Minimally invasive medial hip approach

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.

Dislocation fracture of the femoral head in adult

The smaller the head fragment, the more likely it is located at the bottom and in front of the femoral head, which then determines the most suitable approach.

A CT scan is essential after reduction and before resumption of weight-bearing to verify the size and congruence of the fragments and whether there are foreign bodies and/or a fracture of the posterior wall.

Classifications should include the size of the fragment and whether or not there is an associated fracture of the acetabulum or femoral neck (historical ‘Pipkin’, modernised ‘Chiron’).

In an emergency, the dislocation should be rectified, without completing the fracture (sciatic nerve palsy should be diagnosed before reduction). A hip prosthesis may be indicated (age or associated cervical fracture).

Delayed orthopaedic treatment is sufficient if congruence is good. A displaced fragment can be resected (foreign bodies and ¼ head), reduced and osteosynthesised (⅓ and ½ head), and a posterior wall fracture reduced and osteosynthesised. Small fragments can be resected under arthroscopy. The approach is medial (Luddloff, Ferguson, Chiron) to remove or osteosynthesise ⅓ or ¼ fragments; posterior for ½ head or a fractured posterior wall.

The results remain quite good in case of resection or an adequately reduced fragment. Long-term osteoarthritis is common (32%) but well tolerated with a low rate of prosthetisation. Avascular necrosis remains a possible complication (8.2%). Sciatic nerve palsy (4% of fracture dislocations) is more common for dislocations associated with posterior wall fractures.

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

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

Minimally invasive medial hip approach for femoral head fixation: How much can we see and what is the anatomical at risk? - A cadaveric injection study

INTRODUCTION

Most Pipkin I and II femoral head fractures are treated with either an anterior or a posterior approach. A medial hip approach is commonly used in children, and some surgeons have suggested it for femoral head fixation. The objectives of this study were to identify the structures at risk with the medial hip approach and to demonstrate the areas of the femoral head exposed using this approach.

METHODS

The first part of this study involved vascular injection conducted in four fresh human cadavers using the medial hip approach. The surgical technique was described and the structures at risk, mainly arteries, were identified. The second part was done in 14 hips to identify and measured the maximum exposure area of the femoral head with the medial hip approach.

RESULTS

The structures at risk with the medial hip approach were the medial femoral circumflex artery (MFCA) after it branches from the deep femoral artery and runs posteromedially across the femoral neck medial to the iliopsoas tendon and the deep branch of the MFCA lies over the posterior hip capsule. The femoral head exposure area in anterior view with anteroinferior articular cartilage exposure was 4.57 ± 1.09 cm². In the medial view with the hip in internal rotation and in external rotation, the inferomedial articular cartilage exposure was 2.50 ± 1.52 cm² and 6.48 ± 2.29 cm², respectively, and the combined area of exposure was 9.49 ± 2.86 cm² . In the posterior view, the posteroinferior articular exposure was 1.69 ± 1.16 cm². The medial hip approach allowed visualization of the small area of the posteroinferior articular cartilage in all specimens. The percentages of visualization of the femoral head articular cartilage in anterior view, medial view and posterior view were 50.07% ± 13.53, 45.56% ± 12.76 and 18.07% ± 11.27%, respectively.

CONCLUSIONS

The structures at risk with the medial hip approach is the MFCA along the anterior acetabular rim and the deep branch on the posteromedial aspect of the femoral neck. It is an alternative which provides excellent access in Pipkin I and some part of Pipkin II, but it requires that the MFCA be protected by the use of meticulous surgical techniques.

Fixation of a fractured femoral head through a medial hip approach: an original approach to the femoral head

The decision to treat a femoral head fracture conservatively or surgically is the subject of ongoing debate. Several surgical approaches have been proposed for the open reduction and internal fixation of femoral head fractures. To our knowledge, fixation through a minimally invasive medial approach has not been described until now. The novel medial hip approach passes between the adductor muscle bellies posteriorly and their aponeuroses anteriorly. It provides direct access to the fracture site and allows for fixation by compression, without needing to dislocate the hip or detach the muscles. Any loose bodies in the joint that cannot be fixed can also be removed during the procedure. These features make the medial hip approach a clinically-relevant treatment option for the surgical management of femoral head fractures.