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Old Unreduced Dislocations
Any dislocation should be reduced as soon as reasonably possible. While a joint is dislocated, the metabolism of its hyaline cartilage is disturbed and synovial fluid functions are impaired. Hyaline cartilage may begin to degenerate during this brief period, and irreversible changes rapidly occur. Consequently, when old unreduced dislocations are finally reduced, normal and painless joint motion and function should not be expected.
When old unreduced dislocations are encountered, especially in the elbow, hip, knee, or ankle, arthroplasty or arthrodesis may be necessary either at the time of reduction or shortly thereafter. The procedure selected depends on individual considerations, such as the joint affected, the condition of the articular cartilage, any associated injuries, and the patient’s age and occupation. Treatment options include reduction alone, reduction with arthroplasty, or arthrodesis.
Reduction alone usually suffices for children and young adults. In older patients, reduction combined with arthroplasty or arthrodesis may be a better course. In patients in whom the dislocation is not restricting daily activities and is not excessively painful, reduction may not be indicated, especially in older patients.
Most old unreduced dislocations require open reduction. However, there is no arbitrary time limit beyond which a dislocation cannot be reduced by closed means. Skeletal traction sometimes will reduce a joint that has been dislocated for several weeks. If 2 to 3 weeks have passed since the injury, manipulation should be done cautiously and gently. Osteoporosis from disuse rapidly weakens the bones after a dislocation, and manipulative techniques may result in fractures. If open techniques are employed, similar care should be taken with use of instruments such as levers because articular surfaces may be further damaged. Excessive force thus should be avoided in both open and closed methods. The most common of old unreduced dislocations are discussed in this chapter.
Foot
Fractures and dislocations around the foot are discussed in Chapter 89 .
Ankle
An old unreduced dislocation of the ankle without a fracture is extremely rare. The type and severity of the dislocation almost always depend on the type and treatment of any associated fractures. An anterior dislocation usually is complicated by a fracture of the anterior margin of the distal articular surface of the tibia. A posterior dislocation usually is complicated either by a fracture of the distal tibia, including its posterior margin and a part of the metaphysis, or by a trimalleolar-type fracture. A lateral dislocation is usually complicated by a lateral or bimalleolar fracture. Fractures of the lower extremity are discussed in Chapter 54 .
Proximal Tibiofibular Joint
Two types of proximal tibiofibular subluxations or dislocations have been described: idiopathic and posttraumatic. The idiopathic type occurs primarily in preadolescent or adolescent children and is more common in girls than in boys. It can also occur in patients in their late 40s and 50s with generalized laxity of ligaments. An idiopathic subluxation usually is treated nonoperatively. If the condition is symptomatic, initial treatment can be cast immobilization. Idiopathic subluxation in a young patient should probably not be treated surgically, because it appears to be a self-limited condition. Surgery may be indicated in older patients if subluxation becomes chronic and painful and does not respond to immobilization.
Posttraumatic, chronic subluxation of the proximal fibula occurs after injuries to the anterior and posterior capsular ligaments of the proximal tibiofibular joint and to the fibular collateral ligament of the knee, often initially not fully appreciated. The ligamentous and capsular structures around the proximal tibiofibular joint are shown in Fig. 61.1 .
An old dislocation of the proximal fibula may not be symptomatic enough to require treatment. When symptoms do occur, it may be as lateral knee pain, instability, arthritis, or as ankle pain. Problems may be minimal with normal activities but experienced as clunking or giving way with certain more strenuous activities. Peroneal nerve dysfunction, particularly decreased foot sensation, can also be troublesome. If symptoms demand, treatment is indicated.
Various treatment options exist. Because of the relative rarity of this problem, decisions on treatment may be hampered by lack of evidence from studies with large numbers or long-term follow-up. Closed reduction alone is not likely to be successful or helpful. Nonoperative treatment may be attempted using a supportive strap, an exercise program, and activity modification. However, when nonoperative treatment is inadequate, surgery may be indicated. Most authors have thought that resection of the proximal fibula is the best option, although some have expressed reservations about using this procedure in children, adolescents, and some athletes.
Arthrodesis has been performed but is problematic. It has been shown that during dorsiflexion of the ankle the proximal fibula rotates around its longitudinal axis. To accommodate lateral plane rotation of the talus and the ankle joint, the fibula must rotate externally.
Attempts at ligamentous reconstruction using biceps, and deep fascia or gracilis grafts have met with at least some early success, and temporary (3 to 6 months) screw fixation also has been described with good early results.
Ligamentous Reconstruction for Old Unreduced Dislocation of the Proximal Tibiofibular Joint
Technique 61.1
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See the technique for removal of a proximal fibular graft (see Technique 1.7).
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It is important when this technique is used that the lateral supporting structures of the knee joint be reconstructed. This is accomplished by preserving the proximal fibular styloid process with its attached ligaments for subsequent attachment to the tibia.
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The fibular dissection should be subperiosteal to prevent injury to the peroneal nerve.
Postoperative Care
A long leg, bent-knee cast is applied and worn for 6 weeks. Treatment thereafter should be as described for acute injuries of the lateral knee ligaments in Chapter 45 .
Knee
Acute dislocation of the knee is usually a true emergency because of the possibility of vascular injury. Old unreduced dislocations of the knee are therefore rare. A useful range of motion is seldom restored after open reduction of such a dislocation. Even though at surgery the articular cartilage may look normal, adhesions usually develop between the articular surfaces ( Fig. 61.2 ). Satisfactory results have been reported after open reduction as long as 4 months after dislocation, and there have been reports of successful gradual reduction of chronic dislocations using the Ilizarov device, the Taylor Spatial Frame, or similar circular and hinged external fixators. Some authors have followed this reduction with arthrodesis, whereas others have described arthroscopic ligamentous reconstruction after reduction as an alternative to an open procedure. In older patients with chronic dislocations, total knee arthroplasty (TKA) may be an option, but this has been reported in only a few patients. Because of recurrent dislocation after TKA with a nonconstrained implant, Chen and Chiu recommended a constraining implant in such situations.
Open Reduction for old Unreduced Dislocation of the Knee
Technique 61.2
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Use an anteromedial approach (see Chapter 1 ) to expose the knee joint. If the patella has been displaced either medially or laterally, make the skin incision to correspond with the normal anatomic location of the medial borders of the quadriceps tendon, patella, and patellar tendon.
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If necessary, dissect the soft structures subperiosteally from the posterior aspect of the femur and tibia. Excise enough fibrous tissue to expose the articular surfaces completely.
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If the cartilage appears undamaged, reduce the dislocation. To maintain reduction, stabilize the joint for 6 weeks with one or two large Steinmann pins or a spanning external fixator. If the cartilage has been irreversibly damaged, proceed with arthrodesis of the knee (see Chapter 8 ) if this is the indicated procedure.
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If arthroplasty is indicated, it is often better to reduce the joint, proceed with the rehabilitation of the extremity, allow the contractures to resolve, and then follow with arthroplasty at a later time. If this course is chosen, immobilize the extremity in a long leg cast or brace until knee motion has started.
Postoperative Care
If arthroplasty is planned, postoperative care is the same as that for acute dislocation of the knee (see Chapter 45 ). If arthrodesis has been performed at the time of open reduction, postoperative care is the same as for arthrodesis (see Chapter 8 ).
If open reduction alone would require too much dissection or if this procedure would damage important structures, an arthroplasty (see Chapter 7 ) or an arthrodesis (see Chapter 8 ) is indicated.
Patella
Old unreduced dislocation of the patella after trauma is rare and should be distinguished clinically from congenital dislocation. Congenital dislocation often is not appreciated initially because the normal patellar ossification does not occur until 3 years of age. A high percentage of traumatic patellar dislocations (16%) are missed when associated knee dislocation is present. Therefore it is important to maintain a high index of suspicion of possible patellar dislocation when medial structures have been severely damaged.
The anatomic abnormalities found in posttraumatic dislocation differ from those found in the congenital type of dislocation. The congenital lesion is accompanied by a flexion contracture of the knee and incongruity of the patella and trochlea; these changes are part of the original pathologic process. In posttraumatic dislocation, an adaptive flattening of the patella occurs, and the knee contracture is a reactive change. Treatment of congenital dislocation of the patella is discussed in Chapter 29 .
Old traumatic patellar dislocations may be treated by observation, patellar realignment, or patellectomy. Knee function can sometimes be satisfactory despite the old unreduced dislocation of the patella. Observation is then the treatment of choice. If the dislocation is not of long duration, if degenerative changes of the patella are minimal or absent, and if the tibiofemoral joint is essentially normal, then open reduction may be helpful. In dislocations of long duration, usually traumatic arthritis will have developed, motion in the joint will be limited, and pain and disability will have resulted. If the patellar degenerative changes appear significant, patellaplasty or patellectomy (see Chapter 45 ) may be indicated. We have had no experience with patellar resurfacing or patellar prostheses for this condition. The long-term prognosis for useful function is guarded regardless of the procedure selected.
Open Reduction for Old Unreduced Dislocation of the Patella
Technique 61.3
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Make a 7.5-cm longitudinal midline incision.
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Dissect laterally deep to the subcutaneous tissue.
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Incise the capsule and synovium parallel with the lateral border of the quadriceps tendon.
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Free the deep surfaces of the quadriceps tendon and of the patella and place these structures in their normal positions.
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Excise the redundant part of the capsule from the medial side of the knee and close the capsule on this side.
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It is important that the general alignment of the extensor mechanism be normal at the completion of the procedure to prevent redislocation of the patella laterally. The fibers of the vastus medialis muscle should be appropriately oriented to the patella. This may require reattachment of a portion of the vastus medialis muscle to the adductor tubercle of the femur.
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Transfer the tibial tuberosity medially to realign the distal portion of the extensor mechanism if necessary (see Chapter 47 ).
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If the articular surface of the patella has degenerated, a patellectomy or a patellaplasty is necessary. Realignment of the extensor mechanism is just as important after patellectomy as it is after open reduction of the patella.
HIP
Old unreduced dislocations of the hip are relatively uncommon in adults. They are usually the result of a motor vehicle accident that also caused head injury, fracture of the ipsilateral femur, or dislocation or fracture of the opposite hip, which drew attention away from the dislocation.
In developing countries, unreduced traumatic dislocations are seen more frequently. The various treatment possibilities include closed reduction, open reduction, heavy traction and abduction, subtrochanteric osteotomy, Girdlestone procedure, arthrodesis, endoprosthetic replacement, and total hip replacement. Like acute dislocations, unreduced dislocations can be classified as anterior or posterior.
Chronic Anterior Dislocations
Traumatic anterior dislocation of the hip is a comparatively rare injury, and little has been written about old unreduced anterior dislocations of the hip. Trochanteric osteotomy has been reported to correct the deformity and improve body mechanics and balance. Although trochanteric osteotomy may give a stable hip, long-term results are not known. Subsequent salvage operations, such as total hip arthroplasty, may be more difficult if the proximal femoral anatomy is distorted.
Intertrochanteric Osteotomy for Chronic Anterior Dislocation of the Hip
Technique 61.4
(AGGARWAL AND SINGH)
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The Gibson approach is used (see Technique 1.72).
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Divide the femur along the line joining the greater and lesser trochanters. Then adduct, extend, and internally rotate the limb.
Postoperative Care
The patient is kept in skin or skeletal traction for 6 weeks to prevent recurrence of the rotational deformity. The patient is allowed to walk with crutches 6 weeks after surgery, and full weight bearing is allowed in 3 to 4 months. Hamada recommended postoperative immobilization in a one and one half spica cast, which includes the normal leg down to the knee. With intertrochanteric osteotomy, early union usually is complete in 3 to 4 months.
A modified Girdlestone arthroplasty has been described for the treatment of unreduced anterior hip dislocations. The femoral neck is exposed through an anterior Smith-Petersen approach (see Technique 1.66) or a Watson-Jones anterolateral approach (see Technique 1.67). A subcapital osteotomy is performed, attempting to leave as much of the femoral neck as possible with the distal fragment. The femoral head is then removed. By manipulating the leg, the cut femoral neck is displaced upward into the acetabulum. Postoperative skeletal traction of 5 kg is maintained for 6 weeks. Gentle active hip flexion is started 10 days after surgery, and non–weight bearing with crutches is begun at 6 weeks. Gradual weight bearing is started at 3 months. Preservation of the femoral neck makes subsequent total hip arthroplasty easier, and this modified subcapital displacement osteotomy for neglected anterior dislocation of the hip treated 6 months or more after dislocation in young patients can serve as a temporizing procedure until definitive total hip arthroplasty is performed later.
Chronic Posterior Dislocations
Unreduced posterior dislocations of the hip are much more common than the anterior type. Two factors that have been reported to contribute to poor results in old posterior dislocations are fracture of the femoral head or medial acetabular wall (Epstein types IV and V) and osteonecrosis, an unpredictable event that may not become apparent on plain radiographs for many months. Primary reconstructive procedures have been shown to give the best results. Although the viability of the femoral head in old unreduced posterior dislocations should determine treatment, use of bone scan or MRI to detect the vascularity of the femoral head before beginning treatment is not mentioned in the literature. In young patients, if the femoral head is thought to be viable, an effort should be made to save it.
For a type I posterior hip dislocation (no fracture or only a minor fracture of the acetabular rim less than 12 weeks from injury), with a viable femoral head, closed reduction under general anesthesia is recommended. After 12 weeks, the acetabulum may fill with fibrous tissue, making a concentric closed reduction impossible. If closed reduction fails, heavy traction and abduction should be considered. If the type I posterior hip dislocation with a viable femoral head has been present for more than 12 weeks, a concentric reduction most often cannot be obtained with closed reduction or heavy traction and abduction, and open reduction is indicated.
Traction and Abduction for Chronic Posterior Hip Dislocation
Technique 61.5
(GUPTA AND SHRAVAT)
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Place a tibial traction pin in the region of the tibial tubercle and place the patient in 18 kg of skeletal traction. The patient is kept in traction and under sedation and muscle relaxation during this time.
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Obtain radiographs on alternate days. Usually by the fifth day, the femoral head should be at or below the level of the acetabulum.
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Gradually abduct the limb and reduce the traction 3.6 kg every fourth day.
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Once the femoral head has been reduced into the acetabulum, maintain 7 kg of traction for the next 2 weeks.
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Remove the traction and begin non–weight bearing exercises for the next 4 weeks. Weight bearing is not allowed for 3 months ( Fig. 61.3 ).
The success of the heavy traction technique depends on achieving a concentric reduction. If the reduction is not concentric, an open reduction to debride any interposed soft tissue or bone fragments is necessary.
For posterior hip dislocations with a viable femoral head that are type II (large uncomminuted fracture of the posterior acetabular rim) or type III (comminuted fracture of the posterior acetabular rim), open reduction and internal fixation should be considered if the injury is less than 3 months old. If the head of the femur is displaced superiorly, preoperative skeletal traction is necessary. With reduction thus accomplished, it is necessary to fix the bone fragments internally to restore stability.
Total hip arthroplasty is recommended for hips with posterior dislocations categorized as type IV (fracture of the acetabular rim and floor) or type V (fracture of the femoral head with or without other fractures) that have been dislocated for more than 3 months. Because of osteonecrosis, poor results have been noted in these types of fracture-dislocations even in some patients who had reduction within 24 hours after injury. If the femoral head is thought to be avascular on MRI or bone scan, a primary reconstructive procedure should be considered rather than open or closed reduction. In young patients, arthrodesis can be considered, although successful fusion may be difficult in the presence of osteonecrosis. As with any arthrodesis of the hip, the status of the ipsilateral knee, the contralateral hip, and the lumbar spine must be considered. Subtrochanteric osteotomy has also been used for old unreduced dislocations of the hip in areas of the world where arthroplasty or endoprosthetic replacements are not readily available. This procedure may be indicated for patients who are relatively pain free and have a reasonable range of hip flexion but have joint contracture or limb-length inequality.
The best results have been reported after total hip arthroplasty. The main problem encountered with total hip arthroplasty in this situation is the creation of adequate acetabular stock when the posterior acetabular lip is fractured or displaced. This is accomplished by open reduction and internal fixation of the fracture fragment or by use of the femoral head as a bone graft (see Chapter 3 ). Ilyas and Rabbani reported successful one-stage total hip arthroplasty in 15 patients with chronic (over 6-month history) posterior dislocations; bulk femoral head autografts were used in 13 patients. Their short- to mid-term results were quite satisfactory, especially considering the complex nature of these particular arthroplasties. All patients had decreased pain and increased range of hip motion after surgery.
In a patient who has had multiple procedures to stabilize a chronically dislocated hip, a total hip arthroplasty with a constrained acetabular component should be considered.
Young and Banza recommended osteotomy of the greater trochanter to improve access to the acetabulum for both anterior and posterior chronic dislocations .
Sternoclavicular Joint
Most authors believe that old unreduced anterior dislocations of the sternoclavicular joint usually cause minimal if any disability, although reports of surgical intervention for this condition have indicated that untreated patients complain of weakness and fatigue of the arm during heavy use or athletic endeavors. Rarely, if ever, is surgical intervention required in this subset of patients. Surgery may, on occasion, be helpful in patients with underlying joint laxity.
Several basic surgical procedures have been described for individuals who may require surgery. The use of fascia lata around the clavicle and first rib was described by Speed, whereas others have used fascia lata between the clavicle and the sternum. The subclavius tendon also has been used to reconstruct the costoclavicular ligaments, and reconstructions using semitendinosus, palmaris longus, or gracilis tendons have had good clinical outcomes. Bak and Fogh reported successful reconstruction of the sternoclavicular joint in 27 patients with palmaris longus and gracilis tendon autografts. Quayle et al. described the use of an artificial ligament for reconstruction of the sternoclavicular joint and costoclavicular ligaments; all four of their young, active patients returned to full activity including competitive sports. Some authors have used a threaded Steinmann pin across the sternoclavicular joint, but migration of metallic fixation into the mediastinum can occur, often with disastrous consequences. Subperiosteal dissection of the sternal origin of the sternocleidomastoid muscle extending inferiorly with a strip of periosteum also has been described. This tendoperiosteal strip is threaded subperiosteally under the medial end of the first rib, up behind the rib, and up through a hole drilled from superior to inferior in the clavicle. It is then sutured back on itself.
Resection of the medial end of the clavicle has been recommended, although upper extremity weakness has been reported after this procedure. It has been emphasized that if the medial end of the clavicle is to be removed because of degenerative changes, the surgeon should be careful not to damage the costoclavicular ligament.
Rockwood recommended a nonoperative “skillful neglect” treatment, although he stated that sternoclavicular arthroplasty with resection of the medial clavicle is occasionally necessary, especially in patients in whom attempts to reduce and to stabilize the joint with suture, fascia, and tendons have failed. He resected 1 inch of the medial clavicle, debrided the intraarticular disc ligament, and stabilized the remaining clavicle to the first rib with a 3-mm cotton Dacron tape or a strip of fascia. He recommended detachment of the clavicular head of the sternocleidomastoid to temporarily resist the upward pull of the clavicle by this muscle. We agree that surgery is rarely indicated primarily; however, if surgery is to be undertaken, we also recommend arthroplasty of the sternoclavicular joint.
Resection or Stabilization of the Medial End of the Clavicle for Old Anterior Sternoclavicular Joint Dislocation
Technique 61.6
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Expose the medial end of the clavicle subperiosteally through an incision approximately 6 cm long parallel to the bone.
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Free the medial end of the bone, grasp it with forceps, lift it anteriorly and superiorly, and clear it of soft-tissue attachments posteriorly. The costoclavicular ligaments are usually torn.
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If the ligaments are attached but stretched, remove only that part of the clavicle medial to these ligaments.
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If the ligaments are torn, resect about 2 cm of bone ( Fig. 61.4 ).
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Bevel the anterosuperior corner of the remaining clavicle for cosmetic purposes.
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If instability is a problem, stabilize the clavicle to the first rib with a 3-mm cotton Dacron tape or a strip of fascia ( Fig. 61.5 ). Detach the clavicular head of the sternocleidomastoid; plicate and close the periosteum.
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Alternatively, stabilize the joint as described by Kawaguchi et al. with a double figure-of-eight gracilis tendon autograft ( Fig. 61.6 ). Harvest the autograft and reinforce it with Krakow-type nonresorbable suture (see Chapter 1 ).
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Stabilize the joint with a 2.0-mm Kirschner wire, pass the autograft in a double figure-of-eight through four drill holes, and secure with two 4.0-mm fully-threaded cancellous interference screws.
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Remove the Kirschner wire at 6 weeks.
Postoperative Care
The shoulder girdle is immobilized in a Velpeau-type dressing or shoulder immobilizer for 3 weeks. A progressive active range-of-motion exercise program is then begun.
Posterior Dislocations
Posterior dislocation of the sternoclavicular joint is an uncommon problem that is seen much less frequently than anterior dislocations. In a chronic state, posterior dislocation can be symptomatic and cause other significant complications involving the trachea, esophagus, or great vessels. Intrathoracic injury and thoracic outlet syndrome have also been reported. Most common symptoms include dysphagia, dyspnea, or cough. In view of the potential complications associated with this injury, especially subclavian artery compression, open reduction of the dislocation is recommended. Preoperative evaluation should include CT of the affected area and possibly arteriography to plan a surgical approach. Consultation with a thoracic surgeon should also be considered. If the reduction is unstable or cannot be achieved, the medial part of the clavicle can be resected. Except for some cosmetic defect, no functional disability has been noted from this procedure.
Stabilization of Old Posterior Sternoclavicular Joint Dislocation
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