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Abstract

Purpose:

Femoral head fracture dislocations are serious articular fractures that are associated with soft tissue injuries and are challenging to treat. Arthroscopic surgery may be a way to treat fracture reduction and fixation, thereby avoiding the need for extensive arthrotomy.

Methods:

We followed up a consecutive series of seven patients with femoral head fracture dislocation via a scope-assisted percutaneous headless screw fixation between 2016 and 2017. The clinical and radiological results were assessed.

Results:

The locations of the fracture were all involving infra-foveal area. The mean follow-up duration was 18 (range 12–24) months. The mean Harris hip score was 90.8 (range 88–93) at the latest follow-up. None of the patients showed early osteoarthritis, heterotopic ossification, or avascular necrosis. The average maximal displacement of the fracture site was improved from preoperative 6.79 mm (range 4.21–12.32) to postoperative 2.76 mm (range 0.97–3.97). Concomitant intra-articular hip lesions secondary to traumatic hip dislocation can also be treated.

Conclusion:

Managing the infra-foveal fracture of the femoral head using arthroscopic reduction and fixation with headless screws can be a safe and minimally invasive option. More patients and longer follow-up are needed for a definite conclusion.

Keywords

femoral head fracture hip arthroscopy radiology trauma

Introduction

Femoral head fractures are rare injuries involving articular lesions that threaten hip function. Joint incongruency and instability are indications for surgical intervention. As with all articular fractures, the treatment goals include anatomical reduction to restore joint congruency, stable fixation consistent with early mobilization, and minimization of surgical damage. A variety of surgical approaches have been advocated for the treatment of femoral head fracture.^1
–3 Open reduction can result in greater damage to the joint, and complications associated with surgery for femoral head fractures have been reported to lead to heterotopic ossification (HO) and avascular necrosis (AVN).^1,3

–8 Surgery needs to be focused on the preservation of blood supply to the femoral head.

Hip arthroscopy has gained increasing attention over the last few years due to technical advances. Arthroscopy-assisted surgery for traumatic hip injuries was first described in 1987 by Goldman et al. during a procedure to extract a bullet lodged in the posterosuperomedial femoral articular surface.⁹ With the development of hip arthroscopy, it has since been used for hip fracture dislocations beyond the roles of diagnosis and foreign body removal. Compared with open reduction and internal fixation, the less invasive approach of arthroscopy-assisted percutaneous fixation has resulted in lower morbidity rates. Combining arthroscopic reduction and internal fixation offers the advantages of making a correct diagnosis and allowing for the evaluation of the fracture reduction and management of accompanying lesions. Herein, we report our experience of arthroscopy-assisted internal fixation in femoral head fracture dislocations.

Materials and methods

This retrospective chart review was approval by the Institutional Review Board of Chang Gung Medical Foundation (IRB number: 201700816B0). Between July 2016 and May 2017, seven young men aged 17–28 years (mean 26 years), all involved in motor vehicle accidents, underwent clinical examinations, which revealed displaced femoral head fracture dislocations (Table 1). No neurovascular injuries were found initially, and emergency closed reduction was performed in the emergency room. Plain radiographs and computed tomography (CT) images after closed reduction showed displaced femoral head fractures. In addition, one of the patients had an ipsilateral femoral shaft fracture. The informed consents were thoroughly explained to all seven patients, who then underwent hip scope-assisted internal fixation surgery. Single surgeon (S-L H) performed all the surgeries. The study was approved by the institutional review board of our hospital.

Table 1.

Patient characteristics, outcome, and radiological results in patients who had femoral head fracture dislocations treated with hip scope-assisted internal fixation surgery.

Case	Age	Sex	Injury site	Pipkin classification	Associated injury	Surgery	Complications	Labrum or ligamentum teres injury	Blood loss	Harris hip score	Maximal displacement (pre-OP → post-OP)	Flexion angle of hip joint
1	24	M	R	Type II	Nil	Hip scope-assisted internal fixation	Nil	+	Minimal	88	4.77 mm à 1.55 mm	>135
2	19	M	R	Type I	Nil	Hip scope-assisted Internal fixation	Nil	+	Minimal	89	4.21 mm → 3.51 mm	>135
3	28	M	R	Type I	Nil	Hip scope-assisted internal fixation	Nil	+	Minimal	91	5.52 mm → 0.97 mm	>135
4	23	M	L	Type II	Nil	Hip scope-assisted internal fixation	Nil	+	Minimal	92	12.32 mm → 3.92 mm	>135
5	20	M	L	Type II	Ipsilateral femoral shaft fracture	Hip scope-assisted internal fixation and CRIF	Temporary sciatic nerve palsy	+	150 cc	Not done	Not done	Not done
6	26	M	L	Type II	Nil	Hip scope-assisted internal fixation	Nil	+	Minimal	92	7.69 mm → 2.65 mm	>135
7	17	M	R	Type II	Nil	Hip scope-assisted internal fixation	Nil	+	Minimal	93	5.32 mm → 3.97 mm	>135

CRIF: closed reduction and internal fixation; Pre-OP: preoperation; Post-OP: postoperation; M: male; R: right; L: left; +: positive.

Surgical indications of internal fixation for the femoral head fracture dislocation were the presence of fracture fragment >2 cm in size and displacement >2 mm from the CT scan. All patients received definite surgeries between 4 days and 7 days after confirming the clinical condition of the patient to be stable. The Harris hip score was used to evaluate the functional outcome. CT scans with 3-D reconstruction was used to calculate the maximal displacement of the fracture site before and 3 months after surgery. After the index surgery, plain pelvic anteroposterior view and hip lateral view were obtained. Ficat classification of the osteonecrosis of the femoral head (ONFH),¹⁰ Brooker classification of HO,¹¹ and joint space width (JSW) of OA <2 mm were parameters for radiological outcomes.

Surgical methods

Under general anesthesia, each patient was placed in the supine position on the fracture table with intermittent traction. The position of the femoral artery was marked with the aid of ultrasonography. We used three standard portals to visualize the hip joint with a 70° arthroscope. A surgical grasper, elevator, and probe were used as joystick methods to reduce fracture fragmentation in hip external rotation. After thorough reduction of the fracture site, percutaneous guidewires were inserted into the femoral head through blunt dissection of the muscle under fluoroscopic guidance. The fracture fragment was fixed with two or three 2-mm Herbert screws, engaged in subchondral bone below the articular surface. Dynamic fluoroscopic examinations confirmed the successful and secure fixation of the fracture fragments without protrusion of the screws (Figure 1). The reduction of the fracture was confirmed with the video taken by the scope through different portals. Small osteochondral fragments in the hip joint and labrum tears were visualized and excised during the surgery. The wound was closed, and no suction drains in the joint were placed.

Figure 1.

(a) We used two cannulated Herbert screws to fixate the ovoid portion of fracture fragments. Two guide pins could support anti-rotational force when inserting the screws. The guide pin was inserted into the fragment perpendicular to the fracture line. (b) Each screw was engaged in the subchondral bone at least 2 mm below the articular surface. (c) Fluoroscopic view of the anterolateral area of the femoral head showing a reduction in fracture fragments toward the femoral head with the use of an elevator in a “joystick” manner. (d) The reduction of fracture can be seen partially under arthroscopy. (e) Two screws were used to allow for the antirational force of the fragments. Multiplanar fluoroscopy after fixation can check the reduction of the fracture site and position of the screws.

The first-generation cephalosporin was given as antibiotic prophylaxis before anesthesia and 24 h after surgery. Patients could walk with toe-touch bearing using crutches and discharged when the wound condition was stable. Patients were assessed clinically at intervals of 1, 3, 6, and 12 months after discharge. Thereafter, follow-ups were conducted annually.

Results

The locations of the fracture were all involving infra-foveal area. The mean operation time for hip scope-assisted internal fixation was 248 (range 170–320) min, and the mean blood loss was minimal, except in case 5. All seven patients had successful internal fixation after reduction of the fracture site. The patients were followed up at the clinic in the mean duration of 18 (range 12–24) months. All the patients were satisfied with the treatment outcomes. The results are summarized in Table 1. Case 5 was excluded because of association with ipsilateral femoral shaft fracture (Figure 2). The mean Harris hip score was 90.8 (range 88–93) at the latest follow-up visit. The mean range of flexion in the injured hip was more than 135°. No pain or limping gait was noted when walking, and the range of motion of the hip joint was symmetric to another site. The problem that everyone complained most often is that they could not completely squat of the injured hip.

Figure 2.

A 20-year-old man (case 5) with a Pipkin type II femoral head fracture dislocation associated with an ipsilateral femoral shaft fracture. (a) Preoperative radiography of 3-D computed tomography image showing the left femoral head fracture dislocation and femoral shaft fracture. (b) After surgical fixation of the femoral head and shaft, the femoral shaft fracture was treated with reduction and internal fixation first, followed by hip scope-assisted internal fixation.

Of the seven patients, all had associated intra-articular soft tissue lesion with ruptured labrum and ligamentum teres. Owing to the detachment of the complex rupture of soft tissue, all were excised by partially resection. In addition, most patients had small osteochondral fragments.

None of the patients showed early OA, HO, or ONFH. Fracture union was achieved without any additional procedure within 3 months in follow-up radiographs in all patients. Postoperative CT scans with 3-D reconstruction verified femoral head congruency with no screw migration. The average maximal displacement of the fracture site was improved from preoperative 6.79 mm (range 4.21–12.32) to postoperative 2.76 mm (range 0.97–3.97) (Figure 3).

Figure 3.

Case 4: a 23-year-old man with a left Pipkin type II femoral head fracture-dislocation. (a to c) Preoperative 3-D computed tomography scan showing a Pipkin type I femoral head fracture. (d to f) Postoperative 3-D computed tomography scan after 3 months verified reduced head fracture, femoral head congruency, fracture site healing, and no screw migration.

Six patients tolerated the procedure well without complications, except in case 5, who had a femoral head and shaft fracture and suffered from temporal sciatic nerve palsy and recovery at 3 months.

Discussion

The goal of surgical treatment for femoral head fracture is to preserve normal function of the hip joint. A major risk of femoral head fractures is OA, which are related to joint incongruence and chondral injury.^12

–17 Therefore, femoral head fractures require anatomical reduction and stable fixation of articular surfaces, allowing immediate active and passive exercises to obtain satisfactory results. Based on the Harris hip score criteria, we had excellent results (mean 90.8 and range 88–93) in all patients. Hip scope-assisted internal fixation may allow for promising short-term functional results and range of motion for hip joint. Our CT scan result also showed that displacement of the fracture site was improved after hip scope surgery (from preoperative 6.79 mm to postoperative 2.76 mm). It is possible to reduce the fracture site using appropriate instrument during surgery. However, we could not achieve anatomical reduction in the limited visual field and working area under scope.

Arthroscopically assisted surgery in patients with hip trauma has become increasingly popular.^18

–22 There were many reports about arthroscopic surgery in femoral head fractures.^23

–26 The detection of intra-articular free osteochondral fragments after hip fracture dislocations has also been reported with hip arthroscopy in addition to plain radiography or computed tomography.^21,27,28 The presence of such fragments in hip joints may contribute to the development of OA.^29
–31 However, removal of these fragments requires an extensive open approach. The osteochondral fragments were removed during the surgery in our cases. The advantages of arthroscopically-assisted internal fixation surgery for femoral head fractures allow the surgeon to diagnose and treat concomitant intra-articular pathologies during the procedure.

One systematic literature review regarding femoral head fractures identified 29 eligible articles describing 453 femoral head fractures in 450 patients. Overall, 3.2% of the cases suffered from wound infections and 3.95% suffered from sciatic nerve palsy as a complication of fracture dislocations. In addition, major late complications related to surgery included AVN (11.9%), post-traumatic arthritis (20%), and HO (16.8%).³² Another review of the literature identified 10 studies about the impact of surgery on the incidence of postoperative HO and AVN after femoral head fractures and reported that the anterior approach resulted in a higher incidence (42.1%) of HO and that the posterior approach resulted in a higher incidence of AVN (16.9%).³³ Regardless of the approach, open surgery seems to result in extensive joint exposure and a greater risk of affecting femoral head blood supply. Hip scope-assisted internal fixation may lower the incidence of major complications. There are no early posttraumatic OA, HO, or ONFH found in our cases during the follow-up period, but a long-term follow-up of the osteoarthritic change in hip joint is still needed.

The anatomical characteristics of the hip joint make internal fixation of femoral head fractures relatively difficult using hip arthroscopy. It is important to position the patient correctly before the surgery. The foot should be in external rotation as far as possible to facilitate visualization of the anteroinferior aspect of the femoral head during the surgery. Instruments such as a grasper, elevator, and probe can be used as a joystick to successfully reduce fracture fragments from the femoral head via different portals. Under ultrasonography, we drew the position of the femoral artery on the skin, and the insertion sites of percutaneous guidewires were positioned lateral to the femoral artery. The blunt dissection of the iliopsoas muscle can prevent femoral nerve injury when inserting the guidewires and screws. The length and position of the screws could be checked by immediate fluoroscopy and arthroscopy.

In our cases, all the fractures healed within 3 months without resorption of fragments. No complications such as wound infection or compartmental syndrome related to arthroscopy were found; however, one patient had temporary sciatic nerve palsy.^34

–37 The operative time was 248 (170–320) min and rather long and we did not have any major complications after surgery. In addition, we noted objective conditions of diminished blood loss, lesser invasiveness, better cosmetic outcomes, and early mobilization and rehabilitation. In the future, we believe that the surgery time could be shortened after gaining experience of hip scope surgery in such patients. However, there are some limitations to this report. First, not all femoral head fractures are suitable for arthroscopic reduction and internal fixation, such as those involving comminuted acetabular fractures and femoral head fragments of less than 1 cm in size which should be removed and those larger should be fixed.^38,39 Second, we do not have data supporting the benefits of this technique over excision of the fracture fragments or nonoperative treatment. Third, we lacked the ability to achieve anatomical reduction within the limited space of the hip joint, especially in the rotation orientation. The learning curve of this procedure is considerable, and further studies comparing this technique with simple excision or open surgery are needed.

Conclusion

Managing some of infra-foveal fracture of the femoral head needs surgery using arthroscopic reduction, and fixation with headless screws can be a safe and minimally invasive option. In addition, concomitant intra-articular hip lesions secondary to traumatic hip dislocation can also be treated. Hip scope-assisted internal fixation may be a safe way to have good short-term outcomes and range of motion for hip joint. The appropriate use of hip arthroscopy may reduce rates of morbidity compared to open reduction by avoiding soft tissue dissection and preserving blood supply to the femoral head.

Supplemental material

Supplemental Material, 201700816B0_IRB_approval_20170608 - Hip arthroscopy-assisted reduction and fixation for femoral head fracture dislocations: Clinical and radiographic short-term results of seven cases

Supplemental Material, 201700816B0_IRB_approval_20170608 for Hip arthroscopy-assisted reduction and fixation for femoral head fracture dislocations: Clinical and radiographic short-term results of seven cases by Shan-Ling Hsu, Chung-Yang Chen, Jih-Yang Ko, Chi-Hsiang Hsu, Hao-Chen Liu and Yu-Der Lu in Journal of Orthopaedic Surgery

Footnotes

Author contributions

All authors made substantive intellectual contributions to this study to qualify as authors. One surgeon, S-L H performed the hip scope surgery and design and study. H-C L and Y-D L collected data of patients. C-Y C performed the analysis of radiography and clinical data. An initial draft of the manuscript was written by S-L H and C-H H and J-Y K redrafted the manuscript parts of the manuscript and provided helpful advice on the final revision. All authors were involved writing the manuscript. All authors read and approved the final manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Shan-Ling Hsu

Supplemental material

Supplemental material for this article is available online.

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