Arthroscopic Fixation of Osteochondral Fracture of Head of Femur. Case Study

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.

The Effect of Humanized Nursing Intervention Guided by Computed Tomography Images on Elderly Patients Undergoing Anesthesia for Femur Intertrochanteric Fractures under Intelligent Reconstruction Algorithm

This research was aimed at analyzing the effect of humanized nursing intervention combined with computed tomography (CT) imaging in the surgical anesthesia of femur intertrochanteric fractures (FIF) in the elderly. An image reconstruction algorithm was proposed based on nonlocal mean (NLM) algorithm, which was named as ONLM, and its performance was analyzed. A total of 114 elderly patients with FIF were equally and randomly divided into a humanized nursing group (57 cases) and a routine nursing group (57 cases). They were performed with CT imaging scan based on the ONLM algorithm, and the clinical indicators of the two groups of patients were recorded. The root mean square error (RMSE) and mean absolute error (MAE) of the CT images constructed using the ONLM algorithm were significantly lower than those using NLM algorithm, edge filtering algorithm, and total variation model, while the peak signal-to-noise ratio (PSNR) was the opposite (P < 0.05). The operation time, hospitalization days, intraoperative blood loss, postoperative drainage, and anesthesia preparation time of patients in the humanized nursing group were significantly lower than those in the routine nursing group. The number of patients with excellent Harris scores in the humanized nursing group was higher than that in the routine nursing group, and the number of patients with poor Harris scores was lower (P < 0.05). The language pain score, facial pain score, and visual analog simulation (VAS) scores of patients in the humanized nursing group were significantly lower than those in the routine nursing group. The numbers of postoperative hip varus and fracture nonunion cases in the humanized nursing group were significantly more than those in the routine nursing group. In short, CT images constructed by the ONLM showed higher performance than those by the traditional algorithm. In addition, CT images constructed by ONLM combined with humanized nursing intervention could more effectively improve the cooperation of patients with surgical anesthesia, reduce surgical pain and fear of patients, improve the prognosis of patients, and lower the occurrence of adverse events.

Arthroscopy-Assisted Reduction and Fixation of Femoral Head and Acetabulum Fractures: A Systematic Review of the Literature

Objective

To perform a systematic review to determine the current arthroscopic techniques of the fixation of femoral head and acetabulum fractures and assess the radiological and functional outcomes reported in literature written in English.

Methods

This review was performed by searching PubMed, Cochrane Library, Scopus, and Web of Science without a filter for time limitation in line with Preferred Reporting Items for Systematic Reviews Protocols (PRISMA‐P) guidelines. Two authors took part in screening and evaluating the literature between December 2020 and January 2021. The terms acetabulum fracture, reduction, fixation, femur head fracture, fracture dislocation of the hip, hip trauma and arthroscopy or arthroscopic, and their combinations were used to search four database engines in the titles and abstracts of the reported papers. Only papers with English titles and abstracts were included. The assessment of the data related to descriptions of the techniques, indications for fracture fixation using arthroscopy, and patient‐related outcomes.

Results

Perfect agreement was detected between the two reviewers during all steps of the review process (κ = 0.81–1.00). Although a meta‐analysis was planned to be carried out, no randomized controlled study comparing either the radiological or functional results of different surgical techniques was detected in the literature. Nineteen studies were included in the study. Of these, 15 were retrospective case reports and four were case series. Twenty‐seven patients were operated on for acetabulum fractures (18 male/nine female). The mean age was 28.3 years (range, 15–53 years). High‐energy traumas including motor vehicle accidents were the most common reason (81%). The duration of follow‐up was a mean of 32 months (range, 12–68 months). Sixteen patients were operated on for femur fractures (12 male/three female). The mean age was 30.1 years (range, 17–50 years). Motor vehicle accident was the most common trauma (70%). Duration of follow‐up had a mean of 18 months (range, 4–60 months). Patient‐related outcomes were excellent for reported cases in both groups despite the fact that an objective scoring system was not used for most of the cases. Moreover, there was no consensus on surgical indications or the techniques.

Conclusions

The techniques of arthroscopic‐assisted fixation of acetabulum and femoral head fracture are so heterogeneous that conclusions cannot be made at this time, but there is potential for this method of treatment to become more popular as the devices used in the procedure develop and as exposure to and experience with hip arthroscopy improves. Further descriptions of reduction and fixation techniques and analysis of outcomes of RCTs are needed.