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Hip dislocation and_femoral_neck_fracture_decision
- 2. Case report Hip dislocation and femoral neck fracture: Decision-making for head preservation Moritz Tannast a, *, Philip W. Mack b , Bernd Klaeser c , Klaus A. Siebenrock a a Department of Orthopaedic Surgery, Inselspital, University of Bern, Murtenstrasse, 3010 Bern, Switzerland b Shriner’s Hospital for Children, Springfield, MA, USA c Department of Nuclear Medicine, Inselspital, University of Bern, Switzerland Introduction Hip dislocation with femoral neck fracture is a rare injury in young adults and is a challenging problem. It is fraught with potentially devastating consequences including avascular necrosis and subsequent early secondary osteoarthritis. We identified only 30 cases reported in literature that bear this fracture pattern (Table 1). Of note 17/30 cases were treated by open reduction and internal fixation and 9 of these 17 have developed avascular necrosis leading to eventual prosthetic replacement. Based on this evidence in literature many authors have even proposed primary hemi- or total hip arthroplasty. Although femoral head viability and risk of subsequent avascular necrosis were of major concern in all prior reports none of the previous reports or discussions has alluded to decision- making based on intraoperative integrity of the medial femoral circumflex artery (MCFA) and retinacular vessels for deciding between osteosynthesis versus joint replacement. The precise knowledge of the MFCA topography and surgical anatomy has led to the development of the safe surgical hip dislocation, a technique developed at our institution for complete dislocation of the femoral head without the risk of avascular necrosis by protecting the MFCA.8,9 Accurate knowledge of anatomy and intraoperative assessment of its integrity is an essential step for hip-joint preserving surgery. The purpose of this article is to use evidence-based medicine to give current perspective in modern orthopaedic management of this devastating injury pattern. We have presented an illustrative case report to outline the steps in decision-making. We further provide an algorithm for the management of this injury that will hopefully aid clinicians in approaching these patients. Illustrative case example Written consent was obtained from the patient for the publication of this case report. A 31-year-old man presented to our level I trauma centre as a transfer from a rural centre 3 h after being involved in a motor vehicle accident. The patient was healthy and had no previous medical issues. On primary survey the patient was haemodynamically stable. Physical examination revealed a stable pelvis with abduction, external rotation and shortening of his right lower extremity. Distal pulses were palpable with sciatic, femoral and obturator nerve function grossly intact. Pelvic exam was stable. A routine anteroposterior pelvic radiograph, Judet views13 and additional computed tomography showed a completely displaced trans- cervical femoral neck fracture with posterior hip dislocation in addition to a transverse acetabular fracture (Fig. 1). The only other orthopaedic injury noted was an intraarticular distal phalanx fracture of the thumb. There were no additional systemic injuries. The patient was taken to the operating room with in an hour of presenting to the emergency room (5 h after the primary injury). He was placed in a lateral decubitus position with his right hip exposed through a previously described modified Kocher Langen- beck approach.31 After splitting of the fascia latae and the gluteus maximus muscle, the femoral head was found lying posterior to the greater trochanter (Fig. 2A). The tendon of the piriformis muscle was partially torn as were the triceps coxae and the inferior portion of the gluteus minimus muscle. A trochanteric flip osteotomy was performed and a z-shaped capsulotomy was completed. By means of a retrograde-inserted Schanz screw, the head was gently reduced. Careful inspection at this point revealed an intact vessel bundle of the MFCA in the posterior aspect of the femur with a preserved retinaculum in the posterosuperior femoral neck leading to the femoral head (Fig. 2B). By lifting up the femur with a bone hook, the intact tendon of the obturator externus was evident, thus suggesting a preserved extracapsular course of the MFCA.9 Based on the structural integrity of the retinaculum and the intact obturator externus muscle/tendon a Injury, Int. J. Care Injured 40 (2009) 1118–1124 A R T I C L E I N F O Article history: Accepted 22 June 2009 * Corresponding author. Tel.: +41 31 632 2222; fax: +41 31 632 3600. E-mail address: moritz.tannast@insel.ch (M. Tannast). Contents lists available at ScienceDirect Injury journal homepage: www.elsevier.com/locate/injury 0020–1383/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2009.06.166
- 3. decision was taken to perform osteosynthesis with 6.5 mm cancellous screw fixation. Additionally, the defect in the ante- roinferior femoral neck was grafted with autologous cancellous bone obtained from the greater trochanter. The acetabular fracture was anatomically reduced and fixed with a 7-hole-3.5 mm reconstruction plate (Fig. 3B). The initial postoperative course was uneventful. Due to the rare nature if the injury in this patient, to confirm the integrity of the MFCA and the femoral head blood supply, a selective femoral angiography and a bone scan were performed postoperatively (although this is not a routine for our institution). The femoral angiography demonstrated the integrity of the extracapsular course of the MFCA (Fig. 4A). The 2-phase bone scan confirmed that there was perfusion to the femoral head and showed a posttraumatic increase of bone metabolism in the femoral neck and head (Fig. 4B). The patient was kept NWB on crutches. A follow-up bone scan 3 weeks postoperatively (again performed in this case as an exception due to the rare nature of the injury and femoral head preservation that was performed) re-confirmed the preserved perfusion and viability of the femoral head (Fig. 4C). At the 8-week follow-up, radiographs unfortunately partial loss of reduction and early signs of implant failure. The compliance of weight-bearing status of the patient remained questionable. Nevertheless, a prompt decision was taken to revise the fixation Table 1 Overview of the literature of hip dislocations associated with femoral neck fractures (ORIF = open reduction and internal fixation, AVN = avascular necrosis of the femoral head, THA = total hip arthroplasty, TO = trochanter osteotomy). Author, year Number of cases Age of patient (years) Direction dislocation Intraoperative bleeding of the head Treatment Associated fractures of the pelvis/hip AVN Surgical approach Baba et al., 20021 1 36 Anterior – ORIF Pelvic ring fracture, acetabular fracture Yes Lateral transtrochanteric Du¨ mmer et al., 19992 2 48 Obturator – THA – – Posterolateral 50 Posterior – THA – – Posterior Duygulu et al., 20063 1 52 Posterior – ORIF Pelvic ring injury, acetabular fracture, femoral shaft fracture No Posterolateral Esenkaya et al., 20025 1 39 Anterior – THA – – Lateral Fernandes, 19816 1 60 Posterior – Unipolar hemiprosthesis Femoral head fracture – Posterolateral Fina et al., 19707 5 65 Posterior – Unipolar hemiprosthesis – – – 36 Posterior – Unipolar hemiprosthesis – – – 10 Anterior – ORIF – Yes – 50 Posterior – ORIF Acetabular fracture Yes – 57 Posterior – ORIF Femoral head and shaft fracture Yes – Hougaard et al., 198811 2 62 – – Conservative – – No surgery 63 – – Unipolar hemiprosthesis – – – Izquierdo et al., 199412 1 17 Obturator – ORIF Fragment at the posterosuperior neck Yes Lateral transtrochanteric Klasen et al., 198414 2 19 Posterior No bleeding ORIF Acetabular fracture Yes – 41 – – ORIF Acetabular fracture No – Kumar et al., 198515 1 33 Posterior – ORIF – No – Maini et al., 200416 1 25 Posterior – ORIF Greater trochanter fracture Yes Posterolateral McClelland et al., 198717 1 28 Obturator – Bipolar hemiprosthesis Indentation fracture of the femoral head – Posterolateral Mehara et al., 199518 1 45 Posterior – Unipolar hemiprosthesis Indentation fracture of the femoral head – Posterior Meinhard et al., 198719 1 27 Central – ORIF Acetabular fracture No Posterolateral with TO Meller Y et al., 198220 1 24 Posterior – Unipolar hemiprosthesis Femoral head fracture – Posterolateral Mestdagh et al., 199122 1 52 Central – Traction, secondary THA Pelvic ring injury, acetabular fracture No Posterolateral with TO Newman, 197423 1 40 Posterior – Conservative Acetabular fracture No No surgery Peterson et al., 195025 1 33 Posterior – Bone grafting, traction – Yes Smith–Petersen Polesky et al., 197226 1 81 Anterior – Unipolar hemiprosthesis Acetabular fracture – Anterolateral Sadler et al., 198527 1 77 Anterior – ORIF – Yes Watson–Jones Saragaglia et al., 198728 3 41 Posterior – ORIF – No Kocher Langenbeck 22 Posterior – ORIF Acetabular fracture No Kocher Langenbeck 38 Posterior – ORIF Acetabular fracture No Kocher Langenbeck Present study 1 31 Posterior No bleeding ORIF Acetabular fracture No Surgical dislocation M. Tannast et al. / Injury, Int. J. Care Injured 40 (2009) 1118–1124 1119
- 4. and perform an additional valgus intertrochanteric osteotomy to decrease the Pauwel’s angle and convert the shear forces to compressive forces. Surgical approach was performed through the original skin incision and the trochanteric flip osteotomy was used again (Fig. 3C). Intraoperatively, brisk bleeding present after drilling of the femoral head was a reassuring sign.10 Inserting the 2 mm laser-Doppler-flowmetry24 probe demonstrated strong pulsatile signals emanating from the femoral head (Fig. 4D). The patient was carefully instructed to be compliant about NWB this time and repeatedly reinforced that this was the final salvage procedure. Radiographic examination, 8 weeks after the revision (4 months after the accident), showed signs of healing in both the femoral neck and the transverse acetabular fracture. Patient was eventually progressed to PWB at 8 weeks and then with documented good signs of healing, progressed to FWB at 12 weeks. At the most recent follow-up, 4.7 years after injury, the patient remained completely asymptomatic with full, symmetrical, and unrestricted range of motion of the hip. According to the Medical Research Council (MRC) muscle strength grading system, the hip abductor strength was M5. The total Merle-d’Aubigne´ hip score21 was 18, depicting an excellent outcome. Routine roentgenograms showed no radiographic evidence of avascular necrosis of the femoral head or progression of arthritis (Fig. 3D). The patient has returned to his full-time occupation as a forester without restrictions. Relevant surgical anatomy A detailed knowledge of the vascular supply to the proximal femur forms the essential basis for safe hip preserving surgery. The medial circumflex femoral artery (MFCA) provides the main and Fig. 2. (A) Intraoperatively, after splitting of the fascia lata and the gluteus maximus muscle, the femoral head (*) was found lying posterior to the osteotomized greater trochanter (OGT). (B) This figure shows the view from anterior after reduction and provisory fixation with k-wires (KW). The retinaculum with the terminal branches of the medial circumflex femoral artery was intact (arrows). Fig. 1. The preoperative anteroposterior pelvic radiograph (A), Judet views (B, C) and computed tomography show the severely displaced lateral femoral neck fracture with posterior dislocation of the femoral head in combination with a transverse acetabular fracture. M. Tannast et al. / Injury, Int. J. Care Injured 40 (2009) 1118–11241120
- 5. critical blood supply to the femoral head in an adult.9,29 The deep branch of the MFCA runs towards the intertrochanteric crest between the pectineus medially and the iliopsoas tendon laterally (Fig. 5A) along the inferior border of the obturator externus muscle (Fig. 5C). After crossing this tendon posteriorly, a constant trochanteric branch is delivered adjacent to the proximal border of the quadratus femoris (Fig. 5C). Thereafter, the deep branch of the MFCA runs anterior to the tendon of the triceps coxae muscles (gemelli and obturator internus muscles) to perforate the hip capsule obliquely just cranial to the insertion of the tendon of the superior gemellus and distal to the tendon of piriformis. It then splits into two to five retinacular vessels lying in a mobile layer of connective tissue on the posterosuperior aspect of the femoral neck and enters the femoral head lateral to the bone–cartilage junction (Fig. 5D). Proposed algorithm Management of femoral neck fractures by itself can be a challenging problem. To add to it an associated hip dislocation can make the situation more complex and therefore decision-making becomes more a matter of experience than objectivity. Based on the previous technique of safe surgical dislocation described at our institution, we believe that an algorithmic approach can be used for these difficult injuries. Our proposed algorithm is outlined in Fig. 6. Discussion Femoral neck fractures with hip dislocation are a challenging problem. By protecting the MCFA and its retinacular vessels adjacent to the posterosuperior femoral neck, a safe and complete dislocation of the femoral head is possible without the risk of avascular necrosis. Knowledge of this topographic anatomy, the anatomical course of the MCFA, and the importance of an intact obturator externus muscle, are absolutely critical in the intrao- perative decision-making for preservation of the native femoral head. Femoral neck fracture with hip dislocation is a rare injury. As mentioned before, we could identify only 30 cases with this fracture pattern upon a thorough review of the English literature (Table 1). Treatment options based on literature review include conservative treatment, traction, osteosynthesis, hemiarthroplasty or primary total hip arthroplasty. The only reported case in which successful conservative treatment was achieved was presented by Newman.23 He suggested attempting closed reduction before performing open surgery. However, closed reduction, even when performed gently, may be proved to be very harmful and these manoeuvres are hard to control. Such manipulation could create additional damage to the frail bridge of preserved retinacular vessels thereby causing definite devascularization.4,26 Some authors who recommend immediate endoprosthetic replacement justify their approach by pointing the high likelihood of ‘ques- tionable viability’.7 These reports have failed to assess and report the intraoperative integrity of the MFCA or the viability of the femoral head. McClelland based his decision to abandon femoral head preservation and osteosynthesis by the noted absence of capsular bleeding and absent bleeding of the round ligament.17 However, we now know from anatomic studies that the medial epiphyseal artery via the round ligament typically perfuses only the area adjacent to the fovea and rarely supplies a significant area of the head in adults.9,29 Although intraoperative drilling of the femoral head is a reliable sign of femoral head vascularization,10 it may be less reliable in Fig. 3. (A) Osteosynthesis was performed using two 6.5 mm screws via a modified Kocher-Langenbeck approach with trochanteric osteotomy. The acetabular fracture was fixed with a 7-hole-3.5 mm reconstruction plate. (B) Eight weeks postoperatively, a delayed union with loss of reduction and screw breakage was observed. (C) A 20-degrees valgus intertrochanteric osteotomy was subsequently performed using the same trochanteric flip osteotomy approach used previously. (D) At latest follow-up (4.7 years after injury), no signs of avascular necrosis are present after partial hardware removal. M. Tannast et al. / Injury, Int. J. Care Injured 40 (2009) 1118–1124 1121
- 6. dislocated fractures for multiple reasons. Hip dislocation can lead to traction, compression and spasm of the femoral, deep femoral and their circumflex arteries.30,32 These pathological factors may be reversible by early reduction of the dislocation.30,32 Although the blood flow of the MFCA during head dislocation might be compromised, the perfusion of the head can be preserved due to existing collaterals that are not under traction, e.g. the inferior gluteal artery.9,32 The intactness of MCFA and the retinaculum as such remains an import sign and decision-making point to proceed with femoral head preservation despite presence or absence of Fig. 4. (A) A selective angiography of the femoral artery was performed postoperatively to confirm the integrity of the extracapsular course of the medial femoral circumflex artery (CFA = common femoral artery, SFA = superficial femoral artery, PFA = profund femoral artery, MCFA = medial femoral circumflex artery, LCFA = lateral femoral circumflex artery, PV = perforating vessels). (B) This bone scan which was taken postoperatively after the first operation shows posttraumatic changes with increased perfusion and bone metabolism in the right femoral neck and head (arrow) indicate preserved viability of the femoral head. (C) The control scan three weeks after the index operations shows persistent increase of perfusion and metabolism in the femoral neck and head as a sign of ongoing bone healing and preserved viability of the femoral head. (D) At the time of revision, the laser Doppler flowmetry shows a strong pulsatile signal emanating from the femoral head. M. Tannast et al. / Injury, Int. J. Care Injured 40 (2009) 1118–11241122
- 7. Fig. 5. (A) The deep branch of the MFCA runs towards the intertrochanteric crest between the pectineus medially and the iliopsoas tendon laterally. (B) The MCFA then runs along the inferior border of the obturator externus muscle. (C) After overcrossing the tendon of the obturator externus muscle, a constant trochanteric branch is given off adjacent to the proximal border of the quadratus femoris. Then, the MFCA undercrosses the tendon of the triceps coxae muscles (gemelli and obturator internus muscles) to perforate the hip capsule obliquely just cranial to the insertion of the tendon of the superior gemellus and distal to the tendon of piriformis. (D) It then splits up into 2–5 retinacular vessels lying in a mobile layer of connective tissue on the posterosuperior aspect of the femoral neck and enters the femoral head lateral to the bone-cartilage junction. Fig. 6. Proposed algorithm. M. Tannast et al. / Injury, Int. J. Care Injured 40 (2009) 1118–1124 1123
- 8. femoral head bleeding upon intraoperative drilling in these complex cases of femoral neck fracture with hip dislocation. In our experience, femoral neck fracture associated with hip dislocation does not represent an ultimate sign of irrevocable avascularity to the femoral head. As shown in our illustrative case, the retinaculum with its mobile layer of connective tissue on the posterosuperior aspect of the femoral neck remained in continuity and protected the terminal branches of the MFCA. Any attempts at closed reduction could have definitely harmed the remaining perfusion of the retinacular vessels and we would certainly not recommend that. As mentioned in our proposed algorithm, we suggest an open reduction and internal fixation utilizing the MCFA preserving trochanteric flip osteotomy as soon as possible and if the patient is stable enough to undergo the anaesthesia and surgical procedure. In our opinion, preservation of the dislocated femoral head via osteosynthesis, the trochanteric flip osteotomy surgical approach and assessment of the MCFA integrity provides a safe and rationale strategy for attempted joint preservation. Conflict of interest statement There are no conflicts of interest. Acknowledgements The authors thank Dr. Harish Hosalkar for his help in manu- script preparation. References [1] Baba T, Hitachi K, Kaneko K. Fracture-dislocation of the hip with ipsilateral femoral neck fracture. Eur J Orthop Surg Traumatol 2002;12:102–4. [2] Du¨mmer RE, Sanzana ES. Hip dislocations associated with ipsilateral femoral neck fracture. Int Orthop 1999;23:353–4. [3] Duygulu F, Calis M, Argun M, Guney A. Unusual combination of femoral head dislocation associated acetabular fracture with ipsilateral neck and shaft fractures: a case report. J Trauma 2006;61:1545–8. [4] Epstein HC, Wiss DA, Cozen L. Posterior fracture dislocation of the hip with fractures of the femoral head. Clin Orthop Relat Res 1985;201:9–17. [5] Esenkaya I, Gorgec M. Traumatic anterior dislocation of the hip associated with ipsilateral femoral neck fracture: a case report. Acta Orthop Traumatol Turc 2002;36:366–8. [6] Fernandes A. Traumatic posterior dislocation of hip joint with a fracture of the head and neck of the femur on the same side: a case report. Injury 1981;12:487–90. [7] Fina CP, Kelly PJ. Dislocations of the hip with fractures of the proximal femur. J Trauma 1970;10:77–87. [8] Ganz R, Gill TJ, Gautier E, et al. Surgical dislocation of the adult hip. A technique with full access to femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br 2001;83:1119–24. [9] Gautier E, Ganz K, Krugel N, et al. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br 2000;82:679–83. [10] Gill TJ, Sledge JB, Ekkernkamp A, Ganz R. 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