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Zuelzer DA, Ryan L, Mayer R, Pease T, Warner S, Eastman J, Wright RD, Routt MLC. Using an Intraoperative Stress Examination to Direct Treatment in Posterior Femoral Head Fracture-Dislocations. J Orthop Trauma 2024; 38:641-647. [PMID: 39213419 DOI: 10.1097/bot.0000000000002912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To examine the results of a treatment algorithm incorporating an examination under anesthesia (EUA) performed intraoperatively after fixation of the femoral head through a Smith-Petersen approach to determine the need for posterior wall or capsule repair. METHODS DESIGN Retrospective review. SETTING Two Level 1 trauma centers. PATIENT SELECTION CRITERIA All acute, traumatic femoral head fractures from posterior hip dislocations treated at participating centers over a 5-year period from 2017 to 2022. Injuries were classified according to the Pipkin system. OUTCOME MEASURES AND COMPARISONS The primary outcome was the result of intraoperative EUA performed after femoral head fixation to determine the need for Kocher-Langenbeck exposure for posterior wall and/or capsule fixation. The secondary outcomes included rates of avascular necrosis, heterotopic bone formation, late instability, and conversion to total hip arthroplasty (THA). RESULTS In total, 63 men and 22 women with a mean age of 32.5 (range 18-71) years were studied. Seventy-nine of 85 (92.9%) patients had a stable EUA after fixation of the femoral head through a Smith-Petersen approach. Six (6/85, 7.1%) underwent an additional Kocher-Langenbeck approach for posterior wall or capsule fixation. This included 1 Pipkin I, 1 Pipkin II, and 4 Pipkin IV injuries. Of the Pipkin IV injuries, 51/55 (92.7%) had stable EUA and did not require fixation of their posterior wall. This included seven patients with wall involvement >20%. Five patients were excluded because of planned fixation of their posterior wall based on preoperative imaging. Of patients with at least 6 months follow-up, 16 of 65 (26.4%) developed radiographic evidence of avascular necrosis and 21 of 65 (32.3%) evidence of heterotopic bone formation. Seven out of 65 (10.8%) were converted to THA over the study period. When comparing patients with a single exposure and those with additional KL exposure, it was found that they did not vary in their rate of avascular necrosis (27.1% vs. 0.0%, P = 0.3228), heterotopic ossification formation (30.5% vs. 50.0%, P = 0.3788), or conversion to THA (10.2% vs. 16.7%, P = 0.510). CONCLUSIONS This study found residual posterior hip instability after femoral head fixation in patients with and without posterior wall fractures after posterior dislocations. The results of this study support the use of an EUA after femoral head fixation to identify residual posterior hip instability in all femoral head fractures from posterior hip dislocations, regardless of Pipkin type. Use of the Smith-Petersen exposure remains a viable surgical option and may be improved with the incorporation of an EUA after femoral head fixation. For Pipkin IV injuries with posterior wall fractures with indeterminate stability, an EUA accurately identifies residual instability. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- David A Zuelzer
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky School of Medicine, Lexington, KY; and
| | - Lunden Ryan
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky School of Medicine, Lexington, KY; and
| | - Ryan Mayer
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Tyler Pease
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky School of Medicine, Lexington, KY; and
| | - Stephen Warner
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Jon Eastman
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Raymond D Wright
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky School of Medicine, Lexington, KY; and
| | - Milton L C Routt
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX
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Schaffer NE, Luther L, Tatman LM, Mitchell PM. Femoral Head Fractures: Evaluation, Management, and Outcomes. J Am Acad Orthop Surg 2024; 32:929-937. [PMID: 38968607 DOI: 10.5435/jaaos-d-23-01121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 05/18/2024] [Indexed: 07/07/2024] Open
Abstract
Fractures of the femoral head typically occur after high-energy trauma. Radiographs and cross-sectional imaging are used to appropriately classify and identify associated injuries or morphologic characteristics that may influence management. Identification of the radiographic and clinical hallmarks of an irreducible variant is critical to optimizing the patient's outcome. Nonsurgical treatment can be used in the setting of small, infrafoveal femoral head fractures without hip instability. When surgical treatment is indicated, an anterior (Smith-Petersen), posterior (Kocher-Langenbeck), or surgical hip dislocation approach may be used depending on injury details and surgeon preference. The purpose of this review was to summarize current evidence on femoral head fractures regarding indications, variant patterns, surgical approaches, and outcomes.
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Affiliation(s)
- Nathaniel E Schaffer
- From the Western Washington Medical Group, Everett, WA (Schaffer), and the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN (Luther, Tatman, and Mitchell)
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Gänsslen A, Lindtner RA, Krappinger D, Franke J. Pipkin fractures: fracture type-specific management. Arch Orthop Trauma Surg 2024; 144:4601-4614. [PMID: 39349876 DOI: 10.1007/s00402-024-05576-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2024] [Accepted: 09/10/2024] [Indexed: 11/20/2024]
Abstract
Femoral head fractures are rare, which limits the experience of individual surgeons with these injuries. This overview examines historical data, injury mechanisms, and classification systems, as well as epidemiological data from larger patient cohorts. Significant controversies persist regarding the optimal surgical approach and fracture-type-specific treatment for Pipkin fractures. The literature is often inconsistent, as many studies fail to differentiate between specific fracture types and instead report aggregated results, leading to ambiguous conclusions about the most effective treatment strategies. Thus, this article reviews fracture-type-specific outcomes of both non-operative and operative treatments over the past 25 years and summarizes their clinical implications, with the aim of assisting surgeons in their decision-making processes.
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Affiliation(s)
- Axel Gänsslen
- Trauma Department, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
- University Hospital, Johannes Wesling Hospital, Hans-Nolte-Straße 1, 32429, Minden, Germany.
| | - Richard A Lindtner
- Department of Orthopaedic and Trauma Surgery, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Dietmar Krappinger
- Department of Orthopaedic and Trauma Surgery, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Jochen Franke
- Trauma Department, Tauernkliniken, Paracelsusstraße 8, 5700, Zell, Austria
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Kloub M, Látal P, Giannoudis P. Techniques and results of reconstruction of femoral head fractures: An Update. Injury 2024; 55:111473. [PMID: 38538488 DOI: 10.1016/j.injury.2024.111473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/16/2024] [Accepted: 02/25/2024] [Indexed: 05/24/2024]
Abstract
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.
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Affiliation(s)
- Martin Kloub
- Department of Traumatology Hospital České Budějovice, Czech Republic.
| | - Pavel Látal
- Department of Traumatology Hospital České Budějovice, Czech Republic
| | - Peter Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
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Shakya S, Chen J, Sun J, Xiang Z. Management and outcome of patients with femoral head fractures: the mid-term follow-up with injuries and associated prognostic factors. BMC Musculoskelet Disord 2023; 24:311. [PMID: 37081472 PMCID: PMC10116746 DOI: 10.1186/s12891-023-06317-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/13/2023] [Indexed: 04/22/2023] Open
Abstract
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.
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Affiliation(s)
- Sujan Shakya
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Jialei Chen
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China.
| | - Jiachen Sun
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Zhou Xiang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
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Rojas-Sayol R, De Caso J, Valera M. Arthroscopic-Assisted Percutaneous Fixation of a Femoral Head Fracture (Pipkin II): A Case Report. JBJS Case Connect 2022; 12:01709767-202209000-00027. [PMID: 36040067 DOI: 10.2106/jbjs.cc.22.00194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
CASE Fractures of the femoral head are infrequent injuries with potentially devastating complications. Pipkin type II fractures often require surgical fixation. It involves intraarticular approaches that may increase the inherent morbidity of these fractures. Hip arthroscopy minimizes surgical aggression and allows for direct control of fracture reduction. We present a case report of an arthroscopic-assisted percutaneous fixation of a Pipkin-II femoral head fracture. A hip arthroscopy without traction and percutaneous screw fixation was conducted under arthroscopic and fluoroscopic guidance. CONCLUSION Arthroscopic-assisted percutaneous fixation is a useful technique for optimal femoral head fracture treatment and may also minimize surgical morbidity and optimize early recovery.
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Affiliation(s)
- Roger Rojas-Sayol
- Orthopedic Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - J De Caso
- Trauma Orthopaedic Surgery Unit, Department of Orthopaedic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M Valera
- Hip Orthopaedic Surgery Unit, Department of Orthopaedic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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Lian S, Yang Z, Hu Z, Mu W. 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. BMC Surg 2022; 22:165. [PMID: 35538455 PMCID: PMC9092786 DOI: 10.1186/s12893-022-01597-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/12/2022] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Shichao Lian
- Department of Traumatic Orthopedics, Shandong Provincial Hospital, Shandong University, No. 324 Jingwu Weiqi Road, Jinan, 250012, Shandong, China.,Zoucheng People's Hospital, No. 59 Qianquan Road, Zoucheng, 273500, Shandong, China
| | - Zhong Yang
- Binzhou Medical University, No. 346 Guanhai Road, Yantai, 264003, Shandong, China
| | - Zongliang Hu
- Department of Traumatic Orthopedics, Shandong Provincial Hospital, Shandong University, No. 324 Jingwu Weiqi Road, Jinan, 250012, Shandong, China
| | - Weidong Mu
- Department of Traumatic Orthopedics, Shandong Provincial Hospital, Shandong University, No. 324 Jingwu Weiqi Road, Jinan, 250012, Shandong, China.
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Which Surgical Approach Provides Maximum Visualization and Access for Open Reduction and Internal Fixation of Femoral Head Fractures? J Orthop Trauma 2022; 36:S12-S16. [PMID: 35061645 DOI: 10.1097/bot.0000000000002308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 02/02/2023]
Abstract
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.
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Tsai SHL, Tai WC, Fu TS, Tischler EH, Rahman R, Lim YK, Yu YH, Su CY. Does Surgical Repair Benefit Pipkin Type I Femoral Head Fractures?: A Systematic Review and Meta-Analysis. LIFE (BASEL, SWITZERLAND) 2022; 12:life12010071. [PMID: 35054465 PMCID: PMC8780341 DOI: 10.3390/life12010071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 12/31/2021] [Accepted: 01/01/2022] [Indexed: 11/16/2022]
Abstract
Background: Femoral head fractures are rare injuries with or without traumatic dislocations. The management of these fractures is crucial to prevent the development of severe complications and to achieve optimal functional outcomes. Wide treatment options for Pipkin 1 femoral head fractures range from fragment excision, fixation following open reduction with internal fixation, or conservative treatment such as close reduction alone after fracture dislocation. However, the best decision making remains controversial not only due to lack of large trials, but also inconsistent results reported. Therefore, we aim to compare the operative with nonoperative outcomes of Pipkin type 1 patients. Patients and Methods: We systemically searched MEDLINE, EMBASE, Cochrane library, In-Process & Other Non-Indexed Citations to identify studies assessing outcomes of Pipkin type 1 patients after conservative treatment, and open reduction with excision or fixation. Data on comparison of clinical outcomes of each management were extracted including arthritis, heterotopic ossification (HO), avascular necrosis (AVN), and functional scores (Thompson Epstein, Merle' d Augine and Postel Score). We performed a meta-analysis with the available data. Results: Eight studies (7 case series and 1 RCT) were included in this study. In a pooled analysis, the overall rate of arthritis was 37% (95% CI, 2-79%), HO was 20% (95% CI, 2-45%), and AVN was 3% (95% CI, 0-16%). In comparison of management types, the excision group reached the best functional outcomes including Thompson Epstein Score (poor to worse, 9%; 95% CI, 0-27%) and Merle d' Aubigne and Postel Score (poor to worse, 18%; 95% CI, 3-38%); ORIF group had the highest AVN rate (11%; 95% CI, 0-92%); conservative treatment had the highest arthritis rate (67%; 95% CI: 0-100%) and lowest HO rate (2%; 95% CI, 0-28%). Discussion: This meta-analysis demonstrates that different procedures lead to various clinical outcomes: fragment excision may achieve better function, conservative treatment may result in a higher arthritis rate, while ORIFs may have a higher AVN rate. These findings may assist surgeons in tailoring their decision-making to specific patient profiles. Future RCTs with multicenter efforts are needed to validate associations found in this study. Level of Evidence: II, systematic review and meta-analysis.
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Affiliation(s)
- Sung Huang Laurent Tsai
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Keelung 204 and School of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (S.H.L.T.); (T.-S.F.); (Y.-K.L.)
- The Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA; (E.H.T.); (R.R.)
| | - Wei-Che Tai
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou branch, and School of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (W.-C.T.); (Y.-H.Y.)
| | - Tsai-Sheng Fu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Keelung 204 and School of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (S.H.L.T.); (T.-S.F.); (Y.-K.L.)
| | - Eric H. Tischler
- The Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA; (E.H.T.); (R.R.)
- Department of Orthopaedic Surgery and Rehabilitation Medicine, Downstate Medical Center, State University of New York, Brooklyn, NY 11203, USA
| | - Rafa Rahman
- The Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA; (E.H.T.); (R.R.)
| | - Yong-Kuan Lim
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Keelung 204 and School of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (S.H.L.T.); (T.-S.F.); (Y.-K.L.)
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou branch, and School of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (W.-C.T.); (Y.-H.Y.)
| | - Yi-Hsun Yu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou branch, and School of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (W.-C.T.); (Y.-H.Y.)
| | - Chun-Yi Su
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Keelung 204 and School of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (S.H.L.T.); (T.-S.F.); (Y.-K.L.)
- Correspondence:
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De Mauro D, Rovere G, Smakaj A, Marino S, Ciolli G, Perna A, Battiato C, El Ezzo O, Liuzza F. Gibson approach and surgical hip dislocation according to Ganz in the treatment of femoral head fractures. BMC Musculoskelet Disord 2021; 22:961. [PMID: 34789202 PMCID: PMC8597876 DOI: 10.1186/s12891-021-04800-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 10/19/2021] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Domenico De Mauro
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Rovere
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Amarildo Smakaj
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Silvia Marino
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianluca Ciolli
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Perna
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Omar El Ezzo
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Liuzza
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, Rome, Italy.
- Università Cattolica del Sacro Cuore, Rome, Italy.
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Khalifa AA, Refai O, Farouk O, Abdelnasser MK. Management of femoral head fractures through surgical hip dislocation (SHD): a demanding but safe technique. Arch Orthop Trauma Surg 2021; 141:1701-1710. [PMID: 33113013 DOI: 10.1007/s00402-020-03666-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 10/15/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Femoral head fractures considered to be rare injuries. Surgical intervention is indicated for major fragment displacement or in the presence of instability. Surgical management can be achieved through either Anterior, posterior, and trans-trochanteric surgical approaches. Surgical hip dislocation (SHD) has been advocated by many authors to be a safe and effective alternative way of management. The aim of this study was to report on the accuracy of fracture reduction, procedure safety, and outcomes of using SHD in the management of femoral head fractures. PATIENTS AND METHODS Between 2011 and 2017, 31 patients presented with femoral head fracture were treated through SHD. At a mean follow-up of 48 months, 27 patients were available for the study with a mean age of 33.8 years. Patient demographics, clinical evaluation according to modified Harris hip score and modified Merle d'Aubigne and Postel score, radiographic fracture reduction according to Matta's criteria, and any complications were reported. RESULTS Excellent and good clinical outcomes were reported in 25 (92.6%) and 24 (89%) patients according to the modified Harris hip and modified Merle d'Aubigne and Postel scores, respectively. Anatomic fracture reduction was achieved in 21 (77.8%) patients. Two (7.4%) patients developed AVN, one (3.6%) patient developed hip OA (grade 3 according to Tönnis classification), and five (18.5%) patients developed asymptomatic Brooker stage I heterotopic ossification. No infection or trochanteric flip osteotomy fragment non-union was reported. CONCLUSIONS SHD offers a safe and efficient approach for femoral head fractures management with acceptable clinical outcomes as well as complication rates. Giving the advantage of fully exposing the femoral head and the acetabulum which enables the surgeon to anatomically reduce the fracture and treat any associated injuries, SHD is recommended besides other approaches for the management of femoral head fractures.
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Affiliation(s)
- Ahmed A Khalifa
- Orthopaedic Department, Assiut University Hospital, Assiut, Egypt.
- Orthopaedic and Traumatology Department, Qena Faculty of Medicine and University Hospital, South Valley University, Kilo 6 Qena-Safaga highway, Qena, 83523, Egypt.
| | - Omar Refai
- Orthopaedic Department, Assiut University Hospital, Assiut, Egypt
| | - Osama Farouk
- Orthopaedic Department, Assiut University Hospital, Assiut, Egypt
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Chouhan D, Behera P, Ansari MT, Digge VK. Posterior hip dislocation associated with concomitant ipsilateral femoral head and shaft fractures: an unusual combination of injuries. BMJ Case Rep 2021; 14:e244453. [PMID: 34446518 PMCID: PMC8395262 DOI: 10.1136/bcr-2021-244453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 11/04/2022] Open
Abstract
The combination of posterior hip dislocation with an ipsilateral femoral head and shaft fractures is unusual. While cases of concomitant fractures of femoral head and shaft have been previously reported, the treatment of such injuries is challenging. Presence of an associated hip dislocation further complicates the matter. A timely diagnosis and treatment are crucial to have a good outcome.We are presenting the case of a 20-year-old man who sustained a traumatic posterior hip dislocation with ipsilateral femoral shaft and femur head fractures. After reducing the hip, we fixed the femoral shaft with a retrograde femur nail and the femoral head by the trochanteric flip approach in the same sitting. The patient returned to his pre-injury occupation after 4 months. He has been doing well until his last follow-up, 1 year after the surgery, thus emphasising the utility of following basic principles of trauma management in the management of unusual injuries.
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Affiliation(s)
- Deepak Chouhan
- Department of Orthopaedics, Kashmiri hospital and Heart care centre, Sunam, Punjab, India
| | - Prateek Behera
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Mohammed Tahir Ansari
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Kumar Digge
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
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13
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Khalifa AA, Haridy MA, Fergany A. Safety and efficacy of surgical hip dislocation in managing femoral head fractures: A systematic review and meta-analysis. World J Orthop 2021; 12:604-619. [PMID: 34485106 PMCID: PMC8384609 DOI: 10.5312/wjo.v12.i8.604] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/20/2021] [Accepted: 07/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Femoral head fractures (FHFs) are considered relatively uncommon injuries; however, open reduction and internal fixation is preferred for most displaced fractures. Several surgical approaches had been utilized with controversial results; surgical hip dislocation (SHD) is among these approaches, with the reputation of being demanding and leading to higher complication rates.
AIM To determine the efficacy and safety of SHD in managing FHFs by reviewing the results reported in the literature.
METHODS Major databases including PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched to identify studies reporting on outcomes of SHD utilized as an approach in treating FHFs. We extracted basic studies data, surgery-related data, functional outcomes, radiological outcomes, and postoperative complications. We calculated the mean differences for continuous data with 95% confidence intervals for each outcome and the odds ratio with 95% confidence intervals for binary outcomes. P < 0.05 was considered significant.
RESULTS Our search retrieved nine studies meeting our inclusion criteria, with a total of 129 FHFs. The results of our analysis revealed that the average operation time was 123.74 min, while the average blood loss was 491.89 mL. After an average follow-up of 38.4 mo, a satisfactory clinical outcome was achieved in 85% of patients, with 74% obtained anatomical fracture reduction. Overall complication rate ranged from 30% to 86%, with avascular necrosis, heterotopic ossification, and osteoarthritis being the most common complications occurring at an incidence of 12%, 25%, and 16%, respectively. Trochanteric flip osteotomy nonunion and trochanteric bursitis as a unique complication of SHD occurred at an incidence of 3.4% and 3.8%, respectively.
CONCLUSION The integration of SHD approach for dealing with FHFs offered acceptable functional and radiological outcomes with a wide range of safety in regards to the hip joint vascularity and the development of avascular necrosis, the formation of heterotopic ossification, and the development of posttraumatic osteoarthritis; however, it still carries its unique risk of trochanteric flip osteotomy nonunion and persistent lateral thigh pain.
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Affiliation(s)
- Ahmed A Khalifa
- Department of Orthopaedic, Qena Faculty of Medicine and University Hospital, South Valley University, Qena 83523, Qina, Egypt
| | - Mohamed A Haridy
- Department of Orthopaedic, Ibri Regional Hospital, Ibri 511, Oman
| | - Ali Fergany
- Department of Orthopaedic, Assiut University Hospital, Assiut 71515, Egypt
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A case report of femoral head fracture with osteochondral lesion treated by osteosynthesis and biomimetic scaffold: 2-year clinical and radiological follow-up. J Exp Orthop 2021; 8:48. [PMID: 34212301 PMCID: PMC8249539 DOI: 10.1186/s40634-021-00362-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/03/2021] [Indexed: 11/10/2022] Open
Abstract
The aim of the present study was to present clinical and radiological outcome of a hip fracture-dislocation of the femoral head treated with biomimetic osteochondral scaffold. An 18-year-old male was admitted to the hospital after a motorcycle-accident. He presented with an obturator hip dislocation with a type IVA femoral head fracture according to Brumback classification system. The patient underwent surgery 5 days after accident. The largest osteochondral fragment was reduced and stabilized with 2 screws, and the small fragments were removed. The residual osteochondral area was replaced by a biomimetic nanostructured osteochondral scaffold. At 1-year follow-up the patient did not complain of hip pain and could walk without limp. At 2-year follow-up he was able to run with no pain and he returned to practice sports. Repeated radiographs and magnetic resonance imaging studies of the hip showed no signs of osteoarthritis or evidence of avascular necrosis. A hyaline-like signal on the surface of the scaffold was observed with restoration of the articular surface and progressive decrease of the subchondral edema. The results of the present study showed that the biomimetic nanostructured osteochondral scaffold could be a promising and safe option for the treatment of traumatic osteochondral lesions of the femoral head. Study Design: Case report.
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Articular Femoral Head Fracture Management: A Meta-analysis of Literature. Indian J Orthop 2021; 55:304-313. [PMID: 34306543 PMCID: PMC8275725 DOI: 10.1007/s43465-021-00431-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 05/20/2021] [Indexed: 02/04/2023]
Abstract
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.
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16
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Wang J, Yi C, Wang S, Wang L, Jia H, Chen B, Huan Y. The elastoplastic numerical model and verification by macroindentation experiment of femoral head. Comput Methods Biomech Biomed Engin 2021; 24:1588-1594. [PMID: 33749449 DOI: 10.1080/10255842.2021.1902510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
For internal fixation of proximal femoral fractures, a screw is commonly placed into the femoral head; therefore, mechanical matching of the femoral head and screw is important. This article proposes an elastoplastic numerical model of the femoral head that takes nonlinear deformation and cancellous bone heterogeneity into account. Force-depth curves from finite element analysis based on the model were compared with those from macroindentation experiments. The maximum difference between the indentation depth shown by the finite element model and that found with macroindentation testing was 5.9%, which demonstrates that the model is valid.
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Affiliation(s)
- Jun Wang
- State Key Laboratory of Nonlinear Mechanics (LNM), Institute of Mechanics, Chinese Academy of Sciences, Beijing, China.,School of Engineering Science, University of Chinese Academy of Sciences, Beijing, China
| | - Chen Yi
- Department of Traumatic Orthopedics, Beijing Jishuitan Hospital, Beijing, China
| | - Sufang Wang
- State Key Laboratory of Nonlinear Mechanics (LNM), Institute of Mechanics, Chinese Academy of Sciences, Beijing, China.,School of Engineering Science, University of Chinese Academy of Sciences, Beijing, China
| | - Ling Wang
- Department of Radiology, Beijing Jishuitan Hospital, Beijing, China
| | - Haiyou Jia
- State Key Laboratory of Nonlinear Mechanics (LNM), Institute of Mechanics, Chinese Academy of Sciences, Beijing, China.,School of Engineering Science, University of Chinese Academy of Sciences, Beijing, China
| | - Bo Chen
- State Key Laboratory of Nonlinear Mechanics (LNM), Institute of Mechanics, Chinese Academy of Sciences, Beijing, China.,School of Engineering Science, University of Chinese Academy of Sciences, Beijing, China
| | - Yong Huan
- State Key Laboratory of Nonlinear Mechanics (LNM), Institute of Mechanics, Chinese Academy of Sciences, Beijing, China.,School of Engineering Science, University of Chinese Academy of Sciences, Beijing, China.,Beijing Key Laboratory of Engineered Construction and Mechanobiology, Beijing, China
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17
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Liu Y, Dai J, Wang XD, Guo ZX, Zhu LQ, Zhen YF. Open reduction and Herbert screw fixation of Pipkin type IV femoral head fracture in an adolescent: A case report. World J Clin Cases 2021; 9:898-903. [PMID: 33585637 PMCID: PMC7852633 DOI: 10.12998/wjcc.v9.i4.898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/17/2020] [Accepted: 12/16/2020] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Yao Liu
- Department of Orthopaedics, Children’s Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Jin Dai
- Department of Orthopaedics, Children’s Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Xiao-Dong Wang
- Department of Orthopaedics, Children’s Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Zhi-Xiong Guo
- Department of Orthopaedics, Children’s Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Lun-Qing Zhu
- Department of Orthopaedics, Children’s Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Yun-Fang Zhen
- Department of Orthopaedics, Children’s Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
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Patient-Reported Outcomes of Femoral Head Fractures with a Minimum 10-Year Follow-Up. J Orthop Trauma 2020; 34:621-625. [PMID: 32618812 DOI: 10.1097/bot.0000000000001880] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the clinical-reported and patient-reported outcomes of patients with femoral head fractures treated at a single level I trauma center with a minimum 10-year follow-up. DESIGN Retrospective review. SETTING Academic Level-1 Trauma Center. PATIENTS/PARTICIPANTS One hundred one consecutive femoral head fractures were identified for this study. The final study group consisted of 28 patients with a minimum of 10 years of clinical follow-up. INTERVENTION All patients were treated with one or in combination with the following treatments: nonoperative management, open reduction and internal fixation, fragment excision, or total hip arthroplasty (THA). MAIN OUTCOME MEASURES The Oxford Hip Score (OHS) at final follow-up along with clinical and radiological complications: infection, avascular necrosis, post-traumatic osteoarthritis, heterotopic ossification, and conversion to THA. RESULTS Twenty-eight patients with greater than 10 years of follow-up were included in this evaluation. The average follow-up was 14 years, and the average age was 39.2 years. Surgical management occurred in 86% of patients, and the mean time to definitive treatment was 3.7 days. Overall, 21 patients (75%) experienced a complication. Seven patients (30%) were later converted to a THA at an average of 6.4 years from initial injury. Three of the 7 late THA conversions (43%) required later revision. OHSs were obtained in all 28 patients at the final follow-up. The average OHS was 36.6. The mean OHS of the native hips was 37 at an average follow-up of 13.6 years. The mean OHS of primary THA was 41, and the mean OHS of secondary THA at final follow-up was 31.4, but this was not statistically significant (P = 0.134). CONCLUSIONS Patients should be counseled that the long-term results of open reduction and internal fixation may be satisfactory but unfortunately are not predictable. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Pipkin type IV femoral head fractures: a case series and review of literature. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:791-795. [PMID: 33211232 DOI: 10.1007/s00590-020-02838-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 11/12/2020] [Indexed: 12/21/2022]
Abstract
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.
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Wang ZH, Li KN, Zhao P, Chen ED, Zheng J. In Situ Reduction and Fixation of the Anterior Medial Fenestration Approach for Femoral Head Fracture. Orthop Surg 2019; 11:1163-1172. [PMID: 31762204 PMCID: PMC6904651 DOI: 10.1111/os.12578] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 10/12/2019] [Accepted: 10/20/2019] [Indexed: 11/26/2022] Open
Abstract
Objective To investigate the feasibility and clinical application of the anterior medial fenestration approach in the treatment of Pipkin type I and II femoral head fractures. Methods The hips of two anti‐corrosion adult specimens treated with formalin were dissected and the anatomical structures and directional characteristics of the anterior medial main muscles, ligaments, blood vessels, and nerves were observed. The anterior medial fenestration approach was performed on bilateral hips of four fresh frozen specimens to determine the required pulling direction of the stripped muscles and ligaments during surgery. In addition, the vascular and nerve traction protection directions exposed in the approach were observed and analyzed. The feasibility of this approach was assessed, and the operative approach and critical anatomical depth were measured. We retrospectively analyzed 12 patients with Pipkin type I and II femoral head fractures who underwent in situ reduction and fixation by anterior medial fenestration in our hospital from February 2016 to April 2018. The study group included 3 men and 9 women aged 37–59 years (mean, 48.50 years). There were 8 cases of Pipkin type I and 4 cases of Pipkin type II. The operation time, blood loss, fracture healing time, last Thompson–Epstein evaluation, and Harris score were recorded. Results A total of 8 fresh frozen specimens from 4 bilateral hips were exposed by anterior medial fenestration. The upper boundary of observation fenestration was the pubic body (anterior acetabulum), and the outer upper boundary was the iliacus and the psoas muscle. The lateral boundary was the rectus femoris and the femoral vessels, while the lower boundary was the transverse branch of the medial femoral circumflex artery and vein. The medial boundary was the pubis muscle, the short adductor muscle, and the long adductor muscle. The pubofemoral and iliofemoral ligaments were observed during fenestration. By cutting open the joint capsule and moving the hip joint, the four quadrants of the femoral head can be exposed. Twelve patients with femoral head fractures who were treated with anterior medial fenestration underwent in situ reduction and fixation. The operation time was 96.25–118.75 min (median, 100 min), and the blood loss was 115.00 ± 22.76 mL. The follow‐up time was 18.58 ± 4.48 months, and the fracture healing time was 144.17 ± 14.53 days. The last Thompson–Epstein evaluation was excellent in 6 cases, good in 4 cases, and fair in 2 cases; the excellent and good rate was 83.33%. Finally, the last Harris score was 85.08 ± 5.73 points. Conclusions The upper and lower boundaries, inner and outer boundaries, and rear anatomical structure of the anterior medial fenestration approach were defined. The movable hip joint can expose the four quadrants in front of the femoral head in this fenestration. Anterior medial fenestration in situ reduction and fixation surgery is feasible and safe for the treatment of Pipkin type I and II femoral head fractures.
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Affiliation(s)
- Zheng-Hao Wang
- Affiliated Hospital of Chengdu University, Department of Orthopaedic Surgery, Chengdu, China
| | - Kai-Nan Li
- Affiliated Hospital of Chengdu University, Department of Orthopaedic Surgery, Chengdu, China
| | - Ping Zhao
- Affiliated Hospital of Chengdu University, Department of Orthopaedic Surgery, Chengdu, China
| | - Er-Dong Chen
- Affiliated Hospital of Chengdu University, Department of Orthopaedic Surgery, Chengdu, China
| | - Jiang Zheng
- Affiliated Hospital of Chengdu University, Department of Orthopaedic Surgery, Chengdu, China
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21
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Management of Pipkin Fractures Using a Safe Surgical Hip Dislocation. Case Rep Orthop 2019; 2019:3526018. [PMID: 31772800 PMCID: PMC6854175 DOI: 10.1155/2019/3526018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 08/30/2019] [Indexed: 12/17/2022] Open
Abstract
Introduction Pipkin fractures are rare events and usually occur as a consequence for high-energy trauma. Surgery to obtain anatomical reduction and fixation is the mainstay treatment for the majority of these injuries; nonetheless, controversy exists regarding the best surgical approach. Description of the Case We present the case of a 41-year-old male, which sustained a type II Pipkin fracture following a motorcycle accident. In the emergency department, an emergent closed reduction was performed, followed by surgery five days later. Using a surgical hip dislocation, a successful anatomical reduction and fixation was performed. After three years of follow-up, the patient presented with a normal range of motion, absent signs for avascular necrosis or posttraumatic arthritis, but with a grade II heterotopic ossification. Discussion Safe surgical hip dislocation allows full access to the femoral head and acetabulum, without increasing the risk for a femoral head avascular necrosis or posttraumatic arthritis. Simultaneously, this surgical approach gives the opportunity to repair associated acetabular or labral lesions, which explains the growing popularity with this technique. Conclusion Although technically demanding, safe surgical hip dislocation represents an excellent option in the reduction and fixation for Pipkin fractures.
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22
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Del Core MA, Gross B, Ahn J, Wallace SB, Starr A. Clinical and Radiographic Outcomes of Femoral Head Fractures Associated with Traumatic Hip Dislocations. Strategies Trauma Limb Reconstr 2019; 14:6-10. [PMID: 32559260 PMCID: PMC7001600 DOI: 10.5005/jp-journals-10080-1416] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Michael A Del Core
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | - Bruno Gross
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | - Junho Ahn
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | - Stephen Blake Wallace
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | - Adam Starr
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, Texas, USA
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Li Q, Huang F, Xiang Z, Fang Y, Zhong G, Yi M, Zhao X, Liu L. [Modified Hueter direct anterior approach for treatment of Pipkin type Ⅰ and Ⅱ femoral head fractures]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:334-337. [PMID: 29806284 DOI: 10.7507/1002-1892.201710073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Qin Li
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;Department of Orthopaedics, Tibetan Chengdu Office Branch Hospital of West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Fuguo Huang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Zhou Xiang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Yue Fang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Gang Zhong
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Min Yi
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Xiaodan Zhao
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Lei Liu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041,
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Affiliation(s)
- Nicholas M Romeo
- Department of Orthopaedics and Sports Medicine, Harborview Medical Center - University of Washington, Seattle, WA, USA
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Wang CG, Li YM, Zhang HF, Li H, Li ZJ. Anterior approach versus posterior approach for Pipkin I and II femoral head fractures: A systemic review and meta-analysis. Int J Surg 2016; 27:176-181. [PMID: 26854958 DOI: 10.1016/j.ijsu.2016.02.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 12/30/2015] [Accepted: 02/02/2016] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Chen-Guang Wang
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, People's Republic of China
| | - Yao-Min Li
- Department of Rehabilitation, Tianjin Hospital, Tianjin 300211, People's Republic of China
| | - Hua-Feng Zhang
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, People's Republic of China
| | - Hui Li
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, People's Republic of China
| | - Zhi-Jun Li
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, People's Republic of China.
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Affiliation(s)
- Geoffrey S Marecek
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, 1520 San Pablo, Suite 2000, Los Angeles, CA 90033
| | - John A Scolaro
- Department of Orthopaedic Surgery, University of California, Irvine, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA 92868
| | - Milton L Chip Routt
- University of Texas-Health Sciences Center at Houston, 6431 Fannin Street, Houston, TX 77030
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Park KS, Lee KB, Na BR, Yoon TR. Clinical and radiographic outcomes of femoral head fractures: excision vs. fixation of fragment in Pipkin type I: what is the optimal choice for femoral head fracture? J Orthop Sci 2015; 20:702-7. [PMID: 25952457 DOI: 10.1007/s00776-015-0732-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 04/21/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND In this work, we present relatively long-term results of femoral head fractures with a specific focus on Pipkin type I fractures. METHODS Fifty-nine femoral head fractures were treated according to modified Pipkin's classification as follows: type I, small fragment distal to the fovea centralis (FC); type II, large fragment distal to the FC; type III, large fragment proximal to the FC; type IV, comminuted fracture. There were 15 cases of type I, 28 of type II, 9 of type III, and 7 of type IV fractures. Conservative treatment with skeletal traction was performed in 4 type II cases, excision of the fragment in 15 type I and 10 type II cases, fixation of the fragment in 14 type II and all 9 type III cases, and total hip replacement in all 7 type IV cases. The overall clinical and radiographic outcomes were evaluated using previously published criteria, focusing on the results in Pipkin type I fractures with relatively large fragments. RESULTS Based on Epstein criteria, in type II fractures, excellent or good clinical results were seen in 6 of 10 patients (60.0 %) treated by excision of the fragment and 12 of 14 patients (85.7 %) treated by internal fixation (p = 0.05). Also, excellent or good radiologic results were seen in 4 of 10 (40.0 %) patients treated by excision of the fragment and 12 of 14 (85.7 %) patients treated by internal fixation (p = 0.03). CONCLUSIONS Even in Pipkin type I fractures, if the fragment is large (modified Pipkin type II), early reduction and internal fixation can produce good results.
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Affiliation(s)
- Kyung-Soon Park
- Department of Orthopedic Surgery, Center for Joint Disease at Chonnam National University Hwasun Hospital, 322, SeoYang-Ro, Hwasun-Eup, Hwasun-Gun, Jeonnam, 519-809, Republic of Korea
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Abstract
Displaced femoral head fractures often require open reduction and internal fixation. This article describes 3 cases of displaced large-fragment femoral head fractures (OTA 31-C1.3) that were treated by arthroscopic reduction and internal fixation, which was accomplished using an anterolateral viewing portal, an anterior portal, and an accessory distal anterior working portal. By 3 months postoperatively, all 3 patients had returned to full function. Therefore, we conclude that an arthroscopic approach results in stable fixation and early joint motion, thereby effectively treating displaced femoral head fractures in a minimally invasive manner.
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Park MS, Her IS, Cho HM, Chung YY. Internal fixation of femoral head fractures (Pipkin I) using hip arthroscopy. Knee Surg Sports Traumatol Arthrosc 2014; 22:898-901. [PMID: 24402047 DOI: 10.1007/s00167-013-2821-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 12/23/2013] [Indexed: 12/31/2022]
Abstract
A hip arthroscopy technique for the reduction and internal fixation of a displaced femoral head fracture is presented. Open treatment is often required for femoral head fractures. However, it is shown below how large fragments of a femoral head fracture-dislocation were reduced and internally fixated using hip arthroscopy. This was performed in the supine position using skeletal traction. The accessory distal anterior portal was used for internal fixation when a hip was positioned in abduction with external rotation. A satisfactory outcome was reported. Recovery was immediate and cosmetics were excellent. We conclude that hip arthroscopy is a valuable option for managing femoral head fracture-dislocations (Pipkin I).
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Affiliation(s)
- Myung-Sik Park
- Department of Orthopedic Surgery, Biomedical Research Institute of Clinical Medicine, Chonbuk National University Hospital, Chonju, 561-712, Korea,
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