza venoasa masiva a regiunii bazinului si a
membrelor inferioare
osteoartrita
Complicatii locale tardive
NACF
coxartroza
osificarile posttraumatice
atrofii musculare
atitudini vicioase permanente+impotenta
functionala +dureri+retractii musculare
ingrosari si osificari ale capsulei
tendinita m.rotatori ai soldului
luxatia recidivanta de sold


Cauze de ireductibilitate
anterioara:
interpunerea unui fragment din bureletul cotiloidian/ a capsului rupte/
tendonul psoasului
dreptul anterior
strangularea colului femural intr-o bresa capsulara mica ce a permis luxarea, dar nu
mai pemite reducerea
posterioara:
fragment osos
tendonul m. piramidal, m. obturator intern
marele fesier
capsula
ligamentul rotund
lig. iliofemural
labrum-ul
peretele posterior

Luxatia traumatica recenta incoercibila de sold
capul femural se redisloca la incetarea tractiunii si a
manevrelor ortopedice
frecvent este cauzata de o fractura acetabulara cu fragment
mare posterior (tip III Thompson si Epstein)
exceptional poate fi cauzata de interpunerea de capsula,
burelet glenoidian sau alte leziuni de parti moi
necesita interventia chirurgicala pt. preventia lezarii
vaselor capsulare
p.o. este necesara extensia continua pe atela Braun-Bhler
unii autori se poate temporiza interventia 10-15 zile daca
se mentine reduceea sub extensie
Managementul initial
reducere trebuie efectuata rapid pentru preventia
complicatiilor
daca e posibil, reducerea trebuie efectuata in UPU/ sala de
operatie, sub anestezie si relaxare musculara
daca anestezia generala nu este posibila, trebuie tentata
reducerea sub sedare i.v
indiferent de tipul de luxatie, tractiunea se face in pozitie
vicioasa, cu pacientul in decubit dorsal
in timpul reducerii se cauta stabilitatea
trebuie efectuate Rx postreducere, pentru confirmare
Algoritmul postreductional
fara ADD sau RI
fara flexie >60
o

pentru luxatii simple extensie transosoasa 10-12
zile urmata de mobilizare activa inca 10-20 zile.
mersul cu sprijin integral este permis dupa 3-4
saptamani
cand nu poate efectuata extensia transscheletica
continua imobilizare gipsata 2 saptamani
program de kineto pentru prevenirea atrofiilor
musculare, redorilor posttraumatice si a
calcificarilor periarticulare
Metoda Bhler
Metoda Allis

Metoda Stimson (Djanelidze)

Metoda tractiunii laterale

Metoda umarului (Marya si Samuel/Enhalt)

Metoda East Baltimore lift

Tehnica Nordt (1999)

Metoda Spitalului de UrgentaFloreasca

Reducerea luxatiilor atipice
Se transforma in luxatii posterioare prin
miscari de circumductie apoi se reduc dupa
tehnica cunoscuta
Extensie continua 3-4 zile dupa care se face
reducerea
Verificarea stabilitatii reducerii
Soldul este flectat la 90
o

Daca soldul ramane stabil, se aplica RI,
ADD, si compresiune spre posterior
In functie de gradul de flexie, ADD si RI se
apreciaza stabilitatea postreductionala
!!! Fracturile de perete posterior cotiloidian
fac dificila aprecierea stabilitatii

Luxatia veche traumatica de sold
frecvent datorita nerecunoasterii ei la politraumatizati
( luxatii atipice)
devin ireductibile intr-un interval de timp cateva
saptamani-2 luni
necesita extensie continua cu 10-15 kg/ 10-15 zile pt
coborarea capului femural si prevenirea elongarii n. sciatic/
a vaselor femurale in momentul reducerii + reducere
sangeranda
dupa 3 luni, cartilajul articular este compromisprotezare
Indicatia de reducere sangeranda
luxatie ireductibila
leziunea iatrogenica a n. sciatic
reducere incoercibila cu fragmente
incarcerate/ interpozitie de parti moi
reducere incoercibila cu fractura tip I Pipkin
fractura de femur controlateral
Anterior Smith-Petersen/ Hardinge
Anterolateral Watson-Jones

permite vizualizarea si extragerea tesutului
interpus
plasarea unui cui Schanz in regiunea
interetrohanteriana permite mobilizare
extremitatii femurale superioare
este indicata repararea capsului fara disectia
de amploare

Posterior Kocher-Langenbeck
permite vizualizarea si extragerea tesutului
interpus
permite repararea peretelui posterior
acetabular

Type of Posterior Dislocation
depends on:
Direction of applied force.

Position of hip.

Strength of patients bone.
Physical Examination: Classical
Appearance
Posterior Dislocation: Hip flexed, internally
rotated, adducted.
Physical Examination: Classical
Appearance
Anterior Dislocation: Extreme external rotation,
less-pronounced abduction
and flexion.
Unclassical presentation
(posture) if:
femoral head or neck fracture
femoral shaft fracture
obtunded patient
Physical Examination
Pain to palpation of hip.
Pain with attempted motion of hip.
Possible neurological impairment:
Thorough exam essential!
Radiographs: AP Pelvis X-Ray
In primary survey of ATLS Protocol.
Should allow diagnosis and show direction of dislocation.
Femoral head not centered in acetabulum.
Femoral head appears larger (anterior) or smaller (posterior).
Usually provides enough information to proceed with closed
reduction.
Reasons to Obtain More
X-Rays Before Hip Reduction
View of femoral neck inadequate to rule out
fracture.

Patient requires CT scan of abdomen/pelvis for
hemodynamic instability
and additional time to obtain 2-3 mm cuts through
acetabulum + femoral head/neck would be minimal.
X-rays after Hip Reduction:
AP pelvis, Lateral Hip x-ray.
Judet views of pelvis.
CT scan with 2-3 mm cuts.
CT Scan
Most helpful after hip reduction.
Reveals: Non-displaced fractures.
Congruity of reduction.
Intra-articular fragments.
Size of bony fragments.
MRI Scan
Will reveal labral tear and soft-tissue
anatomy.
Has not been shown to be of benefit in acute
evaluation and treatment of hip dislocations.
Clinical Management:
Emergent Treatment
Dislocated hip is an emergency.

Goal is to reduce risk of AVN and DJD.

Evaluation and treatment must be streamlined.
Emergent Reduction
Allows restoration of flow through occluded or
compressed vessels.
Literature supports decreased AVN with earlier
reduction.
Requires proper anesthesia.
Requires team (i.e. more than one person).
Anesthesia
General anesthesia with muscle relaxation facilitates
reduction, but is not necessary.
Conscious sedation is acceptable.
Attempts at reduction with inadequate analgesia/
sedation will cause unnecessary pain, create muscle
spasm, and make subsequent attempts at reduction
more difficult.
General Anesthesia if:
Patient is to be intubated emergently in
Emergency Room.
Patient is being transported to Operating
Room for emergent head, abdominal or
chest surgery.
Take advantage of opportunity.
Reduction Maneuvers
Allis: Patient supine.
Requires at least two people.

Stimson: Patient prone, hip flexed and
leg off stretcher.
Requires one person.
Impractical in trauma (i.e. most
patients).
Allis Maneuver
Assistant: Stabilizes pelvis
Posterior-directed force on both ASISs
Surgeon: Stands on stretcher
Gently flexes hip to 90
0
Applies progressively increasing traction to
the extremity
Applies adduction with internal rotation
Reduction can often be seen and felt
Reduced Hip
Moves more freely
Patient more comfortable

Requires testing of stability
Simply flexing hip to 90
0
does not
sufficiently test stability
Stability Test
1. Hip flexed to 90
o

2. If hip remains stable, apply internal rotation,
adduction and posterior force.
3. The amount of flexion, adduction and internal
rotation that is necessary to cause hip dislocation
should be documented.
4. Caution!: Large posterior wall fractures may
make appreciation of dislocation difficult.
Irreducible Hip
Requires emergent reduction in O.R.
Pre-op CT obtained if it will not cause delay.
One more attempt at closed reduction in O.R. with
anesthesia.
Repeated efforts not likely to be successful and may create
harm to the neurovascular structures or the articular
cartilage.

Surgical approach from side of dislocation.
Hip Dislocation:
Nonoperative Treatment
If hip stable after reduction, and reduction congruent.
Maintain patient comfort.
ROM precautions (No Adduction, Internal Rotation).
No flexion > 60
o
.

Early mobilization.
Touch down weight-bearing for 4-6 weeks.
Repeat x-rays before allowing weight-bearing.
Hip Dislocation:
Indications for Operative Treatment
1. Irreducible hip dislocation
2. Hip dislocation with femoral neck fracture
3. Incarcerated fragment in joint
4. Incongruent reduction
5. Unstable hip after reduction
1. Irreducible Hip Dislocation: Anterior
Smith-Peterson approach
Watson-Jones is an alternate approach
1. Allows visualization and retraction of interposed
tissue.
2. Placement of Schanz pin in intertrochanteric
region of femur will assist in manipulation of the
proximal femur.
3. Repair capsule, if this can be accomplished
without further dissection.
1. Kocher-Langenbeck approach.

1. Remove interposed tissue, or
release buttonhole.

1. Repair posterior wall of acetabulum if
fractured and amenable to fixation.
1. Irreducible Hip Dislocation: Posterior
Irreducible Posterior Dislocation
with Large Femoral Head Fracture
Fortunately, these are rare.

Difficult to fix femoral head fracture from
posterior approach without transecting
ligamentum teres.
Three Options
1. Detach femoral head from ligamentum teres,
repair femoral head fracture with hip dislocated,
reduce hip.
2. Close posterior wound, fix femoral head fracture
from anterior approach (either now or later).
3. Ganz trochanteric flip osteotomy.

Best option not known: Damage to blood supply
from anterior capsulotomy vs. damage to blood supply
from transecting ligamentum teres.

These will be discussed in detail in femoral head
fracture section.
2. Hip Dislocation with Femoral
Neck Fracture
Attempts at closed reduction potentiate chance of fracture
displacement with consequent increased risk of AVN.

If femoral neck fracture is already displaced, then the
ability to reduce the head by closed means is markedly
compromised.

Thus, closed reduction should not be attempted.
2. Hip Dislocation with Femoral
Neck Fracture
Usually the dislocation is posterior.
Thus, Kocher-Langenbeck approach.
If fracture is non-displaced, stabilize fracture
with parallel lag screws first.
If fracture is displaced, open reduction of
femoral head into acetabulum, reduction of
femoral neck fracture, and stabilization of
femoral neck fracture.
3. Incarcerated
Fragment
Can be detected on x-ray or CT scan.

Surgical removal necessary to prevent abrasive wear of the
articular cartilage.

Posterior approach allows best visualization of acetabulum
(with distraction or intra-op dislocation).

Anterior approach only if:
dislocation was anterior and,
fragment is readily accessible anteriorly.
4. Incongruent Reduction
From:
Acetabulum Fracture (weight-bearing
portion).
Femoral Head Fracture (any portion).
Interposed tissue.

Goal: achieve congruence by removing interposed
tissue and/or reducing and stabilizing fracture.
5. Unstable Hip after Reduction
Due to posterior wall and/or femoral head fracture.
Requires reduction and stabilization fracture.

Labral detachment or tear
Highly uncommon cause of instability.
Its presence in the unstable hip would justify surgical repair.
MRI may be helpful in establishing diagnosis.
Results of Treatment
Large range: from normal to severe pain and degeneration.
In general, dislocations with associated femoral head or
acetabulum fractures fare worse.
Dislocations with fractures of both the femoral head and the
acetabulum have a strong association with poor results.
Irreducible hip dislocations have a strong association with poor
results.
13/23 (61%) poor and 3/23 (13%) fair results.
McKee, Garay, Schemitsch, Kreder, Stephen. Irreducible fracture-dislocation of
the hip: a severe injury with a poor prognosis. J Orthop Trauma. 1998.

Complications of Hip Dislocation
Avascular Necrosis (AVN): 1-20%

Several authors have shown a positive
correlation between duration of dislocation and
rate of AVN.

Results are best if hip reduced within six hours.
Post-traumatic Osteoarthritis
Can occur with or without AVN.
May be unavoidable in cases with severe
cartilaginous injury.
Incidence increases with associated femoral head
or acetabulum fractures.
Efforts to minimize osteoarthritis are best directed
at achieving anatomic reduction of injury and
preventing abrasive wear between articular
carrtilage and sharp bone edges.
Recurrent Dislocation
Rare, unless an underlying bony instability has not
been surgically corrected (e.g. excision of large
posterior wall fragment instead of ORIF).
Some cases involve pure dislocation with inadequate
soft-tissue healing may benefit from surgical
imbrication (rare).
Can occur from detached labrum, which would
benefit from repair (rare).
Recurrent Dislocation Caused by
Defect in Posterior Wall and/or Femoral
Head
Can occur after excision of fractured fragment.
Pelvic or intertrochanteric osteotomy could alter the
alignment of the hip to improve stability.
Bony block could also provide stability.
Delayed Diagnosis of Hip Dislocation
Increased incidence in multiple trauma patients.
Higher if patient has altered sensorium.
Results in: more difficult closed reduction.
higher incidence of AVN.

In NO Case should a hip dislocation be treated
without reduction.
Sciatic Nerve Injury
Occurs in up to 20% of patients with hip
dislocation.

Nerve stretched, compressed or transected.

With reduction: 40% complete resolution
25-35% partial resolution
Sciatic Nerve Palsy:
If No Improvement after 34 Weeks
EMG and Nerve Conduction Studies for
baseline information and for prognosis.

Allows localization of injury in the event that
surgery is required.
Foot Drop
Splinting (i.e. ankle-foot-orthosis):

Improves gait
Prevents contracture

Infection
Incidence 1-5%
Lowest with prophylactic antibiotics and
limited surgical approaches
Infection: Treatment Principles
Maintenance of joint stability.
Debridement of devitalized tissue.
Intravenous antibiotics.
Hardware removed only when fracture healed.
Iatrogenic Sciatic Nerve Injury
Most common with posterior approach to hip.

Results from prolonged retraction on nerve.
Iatrogenic Sciatic Nerve Injury
Prevention:
Maintain hip in full extension
Maintain knee in flexion
Avoid retractors in lesser sciatic notch
? Intra-operative nerve monitoring (SSEP, motor
monitoring)
Thromboembolism
Hip dislocation = high risk patient.

Prophylactic treatment with:
low molecular weight heparin, or
coumadin

Early postoperative mobilization.

Discontinue prophylaxis after 2-6 weeks (if
patient mobile).
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