Operative versus nonoperative management of Pipkin type-II fractures associated with posterior hip dislocation

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.

Intermediate to Long-Term Results Following Traumatic Hip Dislocation: Characteristics, CT-Based Analysis, and Patient-Reported Outcome Measures

BACKGROUND

Traumatic hip dislocation is a rare yet severe injury. As the long-term morbidity, subsequent complications, and clinical outcomes are nearly unknown, we aimed to analyze traumatic hip dislocations and identify specific factors that may predict the clinical outcome.

METHODS

Data on injury-related characteristics and computed tomographic (CT) scans for all consecutive adult patients who had been managed for traumatic hip dislocation between 2009 and 2021 were analyzed. At the time of follow-up, the patients were assessed with regard to osteonecrosis, posttraumatic osteoarthritis (OA), further operations and complications, return to sports and work, and patient-reported outcome measures (PROMs), including the Tegner Activity Scale and modified Harris hip score.

RESULTS

One hundred and twelve patients (mean age [and standard deviation], 43.12 ± 16.6 years) were included. Associated acetabular rim and femoral head fractures (Pipkin Type I to IV) were observed in 44% and 40% of patients, respectively. Concomitant injuries occurred in 67% of the patients, most commonly involving the knee (29% of patients). Sixty-nine patients (61.6%) were available for follow-up; the mean duration of follow-up was 6.02 ± 3.76 years. The rates of osteonecrosis and posttraumatic OA were 13% and 31.9%, respectively, and were independent of the timing of hip reduction, leading to subsequent total hip arthroplasty (THA) in 19% of patients. Sciatic nerve injury occurred in 27.5% of the patients who were available for follow-up. Both THA and sciatic nerve injury were associated with posterior acetabular rim or Pipkin Type-IV fractures (p < 0.001). Only 33.3% of the patients returned to their pre-injury level of sports, 24.6% did not return to work, and 27.5% reported having sexual dysfunction. PROMs (Tegner Activity Scale, modified Harris hip score) were significantly worse in patients with osteonecrosis, posttraumatic OA, or residual sciatic nerve injury (p < 0.05).

CONCLUSIONS

Traumatic hip dislocations are predominantly associated with Pipkin and acetabular rim fractures, leading to overall limitations of activities of daily living, sports, and sexual function at intermediate to long-term follow-up. Patients with associated acetabular rim or Pipkin Type-IV fractures are most likely to require THA for the treatment of osteonecrosis or posttraumatic OA and are at greater risk for sustaining sciatic nerve injury.

LEVEL OF EVIDENCE

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

Pipkin Type I and II femoral head fractures: internal fixation or excision?-from the hip arthroscopy perspective

The treatment of patients with femoral head fractures with regard to fixation versus excision is controversial. This study aimed to compare the results of fixation and excision in hip arthroscopy-assisted surgery. This retrospective study included adult patients with femoral head fractures who were treated with hip arthroscopy surgery from March 2016 to April 2020, with a minimum follow-up of 24 months. The patients were divided into two groups: Group 1 (fixation group) and Group 2 (excision group). To compare the therapeutic effects between the two groups, clinical and radiographic outcomes, operative time, pain score, length of hospital stay after surgery and related complications were investigated. There were 13 (mean duration, 47.5 months; range, 24-72 months) and 8 (mean duration, 48.6 months; range, 26-74 months) patients in the fixation and excision groups, respectively. The excision group had better functional results than the fixation group in terms of the median modified Harris hip score (P = 0.009). No significant differences were observed in operative time, pain score or hospital stay after surgery between the two groups. Further, no osteonecrosis of the femoral head or traumatic arthritis occurred in either group. A piece of fracture fragment >2 cm can be considered for hip arthroscopy-assisted internal fixation, whereas the others can be removed. The excision group had better outcomes than the fixation group. Hence, hip arthroscopy-assisted internal fixation or excision of bony fragments led to satisfactory short-term clinical and radiological results for the treatment of Pipkin Type I and II femoral head fractures.

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.

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

Articular Femoral Head Fracture Management: A Meta-analysis of Literature

PURPOSE

Articular fractures of the proximal femur are seldom encountered and there are few studies in literature regarding this topic. To date, only a few large series have adequate follow-up and exhaustive description of treatment and outcome, which, however, often result incomplete and do not allow a comparison. Since there are still uncertainties and debates on which the treatment gold standard should be, the goal of the present study is to carry out a meta-analysis on type I and II Pipkin fracture management to establish the best treatment according to EBM.

METHODS

Studies regarding acetabular fractures of the femur head were identified from Google Scholar, Cochrane Library, Medline, ScienceDirect and PubMed; gray studies were searched from the included references' literature, and using general search engines and Social media; the query to be temporally extended from 1996 to 2020. Only comparative studies were included; we ruled out case-reports, case series, author's opinion, register databases.

RESULTS

Comparing conservative and surgical treatment, we found evidence of a better outcome choosing surgical treatment. We found a significant better outcome with open reduction internal fixation, instead of fragment excision. Comparing failure rate of surgical approaches, we found no statistically significant difference.

CONCLUSION

Our study proves that there is evidence in favor of operative treatment rather than conservative in complete or displaced Pipkin fracture Type I + II; open reduction internal fixation should be preferred rather than fragment excision, whenever possible.

LEVEL OF EVIDENCE

III. Therapeutic.

Failed reduction of posterior hip dislocation accompanied by femoral head fracture: causes and resolving strategy

BACKGROUND

We investigated the causes of failure of the Allis manoeuvre for posterior hip dislocations with an associated Pipkin type I femoral head fractures. The effectiveness of a modified Allis manoeuvre was also evaluated.

METHODS

From January 2013 to December 2016, we enrolled five patients with a posterior hip dislocation associated by a Pipkin type I femoral head fracture who were treated initially with the Allis manoeuvre that subsequently failed. Radiographic evaluations were performed to determine the cause of failure, and then a modified Allis manoeuvre was performed. During this procedure, the hip and knee joints of the injured lower limb were both flexed to 90°, and the leg was pulled posteriorly following an upward force to reduce the dislocation. Reduction was assessed by radiographic evaluation.

RESULTS

In all patients, the fractured femoral head was incarcerated on the superior edge of the posterior rim of the acetabulum, resulting in failure of the conventional Allis manoeuvre. Satisfactory reduction was achieved with a modified Allis manoeuvre. The mean follow-up duration was 31 months. The femoral head fracture healed after four months on average. The mean Harris score was 91 at the final follow-up. Re-dislocation or femoral head necrosis was not observed.

CONCLUSIONS

For posterior hip dislocations associated with a Pipkin type I femoral head fracture, failed reduction is often caused by incarceration of the fractured femoral head on the superior edge of the posterior rim of the acetabulum. The modified Allis manoeuvre can effectively reduce the combined injury in a closed fashion.

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.

Surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms

BACKGROUND

A comprehensive overview of treatments of common fractures is missing, although it would be important for shared decision-making in clinical practice. The aim was to determine benefits and harms of surgical compared to non-surgical treatments for traumatic skeletal fractures.

METHODS

We searched Medline, Embase, CINAHL, Web of Science, and CENTRAL until November 2018, for randomized trials of surgical treatment in comparison with or in addition to non-surgical treatment of fractures in adults. For harms, only trials with patient enrollment in 2000 or later were included, while no time restriction was applied to benefits. Two reviewers independently assessed studies for inclusion, extracted data from full-text trials, and performed risk of bias assessment. Outcomes were self-reported pain, function, and quality of life, and serious adverse events (SAEs). Random effects model (Hedges' g) was used.

RESULTS

Out of 28375 records screened, we included 61 trials and performed meta-analysis on 12 fracture types in 11 sites: calcaneus, clavicula, femur, humerus, malleolus, metacarpus, metatarsus, radius, rib, scaphoideum, and thoraco-lumbar spine. Seven other fracture types only had one trial available. For distal radius fractures, the standardized mean difference (SMD) was 0.31 (95% CI 0.10 to 0.53, n = 378 participants) for function, favoring surgery, however, with greater risk of SAEs (RR = 3.10 (1.42 to 6.77), n = 436). For displaced intra-articular calcaneus fractures, SMD was 0.64 (0.13 to 1.16) for function (n = 244) and 0.19 (0.01 to 0.36) for quality of life (n = 506) favoring surgery. Surgery was associated with a smaller risk of SAE than non-surgical treatment for displaced midshaft clavicular fractures (RR = 0.62 (0.42 to 0.92), n = 1394). None of the other comparisons showed statistical significance differences and insufficient data existed for most of the common fracture types.

CONCLUSIONS

Of 12 fracture types with more than one trial, only two demonstrated a difference in favor of surgery (distal radius fractures and displaced intra-articular calcaneus fractures), one of which demonstrated a greater risk of harms in the surgical group (distal radius fractures). Our results highlight the current paucity of high-quality randomized trials for common fracture types and a considerable heterogeneity and risk of bias in several of the available trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015020805.

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 .

Clinical and Radiographic Outcomes of Femoral Head Fractures Associated with Traumatic Hip Dislocations

Background

Femoral head fractures are an uncommon but severe injury. These high-energy injuries typically occur in association with traumatic hip dislocations. Initial treatment includes urgent concentric reduction; however, controversy exists regarding specific fracture management. The well-known complications of avascular necrosis (AVN), posttraumatic arthritis (PTA), and heterotrophic ossification can leave patients with a significant functional loss of their affected hip. The purpose of this study is to evaluate the clinical and radiographic outcomes of femoral head fractures.

Methods

A retrospective review was performed at our institution assessing all patients who presented from 2007 to 2015 with a femoral head fracture associated with a hip dislocation and at least 6 months of clinical and radiographic follow-up. Twenty-two patients met our inclusion criteria. There were 15 males and 7 females with an average age of 36 years (range: 17-55). The average follow-up time was 18 months (range: 6-102). Fractures were classified according to the Pipkin classification. The Thompson and Epstein score was used to determine functional outcomes.

Results

There were five, Pipkin I, 3 Pipkin II, 0 Pipkin III, and 14 Pipkin IV, femoral head fractures. Sixteen patients were successfully closed reduced in the emergency department (ED) and six patients required open reduction after failed reduction in the ED. Four patients (18%) were successfully treated with closed reduction alone and 18 patients (82%) required operative intervention. Of those undergoing operative intervention, one patient underwent excision of the femoral head fragment, seven underwent open reduction internal fixation (ORIF) of the femoral head, nine underwent ORIF of the acetabulum, and one underwent ORIF of the femoral head and the acetabulum. Nine patients (41%) had an uneventful postoperative course. Two patients (9%) developed AVN, both requiring total hip arthroplasty (THA). Five patients (23%) developed PTA, two eventually requiring a THA. Two patients (9%) had sciatic nerve palsy. One patient (5%) developed a postoperative infection and four patients (18%) developed heterotrophic ossification (HO), none requiring operative treatment. Two patients (9%) had persistent anterolateral (AL) thigh numbness. Overall functional results were excellent in six patients (27%), good in six (27%), fair in seven (32%), and poor in three patients (14%). Four patients (18%) required a THA.

Conclusion

Femoral head fractures are a rare injury with well-known complications. Early diagnosis and concentric reduction are the prerequisites for successful treatment. This study adds to the growing literature on femoral head fractures associated with hip dislocations in efforts to define treatment plans and to guide patient expectations.

How to cite this article

Del Core MA, Gross B, Ahn J, et al. Clinical and Radiographic Outcomes of Femoral Head Fractures Associated with Traumatic Hip Dislocations. Strategies Trauma Limb Reconstr 2019;14(1):6-10.

Middle-term follow-up results of Pipkin type IV femoral head fracture patients treated by reconstruction plate and bioabsorbable screws

PURPOSE

To investigate the mid-term curative effects of the treatment of Pipkin type IV femoral head fractures using a reconstruction plate and bioabsorbable screws and provide the evidence for clinical practice.

METHODS

From February 2010 to September 2014, 21 patients with Pipkin type IV femoral head fractures were treated surgically. There were 13 males and 8 females with an average age of 41.1 years (range, 20-65 years). The causes of the fractures included traffic accidents (13 cases), falls from a height (four cases), heavy lifting injuries (three cases), and sport injury (one case). All patients were followed up with radiography and three-dimensional reconstruction computed tomography and other checks and any complications were actively managed. Closed reduction of fracture-dislocation of the hip was attempted under general anesthesia using the Kocher-Langenbeck approach. Femoral head fractures were treated with internal fixation or excision based on the size of the fracture fragments, whereas acetabular fractures were fixed with a reconstruction plate and screws following anatomic reduction.

RESULTS

The incisions healed by primary intention in all patients after surgery, without any infection, deep venous thrombosis, or other complications. All 21 patients were followed up for 36-76 months, with an average follow-up duration of 49 months. Postoperative imaging data showed that all dislocations and fractures were anatomically reduced, and bony union of the fractures was achieved. Heterotopic ossification was found in four patients, post-traumatic osteoarthritis in three, and avascular necrosis of the femoral head in two. At the final follow-up, the assessment of hip joint function according to the Thompson-Epstein scoring scale was excellent in 10 cases, good in six cases, fair in three cases, and poor in two cases. The rate of excellent and good functional outcomes was 76.1%.

CONCLUSION

The mid-term curative effects of a reconstruction plate and bioabsorbable screws in the treatment of Pipkin type IV femoral head fractures is significant, and such the treatment can significantly improve the patient's joint function and quality of life.

Clinical results of femoral head fracture-dislocation treated according to the Pipkin classification

Objective:

To summarize the clinical results of femoral head fracture-dislocation treated according to Pipkin classification.

Methods:

Atotal of 19 patients with femoral head fracture-dislocation were retrospectively analyzed from Mar. 2008 to Mar. 2015. According to the classification of Pipkin criteria, there were 4 cases in Type-I, 6 cases in Type-II, 6 cases in Type-IIIand 3 cases in Type-IV. Various procedures were taken according to the different types of the fracture, the time of the fracture, and the age of the patients. X-ray was examined during the follow-up period and functional evaluation was carried out by Harris Hip Score’s criteria. The clinical therapeutic effects were analyzed.

Results:

All the patientsgot a mean follow-up of 18 months (9-36 months). No patient suffered from infection, skin flap necrosis and X-ray showed no implants loosening or breakage. According to the Harris Hip Score’s criteria, in Type-I, 4 cases were rated as excellent. In Type-II, 2 cases rated as excellent, 3 cases as good and 1 case as fair. In Type-III, 3 cases rated as good, 2 cases as fair and 1 case as poor. In Type-IV, 1 case rated as excellent, 1 case as good and 1 case as fair. The overall rate of excellent and good was 73.7%.

Conclusions:

Pipkin classification is helpful to make preoperative plan and judging the prognosis in cases of femoral head fracture-dislocation. However, multiple factors such as the time from injury to surgery, the ages of patients, the selection of implants should also be considered, which may affect the clinical results.

Management and radiographic outcomes of femoral head fractures

Background

Femoral head fractures are uncommon injuries. Small series constitute the majority of the available literature. Surgical approach and fracture management is variable. The purpose of this study was to evaluate the incidence, method of treatment, and outcomes of consecutive femoral head fractures at a regional academic Level I trauma center.

Materials and methods

A retrospective review of a prospective database was performed over a 13-year period. All AO/OTA 31C femoral head fractures were identified. A surgical approach and fixation method was recorded. Clinical and radiographic evaluation was performed for patients with 6 months or greater follow-up. Radiographs were evaluated for fixation failure, heterotopic ossification (HO), avascular necrosis (AVN) and post-traumatic arthritis.

Results

We identified 164 fractures in 163 patients; 147 fractures were available for review. Treatment was operative reduction and internal fixation (ORIF) in 78 (53.1%), fragment excision in 37 (25.1%) and non-operative in 28 (19%). An anterior approach and mini-fragment screws were used in the majority of patients treated with fixation. Sixty-nine fractures had follow-up greater than 6 months. Sixty-two fractures (89.9%) proceeded to uneventful union. All Pipkin III fractures failed operative fixation. Six patients developed AVN, seven patients had a known conversion to hip arthroplasty; HO developed in 28 (40.6%) patients and rarely required excision.

Conclusions

Fractures of the femoral head are rare. An anterior approach can be used for fragment excision or fixation using mini-fragment screws. Pipkin III fractures represent catastrophic injuries. Non-bridging, asymptomatic HO is common. AVN and posttraumatic degenerative disease of the hip occur but are uncommon.

Level of evidence

IV—prognostic.

Femoral Varus Osteotomy for Hip Instability after Traumatic Fracture Dislocations of the Hip Associated with Femoral Head Fractures: A Report of Two Cases

Fracture of the femoral head and the acetabulum with traumatic dislocation of the hip is a severe injury representing various types and unfavorable outcome. We showed a 45-year-old man with Pipkin type-IV fracture and coxa valga. An immediate closed reduction was achieved followed by open reduction and internal fixation via a posterior approach 6 days later. However, dislocation occurred three times without traumatic events after three weeks. CT demonstrated no displacement of posterior fragments or implant failure. Femoral intertrochanteric varus osteotomy was performed to gain concentric stability and successfully resolved recurrent dislocation. Another 45-year-old woman with Pipkin type-IV fracture and coxa valga also underwent closed reduction initially and then continued conservative treatment. After eight weeks, when she started gait training, progressive pain became symptomatic. Persistent hip pain at weight bearing was not improved in spite of arthroscopic synovectomy and osteochondroplasty. Two years after injury, femoral intertrochanteric varus osteotomy was indicated and her refractory pain was resolved gradually. We suggest that femoral varus osteotomy should be considered for superolateral subluxation associated fracture dislocation of the hip in Pipkin type-IV and coxa valga.

[Complications after osteosynthesis of the proximal femur]

BACKGROUND

Fractures of the proximal femur are among the most common fractures of all bones. Currently nearly every trauma surgeon has to be able to treat proximal femur fractures either with osteosynthesis or with a prosthesis. An increase of 200-300 % of fractures of the proximal femur is expected within the next 30 years. In addition an increase of periprosthetic fractures of the proximal and distal femur can be observed. The correct treatment of these complications is a challenging objective for the trauma surgeon.

OBJECTIVES

This article provides an overview on complications after osteosynthesis of the proximal femur. It contributes treatment options depending on the implant, the patient specific risk factors and the special problems of postoperative care.

METHODS

A selective review of the literature using Pubmed under consideration of experiences gained in the treatment of complications after osteosynthesis of the proximal femur was performed.

CONCLUSIONS

Due to the increasing incidence of fractures of the proximal femur on the one hand and complications after operative treatment of these fractures on the other, the trauma surgeon must provide differentiated therapy concepts depending on the individual risk factors of different patients. Moreover, trauma surgeons must know how to treat the potential complications of these procedures.