TECHNICAL TRICK
Arthroscopic Reduction and Internal Fixation of Femoral Head Fractures Myung-Sik Park, MD, PhD, Sun-Jung Yoon, MD, PhD, and Seung-Min Choi, MD, MS
Summary: 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. Key Words: arthroscopic reduction, arthroscopic internal fixation, femoral head fracture, hip arthroscopy (J Orthop Trauma 2014;28:e164–e168)
INTRODUCTION Femoral head fractures are relatively uncommon; however, appropriate treatment of these fractures is of prime importance to help prevent the development of posttraumatic osteoarthritis.1–3 Pipkin4 classified these fractures according to the morphology of the fracture and its combination with femoral neck and/or acetabular fractures. Treatment of isolated femoral head fractures after posterior hip dislocation has been controversial. Nondisplaced Pipkin type 1 (OTA 31-C1)5 fractures have typically been treated in a closed manner; however, displaced large fractures traditionally have required open fixation and internal fixation with excision of small displaced osteochondral fragments or loose bodies using a surgical dislocation.6 Hip arthroscopy has been increasingly used as a less invasive surgical procedure for the diagnosis and treatment of femoroacetabular impingement7,8 and for the extraction of loose bodies as a result of trauma.9,10 Theoretically, an Accepted for publication November 21, 2013. From the Department of Orthopedic Surgery, Chonbuk National University Hospital, Biomedical Research Institute of Clinical Medicine, Jeonju, South Korea. Supported by Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, South Korea. The authors report no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions this article on the journal’s Web site (www.jorthotrauma.com). Reprints: Sun-Jung Yoon, MD, PhD, Department of Orthopedic Surgery, Chonbuk National University Hospital, Biomedical Research Institute of Clinical Medicine, Jeonju 561-712, South Korea (e-mail: sunjungyoon@ jbnu.ac.kr). Copyright © 2014 by Lippincott Williams & Wilkins
e164
| www.jorthotrauma.com
arthroscopic technique may decrease the morbidity associated with an open treatment for femoral head fracture. Previously, Lasfort el al. reported the removal of osteochondral fragments via hip arthroscopy in 2 hips,11 and more recently, some authors have described the arthroscopic reduction and internal fixation of an isolated suprafoveal surface fracture of the femoral head in 1 hip.12 For our study, we performed entirely arthroscopic reduction and internal fixation of 3 displaced infrafoveal Pipkin type 1 (OTA 31-C1.3) fractures. We found that the arthroscopic technique resulted in successful outcomes in these 3 consecutive cases. To our knowledge, these are the first reported cases of Pipkin type 1 (OTA 31-C1.3) femoral head fractures that were successfully treated by hip arthroscopy.
SURGICAL TECHNIQUE The senior author (M.-S.P.) performed the 3 entirely arthroscopic reduction and internal fixation procedures for OTA 31-C1.3 femoral head fractures between November 2010 and July 2011. The first patient was a 50-year-old woman who had been involved in a motor vehicle accident. She was initially evaluated at an outside hospital, and a closed reduction of her posteriorly dislocated left hip was accomplished by an emergency physician before her being transferred to our trauma center for the treatment of the femoral head fracture. Postreduction pelvic radiographs and computed tomography (CT) revealed a Pipkin type 1 (OTA 31-C1.3), distally displaced, femoral head fracture (Figs. 1A–H). She remained neurovascularly intact distal to the injury. The second patient was a 34-year-old man who had also been involved in a motor vehicle accident and who was referred to our trauma center for the treatment of a femoral head fracture. The physical examination revealed hip pain after the completion of closed reduction for a posterior hip dislocation. Pelvic radiographs and 3-dimensional CT revealed a Pipkin type 1 (OTA 31-C1.3) displaced fracture (Figs. 2A–F). He also had a normal neurovascular examination distal to the injury. The third patient was a 46-year old man who has been involved in a motor vehicle collision. He presented to the emergency department of our hospital with the history of high-velocity collision of his car against a truck. The crash impact was predominantly on both his knees with an axial transfer of energy along the thighs to his hips. On physical examination, his left hip was flexed and adducted, and a closed reduction of his posteriorly dislocated left hip was accomplished. Postreduction pelvic radiographs and CT J Orthop Trauma Volume 28, Number 7, July 2014
J Orthop Trauma Volume 28, Number 7, July 2014
Arthroscopic Reduction and Fixation of Femoral Head Fractures
FIGURE 1. The first case is a 50-year-old woman, preoperative pelvis anteroposterior view and CT shows Pipkin type 1 fracture (A, B). Arthroscopic view of large infrafoveal femoral head fracture fragment (C, D). Postoperative pelvis AP view and 3-dimensional CT view (E, F).
revealed a Pipkin type 1 (OTA 31-C1.3) fracture; the femoral head fragment did not reduce to an anatomic position spontaneously after closed reduction. He also had a proximal tibial fracture (OTA 41-B1) on the left side and bilateral ankle fractures (OTA 44-B2). He had a normal neurovascular examination distal to the injury. Seven days after their initial injuries, the patients underwent supine hip arthroscopy with intermittent hip distraction utilizing a commercially available hip positioning system (Smith & Nephew, Andover, MA). For the third patient, additional skeletal traction device was used at distal femur because of ipsilateral proximal tibial fracture. We used an anterolateral viewing portal, an anterior working portal, and an accessory distal anterior portal for arthroscopic screw delivery (Fig. 3A). The mean infusion pressure was adjusted as necessary and was maintained at approximately 60 mm Hg (range, 50–70 mm Hg). After capsulotomy and hematoma evacuation, the hip joint was examined using a 70-degree hip arthroscope. The osteochondral fracture fragment was visualized near the anteromedial aspect of the femoral head. A small area of acetabular cartilage and the labrum of the posterior wall were contused and torn. The ligamentum teres was ruptured at the femoral head insertion, which was consistent with a diagnosis of femoral head fracture with hip dislocation. The mean traction time was 57 minutes (range, 45– 69 minutes). After debridement of loose osteochondral fragments in the acetabulum, traction was released. The 2014 Lippincott Williams & Wilkins
longitudinal section of a T-shaped capsulotomy was performed through the distal anterior portal for further exposure of the head–neck junction and femoral head fracture area. To more easily access the fracture site of femoral head arthroscopically, the perineal post could be removed (Fig. 3B). A distally displaced inferomedial fracture fragment was visualized when the patient was positioned in 90 degrees of knee flexion and 45 degrees of hip flexion. The assistant maintained 30 degrees of hip abduction and external rotation to gradually position the inferior medial portion of femoral head toward the anterior working portal (Fig. 3C). We also used an accessory distal anterior portal located 3-finger breadths distal to the anterior portal along the longitudinal anterior superior iliac spine line. Displaced fracture fragments were reduced using switching sticks and curved curettes via the accessory distal portal and anterolateral portal. The fracture fragments were reduced and maintained in anatomic position by 2 small Kirschner wires through the anterior portal. Percutaneous fixation was accomplished through the accessory distal anterior portal using a 3.5-mm cortical screw (30-mm length) for the first patient. In this case, we were unable to use a cannulated screw system because the drive handle of the cannulated screw was too short to reach the fracture fragments arthroscopically. Instead, we used a 3.5-mm cortical screw with absorbable suture (#2-0 Vicryl; Ethicon, NJ, USA) tied onto the screw head during insertion to prevent the loss of the screw. This approach would also have allowed us to retrieve the screw from the depths of the www.jorthotrauma.com |
e165
Park et al
J Orthop Trauma Volume 28, Number 7, July 2014
FIGURE 2. The second case is a 43-year-old male patient. A preoperative pelvis anteroposterior view shows dislocation and after reduction views (A, B). Arthroscopic view of large femoral fracture fragment (C, D). Postoperative pelvis AP view and 3-dimensional CT view shows reduced fracture fragment fixed with a screw (E, F).
wound if the screw had disengaged from the screwdriver before insertion into the bone (see Video, Supplemental Digital Content 1, http://links.lww.com/BOT/A125, which demonstrates the arthroscopic reduction and fixation of femoral head fracture). For the second case, we used a long screwdriver handle to insert a cannulated screw (4.0 · 30 mm) for fixation. After reduction and insertion of the screw into the fracture fragment, we performed a dynamic test under arthroscopy using an image intensifier to evaluate the stability of the fracture fragment and impingement. We found that 1 screw was sufficient for stable fixation. The capsulotomy was then closed along the longitudinal section of the T-shaped incision. The patients were non–weight bearing in the immediate postoperative period but were allowed to ambulate with crutches at postoperative day 3. Postoperative radiographs (Figs. 1E, 2E) and 3-dimensional CT (Figs. 1F, 2F) revealed no screw migration or displacement of fracture fragments. Active leg raising and range of motion exercises were encouraged for the first 3 postoperative days. At 2 weeks, we recommended partial weightbearing ambulation with 2 crutches. Full–weight bearing was allowed after 6 weeks. By 6 weeks postoperatively, neither patient experienced pain or mechanical symptoms. By 3 months postoperatively, the first 2 patients had resumed full activities and had negative anterior impingement and Patrick tests. At 12 months
e166
| www.jorthotrauma.com
postoperatively, the first 2 patients remained pleased with the outcome (14 and 16 months). For the third patient, he was allowed ambulation with full–weight bearing without support at 3 months after postoperatively because of his ipsilateral proximal tibial fracture and bilateral ankle fractures. At the last follow-up, the patient remained asymptomatic hip except for mild discomfort around his left proximal tibia and ankle, and he has been able to carry out his routine activities with minimal difficulties. Postoperative imaging included radiographs and CT with 3-dimensional reconstruction demonstrating the maintenance of fracture reduction with no joint space narrowing or subluxation. To date, the fixation screws have not migrated in all 3 cases.
DISCUSSION Fractures of the femoral head occur in 6%–15% of cases of traumatic hip dislocation.1–3,13 The fractures are more common in posterior dislocations but may also be observed in anterior dislocations.14,15 Femoral head fractures worsen the prognosis of the dislocation, with spontaneous evolution to osteoarthritis in more than 50% of cases.13 Appropriate management of these femoral head fractures after reduction of hip dislocation is controversial. The goals of definitive treatment of femoral head fractures are to achieve anatomic reduction, to maintain joint stability, and to remove any interposed bone 2014 Lippincott Williams & Wilkins
J Orthop Trauma Volume 28, Number 7, July 2014
Arthroscopic Reduction and Fixation of Femoral Head Fractures
FIGURE 3. A, An accessory third portal is made by 3-finger breadth distal to anterior portal. B, Capsulotomy is made from anterior to anterolateral portal and longitudinal line of T-cut is made through distal anterior portal after traction released. C, Viewing from the anterior portal, the fracture line of the femoral head is identified with the hip flexed, abducted, and externally rotated.
fragments. These aims may be achieved either surgically or nonsurgically, depending on the size, location, and degree of fracture displacement. Nonsurgical treatment of femoral head fractures is acceptable when anatomic reduction is achieved and the hip joint is stable after closed reduction or if the small fragments is free inferior to the fovea. Surgical indications include nonanatomic reduction of the femoral head articular surface, instability of the hip joint, or the presence of intraarticular incarcerated fragments that prevent congruent joint reduction. The decision regarding whether fragments should be internally fixed or simply excised remains controversial.16 In our experience, the patients who underwent surgical excision tended to have fracture patterns that were not amenable to fixation or that were caudad to the fovea. Most surgeons agree that the factors that influence treatment include fragment size, degree of comminution, and location of the fragment in relation to the weight bearing surface of the femoral head. In the case of a fracture fragment large enough to allow internal fixation, reduction and internal fixation should be attempted with the goal of creating a smooth femoral head articular surface. There are some disadvantages to open reduction; arthrotomy and relocation can potentially disrupt the hip’s complex circulation.17 Although technically demanding, hip arthroscopy offers a less invasive approach that may be performed on an outpatient basis if the patient has no other injuries. In our cases, hip arthroscopy allowed us to achieve early rehabilitation and outstanding cosmesis. A recent review of the orthopedic literature documents the utility of hip arthroscopy in trauma, including for the removal of posttraumatic osteochondral loose bodies and interposed tissues.9,10,18 Lansford and Munns11 reported arthroscopic excision of small fragments in Pipkin type 1 2014 Lippincott Williams & Wilkins
fractures. Recently, Matsuda12 reported internal fixation of a suprafoveal fracture using hip arthroscopy in one case with good results. It is unclear whether that case was an actual Pipkin type 1 fracture or a variant of a Pipkin type 2 fracture because the fracture fragment originated in the suprafoveal area. A large displaced fragment of the infrafoveal portion resulted in more difficult reduction and internal fixation, which required injured extremity abduction and external rotation of the hip after the release of traction. To successfully perform arthroscopic internal fixation of a femoral head fracture rather than simply excising fragments, the surgeon must be knowledgeable about the safe portal placement around the hip,19 the use of a capsulotomy similar to that used in arthroscopic femoroacetabular impingement surgery,20 and the use of intermittent hip distraction permitting reduction within the confines of the acetabulum. The surgeon must also be comfortable with use of the 70-degree arthroscope that aids the procedure. In addition, careful management of intraarticular fluid pressure to minimize the risk of iatrogenic fluid extravasation into the intraabdominal20 and retroperitoneal space is critical.21–22 In our cases, we utilized an accessory distal anterior portal and T-shaped capsulotomy to facilitate internal fixation of the screw into the femoral head. The surgeon should have an inferior medial view of the femoral head while the patient is in a position of hip flexion, abduction, and external rotation after the removal of the perineal post. Based on our experience, we also suggest having access to an extralong screwdriver handle for 3.5 or 4.0-mm cannulated screws. The ideal internal fixation material remains under debate. We prefer a metallic screw to bioabsorbable material because a metallic screw is more easily visualized radiographically, which allows the surgeon to determine its position intraoperatively. The metallic screw also reduces www.jorthotrauma.com |
e167
J Orthop Trauma Volume 28, Number 7, July 2014
Park et al
the risk of implant breakage associated with a small-diameter bioabsorbable screw. We propose the following surgical indications for arthroscopic reduction and internal fixation of femoral head fracture: (1) displaced, large femoral head fracture configuration, (2) severely limited range of motion and impingement signs following conservative treatment, and (3) femoral head fracture associated with intraarticular lesions, such as loose bodies, labral tears, or ligamentum teres injury. Possible contraindications to arthroscopic surgery for femoral head fractures include the following: (1) instability with recurrent dislocation following closed reduction and (2) acetabular fractures with column fractures that can cause fluid extravasation during hip arthroscopy. If the femoral head fractures had not been reducible by arthroscopic methods, open reduction and internal fixation to achieve anatomic femoral head contours may have been preferable to the arthroscopic approach we used.
CONCLUSIONS Although the Pipkin type 1 fracture dislocation is rare, there is an increasing interest in arthroscopic management of large displaced fragments, due in large part to the advanced surgical techniques learned from the arthroscopic management of femoroacetabular impingement. We have presented 2 cases of successful internally fixated displaced infrafoveal fractures of the femoral head (Pipkin type 1, OTA 31-C1.3) performed arthroscopically, which show promise for the utility of arthroscopy for the management of hip trauma in the future. REFERENCES 1. Hougaard K, Thomsen PB. Traumatic posterior fracture-dislocation of the hip with fracture of the femoral head or neck, or both. J Bone Joint Surg Am. 1988;70:233–239. 2. Roeder LF, DeLee JC. Femoral head fractures associated with posterior hip dislocation. Clin Orthop Relat Res. 1980;147:121–130. 3. Sahin V, Karakas ES, Aksu S, et al. Traumatic dislocation and fracturedislocation of the hip. A long-term follow-up study. J Trauma. 2003;54: 520–529.
e168
| www.jorthotrauma.com
4. Pipkin G. Treatment of grade IV fracture dislocation of the hip. J Bone Joint Surg Am. 1957;39:1027–1042. 5. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(suppl 10):S1–S163. 6. Oransky M, Martinelli N, Sanzarello I, et al. Fractures of the femoral head: a long-term follow-up study. Musculoskelet Surg. 2012;96:95–99. 7. Philippon MJ, Schenker ML. Arthroscopy for the treatment of femoroacetabular impingement in the athlete. Clin Sports Med. 2006;25:299– 308. 8. Sampson TG. Arthroscopic treatment of femoroacetabular impingement. Tech Orthop. 2005;20:56–62. 9. Mullis BH, Dahners LE. Hip arthroscopy to remove loose bodies after traumatic dislocation. J Orthop Trauma. 2006;20:22–26. 10. Owens BD, Busconi BD. Arthroscopy for hip dislocation and fracturedislocation. Am J Orthop (Belle Mead NJ). 2006;35:584–587. 11. Lansford T, Munns SW. Arthroscopic treatment of Pipkin type I femoral head fractures: a report of 2 cases. J Orthop Trauma. 2012;26:e94–e96. 12. Matsuda DK. A rare fracture, an even rarer treatment: the arthroscopic reduction and internal fixation of an isolated femoral head fracture. Arthroscopy. 2009;25:408–412. 13. Epstein HC, Wiss DA, Cozen L. Posterior fracture dislocation of the hip with fractures of the femoral head. Clin Orthop Relat Res. 1985;201:9– 17. 14. DeLee JC, Evans JA, Thomas J. Anterior dislocation of the hip and associated femoral-head fractures. J Bone Joint Surg Am. 1980;62: 960–964. 15. Dussault RG, Beauregard G, Fauteaux P, et al. Femoral head defect following anterior hip dislocation. Radiology. 1980;135:627–629. 16. Ross JR, Gardner MJ. Femoral head fractures. Curr Rev Musculoskelet Med. 2012;5:199–205. 17. Epstein HC. Posterior fracture-dislocations of the hip; long-term followup. J Bone Joint Surg Am. 1974;56:1103–1127. 18. Yamamoto Y, Ide T. Usefulness of arthroscopic surgery in hip trauma cases. Arthroscopy. 2003;19:269–273. 19. Robertson WJ, Kelly BT. The safe zone for hip arthroscopy: a cadaveric assessment of central, peripheral, and lateral compartment portal placement. Arthroscopy. 2008;24:1019–1026. 20. Kampa RJ, Prasthofer A. The internervous safe zone for incision of the capsule of the hip. A cadaver study. J Bone Joint Surg Br. 2007;89:971– 976. 21. Haupt U, Volkle D, Waldherr C, et al. Intra- and retroperitoneal irrigation liquid after arthroscopy of the hip joint. Arthroscopy. 2008;24:966–968. 22. Bartlett CS, DiFelice GS, Buly RL, et al. Cardiac arrest as a result of intraabdominal extravasation of fluid during arthroscopic removal of a loose body from hip joint of a patient with an acetabular fracture. J Orthop Trauma. 1998;12:294–299.
2014 Lippincott Williams & Wilkins
Arthroscopic Reduction and Internal Fixation of Femoral Head Fractures Myung-Sik Park, MD, PhD, Sun-Jung Yoon, MD, PhD, and Seung-Min Choi, MD, MS
Summary: 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. Key Words: arthroscopic reduction, arthroscopic internal fixation, femoral head fracture, hip arthroscopy (J Orthop Trauma 2014;28:e164–e168)
INTRODUCTION Femoral head fractures are relatively uncommon; however, appropriate treatment of these fractures is of prime importance to help prevent the development of posttraumatic osteoarthritis.1–3 Pipkin4 classified these fractures according to the morphology of the fracture and its combination with femoral neck and/or acetabular fractures. Treatment of isolated femoral head fractures after posterior hip dislocation has been controversial. Nondisplaced Pipkin type 1 (OTA 31-C1)5 fractures have typically been treated in a closed manner; however, displaced large fractures traditionally have required open fixation and internal fixation with excision of small displaced osteochondral fragments or loose bodies using a surgical dislocation.6 Hip arthroscopy has been increasingly used as a less invasive surgical procedure for the diagnosis and treatment of femoroacetabular impingement7,8 and for the extraction of loose bodies as a result of trauma.9,10 Theoretically, an Accepted for publication November 21, 2013. From the Department of Orthopedic Surgery, Chonbuk National University Hospital, Biomedical Research Institute of Clinical Medicine, Jeonju, South Korea. Supported by Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, South Korea. The authors report no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions this article on the journal’s Web site (www.jorthotrauma.com). Reprints: Sun-Jung Yoon, MD, PhD, Department of Orthopedic Surgery, Chonbuk National University Hospital, Biomedical Research Institute of Clinical Medicine, Jeonju 561-712, South Korea (e-mail: sunjungyoon@ jbnu.ac.kr). Copyright © 2014 by Lippincott Williams & Wilkins
e164
| www.jorthotrauma.com
arthroscopic technique may decrease the morbidity associated with an open treatment for femoral head fracture. Previously, Lasfort el al. reported the removal of osteochondral fragments via hip arthroscopy in 2 hips,11 and more recently, some authors have described the arthroscopic reduction and internal fixation of an isolated suprafoveal surface fracture of the femoral head in 1 hip.12 For our study, we performed entirely arthroscopic reduction and internal fixation of 3 displaced infrafoveal Pipkin type 1 (OTA 31-C1.3) fractures. We found that the arthroscopic technique resulted in successful outcomes in these 3 consecutive cases. To our knowledge, these are the first reported cases of Pipkin type 1 (OTA 31-C1.3) femoral head fractures that were successfully treated by hip arthroscopy.
SURGICAL TECHNIQUE The senior author (M.-S.P.) performed the 3 entirely arthroscopic reduction and internal fixation procedures for OTA 31-C1.3 femoral head fractures between November 2010 and July 2011. The first patient was a 50-year-old woman who had been involved in a motor vehicle accident. She was initially evaluated at an outside hospital, and a closed reduction of her posteriorly dislocated left hip was accomplished by an emergency physician before her being transferred to our trauma center for the treatment of the femoral head fracture. Postreduction pelvic radiographs and computed tomography (CT) revealed a Pipkin type 1 (OTA 31-C1.3), distally displaced, femoral head fracture (Figs. 1A–H). She remained neurovascularly intact distal to the injury. The second patient was a 34-year-old man who had also been involved in a motor vehicle accident and who was referred to our trauma center for the treatment of a femoral head fracture. The physical examination revealed hip pain after the completion of closed reduction for a posterior hip dislocation. Pelvic radiographs and 3-dimensional CT revealed a Pipkin type 1 (OTA 31-C1.3) displaced fracture (Figs. 2A–F). He also had a normal neurovascular examination distal to the injury. The third patient was a 46-year old man who has been involved in a motor vehicle collision. He presented to the emergency department of our hospital with the history of high-velocity collision of his car against a truck. The crash impact was predominantly on both his knees with an axial transfer of energy along the thighs to his hips. On physical examination, his left hip was flexed and adducted, and a closed reduction of his posteriorly dislocated left hip was accomplished. Postreduction pelvic radiographs and CT J Orthop Trauma Volume 28, Number 7, July 2014
J Orthop Trauma Volume 28, Number 7, July 2014
Arthroscopic Reduction and Fixation of Femoral Head Fractures
FIGURE 1. The first case is a 50-year-old woman, preoperative pelvis anteroposterior view and CT shows Pipkin type 1 fracture (A, B). Arthroscopic view of large infrafoveal femoral head fracture fragment (C, D). Postoperative pelvis AP view and 3-dimensional CT view (E, F).
revealed a Pipkin type 1 (OTA 31-C1.3) fracture; the femoral head fragment did not reduce to an anatomic position spontaneously after closed reduction. He also had a proximal tibial fracture (OTA 41-B1) on the left side and bilateral ankle fractures (OTA 44-B2). He had a normal neurovascular examination distal to the injury. Seven days after their initial injuries, the patients underwent supine hip arthroscopy with intermittent hip distraction utilizing a commercially available hip positioning system (Smith & Nephew, Andover, MA). For the third patient, additional skeletal traction device was used at distal femur because of ipsilateral proximal tibial fracture. We used an anterolateral viewing portal, an anterior working portal, and an accessory distal anterior portal for arthroscopic screw delivery (Fig. 3A). The mean infusion pressure was adjusted as necessary and was maintained at approximately 60 mm Hg (range, 50–70 mm Hg). After capsulotomy and hematoma evacuation, the hip joint was examined using a 70-degree hip arthroscope. The osteochondral fracture fragment was visualized near the anteromedial aspect of the femoral head. A small area of acetabular cartilage and the labrum of the posterior wall were contused and torn. The ligamentum teres was ruptured at the femoral head insertion, which was consistent with a diagnosis of femoral head fracture with hip dislocation. The mean traction time was 57 minutes (range, 45– 69 minutes). After debridement of loose osteochondral fragments in the acetabulum, traction was released. The 2014 Lippincott Williams & Wilkins
longitudinal section of a T-shaped capsulotomy was performed through the distal anterior portal for further exposure of the head–neck junction and femoral head fracture area. To more easily access the fracture site of femoral head arthroscopically, the perineal post could be removed (Fig. 3B). A distally displaced inferomedial fracture fragment was visualized when the patient was positioned in 90 degrees of knee flexion and 45 degrees of hip flexion. The assistant maintained 30 degrees of hip abduction and external rotation to gradually position the inferior medial portion of femoral head toward the anterior working portal (Fig. 3C). We also used an accessory distal anterior portal located 3-finger breadths distal to the anterior portal along the longitudinal anterior superior iliac spine line. Displaced fracture fragments were reduced using switching sticks and curved curettes via the accessory distal portal and anterolateral portal. The fracture fragments were reduced and maintained in anatomic position by 2 small Kirschner wires through the anterior portal. Percutaneous fixation was accomplished through the accessory distal anterior portal using a 3.5-mm cortical screw (30-mm length) for the first patient. In this case, we were unable to use a cannulated screw system because the drive handle of the cannulated screw was too short to reach the fracture fragments arthroscopically. Instead, we used a 3.5-mm cortical screw with absorbable suture (#2-0 Vicryl; Ethicon, NJ, USA) tied onto the screw head during insertion to prevent the loss of the screw. This approach would also have allowed us to retrieve the screw from the depths of the www.jorthotrauma.com |
e165
Park et al
J Orthop Trauma Volume 28, Number 7, July 2014
FIGURE 2. The second case is a 43-year-old male patient. A preoperative pelvis anteroposterior view shows dislocation and after reduction views (A, B). Arthroscopic view of large femoral fracture fragment (C, D). Postoperative pelvis AP view and 3-dimensional CT view shows reduced fracture fragment fixed with a screw (E, F).
wound if the screw had disengaged from the screwdriver before insertion into the bone (see Video, Supplemental Digital Content 1, http://links.lww.com/BOT/A125, which demonstrates the arthroscopic reduction and fixation of femoral head fracture). For the second case, we used a long screwdriver handle to insert a cannulated screw (4.0 · 30 mm) for fixation. After reduction and insertion of the screw into the fracture fragment, we performed a dynamic test under arthroscopy using an image intensifier to evaluate the stability of the fracture fragment and impingement. We found that 1 screw was sufficient for stable fixation. The capsulotomy was then closed along the longitudinal section of the T-shaped incision. The patients were non–weight bearing in the immediate postoperative period but were allowed to ambulate with crutches at postoperative day 3. Postoperative radiographs (Figs. 1E, 2E) and 3-dimensional CT (Figs. 1F, 2F) revealed no screw migration or displacement of fracture fragments. Active leg raising and range of motion exercises were encouraged for the first 3 postoperative days. At 2 weeks, we recommended partial weightbearing ambulation with 2 crutches. Full–weight bearing was allowed after 6 weeks. By 6 weeks postoperatively, neither patient experienced pain or mechanical symptoms. By 3 months postoperatively, the first 2 patients had resumed full activities and had negative anterior impingement and Patrick tests. At 12 months
e166
| www.jorthotrauma.com
postoperatively, the first 2 patients remained pleased with the outcome (14 and 16 months). For the third patient, he was allowed ambulation with full–weight bearing without support at 3 months after postoperatively because of his ipsilateral proximal tibial fracture and bilateral ankle fractures. At the last follow-up, the patient remained asymptomatic hip except for mild discomfort around his left proximal tibia and ankle, and he has been able to carry out his routine activities with minimal difficulties. Postoperative imaging included radiographs and CT with 3-dimensional reconstruction demonstrating the maintenance of fracture reduction with no joint space narrowing or subluxation. To date, the fixation screws have not migrated in all 3 cases.
DISCUSSION Fractures of the femoral head occur in 6%–15% of cases of traumatic hip dislocation.1–3,13 The fractures are more common in posterior dislocations but may also be observed in anterior dislocations.14,15 Femoral head fractures worsen the prognosis of the dislocation, with spontaneous evolution to osteoarthritis in more than 50% of cases.13 Appropriate management of these femoral head fractures after reduction of hip dislocation is controversial. The goals of definitive treatment of femoral head fractures are to achieve anatomic reduction, to maintain joint stability, and to remove any interposed bone 2014 Lippincott Williams & Wilkins
J Orthop Trauma Volume 28, Number 7, July 2014
Arthroscopic Reduction and Fixation of Femoral Head Fractures
FIGURE 3. A, An accessory third portal is made by 3-finger breadth distal to anterior portal. B, Capsulotomy is made from anterior to anterolateral portal and longitudinal line of T-cut is made through distal anterior portal after traction released. C, Viewing from the anterior portal, the fracture line of the femoral head is identified with the hip flexed, abducted, and externally rotated.
fragments. These aims may be achieved either surgically or nonsurgically, depending on the size, location, and degree of fracture displacement. Nonsurgical treatment of femoral head fractures is acceptable when anatomic reduction is achieved and the hip joint is stable after closed reduction or if the small fragments is free inferior to the fovea. Surgical indications include nonanatomic reduction of the femoral head articular surface, instability of the hip joint, or the presence of intraarticular incarcerated fragments that prevent congruent joint reduction. The decision regarding whether fragments should be internally fixed or simply excised remains controversial.16 In our experience, the patients who underwent surgical excision tended to have fracture patterns that were not amenable to fixation or that were caudad to the fovea. Most surgeons agree that the factors that influence treatment include fragment size, degree of comminution, and location of the fragment in relation to the weight bearing surface of the femoral head. In the case of a fracture fragment large enough to allow internal fixation, reduction and internal fixation should be attempted with the goal of creating a smooth femoral head articular surface. There are some disadvantages to open reduction; arthrotomy and relocation can potentially disrupt the hip’s complex circulation.17 Although technically demanding, hip arthroscopy offers a less invasive approach that may be performed on an outpatient basis if the patient has no other injuries. In our cases, hip arthroscopy allowed us to achieve early rehabilitation and outstanding cosmesis. A recent review of the orthopedic literature documents the utility of hip arthroscopy in trauma, including for the removal of posttraumatic osteochondral loose bodies and interposed tissues.9,10,18 Lansford and Munns11 reported arthroscopic excision of small fragments in Pipkin type 1 2014 Lippincott Williams & Wilkins
fractures. Recently, Matsuda12 reported internal fixation of a suprafoveal fracture using hip arthroscopy in one case with good results. It is unclear whether that case was an actual Pipkin type 1 fracture or a variant of a Pipkin type 2 fracture because the fracture fragment originated in the suprafoveal area. A large displaced fragment of the infrafoveal portion resulted in more difficult reduction and internal fixation, which required injured extremity abduction and external rotation of the hip after the release of traction. To successfully perform arthroscopic internal fixation of a femoral head fracture rather than simply excising fragments, the surgeon must be knowledgeable about the safe portal placement around the hip,19 the use of a capsulotomy similar to that used in arthroscopic femoroacetabular impingement surgery,20 and the use of intermittent hip distraction permitting reduction within the confines of the acetabulum. The surgeon must also be comfortable with use of the 70-degree arthroscope that aids the procedure. In addition, careful management of intraarticular fluid pressure to minimize the risk of iatrogenic fluid extravasation into the intraabdominal20 and retroperitoneal space is critical.21–22 In our cases, we utilized an accessory distal anterior portal and T-shaped capsulotomy to facilitate internal fixation of the screw into the femoral head. The surgeon should have an inferior medial view of the femoral head while the patient is in a position of hip flexion, abduction, and external rotation after the removal of the perineal post. Based on our experience, we also suggest having access to an extralong screwdriver handle for 3.5 or 4.0-mm cannulated screws. The ideal internal fixation material remains under debate. We prefer a metallic screw to bioabsorbable material because a metallic screw is more easily visualized radiographically, which allows the surgeon to determine its position intraoperatively. The metallic screw also reduces www.jorthotrauma.com |
e167
J Orthop Trauma Volume 28, Number 7, July 2014
Park et al
the risk of implant breakage associated with a small-diameter bioabsorbable screw. We propose the following surgical indications for arthroscopic reduction and internal fixation of femoral head fracture: (1) displaced, large femoral head fracture configuration, (2) severely limited range of motion and impingement signs following conservative treatment, and (3) femoral head fracture associated with intraarticular lesions, such as loose bodies, labral tears, or ligamentum teres injury. Possible contraindications to arthroscopic surgery for femoral head fractures include the following: (1) instability with recurrent dislocation following closed reduction and (2) acetabular fractures with column fractures that can cause fluid extravasation during hip arthroscopy. If the femoral head fractures had not been reducible by arthroscopic methods, open reduction and internal fixation to achieve anatomic femoral head contours may have been preferable to the arthroscopic approach we used.
CONCLUSIONS Although the Pipkin type 1 fracture dislocation is rare, there is an increasing interest in arthroscopic management of large displaced fragments, due in large part to the advanced surgical techniques learned from the arthroscopic management of femoroacetabular impingement. We have presented 2 cases of successful internally fixated displaced infrafoveal fractures of the femoral head (Pipkin type 1, OTA 31-C1.3) performed arthroscopically, which show promise for the utility of arthroscopy for the management of hip trauma in the future. REFERENCES 1. Hougaard K, Thomsen PB. Traumatic posterior fracture-dislocation of the hip with fracture of the femoral head or neck, or both. J Bone Joint Surg Am. 1988;70:233–239. 2. Roeder LF, DeLee JC. Femoral head fractures associated with posterior hip dislocation. Clin Orthop Relat Res. 1980;147:121–130. 3. Sahin V, Karakas ES, Aksu S, et al. Traumatic dislocation and fracturedislocation of the hip. A long-term follow-up study. J Trauma. 2003;54: 520–529.
e168
| www.jorthotrauma.com
4. Pipkin G. Treatment of grade IV fracture dislocation of the hip. J Bone Joint Surg Am. 1957;39:1027–1042. 5. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(suppl 10):S1–S163. 6. Oransky M, Martinelli N, Sanzarello I, et al. Fractures of the femoral head: a long-term follow-up study. Musculoskelet Surg. 2012;96:95–99. 7. Philippon MJ, Schenker ML. Arthroscopy for the treatment of femoroacetabular impingement in the athlete. Clin Sports Med. 2006;25:299– 308. 8. Sampson TG. Arthroscopic treatment of femoroacetabular impingement. Tech Orthop. 2005;20:56–62. 9. Mullis BH, Dahners LE. Hip arthroscopy to remove loose bodies after traumatic dislocation. J Orthop Trauma. 2006;20:22–26. 10. Owens BD, Busconi BD. Arthroscopy for hip dislocation and fracturedislocation. Am J Orthop (Belle Mead NJ). 2006;35:584–587. 11. Lansford T, Munns SW. Arthroscopic treatment of Pipkin type I femoral head fractures: a report of 2 cases. J Orthop Trauma. 2012;26:e94–e96. 12. Matsuda DK. A rare fracture, an even rarer treatment: the arthroscopic reduction and internal fixation of an isolated femoral head fracture. Arthroscopy. 2009;25:408–412. 13. Epstein HC, Wiss DA, Cozen L. Posterior fracture dislocation of the hip with fractures of the femoral head. Clin Orthop Relat Res. 1985;201:9– 17. 14. DeLee JC, Evans JA, Thomas J. Anterior dislocation of the hip and associated femoral-head fractures. J Bone Joint Surg Am. 1980;62: 960–964. 15. Dussault RG, Beauregard G, Fauteaux P, et al. Femoral head defect following anterior hip dislocation. Radiology. 1980;135:627–629. 16. Ross JR, Gardner MJ. Femoral head fractures. Curr Rev Musculoskelet Med. 2012;5:199–205. 17. Epstein HC. Posterior fracture-dislocations of the hip; long-term followup. J Bone Joint Surg Am. 1974;56:1103–1127. 18. Yamamoto Y, Ide T. Usefulness of arthroscopic surgery in hip trauma cases. Arthroscopy. 2003;19:269–273. 19. Robertson WJ, Kelly BT. The safe zone for hip arthroscopy: a cadaveric assessment of central, peripheral, and lateral compartment portal placement. Arthroscopy. 2008;24:1019–1026. 20. Kampa RJ, Prasthofer A. The internervous safe zone for incision of the capsule of the hip. A cadaver study. J Bone Joint Surg Br. 2007;89:971– 976. 21. Haupt U, Volkle D, Waldherr C, et al. Intra- and retroperitoneal irrigation liquid after arthroscopy of the hip joint. Arthroscopy. 2008;24:966–968. 22. Bartlett CS, DiFelice GS, Buly RL, et al. Cardiac arrest as a result of intraabdominal extravasation of fluid during arthroscopic removal of a loose body from hip joint of a patient with an acetabular fracture. J Orthop Trauma. 1998;12:294–299.
2014 Lippincott Williams & Wilkins
