Management and Outcome of Pipkin Type I and Type II Femoral Head Fractures by Ganz Surgical Dislocation of the Hip

Abstract

Introduction Femoral head fractures, specifically Pipkin Type I and Type II, are uncommon injuries often linked with posterior hip dislocations. Management strategies for these fractures range from conservative treatments to various surgical procedures, with open reduction and internal fixation (ORIF) being a notable option. The surgical approach for ORIF varies, and due to the rarity of the injury, a standardized management protocol is lacking. This study aims to evaluate the outcome of managing Pipkin Type I and Type II femoral head fractures using ORIF through Ganz surgical dislocation of the hip, assessing complications and analyzing the functional outcome by radiographic assessment and functional evaluation. Methods This is a retrospective descriptive study of managing six cases of Pipkin Type I and Type II femoral head fractures with ORIF through Ganz surgical dislocation of the hip. Follow-up periods ranged from 19 to 96 months, and outcomes were evaluated using Matta's criteria for radiographic assessment and the Modified Harris Hip Score for functional evaluation. Results Known complications such as avascular necrosis (AVN) of the femoral head, heterotopic ossification (HO), post-traumatic arthritis (PTA), non-union of trochanteric osteotomy, and fracture non-union were monitored. Results showed one case of AVN, which occurred in a case of delayed open surgery following a failed primary closed reduction. All trochanteric osteotomies and femoral head fractures healed appropriately. No instances of HO or PTA were observed, even in the patient with the longest follow-up of 96 months. Discussion Controversy still exists in management and outcome of femoral head fracture among closed reduction alone, excision and ORIF using different techniques and approaches. Ganz surgical dislocation of the hip offers 360-degree visualization of acetabulum and nearly 360-degree visualization of head femur and hence an ideal exposure for working on femoral head and acetabulum. The study concludes that ORIF of femoral head fractures using the Ganz surgical dislocation approach is a viable treatment option, offering satisfactory outcomes with a low complication rate. The absence of PTA in long-term follow-ups may be attributed to meticulous removal of loose bodies and precise congruent reduction and fixation of head fragments.

Keywords: avn of femoral head; ganz surgical dislocation of hip; heterotopic ossification (ho); pipkin fracture; post traumatic arthritis (pta).

Figure 1. Pipkin Type II fracture left head femur with ipsilateral fracture shaft femur in a 69 years male (case no 1)

Figure 2. X-ray both hips anteroposterior (AP) and lateral (Lat) view of case no 2

Figure 3. Immediate post operative C arm image

Figure 4. Computed tomography (CT) scan with 3D reconstruction delineating femoral head fragment size and multiple loose fragments of case no 1

Figure 5. Line of trochanteric osteotomy

image credit: Sandip Das, presented with permission

Figure 6. Digastric trochanteric flip osteotomy

image credit: Sandip Das, presented with permission

Figure 7. Line of capsulotomy

image credit: Sandip Das, presented with permission

Figure 8. Position of patient and limb

image credit: Sandip Das, presented with permission

Figure 9. 360-degree visualisation of acetabulum and head with surgical dislocation of hip

image credit: Sandip Das, presented with permission

Figure 10. Open Reduction and Internal Fixation (ORIF) fracture head femur with three 4 mm titanium cancellous screws after debridement, removal of loose fragments and sandy particles by thorough lavage done with Ganz Surgical Dislocation of hip

Figure 11. Per operative – Open Reduction and Internal Fixation (ORIF) – negative drilling test

Figure 12. 12 weeks follow-up, both trochanteric osteotomy and fracture head fragment united with interlocking nail for ipsilateral fracture shaft femur.

Figure 13. At 19 months follow-up – avascular necrosis (AVN) developed (case no 2)

Figure 14. Excised head of femur of case no 2 – irregular articular surface with collapse as avascular necrosis (AVN) developed with union of fracture head femur

Figure 15. At 96 months follow-up, X-ray of both hips anteroposterior (AP) view – no signs of avascular necrosis (AVN) or post-traumatic arthritis (PTA)

Figure 16. At 96 months follow-up, X-ray of both hips frog lateral view – no signs of avascular necrosis (AVN) or post-traumatic arthritis (PTA)

Figure 17. Total Hip Replacement (THR) performed