Management of femoral head fractures through surgical hip dislocation (SHD): a demanding but safe technique

Clinical analysis of Ganz approach in the treatment of Pipkin type IV fracture: a retrospective review

PURPOSE

This study aimed to evaluate the early clinical outcomes of the Ganz approach in treating Pipkin IV fractures.

METHODS

From January 2016 to January 2021, 22 patients with Pipkin IV fracture were treated in our department with Ganz approach. The operation time, intraoperative blood loss, fracture healing time, the incidence of postoperative complications such as heterotopic ossification of hip joint and avascular necrosis of femoral head were recorded. Radiological assessment of fracture reduction was achieved using Matta's evaluation criteria. The functional recovery of the hip joint was assessed using the Harris Hip Score at one year and before the current study, as well as the modified Merle d'Aubigné and Postel score during the final evaluation.

RESULTS

21 patients were available for follow up. The average intraoperative blood loss was 145.5 ± 39.3 ml and the average operation time was 150.4 ± 40.6 min. The average follow-up time was 39.2 ± 11.2 months. X-ray confirmed bony healing of the femoral head, acetabular fractures, and greater trochanter osteotomy, with an average healing time of 7.22 ± 3 months. The difference between the Harris hip score of hip joint at one year and at the last follow-up was not statistically significant (p = 0.06). At final follow up with the modified Merle D'Aubigne Postel score, nine had excellent functional outcome; ten presented very good to good result while two patients had average (one) to poor (one) result. Two (9.5%) patient developed osteonecrosis (avascular necrosis) of the femoral head.

CONCLUSION

The Ganz approach effectively preserves the blood supply to the femoral head, moreover, it also fully expose the operative fields such as hip joint and femoral head, achieving satisfactory clinical outcomes, making it a valuable option for clinical application.

Comparison of the efficacy of the modified S-P approach and the Ganz method for surgical hip dislocation in Pipkin I fractures: an early follow-up study

BACKGROUND

Femoral head fractures result from high-energy trauma and may be associated with posterior dislocation of the hip joint. An appropriate surgical approach is essential for improving clinical outcomes and preventing complications. This study aims to compare the clinical efficacy of the modified Smith-Peterson (mS-P) approach and Ganz surgical dislocation (GSD) approach in the treatment of Pipkin I fractures.

METHODS

We conducted a retrospective analysis of patients diagnosed with Pipkin I fractures at Pidu District People's Hospital from June 2010 to May 2020. Of these, 11 cases were treated with the mS-P approach and 12 cases were treated with the GSD approach. All patients were followed for 12-55 months, with a mean duration of 37.7 months. Basic demographic information, perioperative-related records, postoperative complications, and outcomes at the final follow-up were compared. Functional evaluations included the Thompson-Epstein Score, the Modified Harris Hip Score (MHHS), and the Vail Hip Score (VHS).

RESULTS

Overall, 21 patients were included in the study. We found that the mS-P approach was associated with a smaller incision, shorter operative time, and reduced intraoperative blood loss compared to the GSD approach (P < 0.05). The mean MHHS was 83.5 ± 9.14 and 75 ± 9.22 in the mS-P group and GSD group, respectively, P = 0.048. The mean VHS was 83.9 ± 7.4 and 74.4 ± 11.28 in the mS-P group and GSD group, respectively, P = 0.034. Thompson-Epstein scores in the mS-P group were excellent (6 patients), good (3 patients), and fair (1 patient). In the GSD group, the scores were excellent (3 patients), good (5 patients), and fair (2 patients). Among the postoperative complications, avascular necrosis (AVN) occurred in 1 patient in each of the mS-P and GSD groups. Heterotopic ossification (HO) occurred in 5 patients in each of the mS-P and GSD groups. 2 patients in the mS-P group developed post-traumatic osteoarthritis (PTOA), compared to 5 patients in the GSD group. One patient in the GSD group developed a sciatic nerve injury (SNI).

CONCLUSIONS

This study suggests that the mS-P approach offers advantages over the GSD approach in terms of surgical efficiency and surgical trauma. However, longer-term follow-up is required to fully assess complications and functional outcomes.

Pipkin fractures: fracture type-specific management

Femoral head fractures are rare, which limits the experience of individual surgeons with these injuries. This overview examines historical data, injury mechanisms, and classification systems, as well as epidemiological data from larger patient cohorts. Significant controversies persist regarding the optimal surgical approach and fracture-type-specific treatment for Pipkin fractures. The literature is often inconsistent, as many studies fail to differentiate between specific fracture types and instead report aggregated results, leading to ambiguous conclusions about the most effective treatment strategies. Thus, this article reviews fracture-type-specific outcomes of both non-operative and operative treatments over the past 25 years and summarizes their clinical implications, with the aim of assisting surgeons in their decision-making processes.

Techniques and results of reconstruction of femoral head fractures: An Update

A narrative review of the literature was conducted to examine the data on femoral head fractures, with a particular focus on their management, complications and clinical outcomes. A PRISMA strategy was used. Medline and Scopus library databases were queried using pre-defined MeSH terms and Boolean operators. Quality of evidence was evaluated based on OCEBM and GRADE systems. The 50 eligible articles that met the predefined inclusion criteria reported on 1403 femoral head fractures. A detailed analysis of the surgical approaches used was performed in 38 articles with 856 fractures. Most fractures were treated surgically (90,8 %) with preferred anatomical reconstruction in 76,7 % of all operatively treated cases. Posterior approaches were the most common (52.5 %). This was evenly split between surgical hip dislocation and the classic Kocher-Langenbeck approach. 70.5 % of surgically treated cases achieved excellent or good result according to Thompson-Epstein criteria. Highest rate of excellent results showed minimal invasive osteosynthesis and surgical hip dislocation. Major late complications were avascular necrosis (10.8 %), post-traumatic arthritis (16.2 %) and heterotopic ossification (20.8 %). Secondary THA was necessary in 6.9 %. Highest rate of major complications was joined with anterior approach (77 %), lowest rate from frequently used approaches surgical hip dislocation (37.8 %). Conservative treatment recedes into the background. The Ganz flip osteotomy with surgical hip dislocation allows safe treatment of all types of fractures and should be considered the first choice, offering the lowest rate of complications and one of the best functional outcomes. Reconstruction of Pipkin Type III fractures should be reserved for very young patients due to high rate of major complications.

Management and outcome of patients with femoral head fractures: the mid-term follow-up with injuries and associated prognostic factors

BACKGROUND

Femoral head fractures are rare injuries often associated with poor functional outcomes and complications. The purpose of this study was to evaluate the incidence, treatment methods and approaches, complications, and functional outcomes of femoral head fractures.

METHODS

We retrospectively reviewed 50 patients who sustained femoral head fractures between January 2011 and December 2018. There were thirty-seven (74%) males and thirteen (26%) females with a median age of 40 years. According to Pipkin's classification, there were eighteen (36%) Pipkin I, ten (20%) Pipkin II, eight (16%) Pipkin III, and fourteen (28%) Pipkin IV patients. Treatment methods were categorized into non-operative, operative by open reduction and internal fixation (ORIF), and immediate total hip replacement (THR). The recorded surgical approach consists of an anterior(S-P) approach, posterior(K-L) approach, lateral stab, and combined anterior + lateral stab approach for fixation. The patients were also stratified by the Injury Severity Score (ISS), associated injuries, and, mechanism of injuries. The modified harris hip score (MHHS) was used to evaluate the ongoing complications with the clinical outcome of patients with two years or greater follow-up.

RESULTS

Eight (16%) patients were managed successfully with closed reduction without surgery and thirty-seven (74%) patients required operative reduction and internal fixation (ORIF) of the femoral head and acetabulum, and 5 (10%) patients required immediate THR. Six (12%) patients developed AVN, and four (8%) required a secondary THR. Sixteen patients (33%) developed post-traumatic osteoarthritis (PTOA), eight (16%) developed heterotopic ossification (HO) and six patients (12%) had sciatic nerve injury, none requiring operative treatment. Overall functional results according to MHHS were, excellent in two (4%) patients, good in sixteen (32%) patients, fair in twenty-two (44%) patients, and poor in ten (20%) patients. A statistically significant difference in outcome was observed among four pipkin subtypes.

CONCLUSION

Femoral head fractures are rare injuries often associated with poor outcomes. In this study, we report the functional outcomes and complications of all treatment approaches for femoral head fracture based on the Pipkin classification. The treatment aim should always be the anatomical reduction of the fragments. This study, adds to the growing literature on femoral head fracture and provides a reference for the clinical treatment to guide patient management.

TRIAL REGISTRATION

Our study was approved by the Clinical Research and Biomedical Ethical Committee of West China Hospital, Sichuan University, and was performed in accordance with the Declaration of Helsinki. All participants provided written informed consent to participate in this study.

A bibliometric analysis and visualization of research trends on surgical hip dislocation

Surgical hip dislocation (SHD) is a powerful and safe approach used to address pathologic lesions around the hip joint, and therefore, many studies have been conducted in this field. However, no bibliometric studies regarding the global research trend concerning SHD have been studied yet. This study aims to determine the research status in the field of SHD research between 2001 and 2021. The publications related to SHD from 2001 to 2021 were retrieved from the Web of Science Core Collection. Three bibliometric tools were used for this study. The main analyses include publication counts, contributions of countries, institutions, authors, journals and funding agencies, as well as analyses on clustering of references and keywords. In total, 498 articles were identified. The annual publication counts of SHD showed an ascending tendency as a whole. The United States has the most prominent contributions, with the most number of publications and the highest value of H-index. The University of Bern was the organization that produced the most literature. Professors Ganz R, Siebenrock KA, Tannast M, Steppacher SD and Leunig M were the core authors in this field. The most productive journal was Clinical Orthopaedics and Related Research. Burst keyword detection suggested that the following research directions, including 'surgical hip dislocation', 'outcome', 'fixation' and 'pain', are considered the research hotspots and deserve more attention. In conclusion, this is the first bibliometric analysis that provides a comprehensive overview of SHD research, which may assist investigators in exploring new directions for this technique.

The management of segmental femur fractures: the radiographic 'cover-up' test to guide decision making

BACKGROUND

Segmental femur fractures often pose management challenges regarding the optimal fixation choice and sequence of surgical events.

METHODS

Retrospective review of clinical records and radiographic data of adult patients with segmental femur fractures treated by a conceptual radiographic cover-up test to determine the ideal fixation method between January 2019 and December 2020.

RESULTS

Forty patients with 84 individual fractures underwent fracture fixation. The most consistent fracture combinations were intertrochanter-diaphysis (AO31A-AO32) fractures (25%, n = 10) and femur neck-diaphysis (AO31B-AO32) fractures (20%, n = 8). Compared to evidence-based fracture management, the gold standard treatment was used for the fixation of 78 fractures (93%). One patient required revision for fixation failure of a diaphyseal fracture, and two fractures, both open diaphysis injuries, developed fracture-related infections.

CONCLUSION

Anatomical alignment and high union rates are possible for segmental femur fractures treated by evidence-based fracture fixation principles. A conceptual radiographic cover-up test assists in matching the best possible implant for each fracture.

Management of femoral head fracture by Ganz surgical dislocation of the hip

INTRODUCTION

Posterior hip dislocation is the commonest type of hip dislocation. It is associated with femoral head fracture in 7% of cases. Urgent and congruent hip reduction is mandatory to improve clinical outcomes and avoid irreversible complications. The purpose of this study is to assess the safety and functional and radiological outcomes of surgical hip dislocation by Ganz technique for treatment of femoral head fracture.

PATIENTS AND METHODS

In this retrospective study, 18 cases of femoral head fracture were included. Six cases had Pipkin type I and 12 had Pipkin type II fracture. They were treated through surgical hip dislocation. All cases were followed up for at least 24 months. Matta's criteria were used for radiological evaluation (plain radiographs). Functional evaluation was done using Harris Hip Score and modified Merle d'Aubigne and Postel score at final follow-up.

RESULTS

No patients were lost during the follow-up period. No signs of infection or wound dehiscence were noted in this study. There was one case of osteonecrosis. All cases had labral injury, which was debrided. None of our cases needed suture anchor repair of the labrum. Radiographical evaluation according to Matta's criteria yielded anatomic fracture reduction in 17 patients but imperfect in 1 patient. According to Harris Hip Score, four Pipkin type I cases were rated as excellent and two as good. Among cases of Pipkin type II fracture, six were rated as excellent, four as good, one as fair, and one as poor. According to modified Merle d'Aubigne and Postel score, 11 cases had excellent results, 5 cases were rated as good, one as fair, while one case had poor results.

CONCLUSION

Open reduction and internal fixation of femoral head fracture using surgical hip dislocation through Ganz approach is a viable treatment option and provides satisfactory results with low complication rate.

Surgical Approaches for Managing Femoral Head Fractures (FHFs); What and How to Choose from the Different Options?

Femoral head fractures (FHFs) are considered a relatively uncommon injury; however, they carry a challenge to the trauma surgeon. Choosing the appropriate management option, either conservatively or surgically, if the latter was chosen, should it be open reduction and internal fixation or simple excision of the fragment, or acute total hip arthroplasty. Furthermore, selecting the best surgical approach through which surgical management could be performed depends on the fracture classification, the familiarity of the surgeon, and the presence of associated injuries. All approaches to the hip, including hip arthroscopy, had been proposed for the management of FHFs; however, the difference among approaches is related to the complexity of the approach, the need for special training or equipment, the effect of the approach on the functional outcomes as well as the rate of postoperative complications. This review discussed the possible surgical approaches used to manage FHFs, advantages, and disadvantages for each, and offered a guideline for selecting the most appropriate surgical approach.

Safety and efficacy of surgical hip dislocation in managing femoral head fractures: A systematic review and meta-analysis

BACKGROUND

Femoral head fractures (FHFs) are considered relatively uncommon injuries; however, open reduction and internal fixation is preferred for most displaced fractures. Several surgical approaches had been utilized with controversial results; surgical hip dislocation (SHD) is among these approaches, with the reputation of being demanding and leading to higher complication rates.

AIM

To determine the efficacy and safety of SHD in managing FHFs by reviewing the results reported in the literature.

METHODS

Major databases including PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched to identify studies reporting on outcomes of SHD utilized as an approach in treating FHFs. We extracted basic studies data, surgery-related data, functional outcomes, radiological outcomes, and postoperative complications. We calculated the mean differences for continuous data with 95% confidence intervals for each outcome and the odds ratio with 95% confidence intervals for binary outcomes. P < 0.05 was considered significant.

RESULTS

Our search retrieved nine studies meeting our inclusion criteria, with a total of 129 FHFs. The results of our analysis revealed that the average operation time was 123.74 min, while the average blood loss was 491.89 mL. After an average follow-up of 38.4 mo, a satisfactory clinical outcome was achieved in 85% of patients, with 74% obtained anatomical fracture reduction. Overall complication rate ranged from 30% to 86%, with avascular necrosis, heterotopic ossification, and osteoarthritis being the most common complications occurring at an incidence of 12%, 25%, and 16%, respectively. Trochanteric flip osteotomy nonunion and trochanteric bursitis as a unique complication of SHD occurred at an incidence of 3.4% and 3.8%, respectively.

CONCLUSION

The integration of SHD approach for dealing with FHFs offered acceptable functional and radiological outcomes with a wide range of safety in regards to the hip joint vascularity and the development of avascular necrosis, the formation of heterotopic ossification, and the development of posttraumatic osteoarthritis; however, it still carries its unique risk of trochanteric flip osteotomy nonunion and persistent lateral thigh pain.