Unusual combination of femoral head dislocation associated acetabular fracture with multipart femoral fractures: Case report

IntroductionTraumatic hip dislocation associated with femur intertrocanteric fracture is a rare and severe injury and it frequently occurs following a high energy trauma, Associated acetabular fractures with this injury are even more rare and potentially cause devastating consequences including avascular necrosis of the femoral head and subsequent early secondary osteoarthritis of the hip joint.Presentation of caseIn this case report, we present a 20 year old polytraumatized patient with traumatic hip dislocation associated with ipsilateral acetabulum fracture and simultaneous fractures of the ipsilateral femur.DiscussionTraumatic hip dislocation associated with femur intertrochanteric fracture is a rare and severe injury and it frequently occurs following a high energy trauma. In polytraumatized patients, musculoskeletal injuries are the most common lesions requiring surgical intervention frequently presenting challenging scenarios in terms of functional outcome and quality of life. Osteonecrosis of the femoral head is a serious and unpredictable complication that may occur after displaced femoral neck fracture and traumatic hip dislocation due to the disturbed blood supply of the femoral head.ConclusionA staged treatment strategy may be useful managing an unstable polytraumatized patient or a patient who requires prolonged transfer to receive definitive care.     

Three part posterior fracture dislocation of the hip without fracture of the femoral head: review of literature and a case report

This case report describes a rare posterior dislocation of the hip with fractures of the ipsilateral femoral neck and greater trochanter, without fracture of the femoral head, in a young adult male following a railway accident. This patient was managed within 6h of injury by open reconstruction. This unusual injury has not been reported previously. Cases of posterior fracture dislocation of the hip with a fracture of the femoral neck without fracture of the femoral head were reviewed from the literature. Mechanism of injury, controversies regarding operative procedures and appropriate surgical approach are discussed. The authors also believe that this injury pattern merits inclusion in the existing classification system of fracture dislocation of hip for management and prediction of outcome.     

Transient epiphyseal lesion of the femoral head after traumatic hip dislocation: A case report

IntroductionWe experienced a rare case in which magnetic resonance imaging (MRI) showed a transient epiphyseal lesion of the femoral head four months after traumatic hip dislocation. To our knowledge, there have been no previously published reports on the development of such transient lesions after traumatic hip dislocation involving no abnormalities just after dislocation.Presentation of caseWe report a 22-year-old man who showed a transient epiphyseal lesion of the femoral head after traumatic hip dislocation. On MRI performed two days after dislocation, no bony injuries were observed around the hip joint. Four months after dislocation, the patient suddenly experienced right hip pain without any new trauma or injury. A low-intensity band convex to the articular surface was apparent above the epiphyseal scar on T1-weighted imaging, and bone marrow edema was observed around the band lesion on short-tau inversion recovery imaging. Following a two-month period of non-surgical conservative therapy, the patient’s hip pain resolved and the low-intensity band was no longer observed on follow-up MRI.DiscussionAlthough the detailed pathogenesis of this transient changes was unclear, we speculate that prolonged rest after traumatic hip dislocation may contribute to bone insufficiency, resulting in an insufficiency fracture of the femoral head.ConclusionThis study suggests that transient epiphyseal lesions of the femoral head may occur in patients with a history of traumatic hip dislocation associated with an adapted long-term rest.     

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

IntroductionDelayed reduction of the hip in femoral head fracture dislocation increases the risk of osteonecrosis and adversely affects the functional outcome.Materials and MethodsThis 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).ResultsThere 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.ConclusionThe 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.     

Surgical treatment and prognosis of acetabular fractures associated with ipsilateral femoral neck fractures

Combined ipsilateral acetabular and femoral neck fractures are the result of high-energy trauma. Satisfactory treatment for this injury pattern remains a challenge, since traditional open reduction and internal fixation (ORIF) is always accompanied by a high prevalence of posttraumatic arthritis and avascular necrosis of the femoral head. Eight of 502 acetabular fractures from 1990 to 2008 were diagnosed with combined ipsilateral femoral neck fracture, in which 5 patients' fractures were associated with hip dislocation. These patients were injured from falls, traffic accidents, or crushing accidents. Radiographs and computed tomography scans were taken to check acetabular and femoral neck fractures. All of the patients underwent surgery using appropriate approaches and techniques. Postoperative radiographs demonstrated anatomic or satisfactory reduction for acetabular fractures as well as excellent or good reduction for femoral neck fractures in all of the patients. Follow-up radiographs showed femoral head necrosis in the 5 patients with femoral head dislocations, but not in the other 3 patients. We have seen few patients with this injury pattern, which makes us unable to detect significant differences between the patients associated with femoral head dislocation and those without femoral head dislocation. But by considering the results of our study and those reported in the literature, we believe that for patients with ipsilateral acetabular and femoral neck fractures without hip dislocation, satisfactory results could be expected after ORIF. But for those cases associated with hip dislocation, alternative methods such as acute THR as primary treatment are worthy of consideration.     

Obturator hip dislocation with ipsilateral fractures of the femoral head and femoral neck. A case report

A 28-year-old female pedestrians, struck by an automobile, sustained an obturator hip dislocation with concomitant ipsilateral fractures of both the femoral head and femoral neck. This unusual hip injury seems not to have been previously reported. The femoral neck fracture was widely separated from the shaft, and unfortunately, a 6-mm deep indentation fracture involved the anterosuperior portion of the articulating surface of the femoral head. This complex injury was treated with a press-fit bipolar prosthesis.     

Bilateral irreducible asymmetrical fracture-dislocation of the hip: A case report and literature review

Introduction and importanceBilateral hip dislocation is a rare injury. Bilateral asymmetrical fracture-dislocation is an even rarer type of injury. Apart from its rarity, prompt diagnosis of this condition and emergent treatment is necessary to prevent complications.Case presentationHere we present a 32 years old patient admitted with bilateral asymmetrical dislocation of hips following high energy motor traffic accident.Clinical findings and investigationsComputed tomography revealed bilateral asymmetrical hip dislocations (Left hip anterior dislocation and the right hip posterior dislocation) with a small femoral head fracture on the right side and a large Pipkin I fracture on the left side.Intervention and outcomeClosed reduction of bilateral hips failed under general anaesthesia and rendered immediate open reduction of both hips through different approaches and fixation of the osteochondral fragment. Rehabilitation was challenging as the patient has been recovering from a head injury and bilateral lower limb involvement. The patient is under follow-up for any evidence of avascular necrosis of the femoral heads and myositis ossificans.Relevance and impactBilateral irreducible asymmetrical fracture-dislocations of the hip joint are rarest of its kind. Pre-operative emergent computed tomography is very helpful to identify fracture-dislocations and help in the planning of osteosynthesis. Preparation for open reduction while undergoing a close reduction is essential.     

Traumatic posterior fracture-dislocation of the hip with fracture of the femoral head or neck, or both

To determine the prognosis and best treatment for patients who have a posterior dislocation of the hip associated with a fracture of the femoral head or neck (Grade IV, according to the classification of Stewart and Milford), we surveyed the records of 201 patients who had been treated for 203 posterior dislocations from 1958 to 1985 and selected the cases of 19 patients (19 posterior fracture-dislocations of the hip) for further review. Each of the injuries had resulted from a motor-vehicle accident. Thirteen patients had had a posterior dislocation with an associated fracture of the femoral head located either caudad or cephalad to the fovea centralis (Pipkin Type-I or Type-II injury), one had had a posterior dislocation with associated fractures of the femoral head and neck (Pipkin Type III), two had had a posterior dislocation with associated fractures of the femoral head and the acetabular rim (Pipkin Type IV), and three had had a fracture-dislocation that we could not categorize according to the Pipkin classification. Twelve patients had been treated by closed reduction for a Type-I or Type-II injury; one, by open reduction after an unsuccessful closed reduction for a Type-I injury; one, by primary total hip replacement for a Type-III injury; and three, by open reduction with screw fixation of the acetabular fracture and removal of the fragment of the head for two Type-IV injuries and one unclassified injury. An additional two patients had had both a fracture of the femoral neck and a dislocation; one hip was treated primarily with a Moore prosthesis and the other was left unreduced.(ABSTRACT TRUNCATED AT 250 WORDS)     

闭合复位技术治疗外展嵌插型股骨颈骨折

目的: 探讨C形臂X线监测下闭合复位技术3枚螺钉固定外展嵌插型股骨颈骨折的可行性。方法: 回顾性分析2014年1月至2019年12月接受手术的17例外展嵌插型股骨颈骨折患者,男10例,女7例,年龄21~59(42.09±7.30)岁。根据术前的X线和CT资料,明确股骨头后倾及外展移位角度,2枚直径2 mm克氏针交叉从股骨头外侧和前方轻敲入髋臼顶盖骨质内,将近骨折段固定在髋臼上,在C形臂X线监测下逆骨折移位方向,逐渐内旋内收下肢(远骨折段),使远骨折端对合近骨折端完成解剖复位后3枚空心螺钉内固定。评价Garden指数,观察术后并发症,进行Harris功能评分。结果: 17例外展嵌插型股骨颈骨折均顺利完成闭合复位内固定,手术时间36~68(43.87±7.63) min,术中出血15~50(28.36±5.93) ml。术中Garden指数评价骨折复位质量,解剖复位12例,可接受复位5例,无复位不成功改开放复位病例。17例获得随访,时间3~41(27.5±8.4)个月。无股骨头坏死、骨折不愈合、髋关节撞击征、股骨颈缩短等并发症出现,MRI检查未发现有股骨头坏死及关节软骨损伤表现。术后2年髋关节Harris评分优13例,良4例。结论: 闭合复位3枚螺钉内固定手术技术治疗外展嵌插型股骨颈骨折可获得良好的解剖复位率及治疗效果。     

Anterior Hip Dislocation: Characterization of a Rare Injury and Predictors of Functional Outcome

BackgroundAnterior native hip dislocation remains poorly studied due to the rarity of the injury. The aim of this study was to describe injury characteristics of anterior hip dislocation, detail its initial treatment, and determine the intermediate term outcomes including the rate of conversion to total hip arthroplasty (THA).MethodsA cross-sectional study was performed at a single urban academic Level 1 trauma center for patients who sustained traumatic anterior hip dislocations from 2010-2017. Baseline demographic, injury, and treatment data were recorded. Patients were contacted to inquire about subsequent surgery and complete functional outcome questionnaires. Available post-operative radiographs were also reviewed.ResultsThirty-two anterior hip dislocations met inclusion criteria and were included in the study. 69% of dislocations were obturator dislocations and 31% iliac dislocations. Only 22% were simple dislocations with the remainder having an associated femoral head fracture and/or acetabular fracture. Iliac dislocations were more likely to be associated with acetabular fractures and require surgical treatment while obturator dislocations were more likely to be simple dislocations or have femoral head fractures. Excluding two patients treated with acute THA at the time of injury, follow-up information was available for 16 patients at a minimum of eighteen months from the time of injury. Only one required subsequent conversion to THA. For the remaining fifteen patients, modified Harris hip scores (mHHS) averaged 82.6, PROMIS global physical health averaged 51.9, and PROMIS global mental health averaged 48.3 with mean follow-up of 4.2 years. mHHS was significantly higher for obturator dislocations and a negative association was seen with age.ConclusionsObturator dislocations occurred twice as frequently as iliac dislocations. Associated acetabular or femoral head fractures are common. Conversion to THA was low, occurring in only 1 of 16 patients not treated with acute arthroplasty. Obturator dislocations and age less than 45 years old at the time of injury were associated with better functional outcome at intermediate term follow-up.     

股骨颈骨折内固定失败Ⅱ期行髋关节置换的早期疗效

目的:研究青壮年股骨颈骨折患者内固定失败后Ⅱ期行髋关节置换的早期临床疗效。方法:2008年6月至2010年6月,对24例股骨颈骨折内固定术后股骨头坏死患者行全髋关节置换术,其中男12例,女12例;年龄18～58岁,平均42.9岁。术后行X线检查,并根据Harris评分标准评价临床疗效。结果:23例获得随访,平均随访时间34.4个月(25～48个月),1例术后并发髋关节脱位,未发现髋关节感染、松动或假体周围骨折等并发症。Harris评分为90.9±4.3,优18例,良4例,可1例。结论:Ⅱ期全髋关节置换治疗股骨颈骨折内固定术后并发股骨头坏死,术中手术难度增加,但可以获得良好的早期疗效。     

Femoral neck fracture complicating orthopedic reposition of a dislocated hip: four cases

Posterior dislocation of the femoral head with fracture is an exceptional hip injury. Emergency reduction is required. Reposition into the acetabular cavity of the dislocated femoral head may not be feasible. Irreducibility, instability, and more rarely accidental fracture of the femoral neck may also occur. We encountered this latter complication in four patients and report here its frequency and mechanism and propose preventive therapeutic measures. Seventy dislocations and fracture-dislocations of the hip were treated in our unit from March 1997 to February 2003. Among these cases, fourteen hip dislocations were complicated by femoral head fractures. Fracture of the femoral neck occurred during reduction in four. All four cases occurred in men, mean age 49.7 years, who were traffic accident victims (drivers or passengers). There were two Pipkin IV fracture-dislocations and two Pipkin II. The first reduction, achieved under general anesthesia in an emergency setting, was performed by an orthopedic surgeon in one patient and a general surgeon in three patients. Arthroplasty was used to treat the femoral neck fracture in three patients and pinning in one. We reviewed retrospectively the clinical and imaging data before and after reduction. Sub-capital fracture situated 4.0 cm (mean, range 3.5-4.5 cm) from the lesser trochanter occurred in all four cases. The head remained attached above and posteriorly to the acetabulum and was rotated less than 90 degrees . The fragment remaining in the acetabulum was displaced in two cases. In one patient, the fracture-dislocation of the head was associated with a fracture of the posterior rim of the acetabulum. This complication appears to result from an abrupt inappropriate reduction movement. The neck fracture would occur when capsulomuscular retention of the femoral head is associated with a head defect which catches on the rim of the acetabulum during the reduction movement. Neck fracture during reduction of traumatic hip dislocation is a serious complication. Prevention of this iatrogenic event requires a slow, progressive reduction limiting the trauma to a minimum; first intention open surgery may be required in selected cases.     

股骨近端缩短及全髋置换术治疗陈旧股骨颈骨折伴严重髋关节脱位

目的 探讨陈旧股骨颈骨折伴严重髋关节脱位的有效治疗方法及临床疗效。方法 自1996年4月采用股骨近端缩短及全髋置换术治疗7例陈旧股骨颈骨折伴严重的髋关节脱位的患者。结果 7例患者平均为51岁,术后随访平均为27．3个月,在近期随访过程中,按Harris评分由手术前的36．7分增加至术后84．3分,髋臼及股骨柄假体位置良好,未出现假体松动和下沉,也未出现截骨处骨不愈合。结论 股骨近端缩短及全髋置换术治疗陈旧股骨颈骨折伴严重髋关节脱位,近期疗效十分满意,其后期疗效有待进一步随访观察。     

改良EPSTR预防全髋置换术后脱位

目的：探讨改良EPSTR法预防全髋置换术后脱位的临床疗效。方法：2006年1月至2007年5月,在85例（87髋）全髋置换中采用改良EPSTR法对后路结构进行修补,男39例,女46例;年龄62～85岁,平均69.5岁。新鲜股骨颈骨折58髋,股骨头坏死25髋,髋关节骨关节炎3髋,股骨粗隆间骨折内固定失败1髋。结果：85例均获随访,时间8～24个月,平均15个月,没有发现髋关节后脱位、髋关节外旋挛缩畸形和大转子骨折,术后6个月Harris评分平均为（89.2±4.5）分。结论：改良EPSTR法是一种预防全髋置换术后脱位的有效和简捷的方法,具有临床应用价值。     

Superior fracture-dislocation of the hip

A case of superior fracture-dislocation of the hip following a low-energy injury is reported. The direction of the dislocation is uncommon. Radiological investigation was delayed for 5 months and then showed the appearances of a radiologically perfect false acetabulum. The fracture-dislocation was a type IV with an associated fracture of the femoral neck, an injury which is expected to produce a high rate of avascular necrosis of the femoral head. However, bone scans suggested that the femoral head was viable.     

Evaluation of osteosynthesis with dual fibular bone grafting for neglected femoral neck fractures

BackgroundFemoral neck fractures in young adults is an unsolved problem and neglected femoral neck fractures presents more challenge to the orthopaedics surgeon if femoral head salvage is attempted. We reviewed the operative results of neglected femoral neck fractures in young adults with fixation with dual fibular bone grafting Purpose of study was evaluation of epidemiological, clinical, functional, rehabilitative outcome and complications in such patients.MethodsTwentyeight patients in age group 18–50 years were operated having fracture neck femur by dual fibular bone grafting in the Department of Orthopaedics, S.N. Medical College, Agra in (May 2005–February 2008) and divided into two groups. Group A: comprised of 8 patients treated by dual fibular bone grafting alone and Group B: comprised of 18 patients treated by dual fibular bone grafting with single cancellous hip screw.ResultsAll the patients of the present series were having neglected intracapsular fracture, neck femur which were treated by dual fibular bone grafting with or without cancellous hip screw fixation. Majority of the patients had good to fair result according to Larson method with average time of union 16 weeks. All patients had useful range of movement at hip. Satisfactory union was achieved in all patients except two.ConclusionDouble bone grafting is a simple and cost effective modality of treatment for late femoral neck fracture with good results. It is a stable and biological method of fixation with preservation of natural femoral head with fewer complications.     

Posterior dislocation of the hip joint with fracture of both the femoral head and neck

Fracture of both the femoral head and neck associated with posterior hip dislocation is a rare injury. This report describes a rare case of fracture-dislocation of the hip joint with a separated femoral head with a residual fragment in the acetabulum, and a subcapital fracture. We performed open reduction with internal fixation immediately after the injury. Osteonecrosis of the femoral head was detected one year after the surgery, however this patient had no symptoms related to the hip joint.     

Posterior dislocation of the hip with ipsilateral displaced femoral neck fracture

Traumatic posterior dislocation of hip associated with ipsilateral displaced femoral neck fracture is a rare injury. Moreover, the management of such patients evokes strong views regarding primary replacement or preserving the femoral head. We presented a case of young adult with such an injury. He was operated upon with reduction of the dislocation and fixation of femoral neck fracture with the help of cancellous screws. Two years later, the fracture had united and the patient was asymptomatic. We further proposed the mechanism of injury for such a fracture and discussed the management in the changing trauma scenario of the developing world.     

Does total hip arthroplasty provide better outcomes than hemiarthroplasty for the femoral neck fracture? A systematic review and meta-analysis

Purpose: By comparing the outcomes of total hip arthroplasty with hemiarthroplasty in elderly patients with a femoral neck fracture to investigate the one-year mortality, dislocation, infection, reoperation rate, and thromboembolic event. Methods: The PubMed, EMBASE databases, and Cochrane library were systematically searched from the inception dates to April 1, 2020 for relevant randomized controlled trials in English language using the keywords: “total hip arthroplasty”, “hemiarthroplasty” and “femoral neck fracture” to identify systematic reviews and meta-analyses. Two reviewers independently selected articles, extracted data, assessed the quality evidence and risk bias of included trials using the Cochrane Collaboration’ stools, and discussed any disagreements. The third reviewer was consulted for any doubts or uncertainty. We derived risk ratios and 95% confidence intervals. Mortality was defined as the primary outcome. Secondary outcomes were other complications, dislocation, infection, reoperation rate, and thromboembolic event. Results: This meta-analysis included 10 studies with 1419 patients, which indicated that there were no significant differences between hemiarthroplasty and total hip arthroplasty in reoperation, infection rate, and thromboembolic event. However, there was a lower mortality and dislocation rate association with total hip arthroplasty at the one-year follow-up. Conclusion: Based on our results, we found that total hip arthroplasty was better than hemiarthroplasty for a hip fracture at one-year follow-up.     

Displaced acetabular fractures in the elderly: Results after open reduction and internal fixation

BackgroundThe optimal management of elderly patients with displaced acetabular fractures remains controversial. This paper aims to summarize the clinical results of open reduction and internal fixation (ORIF) and the possible factors influencing them.MethodsRadiographic and clinical data on 52 elderly patients with displaced acetabular fractures that were treated by ORIF between May 2000 and May 2008 were retrospectively analysed. Data, such as fracture type (Letournel's classification system), quality of reduction, clinical outcomes (Harris hip score and modified Merle d’Aubigne-Postel score), and radiological outcomes (Matta score), were evaluated.ResultsGood to excellent clinical and radiological outcomes were recorded in 43 (82.7%) and 37 patients (71.2%), respectively. Acetabular fractures without radiographic features, such as quadrilateral plate fracture, Gull sign, posterior dislocation of hip, posterior wall marginal impaction, comminuted posterior wall fracture, and femoral head injury, can still achieve good to excellent outcomes. However, patients with the abovementioned radiographic features tend to achieve fair or poor outcomes. When an acetabular fracture with the aforementioned features, except for femoral head injury, can achieve and maintain anatomic reduction until complete fracture healing, the difference between fractures with and without the radiographic features is no longer significant. The results indicate that the outcomes are more affected by reduction rather than radiographic features.ConclusionORIF may be suggested for displaced acetabular fractures in the elderly. Good to excellent outcomes and a high degree of patient satisfaction can be achieved in majority of the patients. We recommend ORIF as the preferred treatment for displaced acetabular fractures without the abovementioned radiographic features.Level of evidenceTherapeutic level IV.