Operative Techniken

Oper Orthop Traumatol 2014 · 26:591–602 B.R. Moed

DOI 10.1007/s00064-011-0111-1 Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis
Received: 13 May 2012
Revised: 9 February 2013
Accepted: 26 April 2013
Published online: 15. November 2014
© Springer-Verlag Berlin Heidelberg 2014 The modified  
Redaktion Gibson approach to
the acetabulum
D.C. Wirtz, Bonn
Zeichner
R. Himmelhan, Mannheim

Introductory remarks Advantages F The midlateral (rather than posterior)

position of the skin incision will often
The Kocher–Langenbeck incision has F Since the gluteus maximus muscle is avoid incision through an area of in-
been established as the preferred posteri- not split, the neurovascular supply jured posterior soft tissue (. Fig. 3)
or surgical approach to the acetabulum [3, to the anterior portion of the gluteus F This approach can be easily combined
7]. However, the modified Gibson surgi- maximus muscle is not at risk. with a trigastric trochanteric osteoto-
cal exposure of the acetabulum is a use- F As compared to the Kocher–Langen- my to further extend access or facili-
ful alternative. In 1950, Alexander Gib- beck, anterosuperior visualization and tate intraoperative dislocation of the
son described a posterior exposure of the access are extended (. Fig. 1). femoral head, as required.
hip which was, by his account, a modi- F The straight incision makes the mod-
fication of the Kocher approach [2]. His ified Gibson cosmetically appealing, Disadvantages
modification appears to have consisted of especially in obese female patients
moving the superior limb of the skin in- who have a higher risk for a postoper- F Some limitation of access in the re-
cision somewhat more anterior, although ative “saddlebag” soft tissue deformity gion where the neurovascular bun-
still maintaining an angled configuration. (. Fig. 2). dle of the gluteus maximus muscle
Modifications of the classic Gibson ap-
proach include limiting the extent of hip
Tab. 1  Choice of surgical approach for fracture patterns involving the posterior wall and/or
joint capsulotomy, abandoning the de-
column
tachment of the gluteus medius and min-
Fracture type Modified Kocher– Ilioin- Combined Extended
imus tendons from the greater trochanter, Gibson Langenbeck guinal anterior and iliofemoral
and straightening the angled incision. In posterior
addition to the straight skin incision, this Elementary
modified Gibson approach differs from Posterior wall Xa X      
the Kocher–Langenbeck approach in its Posterior column Xa X      
proximal deep dissection. Rather than Transverse infra/juxta- Xa X X    
splitting of the gluteus maximus muscle, tectal
the interval between the gluteus maximus Transverse transtectal X X X   X
and tensor fasciae latae muscles is devel- Associated
oped. In this way, risk of iatrogenic injury Posterior column and wall Xa X      
to the neurovascular supply to the anteri- Anterior and posterior     X X X
or portion of the gluteus maximus muscle hemitransverse
is eliminated. In addition, anterosuperior Transverse infra/juxtatec- Xa X      
visualization and surgical access are ex- tal and post wall
tended. This approach can be used in any Transverse transtectal and X X     X
situation that would otherwise call for the posterior wall
Kocher–Langenbeck approach (. Tab. 1). T-shaped infra/juxtatectal Xa X X X  
T-shaped transtectal       X X
X in bold denotes the generally preferred approachaIndicates the author’s current preferred approach in lieu of
the Kocher–Langenbeck approach

Operative Orthopädie und Traumatologie 6 · 2014  | 591

 Operative Techniken

F When use of a midlateral skin in-

cision is needed to avoid incision
through an area of injured posterior
soft tissue

Contraindications
F Fractures of the anterior column and/
or wall
F Transtectal T-shaped fractures
F Transverse fractures and infra/juxta-
tectal T-shaped fractures having the
major displacement anteriorly at the
pelvic brim with only minor posterior
displacement.
F Both column fractures
F Relative contraindication: presence of
closed degloving soft-tissue injuries
over the trochanteric region associat-
ed with underlying hematoma forma-
Fig. 1 8 a The Kocher–Langenbeck surgical access (dots show the available area of direct visualization; tion and fat necrosis (Morel–Lavallée
horizontal lines show the area of indirect access; vertical lines show the area of direct access ­extended lesion)
by release of the quadratus femoris muscle origin). b Using the modified Gibson approach, antero­
F Relative contraindication: when pre-
superior direct visualization and access are extended (solid black area). (Courtesy of the author, Ber-
ton R. Moed) operative planning indicates that ac-
cess to the entire greater sciatic notch
is required in a patient with a very
Fig. 2 9 The modified
Gibson skin incision large gluteus maximus muscle
shown as compared
with previous skin inci- Patient information
sions. The greater tro-
chanter is outlined by
F Discuss conservative treatment alter-
black dashes (D). The
straight line (C, D, E) natives
shows the current skin F Usual surgical risks
incision for the modi- F Have available approximately two
fied Gibson approach units of blood, depending on the frac-
superimposed on the
ture pattern
muscles and fascia.
The angled line (B, D, E) F Risk of postoperative venous throm-
shows the location of boembolism
Gibson’s original skin F Postoperatively, patient mobilization
incision [3]. The an- as quickly as the associated injuries
gled line (A, D, E) shows
will allow
the location of the Ko-
cher–Langenbeck skin F Out of bed on the first postoperative
incision. (Courtesy of day followed by active exercises to re-
the author, Berton R. gain muscle strength and hip range-
Moed) of-motion
F Hospital stay of 3–7 days for an isolat-
emerges from the greater sciatic notch Indications ed injury having an uneventful hospi-
when this muscle is very large. tal course
F Adding a trochanteric osteotomy in- F Any surgery that would otherwise F Restricted weight-bearing for 10–
creases the risk of osteonecrosis of call for the Kocher–Langenbeck ap- 12 weeks postoperatively
the femoral head if the osteotomy is proach, such as the treatment of pos- F Progression from partial to full
too medial, extending into the base of terior wall, posterior column, poste- weight-bearing depending on the
the neck and potentially injuring the rior column and wall, transverse and fracture type and progression of frac-
blood supply to the femoral head. posterior wall, and selected transverse ture healing
and T-shaped acetabular fracture
types

592 |  Operative Orthopädie und Traumatologie 6 · 2014

 Abstract · Zusammenfassung
Oper Orthop Traumatol 2014 · 26:591–602  DOI 10.1007/s00064-011-0111-1
© Springer-Verlag Berlin Heidelberg 2014
B.R. Moed
The modified Gibson approach to the acetabulum
Abstract
Objective.  Providing a surgical approach
similar to the Kocher–Langenbeck but hav-
ing improved anterosuperior access, less risk
of injury to branches of the inferior gluteal
nerve supplying the anterior portion of the
gluteus maximus muscle, and improved cos-
mesis.
Indications.  Any surgery that would other­
wise call for the Kocher–Langenbeck ap-
proach.
Contraindications.  Fractures of the anteri-
or column and/or wall; transtectal T-shaped
fractures. Transverse fractures and infra/jux-
tatectal T-shaped fractures having the ma-
jor displacement anteriorly at the pelvic brim
with only minor posterior displacement.
Surgical technique.  Exposure of the aceta­
bulum fracture through a straight skin inci-
Zugang zum Azetabulum in der Modifikation nach Gibson
Zusammenfassung
Ziel.  Operativer Zugangsweg ähnlich wie
nach Kocher-Langenbeck, aber mit besser-
em anterosuperiorem Zugang, geringerem
Verletzungsrisiko für die Äste des N. glutaeus
inferior, die den vorderen Anteil des M. glu-
taeus maximus versorgen, und größerer Un-
aufffälligkeit.
Indikationen.  Operationen, bei denen sonst
der Zugang nach Kocher-Langenbeck erfor­
derlich wäre.
Kontraindikationen.  Frakturen der Vorder-
säule und/oder -wand. Transtektale T-förmige
Frakturen. Querfrakturen und infra-/juxtatek-
tale T-förmige Frakturen, bei denen die wes-
entliche Dislokation vorn am Beckenrand und
nur eine kleinere hintere Dislokation besteht.
Operationstechnik.  Darstellung der Azeta­
bulumfraktur mittels gerader ­Hautinzision
und Freilegung der Ebene zwischen der vor-
F Unless complicated by inadvertent in-
tra-articular malposition, implant re-
moval not required
F Good-to-excellent hip function ex-
pected in approximately 65–85% of
patients depending on the fracture
type
F Return to work at 3–12 months de-
pending on fracture type and type of
employment
F Possibility for limited range of hip
motion and traumatic arthritis
sion, developing the plane between the an-
terior border of the gluteus maximus muscle
and the tensor fasciae latae. The gluteus max-
imus is reflected posteriorly to reveal the un-
derlying deep anatomic structures.
Postoperative management.  Thrombopro-
phylaxis and prophylaxis as indicated for the
prevention of heterotopic ossification are in-
stituted. The patient is mobilized as quickly as
the associated injuries will allow. Toe-touch
weight-bearing is continued for 10–12 weeks.
However, progression to full weight-bearing
should be individualized.
Results.  Between 1996 and 2000, 16 pa-
tients having a fracture of the acetabulum
were operated on through the modified Gib-
son approach with 15 patients followed up
for 1 year or more. Fracture types were poste-
deren Begrenzung des M. glutaeus max-
imus und des M. tensor fasciae latae. Der
M. glutaeus maximus wird nach hinten
umgeklappt, um die tiefen anatomischen
Strukturen sichtbar zu machen.
Nachbehandlung.  Verordnung einer Throm-
boseprophylaxe sowie, bei entsprechender
Indikation, einer Prophylaxe zur Prävention
heterotoper Ossifikationen. Der Patient wird
so schnell mobilisiert, wie es die begleiten-
den Verletzungen erlauben. Zehenbelastung
für 10–12 Wochen. Jedoch sollte der Über-
gang zur Vollbelastung individuell gehand-
habt werden.
Ergebnisse.  Zwischen 1996 und 2000 wur-
den 16 Patienten mit einer Azetabulum-
fraktur über einen modifizierten Zugang-
sweg nach Gibson operiert, bei 15 von ­ihnen
wurde der Verlauf mindestens ein Jahr nach-
F Salvage by total hip arthroplasty
Preoperative work-up
F To make an exact fracture diagno-
sis and classify the injury pattern [3,
4], obtain adequate plain radiographs
with an initial anteroposterior (AP) x-
ray of the pelvis supplemented by an
AP and two 45-degree oblique views
(the obturator oblique view and the
iliac oblique view) centered on the af-
Operative Orthopädie und Traumatologie 6 · 2014  | 593
rior wall in eight patients, transverse in one,
posterior column and wall in two, transverse
and posterior wall in four, and T-shaped in
one. There were no intraoperative or immedi-
ate postoperative complications. Clinical out-
come was determined using a modification
of the method developed by Merle d’Aubigné
and Postel and was good-to-excellent in 14
patients and poor in one (a patient who de-
veloped osteonecrosis of the femoral head
unrelated to the approach).
Keywords
Acetabulum fracture · Posterior approach ·
Surgical technique · Gibson approach ·
Outcome
beobachtet. An Frakturtypen lagen vor: Hin-
terwandfraktur bei 8, Querfraktur bei ei-
nem, Hintersäule und -wand bei zwei, Quer-
und Hinterwandfraktur bei 4 sowie T-förmi-
ge Fraktur bei einem Patienten. Es gab weder
intra- noch unmittelbar postoperative Kom-
plikationen. Das klinische Ergebnis wurde
anhand einer Modifikation der von ­Merle
d’Aubigné und Postel entwickelten ­Methode
ermittelt und war bei 14 Patienten gut bis
ausgezeichnet sowie bei einem schlecht (Pa-
tient, bei dem eine Osteonekrose des Fe-
murkopfes unabhängig vom Zugangsweg
auftrat).
Schlüsselwörter
Azetabulumfraktur · Posteriorer Zugang ·
Chirurgische Technik · Gibson-Zugang ·
Ergebnis
fected hip as well as a standard two-
dimensional computed tomography
(CT) scan.
F A high-quality three-dimensional CT
reconstruction may be helpful but is
not essential.
F Check and document the neurologic
and vascular status.
F Check the local soft tissues for a Mo-
rel–Lavallée lesion.
F Operative treatment is generally de-
layed a few days to allow stabilization
 Operative Techniken

Fig. 3 8 Photograph at the time of surgery of the posterior soft tissues in a 58-year-old man (the patient is prone with his
head to the right) (a) showing an excoriated buttock (X) and ecchymosis of the posterior thigh (*). Operative treatment had
been delayed 17 days due to pulmonary problems. b A Kocher–Langenbeck incision (K-L) would have involved the area of
excoriated­skin, but the modified Gibson approach (M-G) avoided this area. (Courtesy of the author, Berton R. Moed.)

of the patient’s general status and for
preoperative planning.
F Preoperatively, skeletal, femoral-pin
traction is recommended to maintain
an unstable hip in a located position
and to prevent any potential damage
to the femoral head articular surface
from abrasion by the acetabular frac-
ture surfaces.
F Administer perioperative broad-spec-
trum prophylactic antibiotics.
F Perioperatively, a urinary catheter
should be inserted.
F The intraoperative use of an autolo-
gous blood transfusion system may
decrease the need for transfusion of
homologous banked blood.
F If a fracture table is to be used intra-
operatively to apply traction, only one
scrubbed surgical assistant may be re-
quired, but two are preferred. If man-
ual traction is to be used, an addition-
al assistant should be available.
Surgical instruments
and implants
F Complete set of reduction forceps.
F Complete set of 4.5- and 3.5-mm
screws including lengths up to
120 mm.
F Mini-fragment screws up to 40 mm
in length for fixation of comminuted
wall fragments.
F Small fragment reconstruction and
one-third tubular plates with appro-
priate bending instruments.
F All of the above are available from
DePuy Synthes (West Chester, PA,
USA, and Umkirch, Germany) or
Stryker Orthopaedics (Mahwah, NJ,
USA, and Geneva, Switzerland).
F Long drill bits are always needed.
F An oscillating drill is desirable.
Anesthesia and positioning
F General endotracheal anesthesia is
preferred.
F The patient can be can placed in ei-
ther the lateral or the prone position;
however, the posterior approach is
generally thought to be most effective
with the patient placed prone on a
fracture table, especially for complex
fracture patterns (. Fig. 4).
F When combined with a trigastric tro-
chanteric osteotomy to facilitate intra-
operative dislocation of the femoral
head, the lateral position is preferred.
F Whatever the patient position, the
operating table must be radiolucent,
allowing use of intraoperative fluoros-
copy sufficient to assess fracture re-
duction and hardware location.

594 |  Operative Orthopädie und Traumatologie 6 · 2014

Surgical technique
(. Fig. 4, 5, 6, 7, 8, 9, 10, 11, 12)

Fig. 4 9 Photograph
of a patient prone on
a fracture table for sur-
gery on the right ace-
tabulum. (Courtesy of
the author, Berton R.
Moed)

Fig. 5 9 A straight skin

incision begins mid-
lateral in the thigh, ex-
tending toward the tip
of the greater trochan-
ter, and then proximal-
ly to the level of the ili-
ac crest (as in the clini-
cal example in . Fig.
3b). Depending on the
size of the patient, this
incision ranges from 20
to 30 cm in length

Operative Orthopädie und Traumatologie 6 · 2014  | 595

 Operative Techniken

Fig. 6 8 a The dissection is carried through the subcutaneous tissue onto the iliotibial band and the
fascia over the gluteus maximus. b The anterior border of the gluteus maximus can be identified by
branches from the inferior gluteal artery that perforate the fasciae latae and continue into the subcu-
taneous tissue [1]

596 |  Operative Orthopädie und Traumatologie 6 · 2014

 Fig. 7 9 The fascial in-
cision begins distal to
the level of the great-
er trochanter midlater-
al in the thigh, running
proximally as the ante-
rior border of the glu-
teus maximus muscle
is identified, and end-
ing at the level of the
iliac crest

Fig. 8 8 a Superiorly, the gluteus medius muscle must be separated from the undersurface of the thick gluteal fascia from
which it takes part of its origin. The gluteus medius muscle is exposed showing a somewhat roughed area where it has been
released from the overlying fascia. b Corresponding clinical photo. White arrowheads: incision through the fascia showing the
cut edges of the fascia; asterisk: the insertion of the gluteus maximus muscle into the gluteal tuberosity of the femur; T: the
greater trochanter. The gluteus maximus is reflected posteriorly showing its undersurface. (Courtesy of the author, Berton R.
Moed)

Operative Orthopädie und Traumatologie 6 · 2014  | 597

 Operative Techniken

Fig. 9 8 Retraction of the gluteus maximus muscle posterolaterally and the gluteal fascia/iliotibial
tract anteromedially revealing the underlying anatomic structures

Fig. 10 8 The entire gluteus maximus muscle mass can be reflected posteriorly hinged on and with-
out any compromise of the inferior gluteal neurovascular bundle. Posterolateral retraction of the glu-
teus maximus muscle is aided by release of its distal insertion into the femur

598 |  Operative Orthopädie und Traumatologie 6 · 2014

 Fig. 11 9 The deep dissection is the same as
that of the Kocher–Langenbeck approach. The
sciatic nerve is identified superficial to the qua-
dratus femoris muscle and traced proximally to-
ward the sciatic notch. After release of the short
external rotators and the piriformis muscle, a
specialized retractor (*) is placed into the less-
er sciatic notch. Posterolateral retraction of the
gluteus maximus muscle is further facilitated,
if needed, by partial release of its anterosuperi-
or origin and fascia from the iliac crest without
extending the skin incision. Anterior retraction
of the gluteus medius muscle without the pres-
ence of any overlying gluteus maximus muscle
facilitates the anterosuperior access

Special considerations

Fig. 12 9 For additional anterosuperior expo-

sure, as well as intra-articular access, a trigas-
tric trochanteric osteotomy may be performed
[1, 11]. The vastus lateralis muscle is detached
from the femur at its posterior insertion over a
distance of about 5 cm distal to its origin at the
vastus lateralis ridge. A cut is made with an os-
cillating saw along a line that starts at the pos-
terosuperior tip of the greater trochanter (leav-
ing some muscle fibers attached to the intact
part of the trochanter) and extends distally to-
ward the vastus lateralis tubercle, maintaining
15 mm thickness of the osteotomized fragment.
The insertions of the gluteus medius, ­gluteus
minimus, and vastus lateralis should be pre-
served on the osteotomized trochanteric frag-
ment. All external rotator tendons of insertion
remain on the femur

Operative Orthopädie und Traumatologie 6 · 2014  | 599

 Operative Techniken
Postoperative management
F The patient is mobilized as quickly as
the associated injuries will allow. Out
of bed on the first or second postop-
erative day, the patient then begins
physical therapy for muscle strength-
ening and active range-of-motion ex-
ercises.
F Thromboprophylaxis using external
pneumatic compression devices ap-
plied to the lower extremities is ini-
tiated immediately postoperatively
with chemoprophylaxis usually added
within 48 h postoperatively, depend-
ing on the hemostatic status of the
wound.
F For the prevention of heterotopic os-
sification, prophylaxis should be con-
sidered based on the fracture type,
associated patient conditions, and
the experience of the surgeon. Indo-
methacin is recommended at a dose
of 25 mg three times daily beginning
within 24 h of surgery and continued
for 4–6 weeks [6, 10].
F Suction drains are removed after
drainage has decreased to less than
20 cc/day, usually on the second post-
operative day.
600 |  Operative Orthopädie und Traumatologie 6 · 2014
F Three standard plain radiographs (an
AP and two 45-degree oblique ra-
diographic views) are obtained be-
fore discharge from the hospi-
tal and at regular postoperative in-
tervals (2 weeks, 6 weeks, 12 weeks,
6 months, 1 year, and 2 years).
F Partial, toe-touch weight-bearing
with crutches or a walker is begun
and continued for 10–12 weeks. How-
ever, progression to full weight-bear-
ing should be individualized.
F Implant removal is usually not neces-
sary.
Errors, hazards, and
complications
F Injury to the sciatic nerve: This is the
most important potential complica-
tion and can be caused by direct com-
pression, stretch, or laceration. Treat-
ment consists of an ankle–foot ortho-
sis and observation.
F Laceration of the superior gluteal ar-
tery: Severe bleeding can result. Ap-
plying topical thrombogenic agents
and direct pressure with packing is
usually effective in obtaining hemo-
stasis. Continued bleeding, requiring
Fig. 13 9 a Anteropos-
terior radiograph show-
ing injury of the patient in
. Fig. 3a, b. b Comput-
ed tomography (CT) sec-
tion through the weight-
bearing dome. c Postop-
erative radiograph show-
ing an anatomic reduction.
d Postoperative CT section
through the weight-bear-
ing dome. (Courtesy of the
author, Berton R. Moed)
angioembolization or retroperitone-
al exposure for vessel control, is ex-
tremely rare.
F Postoperative infection: Urgent sur-
gical debridement is required. Se-
cure internal fixation should be main-
tained until the fracture has united.
F Heterotopic bone formation: De-
pending on its extent, this can lim-
it hip motion. After the bone has ma-
tured, it can be excised to regain hip
motion.
F Postoperative venous thromboembo-
lism: Limb swelling or severe pulmo-
nary compromise (and death) may
result. Anticoagulant therapy is re-
quired.
Results
Retrospective analysis revealed that be-
tween 1996 and 2000, 16 patients with
fractures of the acetabulum were oper-
ated on through the described modified
Gibson approach [6]. As this retrospec-
tive series represents a pilot study of the
technique, having specific limited initial
indications, these 16 cases comprise less
than 10% of the total number of posteri-
or approaches performed during that time
Fig. 14 8 a Anteroposterior (AP) radiograph of the initial injury of a 45-year-old man involved in a motor vehicle accident sus-
taining a posterior wall fracture. b AP radiograph after reduction of the hip dislocation. c CT section showing the anterior ex-
tent of the fracture. d Postoperative radiograph showing an anatomic reduction. e Postoperative CT section showing the ana-
tomic reduction. f Follow-up AP radiograph after 3.5 years. (Courtesy of the author, Berton R. Moed)

Fig. 15 8 a Radiograph of the initial injury of a 45-year-old man involved in a motor vehicle accident sustaining a transverse
and posterior wall fracture with intra-articular comminution. b Representative CT section showing the involvement through
the weight-bearing dome. Postoperative (c) AP, (d) obturator oblique, and (e) iliac oblique radiographs showing an anatomic
reduction. f Postoperative CT section through the weight-bearing dome showing the anatomic reduction. g One-year follow-
up AP radiograph. (Courtesy of the author, Berton R. Moed)

Operative Orthopädie und Traumatologie 6 · 2014  | 601

 Operative Techniken
frame. There were 15 male patients and
one female patient, ranging in age from 19
to 72 years (mean age, 40 years). The frac-
ture was caused by a motor vehicle acci-
dent in 15 patients and a fall from a height
in one. During this period, the indications
for use of the modified Gibson approach
was the presence of compromised posteri-
or soft tissues (nine patients) and the im-
provement in anterosuperior access (sev-
en patients).
Fracture types were posterior wall in
eight patients, transverse in one, poste-
rior column and wall in two, transverse
and posterior wall in four, and T-shaped
in one. Fifteen patients were operated on
in the prone position on a fracture table
(. Fig. 4). One patient with a posterior
wall fracture was operated on in the lat-
eral position on a radiolucent operating
room table. All 16 patients were treated
within 3 weeks of injury (mean, 5 days;
range, 1–17 days). There were no intraop-
erative or immediate postoperative com-
plications. None of the cases required a
trochanteric osteotomy.
Postoperatively, three standard radio-
graphs of the pelvis were obtained to as-
sess fracture reduction, which was classi-
fied into three groups as defined by Mat-
ta: 0–1 mm (anatomic), 2–3 mm (imper-
fect), and greater than 3 mm (unsatisfac-
tory) [5]. Using this system, the reduction
was graded as anatomic in 15 patients and
as imperfect in one patient. In 15 patients,
follow-up ranged from 12 to 51 months
(mean, 25 months). Follow-up up was
limited to 6 months in one patient who
died from unrelated causes. Complica-
tions identified during the follow-up pe-
riod were limited. A proximal deep vein
thrombosis of the lower extremity ipsi-
lateral to the fractured acetabulum oc-
curred in one patient after discharge from
the hospital. One patient developed osteo-
necrosis subsequent to prolonged (great-
er than 24 h) dislocation of the hip at the
time of his initial fracture trauma. Hetero-
topic ossification, which was classified us-
ing the method described by Brooker et
al. as modified by Moed and Smith [9],
did not occur in 11 patients, was minimal
(Class 1) in two patients, and was Class 2
in three patients. Severe heterotopic ossifi-
cation (Class 3 or 4) associated with a loss
602 |  Operative Orthopädie und Traumatologie 6 · 2014
of hip motion [9] did not occur in any pa-
tient.
At final follow-up, the three standard
radiographs of the pelvis obtained to as-
sess radiographic outcome were grad-
ed according to the criteria described by
Matta [5] as follows: excellent indicates a
normal-appearing hip, good signifies mild
changes with minimal sclerosis and joint
narrowing (1 mm or less), fair means in-
termediate changes with moderate sclero-
sis and joint narrowing (less than 50%),
and poor represents advanced changes.
With this system, radiographic outcome
was excellent in 13 patients, good in one,
fair in one, and poor in one (. Fig. 13, 14,
15). Clinical outcome was determined us-
ing a modification of the method devel-
oped by Merle d’Aubigné and Postel [3,
8]. This score evaluates pain symptoms,
the ability to walk, and range of motion of
the hip using a scoring system of excellent,
very good, good, fair, and poor. Of the 15
patients with follow-up of at least 1 year,
the outcome was excellent in eight pa-
tients, very good in four, good in two, and
poor in one (the patient who developed
osteonecrosis). Therefore, a good-to-ex-
cellent clinical outcome was achieved in
93% of the patients in this small series.
Corresponding address
Prof. B.R. Moed
Department of Orthopaedic Surgery,
Saint Louis University School of Medicine
3635 Vista Avenue,
7th Floor Desloge Towers,
St. Louis, Missouri, USA
moedbr@slu.edu
Compliance with ethical
guidelines
Conflict of interest.  B.R. Moed states that there are
no conflicts of interest.
All studies on humans described in the present man-
uscript were carried out with the approval of the re-
sponsible ethics committee and in accordance with
national law and the Helsinki Declaration of 1975 (in its
current, revised form). Informed consent was obtained
from all patients included in studies.
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