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ISOLATED

LONG-TERM

TRAUMATIC
RESULTS IN 50 PATIENTS

DISLOCATION

OF

THE

HIP

K. E. DREINHOFER, From

S. R. SCHWARZKOPF, Medical School, Germany

N. P. HAAS,

H. TSCHERNE

the Hannover

From 1974 to 1989, we treated 50 patients with a simple dislocation of the hip: 38 were posterior dislocations and 12 were anterior. All dislocations primarily treated at our hospital were reduced by closed methods within three hours (mean 85 minutes (10 to 180)) and 43 were reviewed after an average follow-up of 8 years (2 to 17). It is widely held that isolated hip dislocation reduced within six hours gives an excellent outcome, but we found a significant number of complications. There were radiological signs of partial avascular necrosis in two, mild osteoarthritis in seven, and moderate degeneration in two. Heterotopic ossification was seen in four patients, but 29 of 33 MIII examinations were normal. Objective evaluation according to the Thompson and Epstein (1951) criteria showed fair and poor results in 3 of 12 anterior dislocations, but in 16 of 30 posterior dislocations. In six of the seven patients with no other severe injury, the hip had an excellent or good result; in only three of the eight patients with severe multiple injuries was this the case. The important factors in the long-term prognosis appear to be the direction of the dislocation and the overall
severity
J BoneJoint
Received

Hip dislocation may be anterior or posterior. Classifications based on the severity of associated bone involvement have
been developed for both common anterior posterior dislocations displacement 1954).
simple

(Epstein There

1973) are few


of

and for the more

(Thompson
dislocation

and Epstein 1951; Stewart and Milford reports of the long-term outcome after

the hip without


generally the

fracture
prognosis

(type
has

I in all classifications),
been considered to be

but
good

(Nicoll
Reigstad avascular associated

1952;

Hunter

1969; Kristensen

and Stougaard

1974;

1980; Jacob, Rao and Ciccarelli 1987). Subsequent necrosis (AVN) of the femoral head has been with a long interval between injury and reduction McCarroll Rosenthal Hougaard reported and Mulhollan 1975; and Coker 1979; Epstein and Thomsen 1986), but the later development of

(Bray 1962; Stewart, Weigand Ct al 1978; 1980; Reigstad 1980; other authors have

osteoarthritis

in up to 25% of the hips (Upadhyay,

Moulton

and Srikrishnamurthy 1983; Hougaard and Thomsen 1987). We have made a retrospective study of the treatment and long-term results in a series of patients with simple dislocation of the hip in respect of prognostic factors.

of injuries.
Surg
30 April

fBr/ /993;

1994;
Accepted

76-B:fs--12.
21 June

/993

PATIENTS From
dislocation

AND

METHODS a total
hip were

1972

to 1989
of the

of 421
admitted

patients
to the

with

traumatic
of

Department

Trauma excluded
(shear

Surgery, and

Hannover

Medical

School, or femoral 50 patients were

Germany.

We

all those with indentation), dislocations

acetabular leaving (Table

head fractures with isolated 34 men and 16

traumatic

I). There

women with a mean age of 29 years (5 to 62). The highest incidence was between 20 and 30 years (Fig. 1). The right

hip was
patients K. E. DreinhOfer, MD, Orthopaedic
Orthopaedic Surgery,

involved
had bilateral

in 27 patients,
dislocations.

and the left in 23. Two


accidents, II). The seven of combined

Registrar
Registrar Universitht

S. R. Schwarzkopf, MD, Department of Orthopaedic D-89081 Ulm, Germany. N. P. Haas, MD, Professor

whom
Ulm, Oherer Eselsberg,

Forty had been were wearing and meant

involved in traffic a seat-belt (Table

air-rescue Germany

physician-equipped ambulance that 48 of the 50 patients had

system in been treated

Department Germany.

of

Trauma

Surgery,

Freie

Universitht,

D-13353

Berlin,

at the scene of the accident time, defined as the interval a hospital,


patients were

by a physician. The mean rescue from the accident until arrival at (15 to 150).
and of the

H. Tschernc,
Department Hannover, Correspondence 1994 British 0301-620X194/1695

MD, Professor
of Trauma Germany. should Editorial Surgery, be sent Society $2.00 Hannover Medical School, D-30625

was

43 minutes
primarily

Thirty-seven
treated accident at our

of the
hospital

diagnosed

to Dr K. E. Dreinhdfer. of Bone and Joint Surgery

and

of the

13 primarily
within 12

treated
hours

in another In four of

hospital, these

12 were
because of

transferred

additional

severe

injuries.

cases

the

THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

ISOLATED

TRAUMATIC

DISLOCATION

OF

THE

HIP

Table

I. Details

of 50 patients

with

isolated

traumatic Injury seventy (PTS)t 34 2 12 32 27 1 I 1 10 32


5

dislocations

of the hip Objective result (Epstein8J


3 3 Mild Mild llb

Case
1

Sex M

Age (yr)
21

Treatment group
A

Direction Post-sup Post-sup Post-sup Post-sup Post-sup Ant-sup Post-sup Post-sup Post-sup Post-inf
Post-sup

Reduction time (mm) 120 45


70

Osteoarthritis

AVN (Stulberg)

Ossification (Brooker)

Subjective result 2
1 3 3 4 I I

Follow-up (mth) 37
42 53 137 111 149 99 128 45

Follow-up evaluation New


New New New New New

2
3
4

M
F M

16
49 16

A
A A

I I

3 3

50 55
150

5
6 7

M
M M

18
31 20

A
A A A A A A

60
60 70

New
New New

8
9

M
M

38
3(1

Ila

3 3

1 3

10 11 12
13

M
F

32
21

60 70 50
90

Mild

2
1

104
126

New
New

F
M

31
21

A
A

Ant-inf
A.nt-inf

32
10

2 I Moderate 3
4 3 Mild Ila 3 1 4 3 3

75
56 129 122 93

New
New New New New

14 15 16 17 18 19

M F M F M M

59 47 26 19 58 20

A A A A A A
A A

Post-sup Post-sup Post-sup Ant-inf Ant-inf Post-sup Ant-sup


Ant-sup Post-sup

5 2 6 8 12 53 34
6 47

80 150 180
70

2 2 2

2
I 3

187
129 177

New
New New

60 70 95

20
21 22
23

F
M F
M

21
55

1
I Mild II 2 3 2 2
I 1 3 1 1 1

139
58 91

New
New New New New

50
10 70 45
150

41
30

A
A

Ant-inf
Post-sup

15
5

106
35

24 25 26 27 28
29

F M F F F
M

50 57 46 21 62
32

A A A A A
A

Ant-inf
Post-sup Ant-inf Post-sup Post-sup Post-sup

15
11 6 18 6 20

2
1 1

84
65 63 67

New
New New New

120
110

50 80
240 I

2 2
2

1
1 1

81
160
48

New
New New

30 31 32
33 34

F M M
M M

19 5 50
40 20 16

B B C
C C C

Post-sup
Post-sup Post-sup

1
1 6

270 ha 2

1
1 3 1

46
126 121

New
New New New

Iha

I II

3
3

Post-sup Ant-sup Post-sup Post-sup Ant-inf


Post-sup Post-sup

10 52 4 14 15
1 20

35
36 37
38

F
M M
F

3
3

100 58 159
51

16 21
59

C C
C

1 2
1

New New
New

2 Mild 150 120


110 360 Mild IV

3
2
4

39 40
41 42 43

M M
M M M

22 29
20 33 18

A A
A B D

47 28

Chart Chart

Post-sup
Post-sup Post-sup Post-sup

1
14 18 15

2 Moderate hIb

105
58 124

Chart Chart
Arthroplasty No No
Died Died Died Died

III

44 45 46 47 48 49 50
*

M M M M F M F

45 32 22 21 32 26 46

A A A A A B C at reporting

105 60
50

Post-sup
Post-sup Post-sup Post-sup Post-sup

15
43 66 69 64

90

110
150

Post-sup
hospital; months

53
treatment elsewhere, reduction at centre; C, reduction elsewhere, later treatment at centre;

Died
D, primary treatment

A, all treatment

B, primary

elsewhere,

arthroplasty
2, good;

after eight
3, fair;

t see text :: 1, excellent;

4, poor

VOL. 76-B,

No. 1, JANUARY

1994

K.

E.

DRE1NHOFER,

5.

R. SCHWARZKOPF,

N.

P. HAAS.

H. TSCHERNE

Table

II. Aetiology hip dislocations

ofSO

isolated

Number Car accidents Driver Front-seat


Rear-seat

25 15 passenger
passenger 5 5

Truckdriver Motorcycle Pedestrian accidents accident

4 10 1 3
I

Sport accidents Skiing

Biking
Sledge

1
1

Falls

3 objects
accidents

Age in years
Fig. Age hip. and sex distribution of 50 patients 1

Falling
Rollover

1
3

with

traumatic

dislocation

of the

dislocation
within months at which ofthe after

was diagnosed
the accident radiographs protocol

after transfer,
One patient because showed includes

but all were reduced


was referred nerve eight paralysis dislocation radiograph of

Table III. dislocations

Associated

injuries

in 43

patients

with

isolated

hip

six hours time

of the injury.

of sciatic an unreduced a pelvic

Number Head Upper


Thoracic

injury extremity
injury

37 fracture 22
20

hip. Our routine

every
( 37

severely
superior

injured
were
and one

or comatose
inferior) and

patient,
12 were

and therefore
were
anterior

no
(four

dislocations

overlooked.

Thirty-eight

posterior

Spinal

fracture

2
10 4 3

superior injuries,
Polytrauma maximum

and eight inferior); multiple in 14 (Table


Score; was 69. Tscherne

43 patients had associated III). The mean PTS (Hannover


et al 1987) was 19, while the

Abdominal injuries Spleen Small bowel Bladder

Urethra Pelvic injuries


fracture, contralateral

2 I 12
5

The mean reduction time, defined as the interval from the accident until reduction was 70 minutes (10 to 180) in the 37 patients treated primarily at our hospital (treatment group A), one patient having reduction at the scene of the

Acetabular

Pelvic fracture Fracture of the symphysis sacroiliacjoint Sciatic nerve palsy

5 and 2 2
Contralateral 33 Ipsilateral 1

accident. The mean reduction time in four of the patients treated primarily elsewhere and reduced at our hospital was
260 minutes whose hips (150 to 375) (group B). For had been reduced at another the eight patients hospital no exact

Lower extremity Femoral shaft Subtrochanteric

fracture fracture

timing
first

was available

but all were transferred


C). were performed methods were under successful

to us during

the

Knee ligament injury Tibial head fracture Tibial shaft fracture


Fibular fracture

5 2
1

3 4

12 hours (group All reductions thesia, and closed

general anaesin 48. After

closed reduction one patient had widening of the joint space; arthrotomy showed an interposed labrum. The patient with an unreduced dislocation at eight months had developed severe deformity of the displaced femoral head; this was treated by skeletal traction for four weeks followed by a total hip replacement. Further treatment varied according to the associated injuries. We did not use skeletal traction. Early mobilisation was advised with partial weight-bearing weeks. During any period of bed rest injuries, patients joint movement. had physiotherapy with for two to three required for other active and passive were

Malleolar fracture Talar fracture Calcaneal fracture Cuneiform fracture Metatarsal fracture

1 I 1

Follow-up. Five patients died from severe injuries; their average PTS was 59 (43 to 69). Six patients refused to
participate in the follow-up study, but for four of them we

had full clinical and radiological follow-up for 2.5 to 9 years (mean 4.5). The patient with very late reduction treated by hip replacement was also excluded. Thus, long-term available for results after a mean of 8 years (2 to 17) 42 patients, with a recent clinical and
THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

ISOLATED

TRAUMATIC

DISLOCATiON

OF

THE

HIP

radiological

examination

in

38

of

them.

The

latter

had two

Radiological patients

signs

of AVN were cystic

(Stulberg changes

llb)

were

seen ha)

in in

clinical assessment and AP and lateral radiographs. We graded necrosis using the classification of Stulberg et al (1989) and heterotopic ossification on the grading of Brooker et al (1973). Thirty-three patients were also examined by MRI, with results classified according to Mitchell et al

and there

(Stulberg

four. Of the 33 MRI examinations, 29 were normal. Four hips showed pathological changes: one in Mitchell class A, two in class C and one in class D. All four hips also showed radiological The evaluated changes. objective according clinical to Thompson and radiological and Epstein data (1951): were 23 of systems good or in these

(1989). (1951)
judgement

We used Thompson and Epsteins to rate the clinical result and recorded
of the patients as excellent, good,

classification

the subjective
fair or poor.

42 hips had excellent or good results. By the scoring of Merle dAubign#{233} and Postel (1954), 37 were excellent and the Harris (1969) score gave 33 categories. The subjective opinions in 28 of the 38 seen for late review. factors on the outcome is given

RESULTS The objective clinical results were excellent or good in 23 of 42 patients; the subjective opinion was excellent or good in 28 of 38 patients. There was heterotopic ossification in 16 hips: 12 were in Brooker grade I, two in grade II, one in grade III and one in grade IV. The last two patients with severe ossification had had severe head injuries with subarachnoid on respirators. bleeding and spent 25 and 31 days respectively

were good or excellent The influence of various IV.

in Table

Direction

of dislocation.

There were fair results

in only

one

quarter of the anterior dislocations, but in more than 50% of the posterior dislocations (p < 0.18). In the anterior group only one hip showed mild osteoarthritis and one low-grade heterotopic ossification (Brooker H).

Injury

severity.

The grade

of the initial

injury

affected

the

Table

IV.

Results

related

to various

factors Thompson and E pstein Fair grade

Heterotopic
Number Direction of dislocation 4 8 30 1 (P1S score) 23
11

Excellent/Good

Poor

AVN

Osteoarthritis

ossification

Anterosuperior

Anteroinferior Posterosuperior Posteroinferior Injury severity <12


12to30

3 6 15

1 2 12 1

1 3 6 1 7 1 3

13
7

9
2

1
2

4
2

2
4 2

31to49 >49 Reduction <60 bOtol2O


12lto240

6 2 time in minutes 12 15
6

2 I

4 I

1 1

7 9
4

5 4
2

2 1

1 1
1

3 3
1

1 1 1

241to360 Site of treatment All treatment at reporting hospital Primary treatment elsewhere, reduction at centre
Reduction elsewhere,

32 3 7

19 2 2

11

2 1

3 1 2

7 1 1

1 1 2

later treatment Age (years)


<20 20to29

at centre

8 13

30to49 >50 Duration 2toS 6tolO


>10

13 8 of follow-up (years) 14 14
14

4 8 5

4 4

1 2

1 1

7 1

1 I

4 1

4 2

5 10
8

7 4
5

2
1

3 1
2

4 3
2

2 2

Nine

patients

had

signs

of

osteoarthritis;

seven

had

final

outcome.

Five

of the seven

with

severe

multiple

injuries

irregular

femoral with

heads pronounced

and acetabula

with

mild

or moderate

narrowing
acetabula
VOL. 76-B.

of the joint

space,

two had deformed

heads

and

had only fair results; six of the seven patients with isolated dislocations had excellent or good results, while one had
mild pain and cystic changes on the radiograph. The

narrowing.

No. I, JANUARY

1994

10

K.

E.

DREINHOFER,

S. R. SCHWARZKOPF,

N. P. HAAS,

H. TSCHERNE

incidence
patients

of osteoarthritis
(7/18) than in

was
those

greater
with only

in multiply-injured
minor associated

We found that only fair results,

five of seven multiply-injured while six of seven with isolated

patients injuries common

had did

injuries

(2/23).

well. Similar to reduction.


between
treated (Stulberg ha)

findings

were reported
severe injuries

by Yang
were

et al (1991). fractures

In
in

Time
under
patients cystic

from
six

injury
hours

Despite
and
hospital and two

the short
reduction
two hips

injury
at our

delay in all
developed

of 35

our

series

associated

more

the contralateral

leg: there

were

three ipsilateral

as

primarily changes

showed

subchondral

sequestrae,

the the
and

crescent

sign

(Stulberg

lib).

We

found

no

against 20 contralateral of the acetabulum). transmission of forces (1981)

fractures, (15 of long bones This difference indicates in the two limbs.

and five different

statistical
between
minutes the seven

difference
results
those

(Fishers
in dislocations
which referred had after

exact
a delay

test two
reduced

tail;

in less

1.0) than 60
=

In the right-hand drive UK Upadhyay and Moulton found that the left hip was involved twice as often as

of 1 to 6 hours.

Five

of

the right and Levin


in the USA posteriorly

(1992)

reported

that in automobile

drivers

patients

reduction

at another
had severe

hospital
associated

had
injuries.

only

fair

results,

but

all

these

there was a tendency for the left hip to dislocate and for the right hip to suffer posterior fractureor pure anterior between the cause dislocation. We of the dislocation,
others have reported

Age
more former
thritis;

of patient.
at the group,
this was

Six of the eight


of injury had
present

patients
excellent

aged 50 years
or good results,

or

dislocation correlation
site, and the

found no the injured


that the

time

had

final

results,

but

compared

with

17 of the 34 younger
however,
already

patients.
time of the

Three
accident

of the
osteoarin

cause

of the that

dislocation et al 1983; reduced

affected Yang femoral

long-term

complications It has also predisposed been to

evidence
at the

of bilateral

(Upadhyay reported

et al 1991). anteversion

two.

traumatic of follow-up. Patients with the shortest period of had the highest incidence of fair and poor results;
demonstrate no increase in incidence of post-

dislocation

(Upadhyay,

Moulton

and

Burwell

Duration follow-up
we could

1985; de la Caffini#{232}re and Ould Ouali 1989), not verify this in our patients when compared

but we could with normal

traumatic arthritis with time. Correlation of AVN and osteoarthritis.

A subchondral

volunteers (unpublished data). Long-term complications are generally believed to be caused by insufficient blood supply to the femoral head. In

crescent sign appeared in two femoral heads; one of these developed mild and one moderate osteoarthritis. One of the four hips with cystic changes developed mild signs of osteoarthritis, degenerative respectively. Correlation of clinical In 33 of the 42 patients radiological result. Seven and radiological the clinical status patients results (Table V). correlated with the clinical but changes the other after three follow-up showed no evidence of of 4, 10, and 1 1 years

rabbits,
supply hours
achieved

Duncan

and

Shim

(1977)

showed

that

the blood

to the femoral of continued


only after

head reached a minimum within 24 dislocation. Complete recovery was


early reduction; replacement later than

12

hours

after

injury

did

not

improve

the

circulatory

Table
and

V.

Correlation
results

between

clinical

had a fair or poor

radiological

result

despite

a normal

radiograph,

usually

because

of pain.
hip with with mild
Radiology
Normal Abnormal

Clinical

result Fair/Poor 7 10

Good clinical results were associated in one moderate heterotopic ossification, and in another, osteoarthritis Correlation There objective than was and cystic between only findings. a weak The result changes objective correlation patients according own

Excellent/Good 23 2

in the femoral head. and subjective results. between evaluation in five. to Thompson subjective was and better recovery. tion is the

the objective

and Epstein

Clinical most

studies important

also

indicated initial

that

prompt

reducwith the

(1951)

in 17, the same in 16 and worse

management,

DISCUSSION Traumatic uncommon has been


belts are

critical delay being reported by some authors to be 12 hours (Bray 1962; Epstein 1974). More recent articles recommend reduction within 6 hours (Weigand et al 1978; Hougaard and dislocation of the hip was once considered to be
Thomsen studies 1986; included Jaskulka enough et patients al 1991), with hips but none reduced of these

(Armstrong 1948), and the increase attributed to traffic accidents, especially


not worn (Epstein 1980; Jacob et al

in incidence when seat


1987). As in

between

7 and 12 hours. difference between 12 and 24 hours. We cannot


tions primarily

Yang delay resolve

et al (1991) of less than this


at our

found 12 hours since


were

no statistical and between all the dislocadiagnosed and

other

recent

series

(Hougaard

and Thomsen injury

1987; was

Jaskulka, the most with

Fischer and Fenzl 1991), a dashboard common mechanism in our cases. Most hip dislocations are said
severe concomitant injuries (Suraci

question,
hospital

treated

to be associated

1986;

Jaskulka

et al

reduced however, we found


early

within three hours. Even did not exclude deleterious no significant


and

this very short interval, long-term effects, and in outcome


six hours.

1991), but the effect of the severity of general final outcome at the hip has not been addressed

injury on the previously.

difference
reduction within

between
We did

very
find

reduction

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

ISOLATED

TRAUMATIC

DISLOCATION

OF THE

HIP

11

significantly and referred inadequate reduction.

worse information

results

for dislocations 12 hours about the timing

reduced and

elsewhere hut have of the

outcomes this: we dislocations agree with hut cannot

mainly had fair

due to osteoarthritis. or poor outcomes

Our results dislocations.

confirmed

to us within

of the accident, method

in 16 of 30 posterior We therefore is important, AVN of the

and 3 of 12 anterior

Upadhyay et al (1983) found that the incidence of secondary osteoarthritis increased with time but both Epstein (1980) and Hougaard and Thomsen (1987) reported that this complication usually developed within five years of dislocation, as seen in our series. There rate ofdegeneration with increased authors have hips in older reported patients also seems to be a higher injury severity, and some

Levin (1992) that prompt reduction prevent complications in all cases.

femoral head and arthritis may result from the initial injury and not from delay in reduction. It is difficult to compare our results with other reported series especially systems. The designed because of the use of different Merle dAubign#{233} and Harris of arthroplasties, while classification scores were the Thomp-

an increasing number of osteoarthritic (Hunter 1969; Upadhyay et al 1983), (Epstein

for evaluation

although this was not confirmed in other reports 1980; Hougaard and Thomsen 1986) or our series.

son and Epstein score primarily Their original criteria imply that of pain should of be all classified other explain studies regardless criteria; worse parameters.

assesses hip dislocations. all patients with any kind only We used a fair these result, rigid

as having

For many
period 1962;

years,

prolonged

immobilisation
were recommended and Weiss 1977),

and a long
(Bray but recent

of non-weight-bearing Hunter 1969; Bromberg

this may partly than those of

the fact that our results were which either used another et al 1983; Schlickewei Jacob et al 1987; et al 1993) or a criteria

investigations have failed to show deleterious early mobilisation (Hougaard and Thomsen

effects from 1987; Jaskulka

classification Hougaard
different

system (Upadhyay and Thomson 1987;


interpretation

et al 1991; Schlickewei et al 1993). Simple traumatic dislocation ofthe hip without fracture, rapidly reduced, has been considered to have few long-term complications, 100% (Stewart with excellent or good results in 85% to et al 1975; Weigand et al 1978; Hougaard

of the Thompson

and Epstein

(Jaskulka

et al 1991).

Conclusions.
that an isolated excellent

We do not agree
hip dislocations outcome: In our were we series found

with the widely


within a substantial factors of the dislocation

held view
have of number (better

reduced

six hours

and

Thomsen

1987;

Jacob

et al 1987;

Niederwieser

and

complications.

the important

for long-

Primavesi 1991; Yang et al 1991; Schlickewei Ct al 1993), or in other series 75% (Lamke 1970; Epstein 1980; Upadhyay et al 1983; Jaskulka et al 1991). By contrast, W#{246}lfel et al

term prognosis
for anterior
to the patient.

the direction

dislocation)

and the overall

severity

of all injuries

(1991),
dislocation

reviewing
treated

42 results
by traction

at 6 to 20 years
for four weeks found

after
and

isolated
and non2 poor
No benefits commercial in any form party related have been received directly or indirectly or will be received to the subject of this from article. a

weight-bearing

for 3 to 4 months,

15 fair

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JR.
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J Bone

one 30-B:

Hougaard
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K, Thomsen

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[Am] 1987;

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69-A:679-83. [Br] of the 1969;

EA. Traumatic dislocation over a twelve-year period. 1115-34. E, Weiss AB. 1977; 70:8-11. Posterior

of the hip: army experience J Bone Joint Surg [Am] fracture-dislocation

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results 44-A: Jacob South

GA. Posterior dislocation review of fifty-seven patients.

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38-44.
JR, Rao JP, dislocation ofthe
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Bromberg MedJ

of the

Ciccarelli C. hip: a long-term

dislocation study. Clin

and fracture Orthop 1987; of of the

Brooker AF, Bowerman JW, ossification following total of classification. J BoneJoint de

Robinson RA, Riley LH Jr. Ectopic hip replacement: incidence and a method Surg [Am] 1973; 55-A:1629-32.

Jaskulka
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