i think  Revision of the cup, as you thing that acetabular component is worn superiorly

Vascular 

Since it is mentioned that it is not known how long time is this hip dislocated the key question is what brought this lady to intensive clinical attention after 4 years of living in the nursing home . If it is sudden pain or immobility or both then treatment should be considered. At this point several things should be considered : Vascular dementia ( versus Alzheimers Dem ) may give hope for several more years of stability - provided her general condition ( cardiovascular ) is satisfactory. A thorough preoperative evaluation should be performed and the option of open reduction should be considered and discussed with the legal guardians of this lady.

I concur with Dr Leibovitz. The reasons for hospitilisation as well as for the possible neglect should be clairfied as good as possible. I'd like to add that not only the functional status pf the patient herself should be considered but indirect effects as the ease of nursing.

I questioned how is her mobilisation , is she capable of doing hygiene  and can she walk ; if so I woud treat with open reduction with cup revision .İf she depends on wheel chair --Ignore and leave it out.

Nursing home reported that she was mobile using a frame between two assistants. She was in the nursing home as immediate family was living far away and it was safer for her to be "hospitalised".  Her hips were in some fix flexion deformity (she could not extend the hips in more than 45 degrees), indicating that she was mainly chair bound. I do not think that she was able to care for her own hygiene. There is no witnessed fall and she was not complaining of pain. When newly hired member of staff went to her it was observed that the leg was in some internal rotation and some shortening, that it was never mentioned before. I suspect she was neglected from some members of staff. It is not known for how long. My gut feeling was to ignore.

These additional clinical details are pro of a conservative approach. Yet the family should be updated.

What was the indication of doing the x-rays now? Were there any new symptoms or does she has pain and difficulty in weight bearing? If so then an excision arthroplasty may serve as a safe and less morbid surgery to relieve her symptoms. Please share her x-rays also.

If you want to do some decent level of rehab following any extensive surgery, with her vascular dementia, I recommend a person working with her who know how to keep her calm and focused. This would be in addition to the PT during PT sessions. Someone who is 1:1 with her during PT and and prescribed exercises outside of PT. Otherwise, rehab might not be possible.

In your question, you do not say if the elderly patient was at bed before dislocation of her total hip replacement or not ......

Is yes, I can ignore the dislocation.

If not, you must consider the relationship between advantages in quality of her life and surgery risks.

I think the same things of Kemal Gokkus.  

Thank you but I think that it is mentioned that she was mobile using frame between two assistants. This was the report of the nursing home but as she had bilateral lack of full extension of the hips I feel that they were lying and that she was "forgotten" in her chair so the hips had developed limited extension. If this was not clear I apologise.

Answering the points made by other colleagues

Family informed about the situation

Xrays probably made out of fear for responsibility as this newly employed staff observed the difference and did not ignore the patient. I do not think that patient on this stage gives any signs of pain or discomfort. Again this indicates long standing condition but it is unknown the length of time that the hip was dislocated.

 In this scenario, if there has been no recent change and the patient is pain-free then leave as it is.

I would of course be sure that th family understood all the ramifications of this patient's disorder.  It is important since there is some dementia that the close family relatives understand the ramifications of the decision.

Rita what do you mean by " all the ramifications of this patient's disorder  " ? .

Dear all family had second thoughts and asked for second opinion as they have the right to do. They transferred the patient under another colleague. I will let you know with his permission about the treatment and results.

 I think it's depend from the quality of life in such situation. There are two possibilities;

1. To ignore and leave it out

2. Revision by using anterolateral approach and Dual Mobility or tripolar unconstrained acetabular components.

 Colleague decided under family's pressure for revision surgery.

Ah, dear. Well, I hope she goes through it smoothly. Thanks for closing the circle.

Further feedback on the case which it is not as everybody would wish to end. These news are published with the verbal agreement of the treating colleague who took over the case, as my personal feeling was to be left alone and the relatives were not prepared to accept. Revision is done following the wishes of the relatives. Relocation was difficult as the soft tissues were very tight indicating that this was chronic dislocation. Releases were necessary. Despite this the hip re-dislocated, traction applied but not tolerated and due to pressure the surgical wound open and the prosthesis as well as the proximal femur protruded through. As result the decision of the colleague was to remove the proximal third of the femur with the prosthesis so it would be possible for the wound to be closed. Patient never was septic, thank God for this. Bottom line; sometimes non operative treatment would have better results. And the question is. How could you convince the relatives that this is better? Was it from the start a potential medico-legal case against the nursing home and they wanted to prove their point? Difficult to answer.

George, it's so frustrating and sad, isn't it? Thank you for following up with us. Here's to her further recovery.

I assume that the patient was not able to walk formerly for a long time, before hip dislocation was suspected. I consider that it is important to discard than the dislocation is not involved in functional impairment or pain (agitation also in case of very serious cognitive impairment) in this patient.

In case of no added problem to his/her condition because of the dislocation probably I would no consider to make more medical procedures.

Key decisions have to be taken after a comprehensive geriatric asessment of the patient