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Operative Treatment of Displaced Pipkin Type I and II Femoral Head Fractures

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Operative Treatment of Displaced Pipkin Type I and II Femoral Head Fractures Arch Orthop Trauma Surg (2014) 134:637–644 DOI 10.1007/s00402-014-1960-5 TRAUMA SURGERY Operative treatment of displaced Pipkin type I and II femoral head fractures Mohamed Fathy Mostafa · Wael El-Adl · Mostafa Abd-Elkalek El-Sayed Received: 13 June 2013 / Published online: 26 February 2014 © Springer-Verlag Berlin Heidelberg 2014 Abstract one patient (8.1 %) of trochanteric flip-approached group Background and purpose The optimal surgical approach and two (18.1 %) of posterior approach group. All patients for the treatment of femoral head fracture remains con- were followed up for an average of 31 months (range 24– troversial. We retrospectively reviewed patients with Pip- 84). Except for one patient, the final outcomes were equal kin type I and II femoral head fractures managed surgi- in the two groups. cally through posterior Kocher–Langenbeck approach and Conclusions Despite the limited number of patients, we Ganz trochanteric flip approach aiming to define the best can conclude that good final outcome does not necessarily approach with the least morbidity. follow a specific approach. Patients and methods Between May 1995 and Novem- ber 2010, 23 patients (14 men and 9 women) with an Keywords Femoral head · Pipkin · Trochanteric flip · average age of 39.1 years (range 27–62) were treated by Kocher–Langenbeck open reduction and internal fixation of femoral head frac- tures (5, Pipkin type I; and 18, type II) through Kocher– Langenbeck approach in 11 patients and trochanteric flip Introduction (digastric) osteotomy in 12. The two approaches were com- pared regarding operative time, difficulty of reduction and Fracture of the femoral head represents a severe injury to fixation, amount of blood loss, occurrence of femoral head the hip joint and historically has been associated with a rel- osteonecrosis or heterotopic ossification and the final func- atively poor functional outcome [1]. About 5–15 % of pos- tional outcome. The scale of Brooker was used to document terior hip dislocations have been reported to be associated heterotopic ossification. The modified Merle d’Aubigne with femoral head fractures [1–3]. The most widely used and Postel as well as Thompson and Epstein scores were classification was that of Pipkin [4] which is based on the used for final evaluation. location of the femoral head fracture in relation to the fovea Results Trochanteric flip approach was associated with and additional lesion on the femoral neck or acetabulum less operative time, less blood loss and improved visu- (Fig. 1). alization facilitating direct screw fixation compared with The first description of femoral head fracture following Kocher–Langenbeck approach. Non-union of the trochan- posterior hip dislocation was by Birkett [5]. Several case teric osteotomy developed in one patient. Heterotopic series have subsequently been published, however, lack of ossification was seen more in trochanteric flip-approached uniformly applied classification, limitations in the study cases. Avascular necrosis of the femoral head occurred in design and insufficient length of follow-up make it dif- ficult to establish any firm conclusions regarding the opti- mal treatment of femoral head fracture. There is still no M. F. Mostafa (*) · W. El-Adl · M. A.-E. El-Sayed consensus on the management of Pipkin type I and type II Department of Orthopedic Surgery, Mansoura University injuries: whether to treat these fractures operatively or non- Hospital, 36 Al-Gomhoria Street, P.O. Box 35516, Mansoura, Egypt operatively, whether to fix or excise the head fragment, or e-mail: [email protected] which surgical approach to use [6–8]. Although satisfactory 1 3 638 Arch Orthop Trauma Surg (2014) 134:637–644 Fig. 1 The Pipkin classification. Type I femoral head fracture inferior ral neck fracture. Type IV any femoral head fracture with an associ- to the fovea centralis. Type II fracture extended superior to the fovea ated acetabular fracture centralis. Type III any femoral head fracture with an associated femo- results have been reported with closed or open reduction through posterior Kocher–Langenbeck approach or Ganz and traction treatment, most currently studies recommend trochanteric flip approach and had complete radiographic open reduction and internal fixation of displaced femoral and clinical follow-up for a minimum of two years. Patients head fractures with well-recessed cancellous or Herbert treated through anterior Smith–Petersen approach or ante- screws [9–11]. rolateral Watson–Jones approach were excluded from this The effect of the surgical approach on postoperative het- study. By February 2004 we popularized the trochanteric erotopic ossification (HO) and avascular necrosis (AVN) of flip approach for surgical management of all types of dis- the femoral head is unclear. Orthopedic surgeons continue placed femoral head fractures except cases of Pipkin type to discuss which approach is better for femoral head frac- IV with low posterior wall fractures. tures. Anterior approach was contraindicated by Epstein A total of 23 patients was available, 11 were treated et al. [1]. They noted that most of the blood supply is dam- through Kocher–Langenbeck approach (group A) and 12 aged with posterior dislocation, and a surgical procedure through trochanteric flip approach (group B). There were that embarrasses whatever blood supply remains is there- 14 males and 9 females with an average age of 39.1 years fore inadvisable. Heterotopic ossification has been noted (range 27–62 years) at the time of injury. According to the to occur with a higher incidence in patients who undergo Pipkin classification, five fractures were classified as type an anterior approach [12, 13]. Recently a posterior-based I and 18 as type II. All fractures were associated with pos- approach with a trochanteric-flip osteotomy and a surgi- terior hip dislocation and secondary to motor vehicle acci- cal hip dislocation has been advocated for the management dents in 16 patients, motorcycle accidents in 5, and fall of the femoral head fractures [14, 15]. This approach pre- from height in 2. Associated injuries were present in eight serves the deep branch of the medial femoral circumflex patients (three head injuries, five multiple other fractures) artery (MFCA) and at the same time allows unimpaired with an average injury severity score of 19 (range 10–30). complete visibility of the femoral head. All patients presented to our emergency department and The current study was conducted to compare two surgi- after initial evaluation according to the Adult Trauma Life cal approaches (Kocher–Langenbeck approach and Ganz Support (ATLS™) guidelines, immediate closed reduction trochanteric flip osteotomy approach) used for the sur- of the hip fracture dislocation was attempted under gen- gical treatment of Pipkin type I and type II femoral head eral anaesthesia. Sufficient muscle relaxation was essential fractures over a 12-year period aiming to ascertain which to prevent further cartilage damage as well as iatrogenic approach is safe and reliable. femoral neck fracture. Failed closed reduction (one case) indicated open reduction and internal fixation. Follow- Patients and methods ing reduction, plain radiographs in two planes and a spiral computed tomography scan were performed to evaluate the We retrospectively reviewed the records and radiographs of quality of reduction. Operative treatment was indicated for all patients with femoral head fractures who were treated fractures displaced 2 mm or more. surgically by open reduction and internal fixation at our institution between May 1995 and November 2010. Inclu- Surgical technique sion criteria were adult patients with Pipkin type I and type II femoral head fractures of greater than 2 mm dis- Surgery was performed with the patients in the lateral placement, underwent open reduction and internal fixation decubitus position on the contralateral side using a standard 1 3 Arch Orthop Trauma Surg (2014) 134:637–644 639 Table 1 Modified Merle Score Pain Ambulation ROM (%) d’Aubigne-postel score [17] 6 No pain Normal 95–100 The overall numeric score is 5 Slight or intermittent No cane, but slight limp 80–94 given by adding the domain 4 Pain after ambulation, but disappears Long distance with cane or crutch 60–79 scores 3 Moderately severe, permits ambulation Limited, even with support 40–59 Clinical grades: Excellent 18, 2 Severe with ambulation Very limited Good 15–17, Fair 12–14, Poor 1 Severe, prevents ambulation Bedridden 0–39 3–11 OR table. Patients were draped in a manner to allow free repaired femoral head was then gently reduced after careful movement of the injured limb. In the posterior Kocher– retraction of the cut edges of the capsule. The capsular tear Langenbeck approached hips (group A), the posterior was repaired, piriformis tendon was reattached and all mus- border of the gluteus medius and minimus was identified cle tears were repaired. and retracted to expose the posterosuperior aspect of the In the group of patients who were treated through tro- hip capsule. This was facilitated by abduction and internal chanteric flip approach (group B), patient’s position and rotation of the limb. The piriformis tendon was tagged and skin incision were the same as in Kocher–Langenbeck released but the short external rotators (gemelli and obtura- approach. The original approach of Ganz et al. [14] was tor internus) were preserved. In most of patients, the pos- strictly followed without modification. The trochanteric terior capsule was injured and the femoral head came out flip osteotomy was carefully performed staying lateral to through the interval between the piriformis and the short the insertion of the short external rotators. Care was taken external rotators injuring the fleshy muscles. The extent of to avoid injury of the acetabular labrum while doing cap- this injury was assessed carefully and protected. Of special sulotomy. The fractured fragment was handled, reduced interest was the potential damage to the obturator externus and stabilized in the same way as in Kocher–Langenbeck muscle which may indicate more severe damage because approach.
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