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Femoral Head Fractures
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Femoral Head Fractures
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Language: EN.
Segment:0 .
HITESH GOPALAN: Welcome all of you to this live program on Orthopaedic principals. Today, our guest of honor is Dr. Ashok Sunil Gavaskar from Chennai, India. Dr. Gavaskar is currently the Clinical Lead of Orthopedics and heads the joint reconstruction trauma service at the RELA Institute and Medical Center in Chennai, India. He is a distinguished member of the AO Trauma Technical Commission as part of the Asia-Pacific expert group.
HITESH GOPALAN: He's an honorable member for the International Advisory Board for the Journal of the American Academy of Orthopedic Surgeons, and he also serves as an associate for the Indian Journal of Orthopedics and the European Journal of Orthopedic Surgery and Traumatology. If you notice, Dr. Gavaskar has delivered a lecture on a channel which has already reached a huge audience and today's my great honour to bring back Dr. Ashok Sunil Gavaskar for this wonderful live program.
HITESH GOPALAN: Over to you Shok.
ASHOK GAVASKAR: Thanks, thanks Hitesh for the intro, like we did once last year and again, like we are getting started this year in Jan. So the topic in focus here is Femoral Head Fractures and over the next half an hour or so, like I'll try to share our experience, which has been quite, quite an extensive experience on this kind of injuries over the last 10 to 15 years.
ASHOK GAVASKAR: And what I'll try to do is like focus predominantly on the current concepts involved in mostly surgical treatment of these more relatively complex injuries. So to get going.
HITESH GOPALAN: There is a cursor at the left hand bottom. You can use the forward button. Yeah OK.
ASHOK GAVASKAR: So if you look at femoral head fractures, they are typically shear injuries. These fractures occur as part of the hip dislocation most commonly, but not necessarily always. So what happens is that when the femoral head it is driven out of the acetabulum, the femoral head it tends to shear off due to impact over the posterior wall. And these fractures can vary in size, location and the extent of comminution and impaction.
ASHOK GAVASKAR: These fractures not necessarily have to be shear injuries always. You can also have avulsion injuries and impaction injuries of the femoral head too. As I told you, these fractures occur as commonly as part of a fracture dislocation pattern posterior in direction most of the times, but not necessarily always. You can have these fractures as part of an anterior dislocation as well.
ASHOK GAVASKAR: These fractures tend to be more commonly impaction type in anterior dislocation and shear injuries in posterior dislocations. The majority of femoral head fractures are associated with injuries to the acetabulum labrum as well. Whether treating this labral injuries have an impact on outcome is not very clear. But whenever possible, if you get a chance to treat this labral injuries operatively, you should do it, especially if the injury extends into the posterior superior weight bearing dome region.
ASHOK GAVASKAR: And if you look at the mechanism of violence in these injuries, depending upon the position of the limb at the moment of impact, you can get injuries in different quadrants of the femoral head and depending on the position of the limb and the direction of violence, the acetabular fracture pattern, which can be associated with these injuries can also vary.
ASHOK GAVASKAR: If you look at the classification of these femoral head injuries, there are different descriptive classification systems, but probably the most popular one is the one by Gareth Pitkin, which was described way back in 1957. He was a North American surgeon who would describe these injuries and classified them into four types based on the attachment of the ligament amputees [?] to the femoral head fractured fragment.
ASHOK GAVASKAR: So he based on this, he classified them into 1 and 2. Type 1 injuries where the fracture fragment is inferior to the four volar ligament attachment and type 2 injuries where the fracture fragment carry the attachment of the ligament on itself. Type 3 and 4 are variations where you can have one and 2 injuries in combination with ephemeral leg or acetabular fracture pattern. And the rationale for classifying it this way was he believed if you have a femoral head fracture segment that is not connected to the volar ligament, the amount of rotation on this fragment will be much lesser, that these fractures can be treated non operatively once you reduce the hip joint, whereas the type 2 injury with the ligament attached to the fragment, the amount of rotation is much more and this creates incongruency most of the time
ASHOK GAVASKAR: and these fractures will require surgical treatment. And if you look at his old paper in 1957, he recommended non operative treatment for these injuries just because at that point of time he did not get great outcomes with surgical treatment for this fractures. But this fracture has as to this classification has stood the test of time and we still use it. It is extremely descriptive, but if you ask me, has this classification has been validated so far? No.
ASHOK GAVASKAR: Probably because most of the studies have small number of fractures, these are not very common injuries. But if you ask me, if you ask me, how good is the entire observer variation in this classification system? It's pretty good, especially the advent of CT scans, it is quite easy to understand the fracture patterns, very simple, descriptive and very easy to use as well.
ASHOK GAVASKAR: And also there are a lot of studies which have kind of prognostication injuries based on these patterns. We all know that Pipkin I does better than Pipkin II, Pipkin IV us better than Pipkin III and similarly, Pipkin III probably does the worst. So you can prognosticate your injury after surgical or nonsurgical treatment based on this classification as well.
ASHOK GAVASKAR: But I would still accept that the classification is not complete. It is deficient in a lot of aspects, if you ask me, like it doesn't give you any indication depend based on the fragment size or displacement. Also, if you look at Pipkin IIII, the classification does not describe the different variations in acetabular fracture pattern clearly. So there are a lot of deficiencies in this classification system, but I would probably still say this is the most popular and this is what we use as well.
ASHOK GAVASKAR: Apart from this system, you also have the Brumback system, which is probably the most comprehensive system and also I would say the best to prognosticate because it takes into account the direction of dislocation, the amount of joint stability, and also describes acetabular fracture patterns much better. Yoon is just a modification of the Pipkin system, and you also have the AO-OTA system as well. So these are some of the classification systems that you can use for Pipkin femoral head fractures.
ASHOK GAVASKAR: But as I said, the Pipkin system is the most popular. So this is Pipkin's classification system. And based on this, if you look at the prevalence of these injuries, how we treat them and prognosis and this data, I have collated from the paper from Chip Routt and his colleagues, this is the largest paper on the topic and if you look at the Pipkin I and II injuries in this paper, the Pipkin II or the supra-foveal injuries were much more common compared to Pipkin I.
ASHOK GAVASKAR: But if you look at all of the papers and including the journal, this meta analysis {INAUDIBLE} in 2009 injury, Pipkin I fractures tend to be more common. And even in our series between I's, they're more common than II. But apart from that like that stuff, the distribution is quite same. Pipkin IIII is next common, and the least common would be Pipkin III.
ASHOK GAVASKAR: And if you look at treatment based on this classification system, I and II, you can treat them either by non-operating or operating means. Non-operating you can opt for if you have an absolutely concentric reduction with good joint stability or else these fractures will require open reduction and internal fixation and the prognosis of either I and II tend to be pretty good with what I have.
ASHOK GAVASKAR: Type IV, again, depending on the acetabular fracture pattern, most often we will be doing an osteosynthesis and very rarely an acid and primary arthroplasty, especially in older patients and that will be determined by the acetabular fracture pattern, than the femoral fracture pattern. And with these injuries, the prognosis is not too bad. With the ORIF, they tend to do pretty well, varus {INAUDIBLE] do the worst with osteosynthesis.
ASHOK GAVASKAR: And if you look at studies after studies repetitively, more studies indicate a very poor prognosis if you are doing an osteosynthesis and primary arthroplasty does have a role in these fractures. So for prognosis of 53 injuries, it is quite bad with osteosynthesis. And if you look at the Milton Shipraus paper, there are another 10 percentage of injuries which does not fit into any one of these types, or to subtypes and these are predominantly impaction injuries which is not taken into account in the Pipkin classification system.
ASHOK GAVASKAR: So if you look at I and II, these fractures, as I told you, can be treated non operatively if you have an absolutely displaced fracture. Once you reduce the joint and you have stabilized situation. Or else, these fractures most often will require surgery in view of incongruent reduction, or if you have an unstable hip joint after reduction, or sometimes you might also have irreducible hip. So in this situation, you will require operative treatment to treat these injuries.
ASHOK GAVASKAR: And how do you treat them operatively? Most often, all type II's and most type I's will undergo fixation with some sort of screws, either mini fragment counter sunk screws or headless screws, rarely in some small type 1 infraviola lesions, which are too comminuted or too small to fix. These fragments can be safely excised without loss of hip stability or function. So whenever you deal with these injuries, the first step is to get your hip reduced, closed as an emergency in the ER.
ASHOK GAVASKAR: We do not do a pre-operative CT scan, but you can think of a pre-operative CT scan if you are doubtful, especially if you have an acetabular fracture pattern in association or if you think you have an un-displaced femoral neck fracture, in this case, an improper loss reduction can be catastrophic. But otherwise, in types I and II, we tend to reduce the hip joint and then do a post reduction CT image, which can give you a tremendous amount of information.
ASHOK GAVASKAR: On, on the femoral head fracture location, the size of the fragment, the amount of comminution you have, is there any loose articular fragments that is compromising congruity? And you can also look at the associated acetabular fracture pattern and also an ephemeral neck fracture that is present. So all of these things can be looked on in your appropriate post-op post reduction CT, so that you can plan surgical treatment.
ASHOK GAVASKAR: Or you can also think about creating distractions non operatively if your CT shows a concentric reduction. So if you opt for surgical reduction in Pipkin I and II, depending on what you do, excise or fix it, you can offer different surgical approaches. The surgical approach can be kind of broadly classified into ones that access the hip from posterior and the ones that access the hip from anterior same surgical dislocation, something kind of a lateral based approach, which gives you access to both posterior and anterior areas of the hip joint.
ASHOK GAVASKAR: So if you are looking at excision of the fragment based on your CT scans or x-rays, you can do it by using a Kocherl-Langenbeck approach as well. Not all the time, but sometimes if your fragment location is as such that it is situated in the posterior superior or the posterior side of the acetabular, these fragments can be retrieved through the Kocher-langenbeck approach sometimes, but not always. But the most common way to do these fractures would be to either access them anteriorly through a neutral interval or through a safe surgical dislocation.
ASHOK GAVASKAR: So for excision, our preference is to do a Heuters direct anterior approach and sometimes you can, as I said, do it through a Kocher-langenbeck as well. For fixation, it is always the direct anterior or the safe surgical dislocation. For I and II, our preference is to do a direct anterior neutral approach. Though we have done a lot of work on safe surgical dislocation, we have kind of moved on to the Heuter approach for these injuries in most of the patients.
ASHOK GAVASKAR: So these are kind of like descriptions of both these approaches. For the modified Heuter's, like you come from anterior area user utilizing the plane between the tensor facial latta and the rectus femorus, sorry, and sartorius and in the deeper plane you do a tenotomy of the direct head of rectus and then you do a capsulotomy and either dislocate or non or keep the in-situ and fix those fractures if it is amenable to do that.
ASHOK GAVASKAR: And for a safe surgical dislocation, as I said, you do this in a lateral position. You do, you kind of like you utilize an anterior capsulotomy which is facilitated by doing a Ganz trochanter, flip osteotomy, and then you can dislocate the access, the femoral head and also the acetabulum to do your fixation. And I'll kind of take you through both these approaches and also show you some illustrative cases to illustrate where we choose, what approach in such patients.
ASHOK GAVASKAR: So if you are going to do a safe surgical dislocation, this is how we would set patients up. So these patients are typically done in lateral position and you will require one or two assistants, and this is the kind of setup you need. You will need a saw blade, you will need reduction clamps, the pointed one for small and the big ones to kind of reduce your head and also to reduce your osteotomy, you will require a bone to help you dislocate and with a safe surgical dislocation it gives you access to the acetabular as well.
ASHOK GAVASKAR: So if you have labral tears , you can fix them. So if you have suture anchors, it will be useful as well. Apart from this implants, either mini fragment or headless compression screws. And this is kind of the overall overview of how this approach would be done. A lateral approach, a straight incision centered over the greater trochanter you can utilize through to plains, either Gibson interval between the gluteus medius and the maximus, or you can also split the maximus and get inside deeper as well.
ASHOK GAVASKAR: And once you are in, isolate the gluteus medius and the vastus, retract them both, and that will delineate your line of osteotomy. So make sure your osteotomy exits distal to the vastus ridge so that it is balanced by the pull of both those muscles. And at the end of osteotomy all your posterior structures are left intact, and then with gradual dissection anteriorly, you can expose the anterior capsule, which will be taken down in a z shaped manner, helping you to dislocate
ASHOK GAVASKAR: and then fix the femoral head. Close the capsulotomy and finally put your osteotomy back. So if you want to have a look at that, you can check one of our videos on YouTube on the topic as well. And a couple of illustrative cases. This is a 23-year-old male with a Pipkin type II injury with an incongruent reduction after closed reduction of the hip dislocation.
ASHOK GAVASKAR: He also had concomitant pelvic ring and spinal injuries as well and these are x-rays at around six months showing good reduction and fixation of the head fracture and also the osteotomy. Another patient 20-year-old multiply injured has got a type I Pipkin injury. He also had an unstable acetabular fracture on the right side, femoral fracture on the right, and a couple of tibial fractures as well.
ASHOK GAVASKAR: And if you can look at the femoral head injury, you can look at the femoral head fragment, dislocated way below the acetabulum. And this guy underwent a safe surgical dislocation, fixation of the femoral head fracture with 2.4 millimeter counter sunk screws. And he also underwent posterior superior labral repair. And these are his x-rays, immediately post-op and a two year follow up. You can see all his fractures have healed, some head show at 2 years, but not compromising its function or movement.
ASHOK GAVASKAR: And he has a pain free and a fully functional hip. Another male, another 27-year-old motor vehicle accident, Pipkin II with a femoral shaft and this guy was taken up upfront, upfront by my colleague who fixed the femoral shaft fracture and then I did the femoral head fracture in the second stage. And if you are going to treat femoral shaft fractures and if you are going to contemplate a safe surgical dislocation, you ought to be really careful so that you don't compromise your trochanter osteotomy side.
ASHOK GAVASKAR: Anti grade nailing of femoral shaft fractures in such situations where you require a safe surgical dislocation is quite safe in terms of infection or wound complications. And this has been shown by the group of colleagues from North America. So if we have a femoral shaft, you can go and do an anti grade nailing. It's quite safe, but make sure you use a trochanteric entry nail.
ASHOK GAVASKAR: Do not use sorry, make sure you use a bio-deformis entry nail. Don't use a trochanteric entry. If you look at this case, this is not exactly a trochanteric, they can be kind of a formis. But if I do this right now, I probably go a lot more medial. And in this case, we still very able to do the osteotomy and then get this femoral head fixed and this labral injury fixed as well.
ASHOK GAVASKAR: This guy had a lot of cartilage injury and this was in six months and this was around 4.5 years and he still has not come in for a hip replacement. You can see a lot of resorption of his cartilage, yet he still has some weight bearing domain and he's pain free still so does not want to come in so sooner or later he will require an hip replacement.
ASHOK GAVASKAR: So if you look at our results for Pipkin I and II injuries by using a safe surgical dislocation, we had around 28 patients. 26 were followed up for more than two years and we did ORIF in all type II injuries and in most type I injuries as well, except two patients, the functional outcome was brilliant as it is in most of the series other from everywhere in the world as well.
ASHOK GAVASKAR: Their function were excellent, patients who had problematic function and arthritis, chondral defects which we had noticed intraoperatively and patients who had a labral injury also had kind of a not so good in function. If you look at the most commonest complications in our series, we did not have any in most patients, the most commonest complication was anatomic ossification, which were either grade 1 or 2 and one grade 3 as well, and degenerative arthritis in 3 patients who required a total hip replacement.
ASHOK GAVASKAR: So coming to the second approach, the Heuters direct anterior, this is how you would set a patient up for a direct anterior. Patient isn't supine. You might require some inflection. The incision runs vertically downwards, starting around 2cm distal and lateral to the antero-supero-lateral ex spinal, it will require around 8 to 10cm incision.
ASHOK GAVASKAR: The number of tools you require are much lesser compared to a safe surgical dislocation. You would require pointed reduction clamps, some wires, and then either a mini fragment or headless compression screws. Again, this is a overview of the entire surgical approach. And once you go inside, once you spread that fascia over the tensor, you might encounter the larger cutaneous femoral nerve. And if you encounter them, make sure you protect it throughout the procedure.
ASHOK GAVASKAR: And once you go into the deeper plane, you will see the branches of the lateral circumflex femoral vessels in the second image. Make sure you tackle them, we tend to ligate them and then once you go deeper, you will get the isolate the direct end of rectus, which can be identified by its physical appearance. And once you identify it, we do a tenotomy in all cases that facilitates exposure to grade B and then capsulotomy
ASHOK GAVASKAR: To me we prefer a T shape capsulotomy to me for main reason is like if you do a t-shape capsulotomy, if you have an infra wheeler fracture with no displacement or minimal displacement, you can clamp it and fix those fractures without dislocating by bringing the leg into a kind of flexion abduction, external rotation position, you don't have to dislocate the hip. So the inferior limb of the T facilitates that. But in cases where you have displacement that are not amenable for reduction in situ, you can go ahead and dislocate as we have shown in figure E and then complete your fixation outside the acetabulum and then relocate your hip.
ASHOK GAVASKAR: So again, like if you want to look at the video, our video is available in one of the archives of the American Academy under the OVT platform. So this is, again, an illustrative example. This is a 31-year-old male with a type II displaced femoral head fracture. He also had abdominal and craniofacial injuries, which were treated conservatively. And these are his follow up X-rays and outcomes that are around six months.
ASHOK GAVASKAR: Again, like, as you can see, you don't need an osteotomy, you can go ahead and fix it, and these patients tend to do pretty well. And we did look at our results comparing both the Heauters group and the safe surgical dislocation group. We had around 60 patients comprising of around 32 surgical dislocation, around 28 modified Heuters and when we compared what we found was patients who underwent Heuters approach required less surgical time and less blood loss and also had better pain scores
ASHOK GAVASKAR: during the immediate post-operative period. But if you look at the overall functional outcome, it wasn't different and also the number of complications, the complication distribution was also very similar across both groups. So in terms of outcome, long term and complication, there wasn't much difference, but in terms of perioperative outcome, patients who underwent the Heuter approach did better.
ASHOK GAVASKAR: So these are some of the salient merits and demerits that I can think of go this approach so if you want 360 degree exposure, of the acetabulum, then safe surgical dislocation is a way to go. It also helps you to identify and treat posterior labral tears, and you can also treat concomitant acetabular injuries, that is the Pipkin IV if you have them. But we saw more heterotopic ossification with safe surgical dislocation compared to the Heuter approach.
ASHOK GAVASKAR: The Heuter approach, the pros are less surgical steps, so less time you can do it supine so it is easy to deal with other injuries. If you are dealing with poorly traumatized patients, you don't need an osteotomy so it avoids potential problems if you need a hip replacement in future, especially the hardware there. The unique complication with the Heuter approach would be the injury to the larger transfemoral nerve which we encountered in a couple of patients as well.
ASHOK GAVASKAR: So these are points that come to the point that you can think of, and keep in mind when you choose your surgical approach, when you want to treat these fractures. So coming to Pipkin III injuries, these fractures have either a Pipkin I or II injury with an associate, femoral neck fracture. So you can best describe them as segmental intra-capsular fracture of the proximal femur, where you have a femoral head fracture and then a break in the femoral neck as well.
ASHOK GAVASKAR: So these fracture patterns are like 1 and 2. Even the 1 and 2 are more common, they are dislocation as well. These fractures are almost always a social dislocation. Otherwise you don't have them. So for these injuries, closed reduction is practically impossible. If you have a displaced femoral neck fracture. And if you have an undisplaced femoral neck fracture, and if you contemplate open reduction and internal fixation of those injuries, then it is extremely unsafe to think of a closed reduction because you can make it completely displaced and it might rob you of an opportunity to posterior synthesis.
ASHOK GAVASKAR: So make sure you have this in mind and most often you will require a pre-operative CT scan. So how to treat them? This is one injury where there is a big role for primary arthroplasty because for ORIF type III injuries has been uniformly described with poor results. If you look at the first reference paper by Peter Giannoudis from Leeds, which is kind of systematic review,
ASHOK GAVASKAR: they did not have a single patient who had an excellent outcome after ORIF, type IV critical injuries. And if you look at the second paper, these guys looked at around 110 patients in femoral injuries and there were 4 Pipkin III fractures. Of the four, one had primary arthroplasty and three went on to fail and had secondary arthroplasty. So all four of them ultimately ended up having a total hip replacement.
ASHOK GAVASKAR: And this is the largest series on the topic, again, from Milton Chip and his colleagues. These guys looked at around 140 odd fractures. Across I, II, III and IV Pipkin types, and they had 7 Pipkin III injuries. Of the seven patients, all seven actually underwent ORIF. After ORIF, two patients failed within 12 weeks and 5 patients went on to fail after six months, either due to catastrophic fixation failures or due to AVN.
ASHOK GAVASKAR: Ultimately, all seven of them failed, and their conclusion was primary arthroplasty should be strongly considered for Pipkin III injuries and that is what our opinion is as well and our preference is to do a primary in these injuries. And if you look at our experience, we have had three cases, so far in our experience over the last ten, 15 years with a mean age of around 39 years.
ASHOK GAVASKAR: And all these patients ended up having primary hip replacement and this is one of those patients who underwent an hip replacement at 29 years, and at around 8 years, follow up is still doing great, doing everything. So this is what our experience about Pipkin III injuries, which is not very different from all over the world. So but if at all, you contemplate an open reduction internal fixation for a Pipkin III injury,
ASHOK GAVASKAR: you can do that, especially if you have an undisplaced femoral neck fracture or even if you want to do it, displaced femoral neck fracture pattern. If you want to have any kind of an objective criteria of how to do that, this is one paper you can look at. The paper from Bone Group, which kind of looked at fracture patterns involving femoral neck and femoral head with a dislocation injury.
ASHOK GAVASKAR: And their conclusion was like, you can do a safe surgical dislocation for these injuries and look at the status of the postero superior retinalacular vessels and these are images from their article and if you have intact posterosuperior retinal blood vessels, then yes, you can contemplate OR or ORIF and expect to get good outcomes. And if they are disrupted, primary arthroplasty is probably a better initial management.
ASHOK GAVASKAR: And this is one paper that I could look at but having said that, we have not done an ORIF in a Pipkin III injury so far. What about Pipkin IV? In Pipkin IV injuries, you have an acetabular fracture in association and you can have any of the 10 types of acetabular fractures that are described. But the most common injury pattern that you see is the posterior wall, and that is what Pipkin describes in this paper.
ASHOK GAVASKAR: And when you have the posterior wall injury in combination to femoral head fracture, closed reduction is possible unlike we can treat but you have to be really, really careful because these injuries sometimes can have major femoral head impaction along the disrupted posteriol wall and if you inadvertently break your femoral neck during your loss reduction, you can kind of make the entire femoral head non-viable and non amendable for fixation.
ASHOK GAVASKAR: So you have to be really careful if you are going to contemplate close reduction for a Pipkin IV injury with an associated posterior wall and be really careful about it. And this is one instance where I always get a pre-operative CT scan so that I can look at how much of an impaction is there along the posterior rim. You can also look at the posterior wall characteristics.
ASHOK GAVASKAR: Where is the exit of the posterior wall? How much chunk is it involving? Because depending on that, I can choose my surgical approach, which I will touch upon in the next slide. And also you can look at whether you have an undisplaced femoral neck fracture, in which case you might kind of change your surgical strategy so it makes a lot of sense to get a pre-operative CT scan in a Pipkin IV injury.
ASHOK GAVASKAR: So if you are going to treat this fracture surgically, whether you have a femoral head and a posterior wall fracture, how do you approach that? There are papers in reported where they have successfully used the Kocher-langenbeck approach to treat both these fractures and yet get good results without any problems with femoral advanced clarity. And compared to types I and II, where the anatomical location of the femoral head and the impact posterior wall may not kind of allow you to do a fixation through the Kocher-langenbeck approach. In type IV
ASHOK GAVASKAR: with the posterior wall broken, it might be a lot more easier to access the anteriorly broken femoral head and still get some fixation on it. So it is possible. It may not be always possible in all fracture patterns, but it is possible. So this is one approach that you can think of. But that is not something that we prefer all the time, even though it is reported. What our preference would be to do either an anteriorial based surgical approach like the Heuters, fix the femoral head
ASHOK GAVASKAR: and then stretch the posterior wall injury if it needs to. And if the EP is stable and the wall involvement is minimal, we might choose to conservatively treat the posterior wall. And this is a strategy popularized by Chip Routt and his colleagues, and I think it makes pretty good sense. But if you have a fracture pattern that needs fixation of both fractures, then you can also opt for a safe surgical dislocation.
ASHOK GAVASKAR: You can do both these fractures through a single approach without any change in position. If you are going to contemplate an anterior based surgical approach, where I do a direct anterior fix the femoral head and then stress the femoral acetabular wall, and if I find it unstable, I have to change position and then come back lateral or in prone and fix up my posterior wall. So that's kind of a cumbersome, but if you want to avoid that, you can then choose a safe surgical dislocation.
ASHOK GAVASKAR: So for us, these are the two approaches which we will contemplate to do when we have a a Pipkin IV injury, where we have an associated posterior wall in the femoral head injury. So I'll just show you a couple of examples. The 35-year-old female with a Pipkin IV injury she's gotten an MVA femoral hip fracture and you can see the acetabular wall pattern, small, not too cranial lateral.
ASHOK GAVASKAR: So if you want to look at the determinants of stability in the posterior wall, it is there's a great paper from our view in Jody by Reza Firozabad, which describes the instability in posterior wall injury. That's a great read. So if you have a very cranial exit or fractures involving a bigger chunk, those fractures are almost always going to make the EAP unstable.
ASHOK GAVASKAR: So even if you have a smaller chunk in a much cranial location, these fractures might require surgical treatment. So in those cases, you can kind of go to a safe surgical dislocation straight away. But this fracture was not too cranial, but the patient had an incongruent adduction, as you can see by the post production CT scans and here we went through the direct anterior approach retrieved and fixed for a femoral head fracture and then subject to the patient process examination.
ASHOK GAVASKAR: Then these are the images with and without stress in an object or oblique view. As you can see, they demonstrate no instability and this patient was chosen to be treated non surgically for the posterior wall. And these are at post-operative x-rays. We do keep them on it, precautions for six weeks to prevent any kind of instability.
ASHOK GAVASKAR: And I don't have a follow up except because this is one of the recent case, but we have done this in a few patients with pretty successful outcome. So another case, this is a 20-year-old male motor vehicle collision again posted a wall fracture and a femoral head injury. In this case, again, like if you look at the femoral, the posterial wall fragment is pretty small, but the Pipkin injury is type II and it is incongruent.
ASHOK GAVASKAR: So we chose to reduce and fix them both and we did it through a safe surgical dislocation and this is how it looks like postoperatively, and this is what it looks like around three months and this is the patient with pretty good outcome. So if you want to, again, look at safe surgical dislocation and understand the surgical technique of doing it for a Pipkin IV injury, again, you can look at all of our videos in the orthopedic video data on the topic.
ASHOK GAVASKAR: So another case again and I posterior wall injury with an intra femoral fracture. Again, these patterns, we know that they make the hip unstable, so there is no way you are going to treat this non operatively, so we go straight away to a safe surgical dislocation. In this case, we excised a formula fragment and fixed the posterior wall and this is how it looks like at around 24 months with good hip function and a congruent hip joint.
ASHOK GAVASKAR: Another probably the last kid. This is a 60-year-old male who presented to us with a Pipkin IV injury three weeks post after he got injured and when we saw him get severe marginal impaction. You can see the posterior wall, pretty cranial and also the femoral head fracture involving a major chunk of the entire femoral head. And this is what it looks like when we went in, the intra formula fragment was not reconstructable,
ASHOK GAVASKAR: and so we excised it, we fixed the posterior wall, and this is how it looked like immediately after surgery and this is at around 12 weeks post fixation. We completely lost the femoral head and then we reconstructed him by doing a total hip replacement with the metal augment to address the defect posterosuperior. So this is unpublished data of us where we looked at 23 patients with Pipkin IV injuries.
ASHOK GAVASKAR: We were followed up for around 43 months, meaning we did ORIF in all and after maximum appear at around two to four year follow up, four of them had been converted to a secondary total hip replacement. Function was good, not bad as Pipkin III I supported some of the studies at the same time, not as good as I and II. And the major reasons for a compromised function and need for secondary replacement include chondrol defects, marginal impaction in the posterior wall and delay in presentation.
ASHOK GAVASKAR: And again, if you look at complications we had even in this subset of patients, atopic calcification was still the most commonest complication. If you look at other published studies on Pipkin IV's, most of them are associated with very similar outcomes that we have shown in the previous slide. Patients tend to do pretty well. High rates of union, problems include arthoscopic calcification and nonunion, so Pipkin IV's tend to do good, not as good as between I and II, but much better than Pipkin III.
ASHOK GAVASKAR: So in summary, Pipkin femoral head fractures often need surgical treatment in view of in congruency, irreducibility and instability. And in terms of outcome, Pipkin I and II tend to do pretty well after ORIF or excision If you have very small type I fragment, you can choose either to use the direct anterior or the surgical dislocation approach.
ASHOK GAVASKAR: Both do very well, but we do think Heuter is much simpler, will take you much less of your time to do it. For Pipkin III injuries, if you have an older patient, arthroplasty is definitely the way to go. But if you have a younger patient, our first choice is still an arthroplasty for a displaced fracture pattern. But if I have a non displaced femoral neck, which I haven't had so far, I might probably contemplate for IF and for approaching
ASHOK GAVASKAR: if you are going to do an ORIF again, you can still do a neutral approach or a safe surgical dislocation, but we would still think a safe surgical dislocation is safer because you do not have to think of a closed reduction to do a Heuters. And uniformly, regardless of whatever approach you use for open reduction, internal fixation results are poor, but Pipkin IV,
ASHOK GAVASKAR: ORIF is the treatment of choice, arthroplasty can be contemplated in select patients who are older, depending on the acetabular fracture pattern and the outcome, and the choice of surgical approach that you use in these patients will again, depend on the acetabular fracture pattern, most commonly posteral, wall which you can deal with safe surgical dislocation. You can also treat someone with posterior wall non operatively if you are stable and have a small fragment.
ASHOK GAVASKAR: If you have other complex fracture patterns, depending on the fracture pattern, you might choose either an anterior or a posterior based surgical approach to treat it. Thank you.
HITESH GOPALAN: Thank you, Sunil. Sunil, you can stop sharing your screen.
HITESH GOPALAN: And yeah, thank you Sunil for this fabulous presentation and absolutely amazing cases as well. Sunil, a few questions. So one of the problems in a type III is that, I mean, is a femoral neck fracture, right? So invariably, what on all the I mean, most of the x-rays that they've shown, the femoral neck is invariably a sub capital type.
HITESH GOPALAN: And do you think that is one of the reasons for the poorer prognosis? Suppose it was more of a transfer vehicle, or do you think the reduction and fixation would have given a better outcome?
ASHOK GAVASKAR: We have seen like a couple of patterns. Like one is like exactly the fracture propagating from where the femoral head structure is kind of like finishes like it propagates superiorly and you have an un displaced neck and/or sorry or a displaced neck.
ASHOK GAVASKAR: So that is probably the most common pattern that we have seen. And we have also seen trans-cervical patterns. In trans-cervical patterns, what we have seen is the fracture plane is actually much more vertical. It is not transverse actually. So, so with this spike patterns, like most often if you are thinking of fixation, prognosis even for a femoral head fracture can be a neck fracture can be sometimes suboptimal for a 3 and injury.
ASHOK GAVASKAR: So when you have a femoral head fracture in combination with that, outcomes can be a lot more complicated. So but the most common type III pattern that we have seen in very limited numbers is sub capital, where the neck fracture takes off, where the femoral head fracture stops.
HITESH GOPALAN: Thank you, Sunil, for that.
HITESH GOPALAN: And do you think there's a role for bio-absorbable screws instead of titanium? Even the titanium, I mean, it's compatible with them are there could be some artifacts, right? So there are a couple of papers, for example, there's a paper in COR way back in 2005 that they looked at bio-absorbable screws for who had fractures. What do you think about it?
ASHOK GAVASKAR: Yeah, actually, we have used it.
ASHOK GAVASKAR: We have used it. And we have seen breakages actually when we are using it, so I do not know whether it's something that is available to us in our country, but I'm not sure about it. So what the problems with our what we have is two one, we don't get big lengths. Of course, you don't need very long lengths in these ones, but that whatever length we have is much smaller sometimes.
ASHOK GAVASKAR: And also the fracture, the screws tend to break, so in one of those cases, when we tighten like we broke two to three screws and once we break them, it is quite difficult to remove them, and so we had to really like cut it off and make sure it doesn't create any condral damage. So that is our experience with bio-absorbable screws. Otherwise, like if you have them, you can use them. I don't think there is any problems with that because like once you have reduced and fixed it, you actually don't need very strong fixation because that acetabulum kinds of acts a buttress to maintain your fixation.
ASHOK GAVASKAR: So I don't think you will see lots of reduction in femoral head fractures after fixation.
HITESH GOPALAN: Thank you, Sunil. And Sunil, there's a trend for hip arthroscopy, for example, a type I. Pipkin. A lot of surgeons, even someone has published a step by step approach as to how you can do a hip arthroscopy, for example, for a type 1 Pipkin. What do you think about it?
ASHOK GAVASKAR: Yeah, I think it's absolutely feasible for a type 1 Pipkin is you can go again and if you are looking at fragment excision or even fixation like yes, it is possible to manipulate minor, minor modifications possible, but like if you have major displacements, rotations into two, I think it will be difficult. I'm not sure it's feasible, but type 1, yes, it's possible. It's described.
HITESH GOPALAN: Thank you, Sunil. We do not have any experience. Yeah, just one last question before we wind up. Sunil, you mentioned about a very common scenario that is a type VI Pipkin when you have an acetabular fracture as well as femoral head, right? So suppose a femoral head be the primary fracture line and the primary component dislocated anteriorly.
HITESH GOPALAN: Do you think a separate approach, for example, use Heuter and a Kocher-langenbeck or do you would you prefer a surgical dislocation? Because, again, Kocher-langenbeck, you're going through the posterior area, young patient, capsular injury. So do you think surgical dislocation has advantages?
ASHOK GAVASKAR: Yeah so our preference is like so we don't do the Kocher-langenbeck but but I included it because it has been reported so but I think in a Pipkin IV compared to a I and II in regards to femoral fixation if you're contemplating a Kocher-langenbeck, it might be more easier but
ASHOK GAVASKAR: that is my comment. But that is not something that we do. But like what we do is like, as I said, like we tend to do the safe surgical dislocation most of times, but like in the recent probably last two years, like we have kind of followed the description by Milton Chip brought in this paper. In select patterns where you have a small acetabular posterior wall or the fragment, which is not too cranial, which I think will not compromise the hip stability in any way.
ASHOK GAVASKAR: So in those cases, like I do not have to do a more laborious or an elaborate approach like the safe surgical dislocation, do an osteotomy. So once we have a reduction, once we have relocated the hip joint, then we, I do a direct anterior, put back the femoral head and then stress it, and most often like if you have decided based on the preoperative CT correctly again here one good paper to look at is the one that I quoted from , Razor from like from the Arborview center, I think in JO in 2010.
ASHOK GAVASKAR: So that's a great paper which looks at various aspects of stability in the posterior wall fracture. So if you do not have a very cranial exit or fracture that are involving more than 20% of the posterior wall, those are the ones based on your preoperative CT that you choose for this kind of a select approach where you do it and then stress it, and if it is stable, treat them conservatively, hip precautions and you do not have to go posteriorly
ASHOK GAVASKAR: and those patients we have done around four or five, we have had pretty good results. So we have not had to repent our decision. But if I can make out, OK, these are bad posterior wall fracture, bad actor. Two cranial or too big a wall, then I would say go ahead and do a safe surgical dislocation and address both.
HITESH GOPALAN: Thank you, Sunil.
HITESH GOPALAN: Sunil, I think that's all the questions that we have for the session. Thank you for this wonderful presentation and I'm sure is going to benefit a lot of people. Thank you.
Segment:0 .
HITESH GOPALAN: Welcome all of you to this live program on Orthopaedic principals. Today, our guest of honor is Dr. Ashok Sunil Gavaskar from Chennai, India. Dr. Gavaskar is currently the Clinical Lead of Orthopedics and heads the joint reconstruction trauma service at the RELA Institute and Medical Center in Chennai, India. He is a distinguished member of the AO Trauma Technical Commission as part of the Asia-Pacific expert group.
HITESH GOPALAN: He's an honorable member for the International Advisory Board for the Journal of the American Academy of Orthopedic Surgeons, and he also serves as an associate for the Indian Journal of Orthopedics and the European Journal of Orthopedic Surgery and Traumatology. If you notice, Dr. Gavaskar has delivered a lecture on a channel which has already reached a huge audience and today's my great honour to bring back Dr. Ashok Sunil Gavaskar for this wonderful live program.
HITESH GOPALAN: Over to you Shok.
ASHOK GAVASKAR: Thanks, thanks Hitesh for the intro, like we did once last year and again, like we are getting started this year in Jan. So the topic in focus here is Femoral Head Fractures and over the next half an hour or so, like I'll try to share our experience, which has been quite, quite an extensive experience on this kind of injuries over the last 10 to 15 years.
ASHOK GAVASKAR: And what I'll try to do is like focus predominantly on the current concepts involved in mostly surgical treatment of these more relatively complex injuries. So to get going.
HITESH GOPALAN: There is a cursor at the left hand bottom. You can use the forward button. Yeah OK.
ASHOK GAVASKAR: So if you look at femoral head fractures, they are typically shear injuries. These fractures occur as part of the hip dislocation most commonly, but not necessarily always. So what happens is that when the femoral head it is driven out of the acetabulum, the femoral head it tends to shear off due to impact over the posterior wall. And these fractures can vary in size, location and the extent of comminution and impaction.
ASHOK GAVASKAR: These fractures not necessarily have to be shear injuries always. You can also have avulsion injuries and impaction injuries of the femoral head too. As I told you, these fractures occur as commonly as part of a fracture dislocation pattern posterior in direction most of the times, but not necessarily always. You can have these fractures as part of an anterior dislocation as well.
ASHOK GAVASKAR: These fractures tend to be more commonly impaction type in anterior dislocation and shear injuries in posterior dislocations. The majority of femoral head fractures are associated with injuries to the acetabulum labrum as well. Whether treating this labral injuries have an impact on outcome is not very clear. But whenever possible, if you get a chance to treat this labral injuries operatively, you should do it, especially if the injury extends into the posterior superior weight bearing dome region.
ASHOK GAVASKAR: And if you look at the mechanism of violence in these injuries, depending upon the position of the limb at the moment of impact, you can get injuries in different quadrants of the femoral head and depending on the position of the limb and the direction of violence, the acetabular fracture pattern, which can be associated with these injuries can also vary.
ASHOK GAVASKAR: If you look at the classification of these femoral head injuries, there are different descriptive classification systems, but probably the most popular one is the one by Gareth Pitkin, which was described way back in 1957. He was a North American surgeon who would describe these injuries and classified them into four types based on the attachment of the ligament amputees [?] to the femoral head fractured fragment.
ASHOK GAVASKAR: So he based on this, he classified them into 1 and 2. Type 1 injuries where the fracture fragment is inferior to the four volar ligament attachment and type 2 injuries where the fracture fragment carry the attachment of the ligament on itself. Type 3 and 4 are variations where you can have one and 2 injuries in combination with ephemeral leg or acetabular fracture pattern. And the rationale for classifying it this way was he believed if you have a femoral head fracture segment that is not connected to the volar ligament, the amount of rotation on this fragment will be much lesser, that these fractures can be treated non operatively once you reduce the hip joint, whereas the type 2 injury with the ligament attached to the fragment, the amount of rotation is much more and this creates incongruency most of the time
ASHOK GAVASKAR: and these fractures will require surgical treatment. And if you look at his old paper in 1957, he recommended non operative treatment for these injuries just because at that point of time he did not get great outcomes with surgical treatment for this fractures. But this fracture has as to this classification has stood the test of time and we still use it. It is extremely descriptive, but if you ask me, has this classification has been validated so far? No.
ASHOK GAVASKAR: Probably because most of the studies have small number of fractures, these are not very common injuries. But if you ask me, if you ask me, how good is the entire observer variation in this classification system? It's pretty good, especially the advent of CT scans, it is quite easy to understand the fracture patterns, very simple, descriptive and very easy to use as well.
ASHOK GAVASKAR: And also there are a lot of studies which have kind of prognostication injuries based on these patterns. We all know that Pipkin I does better than Pipkin II, Pipkin IV us better than Pipkin III and similarly, Pipkin III probably does the worst. So you can prognosticate your injury after surgical or nonsurgical treatment based on this classification as well.
ASHOK GAVASKAR: But I would still accept that the classification is not complete. It is deficient in a lot of aspects, if you ask me, like it doesn't give you any indication depend based on the fragment size or displacement. Also, if you look at Pipkin IIII, the classification does not describe the different variations in acetabular fracture pattern clearly. So there are a lot of deficiencies in this classification system, but I would probably still say this is the most popular and this is what we use as well.
ASHOK GAVASKAR: Apart from this system, you also have the Brumback system, which is probably the most comprehensive system and also I would say the best to prognosticate because it takes into account the direction of dislocation, the amount of joint stability, and also describes acetabular fracture patterns much better. Yoon is just a modification of the Pipkin system, and you also have the AO-OTA system as well. So these are some of the classification systems that you can use for Pipkin femoral head fractures.
ASHOK GAVASKAR: But as I said, the Pipkin system is the most popular. So this is Pipkin's classification system. And based on this, if you look at the prevalence of these injuries, how we treat them and prognosis and this data, I have collated from the paper from Chip Routt and his colleagues, this is the largest paper on the topic and if you look at the Pipkin I and II injuries in this paper, the Pipkin II or the supra-foveal injuries were much more common compared to Pipkin I.
ASHOK GAVASKAR: But if you look at all of the papers and including the journal, this meta analysis {INAUDIBLE} in 2009 injury, Pipkin I fractures tend to be more common. And even in our series between I's, they're more common than II. But apart from that like that stuff, the distribution is quite same. Pipkin IIII is next common, and the least common would be Pipkin III.
ASHOK GAVASKAR: And if you look at treatment based on this classification system, I and II, you can treat them either by non-operating or operating means. Non-operating you can opt for if you have an absolutely concentric reduction with good joint stability or else these fractures will require open reduction and internal fixation and the prognosis of either I and II tend to be pretty good with what I have.
ASHOK GAVASKAR: Type IV, again, depending on the acetabular fracture pattern, most often we will be doing an osteosynthesis and very rarely an acid and primary arthroplasty, especially in older patients and that will be determined by the acetabular fracture pattern, than the femoral fracture pattern. And with these injuries, the prognosis is not too bad. With the ORIF, they tend to do pretty well, varus {INAUDIBLE] do the worst with osteosynthesis.
ASHOK GAVASKAR: And if you look at studies after studies repetitively, more studies indicate a very poor prognosis if you are doing an osteosynthesis and primary arthroplasty does have a role in these fractures. So for prognosis of 53 injuries, it is quite bad with osteosynthesis. And if you look at the Milton Shipraus paper, there are another 10 percentage of injuries which does not fit into any one of these types, or to subtypes and these are predominantly impaction injuries which is not taken into account in the Pipkin classification system.
ASHOK GAVASKAR: So if you look at I and II, these fractures, as I told you, can be treated non operatively if you have an absolutely displaced fracture. Once you reduce the joint and you have stabilized situation. Or else, these fractures most often will require surgery in view of incongruent reduction, or if you have an unstable hip joint after reduction, or sometimes you might also have irreducible hip. So in this situation, you will require operative treatment to treat these injuries.
ASHOK GAVASKAR: And how do you treat them operatively? Most often, all type II's and most type I's will undergo fixation with some sort of screws, either mini fragment counter sunk screws or headless screws, rarely in some small type 1 infraviola lesions, which are too comminuted or too small to fix. These fragments can be safely excised without loss of hip stability or function. So whenever you deal with these injuries, the first step is to get your hip reduced, closed as an emergency in the ER.
ASHOK GAVASKAR: We do not do a pre-operative CT scan, but you can think of a pre-operative CT scan if you are doubtful, especially if you have an acetabular fracture pattern in association or if you think you have an un-displaced femoral neck fracture, in this case, an improper loss reduction can be catastrophic. But otherwise, in types I and II, we tend to reduce the hip joint and then do a post reduction CT image, which can give you a tremendous amount of information.
ASHOK GAVASKAR: On, on the femoral head fracture location, the size of the fragment, the amount of comminution you have, is there any loose articular fragments that is compromising congruity? And you can also look at the associated acetabular fracture pattern and also an ephemeral neck fracture that is present. So all of these things can be looked on in your appropriate post-op post reduction CT, so that you can plan surgical treatment.
ASHOK GAVASKAR: Or you can also think about creating distractions non operatively if your CT shows a concentric reduction. So if you opt for surgical reduction in Pipkin I and II, depending on what you do, excise or fix it, you can offer different surgical approaches. The surgical approach can be kind of broadly classified into ones that access the hip from posterior and the ones that access the hip from anterior same surgical dislocation, something kind of a lateral based approach, which gives you access to both posterior and anterior areas of the hip joint.
ASHOK GAVASKAR: So if you are looking at excision of the fragment based on your CT scans or x-rays, you can do it by using a Kocherl-Langenbeck approach as well. Not all the time, but sometimes if your fragment location is as such that it is situated in the posterior superior or the posterior side of the acetabular, these fragments can be retrieved through the Kocher-langenbeck approach sometimes, but not always. But the most common way to do these fractures would be to either access them anteriorly through a neutral interval or through a safe surgical dislocation.
ASHOK GAVASKAR: So for excision, our preference is to do a Heuters direct anterior approach and sometimes you can, as I said, do it through a Kocher-langenbeck as well. For fixation, it is always the direct anterior or the safe surgical dislocation. For I and II, our preference is to do a direct anterior neutral approach. Though we have done a lot of work on safe surgical dislocation, we have kind of moved on to the Heuter approach for these injuries in most of the patients.
ASHOK GAVASKAR: So these are kind of like descriptions of both these approaches. For the modified Heuter's, like you come from anterior area user utilizing the plane between the tensor facial latta and the rectus femorus, sorry, and sartorius and in the deeper plane you do a tenotomy of the direct head of rectus and then you do a capsulotomy and either dislocate or non or keep the in-situ and fix those fractures if it is amenable to do that.
ASHOK GAVASKAR: And for a safe surgical dislocation, as I said, you do this in a lateral position. You do, you kind of like you utilize an anterior capsulotomy which is facilitated by doing a Ganz trochanter, flip osteotomy, and then you can dislocate the access, the femoral head and also the acetabulum to do your fixation. And I'll kind of take you through both these approaches and also show you some illustrative cases to illustrate where we choose, what approach in such patients.
ASHOK GAVASKAR: So if you are going to do a safe surgical dislocation, this is how we would set patients up. So these patients are typically done in lateral position and you will require one or two assistants, and this is the kind of setup you need. You will need a saw blade, you will need reduction clamps, the pointed one for small and the big ones to kind of reduce your head and also to reduce your osteotomy, you will require a bone to help you dislocate and with a safe surgical dislocation it gives you access to the acetabular as well.
ASHOK GAVASKAR: So if you have labral tears , you can fix them. So if you have suture anchors, it will be useful as well. Apart from this implants, either mini fragment or headless compression screws. And this is kind of the overall overview of how this approach would be done. A lateral approach, a straight incision centered over the greater trochanter you can utilize through to plains, either Gibson interval between the gluteus medius and the maximus, or you can also split the maximus and get inside deeper as well.
ASHOK GAVASKAR: And once you are in, isolate the gluteus medius and the vastus, retract them both, and that will delineate your line of osteotomy. So make sure your osteotomy exits distal to the vastus ridge so that it is balanced by the pull of both those muscles. And at the end of osteotomy all your posterior structures are left intact, and then with gradual dissection anteriorly, you can expose the anterior capsule, which will be taken down in a z shaped manner, helping you to dislocate
ASHOK GAVASKAR: and then fix the femoral head. Close the capsulotomy and finally put your osteotomy back. So if you want to have a look at that, you can check one of our videos on YouTube on the topic as well. And a couple of illustrative cases. This is a 23-year-old male with a Pipkin type II injury with an incongruent reduction after closed reduction of the hip dislocation.
ASHOK GAVASKAR: He also had concomitant pelvic ring and spinal injuries as well and these are x-rays at around six months showing good reduction and fixation of the head fracture and also the osteotomy. Another patient 20-year-old multiply injured has got a type I Pipkin injury. He also had an unstable acetabular fracture on the right side, femoral fracture on the right, and a couple of tibial fractures as well.
ASHOK GAVASKAR: And if you can look at the femoral head injury, you can look at the femoral head fragment, dislocated way below the acetabulum. And this guy underwent a safe surgical dislocation, fixation of the femoral head fracture with 2.4 millimeter counter sunk screws. And he also underwent posterior superior labral repair. And these are his x-rays, immediately post-op and a two year follow up. You can see all his fractures have healed, some head show at 2 years, but not compromising its function or movement.
ASHOK GAVASKAR: And he has a pain free and a fully functional hip. Another male, another 27-year-old motor vehicle accident, Pipkin II with a femoral shaft and this guy was taken up upfront, upfront by my colleague who fixed the femoral shaft fracture and then I did the femoral head fracture in the second stage. And if you are going to treat femoral shaft fractures and if you are going to contemplate a safe surgical dislocation, you ought to be really careful so that you don't compromise your trochanter osteotomy side.
ASHOK GAVASKAR: Anti grade nailing of femoral shaft fractures in such situations where you require a safe surgical dislocation is quite safe in terms of infection or wound complications. And this has been shown by the group of colleagues from North America. So if we have a femoral shaft, you can go and do an anti grade nailing. It's quite safe, but make sure you use a trochanteric entry nail.
ASHOK GAVASKAR: Do not use sorry, make sure you use a bio-deformis entry nail. Don't use a trochanteric entry. If you look at this case, this is not exactly a trochanteric, they can be kind of a formis. But if I do this right now, I probably go a lot more medial. And in this case, we still very able to do the osteotomy and then get this femoral head fixed and this labral injury fixed as well.
ASHOK GAVASKAR: This guy had a lot of cartilage injury and this was in six months and this was around 4.5 years and he still has not come in for a hip replacement. You can see a lot of resorption of his cartilage, yet he still has some weight bearing domain and he's pain free still so does not want to come in so sooner or later he will require an hip replacement.
ASHOK GAVASKAR: So if you look at our results for Pipkin I and II injuries by using a safe surgical dislocation, we had around 28 patients. 26 were followed up for more than two years and we did ORIF in all type II injuries and in most type I injuries as well, except two patients, the functional outcome was brilliant as it is in most of the series other from everywhere in the world as well.
ASHOK GAVASKAR: Their function were excellent, patients who had problematic function and arthritis, chondral defects which we had noticed intraoperatively and patients who had a labral injury also had kind of a not so good in function. If you look at the most commonest complications in our series, we did not have any in most patients, the most commonest complication was anatomic ossification, which were either grade 1 or 2 and one grade 3 as well, and degenerative arthritis in 3 patients who required a total hip replacement.
ASHOK GAVASKAR: So coming to the second approach, the Heuters direct anterior, this is how you would set a patient up for a direct anterior. Patient isn't supine. You might require some inflection. The incision runs vertically downwards, starting around 2cm distal and lateral to the antero-supero-lateral ex spinal, it will require around 8 to 10cm incision.
ASHOK GAVASKAR: The number of tools you require are much lesser compared to a safe surgical dislocation. You would require pointed reduction clamps, some wires, and then either a mini fragment or headless compression screws. Again, this is a overview of the entire surgical approach. And once you go inside, once you spread that fascia over the tensor, you might encounter the larger cutaneous femoral nerve. And if you encounter them, make sure you protect it throughout the procedure.
ASHOK GAVASKAR: And once you go into the deeper plane, you will see the branches of the lateral circumflex femoral vessels in the second image. Make sure you tackle them, we tend to ligate them and then once you go deeper, you will get the isolate the direct end of rectus, which can be identified by its physical appearance. And once you identify it, we do a tenotomy in all cases that facilitates exposure to grade B and then capsulotomy
ASHOK GAVASKAR: To me we prefer a T shape capsulotomy to me for main reason is like if you do a t-shape capsulotomy, if you have an infra wheeler fracture with no displacement or minimal displacement, you can clamp it and fix those fractures without dislocating by bringing the leg into a kind of flexion abduction, external rotation position, you don't have to dislocate the hip. So the inferior limb of the T facilitates that. But in cases where you have displacement that are not amenable for reduction in situ, you can go ahead and dislocate as we have shown in figure E and then complete your fixation outside the acetabulum and then relocate your hip.
ASHOK GAVASKAR: So again, like if you want to look at the video, our video is available in one of the archives of the American Academy under the OVT platform. So this is, again, an illustrative example. This is a 31-year-old male with a type II displaced femoral head fracture. He also had abdominal and craniofacial injuries, which were treated conservatively. And these are his follow up X-rays and outcomes that are around six months.
ASHOK GAVASKAR: Again, like, as you can see, you don't need an osteotomy, you can go ahead and fix it, and these patients tend to do pretty well. And we did look at our results comparing both the Heauters group and the safe surgical dislocation group. We had around 60 patients comprising of around 32 surgical dislocation, around 28 modified Heuters and when we compared what we found was patients who underwent Heuters approach required less surgical time and less blood loss and also had better pain scores
ASHOK GAVASKAR: during the immediate post-operative period. But if you look at the overall functional outcome, it wasn't different and also the number of complications, the complication distribution was also very similar across both groups. So in terms of outcome, long term and complication, there wasn't much difference, but in terms of perioperative outcome, patients who underwent the Heuter approach did better.
ASHOK GAVASKAR: So these are some of the salient merits and demerits that I can think of go this approach so if you want 360 degree exposure, of the acetabulum, then safe surgical dislocation is a way to go. It also helps you to identify and treat posterior labral tears, and you can also treat concomitant acetabular injuries, that is the Pipkin IV if you have them. But we saw more heterotopic ossification with safe surgical dislocation compared to the Heuter approach.
ASHOK GAVASKAR: The Heuter approach, the pros are less surgical steps, so less time you can do it supine so it is easy to deal with other injuries. If you are dealing with poorly traumatized patients, you don't need an osteotomy so it avoids potential problems if you need a hip replacement in future, especially the hardware there. The unique complication with the Heuter approach would be the injury to the larger transfemoral nerve which we encountered in a couple of patients as well.
ASHOK GAVASKAR: So these are points that come to the point that you can think of, and keep in mind when you choose your surgical approach, when you want to treat these fractures. So coming to Pipkin III injuries, these fractures have either a Pipkin I or II injury with an associate, femoral neck fracture. So you can best describe them as segmental intra-capsular fracture of the proximal femur, where you have a femoral head fracture and then a break in the femoral neck as well.
ASHOK GAVASKAR: So these fracture patterns are like 1 and 2. Even the 1 and 2 are more common, they are dislocation as well. These fractures are almost always a social dislocation. Otherwise you don't have them. So for these injuries, closed reduction is practically impossible. If you have a displaced femoral neck fracture. And if you have an undisplaced femoral neck fracture, and if you contemplate open reduction and internal fixation of those injuries, then it is extremely unsafe to think of a closed reduction because you can make it completely displaced and it might rob you of an opportunity to posterior synthesis.
ASHOK GAVASKAR: So make sure you have this in mind and most often you will require a pre-operative CT scan. So how to treat them? This is one injury where there is a big role for primary arthroplasty because for ORIF type III injuries has been uniformly described with poor results. If you look at the first reference paper by Peter Giannoudis from Leeds, which is kind of systematic review,
ASHOK GAVASKAR: they did not have a single patient who had an excellent outcome after ORIF, type IV critical injuries. And if you look at the second paper, these guys looked at around 110 patients in femoral injuries and there were 4 Pipkin III fractures. Of the four, one had primary arthroplasty and three went on to fail and had secondary arthroplasty. So all four of them ultimately ended up having a total hip replacement.
ASHOK GAVASKAR: And this is the largest series on the topic, again, from Milton Chip and his colleagues. These guys looked at around 140 odd fractures. Across I, II, III and IV Pipkin types, and they had 7 Pipkin III injuries. Of the seven patients, all seven actually underwent ORIF. After ORIF, two patients failed within 12 weeks and 5 patients went on to fail after six months, either due to catastrophic fixation failures or due to AVN.
ASHOK GAVASKAR: Ultimately, all seven of them failed, and their conclusion was primary arthroplasty should be strongly considered for Pipkin III injuries and that is what our opinion is as well and our preference is to do a primary in these injuries. And if you look at our experience, we have had three cases, so far in our experience over the last ten, 15 years with a mean age of around 39 years.
ASHOK GAVASKAR: And all these patients ended up having primary hip replacement and this is one of those patients who underwent an hip replacement at 29 years, and at around 8 years, follow up is still doing great, doing everything. So this is what our experience about Pipkin III injuries, which is not very different from all over the world. So but if at all, you contemplate an open reduction internal fixation for a Pipkin III injury,
ASHOK GAVASKAR: you can do that, especially if you have an undisplaced femoral neck fracture or even if you want to do it, displaced femoral neck fracture pattern. If you want to have any kind of an objective criteria of how to do that, this is one paper you can look at. The paper from Bone Group, which kind of looked at fracture patterns involving femoral neck and femoral head with a dislocation injury.
ASHOK GAVASKAR: And their conclusion was like, you can do a safe surgical dislocation for these injuries and look at the status of the postero superior retinalacular vessels and these are images from their article and if you have intact posterosuperior retinal blood vessels, then yes, you can contemplate OR or ORIF and expect to get good outcomes. And if they are disrupted, primary arthroplasty is probably a better initial management.
ASHOK GAVASKAR: And this is one paper that I could look at but having said that, we have not done an ORIF in a Pipkin III injury so far. What about Pipkin IV? In Pipkin IV injuries, you have an acetabular fracture in association and you can have any of the 10 types of acetabular fractures that are described. But the most common injury pattern that you see is the posterior wall, and that is what Pipkin describes in this paper.
ASHOK GAVASKAR: And when you have the posterior wall injury in combination to femoral head fracture, closed reduction is possible unlike we can treat but you have to be really, really careful because these injuries sometimes can have major femoral head impaction along the disrupted posteriol wall and if you inadvertently break your femoral neck during your loss reduction, you can kind of make the entire femoral head non-viable and non amendable for fixation.
ASHOK GAVASKAR: So you have to be really careful if you are going to contemplate close reduction for a Pipkin IV injury with an associated posterior wall and be really careful about it. And this is one instance where I always get a pre-operative CT scan so that I can look at how much of an impaction is there along the posterior rim. You can also look at the posterior wall characteristics.
ASHOK GAVASKAR: Where is the exit of the posterior wall? How much chunk is it involving? Because depending on that, I can choose my surgical approach, which I will touch upon in the next slide. And also you can look at whether you have an undisplaced femoral neck fracture, in which case you might kind of change your surgical strategy so it makes a lot of sense to get a pre-operative CT scan in a Pipkin IV injury.
ASHOK GAVASKAR: So if you are going to treat this fracture surgically, whether you have a femoral head and a posterior wall fracture, how do you approach that? There are papers in reported where they have successfully used the Kocher-langenbeck approach to treat both these fractures and yet get good results without any problems with femoral advanced clarity. And compared to types I and II, where the anatomical location of the femoral head and the impact posterior wall may not kind of allow you to do a fixation through the Kocher-langenbeck approach. In type IV
ASHOK GAVASKAR: with the posterior wall broken, it might be a lot more easier to access the anteriorly broken femoral head and still get some fixation on it. So it is possible. It may not be always possible in all fracture patterns, but it is possible. So this is one approach that you can think of. But that is not something that we prefer all the time, even though it is reported. What our preference would be to do either an anteriorial based surgical approach like the Heuters, fix the femoral head
ASHOK GAVASKAR: and then stretch the posterior wall injury if it needs to. And if the EP is stable and the wall involvement is minimal, we might choose to conservatively treat the posterior wall. And this is a strategy popularized by Chip Routt and his colleagues, and I think it makes pretty good sense. But if you have a fracture pattern that needs fixation of both fractures, then you can also opt for a safe surgical dislocation.
ASHOK GAVASKAR: You can do both these fractures through a single approach without any change in position. If you are going to contemplate an anterior based surgical approach, where I do a direct anterior fix the femoral head and then stress the femoral acetabular wall, and if I find it unstable, I have to change position and then come back lateral or in prone and fix up my posterior wall. So that's kind of a cumbersome, but if you want to avoid that, you can then choose a safe surgical dislocation.
ASHOK GAVASKAR: So for us, these are the two approaches which we will contemplate to do when we have a a Pipkin IV injury, where we have an associated posterior wall in the femoral head injury. So I'll just show you a couple of examples. The 35-year-old female with a Pipkin IV injury she's gotten an MVA femoral hip fracture and you can see the acetabular wall pattern, small, not too cranial lateral.
ASHOK GAVASKAR: So if you want to look at the determinants of stability in the posterior wall, it is there's a great paper from our view in Jody by Reza Firozabad, which describes the instability in posterior wall injury. That's a great read. So if you have a very cranial exit or fractures involving a bigger chunk, those fractures are almost always going to make the EAP unstable.
ASHOK GAVASKAR: So even if you have a smaller chunk in a much cranial location, these fractures might require surgical treatment. So in those cases, you can kind of go to a safe surgical dislocation straight away. But this fracture was not too cranial, but the patient had an incongruent adduction, as you can see by the post production CT scans and here we went through the direct anterior approach retrieved and fixed for a femoral head fracture and then subject to the patient process examination.
ASHOK GAVASKAR: Then these are the images with and without stress in an object or oblique view. As you can see, they demonstrate no instability and this patient was chosen to be treated non surgically for the posterior wall. And these are at post-operative x-rays. We do keep them on it, precautions for six weeks to prevent any kind of instability.
ASHOK GAVASKAR: And I don't have a follow up except because this is one of the recent case, but we have done this in a few patients with pretty successful outcome. So another case, this is a 20-year-old male motor vehicle collision again posted a wall fracture and a femoral head injury. In this case, again, like if you look at the femoral, the posterial wall fragment is pretty small, but the Pipkin injury is type II and it is incongruent.
ASHOK GAVASKAR: So we chose to reduce and fix them both and we did it through a safe surgical dislocation and this is how it looks like postoperatively, and this is what it looks like around three months and this is the patient with pretty good outcome. So if you want to, again, look at safe surgical dislocation and understand the surgical technique of doing it for a Pipkin IV injury, again, you can look at all of our videos in the orthopedic video data on the topic.
ASHOK GAVASKAR: So another case again and I posterior wall injury with an intra femoral fracture. Again, these patterns, we know that they make the hip unstable, so there is no way you are going to treat this non operatively, so we go straight away to a safe surgical dislocation. In this case, we excised a formula fragment and fixed the posterior wall and this is how it looks like at around 24 months with good hip function and a congruent hip joint.
ASHOK GAVASKAR: Another probably the last kid. This is a 60-year-old male who presented to us with a Pipkin IV injury three weeks post after he got injured and when we saw him get severe marginal impaction. You can see the posterior wall, pretty cranial and also the femoral head fracture involving a major chunk of the entire femoral head. And this is what it looks like when we went in, the intra formula fragment was not reconstructable,
ASHOK GAVASKAR: and so we excised it, we fixed the posterior wall, and this is how it looked like immediately after surgery and this is at around 12 weeks post fixation. We completely lost the femoral head and then we reconstructed him by doing a total hip replacement with the metal augment to address the defect posterosuperior. So this is unpublished data of us where we looked at 23 patients with Pipkin IV injuries.
ASHOK GAVASKAR: We were followed up for around 43 months, meaning we did ORIF in all and after maximum appear at around two to four year follow up, four of them had been converted to a secondary total hip replacement. Function was good, not bad as Pipkin III I supported some of the studies at the same time, not as good as I and II. And the major reasons for a compromised function and need for secondary replacement include chondrol defects, marginal impaction in the posterior wall and delay in presentation.
ASHOK GAVASKAR: And again, if you look at complications we had even in this subset of patients, atopic calcification was still the most commonest complication. If you look at other published studies on Pipkin IV's, most of them are associated with very similar outcomes that we have shown in the previous slide. Patients tend to do pretty well. High rates of union, problems include arthoscopic calcification and nonunion, so Pipkin IV's tend to do good, not as good as between I and II, but much better than Pipkin III.
ASHOK GAVASKAR: So in summary, Pipkin femoral head fractures often need surgical treatment in view of in congruency, irreducibility and instability. And in terms of outcome, Pipkin I and II tend to do pretty well after ORIF or excision If you have very small type I fragment, you can choose either to use the direct anterior or the surgical dislocation approach.
ASHOK GAVASKAR: Both do very well, but we do think Heuter is much simpler, will take you much less of your time to do it. For Pipkin III injuries, if you have an older patient, arthroplasty is definitely the way to go. But if you have a younger patient, our first choice is still an arthroplasty for a displaced fracture pattern. But if I have a non displaced femoral neck, which I haven't had so far, I might probably contemplate for IF and for approaching
ASHOK GAVASKAR: if you are going to do an ORIF again, you can still do a neutral approach or a safe surgical dislocation, but we would still think a safe surgical dislocation is safer because you do not have to think of a closed reduction to do a Heuters. And uniformly, regardless of whatever approach you use for open reduction, internal fixation results are poor, but Pipkin IV,
ASHOK GAVASKAR: ORIF is the treatment of choice, arthroplasty can be contemplated in select patients who are older, depending on the acetabular fracture pattern and the outcome, and the choice of surgical approach that you use in these patients will again, depend on the acetabular fracture pattern, most commonly posteral, wall which you can deal with safe surgical dislocation. You can also treat someone with posterior wall non operatively if you are stable and have a small fragment.
ASHOK GAVASKAR: If you have other complex fracture patterns, depending on the fracture pattern, you might choose either an anterior or a posterior based surgical approach to treat it. Thank you.
HITESH GOPALAN: Thank you, Sunil. Sunil, you can stop sharing your screen.
HITESH GOPALAN: And yeah, thank you Sunil for this fabulous presentation and absolutely amazing cases as well. Sunil, a few questions. So one of the problems in a type III is that, I mean, is a femoral neck fracture, right? So invariably, what on all the I mean, most of the x-rays that they've shown, the femoral neck is invariably a sub capital type.
HITESH GOPALAN: And do you think that is one of the reasons for the poorer prognosis? Suppose it was more of a transfer vehicle, or do you think the reduction and fixation would have given a better outcome?
ASHOK GAVASKAR: We have seen like a couple of patterns. Like one is like exactly the fracture propagating from where the femoral head structure is kind of like finishes like it propagates superiorly and you have an un displaced neck and/or sorry or a displaced neck.
ASHOK GAVASKAR: So that is probably the most common pattern that we have seen. And we have also seen trans-cervical patterns. In trans-cervical patterns, what we have seen is the fracture plane is actually much more vertical. It is not transverse actually. So, so with this spike patterns, like most often if you are thinking of fixation, prognosis even for a femoral head fracture can be a neck fracture can be sometimes suboptimal for a 3 and injury.
ASHOK GAVASKAR: So when you have a femoral head fracture in combination with that, outcomes can be a lot more complicated. So but the most common type III pattern that we have seen in very limited numbers is sub capital, where the neck fracture takes off, where the femoral head fracture stops.
HITESH GOPALAN: Thank you, Sunil, for that.
HITESH GOPALAN: And do you think there's a role for bio-absorbable screws instead of titanium? Even the titanium, I mean, it's compatible with them are there could be some artifacts, right? So there are a couple of papers, for example, there's a paper in COR way back in 2005 that they looked at bio-absorbable screws for who had fractures. What do you think about it?
ASHOK GAVASKAR: Yeah, actually, we have used it.
ASHOK GAVASKAR: We have used it. And we have seen breakages actually when we are using it, so I do not know whether it's something that is available to us in our country, but I'm not sure about it. So what the problems with our what we have is two one, we don't get big lengths. Of course, you don't need very long lengths in these ones, but that whatever length we have is much smaller sometimes.
ASHOK GAVASKAR: And also the fracture, the screws tend to break, so in one of those cases, when we tighten like we broke two to three screws and once we break them, it is quite difficult to remove them, and so we had to really like cut it off and make sure it doesn't create any condral damage. So that is our experience with bio-absorbable screws. Otherwise, like if you have them, you can use them. I don't think there is any problems with that because like once you have reduced and fixed it, you actually don't need very strong fixation because that acetabulum kinds of acts a buttress to maintain your fixation.
ASHOK GAVASKAR: So I don't think you will see lots of reduction in femoral head fractures after fixation.
HITESH GOPALAN: Thank you, Sunil. And Sunil, there's a trend for hip arthroscopy, for example, a type I. Pipkin. A lot of surgeons, even someone has published a step by step approach as to how you can do a hip arthroscopy, for example, for a type 1 Pipkin. What do you think about it?
ASHOK GAVASKAR: Yeah, I think it's absolutely feasible for a type 1 Pipkin is you can go again and if you are looking at fragment excision or even fixation like yes, it is possible to manipulate minor, minor modifications possible, but like if you have major displacements, rotations into two, I think it will be difficult. I'm not sure it's feasible, but type 1, yes, it's possible. It's described.
HITESH GOPALAN: Thank you, Sunil. We do not have any experience. Yeah, just one last question before we wind up. Sunil, you mentioned about a very common scenario that is a type VI Pipkin when you have an acetabular fracture as well as femoral head, right? So suppose a femoral head be the primary fracture line and the primary component dislocated anteriorly.
HITESH GOPALAN: Do you think a separate approach, for example, use Heuter and a Kocher-langenbeck or do you would you prefer a surgical dislocation? Because, again, Kocher-langenbeck, you're going through the posterior area, young patient, capsular injury. So do you think surgical dislocation has advantages?
ASHOK GAVASKAR: Yeah so our preference is like so we don't do the Kocher-langenbeck but but I included it because it has been reported so but I think in a Pipkin IV compared to a I and II in regards to femoral fixation if you're contemplating a Kocher-langenbeck, it might be more easier but
ASHOK GAVASKAR: that is my comment. But that is not something that we do. But like what we do is like, as I said, like we tend to do the safe surgical dislocation most of times, but like in the recent probably last two years, like we have kind of followed the description by Milton Chip brought in this paper. In select patterns where you have a small acetabular posterior wall or the fragment, which is not too cranial, which I think will not compromise the hip stability in any way.
ASHOK GAVASKAR: So in those cases, like I do not have to do a more laborious or an elaborate approach like the safe surgical dislocation, do an osteotomy. So once we have a reduction, once we have relocated the hip joint, then we, I do a direct anterior, put back the femoral head and then stress it, and most often like if you have decided based on the preoperative CT correctly again here one good paper to look at is the one that I quoted from , Razor from like from the Arborview center, I think in JO in 2010.
ASHOK GAVASKAR: So that's a great paper which looks at various aspects of stability in the posterior wall fracture. So if you do not have a very cranial exit or fracture that are involving more than 20% of the posterior wall, those are the ones based on your preoperative CT that you choose for this kind of a select approach where you do it and then stress it, and if it is stable, treat them conservatively, hip precautions and you do not have to go posteriorly
ASHOK GAVASKAR: and those patients we have done around four or five, we have had pretty good results. So we have not had to repent our decision. But if I can make out, OK, these are bad posterior wall fracture, bad actor. Two cranial or too big a wall, then I would say go ahead and do a safe surgical dislocation and address both.
HITESH GOPALAN: Thank you, Sunil.
HITESH GOPALAN: Sunil, I think that's all the questions that we have for the session. Thank you for this wonderful presentation and I'm sure is going to benefit a lot of people. Thank you.
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