Malunion of femoral head fractures treated by partial ostectomy: three case reports

Arthroscopic osteosynthesis of femoral head malunion

We present the case of a femoral head malunion with lateral cephalic femoroacetabular impingement managed by arthroscopic osteotomy/takedown, bone grafting, internal fixation, and cephaloplasty. The treatment rationale and surgical technique are presented. A successful outcome at 3 years was obtained with radiographic evidence of union without osteonecrosis. Even beyond acute femoral head osteosynthesis, arthroscopic surgery may enhance the ability to treat femoral head malunions. Moreover, arthroscopic osteosynthesis may address lateral cephalic FAI, a previously unreported condition.

Use of a trochanteric flip osteotomy improves outcomes in Pipkin IV fractures

The optimal surgical approach for combined femoral head and acetabular fractures (Pipkin IV) is controversial because of their rarity and lack of definitive reports. Surgical dislocation with trochanteric flip osteotomy (TFO) allows simultaneous exposure of the acetabulum and femoral head. We protected the obturator internus and inferior capsule during repair with a heavy suture at the inferior extent of the traumatic capsulotomy. We retrospectively reviewed 12 patients with Pipkin IV fractures treated using this approach during a 6-year period. The minimum followup was 24 months (mean, 47 months; range, 24-71 months). Clinical outcomes were measured using the Merle d'Aubigné-Postel and Thompson-Epstein scoring scales. Radiographically, all patients achieved healing of their acetabular fractures; 11 achieved healing of the femoral head fracture and osteonecrosis developed in one patient. The average Merle d'Aubigné-Postel score was 15.6 of 18; using the Thompson-Epstein score, 10 of the 12 patients had good or excellent outcomes, one had a fair outcome, and one had a poor outcome. Trochanteric flip osteotomy allowed for simultaneous exposure and repair of both lesions in Pipkin IV fractures. Using a uniform surgical protocol with TFO rendered clinical results comparable to previously reported outcomes in series of isolated femoral head fractures.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.