Management and outcome of patients with femoral head fractures: the mid-term follow-up with injuries and associated prognostic factors

Abstract

Background: Femoral head fractures are rare injuries often associated with poor functional outcomes and complications. The purpose of this study was to evaluate the incidence, treatment methods and approaches, complications, and functional outcomes of femoral head fractures.

Methods: We retrospectively reviewed 50 patients who sustained femoral head fractures between January 2011 and December 2018. There were thirty-seven (74%) males and thirteen (26%) females with a median age of 40 years. According to Pipkin's classification, there were eighteen (36%) Pipkin I, ten (20%) Pipkin II, eight (16%) Pipkin III, and fourteen (28%) Pipkin IV patients. Treatment methods were categorized into non-operative, operative by open reduction and internal fixation (ORIF), and immediate total hip replacement (THR). The recorded surgical approach consists of an anterior(S-P) approach, posterior(K-L) approach, lateral stab, and combined anterior + lateral stab approach for fixation. The patients were also stratified by the Injury Severity Score (ISS), associated injuries, and, mechanism of injuries. The modified harris hip score (MHHS) was used to evaluate the ongoing complications with the clinical outcome of patients with two years or greater follow-up.

Results: Eight (16%) patients were managed successfully with closed reduction without surgery and thirty-seven (74%) patients required operative reduction and internal fixation (ORIF) of the femoral head and acetabulum, and 5 (10%) patients required immediate THR. Six (12%) patients developed AVN, and four (8%) required a secondary THR. Sixteen patients (33%) developed post-traumatic osteoarthritis (PTOA), eight (16%) developed heterotopic ossification (HO) and six patients (12%) had sciatic nerve injury, none requiring operative treatment. Overall functional results according to MHHS were, excellent in two (4%) patients, good in sixteen (32%) patients, fair in twenty-two (44%) patients, and poor in ten (20%) patients. A statistically significant difference in outcome was observed among four pipkin subtypes.

Conclusion: Femoral head fractures are rare injuries often associated with poor outcomes. In this study, we report the functional outcomes and complications of all treatment approaches for femoral head fracture based on the Pipkin classification. The treatment aim should always be the anatomical reduction of the fragments. This study, adds to the growing literature on femoral head fracture and provides a reference for the clinical treatment to guide patient management.

Trial registration: Our study was approved by the Clinical Research and Biomedical Ethical Committee of West China Hospital, Sichuan University, and was performed in accordance with the Declaration of Helsinki. All participants provided written informed consent to participate in this study.

Keywords: Avascular necrosis; Femoral head fracture; Heterotopic ossification; Pipkin fracture; Post traumatic osteoarthritis; Surgical approach.

Fig. 1

Flow diagram showing femoral head fracture patients’ recruitment, clinical intervention and analysis

Fig. 2

Relative distribution of femoral head fracture in each Pipkin subtype based on different treatment variables

Fig. 3

a A 39 -year-old man with Pipkin type I right femoral head fracture b Anteroposterior (AP) radiographs showing anatomical reduction of the femoral head using anterior approach under direct vision. c AP and d Lateral radiograph of the hip during 3rd-year follow-up after internal fixation

Fig. 4

a Anteroposterior pelvic radiographs showing a 21-year-old male with left Pipkin II fracture-dislocation. b Post-operative X-ray films showing anatomical reduction of the femoral head with one Herbert screw via an anterior approach. c AP radiograph of 4th-year follow-up. d AP and Lateral radiograph of 7th-year follow-up.  There is evidence of post-traumatic osteoarthritis, including some loss of joint space, but there are no indications of AVN or heterotopic ossification

Fig. 5

A 27-year female sustained injury after motor vehicle accident. a Coronal view b 3D CT demonstrated right sided Pipkin III femoral head and neck fracture. c The fracture was anatomically reduced with herbert screw via anterior approach and femoral neck was corrected with three cannulated screw utilizing lateral stab approach

Fig. 6

a Harris hip score measuring functional outcome in relation to different surgical approaches. Data presented as mean ± SD. P-values were calculated using one-way NOVA (analysis of variance). P < 0.05 considered as statistically significant. b Relative distribution of femoral head fracture patients in four Pipkin subtypes based on functional outcome