Can we predict femoral head vitality during surgical hip dislocation?

Abstract

Purpose: Surgical hip dislocation is commonly performed in orthopaedic surgery for several pathologies that often present risk of avascular necrosis (AVN) of femoral head. Observation of blood spilling out from a drill hole, performed in the head after dislocation, has been proposed as a predictive test for AVN. No data have been published about test reliability. Study’s aim was to evaluate the correlation between ‘bleeding sign’ and AVN in surgical dislocation for elective disease and for acetabular fractures.Methods: All patients meeting the indication for surgical dislocation were included in this prospective study. Patients with follow-up shorter than 8 months were excluded. Intra-operative assessment of head vascularity was performed in 44 patients through the ‘bleeding sign’: a 2.0-mm drill hole carried out on the head during surgery. A positive bleeding test was considered an immediate appearance of active bleeding. Development of AVN was considered the main outcome. Necrosis group criteria were detection of type II, III or IV X-ray according to Ficat classification.Results: Forty-four patients with selected acetabular fractures, slipped capital femoral epiphysis and femoral head deformity were enrolled. Mean age was 25 years and mean follow-up was 36 months. Thirty-eight patients presented positive intra-operative bleeding sign and six demonstrated no bleeding. Sensitivity for the ‘bleeding sign’ was 97%, specificity was 83%, positive predictive value was 97%, negative predictive value was 83% and accuracy was 95% (P < 0.001).Conclusions: Bleeding after head drilling is a reliable test for AVN in patients who undergo a surgical hip dislocation.

Necrose avascular pós-cirurgia de Dunn modificada no tratamento do escorregamento da epífise proximal do fêmur*

“…Of the five patients with AVN, three had no perfusion when tested. This correlation was not observed by Upasani et al, 9 but confirmed by Novais et al 27 and Aprato et al 28 Masquijo et al 8 and Upasani et al 9 correlate complications with the surgeon's learning curve and experience. Our series had 4 AVN cases among the first 10 patients, operated on within the first 5 years, and a single AVN case during the last 5 years.…”

Management of femoral head fracture by Ganz surgical dislocation of the hip

“…The drilling test (bleeding sign) is one of the reliable tests to predict the viability of the femoral head in patients who undergo surgical hip dislocation [ 35 , 36 ]. In a study to predict femoral head vitality during surgical hip dislocation, Aprato et al reported that the sensitivity of the drilling test was 97%, while its specificity was 83% [ 35 ]. The test can be performed intraoperatively to determine femoral head viability.…”

Intraoperative assessment of femoral head perfusion during surgical hip dislocation for slipped capital femoral epiphysis

“…The methods of assessing femoral head perfusion that have been described are evaluation of bleeding by creating a drill hole [ 16 , 29 , 33 ], the use of Laser Doppler Flowmetry [ 17 , 20 ] and intracranial pressure monitoring (ICP) [ 14 , 19 ]. Assessing bleeding via a drill hole is a simple way to assess femoral head perfusion but can only be done with open surgeries.…”