Minimally Invasive Medial Hip Approach for Treatment of Displaced Pipkin Type 1 Fractures: Surgical technique, quality of reduction and postoperative complications
Article Sidebar
Main Article Content
Abstract
Background: Treatment of femoral head fracture by surgical dislocation of the hip is claimed to provide full exposure of the femoral head but it is technically complex especially for inexperienced surgeon, and heterotopic ossification or trochanteric associated complications may be encountered. We adopted the minimally invasive medial hip approach technique originally proposed by Chiron to expose the displaced Pipkin type 1 fragment and report the surgical technique, quality of fragment reduction and immediate postoperative complication of this approach.
Patients and Methods: Ten patients who had stable, congruence hip reduction and Pipkin type 1 fracture with residual fragment displacement more than 3 mm were operatively managed by medial approach. The procedure was performed as originally described by Chiron et al. The quality of fragment reduction was evaluated according to Matta's criteria. Patients were monitored for immediate postoperative complications.
Results: Fragment fixation was performed in 9 patients and excision in another. Average operative time and blood loss was 96 minutes and 137 ml respectively. Postoperative fragment reduction quality was classified as anatomical in 4 and imperfect in 5 patients. There was no immediate postoperative complication.
Conclusion: Minimally invasive medial hip approach is a safe and relatively simple alternative exposure for surgical treatment of displaced Pipkin type 1 fracture without immediate major complication. The fragment reduction performance is approaching those achieved by the surgical hip dislocation, with less extensile dissection, and neither osteotomy nor re-dislocation of the hip is necessary.
Article Details
References
2. 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.
3. Foulk DM, Mullis BH. Hip dislocation: evaluation and management. J Am Acad Orthop Surg. 2010; 18(4): 199-209.
4. Larson CB. Fracture dislocation of the hip. Clin Orthop Relat Res. 1973; (92): 147-54.
5. Giordano V, Giordano M, Glória RC, de Souza FS, di Tullio P, Lages MM, et al. General principles for treatment of femoral head fractures. J Clin Orthop Trauma. 2019; 10(1): 155-60.
6. Stannard JP, Harris HW, Volgas DA, Alonso JE, Rodríguez-Merchán EC, Goddard NJ. Functional outcome of patients with femoral head fractures associated with hip dislocations. Clin Orthop Relat Res. 2000; (377): 44-56.
7. Swiontkowski MF, Thorpe M, Seiler JG, Hansen ST. Operative management of femoral head fractures: case-matched comparison of anterior versus posterior approaches for Pipkin 1 and Pipkin 2 fractures. J Orthop Trauma. 1992; 6(4): 437-42.
8. 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(4): 702-7.
9. Stewart MJ, Milford LW. Fracture-dislocation of the hip; an end-result study. J Bone Joint Surg Am. 1954; 36(A:2): 315-42.
10. Thompson VP, Ebstein HC. Traumatic dislocation of the hip; a survey of two hundred and four cases covering a period of twenty-one year. J Bone Joint Surg Am. 1951; 33(3): 746-78.
11. Upadhyay SS, Moulton A. The long-term results of traumatic posterior dislocation of the hip. J Bone Joint Surg Br. 1981; 63(4): 548-51.
12. Lang-Stevenson A, Getty CJM. The Pipkin fracture-dislocation of the hip. Injury. 1987; 18(4): 264-9.
13. 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: 176-81.
14. Ganz R, Gill T, Gautier E, Krugel N, Berlemann U. Surgical dislocation of the adult hip: a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br. 2001; 83-B(8): 1119-24.
15. Henle P, Kloen P, Siebenrock KA. Femoral head injuries: which treatment strategy can be recommended? Injury. 2007; 38(4): 478-88.
16. Guo JJ, Tang N, Yang HL, Qin L, Leung KS. Impact of surgical approach on postoperative heterotopic ossification and avascular necrosis in femoral head fractures: a systematic review. Int Orthop. 2010; 34(3): 319-22.
17. Massè A, Aprato A, Alluto C, Favuto M, Ganz R. Surgical hip dislocation is a reliable approach for treatment of femoral head fractures. Clin Orthop Relat Res. 2015; 473(12): 3744-51.
18. Chiron P, Murgier J, Cavaignac E, Pailhé R, Reina N. Minimally invasive medial hip approach. Orthop Traumatol Surg Res. 2014; 100(6): 687-9.
19. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996; 78(11): 1632-45.
20. Droll KP, Broekhuyse H, O’Brien P. Fracture of the femoral head. J Am Acad Orthop Surg. 2007; 15: 716-27.
21. Chen ZW, Lin B, Zhai WL, Guo ZM, Liang Z, Zheng JP, et al. Conservative versus surgical management of Pipkin type I fractures associated with posterior dislocation of the hip: a randomised controlled trial. Int Orthop. 2011; 35(7): 1077-81.
22. Kokubo Y, Uchida K, Takeno K, Yayama T, Miyazaki T, Negoro K, et al. Dislocated intra-articular femoral head fracture associated with fracture-dislocation of the hip and acetabulum: report of 12 cases and technical notes on s urgical intervention. Eur J Orthop Surg Traumatol. 2013; 23(5): 557-64.
23. Giannoudis PV, Kontakis G, Christoforakis Z, Akula M, Tosounidis T, Koutras C. Management, complications and clinical results of femoral head fractures. Injury. 2009; 40(12): 1245-51.
24. Holmes WJ, Solberg B, Bay BK, Laubach JE, Oldson SA. Biomechanical consequences of excision of displaced Pipkin femoral head fractures. J Orthop Trauma. 2000; 14(2): 149-50.
25. Chiron P, Lafontan V, Reina N. Fracture-dislocations of the femoral head. Orthop Traumatol Surg Res. 2013; 99 Suppl 1: S53-66.
26. Mostafa MF, El-Adl W, El-Sayed MAE. Operative treatment of displaced Pipkin type I and II femoral head fractures. Arch Orthop Trauma Surg. 2014; 134(5): 637-44.
27. Kurtz WJ, Vrabec GA. Fixation of femoral head fractures using the modified Heuter direct anterior approach. J Orthop Trauma. 2009; 23(9): 675-80.
28. Scolaro JA, Marecek G, Firoozabadi R , Krieg JC, Routt ML “Chip.” Management and radiographic outcomes of femoral head fractures. J Orthop Traumatol. 2017; 18(3): 235-41.
29. Gardner MJ, Suk M, Pearle A, Buly RL, Helfet DL, Lorich DG. Surgical dislocation of the hip for fractures of the femoral head. J Orthop Trauma. 2005; 19(5): 334-42.
30. Solberg BD, Moon CN, Franco DP. Use of a trochanteric flip osteotomy improves outcomes in Pipkin IV fractures. Clin Orthop Relat Res. 2009; 467(4): 929-33.
31. Sink EL, Beaulé PE, Sucato D, Kim YJ, Millis MB, Dayton M, et al. Multicenter study of complications following surgical dislocation of the hip. J Bone Joint Surg Am. 2011; 93(12): 1132-6.
32. Ross JR, Schoenecker PL, Clohisy JC. Surgical Dislocation of the Hip: Evolving Indications. HSS J. 2013; 9(1): 60-9.
33. Mallon WJ, Fitch RD. The medial approach to the hip revisited. Orthopedics. 1993; 16(1): 39-42.
34. Kelly RP, Yarbrough III SH. Posterior fracture dislocation of the femoral head with retained medial head fragment. J Trauma. 1971; 11(2): 97-110.
35. Cavaignac E, Laumond G, Régis P, Murgier J, Reina N, Chiron P. Fixation of a fractured femoral head through a medial hip approach: an original approach to the femoral head. Hip Int. 2015; 25(5): 488-91.