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

Surgical Outcomes of Total Hip Arthroplasty With Paavilainen Osteotomy in Patients Who Have High Developmental Hip Dislocation: Mean 4.4-Year Follow-Up

BACKGROUND

Although subtrochanteric osteotomy is a common procedure, the use of Paavilainen osteotomy combined with total hip arthroplasty (THA) for high developmental hip dislocation is less documented. This study assessed the efficacy and complications of this approach, with a particular focus on the risk factors for nonunion postosteotomy.

METHODS

All patients who had high dislocated hip dysplasia who underwent combined THA and Paavilainen osteotomy were retrospectively reviewed with over 1 year of follow-up. A total of 44 patients (51 hips) were included, with an average follow-up period of 4.4 years (range, 1.97 to 6.94). Anatomical data of the hip joints were measured on preoperative and postoperative radiographs. Demographic data, Trendelenburg sign, complications related to this procedure, Harris Hip Score, and EuroQoL-5-Dimension 5-Level health questionnaire were collected from the medical chart. Binary logistic regression analysis was used to identify predictors for bone nonunion.

RESULTS

Out of the 51 hips, eight displayed a positive Trendelenburg sign. Patients' Harris Hip Score saw an improvement from 43.8 ± 11.8 preoperatively to 85.7 ± 11.1 at the latest follow-up (P < 0.001), accompanied by a substantial enhancement in the average EuroQoL-5-Dimension 5-Level score from 0.38 ± 0.15 to 0.87 ± 0.13 (P < 0.001). Non-union, as the most concerning complication, occurred in 12% (seven of 56) of osteotomy cases. The contact length between the osteotomy block and femoral cortex was a key risk factor for nonunion. The receiver operating characteristic analysis identified 2.15 cm as the critical bone contact length for healing.

CONCLUSIONS

Paavilainen osteotomy combined with THA and subtrochanteric osteotomy proved effective and less complex than other techniques for high-dislocation hip dysplasia. A bone contact length between the greater trochanteric fragment and the femoral cortex of less than 2.15 cm is a risk factor for nonunion.

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.

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.

Traumatic Hip Dislocation: Pediatric and Adult Evaluation and Management

Traumatic hip dislocation of a native hip joint represents an orthopaedic emergency that should be treated promptly. Dislocations can be classified based on the associated injuries and the direction of dislocation. Expeditious evaluation, reduction, and management of associated injuries are required to optimize short and long-term function of the hip. There are several important differences between the blood supply and ossification of the pediatric hip that necessitate different strategies for the evaluation and management of traumatic hip dislocations in pediatric patients. Appropriate treatment is dictated by the direction and type of dislocation as well as associated injuries. In addition to closed reduction, arthroscopy, open reduction (potentially with fracture fixation and/or soft-tissue repair), osteotomy, and total hip arthroplasty all have roles in treatment. Consensus on optimal postreduction activity protocols after simple hip dislocation remain unestablished. Short and long-term outcomes are largely driven by the amount of time from injury to reduction and associated injuries.

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.

Midterm results of digastric trochanteric flip osteotomy for high acetabular posterior wall fracture

PURPOSE

Kocher-Langenbeck (K-L) approach is widely used in surgery of posterior wall fracture of acetabulum. However, challenges are frequently encountered in fractures involving the superior dome due to its short of view. We aimed to evaluate the efficacy of digastric trochanteric flip osteotomy (DTFO) in the K-L approach for high posterior wall acetabular fracture (HPWF).

METHODS

From January 2014 to December 2016, 39 patients who suffered high posterior wall fracture (HPWF) were included in this retrospective study. All the patients were divided into two groups according to surgery type (17 standard K-L approach (control group), 22 with DTFO (DTFO group)). The Matta criterion was used to evaluate the accuracy of reduction according to post-operative CT image, while modified Harris hip score and 12-item short-form health survey (SF-12) were applied to measure the clinical outcomes.

RESULTS

The median follow-up period was 55 (45 to 62.5) months. Blood loss and operation time were similar between the two groups. DTFO group achieved much more anatomical reduction than the control group (54.6% vs. 35.3%; OR, 2.2; 95% CI, 0.6 ~ 8.08). Significantly better functional outcomes were found in the DTFO group (10% higher points than the control group, p < 0.05). All the patients receiving good-to-anatomical reduction ended with good or excellent outcomes. The total incidence of complications in the DTFO group was much lower than in the control group (40.9% vs. 70.6%, p = 0.07).

CONCLUSIONS

Compared with the traditional K-L approach, the intraoperative DTFO technique enabled better quality of reduction in patients with HPWF, thus ensuring superior clinical outcomes.

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.

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.

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.

An unusual pattern of posterior wall fracture of acetabulum

BACKGROUND

This study aims to describe an uncommon presentation of posterior wall acetabular fracture-dislocation with displacement of fracture fragment anterior to femoral head with its management and clinico-radiological outcome.

METHODS

This retrospective review was performed at a Level I trauma centre over a period of six years. Hospital records, radiological database, operative register and follow-up data identified 7 patients with anteriorly lying posterior wall fragment of acetabulum. Analysis was performed with 6 patients having complete follow-up ranging from 2 to 7 years. The patients were operated with standard Kocher-Langenbeck approach; modification of this approach with trochanteric flip osteotomy and safe surgical dislocation was performed based on the location of the anteriorly lying fragment. Final functional and radiographic outcome was analysed according to modified Merle D'Aubigné and Postel score, and Matta's grade, respectively.

RESULTS

This uncommon presentation was observed in 11.11% of patients out of 63 patients with isolated posterior wall acetabular fractures managed during the study period. Anteriorly displaced posterior wall fragment was located in anterosuperior (n, 3), anterocentral (n, 2) and anteroinferior (n, 1) quadrants anterior to the femoral head. Final clinical and radiographic outcome revealed good-to-excellent outcome in 5 (83.33%) patients, and poor in one. One patient developed progressive arthrosis of hip which required total hip arthroplasty within 2 years.

CONCLUSION

This unusual pattern of posterior wall fracture requires adequate pre-operative planning, careful handling of the fractured fragments along with its soft tissue attachments during surgery, and preferably a concomitant trochanteric flip osteotomy with/without surgical hip dislocation to achieve good results.

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.

Trochanteric osteotomy for acetabular fracture fixation: a case series and literature review

PURPOSE

This study examined osteotomy union and heterotopic ossification (HO) after performing digastric trochanteric osteotomies during open reduction and internal fixation (ORIF) of acetabular and combined femoral head fractures. Femoral head osteonecrosis and trochanteric screw removal were secondarily assessed.

METHODS

Twenty-six patients treated at a Level I trauma center, from years 2003 to 2019, who received a digastric trochanteric osteotomy during acetabular and combined femoral head fracture ORIF through a posterior surgical approach were retrospectively identified. Osteotomies were fixed with two 3.5 mm cortical lag screws. Rates of osteotomy union, HO, femoral head osteonecrosis, and trochanteric screw removal were determined.

RESULTS

All osteotomies went onto union without displacement or failure of fixation. Only three (12%) patients developed severe HO (modified-Brooker class III-IV). There were no instances of femoral head osteonecrosis and only one (7%) patient required trochanteric screw removal.

CONCLUSIONS

The digastric trochanteric osteotomy heals reliably with low rates of severe HO, femoral head osteonecrosis, and screw removal for soft-tissue irritation. A review of the literature is presented and found comparable findings.