Complications and Functional Outcome of Femoral Head Fracture-Dislocation In Delayed and Neglected Cases

Abstract

Introduction: Delayed reduction of the hip in femoral head fracture dislocation increases the risk of osteonecrosis and adversely affects the functional outcome.

Materials and methods: This retrospective study was designed to evaluate the outcome and complications of 138 patients with femoral head fracture dislocation treated by a single surgeon over a period of 22 years. Only seven patients presented within 24 h of injury and remaining all presented late. The hip joints could be reduced by closed manoeuvre in 105 patients, and 33 patients needed open reduction. The patients were managed conservatively or surgically. The mean follow-up period was 3.57 years (1-18 years).

Results: There were 119 males and 19 females. The mean age was 35.71 years (range, 18-70 years). Forty-two patients were managed conservatively, and 96 patients needed surgical treatment. The Kocher-Langenbeck approach was used in 40 patients, the trochanteric flip osteotomy in 14 patients, the Smith-Peterson approach in 31 patients, and the Watson-Jones approach in one patient. The femoral head fragment was fixed in 47.82% patients and excised in 11.59% patients. Primary total hip replacement (THR) was performed in 7.24% of patients through the posterior approach. 24.63% of patients developed complications with 14.49% of hip osteonecrosis, 2.89% posttraumatic osteoarthritis and 2.17% femoral head resorption. 55% of patients who developed osteonecrosis were operated through the posterior approach. Secondary procedures were needed in 14.48% of patients. The clinical outcome, as evaluated using the modified Harris Hip Score, was good to excellent in 52.89% of patients and poor to fair in 47.11% of patients.

Conclusion: The incidences of osteonecrosis and secondary procedures are increased in delayed and neglected femoral head fracture dislocation. Osteonecrosis is commonly seen in Brumback 2A injuries and posterior-based approaches. All Brumback 3B fractures in such delayed cases should be treated with THR. Osteosynthesis or conservative treatment should be reserved for other types of injuries. A careful selection of treatment plan in such delayed cases can result in a comparable functional outcome as reported in the literature.

Keywords: AVN; Brumback classification; Harris hip score; Hip dislocation; Hip fracture; Osteonecrosis; Pipkin fracture dislocation.

Fig. 1

a 47-year female presented with left-sided femoral head fracture (infrafoveal, Pipkin type I, Brumback type 1A) with posterior hip dislocation, (b) Closed reduction was performed, and the postoperative radiograph showed congruent joint with well-aligned fracture fragment, (c) 10-years after surgery, radiograph showed completely healed fracture with no degeneration in the joint (d) Her functional outcome was excellent and she was able to perform the daily activities

Fig. 2

a, b An interesting case of Brumback type 2A/ Pipkin type II fracture-dislocation in a 34-year male where the femoral head fragment was reversed after hip reduction, (c) Open reduction and internal fixation was performed with small fragment partially threaded screws through Smith-Peterson approach, (d, e) 11-years after the surgery, the radiographs do not show any evidence of arthritis, (f, g) he could perform all daily activities

Fig. 3

a 29-year male with Brumback type 2A/ Pipkin type III fracture-dislocation, (b); Closed reduction was done, and internal fixation was performed through Ganz’s safe surgical hip dislocation. Radiograph after 7 years shows no evidence of osteonecrosis or arthritis. c; the patient had excellent functional activities

Fig. 4

a–d Radiograph and CT scan of Brumback type 3B/ Pipkin type III fracture-dislocation in a 19-year male, (e) The femoral head was reconstructed on the table and then fixed with neck using large fragment partially threaded screws, (f) postoperative radiograph shows the anatomical reconstruction of the femoral head and neck, (g) 5 years after fixation, there was osteonecrosis with femoral head collapse and healing, (h) 8 years after the fixation, the healed osteonecrosis has progressed to femoro-acetabular impingement with mild osteoarthritis changes in the hip, but the functional outcome of the patient is fair as evaluated using modified HHS

Fig. 5

a 24-year male with Right-sided Brumback type 4B injury after closed reduction, (b) Intraoperative picture shows transchondral injury, (c) fixation with multiple mini-screws, (d) 2-years follow up X-ray shows no degeneration in the joint

Fig. 6

a 59-year old male with Brumback type 1B/Pipkin type IV fracture-dislocation, (b) Axial cut section of CT scan shows femoral head fracture and posterior wall acetabulum fracture, (c) The femoral head fragment was excised, and acetabulum fracture was fixed with 3.5 mm reconstruction plate and lag screw, (d, e) 11-years after surgery, the X-ray showed the hip joint degeneration, but the patient had fair outcome