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]

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.

Surgical Approaches for Managing Femoral Head Fractures (FHFs); What and How to Choose from the Different Options?

Femoral head fractures (FHFs) are considered a relatively uncommon injury; however, they carry a challenge to the trauma surgeon. Choosing the appropriate management option, either conservatively or surgically, if the latter was chosen, should it be open reduction and internal fixation or simple excision of the fragment, or acute total hip arthroplasty. Furthermore, selecting the best surgical approach through which surgical management could be performed depends on the fracture classification, the familiarity of the surgeon, and the presence of associated injuries. All approaches to the hip, including hip arthroscopy, had been proposed for the management of FHFs; however, the difference among approaches is related to the complexity of the approach, the need for special training or equipment, the effect of the approach on the functional outcomes as well as the rate of postoperative complications. This review discussed the possible surgical approaches used to manage FHFs, advantages, and disadvantages for each, and offered a guideline for selecting the most appropriate surgical approach.

Management of femoral head fractures through surgical hip dislocation (SHD): a demanding but safe technique

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.

Safety and efficacy of surgical hip dislocation in managing femoral head fractures: A systematic review and meta-analysis

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.

Treatment of Pipkin type I fracture using safe surgical hip dislocation: A case report

We report the clinical and radiological outcomes of a 30-year-old female with femoral head fracture following a posterior hip dislocation. The patient was managed using safe surgical hip dislocation. She had a pain free range of motion of the hip at 1 year postinjury.

[Analysis of effectiveness of greater trochanteric osteotomy approach and K-L posterior approach in patients with type Pipkin fracture]

Objective

To investigate the effectiveness of two surgical approaches in the treatment of type Ⅳ Pipkin fracture.

Methods

The clinical data of 15 patients with type Ⅳ Pipkin fracture treated surgically between July 2013 and June 2018 were retrospectively analyzed. According to different surgical approaches, they were divided into group A (8 cases, using K-L posterior approach) and group B (7 cases, using greater trochanter osteotomy approach). There was no significant difference in gender, age, cause of injury, and interval from injury to operation between the two groups ( P>0.05). The incision length, operation time, intraoperative blood loss, hospital stay, fracture healing time, and complications of the two groups were recorded. Hip joint function recovery was evaluated according to Thompson-Epstein functional evaluation system.

Results

All the 15 patients were followed up 1-5 years, with an average of 2.5 years. There was no significant difference in operation time between the two groups ( t=14.681, P=0.100); the incision length, intraoperative blood loss, and fracture healing time in group A were all greater than those in group B, and the hospital stay was shorter than that in group B, showing significant differences ( P<0.05). In group A, 1 patient presented hip pain, clasthenia, and limited mobility after operation, 1 patient presented ossifying myositis, 1 patient presented osteonecrosis of the femoral head, 1 patient presented fat liquefaction of incision, and 1 patient presented sciatica, with a complication incidence of 62.5%. Postoperative hip pain occurred in 1 patient and ossifying myositis in 2 patients in group B, with a complication incidence of 42.9%. There was no significant difference in the incidence of complications between the two groups ( χ ²=-0.735, P=0.462). At last follow-up, according to Thompson-Epstein functional evaluation system, the results in group A were excellent in 3 cases, good in 2 cases, fair in 2 cases, and poor in 1 case, with an excellent and good rate of 62.5%; in group B, the results were excellent in 4 cases, good in 2 cases, and fair in 1 case, and the excellent and good rate was 85.7%. There was no significant difference in good and fair rate between the two groups ( χ ²=-0.990, P=0.322).

Conclusion

K-L posterior approach is more convenient in the fracture treatment during operation, but it has greater trauma, greater vascular damage, and more blood loss. The greater trochanter osteotomy approach can better protect the blood supply of femoral head, shorten the operation time, reduce intraoperative blood loss, and reduce postoperative complications. It is an ideal way in the surgical treatment of type Ⅳ Pipkin fracture.

Treatment of type IV Pipkin fracture in patients with a high BMI via hip arthroscopy-assisted surgery: a case report

Pipkin type IV femoral head (FH) fracture-dislocations are usually treated via open surgery. There are many surgical approaches for the treatment of this difficult fracture depending on the fracture pattern. Obesity presents another challenging problem in surgical treatment and sometimes leads to a poorer outcome. We discuss herein a patient of a high body mass index (BMI) with a Pipkin type IV FH fracture who underwent open reduction internal fixation (ORIF) of anacetabular fracture with reconstruction plates and hip arthroscopy-assisted fixation of the FH fracture with two Herbert screws via the posterior approach. The intra-articular osteochondral loose bodies were excised by hip arthroscopy simultaneously. The joint congruency and screw positions were checked during surgery by arthroscopy. After 6 months, clinical and computed tomography (CT) follow-ups showed excellent results. The patient of a high BMI recovered immediately and had a satisfactory short-term outcome after hip arthroscopy-assisted surgery. We concluded that hip arthroscopy-assisted surgery is a viable option for the treatment of Pipkin type IV FH fracture-dislocations.