Surgical hip dislocation is a reliable approach for treatment of femoral head fractures

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.

Comparative cadaveric study of the Kocher-Langenbeck approach with and without trochanteric osteotomy in extended posterior wall fractures of the acetabulum

INTRODUCTION

Standard exposure, such as the Kocher-Langenbeck (KL) approach, has a limited ability to access the cranial and anterior portions of the posterior wall with an extended fracture line into the acetabular dome. Augmentation of the KL approach with trochanteric osteotomy (TO) enhances the exposure in this area. We compared the area of surgical exposure in the KL approach with and without additional TO and identified the most anterior exit point of the posterior wall in each surgical approach.

MATERIALS AND METHODS

Ten fresh cadaveric hip specimens were used. The KL approach was initially used for each specimen, followed by additional TO. Surgical exposures were marked, and measurements were taken for anterior and cranial exposure distances, surface area of bony exposure, and posterior wall arc angle (PWAA).

RESULTS

TO significantly increased the anterior exposure distance (65.83 vs. 49.07 mm) and acetabular surface area (43.95 vs. 33.51 cm2) compared to the KL approach alone. PWAA was also significantly higher in the TO group (52.55° vs. 27.63°), indicating enhanced anterior exposure. However, the increase in cranial exposure distance was not statistically significant.

CONCLUSION

The KL approach with TO significantly improved surgical exposure for posterior wall acetabular fractures, especially in the anterior regions. For fractures with a PWAA of 0º-27º, the KL approach alone (in the prone or lateral decubitus positions) is sufficient. If the PWAA is between 27º and 52º, the KL approach in the lateral decubitus position is recommended, with TO planned, if necessary. For fractures with a PWAA greater than 52º, the KL approach with additional TO in the lateral decubitus position is recommended.

LEVEL OF EVIDENCE

IV, cadaveric study.

Open Reduction and Internal Fixation of Femoral Head Fracture After Firearm Injury: A Case Report

CASE

A 21-year-old man presented with a femoral head (FH) fracture from a firearm injury. The FH had a comminuted, minimally displaced fracture with intertrochanteric extension and a retained bullet. This patient was treated with surgical hip dislocation (SHD) and open reduction internal fixation (ORIF). This case describes the operative management of a fracture pattern of the FH not covered within the Pipkin classification. The patient was noted to be progressing well at 1-year follow-up.

CONCLUSION

FH fractures from firearm injuries may present with unique fracture patterns. SHD and ORIF is a viable option for these unique fractures.

Using an Intraoperative Stress Examination to Direct Treatment in Posterior Femoral Head Fracture-Dislocations

OBJECTIVE

To examine the results of a treatment algorithm incorporating an examination under anesthesia (EUA) performed intraoperatively after fixation of the femoral head through a Smith-Petersen approach to determine the need for posterior wall or capsule repair.

METHODS

DESIGN

Retrospective review.

SETTING

Two Level 1 trauma centers.

PATIENT SELECTION CRITERIA

All acute, traumatic femoral head fractures from posterior hip dislocations treated at participating centers over a 5-year period from 2017 to 2022. Injuries were classified according to the Pipkin system.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was the result of intraoperative EUA performed after femoral head fixation to determine the need for Kocher-Langenbeck exposure for posterior wall and/or capsule fixation. The secondary outcomes included rates of avascular necrosis, heterotopic bone formation, late instability, and conversion to total hip arthroplasty (THA).

RESULTS

In total, 63 men and 22 women with a mean age of 32.5 (range 18-71) years were studied. Seventy-nine of 85 (92.9%) patients had a stable EUA after fixation of the femoral head through a Smith-Petersen approach. Six (6/85, 7.1%) underwent an additional Kocher-Langenbeck approach for posterior wall or capsule fixation. This included 1 Pipkin I, 1 Pipkin II, and 4 Pipkin IV injuries. Of the Pipkin IV injuries, 51/55 (92.7%) had stable EUA and did not require fixation of their posterior wall. This included seven patients with wall involvement >20%. Five patients were excluded because of planned fixation of their posterior wall based on preoperative imaging. Of patients with at least 6 months follow-up, 16 of 65 (26.4%) developed radiographic evidence of avascular necrosis and 21 of 65 (32.3%) evidence of heterotopic bone formation. Seven out of 65 (10.8%) were converted to THA over the study period. When comparing patients with a single exposure and those with additional KL exposure, it was found that they did not vary in their rate of avascular necrosis (27.1% vs. 0.0%, P = 0.3228), heterotopic ossification formation (30.5% vs. 50.0%, P = 0.3788), or conversion to THA (10.2% vs. 16.7%, P = 0.510).

CONCLUSIONS

This study found residual posterior hip instability after femoral head fixation in patients with and without posterior wall fractures after posterior dislocations. The results of this study support the use of an EUA after femoral head fixation to identify residual posterior hip instability in all femoral head fractures from posterior hip dislocations, regardless of Pipkin type. Use of the Smith-Petersen exposure remains a viable surgical option and may be improved with the incorporation of an EUA after femoral head fixation. For Pipkin IV injuries with posterior wall fractures with indeterminate stability, an EUA accurately identifies residual instability.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic Management of Pigmented Villonodular Synovitis of the Hip: A Systematic Review

Background/Objectives: Pigmented villonodular synovitis (PVNS) is a benign proliferation of synovial tissue that can cause joint damage. The hip, although less commonly affected than the knee, presents a challenging diagnosis and treatment, with magnetic resonance imaging (MRI) as the gold standard for detection. Surgical excision, arthroscopic or open, is the main treatment approach, but there is no consensus on the best strategy for the hip. The aim of this systematic review is to evaluate the clinical outcomes, complications, and revision rates associated with arthroscopic hip surgery for PVNS. Methods: A systematic review was performed following the PRISMA guidelines. Relevant studies were identified by searching four databases: PubMed, Scopus, Embase, and Medline. Selected articles were evaluated according to the criteria of levels of evidence (LoE). For retrospective studies, the Coleman Methodology Score (mCMS) was used. This systematic review was registered with the International Prospective Register of Systematic Reviews. Results: Six studies satisfied the criteria; these involved 77 patients (48% male, 52% female) with a mean age of 26.4 years and a mean follow-up of 54.3 months. MRI and biopsy confirmed the diagnoses, and arthroscopic synovectomy was the primary treatment. Success rates ranged from 80% to 100%, with a recurrence rate of 7.8%, 1.3% requiring revision surgery, and eight (10.4%) patients in three studies reporting conversion to THA. Complications included mild effusions and residual synovitis. All patients who underwent a subsequent total hip arthroplasty were affected by advanced osteoarthritis. Conclusions: Our systematic review reveals that the use of hip arthroscopy in diagnosing and treating PVNS has shown satisfactory results without increasing the risk of recurrence or complications and can return patients to their former activity levels, provided their preoperative osteochondral status is good and there is early management of PVNS of the hip joint.

Femoral Head Fractures: Evaluation, Management, and Outcomes

Fractures of the femoral head typically occur after high-energy trauma. Radiographs and cross-sectional imaging are used to appropriately classify and identify associated injuries or morphologic characteristics that may influence management. Identification of the radiographic and clinical hallmarks of an irreducible variant is critical to optimizing the patient's outcome. Nonsurgical treatment can be used in the setting of small, infrafoveal femoral head fractures without hip instability. When surgical treatment is indicated, an anterior (Smith-Petersen), posterior (Kocher-Langenbeck), or surgical hip dislocation approach may be used depending on injury details and surgeon preference. The purpose of this review was to summarize current evidence on femoral head fractures regarding indications, variant patterns, surgical approaches, and 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.

Management and Outcome of Pipkin Type I and Type II Femoral Head Fractures by Ganz Surgical Dislocation of the Hip

Introduction Femoral head fractures, specifically Pipkin Type I and Type II, are uncommon injuries often linked with posterior hip dislocations. Management strategies for these fractures range from conservative treatments to various surgical procedures, with open reduction and internal fixation (ORIF) being a notable option. The surgical approach for ORIF varies, and due to the rarity of the injury, a standardized management protocol is lacking. This study aims to evaluate the outcome of managing Pipkin Type I and Type II femoral head fractures using ORIF through Ganz surgical dislocation of the hip, assessing complications and analyzing the functional outcome by radiographic assessment and functional evaluation.  Methods This is a retrospective descriptive study of managing six cases of Pipkin Type I and Type II femoral head fractures with ORIF through Ganz surgical dislocation of the hip. Follow-up periods ranged from 19 to 96 months, and outcomes were evaluated using Matta's criteria for radiographic assessment and the Modified Harris Hip Score for functional evaluation. Results Known complications such as avascular necrosis (AVN) of the femoral head, heterotopic ossification (HO), post-traumatic arthritis (PTA), non-union of trochanteric osteotomy, and fracture non-union were monitored. Results showed one case of AVN, which occurred in a case of delayed open surgery following a failed primary closed reduction. All trochanteric osteotomies and femoral head fractures healed appropriately. No instances of HO or PTA were observed, even in the patient with the longest follow-up of 96 months. Discussion Controversy still exists in management and outcome of femoral head fracture among closed reduction alone, excision and ORIF using different techniques and approaches. Ganz surgical dislocation of the hip offers 360-degree visualization of acetabulum and nearly 360-degree visualization of head femur and hence an ideal exposure for working on femoral head and acetabulum. The study concludes that ORIF of femoral head fractures using the Ganz surgical dislocation approach is a viable treatment option, offering satisfactory outcomes with a low complication rate. The absence of PTA in long-term follow-ups may be attributed to meticulous removal of loose bodies and precise congruent reduction and fixation of head fragments.

Case Report of a Delayed Rare Pipkin Type III Fracture in Adult Male Patient

Introduction

Femoral head fractures are relatively rare compared to other hip pathologies. Despite being infrequent, these fractures can give rise to various complications, even after a successful surgical fixation. To categorize these fractures, Pipkin introduced a classification system, distinguishing them into four types. Among these, Type III (31C.3) fractures are associated with femoral neck fractures and are notably less common, often leading to unfavorable outcomes.

Case Report

We present a case of a Type III Pipkin fracture in a 35-year-old male resulting from a road traffic accident. The patient underwent management with open reduction and internal fixation, utilizing headless compression screws and cancellous cannulated screws. Post-operative, the patient was instructed to remain non-weight bearing, and subsequent follow-ups were conducted to monitor for any potential complications.

Conclusion

Femoral head fractures are recognized for their complexity, with outcomes becoming even more diverse when associated with neck fractures. Effective pre-operative planning, coupled with timely reduction and fixation, plays a pivotal role in the management of these fractures.

The modified Hardinge approach is not inferior to trochanteric flip osteotomy for Pipkin type IV femoral head fractures: a comparative study in 40 patients

PURPOSE

To compare the modified Hardinge approach and trochanteric flip osteotomy for the treatment of Pipkin type IV femoral head fractures.

METHODS

 This retrospective study included 40 patients who underwent surgical treatment for Pipkin type IV femoral head fractures between 2011 and 2020 and completed at least 1 year of follow-up. The clinical outcome of the Merle d'Aubigné-Postel score and radiological outcomes, including the quality of the fracture reduction, osteonecrosis of the femoral head, posttraumatic osteoarthritis, and heterotopic ossification, were compared between the two groups. Conversion to total hip replacement was recorded as the main outcome measure, analyzed by Kaplan-Meier curve and log-rank test.

RESULTS

Nineteen and 21 patients were treated using the modified Hardinge approach (Group A) and trochanteric flip osteotomy (Group B), respectively. The estimated surgical blood loss was significantly higher in Group B (500.00 ± 315.44 mL vs. 246.32 ± 141.35 mL; P = 0.002). Two patients in Group B complained of discomfort caused by the trochanteric screws and requested implant removal. Radiographic outcomes did not differ significantly between the two groups. Clinical outcomes assessed using the Merle d'Aubigné-Postel score 1 year after injury were nearly identical (P = 0.836). Four (21.1%) patients in Group A and three (14.3%) patients in Group B underwent conversion to total hip replacement during the follow-up period; the log-rank test showed no significant difference (P = 0.796).

CONCLUSIONS

The modified Hardinge approach resulted in reduced blood loss, with clinical and radiological outcomes similar to those of trochanteric osteotomy; thus, it is an acceptable alternative to trochanteric flip osteotomy.

Surgical hip dislocation technique through the femoral head fovea fenestration and impaction bone grafting for the treatment of non-traumatic osteonecrosis of the femoral head: a retrospective study

BACKGROUND

Osteonecrosis of the femoral head (ONFH) often leads to the collapse of the femoral head, ultimately resulting in patients undergoing premature total hip arthroplasty (THA). The surgical hip dislocation (SHD) technique is a type of hip-preserving surgery aimed at delaying or avoiding THA. This study aims to evaluate the clinical efficacy of SHD techniques through femoral head fovea fenestration and impaction bone grafting for the treatment of non-traumatic ONFH.

METHODS

A retrospective analysis was conducted on the clinical data of 39 patients (39 hips) with non-traumatic ONFH who underwent SHD for treatment from 2016 to 2017. The Harris hip score (HHS) and the minimum clinically important difference (MCID) are used to evaluate clinical outcomes, while radiographic evaluations are conducted using X-rays. Kaplan-Meier survival analysis defined clinical failure as further THA, and conducted univariate survival analysis and Cox regression analysis. Any complications were recorded.

RESULTS

All patients were followed up for 24-72 months, with an average of (60 ± 13.0) months. At the last follow-up, based on the HHS, 25 patients (64.1%) reported excellent and good clinical outcomes. 29 patients (74.3%) achieved MCID. Imaging evaluation of the postoperative femoral head status showed that 6 cases improved, 20 cases remained stable, and 13 cases showed progressed. Out of 39 hips, 12 hips had postoperative clinical failure, resulting in a clinical success rate of 69.2%. Association Research Circulation Osseous (ARCO) stage, China-Japan Friendship Hospital (CJFH) classification, and postoperative crutch-bearing time are risk factors for clinical failure. Postoperative crutch-bearing time of less than 3 months is an independent risk factor for clinical failure. After surgery, there was one case of sciatic nerve injury and one case of heterotopic ossification. There were no infections or non-union of the greater trochanter osteotomy.

CONCLUSION

The SHD technique through the femoral head fovea fenestration and impaction bone grafting provides a safe and effective method for treating non-traumatic ONFH, with good mid-term clinical outcomes. ARCO staging, CJFH classification, and postoperative crutch-bearing time are risk factors that affect clinical outcomes after surgery and lead to further THA. Insufficient postoperative crutch-bearing time is an independent risk factor for clinical failure.

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.

Arthroscopic Reduction and Fixation of a Pipkin Type-I Femoral Head Fracture

Background

This video article describes the technique for arthroscopic reduction and fixation of Pipkin type-I fractures.

Description

Surgery is performed with the patient in a supine position, with free lower limbs, on a radiolucent table. Arthroscopic superior and anterolateral portals are made similarly to the portals created to evaluate the peripheral compartment during an outside-in (ballooning) technique.1 An additional medial portal is subsequently created in order to aid in reduction and screw placement. The medial portal is created in abduction and external rotation of the hip (i.e., the figure-4 position). The adductor tendon is identified, and the portal is then safely positioned posteriorly to its margin, approximately 4 to 5 cm distal to the inguinal fold, avoiding the saphenous vein (usually identified with an ultrasound scan). The fragment is mobilized, debrided, and then reduced with use of a microfracture awl or a large Kirschner wire (used as a joystick). Following reduction, temporary fixation is performed with use of long Kirschner wires under direct visualization and fluoroscopic guidance. If reduction is satisfactory, definitive fixation can be performed with use of 4.5-mm headless screws through the medial portal. All steps of fragment reduction and fixation are performed through the medial portal, with the patient in the figure-4 position. Once the screws are placed, a final dynamic arthroscopic and fluoroscopic check is performed.

Alternatives

In Pipkin type-I fractures, surgery is recommended when the femoral head fragment is large (exceeding 15% to 20% of the femoral head volume) and displaced (by >3 mm). In such cases, if untreated, spontaneous evolution to osteoarthritis may occur. For fragments smaller than 10% to 15% of the femoral head volume, arthroscopic removal is often the best choice2. Several approaches (e.g., Smith-Petersen, modified Hueter, Kocher-Langenbeck, and surgical safe dislocation) have been proposed for reduction and fixation, with surgical safe dislocation being the most versatile because of the uniquely complete visualization of the femoral head3.

Rationale

The arthroscopic reduction and fixation technique for a non-comminuted Pipkin type-I fracture holds the intrinsic advantages of being less invasive than open surgery in terms of surgical exposure, and having less blood loss, infection risks, and wound complications. Arthroscopy allows direct visualization of the fragment and its reduction surface, along with removal of articular loose bodies and debridement. The surgical time is influenced by the surgeon's experience, but often is no longer than with an open procedure. In the few studies assessing the use of this technique, the rates of osteonecrosis and heterotopic ossification are lower than with open techniques. It is worth noting that the studies assessing the use of this procedure are limited both in number and quality; however, the results of these studies have been excellent. It must also be noted that patients undergoing arthroscopic fixation are mostly selected for this treatment because they have less severe injuries2-12.

Expected Outcomes

Open reduction and fixation through one of a variety of approaches is the gold standard treatment for Pipkin fractures; however, it is a relatively invasive procedure, prone to increased risks of osteonecrosis of the femoral head and heterotopic ossification (from 4% to 78% of cases). In some cases, arthroscopic reduction and fixation can be as effective as open reduction, and carries with it the intrinsic advantages of a keyhole procedure. The reported 4.6% global complication rate following arthroscopic fixation demonstrates the potential advantages of this technique, with limits due to the low numbers of treated cases4.

Important Tips

The operating room should be carefully set up, especially regarding the positions of the C-arm and the arthroscopy tower, which should be double-checked before starting the procedure.The medial portal should be created after identification of the saphenous vein on an ultrasound scan. The anesthesiologist or a radiologist may mark the vein on the skin preoperatively, or the surgeon may extend the arthroscopic portal and perform a superficial dissection to avoid the vessel.Visualization after creation of the portals is usually suboptimal until the hematoma is completely removed. Patience must be maintained in this phase of the procedure.A microfracture awl or a large Kirschner wire can be utilized as a joystick to aid in reduction of the fragment, from either the usual portals or the medial portal. This aid can facilitate rotation of the fragment, which is a key step in the reduction phase.Definitive fixation can be achieved with use of 4.5-mm cannulated headless screws. Large cannulated headless screws have longer and larger Kirschner wires that can also aid in reduction when used as joysticks, reducing the risk of bending or breaking during screw insertion. Additionally, a 4.5-mm screwdriver is longer, allowing easier insertion, especially in patients with a larger thigh. The large diameter should not be a concern because the head is sunk in a non-weight-bearing area of the head.To avoid the risk of misplacement or loss of the screw during its insertion, make use of a cannulated guide handle for 4.5-mm screws, such as the guide utilized in a Latarjet arthroscopic procedure.To prevent screw loss into the joint, utilize a loop-knotted wire around the proximal part of the screw; this wire is cut at the end of the procedure.

Acronyms and Abbreviations

AAFF = arthroscopic-assisted fracture fixationHO = heterotopic ossificationUS = ultrasound/ultrasonographyAP = anteroposteriorCT = computed tomographyASIS = anterosuperior iliac spineGT = greater trochanterSP = Smith-PetersenIF = internal fixationK-wire = Kirschner wire.

Comparison of Postoperative Complications Between Trochanter Flip Osteotomy and Kocher-Langenbeck Approaches for the Treatment of Femoral Head Fractures: A Systematic Review and Meta-analysis

Purpose

The study aims to identify the optimal approach for femoral head fracture (FHF) by comparing the postoperative complications and outcome score of the Kocher-Langenbeck posterior approach (KLP) and trochanteric flip osteotomy (TFO) through a systematic review and meta-analysis.

Methods

MEDLINE, Embase and the Cochrane Library were systematically searched for studies published up to 22 January 2023, which compared TFO to the KLP for FHF treatment. The main outcomes of this meta-analysis were the rate of postoperative complications including osteonecrosis of the femoral head (ONFH), heterotopic ossification (HO), and total hip replacement (THR) conversion rate and Thompson-Epstein (T-E) score at the final follow-up.

Results

We included four studies with 57 cases of FHFs; 27 and 30 patients underwent TFO and the KLP, respectively. Following the pooled analysis, HO incidence was significantly higher in TFO than in the KLP (OR = 4.03; 95% CI 1.10-14.81; P = 0.04; I 2 = 0%), but there were no differences in other variables, including the incidence of ONFH (OR = 0.41; 95% CI 0.07-2.35; P = 0.32; I 2 = 0%), THR conversion rate (OR = 0.82; 95% CI 0.16-4.29; P = 0.81; I 2 = 0%), and number of inferior results in the T-E score (OR = 0.49; 95% CI 0.14-1.73; P = 0.27; I 2 = 0%).

Conclusions

Amongst the posterior approaches for FHFs, the KLP and TFO did not present significant clinical and radiological differences; hence, the approach can be selected depending on the surgeon's experience and preference.

Safe Surgical Dislocation and Open Reduction, Internal Fixation with Herbert Screw for Pipkin's Fracture Head of Femur in an Obese Patient: An Interesting Case Report

Head of femur fractures are relatively rare and tend to be associated with dislocations of the hip and fractures of the acetabulum. Other parts of the femur, namely the neck is also often involved. Only two cases per million are reported on a yearly basis which poses significance due to its extreme rarity. Here, we present a 30-year-old obese male patient with Pipkin's fracture who was treated successfully by us without any major complications.

Influence of associated femoral head fractures on surgical outcomes following osteosynthesis in posterior wall acetabular fractures

Background

To date, no study has compared the surgical outcomes between posterior wall acetabular fractures with and without associated femoral head fractures. Therefore, we evaluated whether an associated femoral head fracture increases the incidence of fracture sequelae, including post-traumatic osteoarthritis (PTOA) and osteonecrosis of the femoral head (ONFH), following osteosynthesis for posterior wall acetabular fractures.

Methods

This retrospective clinical study enrolled 183 patients who underwent osteosynthesis for posterior wall acetabular fractures between 2009 and 2019 at a level-1 trauma center. The incidence of PTOA, ONFH, and conversion to total hip arthroplasty (THA) was reviewed.

Results

The incidence of PTOA, ONFH, and conversion to THA following osteosynthesis were 20.2%, 15.9%, and 17.5%, respectively. The average time for conversion to THA was 18.76 ± 20.15 months (range, 1–82). The results for the comparison of patients with associated femoral head fractures and isolated posterior wall acetabular fractures were insignificant (PTOA: 27.3% vs. 15.7%, p = 0.13; ONFH: 18.2% vs. 14.3%, p = 0.58; conversion to THA: 20.4% vs. 15.7%, p = 0.52). Upon evaluating other variables, only marginal impaction negatively affected ONFH incidence (odds ratio: 2.90).

Conclusions

Our methods failed to demonstrate a significant difference in the rate of PTOA, ONFH, or conversion to THA in posterior wall acetabular fractures with and without an associated femoral head fracture. Beyond femoral head fractures, the marginal impaction of the acetabulum could have led to early sequelae.

Level of evidence

Level III

Open or Arthroscopic Synovectomy Is the Preferred Management Option in Pigmented Villonodular Synovitis of the Hip Joint Without Evidence of Degeneration: A Systematic Review of 20 Studies

Purpose

To provide an up-to-date systematic review on the treatment options for pigmented villonodular synovitis (PVNS) of the hip and provide a grade of recommendation using standardized systems.

Methods

A systematic search of PubMed, Embase, Web of Science, and The Cochrane Library from the date of inception of each database through December 4, 2021, was performed. Studies that described the outcomes of treatment of hip PVNS were identified. These outcomes were discussed and synthesized by three reviewers, and a grade of recommendation was assigned.

Results

Twenty studies were identified. Seven studies described arthroscopic synovectomy, eight studies described open synovectomy, nine studies described arthroplasty, and one study described osmic acid synoviorthesis. Synovectomy, either open or arthroscopic, had similar rates of disease recurrence. Hip arthroplasty had low rates of disease recurrence compared to synovectomy; however, it was associated with significant risk of aseptic loosening in the longer term.

Conclusion

Synovectomy, either open or arthroscopic based on surgeon preference, is favored in the treatment of hip PVNS if there is no evidence of joint space narrowing. Arthroplasty should be considered in cases with joint space narrowing or recurrence following joint preservation therapy. There is insufficient evidence to support synoviorthesis either as monotherapy or adjuvant therapy.

Level of Evidence

IV, systematic review of Level III and IV studies.

Outcomes of surgical hip dislocation combined with bone graft for adolescents and younger adults with osteonecrosis of the femoral head: a case series and literature review

Background

Osteonecrosis of the femoral head (ONFH) may occur in the adolescent and younger adults (AYAs). Total hip arthroplasty (THA) is not the best treatment option for younger patients. Surgical hip dislocation (SHD) combined with bone graft can be used in patients at different stages to reconstruct the bone structure in the head and delay the replacement time. The purpose of this study was to evaluate the effect and potential influencing factors of this surgery for ONFH in AYA patients. 

Methods

We conducted a literature review and a retrospective research of our own cases. The Pubmed, Cochrane Library, EMBASE and CNKI databases were searched from 1 January 2001 to 1 October 2021, for clinical studies. A retrospective case series study of 34 patients (38 hips) treated with SHD combined with bone graft was performed.

Results

A total of 13 studies were included and the results showed that SHD combined with bone grafts had better clinical results for patients with pre- or early post-collapse. In the case series study, we retrospectively analyzed 34 patients (38 hips), and the mean follow-up time was 40.77 ± 15.87 months. One patient died and three patients were converted to THA finally. The post-collapse degree and post-lesion size were better than those before the operation (P < 0.05). The iHOT-12 at the last follow-up was significantly higher than that before the operation (P < 0.05). There were significant differences in the results of hip Harris score (HHS), visual analogue scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) before the operation, 2 years after the operation and at the last follow-up, but the difference was not related to the follow-up time (P < 0.05). There were no significant differences in the final clinical score and arthritic changes among different Japanese Investigation Committee (JIC) classification, the degree of collapse and the size of the necrotic (P > 0.05).

Conclusions

In AYA patients, SHD combined with bone grafting is a potentially good option for hip preservation in ONFH. The differences in JIC classification, collapse degree and lesion size did not affect the final clinical function and the risk of osteoarthritis. Even for very severe cases at collapsed stage, good short-term clinical effects can still be achieved by SHD combined with bone graft.

Trial registration

ChiCTR2100055079.retrospectively registered. 

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05456-w.

A combination of the K-L and S-P approaches for treating acetabular posterior wall factures accompanied by femoral head fractures with open reduction and internal fixation

Background

In clinical practice, acetabular posterior wall fracture combined with femoral head fracture is rare. However, with the increasing number of engineering and traffic accidents, such fractures, have increased significantly in recent years. This paper aims to explore the clinical efficiency of the Kocher-Langenbeck (K-L) and Smith-Petersen (S-P) combined approaches for open reduction and internal fixation (ORIF) of acetabular posterior wall fractures accompanied by femoral head fractures (Pipkin type IV fractures).

Methods

A retrospective study was conducted on 8 patients who underwent open reduction and internal fixation (ORIF) of Pipkin type IV fractures through the K-L combined with S-P approach in our hospital from January 2015 to January 2020. All 8 patients were successfully operated on without serious complications, such as important blood vessel and nerve damage, with an operation time of 143.8 ± 44.38 min and intraoperative blood loss of 225 ± 70.71 ml. Perioperative data were recorded. The Harris score was used to evaluate the clinical effect. Fracture reduction quality was evaluated according to the Matta radiological standard. The grade of ectopic ossification was evaluated by the Brooker grading method, and the stage of femoral head necrosis was evaluated by Ficat-Arlet staging.

Results

The Harris score increased significantly from 57.38 ± 4.779 at 3 months, to 76.13 ± 3.682 at 6 months, 88.25 ± 3.495 at 12 months, and 92.13 ± 2.232 at 36 months postoperatively. After statistical analysis, compared with the previous observation time point, the data comparison differences between the groups were statistically significant. P < 0.001, P < 0.001, P < 0.05). By the time of the latest follow-up, 6 of the 8 patients had recovered to the level of pre-injury sports capacity. In contrast, the other 2 patients remained below the level of pre-injury sports capacity. In terms of imaging evaluation, the quality of fracture reduction on radiographs was graded as excellent in 6 patients and good in 2 patients according to Matta’s criteria. At the last follow-up, no heterotopic ossification or femoral head necrosis was found in of all the images. In addition, the hip joint space was normal in 6 cases, mildly narrowed in 1 case, and clearly narrowed in 1 case.

Conclusions

The K-L combined with S-P approach provides effective exposure for the reduction and fixation of Pipkin type IV fractures and achieves satisfactory clinical outcomes.

Supplementary information

The online version contains supplementary material available at 10.1186/s12893-022-01597-w.

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.

Efficacy of direct anterior approach combined with direct posterior approach in Pipkin IV femoral head fractures

Objective

The study aimed to explore the efficacy of direct anterior approach combined with direct posterior approach in Pipkin IV femoral head fractures.

Methods

The study enrolled 64 patients with Pipkin IV femoral head fractures who were treated at our hospital between March 2019 and April 2020. They were assigned to the control group and the study group using the random number table method with 32 patients in each group and received treatment by the direct anterior approach and treatment by the direct anterior approach combined with the direct posterior approach. The operative time, intraoperative estimated blood loss, postoperative drainage time, drainage volume, time to partial and full weight-bearing, total length of hospital stay and the levels of hemoglobin (Hb) and hematocrit (Hct) in the two groups were compared, and severity of pain and hip function at different time points postoperatively were observed, and the occurrences of complications were compared.

Results

There was no statistical difference in the operative time and intraoperative estimated blood loss between the two groups (P > 0.05). Compared with the control group, the study group had shorter postoperative drainage time, lower drainage volume, shorter time to partial and full weight-bearing, and shorter total length of hospital stay, and the difference was statistically different (P < 0.05). There was no significant difference in Hb and Hct levels between the two groups before surgery (P > 0.05). The levels of Hb and Hct in both groups at postoperative day (POD) 1 were lower than those before surgery, and the levels of Hb and Hct in the study group were significantly higher than those in the control group (P < 0.05). Compared with the control group, the study group had significantly less severe pain at POD 1 and 7 and 1, 3 and 6 months postoperatively (P < 0.05). Compared with the control group, the study group had significantly better hip function at 3, 6 and 12 months postoperatively (P < 0.05). All patients were followed up for 12 months, and 1 case of ectopic ossification appeared in both groups 3 months postoperatively, both Brooker grade I. No special treatment was provided as it did not interfere with the mobility of the hip and caused no apparent discomfort in the patients. In the current study, no incision infection, ischemic necrosis of the femoral head, breakage of the internal fixation device, fracture nonunion and loss of fracture reduction and other complications were reported in any patients.

Conclusion

Direct anterior approach combined with direct posterior approach in Pipkin IV femoral head fractures does not increase operative time and intraoperative estimated blood loss but can lessen severity of pain and promote functional recovery of the hip, leading to a favorable prognosis while not increasing the incidence of complications.

Which Surgical Approach Provides Maximum Visualization and Access for Open Reduction and Internal Fixation of Femoral Head Fractures?

OBJECTIVES

Femoral head fracture open reduction and internal fixation (ORIF) requires adequate surgical access and visualization. The purpose of this study was to objectively characterize femoral head access associated with commonly used surgical approaches. Our hypothesis was that a surgical hip dislocation (SHD) provides the greatest visualization and access to the femoral head.

METHODS

Ten fresh-frozen cadaveric whole-pelvis specimens (n = 20 hips) were used to compare 4 surgical approaches to the femoral head (n = 5 hips per approach): SHD, Smith-Petersen (with and without rectus release), and Hueter. After surgical exposure, standardized and calibrated digital images were captured and analyzed to determine the percent-area visualized. Three independent investigators assessed each specimen to determine surgical visualization and access to the following femoral head anatomic quadrants: anteromedial, anterolateral, posteromedial, and posterolateral. Data were analyzed for significant (P < 0.05) differences using analysis of variance (ANOVA) and Fisher exact tests.

RESULTS

The Hueter approach provided the lowest calculated % visualization. For surgeon visualization, SHD demonstrated a significantly (P < 0.001) higher proportion of visualized anatomic landmarks compared with all other approaches. SHD provided significantly (P < 0.049) more access to the femoral head quadrants compared with all other approaches. The Hueter approach had significantly (P = 0.004) lower surgeon access compared with the Smith-Petersen with release.

CONCLUSIONS

SHD provided superior visualization and access to clinically relevant femoral head anatomy compared with the Smith-Petersen with or without rectus release and Hueter approaches.

Does Surgical Repair Benefit Pipkin Type I Femoral Head Fractures?: A Systematic Review and Meta-Analysis

Background: Femoral head fractures are rare injuries with or without traumatic dislocations. The management of these fractures is crucial to prevent the development of severe complications and to achieve optimal functional outcomes. Wide treatment options for Pipkin 1 femoral head fractures range from fragment excision, fixation following open reduction with internal fixation, or conservative treatment such as close reduction alone after fracture dislocation. However, the best decision making remains controversial not only due to lack of large trials, but also inconsistent results reported. Therefore, we aim to compare the operative with nonoperative outcomes of Pipkin type 1 patients. Patients and Methods: We systemically searched MEDLINE, EMBASE, Cochrane library, In-Process & Other Non-Indexed Citations to identify studies assessing outcomes of Pipkin type 1 patients after conservative treatment, and open reduction with excision or fixation. Data on comparison of clinical outcomes of each management were extracted including arthritis, heterotopic ossification (HO), avascular necrosis (AVN), and functional scores (Thompson Epstein, Merle' d Augine and Postel Score). We performed a meta-analysis with the available data. Results: Eight studies (7 case series and 1 RCT) were included in this study. In a pooled analysis, the overall rate of arthritis was 37% (95% CI, 2-79%), HO was 20% (95% CI, 2-45%), and AVN was 3% (95% CI, 0-16%). In comparison of management types, the excision group reached the best functional outcomes including Thompson Epstein Score (poor to worse, 9%; 95% CI, 0-27%) and Merle d' Aubigne and Postel Score (poor to worse, 18%; 95% CI, 3-38%); ORIF group had the highest AVN rate (11%; 95% CI, 0-92%); conservative treatment had the highest arthritis rate (67%; 95% CI: 0-100%) and lowest HO rate (2%; 95% CI, 0-28%). Discussion: This meta-analysis demonstrates that different procedures lead to various clinical outcomes: fragment excision may achieve better function, conservative treatment may result in a higher arthritis rate, while ORIFs may have a higher AVN rate. These findings may assist surgeons in tailoring their decision-making to specific patient profiles. Future RCTs with multicenter efforts are needed to validate associations found in this study. Level of Evidence: II, systematic review and meta-analysis.

Fractures of the femoral head: a narrative review

Fractures of the femoral head are rare injuries, which typically occur after posterior hip dislocation.

The Pipkin classification, developed in 1957, is the most commonly used classification scheme to date.

The injury is mostly caused by high-energy trauma, such as motor vehicle accidents or falls from a significant height.

Emergency treatment consists of urgent closed reduction of the hip joint, followed by non-operative or operative treatment of the femoral head fracture and any associated injuries.

There is an ongoing controversy about the suitable surgical approach (anterior vs. posterior) for addressing fractures of the femoral head. Fracture location, degree of displacement, joint congruity and the presence of loose fragments, as well as concomitant injuries are crucial factors in choosing the adequate surgical approach.

Long-term complications such as osteonecrosis of the femoral head, posttraumatic osteoarthritis and heterotopic ossification can lead to a relatively poor functional outcome.

Cite this article: EFORT Open Rev 2021;6:1122-1131. DOI: 10.1302/2058-5241.6.210034

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.

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

INTRODUCTION

Femoral head fractures considered to be rare injuries. Surgical intervention is indicated for major fragment displacement or in the presence of instability. Surgical management can be achieved through either Anterior, posterior, and trans-trochanteric surgical approaches. Surgical hip dislocation (SHD) has been advocated by many authors to be a safe and effective alternative way of management. The aim of this study was to report on the accuracy of fracture reduction, procedure safety, and outcomes of using SHD in the management of femoral head fractures.

PATIENTS AND METHODS

Between 2011 and 2017, 31 patients presented with femoral head fracture were treated through SHD. At a mean follow-up of 48 months, 27 patients were available for the study with a mean age of 33.8 years. Patient demographics, clinical evaluation according to modified Harris hip score and modified Merle d'Aubigne and Postel score, radiographic fracture reduction according to Matta's criteria, and any complications were reported.

RESULTS

Excellent and good clinical outcomes were reported in 25 (92.6%) and 24 (89%) patients according to the modified Harris hip and modified Merle d'Aubigne and Postel scores, respectively. Anatomic fracture reduction was achieved in 21 (77.8%) patients. Two (7.4%) patients developed AVN, one (3.6%) patient developed hip OA (grade 3 according to Tönnis classification), and five (18.5%) patients developed asymptomatic Brooker stage I heterotopic ossification. No infection or trochanteric flip osteotomy fragment non-union was reported.

CONCLUSIONS

SHD offers a safe and efficient approach for femoral head fractures management with acceptable clinical outcomes as well as complication rates. Giving the advantage of fully exposing the femoral head and the acetabulum which enables the surgeon to anatomically reduce the fracture and treat any associated injuries, SHD is recommended besides other approaches for the management of femoral head fractures.

Neglected Neck of Femur Fracture Managed by Surgical Hip Dislocation: A Case Report and Literature Review

Introduction

Femoral neck fractures (FNFs) in young adults are relatively uncommon emergency that requires early diagnosis and management possible to prevents joint complications.

Case Report

A 24-year-old male presented with a right hip pain for 3 months after a heavy physical exercise during military training. The imaging exhibited a transcervical FNF with displacement and a potential of avascular necrosis (AVN). The patient was managed by Open reduction and internal fixation through surgical hip dislocation (SHD) and bone grafting from the right iliac bone. The patient returned to his full military services 14 weeks following the surgery and was followed for 3 years without any symptomatic or functional problems.

Conclusion

SHD could be one of the surgical options hired in the management of late presentations of FNFs in young adults with high suspicion of AVN.

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.

Complications and Functional Outcome of Femoral Head Fracture-Dislocation In Delayed and Neglected Cases

INTRODUCTION

Delayed reduction of the hip in femoral head fracture dislocation increases the risk of osteonecrosis and adversely affects the functional outcome.

MATERIALS AND METHODS

This retrospective study was designed to evaluate the outcome and complications of 138 patients with femoral head fracture dislocation treated by a single surgeon over a period of 22 years. Only seven patients presented within 24 h of injury and remaining all presented late. The hip joints could be reduced by closed manoeuvre in 105 patients, and 33 patients needed open reduction. The patients were managed conservatively or surgically. The mean follow-up period was 3.57 years (1-18 years).

RESULTS

There were 119 males and 19 females. The mean age was 35.71 years (range, 18-70 years). Forty-two patients were managed conservatively, and 96 patients needed surgical treatment. The Kocher-Langenbeck approach was used in 40 patients, the trochanteric flip osteotomy in 14 patients, the Smith-Peterson approach in 31 patients, and the Watson-Jones approach in one patient. The femoral head fragment was fixed in 47.82% patients and excised in 11.59% patients. Primary total hip replacement (THR) was performed in 7.24% of patients through the posterior approach. 24.63% of patients developed complications with 14.49% of hip osteonecrosis, 2.89% posttraumatic osteoarthritis and 2.17% femoral head resorption. 55% of patients who developed osteonecrosis were operated through the posterior approach. Secondary procedures were needed in 14.48% of patients. The clinical outcome, as evaluated using the modified Harris Hip Score, was good to excellent in 52.89% of patients and poor to fair in 47.11% of patients.

CONCLUSION

The incidences of osteonecrosis and secondary procedures are increased in delayed and neglected femoral head fracture dislocation. Osteonecrosis is commonly seen in Brumback 2A injuries and posterior-based approaches. All Brumback 3B fractures in such delayed cases should be treated with THR. Osteosynthesis or conservative treatment should be reserved for other types of injuries. A careful selection of treatment plan in such delayed cases can result in a comparable functional outcome as reported in the literature.

Is non-operative management of acetabular fracture a viable option for older patients? A systematic review of the literature for indication, treatments, complications and outcome

There is no consensus about the best treatment for acetabular fracture in older patients. The purpose of this study was to review the current literature looking for indication, perioperative information and outcome of nonoperative management for acetabular fractures in elderly.A systematic review of literature was performed on different research database by using various combination of the keywords "acetabular fracture", "elderly patients", "60 years", "nonoperative", "nonsurgical" and "conservative treatment".Six articles met our inclusion criteria, 315 patients aged 60 or more treated nonoperatively for acetabular fracture were included in the analysis. The average age was 78.1 years, the average follow-up length was 48.7 months. The main criteria for indication of nonoperative management for acetabular fractures were, old age (75 years or more), two or more important medical comorbidities, and minimally or undisplaced fracture. The most frequent fracture pattern was anterior column in 25.3% of cases. Fall from standard height was the most frequent causative mechanism in 80% of patients. A conversion total hip arthroplasty was performed after 8.3% of cases. A 1-year mortality of 18% was reported, an overall mortality of 33.1% at last follow-up was reported.The management of acetabular fractur in elderly is a challenging problem and there is no consensus about the best treatment. Currently, multiple treatment options have been suggested, depending on fracture pattern and patients' general conditions. Although operatively treatment allow for an early recovery, there is not an high level of evidence about the superiority in terms or complications and mortality rate compared to nonoperative treatment.

Pipkin type IV femoral head fractures: a case series and review of literature

INTRODUCTION

Femoral head fractures with associated acetabular fractures are uncommon injuries usually resulting from high-energy mechanisms such as motor vehicle collisions. Outcomes of Pipkin type IV fractures have been historically poor, with high rates of osteonecrosis, post-traumatic arthritis, and heterotopic ossification. The objective of this study was to define the outcomes of operatively treated Pipkin type IV fractures In addition, we reviewed the available literature of this uncommon injury pattern.

METHODS

A retrospective chart review at a single level 1 trauma center from 2007 to 2016 identified 10 patients with Pipkin IV femoral head fractures. Demographic information, fracture type, associated injuries, operative details, and complications were evaluated. Clinical and radiological outcomes were assessed at latest follow-up including conversion to total hip arthroplasty.

RESULTS

Six of the seven patients were treated with open reduction and internal fixation of the femoral head fracture and acetabular fracture through a Kocher-Langenbeck approach aided by a trochanteric flip and one had fragment excision. Six patients (87.5%) developed post-traumatic arthritis. Four (57.1%) later underwent conversion to total hip arthroplasty (THA) a mean of 20.5 months after index procedure.

CONCLUSION

Our study shows a rate of osteonecrosis and osteoarthritis that is even higher than the previously reported studies. The former may relate to longer-term follow-up and the latter possibly due to associated comminuted posterior wall fracture.

Diagnosis, preoperative evaluation, classification and total hip arthroplasty in patients with long-term unreduced hip joint dislocation, secondary osteoarthritis and pseudoarthrosis

BACKGROUND

Neglected long-term unreduced hip joint dislocation with secondary osteoarthritis and pseudoarthrosis poses a great challenge to hip surgeons. However, as this is an uncommon injury, few studies have systematically investigated these patients.

METHODS

We retrospectively reviewed 16 patients from 2010 to 2017. The diagnostic values of three different types of common radiological examinations were evaluated. We evaluated the bone conditions of the original acetabulum and classified the patients into three types (four subtypes). The surgical procedures and prognosis of the patients were also investigated.

RESULTS

With the combined application of X-ray, CT scans and 3D reconstruction, 93.8% of these patients (sensitivity = 93.8%, Youden's index = 0.93, intraclass correlation coefficient = 0.95) could be diagnosed correctly. There were 6/16 (37.5%) type A patients, 4/16 (25.0%) type B1 patients, 5/16 (31.3%) type B2 patients and 1/16 (6.3%) type C patient. For patients with type A injury, the surgical procedures for total hip arthroplasty were similar to "standard" total hip arthroplasty. For patients with type B injury, due to atrophy or partial bone deficiency of the original acetabulum, the surgical procedure for total hip arthroplasty was probably similar to those for patients with developmental dysplasia of the hip. For patients with type C injury, the situation was similar to that of revision surgery. The average Harris hip score postoperatively was 89.94 ± 5.78 points (range: 79-98 points).

CONCLUSIONS

The new classification system could help surgeons estimate potential difficulties during total hip arthroplasty. The prognosis of most patients after total hip arthroplasty is expected to be excellent or good.

Surgical treatment of femoral head fractures

Background

Femoral head fractures (FHF) are uncommon and generally caused by high-energy injuries. Surgical reduction with stable fixation of large fragments is believed to have the best outcomes. This retrospective study intended to report outcomes with surgical treatment at our institution and tried to establish treatment algorithm.

Methods

Through the 6-year period (2003–2008), 35 FHF in 35 consecutive patients (average, 30 years) were surgically treated. All FHF were caused by high-energy trauma. Patients' general condition was stabilized first and hip dislocation was manually reduced immediately. Definite fracture treatment was scheduled after admission for an average of 2.9 days (0.3–11 days). Pipkin classification was used as the treatment guide and open reduction with internal fixation was performed in all 35 FHF.

Results

These FHF included 21 type I, 7 type II, 3 type III, and 4 type IV fractures. The hip joint had been approached by either an anterior or posterior route depending on the individual surgeon. Internal fixation with screws was performed for all 35 FHF. The average admission was 13.8 days (range, 2–35 days). Thirty patients (86%, 30/35) were followed for an average of 3.3 years (at lease 6 months) and all 30 FHF healed. Avascular necrosis of the femoral head was found in 23% (7/30) patients and six patients were converted to hip arthroplasty for developing advanced stages of avascular necrosis. Heterotopic ossification occurred in 43% (13/30) patients. However, only one patient had range of motion limitation. Besides, one patient had moderate hip osteoarthritis.

Conclusions

FHF are uncommon and generally caused by high-energy injuries. Fracture healing can be attained in all femoral head fractures by using open reduction and screw fixation. Our results by using conventional approaches were associated with high complication rates. Further endeavor to improve the outcome should be taken.

Fractures of the acetabulum: from yesterday to tomorrow

Purpose

The aim of this article is to present history, state of the art, and future trends in the treatment of acetabular fractures.

Methods

Review of recent and historical literature.

Results

Acetabular fractures are difficult to treat. The first descriptions of this injury already appeared in ancient Greek history, but intensive development started in the second half of the twentieth century after Judet and Letournel’s seminal work. Their classification is still the gold standard today. It is actually a pre-operative planning system and is used to determine the most appropriate surgical approach. The therapy of choice for dislocated fractures is open reduction and internal fixation. Recent modern techniques based on high-tech computerized planning systems and 3D printing have been successfully integrated into orthopaedic trauma practice.

Conclusion

There is no ideal surgical approach for acetabulum fracture treatment, so new approaches have been developed in recent decades. The best outcome series have shown good or excellent results, between 70 and 80%.

Osteonecrosis of femoral head in young patients with femoral neck fracture: a retrospective study of 250 patients followed for average of 7.5 years

Objective

To investigate the risk factors for osteonecrosis of the femoral head (ONFH) after the treatment of femoral neck fracture in patients under 60 years old.

Methods

A total of 250 cases of femoral neck fracture treated at 3 hospitals in Xuzhou from January 2002 to January 2016 were studied. The patients were followed up for 1~15 years, and the clinical data on femoral head necrosis after the femoral neck operation were analysed retrospectively. Risk factors were recorded, including age, gender, preoperative traction, time from injury to operation, reduction method, type of reduction, BMI, ASA classification, and quality of reduction. Logistic regression analysis was used to evaluate the independent risk factors for ONFH after treatment of femoral neck fracture.

Results

The duration of follow-up was 1~15 years, with an average of 7.5 years. None of the 250 patients had fracture non-union, but 40 (16%) had necrosis of the femoral head. The time to necrosis of the femoral head was 1~7 years after the operation, with an average of 3.8 years. Univariate analysis showed that the type of fracture, the quality of reduction, the removal of internal fixation, BMI and ASA classification were risk factors affecting necrosis of the femoral head in patients with femoral neck fracture, and the difference was statistically significant (P < 0.05). Multivariate analysis showed that internal fixation, fracture type (displacement), reduction quality (dissatisfaction), BMI (> 25), and ASA grade (III + IV) were independent risk factors affecting femoral head necrosis in patients with femoral neck fracture.

Conclusion

A variety of high-risk factors for femoral head necrosis are present after surgery with hollow compression screws for femoral neck fracture in adults. Removal of internal fixation, type of fracture, quality of reduction, BMI, and ASA classification were the most important risk factors influencing the development of femoral head necrosis. During treatment, there should be some targeted measures to reduce the incidence of necrosis of the femoral head.

Modified Ludloff's medial approach for management of Pipkin's type I femoral head fracture

INTRODUCTION

Numerous approaches were described for the management of Pipkin's type I fracture with no consensus on the "standard of care". The strategic thinking of the ideal access is through the medial approach.

MATERIAL AND METHODS

Using Ferguson intermuscular interval, prospective study was done (January 2014-2019) to evaluate radiological and functional outcomes using HHS and Thompson-Epstein criteria. Fracture patterns were subclassified: anterior and posterior-inferior (AI/PI) requiring different reduction positions.

RESULTS

Twenty-one patients (mean FU = 24.3 months (range, 12-48)) were divided into 14 (67.7%) AI and seven PI. Excision was performed in five (23.8%) (AI = 3 (14.3%) and PI = 2) and ORIF in 16 (AI = 11 (52.4%) and PI = 5). At the last follow-up, two (9.5%) were graded as excellent, 11 (52.4%) as good, three (14.3%) as fair, and five as poor.

CONCLUSION

Modified Ludloff's approach provides safe easy direct access to fracture allowing easy excision or direct anatomical reduction, perpendicular compression, and rigid fixation with minimal complications.

In Situ Reduction and Fixation of the Anterior Medial Fenestration Approach for Femoral Head Fracture

Objective

To investigate the feasibility and clinical application of the anterior medial fenestration approach in the treatment of Pipkin type I and II femoral head fractures.

Methods

The hips of two anti‐corrosion adult specimens treated with formalin were dissected and the anatomical structures and directional characteristics of the anterior medial main muscles, ligaments, blood vessels, and nerves were observed. The anterior medial fenestration approach was performed on bilateral hips of four fresh frozen specimens to determine the required pulling direction of the stripped muscles and ligaments during surgery. In addition, the vascular and nerve traction protection directions exposed in the approach were observed and analyzed. The feasibility of this approach was assessed, and the operative approach and critical anatomical depth were measured. We retrospectively analyzed 12 patients with Pipkin type I and II femoral head fractures who underwent in situ reduction and fixation by anterior medial fenestration in our hospital from February 2016 to April 2018. The study group included 3 men and 9 women aged 37–59 years (mean, 48.50 years). There were 8 cases of Pipkin type I and 4 cases of Pipkin type II. The operation time, blood loss, fracture healing time, last Thompson–Epstein evaluation, and Harris score were recorded.

Results

A total of 8 fresh frozen specimens from 4 bilateral hips were exposed by anterior medial fenestration. The upper boundary of observation fenestration was the pubic body (anterior acetabulum), and the outer upper boundary was the iliacus and the psoas muscle. The lateral boundary was the rectus femoris and the femoral vessels, while the lower boundary was the transverse branch of the medial femoral circumflex artery and vein. The medial boundary was the pubis muscle, the short adductor muscle, and the long adductor muscle. The pubofemoral and iliofemoral ligaments were observed during fenestration. By cutting open the joint capsule and moving the hip joint, the four quadrants of the femoral head can be exposed. Twelve patients with femoral head fractures who were treated with anterior medial fenestration underwent in situ reduction and fixation. The operation time was 96.25–118.75 min (median, 100 min), and the blood loss was 115.00 ± 22.76 mL. The follow‐up time was 18.58 ± 4.48 months, and the fracture healing time was 144.17 ± 14.53 days. The last Thompson–Epstein evaluation was excellent in 6 cases, good in 4 cases, and fair in 2 cases; the excellent and good rate was 83.33%. Finally, the last Harris score was 85.08 ± 5.73 points.

Conclusions

The upper and lower boundaries, inner and outer boundaries, and rear anatomical structure of the anterior medial fenestration approach were defined. The movable hip joint can expose the four quadrants in front of the femoral head in this fenestration. Anterior medial fenestration in situ reduction and fixation surgery is feasible and safe for the treatment of Pipkin type I and II femoral head fractures.

3D printing-based Ganz approach for treatment of femoral head fractures: a prospective analysis

BACKGROUND

Femoral head fractures are uncommon injuries. Open reduction and internal fixation (ORIF) of femoral head fracture is the preferred treatment for most patients. There are several surgical approaches and treatments for this difficult fracture. However, the optimal surgical approach for the treatment of femoral head fracture remains controversial. Meanwhile, the operation is difficult and the complications are numerous. We prospectively reviewed patients with femoral head fractures managed surgically through the 3D printing-based Ganz approach to define a better approach with the least morbidity.

PATIENTS AND METHODS

Between 2012 and 2017, a total of 17 patients were included in this study. An exact 1:1 3D printing model of the injured hip side was fabricated for each patient and simulated surgery was finished preoperative. The surgical approach was performed as described by Ganz. Functional assessment was performed using the modified Merle d'Aubigne scores. The reduction of the fracture was evaluated according to Matta's criteria. The incidence of complications, such as heterotopic ossification (HO) and avascular necrosis (AVN), and the need for additional surgery were also documented.

RESULTS

Twelve of 17 patients (four females and eight males) were available for 2 years follow-up. The mean follow-up was 35 months (25-48 months). Average age for the 12 patients was 39.9 ± 12.2 years. According to the Pipkin classification, four patients were type I fracture, three patients were type II fracture, and five patients were type IV fracture. The mean operative time was 124.2 ± 22.1 min, and the estimated blood loss was 437.5 ± 113.1 ml. According to Merle d' Aubigne scores, excellent results were achieved in six of the 12 patients; four good and two poor results occurred in the rest of the patients. On the radiograph evaluation, fracture reduction was defined as anatomical in eight patients, and imperfect in four. Most patients had good outcomes and satisfactory hip function at last follow-up. Almost all great trochanteric osteectomy healed uneventfully. One patient developed symptomatic AVN of the femoral head and underwent THA at 3 years. After THA, she regained a good hip function with the ability to return to work and almost no reduction in sports activities. Heterotopic ossification was found in four cases (type I-1, type II-2, and type III-1).

CONCLUSIONS

The 3D printing-based Ganz approach provides a safe and reliable approach and satisfactory results of treatment in femoral head fractures. Using 3D printed model for the fracture of the femoral head, the fracture can be viewed in every direction to provide an accurate description of fracture characteristics, which contributes to make a reasonable surgical plan for patients. In addition, the 3D printing-based Ganz approach can obtain excellent surgical exposure and protection of the femoral head blood supply, reduce the operation time and intraoperative blood loss, make the precise osteotomy, anatomically fix the intra-articular fragments, and effectively reduce postoperative complications.

TRIAL REGISTRATION

We register our research at http://www.researchregistry.com . The Unique Identifying Number (UIN) from the Research Registry of the study is researchregistry4847 .

Management of Pipkin Fractures Using a Safe Surgical Hip Dislocation

Introduction

Pipkin fractures are rare events and usually occur as a consequence for high-energy trauma. Surgery to obtain anatomical reduction and fixation is the mainstay treatment for the majority of these injuries; nonetheless, controversy exists regarding the best surgical approach.

Description of the Case

We present the case of a 41-year-old male, which sustained a type II Pipkin fracture following a motorcycle accident. In the emergency department, an emergent closed reduction was performed, followed by surgery five days later. Using a surgical hip dislocation, a successful anatomical reduction and fixation was performed. After three years of follow-up, the patient presented with a normal range of motion, absent signs for avascular necrosis or posttraumatic arthritis, but with a grade II heterotopic ossification.

Discussion

Safe surgical hip dislocation allows full access to the femoral head and acetabulum, without increasing the risk for a femoral head avascular necrosis or posttraumatic arthritis. Simultaneously, this surgical approach gives the opportunity to repair associated acetabular or labral lesions, which explains the growing popularity with this technique.

Conclusion

Although technically demanding, safe surgical hip dislocation represents an excellent option in the reduction and fixation for Pipkin fractures.

Case Report of a Rare Pipkin Type III Femoral Head Fracture

Introduction

Femoral head fractures are rare injury compared to other hip pathologies and often associated with posterior hip dislocation. Such fractures are often fraught with complications even after successful surgical fixation. Pipkin described a classification system for such fractures, dividing them into four types, of which Type III (31C.3) fractures are associated with femoral neck fractures. These fractures are the least common and often associated with the worst outcomes.

Case Report

We report a rare case of Pipkin Type III fracture after attempted hip relocation and review literature on this topic. A 35-year-old female sustained a right posterior hip dislocation with femoral head fracture following a fall. After attempts of manipulation and reduction, she sustained an iatrogenic right femoral neck fracture resulting in a Pipkin III femoral head fracture. Open reduction and reduction of fracture achieved through headless compression screw of femoral head and cortical screws of femoral neck. Four months after surgery, the patient under osteonecrosis of the femoral head and subsequently required conversion to a right total hip arthroplasty.

Conclusion

Femoral head fractures have serious sequelae and should be treated with caution. A high index of suspicion is required; hence, if clinically suspicious, proper imaging is paramount to prevent iatrogenic injury to the femoral neck resulting in subsequent avascular necrosis.

Current Uses of the Transtrochanteric Approach to the Hip: A Systematic Review

BACKGROUND

The indications and technique for the transtrochanteric approach to the hip have evolved greatly since its initial popularization in the 1960s. The purpose of this systematic review was to assess current uses of this approach on the basis of indications, osteotomy technique, trochanteric fixation method, complications, and functional outcome.

METHODS

A comprehensive search of MEDLINE and Embase databases from January 2000 to July 2017 was performed in accordance with the PRISMA guidelines. Articles were divided into 3 major categories on the basis of the type of hip surgery performed: (1) primary arthroplasty, (2) revision arthroplasty, and (3) joint-preserving procedures. Patient data were then analyzed according to these 3 categories.

RESULTS

Seventy-six studies (5,028 hips), mainly of Level-IV evidence, were included. Four types of osteotomy were reported for a variety of indications. Rates of nonunion were 6.0% (303 of 5,028) across all studies, 4.2% (39 of 921) for primary arthroplasty, 6.7% (114 of 1,690) for revision arthroplasty, and 4.4% (56 of 1,278) for joint-preserving procedures. Rates of dislocation were 1.5% (14 of 921) for primary arthroplasty and 4.6% (77 of 1,690) for revision arthroplasty. The rate of osteonecrosis after joint-preserving procedures was 1.1% (14 of 1,278). Rates of deep infection were 1.1% (55 of 5,028) across all studies, 0.1% (1 of 921) for primary arthroplasty, 2.1% (36 of 1,690) for revision arthroplasty, and 0.6% (8 of 1,278) for joint-preserving procedures.

CONCLUSIONS

The transtrochanteric approach remains useful in cases requiring extensile exposure of the acetabulum or femoral medullary canal. However, trochanteric complications continue to pose a clinical challenge.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does the Watson-Jones or Modified Smith-Petersen Approach Provide Superior Exposure for Femoral Neck Fracture Fixation?

BACKGROUND

A well-reduced femoral neck fracture is more likely to heal than a poorly reduced one, and increasing the quality of the surgical exposure makes it easier to achieve anatomic fracture reduction. Two open approaches are in common use for femoral neck fractures, the modified Smith-Petersen and Watson-Jones; however, to our knowledge, the quality of exposure of the femoral neck exposure provided by each approach has not been investigated.

QUESTIONS/PURPOSES

(1) What is the respective area of exposed femoral neck afforded by the Watson-Jones and modified Smith-Petersen approaches? (2) Is there a difference in the ability to visualize and/or palpate important anatomic landmarks provided by the Watson-Jones and modified Smith-Petersen approaches?

METHODS

Ten fresh-frozen human pelvi underwent both modified Smith-Petersen (utilizing the caudal extent of the standard Smith-Petersen interval distal to the anterosuperior iliac spine and parallel to the palpable interval between the tensor fascia lata and the sartorius) and Watson-Jones approaches. Dissections were performed by three fellowship-trained orthopaedic traumatologists with extensive experience in both approaches. Exposure (in cm) was quantified with calibrated digital photographs and specialized software. Modified Smith-Petersen approaches were analyzed before and after rectus femoris tenotomy. The ability to visualize and palpate seven clinically relevant anatomic structures (the labrum, femoral head, subcapital femoral neck, basicervical femoral neck, greater trochanter, lesser trochanter, and medial femoral neck) was also recorded. The quantified area of the exposed proximal femur was utilized to compare which approach afforded the largest field of view of the femoral neck and articular surface for assessment of femoral neck fracture and associated femoral head injury. The ability to visualize and palpate surrounding structures was assessed so that we could better understand which approach afforded the ability to assess structures that are relevant to femoral neck fracture reduction and fixation.

RESULTS

After controlling for age, body mass index, height, and sex, we found the modified Smith-Petersen approach provided a mean of 2.36 cm (95% confidence interval [CI], 0.45-4.28 cm; p = 0.015) additional exposure without rectus femoris tenotomy (p = 0.015) and 3.33 cm (95% CI, 1.42-5.24 cm; p = 0.001) additional exposure with a tenotomy compared with the Watson-Jones approach. The labrum, femoral head, subcapital femoral neck, basicervical femoral neck, and greater trochanter were reliably visible and palpable in both approaches. The lesser trochanter was palpable in all of the modified Smith-Petersen and none of the Watson-Jones approaches (p < 0.001). All modified Smith-Petersen approaches (10 of 10) provided visualization and palpation of the medial femoral neck, whereas visualization of the medial femoral neck was only possible in one of 10 Watson-Jones approaches (p < 0.001) and palpation was possible in eight of 10 Watson-Jones versus all 10 modified Smith-Petersen approaches (p = 0.470).

CONCLUSIONS

In the hands of surgeons experienced with both surgical approaches to the femoral neck, the modified Smith-Petersen approach, with or without rectus femoris tenotomy, provides superior exposure of the femoral neck and articular surface as well as visualization and palpation of clinically relevant proximal femoral anatomic landmarks compared with the Watson-Jones approach.

CLINICAL RELEVANCE

Open reduction and internal fixation of a femoral neck fracture is typically performed in a young patient (< 60 years old) with the objective of obtaining anatomic reduction that would not be possible by closed manipulation, thus enhancing healing potential. In the hands of surgeons experienced in both approaches, the modified Smith-Petersen approach offers improved direct access for reduction and fixation. Higher quality reductions and fixation are expected to translate to improved healing potential and outcomes. Although our experimental results are promising, further clinical studies are needed to verify if this larger exposure area imparts increased quality of reduction, healing, and improved outcomes compared with other approaches. The learning curve for the exposure is unclear, but the approach has broad applications and is frequently used in other subspecialties such as for direct anterior THA and pediatric septic hip drainage. Surgeons treating femoral neck fractures with open reduction and fixation should familiarize themselves with the modified Smith-Petersen approach.

Surgical treatment of femoral head fractures through previously controlled hip luxation: four case series and literature review

OBJECTIVE

To report a series of cases of patients treated by fracture of the femoral head through the Ganz pathway with controlled dislocation of the hip.

METHOD

All patients who were surgically treated with a Ganz access route for femoral head fractures were identified in a tertiary referral service for trauma. A review of medical records with X-rays and CT scans was carried out. The radiographic evaluation was classified according to Pipkin and the functional evaluation was performed through the application of the modified Harris Hip Score. Data regarding the quality of reduction, type of fixation, and postoperative complications were collected.

RESULTS

The sample consisted of three men and one woman, with a mean age of 30 years (20-51). Regarding Pipkin's classification, two cases were type I, one type II, and one type IV. Regarding the Harris Hip Score, an average of 65.75 points was obtained (range: 20-86). All cases had anatomical reduction in the intraoperative period. One case presented post-traumatic sciatic nerve praxis and evolved with infection at the surgical site.

CONCLUSION

Surgical treatment of femoral head fractures through controlled hip dislocation is a viable option and can be considered an alternative to classical approaches.

Midterm results of trochanteric flip osteotomy technique for management of fractures around the hip

INTRODUCTION

In this study, we aimed to investigate safety and efficacy of the trochanteric flip osteotomy with surgical hip dislocation technique in selected displaced acetabular and femoral head fractures with clinico-radiological outcome and potential complications.

MATERIALS AND METHODS

We retrospectively reviewed 32 patients from January 2009 to June 2014. Selected displaced acetabular fractures with comminution and/or cranial extension of posterior wall, marginal impaction, intraarticular fragment, femoral head fractures and hip fracture-dislocations were operated by this modified approach of trochanteric flip osteotomy and surgical hip dislocation. Patients were evaluated for fracture reduction, femoral head viability, trochanteric union, abduction power, and functional evaluation was done by Merle d'Aubigné-Postel scoring system. Minimum follow-up was 24 months.

RESULTS

Reduction was judged to be anatomical in 84.38% of cases, and within 1-3 millimetres in 9.38% of cases. All osteotomies healed in an anatomical position. Heterotopic ossification was found in 2 patients limited to Brooker class I. Osteonecrosis developed in 1 patient. 2 patients developed arthritis of the hip as sequelae of poor reduction. Abduction power was MRC 5/5 in all except in 1 patient (4/5). Mean Merle d'Aubigné-Postel score was 16.18; overall good to excellent result was achieved in 87.5% of cases.

CONCLUSIONS

Trochanteric flip osteotomy with surgical dislocation allows better intraarticular assessment, control of intraarticular fragments, assists accurate reduction and the fixation of complex acetabular and femoral head fractures, without compromising femoral head vascularity and abductor strength. This technique has provided excellent midterm results in the management of complex injuries around the hip.

Arthroscopic Treatment of Traumatic Hip Dislocations in Children and Adolescents: A Preliminary Study

INTRODUCTION

Traumatic hip dislocations in children and adolescents require prompt concentric reduction. Incomplete reduction with or without retained osteochondral fragments has traditionally been addressed with open reduction. We report on the use of arthroscopy to remove loose bodies and reduce enfolded soft tissues to obtain concentric reduction in the pediatric and adolescent population. Specific note is made of underlying pathology and arthroscopic intervention.

METHODS

After obtaining Institutional Review Board approval, we performed a retrospective review of patients under the age of 19 who were treated with hip arthroscopy following hip dislocation reduction at a single children's hospital from 2006 to 2013. Clinic notes, operative reports, radiographic images, and arthroscopic photographs were reviewed.

RESULTS

Seven patients were identified (aged 8 to 17) who underwent hip arthroscopy after a posterior hip dislocation. Intra-articular bone fragments were found in 6 of 7 patients and 5 of 7 patients had an incongruent hip joint identified by imaging before surgery. The predominant pathology was avulsion of a small bony fragment attached to the posterior capsular labral soft-tissue complex, which became enfolded and blocked reduction (5 of 7 patients). In all cases, the enfolded soft tissue was reduced without soft tissue or bone repair. Additional loose osteochondral fragments were removed, and in 2 cases an avulsed ligamentum teres was debrided. Average follow-up was 10 months. No avascular necrosis or recurrent instability was identified in any case.

CONCLUSIONS

When incongruent hip joints were arthroscopically evaluated after traumatic dislocation, a consistent pattern of interposition of avulsed posterior bone fragment with attached capsule and labrum was found. Reduction of the capsulolabral complex without repair provided satisfactory short-term outcomes. Arthroscopic treatment of such cases was effective and well tolerated and could lead to considerably less postoperative pain and surgical morbidity than open surgical treatment.

LEVEL OF EVIDENCE

Level IV-case series.

Anterior greater trochanteric muscle pedicle bone grafting: a viable graft option adjunct to hip osteotomy or fracture surgery

INTRODUCTION

The objectives were to evaluate a technique, outcome and complications following anterior greater trochanteric with gluteus medius muscle pedicle bone graft (AMG) procedure in the treatment of adolescent and active adult hip disorders.

METHODS

20 patients (20 hips) with a mean age of 22.7 ± 15.6 (range 10.0-63.5) years who had undergone AMG and been followed up more than 12 months postoperative were retrospectively enrolled in our study. The AMG procedure was performed in conjunction with subcapital osteotomy for slipped capital femoral epiphysis in 12 and open reduction for fracture/dislocation in 8 hips. At the most recent evaluation, patient functional status was rated by the Harris Hip Score (HHS) and radiographic changes were graded according to Tönnis criteria. Complications were defined as Tönnis grade >2 or hip requiring further surgery. Univariate analysis was used to explore factors associated with complications. Spearman's rank correlation coefficient was calculated between HHS and Tönnis grading.

RESULTS

At mean follow-up of 4.4 ± 2.6 (range 1.1-9.5) years, mean HHS was 87.4. Tönnis grading was rated as 0 in 10 hips, 1 in 5 hips, 2 in 2 hips, and 3 in 3 hips. Avascular necrosis of the femoral head as a complication developed in 3 hips (15%). Clinical parameters including age at surgery, duration of follow-up and diagnosis were not significantly associated with postoperative complications. A negative correlation between HHS and Tönnis grade was shown by Spearman's rank correlation (rs = -0.49, p = 0.03).

CONCLUSIONS

The AMG can be safely recommended as an adjunct bone graft procedure when performing anterior open reduction of adolescent and active adult hip disorders.

Patients undergoing surgical hip dislocation for the treatment of acetabular fractures show favourable long-term outcome

Aims

The aims of this study were to determine the cumulative ten-year survivorship of hips treated for acetabular fractures using surgical hip dislocation and to identify factors predictive of an unfavourable outcome.

Patients and Methods

We followed up 60 consecutive patients (61 hips; mean age 36.3 years, standard deviation (sd) 15) who underwent open reduction and internal fixation for a displaced fracture of the acetabulum (24 posterior wall, 18 transverse and posterior wall, ten transverse, and nine others) with a mean follow-up of 12.4 years (sd 3).

Results

Clinical grading was assessed using the modified Merle d’Aubigné score. Radiographic osteoarthritis was graded according to Matta. Kaplan-Meier survivorship and a univariate Cox-regression analysis were carried out using the following endpoints: total hip arthroplasty, a Merle d’Aubigné score of < 15 and/or progression of osteoarthritis.

Conclusion

The ten-year cumulative survivorship was 82% (95% confidence interval 71 to 92). Predictors for the defined endpoints were femoral chondral lesions, marginal impaction, duration of surgery, and age of patient. Cite this article: Bone Joint J 2017;99-B:508–15.

Surgical hip dislocation through a direct lateral approach: A cadaveric study of vascular danger zones

OBJECTIVE

There is limited information on the potential danger to the vascularity of the femoral head during surgical dislocation of the hip using the direct lateral approach. The objective of this study was to investigate the topographical anatomy of the medial femoral circumflex artery (MFCA), the primary source of blood supply to the femoral head, in relationship to the direct lateral approach.

METHODS

Seven unembalmed cadaver hips had dye injection into either the profunda femoris artery or the MFCA. Surgical hip dislocation was then performed through a direct lateral approach, noting the danger zones to the MFCA branches during each step of the exposure.

RESULTS

None of the MFCA branches were found to cross the anterior surgical field superficial to the capsule. The deep (main) branch of the MFCA pierced the inferior capsule at the level of the lesser trochanter after emerging posterior to iliopsoas tendon. Ascending branches up the medial femoral neck were identified at this level. The deep branch then coursed posteriorly terminating in a variable number of vessels ascending the posterior femoral neck. Dislocation of the femoral head did not stretch or alter the course of the deep branch of the MFCA.

CONCLUSION

Safe surgical hip dislocation preserving the MFCA can be performed though a direct lateral approach as long as the inferomedial portion of the anterior capsule is preserved (main branch of the MFCA pierces the capsule at this level). Extracapsular injury is possible from inadvertent dissection at the level of the lesser trochanter or aggressive retraction on the iliopsoas. The posterior capsule should be left intact and instrumentation around the posterior neck should be avoided.