Management of Chronic Hip Dislocation with Ligamentous Tears
For a chronic hip dislocation that has been present for years with supporting ligament tears, total hip arthroplasty (THR) is the definitive treatment, as joint-preserving procedures cannot reverse the structural damage and soft tissue destruction that has occurred over this prolonged timeframe.
Primary Treatment Recommendation
Total hip replacement should be performed as the primary intervention for chronic hip dislocations with ligamentous injury, as this addresses both the mechanical instability and the inevitable cartilage destruction that accompanies long-standing dislocation 1, 2. The evidence demonstrates that:
- THR achieves 43-84% pain-free outcomes at 9.4-year follow-up in patients with advanced hip pathology 1, 2
- Revision rates are acceptable at 0.18-2.04 per 100 person-years 1, 2
- Current treatments cannot reverse hip osteoarthritis or restore damaged cartilage—they only control symptoms 2
Why Joint-Preserving Surgery Is Not Appropriate
Joint-preserving procedures are contraindicated in chronic dislocations because:
- Osteotomy and arthroscopic procedures only redistribute mechanical forces; they do not reverse existing damage 1, 2
- These procedures lack controlled evidence and are appropriate only for younger patients with hip dysplasia or deformity without advanced osteoarthritis 1
- Mosaicplasty is indicated only for focal lesions <3 cm² in patients <45 years old without signs of OA—criteria that chronic dislocations do not meet 1
- Arthroscopic-assisted treatment is designed for developmental dysplasia in children 11-14 months old, not chronic adult dislocations 3
Critical Surgical Considerations
When performing THR for chronic dislocation with ligamentous tears, specific technical modifications are essential:
Component Selection and Positioning
- Use cemented femoral stems, as recommended by AAOS guidelines for hip fractures with compromised bone quality 1
- Restore adequate femoral offset and leg length to optimize soft-tissue tension, as inadequate restoration is a primary cause of post-operative instability 4
- Consider lipped liners to enhance stability, though positioning must be precise to avoid impingement 4
Soft Tissue Management
- Expect significant soft-tissue deficiency and destruction from chronic instability 5, 4
- In cases with severe soft tissue defects, consider reinforcement with artificial ligaments (Leeds-Keio ligament) to restrict internal rotation and encourage posterior fibrous tissue formation, which achieves 82% success in preventing recurrent dislocation 6
- Address abductor deficiency, as this contributes to late dislocation 4
Preoperative Imaging Protocol
Obtain CT without IV contrast before surgery to assess:
- Joint congruence and component positioning requirements 7
- Intraarticular fracture fragments (87.3% sensitivity) 7
- Acetabular wall fractures requiring surgical management 7
- Bony impingement mechanisms 7
Add MRI without IV contrast if soft tissue pathology assessment is needed, particularly for evaluating abductor tendon integrity and muscle injuries that may compromise stability 7
Common Pitfalls to Avoid
Do not attempt closed reduction for chronic dislocations—this is appropriate only for acute traumatic dislocations occurring in the emergency setting 8. Years of dislocation result in:
- Irreversible cartilage destruction 2
- Soft-tissue contractures and deficiency 5, 4
- Acetabular remodeling that prevents stable reduction 3
Do not delay surgical intervention, as prolonged dislocation increases:
- Soft-tissue destruction 4
- Abductor weakness and dysfunction 4
- Technical difficulty of reconstruction 5
Postoperative Stability Measures
Implement multiple strategies to prevent recurrent dislocation:
- Patient education is critical, as most dislocations occur early and are preventable with proper precautions 4
- Multimodal analgesia with preoperative nerve blocks facilitates early mobilization while maintaining hip precautions 1
- Monitor for late dislocation causes including polyethylene wear, infection, or progressive abductor weakness 4
When Constraint Devices Are Needed
If standard THR components fail to provide stability due to severe soft-tissue deficiency, constrained liners or dual-mobility constructs should be considered, as internal and external constraint methods are valuable adjuncts that successfully reduce repeated dislocation 5. However, soft tissue reinforcement with artificial ligaments may be attempted first in intractable cases 6.