Wenn die Hüfte nicht „nur“ luxiert

Gibson approach and surgical hip dislocation according to Ganz in the treatment of femoral head fractures

BACKGROUND

The purpose of the study is to evaluate clinical and radiological outcomes in those patients with femoral head fracture, treated with open reduction and internal fixation through Gibson approach and Ganz flip trochanter osteotomy. The treatment of Pipkin fractures is very challenging, especially for small trauma centers, because of the unusual fracture patterns and high-level surgical skills required.

CASE PRESENTATION

Between 2017 and 2020, nine cases of Pipkin fractures came to the Emergency Department at the Trauma Center of our Hospital in Rome. Inclusion criteria were the diagnosis of femoral head fracture, the open reduction and internal fixation as surgical choice and at least 24 months follow-up. Patients older than 65 years and those treated through total hip replacement or combined hip procedure (CHP) were excluded. Thus, five patients were included in our case series. The clinical outcome was evaluated according to Western Ontario and McMaster Universities Arthritis Index, Vail Hip score, modified Harris Hip score and Merle D'Aubignè Postel score. Radiographic assessment was scored according to Epstein-Thompson classification and heterotopic ossification was assessed through Brooker classification. The mean follow-up was 24 months (range 12-24). Average modified Harris Hip score was 92.1 points (range 75.9-100), and the average Vail score was 81.8 (range 55-95). WOMAC score was assessed in three different subscales, pain (A), stiffness (B) and physical condition (C), with the following results: 1.4 A (range 0-7), 1.2 B (range 0-6) and 6.4 C (range 0-22). Merle d'Aubignè Postel score resulted excellent for four patients and good for one patient. According to Epstein-Thompson score of the radiological outcome, four patients showed a good result and one a fair result. No mechanical or infective complications occurred in the five patients.

CONCLUSIONS

Gibson's approach and surgical hip dislocation through Ganz trochanteric flip osteotomy allow a good exposure of the femoral head and acetabulum, giving us the possibility to perform an anatomical reduction of the fracture. In our case series, satisfactory clinical and radiological short-term results were obtained without significant complications.

New surgical algorithm for femoral head split fractures with anatomical study

BACKGROUND

The femoral head split fracture line is usually located in the anterior-inferior portion of the head. Proper fixation is difficult using the conventional approach without tenotomy, and thus, the authors sought to devise an effective, safe, fixation approach for the most common type of head fracture.

METHODS

Anatomical dissection of 80 femoral triangles was performed. The authors evaluated the locations of femoral nerves, vessels, and branches within femoral triangles. On the basis of these observations we used a new anterior approach via the non-dangerous lateral space of the femoral triangle. This approach was applied to 12 femoral head split fractures treated from 2002 to 2009.

RESULTS

A safe area was found within the femoral triangle at the proximal 17.5-32.5 % of the full length of the rectus femoris. In Brumback type 1A and 2A cases, screws were inserted at right angles relative to the fracture plane through the space.

CONCLUSIONS

This study contributes by providing a new technique for femoral head split fractures. This anterior approach using the lateral aspect of femoral triangle provided excellent and good results for Brumback type 1A and 2A femoral head split fractures. On the basis of this study, we produced new treatment algorithm for femoral head split fracture.

Is femoral head fracture-dislocation management improvable: A retrospective study in 110 cases

INTRODUCTION

There is no established consensus on the diagnosis and treatment of traumatic fracture-dislocation of the femoral head --largely due to the rarity of this injury.

HYPOTHESIS

Analysis of a large series of fracture-dislocations of the femoral head using a single coherent classification should enable the means of diagnosis and treatment of fracture-dislocations of the femoral head to be specified.

OBJECTIVES

The hypothesis was tested by analyzing a retrospective series of 110 patients charts admitted between 1972 and 2008, using Pipkin's classification and an alternative new one, Chiron's classification.

MATERIAL AND METHODS

The series comprised 21 women and 89 men; mean age: 37.1 years. Dislocation was posterior in 102 cases and anterior in eight. Associated lesions comprised 46 fractures of the acetabulum and four of the femoral neck. Classification following Pipkin and Chiron was based on double reading of radiology documents from 102 patients. Treatment was exclusively conservative in 32 cases, and surgical in 78, with 51 posterior, 19 anterior and four medial approaches and four arthroscopic procedures. Surgery comprised osteosynthesis of the femoral head in 30 cases and of the acetabulum in 16, removal of fragments in 40 cases and total hip replacement (THR) in five cases as a primary treatment.

RESULTS

Mean follow-up was 37 months. THR was performed in 25 cases: five as a primary treatment and 20 secondarily, 15 of which were performed within the first 6 months. Significant predictive factors for THR were: old age, Chiron grade 3, and femoral neck fracture. The THR and non-THR groups differed on the Chiron but not on the Pipkin classification at the time of the injury. Specific treatments were not predictive of evolution. Fragment removal was more often by a posterior than an anterior or medial approach.

CONCLUSION

The Chiron classification showed prognostic value for evolution to THR; to be reproducible, it needs to be based on CT data. No particular mode of treatment emerged as preferable. Better initial lesion analysis should enable prognosis and target indications.

LEVEL OF EVIDENCE

Level IV Retrospective study.

[Current therapy options for fractures of the femoral head]

Fractures of the femoral head (Pipkin fractures) are relatively uncommon. In cases of immediate, gentle reposition and considerate soft tissue treatment during operative treatment, Pipkin 1 and 2fractures can heal with good long-term results. However, some long-term problems regularly occur. Conservative therapy is possible in cases of anatomic articulation or the presence of only very small fragments that do not compromise articulation after closed reduction. Differentiated indications for conservative treatment in Pipkin 1 and Pipkin 2 fractures can result in a better outcome than operative treatment. All other fractures should be treated operatively. The approach has to be adapted to fragment size and location. Small fragments in Pipkin 1 fractures can simply be removed, but larger fragments in Pipkin 1 and Pipkin 2 fractures should be fixed, preferably via an anterior approach. Pipkin 3 fractures generally require total hip arthroplasty. Pipkin 4 fractures have a relatively poor outcome. The strategy of treatment depends on the necessity of operative fixation of the acetabular fracture and the size of the femoral fragment. The anterior approach is preferred in cases of stable joint situations with only a small acetabular rim fragment, and in cases of instability the dorsal approach is preferred. Surgical luxation can be advantageous for the treatment of Pipkin 4 fractures.

[Fractures of the femoral head. A multicenter study]

BACKGROUND

Dislocated fractures of the femoral head are highly infrequent injuries. In line with this multicenter study, a follow-up examination of patients with Pipkin fractures was performed in Austrian trauma centers. The aim of this study was to evaluate the types of fractures, the kind of treatment, and the long-term results.

PATIENTS AND METHODS

In sum 46 patients were included in our study. A personal and radiological follow-up examination was carried out. The fractures were classified according to Pipkin.

RESULTS

Patients with type I fractures had the best functional outcome according to the Harris Hip Score, followed by patients with type II fractures, type IV fractures, and finally type III fractures. The result of the radiological follow-up examination showed that patients who were treated conservatively or with extirpation of the fragment had a lower grade of arthrosis. The poorest radiological outcome was seen in patients who underwent surgical treatment with open reduction and internal fixation. The implantation of a total hip prosthesis was necessary in 24% of the patients. A relevant soft tissue calcification was not recorded.

CONCLUSION

The size and location of the fractured fragment has a huge influence on the outcome. An exact anatomical reconstruction of the femoral head, especially of the weight-bearing part, is absolutely necessary.