Can we predict femoral head vitality during surgical hip dislocation?

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.

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.

Modified Dunn procedure versus percutaneous pinning in moderate/severe stable slipped capital femoral epiphyses

BACKGROUND

The modified Dunn procedure (MDP) has risen enthusiasm in treating slipped capital femoral epiphyses (SCFE) due to the anatomic reduction and high patients' satisfaction rates at long-term follow-up. Main aim of this study is to compare clinical and radiographic outcomes of 2 cohorts with moderate to severe stable SCFE treated by MDP and in situ fixation.

METHODS

Medical records were analysed to collect demographic data, comorbidities and time from slip to surgery. The collected postoperative data were: avascular necrosis (AVN); complications; progression of osteoarthritis and subsequent procedures. Southwick angles (SA), alpha angles and Klein line were measured on the preoperative x-rays, on the immediate postoperative period and at the latest follow-up. Outcomes scores were recorded by the following questionnaires: the Harris Hip Score, the Hip disability and Osteoarthritis Outcome Score, the Merle d'Aubigné and Postel score and the Western Ontario and McMaster Universities Arthritis Index. Kaplan-Meier survivorship curve was calculated.

RESULTS

We compared 81 hips treated by MDP with 22 hips treated by in situ pinning (PS) for moderate/severe stable SCFE. No significant differences were found between the 2 groups in terms of age, BMI, comorbidities and preoperative slip angles. At the latest follow-up, postoperative anteroposterior mean slip angles were respectively 6.2 and 19.9° in MDP and PS group (p = 0.3). Slip angles in frog lateral view were 11° in the MDP group and 39.7° in the PS group (p = 0.2). MDP group achieved better correction angles on frog leg view (11° vs. 39.7°; p < 0.001). There was no statistically significant difference in the occurrence of AVN among both groups (19.7% MDP group vs. 31.8% PS group) (p = 0.2).

CONCLUSIONS

The MDP in treating severe stable SCFE showed the best deformities corrections in conjunction with the highest functional scores at long-term follow-up and similar rates of osteonecrosis compared to in situ fixation.

Necrose avascular pós-cirurgia de Dunn modificada no tratamento do escorregamento da epífise proximal do fêmur*

Objective  The present study analyzed the incidence of epiphyseal avascular necrosis in patients with slipped capital femoral epiphysis (SCFE) treated using a modified Dunn technique. In addition, this study determined the correlation of other variables with this incidence and described treatment complications.

Methods  This is a retrospective study with 20 patients treated by the same surgical team from 2009 to 2019 and followed up for 2 to 12 years. The analysis included general features, time from presentation to surgical procedure, classification, and intraoperative blood perfusion of the epiphysis, as well as complications and their treatment.

Results  All cases were severe; 65% were acute on chronic, and 55% of the SCFEs were unstable. Our complication rate was 45%, with 5 cases of avascular necrosis, 2 cases of deep infection, 1 case of material failure, and 1 case of joint instability. The statistical analysis revealed that the risk of necrosis was higher when the surgery occurred after a long hospitalization time and there was no intraoperative epiphyseal perfusion. Four necrosis cases happened within the first 5 years, and 1 case in the last 5 years of the study.

Conclusion  Our study showed that necrosis was the most common complication. It also revealed that surgery delay and lack of intraoperative epiphysis perfusion potentially predispose to avascular necrosis. Although with no statistical significance, coxofemoral instability occurred in chronic SCFE, and surgical fixation with threaded wires was less effective than fixation with a cannulated screw.

The modified Dunn procedure should be reserved for severe cases in which other techniques are not feasible and performed by an experienced, trained, and qualified team.

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.

Hip morphology in slipped capital femoral epiphysis

Several mechanical factors have been related to slipped capital femoral epiphysis (SCFE). Main aim of this study is to investigate the acetabular coverage and acetabular version in unilateral SCFE hips in order to detect a potential pincer-type deformity as predisposing factor; second, we compared those measurements either to the contralateral, uninvolved hips either to a matched healthy control population. A total of 85 patients treated for unilateral SCFE were retrospectively reviewed. The lateral center-edge angle (LCEA) and the Tönnis angle were used to assess acetabular coverage, whereas acetabular retroversion was defined by positive prominent ischial spine (PIS), cross-over sign (COS) and posterior wall sign (PWS). Angles and signs of the affected hips were compared to the contralateral hips and to a matched cohort undergoing an abdominal/pelvic computed tomography for nonorthopedic-related diseases. Affected and unaffected hips of patients with unilateral SCFE had similar morphology in terms of LCEA 28.7° vs. 28° (P = 0.4), Tönnis angle 9° vs. 9° (P = 0.1) and retroversion signs with concomitant rate of PWS and COS 57.6% vs. 50.5% (P = 0.4), PIS 56.4% vs. 49.4% (P = 0.4). Matched healthy controls vs. the affected hips showed a lower LCEA (P < 0.001) and higher Tönnis angle (P < 0.001) in conjunction with a lower incidence of acetabular retroversion: PWS and COS 40% vs. 57.6% (P = 0.01), PIS 43% vs. 56.4% (P = 0.07). A significant retroversion and increased overcoverage were observed in SCFE patients compared to matched healthy controls. In unilateral SCFE, the involved and uninvolved hips showed a substantial symmetry.

Intraoperative assessment of femoral head perfusion during surgical hip dislocation for slipped capital femoral epiphysis

Avascular necrosis is the most devastating complication of slipped capital femoral epiphysis, leading to collapse of the femoral head, increased risk of osteoarthritis and the requirement of early total hip arthroplasty. It is believed that intraoperative femoral head perfusion assessment may be an accurate predictor of post-operative avascular necrosis (radiographic collapse). At our institution, femoral head perfusion is assessed intraoperatively during all sub-capital realignment procedures. We hypothesize that our method is accurate in predicting the risk of developing post-operative avascular necrosis. In this retrospective study, we collected data from all patients that had intraoperative blood flow measurements during sub-capital realignment procedures. We correlated this with long-term radiographs looking for radiographic collapse. The intraoperative femoral head perfusion assessments during sub-capital realignment procedures for slipped capital femoral epiphysis at our institution, between January 2015 and March 2020 inclusive were assessed for reliability. In total, 26 of 35 patients had intraoperative femoral head perfusion present. Only 2 (8%) of these patients developed radiographic collapse. In contrast, 7 (78%) of the 9 patients who did not have femoral head perfusion present intraoperatively developed radiographic collapse, indicating that our method may be reliable in predicting a patient’s post-operative risk of developing avascular necrosis.

Femoral neck osteotomy in skeletally mature patients: surgical technique and midterm results

PURPOSE

Using an extended retinacular flap containing the blood supply for the femoral head, proximal femur osteotomies can be performed at the neck level increasing the potential of correction of complex morphologies. The aim of this study was to analyze the safety, clinical, and radiographic results of this intra-articular surgical technique performed in skeletally mature patients with a minimum follow-up of three years.

METHODS

Fourteen symptomatic adult patients (16 hips) with a mean age of 26 years underwent FNO using surgical hip dislocation and an extended soft tissue flap. Radiographs and radial magnetic resonance imaging (MRI) were obtained before and after surgery to evaluate articular congruency, cartilage damage, and morphologic parameters. Clinical functional evaluation was done using the Nonarthritic Hip Score (NAHS), the Hip Outcome Score (HOS), and the modified Harris Hip Score (mHHS).

RESULTS

After surgery, no avascular necrosis was observed, and all the osteotomies healed without complication. The initial neck/shaft angle (range 120 to 150°) improved in all cases to a mean value of 130° ± 4.6 (p < 0.001). In eight of nine valgus hips, the high-positioned fovea capitis changed to a normal position after surgery. The NAHS score improved from a mean of 36.5 ± 14.9 to 82.9 ± 13.9 points after surgery (p < 0.001). After surgery, the mean HOS was 87.1 ± 17.6 points, and the mean mHHS was 78.6 ± 17 points.

CONCLUSIONS

In this series, femoral neck osteotomy in the adult, although technically more demanding compared with other classic osteotomies, can be considered a safe procedure with considerable potential to correct hip deformities.

Treatment of type IV Pipkin fracture in patients with a high BMI via hip arthroscopy-assisted surgery: a case report

Pipkin type IV femoral head (FH) fracture-dislocations are usually treated via open surgery. There are many surgical approaches for the treatment of this difficult fracture depending on the fracture pattern. Obesity presents another challenging problem in surgical treatment and sometimes leads to a poorer outcome. We discuss herein a patient of a high body mass index (BMI) with a Pipkin type IV FH fracture who underwent open reduction internal fixation (ORIF) of anacetabular fracture with reconstruction plates and hip arthroscopy-assisted fixation of the FH fracture with two Herbert screws via the posterior approach. The intra-articular osteochondral loose bodies were excised by hip arthroscopy simultaneously. The joint congruency and screw positions were checked during surgery by arthroscopy. After 6 months, clinical and computed tomography (CT) follow-ups showed excellent results. The patient of a high BMI recovered immediately and had a satisfactory short-term outcome after hip arthroscopy-assisted surgery. We concluded that hip arthroscopy-assisted surgery is a viable option for the treatment of Pipkin type IV FH fracture-dislocations.

Treatment of Slipped Capital Femoral Epiphysis With the Modified Dunn Procedure: A Multicenter Study

INTRODUCTION

Treatment of moderate to severe slipped capital femoral epiphysis (SCFE) is controversial. Over the last years, 3 institutions in Argentina adopted the modified Dunn procedure for capital realignment in selected cases of SCFE. Our aim in this study was to evaluate the clinical outcome and the rate of complications of patients who had undergone surgical hip dislocation and capital realignment.

METHODS

A multicenter retrospective cohort study of patients who received the modified Dunn procedure from January 2009 to 2013 was performed. Data concerning clinical features, surgical technique, intraoperative findings, and postoperative complications were obtained from all available medical records. The operative results were evaluated on clinical and radiographic criteria.

RESULTS

Twenty patients (21 hips) with a mean of 40.4 months (range, 12 to 84 mo) of follow-up were evaluated. The average Harris Hip score was 76.3 points (range, 40 to 100 points). Seven patients had excellent results, 6 good, 2 fair, and 5 poor. Mean slip angle improved from a preoperative value of 59.1±11.2 degrees to 5.4±2.5 degrees (P=0.001). The mean postoperative alpha angle and neck-shaft angle were 40.8±2 degrees and 131±9.9 degrees, respectively. One patient had a superficial infection that was resolved with oral antibiotics. Six patients had complete osteonecrosis with severe involvement and 4 partial femoral head necrosis with minimal deformity. No patients developed chondrolysis, infection, deep venous thrombosis, heterotopic ossification, nonunion, or nerve palsies.

DISCUSSION

Modified Dunn procedure for treating hip SCFE is a technically demanding surgery with wide variations in the reported outcomes. Although in this series 65% of patients had good or excellent functional results, a high rate of complications was observed. This may be related, among other factors, to the learning curve of the procedure.

LEVEL OF EVIDENCE

Level IV-therapeutic study.

Joint Instability After Anatomic Reconstruction of Severe, Chronic Slipped Capital Femoral Epiphysis: A Report of 3 Cases, with High Femoral Anteversion in 1 and Adaptive Acetabular Roof Deformation in 3

CASES

Joint instability after slipped capital femoral epiphysis (SCFE) reorientation through the physis has been attributed to a combination of capsulotomy and chondrolabral rim damage. We report on 3 hips with severe SCFE with closed physes, in which anatomic correction with femoral neck osteotomy led to joint instability. All 3 had acetabular roof flattening; 1 showed slight additional acetabular retroversion but also increased femoral anteversion.

CONCLUSION

We speculate that the slight roof flattening in all 3 cases and/or the high femoral anteversion in 1 case had contributed to joint instability. Femoral derotation osteotomy was performed in 1 and periacetabular osteotomy was performed in 2 for joint restabilization.