Surgical treatment of femoral head fractures

Abstract

Background: Femoral head fractures (FHF) are uncommon and generally caused by high-energy injuries. Surgical reduction with stable fixation of large fragments is believed to have the best outcomes. This retrospective study intended to report outcomes with surgical treatment at our institution and tried to establish treatment algorithm.

Methods: Through the 6-year period (2003-2008), 35 FHF in 35 consecutive patients (average, 30 years) were surgically treated. All FHF were caused by high-energy trauma. Patients' general condition was stabilized first and hip dislocation was manually reduced immediately. Definite fracture treatment was scheduled after admission for an average of 2.9 days (0.3-11 days). Pipkin classification was used as the treatment guide and open reduction with internal fixation was performed in all 35 FHF.

Results: These FHF included 21 type I, 7 type II, 3 type III, and 4 type IV fractures. The hip joint had been approached by either an anterior or posterior route depending on the individual surgeon. Internal fixation with screws was performed for all 35 FHF. The average admission was 13.8 days (range, 2-35 days). Thirty patients (86%, 30/35) were followed for an average of 3.3 years (at lease 6 months) and all 30 FHF healed. Avascular necrosis of the femoral head was found in 23% (7/30) patients and six patients were converted to hip arthroplasty for developing advanced stages of avascular necrosis. Heterotopic ossification occurred in 43% (13/30) patients. However, only one patient had range of motion limitation. Besides, one patient had moderate hip osteoarthritis.

Conclusions: FHF are uncommon and generally caused by high-energy injuries. Fracture healing can be attained in all femoral head fractures by using open reduction and screw fixation. Our results by using conventional approaches were associated with high complication rates. Further endeavor to improve the outcome should be taken.

Keywords: Avascular necrosis; Femoral head fracture; Heterotopic ossification; Internal fixation; Osteoarthritis.

Fig. 1

(A) A 19-year-old man sustained combined right posterior hip dislocation and a femoral head fracture (Pipkin type I) due to motorcycle accident. (B) The hip dislocation was closely reduced immediately and the femoral head fragment was surgically treated with screw fixation later. The fracture healed at 3 months. (C) There were no avascular necrosis and heterotopic ossification for 2-year follow-up.

Fig. 2

(A) A 45-year-old man sustained combined right posterior hip dislocation with a femoral head fracture (Pipkin type I) due to automobile accident. (B) The fracture fragment was stabilized with two screws but avascular necrosis with nonunion occurred at 6 moths. (C) Total hip arthroplasty was performed within one year.

Fig. 3

(A) A 40-year-old man sustained combined right femoral neck and head fractures (Pipkin type III) due to motorcycle accident. (B) Both fractures were stabilized with screws but avascular necrosis occurred. (C) Bipolar hemiarthroplasty was performed at 6 months.

Fig. 4

(A) A 31-year-old man sustained combined right posterior hip dislocation with a femoral head fracture (Pipkin type II) due to motorcycle accident. (B) The fragment was stabilized with two screws. (C) Low grade of heterotopic ossification (class 1) occurred without symptoms for 3-year follow-up.