the femoral head is paramount in avoiding later avascular necrosis. Sudden bursts of bleeding can be packed and placed under pressure, followed by getting control of the vessel more proximally with a clamp. If the bleeding cannot be controlled due to vessel retraction, 10–20min of pressure may alleviate serious hemorrhage. This can be followed by angiography and embolization when it is available (Fig.12.3) [3]. Bone bleeding can be dealt with reduction of fractures or placing bone wax into arterial entry points that bleed after disruption of the periosteum. The prevention of postoperative hematoma can be aided by the use of tranexamic acid which can be administered through IV, topically, or combining both methods (which may be most effective) [4, 5].

11]. Mid-term intervention includes nerve conduction studies after 3months of

observation with neurodiagnostic testing to evaluate progression of recovery. Approximately 65% recover when caused by the injury and about 75% when it is iatrogenic because they are neuropraxia or axonotmesis [12–15]. It can take 2–3years to fully recover in the case of axonotmesis. Rehabilitation should start right away to prevent equinus deformity of the foot [12]. Late intervention can include tendon transfers if one branch is spared or ankle arthrodesis [10–12]. Postoperative gradual onset of sciatic nerve palsy can be caused by the formation of heterotopic ossication and can be progressive. Identication and decompression can solve this issue.

collapse of the femoral head, and osteoarthritis. The incidence of AVN varies, but recent meta-analysis describes a rate of 8.8% of all Pipkin cases [22]. Pipkin type III fractures have the highest rate of AVN with almost 65% due to fracture of the femoral neck disrupting the femoral circumex vessels, and many advocate imme­diate total hip arthroplasty (THA) for this condition [22] (Fig.12.5). The approach used for open treatment also makes a difference in the rate of AVN with a trochan­teric ip surgery having 2.8 times less incidence of AVN than an anterior approach and 2.1 times less incidence of AVN than a Kocher-Langenbeck approach for treat­ment [22]. Not all cases of AVN go on to pain and collapse [8] (Fig.12.6). The treatment options for AVN depend on the age of the patient. In young patients, attempts at salvage with core decompression may be benecial for some. If there is collapse of the head, there are rotational osteotomies which have success rates of anywhere from 50% to 80% [23, 24], as well as impaction grafting of the AVN seg­ment using a surgical dislocation approach [24–26]. Both of these techniques

symptoms, onset of symptoms, and disability are variable [9, 22, 27, 28]. The initial injury in the intra-articular fracture leads to immediate chondrocyte death and the release of metal metalloprotease in an inammatory cascade within the synovial uid that propagates further chondrocyte injury; therefore, time to reduction and xation has proven to be the best indicator of functional outcome [22]. Pipkin III fractures in individuals >35 yrs should be treated with primary THA due to the high incidence of failure of treatment with ORIF (almost 100% in some studies) [22]. Pipkin IV fractures also have a 28.5% conversion to THA at 12months especially cases of suprafoveal and head impaction or patients of older age and should be con­sidered for immediate THA as well [29].

femoral nerve. The risk may be increased in individuals with higher energy injuries, traumatic brain injury/spinal cord injury, burns, and injured soft tissues enveloping the hip joint [32–34]. HO prevention after pelvic and acetabular surgery has been extensively investigated with most studies using either post-op radiation (800cGy local within 72h) or oral indomethacin (25mg TID start within 24h—6 weeks post-op). A systematic review by Blokhuis etal. in 2009 found that RDT was more effective than indomethacin in preventing HO [32]. A more recent systematic review by Bueno etal. [33] found there was insufcient evidence to show that either was effective in the prevention of HO after acetabular and pelvic surgery, but indometha­cin had more reported complications [33]. Once HO is present and symptomatic, the treatment consists of resection. Of the few reports of HO resection, some advo­cate waiting until the HO is mature with cold bone scans or a normalization of serum alkaline phosphatase [34, 35]. Meanwhile, others advocate early resection as early as 3months to preserve the patient’s range of motion, to facilitate rehab, and to be able to delineate the new bone from native bone [36]. Post-op radiation plus indomethacin for 6 weeks may be employed for recurrence which happens in 30–40% of cases to some degree. Repeat excision may be necessary when resection is done early, but advocates mention the ability to maintain range of motion through­out recovery is a benet. When the HO is posterior to the hip joint (Fig.12.8), the sciatic nerve may need to be decompressed as occasionally it is pushed laterally or encased within the bone leading to symptoms of compression which include pain, weakness, and altered or absent sensation. The easiest way to protect it is to locate it distally and follow it back and then often unroof the tunnel it is encased in with Kerrison Rongeurs. Anterior HO can be hard to excise, and when large, a dissection of the femoral artery and control of the profunda artery prior to excision can prevent uncontrolled bleeding (Fig.12.9). Heterotopic ossication above the joint is less common, and as long as you stay away from the neurovascular structures, you should be ne (Fig.12.10). Outcomes are good with resection but also depend on the original injury [36].