Arthroscopic Reduction and Fixation of a Pipkin Type-I Femoral Head Fracture.

Background: This video article describes the technique for arthroscopic reduction and fixation of Pipkin type-I fractures. Description: Surgery is performed with the patient in a supine position, with free lower limbs, on a radiolucent table. Arthroscopic superior and anterolateral portals are made similarly to the portals created to evaluate the peripheral compartment during an outside-in (ballooning) technique.1 An additional medial portal is subsequently created in order to aid in reduction and screw placement. The medial portal is created in abduction and external rotation of the hip (i.e., the figure-4 position). The adductor tendon is identified, and the portal is then safely positioned posteriorly to its margin, approximately 4 to 5 cm distal to the inguinal fold, avoiding the saphenous vein (usually identified with an ultrasound scan). The fragment is mobilized, debrided, and then reduced with use of a microfracture awl or a large Kirschner wire (used as a joystick). Following reduction, temporary fixation is performed with use of long Kirschner wires under direct visualization and fluoroscopic guidance. If reduction is satisfactory, definitive fixation can be performed with use of 4.5-mm headless screws through the medial portal. All steps of fragment reduction and fixation are performed through the medial portal, with the patient in the figure-4 position. Once the screws are placed, a final dynamic arthroscopic and fluoroscopic check is performed. Alternatives: In Pipkin type-I fractures, surgery is recommended when the femoral head fragment is large (exceeding 15% to 20% of the femoral head volume) and displaced (by >3 mm). In such cases, if untreated, spontaneous evolution to osteoarthritis may occur. For fragments smaller than 10% to 15% of the femoral head volume, arthroscopic removal is often the best choice2. Several approaches (e.g., Smith-Petersen, modified Hueter, Kocher-Langenbeck, and surgical safe dislocation) have been proposed for reduction and fixation, with surgical safe dislocation being the most versatile because of the uniquely complete visualization of the femoral head3. Rationale: The arthroscopic reduction and fixation technique for a non-comminuted Pipkin type-I fracture holds the intrinsic advantages of being less invasive than open surgery in terms of surgical exposure, and having less blood loss, infection risks, and wound complications. Arthroscopy allows direct visualization of the fragment and its reduction surface, along with removal of articular loose bodies and debridement. The surgical time is influenced by the surgeon's experience, but often is no longer than with an open procedure. In the few studies assessing the use of this technique, the rates of osteonecrosis and heterotopic ossification are lower than with open techniques. It is worth noting that the studies assessing the use of this procedure are limited both in number and quality; however, the results of these studies have been excellent. It must also be noted that patients undergoing arthroscopic fixation are mostly selected for this treatment because they have less severe injuries2-12. Expected Outcomes: Open reduction and fixation through one of a variety of approaches is the gold standard treatment for Pipkin fractures; however, it is a relatively invasive procedure, prone to increased risks of osteonecrosis of the femoral head and heterotopic ossification (from 4% to 78% of cases). In some cases, arthroscopic reduction and fixation can be as effective as open reduction, and carries with it the intrinsic advantages of a keyhole procedure. The reported 4.6% global complication rate following arthroscopic fixation demonstrates the potential advantages of this technique, with limits due to the low numbers of treated cases4. Important Tips: The operating room should be carefully set up, especially regarding the positions of the C-arm and the arthroscopy tower, which should be double-checked before starting the procedure.The medial portal should be created after identification of the saphenous vein on an ultrasound scan. The anesthesiologist or a radiologist may mark the vein on the skin preoperatively, or the surgeon may extend the arthroscopic portal and perform a superficial dissection to avoid the vessel.Visualization after creation of the portals is usually suboptimal until the hematoma is completely removed. Patience must be maintained in this phase of the procedure.A microfracture awl or a large Kirschner wire can be utilized as a joystick to aid in reduction of the fragment, from either the usual portals or the medial portal. This aid can facilitate rotation of the fragment, which is a key step in the reduction phase.Definitive fixation can be achieved with use of 4.5-mm cannulated headless screws. Large cannulated headless screws have longer and larger Kirschner wires that can also aid in reduction when used as joysticks, reducing the risk of bending or breaking during screw insertion. Additionally, a 4.5-mm screwdriver is longer, allowing easier insertion, especially in patients with a larger thigh. The large diameter should not be a concern because the head is sunk in a non-weight-bearing area of the head.To avoid the risk of misplacement or loss of the screw during its insertion, make use of a cannulated guide handle for 4.5-mm screws, such as the guide utilized in a Latarjet arthroscopic procedure.To prevent screw loss into the joint, utilize a loop-knotted wire around the proximal part of the screw; this wire is cut at the end of the procedure. Acronyms and Abbreviations: AAFF = arthroscopic-assisted fracture fixationHO = heterotopic ossificationUS = ultrasound/ultrasonographyAP = anteroposteriorCT = computed tomographyASIS = anterosuperior iliac spineGT = greater trochanterSP = Smith-PetersenIF = internal fixationK-wire = Kirschner wire.

Surgical Technique: Arthroscopic Reduction and Fixation of Partial Posterior Wall Acetabular Fractures.

Partial posterior wall fractures are usually fixed with open reduction-internal fixation through an open posterolateral approach, but when the fragment may be fixed without a plate (with screws only), reduction and fixation may also be achieved via hip arthroscopy with the patient in the prone position. This article presents all the surgical steps to perform this procedure.

Ganz femoral head reduction associated with coverage and containment procedures improve radiological and functional outcomes in Perthes' disease.

Aims: Ganz's studies made it possible to address joint deformities on both the femoral and acetabular side brought about by Perthes' disease. Femoral head reduction osteotomy (FHRO) was developed to improve joint congruency, along with periacetabular osteotomy (PAO), which may enhance coverage and containment. The purpose of this study is to show the clinical and morphological outcomes of the technique and the use of an implemented planning approach. Methods: From September 2015 to December 2021, 13 FHROs were performed on 11 patients for Perthes' disease in two centres. Of these, 11 hips had an associated PAO. A specific CT- and MRI-based protocol for virtual simulation of the corrections was developed. Outcomes were assessed with radiological parameters (sphericity index, extrusion index, integrity of the Shenton's line, lateral centre-edge angle (LCEA), Tönnis angle), and clinical parameters (range of motion, visual analogue scale (VAS) for pain, Merle d'Aubigné-Postel score, modified Harris Hip Score (mHHS), and EuroQol five-dimension five-level health questionnaire (EQ-5D-5L)). Early and late complications were reported. Results: The mean follow-up was 39.7 months (standard deviation (SD) 26.4). The mean age at surgery was 11.4 years (SD 1.6). No major complications were recorded. One patient required a total hip arthroplasty. Mean femoral head sphericity increased from 46.8% (SD 9.34%) to 70.2% (SD 15.44; p < 0.001); mean LCEA from 19.2° (SD 9.03°) to 44° (SD 10.27°; p < 0.001); mean extrusion index from 37.8 (SD 8.70) to 7.5 (SD 9.28; p < 0.001); and mean Tönnis angle from 16.5° (SD 12.35°) to 4.8° (SD 4.05°; p = 0.100). The mean VAS improved from 3.55 (SD 3.05) to 1.22 (1.72; p = 0.06); mean Merle d'Aubigné-Postel score from 14.55 (SD 1.74) to 16 (SD 1.6; p = 0.01); and mean mHHS from 60.6 (SD 18.06) to 81 (SD 6.63; p = 0.021). The EQ-5D-5L also showed significant improvements. Conclusion: FHRO associated with periacetabular procedures is a safe technique that showed improved functional, clinical, and morphological outcomes in Perthes' disease. The newly introduced simulation and planning algorithm may help to further refine the technique.

Superior outcomes of total hip arthroplasty without prior lumbar arthrodesis: a systematic review and meta-analysis.

PURPOSE: The number of patients undergoing total hip arthroplasty (THA) surgery after previous lumbar arthrodesis (LA) is rising. Literature suggests that LA may significantly impact pelvic biomechanics and potentially compromise the success of prosthetic hip replacement. This study aims to evaluate complication rates, dislocation rates, and revision rates in patients with prior LA undergoing THA surgery compared to those undergoing THA surgery without prior LA. METHODS: A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A PICOS template was developed to ensure a structured approach. The search for relevant studies was performed across five databases, including Pubmed, Scopus, Embase, Medline, and Cochrane. The selected articles were evaluated based on the Levels of Evidence (LoE) criteria. The Coleman Methodology Score (mCMS) was employed to analyze the retrospective studies. This systematic review and meta-analysis were registered in the International Prospective Register of Systematic Reviews (PROSPERO). For the outcomes that allowed for a meta-analysis performed using R software, a p < 0.05 was considered statistically significant. RESULTS: The final analysis included seventeen studies comprising a total of 3,139,164 cases of THA. Among these cases, 3,081,137 underwent THA surgery alone, while 58,027 patients underwent THA with a previous LA. The study investigated various factors, including dislocation rates, revision rates, and complication, as well as the surgical approach and type of implant used, for both the THA-only group and the group of patients who underwent THA with prior LA. The analysis revealed a statistically significant difference (p < 0.05) for all variables studied, favoring the group of patients who underwent THA alone without prior LA. CONCLUSIONS: This systematic review and meta-analysis demonstrated a statistically significant superiority in all analyzed outcomes for patients who underwent THA-only without prior LA. Specifically, patients with isolated THA implants experienced significantly lower incidences of THA dislocation, wound complications, periprosthetic joint infection, revision, and mechanical complications. LEVEL OF EVIDENCE: Level IV.

Arthroscopic assistance during open reduction and fixation for complex acetabular fractures.

Achieving an anatomical reduction in acetabular fracture is essential but may also be challenging. Most of complex fractures are treated with anterior approaches without direct visualization of the acetabular surface. In this paper, we present the surgical technique for arthroscopic assistance during open reduction and fixation for complex acetabular fractures. To our knowledge, this technique has not been described in the literature yet.

Extended trochanteric osteotomy is a safe procedure in two-stage hip revision: a systematic review of the literature.

BACKGROUND: Extended trochanteric osteotomy (ETO) has proved to be an effective technique in complicated stem removal in femoral aseptic loosening or periprosthetic fracture. Debate remains about its safety in periprosthetic joint infection (PJI). The primary aim of this study is to analyze the ETO reinfection and union rate in two-stage hip revision. MATERIAL AND METHODS: A systematic literature review was performed regarding all studies reporting ETO outcomes in the two-stage revision for hip PJI up to October 2022, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. A literature search was conducted in the following databases: MEDLINE/EMBASE, Scopus, Web of Science, and Cochrane. Quality assessment of the articles was performed using the Methodological Index for Non-Randomized Studies. This systematic review was registered in the International Prospective Registry of Systematic Reviews. Patient demographic, clinical, and surgical data were collected. RESULTS: This systematic review included and analyzed nine clinical studies with a total of 382 ETO PJI hips in two-stage revision. The overall ETO reinfection rate was 8.9% (34 hips), consistent with the reinfection rate after two-stage revision in patients without ETO. The overall ETO union rate was 94.8% (347 hips), comparable to the ETO union rate in non-septic patients. Compared between a group of patients with ETO PJI and a group of patients with non-PJI ETO, there were no significant differences in postoperative complications, both septic and aseptic, and for postoperative HHS. CONCLUSION: ETO proved to be a safe and effective procedure in PJI revisions. It may be a viable option in challenging femoral stem removal during the two-stage hip revision in PJI. LEVEL OF EVIDENCE: IV.

Acute Rockwood type III ACJ dislocation: Conservative vs surgical approach. A systematic review and meta-analysis of current concepts in literature.

BACKGROUND: The most appropriate approach, surgical or conservative, for acute Rockwood type III acromioclavicular joint (ACJ) dislocation is still under debate. In literature, similar results have been reported with both treatments. This review aims to analyze the operative and conservative outcomes of acute Rockwood type III ACJ dislocation to guide orthopedics in daily practice. MATERIAL/METHODS: A systematic review and meta-analysis were performed according to PRISMA guidelines. A PICOS template was developed. Four databases (Pubmed, Scopus, Embase, and Medline) were searched, and eligible articles were evaluated according to the Levels of Evidence. The methodological quality of the articles was assessed through the ROBINS-I and the RoB-2. This review was registered in PROSPERO. RESULTS: Five studies were included, with 73 and 110 patients treated with conservative and surgical approaches, respectively. Three outcomes, Constant Score (CS), coracoclavicular distance (CCD), and acromioclavicular distance (ACD) were analyzed. Only the acromioclavicular distance was statistically significant in the surgical group over the conservative one (p < 0.05); instead, the other two outcomes demonstrated no statistical difference between the two groups. CONCLUSIONS: This study demonstrated statistically significant superiority of the mean ACD score in the radiological follow-up of the surgical group compared to the conservative one. A tendency for better radiological and clinical results, mean CCD and CS scores, respectively, although non statically significant, was reported in the surgical group. High-quality randomized controlled clinical trials should help determine the most appropriate treatment for acute Rockwood type III ACJ dislocations.

Modified Dunn procedure versus percutaneous pinning in moderate/severe stable slipped capital femoral epiphyses.

BACKGROUND: The modified Dunn procedure (MDP) has risen enthusiasm in treating slipped capital femoral epiphyses (SCFE) due to the anatomic reduction and high patients' satisfaction rates at long-term follow-up. Main aim of this study is to compare clinical and radiographic outcomes of 2 cohorts with moderate to severe stable SCFE treated by MDP and in situ fixation. METHODS: Medical records were analysed to collect demographic data, comorbidities and time from slip to surgery. The collected postoperative data were: avascular necrosis (AVN); complications; progression of osteoarthritis and subsequent procedures. Southwick angles (SA), alpha angles and Klein line were measured on the preoperative x-rays, on the immediate postoperative period and at the latest follow-up. Outcomes scores were recorded by the following questionnaires: the Harris Hip Score, the Hip disability and Osteoarthritis Outcome Score, the Merle d'Aubigné and Postel score and the Western Ontario and McMaster Universities Arthritis Index. Kaplan-Meier survivorship curve was calculated. RESULTS: We compared 81 hips treated by MDP with 22 hips treated by in situ pinning (PS) for moderate/severe stable SCFE. No significant differences were found between the 2 groups in terms of age, BMI, comorbidities and preoperative slip angles. At the latest follow-up, postoperative anteroposterior mean slip angles were respectively 6.2 and 19.9° in MDP and PS group (p = 0.3). Slip angles in frog lateral view were 11° in the MDP group and 39.7° in the PS group (p = 0.2). MDP group achieved better correction angles on frog leg view (11° vs. 39.7°; p < 0.001). There was no statistically significant difference in the occurrence of AVN among both groups (19.7% MDP group vs. 31.8% PS group) (p = 0.2). CONCLUSIONS: The MDP in treating severe stable SCFE showed the best deformities corrections in conjunction with the highest functional scores at long-term follow-up and similar rates of osteonecrosis compared to in situ fixation.

Dynamic evaluation of THA components by Prosthesis Impingement Software (PIS).

Background and aim of the work Implant dislocation in total hip arthroplasties (THA) is a common concern amongst the orthopedic surgeons and represents the most frequent complication after primary implant. Several causes could be responsible for the dislocation, including the malpositioning of the components. Conventional imaging techniques frequently fail to detect the mechanical source of dislocation mainly because they could not reproduce a dynamic evaluation of the components. The purpose of this study was to elaborate a diagnostic tool capable to virtually assess if the range of movement (ROM) of a THA is free from anterior and/or superior mechanical impingement. The ultimate aim is to give the surgeon the possibility to weigh the mechanical contribution in a THA dislocation.   Methods A group of patients who underwent THA revision for acute dislocation was compared to a group of non-dislocating THA. CT scans and a virtual model of each patient was obtained. A software called "Prosthesis Impingement Simulator (PIS)" was developed for simulating the (ROM) of the prosthetic hip. The ROM free of mechanical impingement was compared between the two groups.    Results  The PIS test could detect the dislocations with a sensitivity of 71,4%, and a specificity of 85,7%. The Fisher's exact test showed a p-value of 0,02. The Chi-square test found a p-value of 0,009.   Conclusion The PIS seems to be an effective tool for the determination of hip prosthetic impingement, as the main aid of the software is the exclusion of mechanical causes in the event of a dislocation.

3D-Printed Surgical Guiding System for Double Derotational Osteotomy in Congenital Torsional Limb Deformity: A Case Report.

CASE: A 19-year-old woman with persistent anterior knee pain was diagnosed with a complex tibial and femoral torsional deformity (26° of femoral anteversion and 49° of tibial external rotation). To achieve the correct realignment of the lower limb, rotational double osteotomies were needed. After planning the correction on the computed tomography scan and three-dimensional (3D) model, a custom-made 3D-printed guiding system was produced to support the surgery. CONCLUSION: The 3D-printed planning model and the surgical guiding system are crucial elements to achieve optimal results for complex malalignment cases. The "tailored" guides led to a perfect match between the planned correction and the intraoperative result.

Hip morphology in slipped capital femoral epiphysis.

Several mechanical factors have been related to slipped capital femoral epiphysis (SCFE). Main aim of this study is to investigate the acetabular coverage and acetabular version in unilateral SCFE hips in order to detect a potential pincer-type deformity as predisposing factor; second, we compared those measurements either to the contralateral, uninvolved hips either to a matched healthy control population. A total of 85 patients treated for unilateral SCFE were retrospectively reviewed. The lateral center-edge angle (LCEA) and the Tönnis angle were used to assess acetabular coverage, whereas acetabular retroversion was defined by positive prominent ischial spine (PIS), cross-over sign (COS) and posterior wall sign (PWS). Angles and signs of the affected hips were compared to the contralateral hips and to a matched cohort undergoing an abdominal/pelvic computed tomography for nonorthopedic-related diseases. Affected and unaffected hips of patients with unilateral SCFE had similar morphology in terms of LCEA 28.7° vs. 28° (P = 0.4), Tönnis angle 9° vs. 9° (P = 0.1) and retroversion signs with concomitant rate of PWS and COS 57.6% vs. 50.5% (P = 0.4), PIS 56.4% vs. 49.4% (P = 0.4). Matched healthy controls vs. the affected hips showed a lower LCEA (P < 0.001) and higher Tönnis angle (P < 0.001) in conjunction with a lower incidence of acetabular retroversion: PWS and COS 40% vs. 57.6% (P = 0.01), PIS 43% vs. 56.4% (P = 0.07). A significant retroversion and increased overcoverage were observed in SCFE patients compared to matched healthy controls. In unilateral SCFE, the involved and uninvolved hips showed a substantial symmetry.

Fixation plus acute arthroplasty for acetabular fracture in eldery patients.

OBJECTIVE: in elderly patients reduction and fixation of acetabular fractures showed poor outcomes in fracture patterns where cartilage comminution/impaction and/or femoral head dislocation are present; acute arthroplasty with standard uncemented hemispherical cups and posterior plating has been recently proposed, we report on its safety and effectiveness. METHODS: we used this technique to manage 67 displaced acetabular fracture but both column in patients older than 65 years old. RESULTS: fractures of posterior column and/or wall with severe cartilage involvement may be treated safely with acute THA. CONCLUSIONS: Good results in complex fracture patterns may also be achieved.

Management of Paprosky type three B acetabular defects by custom-made components: early results.

PURPOSE: Our study aims at the evaluation of the recently introduced Lima Promade custom-made acetabular device for the treatment of complex acetabular Paprosky 3B defects. METHODS: Between 2016 and 2018, eight patients with major acetabular osteolysis and multiple revisions history were treated with a custom-made implant in a single centre and by a single surgeon. We assessed patients' demographics, peri-operative data, and complications and a specific questionnaire was submitted to the surgeon after each procedure. RESULTS: All the devices were correctly positioned. In two over eight cases, a post-operative dislocation occurred, where extensive soft tissue impairment was present. The questionnaire showed a good pre-operative and intra-operative experience of the surgeon. CONCLUSIONS: The Promade custom-made acetabular system showed encouraging results for complex defects and the entire procedure was positively rated. Further analysis with a higher number of cases and a longer follow-up should be performed for a complete clinical and cost-effective evaluation.

Should hospital managers read the orthopedic literature before surgeons? The example of femur fracture management.

BACKGROUND: Early surgical intervention in the treatment of proximal femur fractures has been shown to significantly reduce mortality and complications. Our study intends to evaluate early surgery rates in a single-center analysis before the clinical advantages of early surgical intervention were demonstrated in the literature (G1), after the orthopedic team aimed to treat those fractures within 48 h (G2), and after early intervention became a primary objective for hospital management (G3). MATERIALS AND METHODS: The hospital charts of 894 proximal femur fractures in patients aged >65 years between 2008 and 2015 were analyzed in a single teaching hospital. The patients were allocated to three groups according to admission date, relative to the introduction of the different targets for early intervention. Our primary aim was to evaluate the differences in the rate of surgical treatment within 48 h in the three groups, and our secondary aim was to see if those differences influenced clinical outcomes. RESULTS: The rate of treatment before 48 h was 23, 49 and 72 % in groups 1, 2 and 3, respectively (p < 0.001). There were no statistically significant differences between the three groups regarding time from surgery to discharge and perioperative mortality. The length of hospitalization was different only between groups 1 and 2. CONCLUSIONS: The adoption of an early treatment goal for proximal femur fractures by the orthopedic team significantly improved the results. However, it was only by introducing this goal into primary hospital management objectives that significantly increased the performance. Level of evidence Level IV (retrospective case-control study).

Cementless total knee arthroplasty.

Interest for uncemented total knee arthroplasty (TKA) has greatly increased in recent years. This technique, less used than cemented knee replacement in the last decades, sees a revival thanks an advance in prosthetic design, instrumentation and operative technique. The related literature in some cases shows conflicting data on survival and on the revision's rate, but in most cases a success rate comparable to cemented TKA is reported. The optimal fixation in TKA is a subject of debate with the majority of surgeons favouring cemented fixation.

Bicompartmental knee arthroplasty.

Total knee arthroplasty (TKA) is the most worldwide practiced surgery for knee osteoarthritis and its efficacy is mightily described by literature. Concerns about the invasiveness of TKA let the introduction of segmental resurfacing of the joint for younger patients with localized osteoarthritis. Bone stock sparing and ligaments preservation are the essence of both unicompartmental knee arthroplasty (UKA) and bicompartmental knee arthroplasty (BKA). Advantages related to BKA are the respect of knee biomechanics, lower complications rates, shorter hospital stay, faster rehabilitation. Moreover, in case of failure of the first implant the conversion to TKA is undemanding and can be compared to a standard prosthesis. Our experience suggest that BKA is a reliable technique in selected cases and especially younger people with higher functional requests can favourably profit from it. Although those results are encouraging, we still need further prospective, randomized, long-term studies to finally assess BKA indications and outcomes.

Arthroscopic approach and anatomy of the hip.

BACKGROUND: Hip arthroscopy has gained popularity among the orthopedic community and a precise assessment of indications, techniques and results is constantly brought on. METHODS: In this chapter the principal standard entry portals for central and peripheral compartment are discussed. The description starts from the superficial landmarks for portals placement and continues with the deep layers. For each entry point an illustration of the main structures encountered is provided and the principal structures at risk for different portals are accurately examined. Articular anatomical description is carried out from the arthroscope point of view and sub-divided into central and peripheral compartment. The two compartments are systematically analyzed and the accessible articular areas for each portal explained. Moreover, some anatomical variations that can be found in the normal hip are reported. CONCLUSION: The anatomical knowledge of the hip joint along with a precise notion of the structures encountered with the arthroscope is an essential requirement for a secure and successful surgery. Level of evidence: V.

Can we predict femoral head vitality during surgical hip dislocation?

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.