Minimally invasive femoral head fracture fixation using three-dimensional navigation: a technical note

Femoral head fractures are rare traumatic injuries that are usually associated with hip dislocations. Open reduction and internal fixation are performed when indicated, but can be associated with a higher risk of avascular necrosis. We report the case of a 24-year-old patient with a Pipkin type II fracture dislocation of the femoral head fixed via a minimally invasive three-dimensional navigated internal fixation technique. This technique minimizes deep soft tissue dissection to the hip capsule and associated vascularity and allows for accurate implant positioning.Level of evidence: Therapeutic case report Level IV.

Specific types of femoral head fractures: be alert for pre-, intra-, and post-operative ipsilateral femoral neck fractures following fracture-dislocation of the femoral head

PURPOSE

Ipsilateral femoral head and neck fractures (iFHNFs) are rare types of fractures that confer extremely poor prognosis among femoral head fractures (FHFs). Owing to the rarity of FHFs, it is challenging to diagnose iFHNFs. In addition, the clinical features of iFHNF have not yet been comprehensively elucidated. Therefore, this retrospective study aimed to summarize and analyze the clinical characteristics of iFHNF using a clinical diagnostic simulation based on a prospectively maintained database.

METHODS

Clinical data of consecutive patients with FHFs, including gender, age, injury side, and associated injuries, were collected and analyzed from a prospectively maintained orthopedic database at a large level-I trauma center for a clinical diagnostic simulation. Patients were stratified according to the presence or absence of iFHNF. Moreover, propensity score matching (PSM) was used to create 1:1 age- and gender-matched couples. Lastly, clinical factors were compared and identified between the two groups before and after matching.

RESULTS

A total of 218 FHF patients were included. Fifteen patients were diagnosed with ipsilateral femoral neck fractures (iFNFs), including preoperative, intraoperative, and postoperative types. There were 177 male and 41 female patients, with a mean age of 40.0 ± 16.5 years. The incidence of two factors, namely acetabular fracture and posterior hip dislocation, were significantly different between the two groups (P < 0.05). Following PSM, 15 pairs of patients were generated. Comparisons revealed that the incidence of posterior hip dislocation was significantly different between the two groups (P < 0.05).

CONCLUSIONS

There were three types of iFHNFs. In the context of FHFs, posterior hip dislocation was associated with iFNFs. Thus, surgeons should remain vigilant, not only intraoperatively but also postoperatively, for iFNFs following FHF and concomitant posterior hip dislocation.

LEVEL OF EVIDENCE

Diagnostic level IV.

Subchondral fatigue fracture of the femoral head with acetabular dysplasia treated by transposition osteotomy of the acetabulum: a case report

Introduction

Subchondral insufficiency fracture of the femoral head commonly occurs in older women with osteoporosis. However, subchondral fatigue fracture of the subchondral femoral head is rare. We present a rare case of fatigue fracture of the subchondral femoral head with acetabular dysplasia.

Case Report

The patient was a 16-year-old male, height 180 cm, weight 112 kg, and body mass index 34.6 kg/m2. Continuous right hip pain appeared after club activity of table tennis a month before admission to our department. Pain was observed on deep flexion of the right hip joint. The FADIR test was positive. X-ray images showed a depressed deformity of the right femoral head loading portion. In addition, the center-edge angle was 10° on the right and 21° on the left, tear drop distance was 12 mm on the right and 8 mm on the left, and bilateral acetabular dysplasia was noted. In magnetic resonance imaging, the T1-weighted image shows low-intensity signal and the T2-weighted image shows high-intensity signal, indicating a fatigue fracture of the femoral head with subchondral depression. Thus, transposition osteotomy of the acetabulum was performed in this case. Postoperatively, the depression portion showed gradual remodeling, and the patient returned to sports after 6 months. Because this patient was highly obese with acetabular dysplasia, a large shear force was applied to the loading portion of the femoral head relative to the acetabular rim. The femoral head was repeatedly forced, resulting in a fatigue fracture. We believe that the stress applied to the depressed portion was dispersed by the transposition osteotomy of the acetabulum, resulting in remodeling.

Conclusion

This is the first report of the transposition osteotomy of the acetabulum for a subchondral fatigue fracture of the femoral head with acetabular dysplasia. Thus, this may serve as a reference in the management of such rare occurrences and pave the way for further understanding of this condition.

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.

Comparison of Postoperative Complications Between Trochanter Flip Osteotomy and Kocher-Langenbeck Approaches for the Treatment of Femoral Head Fractures: A Systematic Review and Meta-analysis

Purpose

The study aims to identify the optimal approach for femoral head fracture (FHF) by comparing the postoperative complications and outcome score of the Kocher-Langenbeck posterior approach (KLP) and trochanteric flip osteotomy (TFO) through a systematic review and meta-analysis.

Methods

MEDLINE, Embase and the Cochrane Library were systematically searched for studies published up to 22 January 2023, which compared TFO to the KLP for FHF treatment. The main outcomes of this meta-analysis were the rate of postoperative complications including osteonecrosis of the femoral head (ONFH), heterotopic ossification (HO), and total hip replacement (THR) conversion rate and Thompson-Epstein (T-E) score at the final follow-up.

Results

We included four studies with 57 cases of FHFs; 27 and 30 patients underwent TFO and the KLP, respectively. Following the pooled analysis, HO incidence was significantly higher in TFO than in the KLP (OR = 4.03; 95% CI 1.10-14.81; P = 0.04; I 2 = 0%), but there were no differences in other variables, including the incidence of ONFH (OR = 0.41; 95% CI 0.07-2.35; P = 0.32; I 2 = 0%), THR conversion rate (OR = 0.82; 95% CI 0.16-4.29; P = 0.81; I 2 = 0%), and number of inferior results in the T-E score (OR = 0.49; 95% CI 0.14-1.73; P = 0.27; I 2 = 0%).

Conclusions

Amongst the posterior approaches for FHFs, the KLP and TFO did not present significant clinical and radiological differences; hence, the approach can be selected depending on the surgeon's experience and preference.

[Disastrous triad of femoral head:femoral neck fracture meeting fracture-dislocation of femoral head]

Femoral head and ipsilateral femoral neck fractures are serious and complicated injuries, which usually yield unsatisfactory results using conventional hip-preserving surgery. The key point of the management and prognosis mainly lies in femoral neck fractures. An apparent and consecutive relationship exists between femoral neck fractures and femoral head fracture-hip dislocation in such injuries. It is believed that disastrous triad of femoral head (DTFH) could summarize these specific injuries, and reflect the injury mechanism and prognostic characteristics. Based on our clinical observation and literature review, DTFH could be divided into three subgroups:TypeⅠ, common DTFH, in which femoral neck fractures occur following femoral head fractures-hip dislocation due to the same trauma; TypeⅡ, iatrogenic DTFH, in which femoral neck fractures come out in the caring process of femoral head fractures-hip dislocation; Type Ⅲ, stressed DTFH, in which femoral neck fractures occur after the management of femoral head fractures-hip dislocation. In the scenario, the line of femoral neck fractures locates distally to the femoral head fractures. Herein, we will discuss clinical characteristics of these types of DTFH.

A combination of the K-L and S-P approaches for treating acetabular posterior wall factures accompanied by femoral head fractures with open reduction and internal fixation

Background

In clinical practice, acetabular posterior wall fracture combined with femoral head fracture is rare. However, with the increasing number of engineering and traffic accidents, such fractures, have increased significantly in recent years. This paper aims to explore the clinical efficiency of the Kocher-Langenbeck (K-L) and Smith-Petersen (S-P) combined approaches for open reduction and internal fixation (ORIF) of acetabular posterior wall fractures accompanied by femoral head fractures (Pipkin type IV fractures).

Methods

A retrospective study was conducted on 8 patients who underwent open reduction and internal fixation (ORIF) of Pipkin type IV fractures through the K-L combined with S-P approach in our hospital from January 2015 to January 2020. All 8 patients were successfully operated on without serious complications, such as important blood vessel and nerve damage, with an operation time of 143.8 ± 44.38 min and intraoperative blood loss of 225 ± 70.71 ml. Perioperative data were recorded. The Harris score was used to evaluate the clinical effect. Fracture reduction quality was evaluated according to the Matta radiological standard. The grade of ectopic ossification was evaluated by the Brooker grading method, and the stage of femoral head necrosis was evaluated by Ficat-Arlet staging.

Results

The Harris score increased significantly from 57.38 ± 4.779 at 3 months, to 76.13 ± 3.682 at 6 months, 88.25 ± 3.495 at 12 months, and 92.13 ± 2.232 at 36 months postoperatively. After statistical analysis, compared with the previous observation time point, the data comparison differences between the groups were statistically significant. P < 0.001, P < 0.001, P < 0.05). By the time of the latest follow-up, 6 of the 8 patients had recovered to the level of pre-injury sports capacity. In contrast, the other 2 patients remained below the level of pre-injury sports capacity. In terms of imaging evaluation, the quality of fracture reduction on radiographs was graded as excellent in 6 patients and good in 2 patients according to Matta’s criteria. At the last follow-up, no heterotopic ossification or femoral head necrosis was found in of all the images. In addition, the hip joint space was normal in 6 cases, mildly narrowed in 1 case, and clearly narrowed in 1 case.

Conclusions

The K-L combined with S-P approach provides effective exposure for the reduction and fixation of Pipkin type IV fractures and achieves satisfactory clinical outcomes.

Supplementary information

The online version contains supplementary material available at 10.1186/s12893-022-01597-w.

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.

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.

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.

Femoral Head Fracture Without Associated Hip Dislocation

We present a rare case of femoral head indentation fracture without associated hip dislocation in an elderly female secondary to a low-energy trauma. She was managed with primary total hip arthroplasty and achieved an excellent functional outcome. We have proposed the mechanism of injury and discussed shortcomings in the present classification systems. A review of literature of such cases is presented along with the rationale for our management decision and the various other treatment modalities available for the surgeon.

Femoral head mosaicplasty by direct anterior approach for an osteochondral impaction without performing surgical hip dislocation

Several surgical methods exist for the treatment of osteochondral lesions of the femoral head. They include osteochondral allograft transfer, femoral osteotomy, microfracture, autologous chondrocyte implantation, and hip arthroplasty. Mosaicplasty is a surgical method in which cylindrical plugs of bone and cartilage are transferred from a donor site to tunnels drilled into the bone and cartilage defects. This paper discusses the use of mosaicplasty by a direct anterior approach without dislocation in the treatment of an acute femoral head osteochondral impaction in a young patient.

Open reduction and Herbert screw fixation of Pipkin type IV femoral head fracture in an adolescent: A case report

BACKGROUND

Femoral head fracture is extremely rare in children. This may be the youngest patient with femoral head fracture ever reported in the literature. There are few pediatric studies that focus on cases treated with open reduction via the modified Hardinge approach.

CASE SUMMARY

A 14-year-old female adolescent suffered a serious traffic accident when she was sitting on the back seat of a motorcycle. A pelvic radiograph and computed tomography revealed a proximal femoral fracture and slight acetabular rim fracture. This was diagnosed as a Pipkin type IV femoral head fracture. An open reduction and Herbert screw fixation was performed via a modified Hardinge approach. After 1-year follow-up, the patient could walk without aid and participate in physical activities. The X-ray results showed that the fractures healed well with no evidence of complications.

CONCLUSION

Open reduction and Herbert screw fixation is an available therapy to treat Pipkin type IV femoral head fractures in children.

Pipkin type IV femoral head fractures: a case series and review of literature. Eur J Orthop Surg Traumatol. 2021;31:791-795. [PMID: 33211232 DOI: 10.1007/s00590-020-02838-5]

INTRODUCTION

Femoral head fractures with associated acetabular fractures are uncommon injuries usually resulting from high-energy mechanisms such as motor vehicle collisions. Outcomes of Pipkin type IV fractures have been historically poor, with high rates of osteonecrosis, post-traumatic arthritis, and heterotopic ossification. The objective of this study was to define the outcomes of operatively treated Pipkin type IV fractures In addition, we reviewed the available literature of this uncommon injury pattern.

METHODS

A retrospective chart review at a single level 1 trauma center from 2007 to 2016 identified 10 patients with Pipkin IV femoral head fractures. Demographic information, fracture type, associated injuries, operative details, and complications were evaluated. Clinical and radiological outcomes were assessed at latest follow-up including conversion to total hip arthroplasty.

RESULTS

Six of the seven patients were treated with open reduction and internal fixation of the femoral head fracture and acetabular fracture through a Kocher-Langenbeck approach aided by a trochanteric flip and one had fragment excision. Six patients (87.5%) developed post-traumatic arthritis. Four (57.1%) later underwent conversion to total hip arthroplasty (THA) a mean of 20.5 months after index procedure.

CONCLUSION

Our study shows a rate of osteonecrosis and osteoarthritis that is even higher than the previously reported studies. The former may relate to longer-term follow-up and the latter possibly due to associated comminuted posterior wall fracture.

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.

Don't sugar coat the COVID (only the vasculature)

This issue of the Biomedical Journal acquaints us with the compelling hypothesis that the vascular glycocalyx lies at the intersection of severe COVID-19 risk factors and damages, and the ways used by artificial intelligence to predict interactions between SARS-CoV-2 and human proteins. Furthermore, we explore the antiviral potential of valinomycin and the long list of COVID-19-related clinical trials, and learn how (not) to fix a broken femoral head. Last but not least, we get to enjoy the tale of the cellular oxygen-sensing system as well as the role of the host complement system during Leptospira infection, and learn that SARS-CoV-2 can sometimes come with a pathogenic plus one.

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.

Traumatic hip fracture-dislocation: A middle-term follow up study and a proposal of new classification system of hip joint associated injury

Traumatic hip fracture dislocation is a rare injury associated with high-energy trauma. Most of these injuries should be surgically treated. Hip dislocation is an orthopaedic emergency and reduction must be performed within 6-8 hours of trauma. We performed a retrospective analysis of 69 patients with "hip joint associated injuries", treated between January 2002 and December 2016. 33 patients were assessed at a mean follow-up of 36.9 months (range 18-132) after surgery. We propose a new classification system in which, different patterns of fracture (head and/or neck and/or acetabular) are described according to different types of hip dislocation. This anatomical-descriptive classification system is based on the concept of hip as a complex anatomical district and contains all possible traumatic injuries associated with hip dislocation. It includes isolated hip dislocation, hip dislocation with femoral head or neck fracture or hip dislocation with acetabular fracture and femoral head fracture. There are 4 groups: Each one of the previous groups is composed by different subgroups. Post-traumatic osteoarthritis is the most common complication of these hip injuries, followed by avascular necrosis of femoral head and heterotopic ossification. The bad prognosis depends on the type of trauma rather than surgical treatment.

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.

[Modified Hueter direct anterior approach for treatment of Pipkin type and femoral head fractures]

Objective

To discuss the effectiveness of the modified Hueter direct anterior approach in treatment of Pipkin typeⅠ and Ⅱ femoral head fractures.

Methods

Between September 2014 and May 2016, 12 patients with Pipkin type Ⅰ and Ⅱ femoral head fractures were treated with the modified Hueter direct anterior approach. There were 8 males and 4 females, aged from 32 to 60 years (mean, 40.2 years). The disease causes included traffic accident injury in 9 cases and falling from height injury in 3 cases. According to Pipkin typing, 8 cases were rated as type Ⅰ and 4 cases as type Ⅱ. The interval of injury and admission was 2-28 hours (mean, 7.2 hours). Reduction was performed in all patients within 6 hours after admission, and then bone traction was given. The operation was performed in 3-7 days (mean, 4.3 days) after redution. The modified Hueter direct anterior approach was applied to expose and fix femoral head fractures by Herbert screws compressively. The operation time and intraoperative blood loss were recorded, and the effectiveness was evaluated according to the Thompson-Epstein scale at last follow-up.

Results

The operation time was 80-130 minutes (mean, 97.5 minutes), and the intraoperative blood loss was 100-200 mL (mean, 130.2 mL). All fractures achieved anatomical reduction and successful fixation. All 12 patients were followed up 12-32 months (mean, 24.3 months). All patients achieved bone union in 15-20 weeks (mean, 16.3 weeks) and no wound infection, lateral femoral cutaneous nerve injury, osteonecrosis of the femoral head, or heterotopic ossification occurred. Traumatic arthritis occured in 3 patients. According to the Thompson-Epstein scale at last follow-up, the results were excellent in 5 cases, good in 5 cases, fair in 2 cases, and the excellent and good rate was 83.3%.

Conclusion

The modified Hueter direct anterior approach has the advantages of clear anatomic structure, less trauma, and shorter operation time, and it can effectively expose and fix the Pipkin typeⅠ and Ⅱ femoral head fractures.

Asymmetric bilateral hip dislocations and unilateral femoral head fracture: A CASE report

Hip is a stabilized joint due to the surrounding ligaments, and muscles, which can dislocate as a result of high energy trauma, high-level falls, and motor vehicle accidents. Traumatic hip dislocations can either be isolated or simultaneously with acetabular and proximal femur fractures. At the same time injury of sciatic, femoral or obturator nerves can be seen. However, avascular necrosis of femoral head, posttraumatic osteoarthritis, and heterotopic ossifications can be seen as prolonged complications. The period prior to the reduction, severity of the trauma, and performing open or close reductions are the major contributors of the prognosis. As an extremely rare entity, bilateral asymmetrical hip dislocations are reported as the 0.01–0.02% of all joint dislocations. Accompanying proximal femoral fractures are pointed out 17%, one of them is femoral head fractures which are orthopedic emergencies that need to be fixed with surgery. However, high incidence of AVN is reported at the end of 2 years even if following early reductions. In our article, traumatic bilateral asymmetric hip dislocations and femoral head fracture is described in the context of a diagnosis, treatment and follow-up.

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

INTRODUCTION

In this study, we aimed to investigate safety and efficacy of the trochanteric flip osteotomy with surgical hip dislocation technique in selected displaced acetabular and femoral head fractures with clinico-radiological outcome and potential complications.

MATERIALS AND METHODS

We retrospectively reviewed 32 patients from January 2009 to June 2014. Selected displaced acetabular fractures with comminution and/or cranial extension of posterior wall, marginal impaction, intraarticular fragment, femoral head fractures and hip fracture-dislocations were operated by this modified approach of trochanteric flip osteotomy and surgical hip dislocation. Patients were evaluated for fracture reduction, femoral head viability, trochanteric union, abduction power, and functional evaluation was done by Merle d'Aubigné-Postel scoring system. Minimum follow-up was 24 months.

RESULTS

Reduction was judged to be anatomical in 84.38% of cases, and within 1-3 millimetres in 9.38% of cases. All osteotomies healed in an anatomical position. Heterotopic ossification was found in 2 patients limited to Brooker class I. Osteonecrosis developed in 1 patient. 2 patients developed arthritis of the hip as sequelae of poor reduction. Abduction power was MRC 5/5 in all except in 1 patient (4/5). Mean Merle d'Aubigné-Postel score was 16.18; overall good to excellent result was achieved in 87.5% of cases.

CONCLUSIONS

Trochanteric flip osteotomy with surgical dislocation allows better intraarticular assessment, control of intraarticular fragments, assists accurate reduction and the fixation of complex acetabular and femoral head fractures, without compromising femoral head vascularity and abductor strength. This technique has provided excellent midterm results in the management of complex injuries around the hip.

Hip arthroscopy enables classification and treatment of precollapse subchondral insufficiency fracture of the femoral head associated intra-articular pathology

PURPOSE

The purposes of this study were to investigate (1) the clinical, radiographic and arthroscopic presentation of patients with subchondral insufficiency fracture of the femoral head (SIFFH) and (2) the outcomes following arthroscopic treatment with internal fixation using hydroxyapatite poly-lactate acid (HA/PLLA) threaded pins and concomitant arthroscopic treatment of associated findings.

METHODS

Nine patients (median age 49.0 years, range 43-65, five female and four male patients) with SIFFH who underwent arthroscopic treatment with labral repair, capsular closure and internal fixation of SIFFH using HA/PLLA pins were retrospectively reviewed. Inclusion criteria were adult patients with precollapse SIFFH with minimum 1-year follow-up (median follow-up 30.0 months, range 12-56).

RESULTS

Acetabular labral tears were observed in all patients. The median BMI was 24.3 kg/m² (range 20.1-31.8). Clinical presentations and radiographic measurements demonstrated mixed type FAI in six patients, borderline developmental dysplasia in two patients and pincer type FAI in one patient. The median MHHS significantly improved from preoperatively (67.1, range 36.3-78.0) to post-operatively (96.8, range 82.5-100; p = 0.001). The median NAHS significantly improved from preoperatively (34.0, range 17-63) to post-operatively (78.0 range 61-80; p = 0.001).

CONCLUSION

SIFFH is associated with bony deformities and labral tears. Precollapse SIFFH can be treated with bioabsorbable pin stabilization of unstable lesions and treatment of associated intra-capsular pathology in those with stable lesions as determined by a new arthroscopic classification system with promising early outcomes.

LEVEL OF EVIDENCE

IV.

Use of the trochanteric flip osteotomy to facilitate internal fixation of a femoral head fracture

We report the case of a 42-year-old male who suffered a fracture–dislocation of the femoral head. After a closed reduction of the hip, this proceeded to an open reduction with internal fixation of the fractured femoral head, in addition to labral repair and micro-fracture of an articular cartilage defect. After considering the risks to the femoral head blood supply, the trochanteric flip osteotomy was used. This provided ample and safe exposure. At 14 months follow-up, the patient-reported outcome measures are favourable: modified Harris Hip Score (81/100), the non-arthritic hip score (92.5/100) and SF-12 (41/48).

Treatment of Hip Dislocations and Associated Injuries: Current State of Care

Hip dislocations, most often caused by motor vehicle accidents or similar high-energy trauma, traverse a large subset of distinct injury patterns. Understanding these patterns and their associated injuries allows surgeons to provide optimal care for these patients both in the early and late postinjury periods. Nonoperative care requires surgeons to understand the indications. Surgical care requires the surgeon to understand the benefits and limitations of several surgical approaches. This article presents the current understanding of hip dislocation treatment, focusing on anatomy, injury classifications, nonoperative and operative management, and postinjury care.

Anterior approach versus posterior approach for Pipkin I and II femoral head fractures: A systemic review and meta-analysis

PURPOSE

We performed a meta-analysis, pooling the results from controlled clinical trials to compare the efficiency of anterior and posterior surgical approaches to Pipkin I and II fractures of the femoral head.

METHODS

Potential academic articles were identified from the Cochrane Library, Medline (1966-2015.5), PubMed (1966-2015.5), Embase (1980-2015.5) and ScienceDirect (1966-2015.5) databases. Gray studies were identified from the references of the included literature. Pooling of the data was performed and analyzed by RevMan software, version 5.1.

RESULTS

Five case-control trials (CCTs) met the inclusion criteria. There were significant differences in the incidence of heterotopic ossification (HO) between the approaches, but no significant differences were found between the two groups regarding functional outcomes of the hip, general postoperative complications, osteonecrosis of the femoral head or post-traumatic arthritis.

CONCLUSION

The present meta-analysis indicated that the posterior approach decreased the risk of heterotopic ossification compared with the anterior approach for the treatment of Pipkin I and II femoral head fractures. No other complications were related to anterior and posterior approaches. Future high-quality randomized, controlled trials (RCTs) are needed to determine the optimal surgical approach and to predict other postoperative complications.

LEVEL OF EVIDENCE

III.

Mosaicplasty for the treatment of a large traumatic osteochondral femoral head lesion: a case report with 2 year follow-up and review of the literature

Different joint-preserving techniques have been described for the treatment of traumatic osteochondral lesions of the femoral head especially in young active patients. Mosaicplasty with autologous transplantation of osteochondral cylinders is an established surgical technique in the knee. Little evidence, however, exists for the treatment of osteochondral lesions in the hip using this technique. Here, we report on the result of treatment of a traumatic 5 cm(2) osteochondral lesion of the femoral head in a young patient treated with mosaicplasty. Grafts were taken from the ipsilateral knee. After 2 years, the outcome was satisfactory with partial return to previous activity level.

Femoral head reduction osteoplasty for fracture dislocation: A surgical technique

BACKGROUND

Femoral head fractures with subchondral impaction and cartilage loss are difficult to treat successfully. Although multiple surgical management options have been described, no one technique has proven superior, particularly in the young high-demand population.

TECHNIQUE

A femoral head reduction osteoplasty was performed following a surgical dislocation of the hip. A peripherally based wedge of bone was resected off the damaged central third of the head followed by reduction and fixation of the remaining fragments. This technique resulted in a smaller yet congruent femoral head.

METHODS

A healthy 40-year old labourer sustained a traumatic crush injury while at work, resulting in a left femoral head fracture dislocation with an associated posterior wall acetabular fracture. Significant femoral head impaction and cartilage loss limited the treatment options.

RESULTS

Intraoperative reduction and postoperative imaging demonstrated near anatomic reconstruction of femoral head with a congruent hip joint. Superiorly at the level of resection, the medial-lateral diameter was reduced by 5-6mm (approximately 12-15% the diameter of the original head) by the osteoplasty. At five years, Harris Hip Score was 86, Oxford Hip Score 36, and UCLA score 89. Hip abductor strength was full, range of motion near normal, and the patient ambulated without antalgia. Radiographs demonstrate a congruent joint and patchy avascular necrosis without collapse. The patient maintained full employment as a labourer.

CONCLUSIONS

Femoral head reduction osteoplasty is a viable option that may produce durable intermediate-term results for complex femoral head fracture with superior impaction and chondral damage.

LEVEL OF EVIDENCE

Level V.

Femoral head fracture without dislocation by low-energy trauma in a young adult

We describe the case of a healthy young man with a femoral head fracture by low-energy trauma that occurred without evidence of hip dislocation. While plain radiographs showed no definite fracture or dislocation, computed tomography (CT) and magnetic resonance imaging (MRI) revealed a femoral head fracture with a wedge-shaped cortical depression at the superomedial aspect of the femoral head. Our patient reported feeling that the right hip had been displaced from its joint for a moment. This probably represented subluxation with spontaneous relocation. The characteristic findings and possible mechanisms of this fracture were postulated on the basis of the sequential 3 dimensional-CT and MRI. The clinical results of conservative treatment were better than those of previously reported indentation fractures.

A polytrauma patient with an unusual posterior fracture-dislocation of the femoral head: a case report

We report a case of a 27-year-old man who was involved in a high-speed car accident. He sustained multiple organ damage including multiple brain petechiae suggesting diffuse axonal damage, aortic dissection, retroperitoneal haematoma and a fracture-dislocation of the right hip with a femoral head fracture and an ipsilateral intertrochanteric fracture. Due to the general condition of the patient, physiological stabilisation was prioritized, and at 2 weeks the fracture-dislocation of the hip was treated with a proximal femoral nail for the intertrochanteric fracture and Herbert screws for the femoral head fracture. Postoperatively, two episodes of recurrent hip dislocation occurred, and this was stabilized eventually with a Steinman pin inserted across the hip joint and taken out 1 month later. Weight-bearing was allowed according to clinical and radiographical assessments. Heterotopic ossification developed around the hip joint, but without evidence of AVN or osteoarthritis. At 18-months follow-up, the fractures had healed and the patient had a Harris Hip score of 79.1. Anatomical reduction and stable fixation of fracture-dislocations of the hip are important for achieving an acceptable result.