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Letters to the Editor to:

Case Reports:
Daniel Schweitzer, Juan M. Breyer, Marcelo Córdova, and Gerardo Fica
Recurrent Anterior Dislocation of the Hip. A Case Report
J Bone Joint Surg Am 2004; 86: 581-583 [Full text] [PDF]
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[Read Letter to the Editor] Dr. Schweitzer responds:
Daniel schweitzer, Juan M. Breyer, Marcelo Cordova, Gerardo Fica   (7 June 2004)
[Read Letter to the Editor] Recurrent hip dislocation. A case report.
Michael Wettstein, Raffaele Garofalo, Olivier Borens, Elyazid Mouhsine   (7 June 2004)

Dr. Schweitzer responds: 7 June 2004
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Daniel schweitzer,
MD
Hospital del Trabajador de Santiago, Santiago-Chile,
Juan M. Breyer, Marcelo Cordova, Gerardo Fica

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Re: Dr. Schweitzer responds:

daniels{at}manquehue.net Daniel schweitzer, et al.

To the Editor:

We would like to thank Drs. Wettstein and colleagues for their comments regarding our case report.

In reponse to why we didn’t perform just an anterior soft tissue repair, we believe that when confronted with a very unstable hip (only minor movements required to produce dislocation) an anterior capsular imbrication alone would not be sufficient to avoid further instability. Due to our concern about rotational deformity after the osteotomy, we decided to do only a 25º rotational osteotomy and not one of 45º as described by Dall et al (1). By so doing we decreased the rotational deformity, but ensured that a re-dislocation would not occur.

In our radiographic and CT-scan measurements, we did not consider this patient to have a dysplastic hip. We agree with Dr. Wettstein that a periacetabular osteotomy would be a reasonable option for this patient; nevertheless, at that time (1997) in our country, the periacetabular osteotomy was not a frequently performed procedure.

In regard to femoral retrotorsion as a cause for femoroacetabular impingement and future osteoarthritis, we think that the slight anterior under coverage of the femoral head will give greater joint clearance and therefore avoid an anterior impingement.

Finally we would like to point out that at the seven year follow-up, the patient's foot angle during walking is normal, it is symmetrical with the opposite side, and there are no clinical or radiographic signs of degenerative arthritis. There is currently no " best treatment" for these rare cases and therefore further reports are needed.

1. Dall D, Macnab I, Gross A. Recurrent anterior dislocation of the hip. J. Bone Joint Surg Am. 1970; 52:574-6.
Recurrent hip dislocation. A case report. 7 June 2004
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Michael Wettstein,
MD
Orthopaedic and Trauma Department University Hospital CH-1011 Lausanne Switzerland,
Raffaele Garofalo, Olivier Borens, Elyazid Mouhsine

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Re: Recurrent hip dislocation. A case report.

michael.wettstein{at}hospvd.ch Michael Wettstein, et al.

To the Editor:

We read with great interest the article “Recurrent anterior dislocation of the hip. A case report.” by D. Schweitzer et al (2004; 86: 581-3). As they stated and showed by an impressive CT-scan slice, we feel that the major probable cause of the recurrent dislocation was the anterior capsulo- ligamentous complex redundancy. We suggest that an intertrochanteric rotation osteotomy was not necessary, all the more that the antetorsion of the femur was probably normal before as showed by the compared left and right hip rotations after the operation. On the other hand, on the X-Ray pictures, we measure an HTE angle of 14° (normal <10°) and a lateral center-edge (LCE) angle of 26° (normal >30°). Furthermore, the anteversion of the acetabulum is measured at 20° on the CT-scan, which is at the upper normal range. These measures show a slight degree of acetabular dysplasia and therefore a slight anterior undercoverage of the femoral head, which could be an osseous cause for a recurrence of the dislocation.

An intertrochanteric rotation osteotomy, as performed by the authors and proposed in the literature(1), leads to a retrotorsion of the femoral neck. Of course, this will help stabilize the head in the acetabulum, but as it has been shown(2), femoral retrotorsion is one cause of femoroacetabular impingement, leading to hip osteoarthritis. This fear is even more important as the patient shows a clear pistol grip deformity of the head-neck junction which is also a cause of impingement (3,4). Furthermore, we did see information about the foot angle during walking and possible adversed effects on knee and muscle balance of the lower leg related to the retrotorsion of the femur. Therefore, we ask whether it would not have been sufficient to do only an anterior capsular shift, as in the Bankart procedure for shoulder instability. It remains open to discussion whether a periacetabular osteotomy would have been an appropriate procedure to correct the slight bony undercoverage and therefore prevent further dislocation.

References:

1. Dall D, Macnab I, Gross A. Recurrent anterior dislocation of the hip. J Bone Joint Surg Am. 1970; 52: 574-6.

2.Tönnis D, Heinecke A. Acetabular and femoral anteversion: Relationship with osteoarthritis of the hip. Current concepts review. J Bone Joint Surg Am. 1999; 81: 1747-70.

3.Stulberg SD, Cordell LD, Harris WH, Ramsey PL, MacEwen GD. Unrecognized childhood hip disease: A major cause of idiopathic osteoarthritis of the hip. In: The Hip. Proc 3rd meeting of the Hip Society. St Louis: CV Mosby Co, 1975: 212-28.

4.Ganz R, Parvizi J, Beck M, Leunig M, Nötzli H, Siebenrock KA. Femoroacetabular impingement. A cause for osteoarthritis of the hip. Clin Orthop 2003; 417: 112-20.