Fracture Management Joint by Joint

Series Editors: Filippo Castoldi · Davide Edoardo Bonasia

Lorenz Büchler
Marius J.B. Keel Editors

Fractures of
the Hip
Fracture Management Joint by Joint
Series editors
Filippo Castoldi
Department of Orthopaedics
CTO Hospital Turin
Torino
Italy

Davide Edoardo Bonasia
University of Torino
AO Ordine Mauriziano
Torino
Italy
This book series aims to provide orthopedic surgeons with up-to-date
practical guidance on the assessment, preoperative work-up, and surgical
management of intra-articular fractures involving different joints, including
the shoulder, knee, hip, elbow, ankle, and wrist. Complex articular fractures
are difficult to treat and sometimes require specific surgical skills appropriate
to the involved joint. In addition, arthroscopic-assisted fracture reduction is
increasing in popularity, but trauma surgeons are generally not trained in
arthroscopic techniques. For these reasons, articular fractures are often
referred by the trauma team to surgeons experienced in the management of
injuries to the joint in question. Therefore, across the world it is becoming
common for orthopedic surgeons to specialize in treating fractures of only
one joint. This series is designed to fill a gap in the literature by presenting the
shared experience of surgeons skilled in the use of arthroscopic and open
techniques on individual joints.

More information about this series at http://www.springer.com/series/13619

Lorenz Büchler  •  Marius J.B. Keel
Editors

Fractures of the Hip

Editors
Lorenz Büchler Marius J.B. Keel
Department of Orthopaedic Surgery Trauma Center Hirslanden
Kantonsspital Aarau Clinic Hirslanden
Aarau Zürich
Switzerland Switzerland

ISSN 2364-3250     ISSN 2364-3269 (electronic)

Fracture Management Joint by Joint
ISBN 978-3-030-18837-5    ISBN 978-3-030-18838-2 (eBook)
https://doi.org/10.1007/978-3-030-18838-2

© Springer Nature Switzerland AG 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
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The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword

This book series aims to provide orthopaedic surgeons with up-to-date practi-
cal guidance on the assessment, preoperative work-up and surgical manage-
ment of intra-articular fractures involving different joints. Complex articular
fractures are difficult to treat and sometimes require specific surgical skills
appropriate to the involved joint. In addition, arthroscopic-assisted fracture
reduction is increasing in popularity, but trauma surgeons are generally not
trained in arthroscopic techniques. For these reasons, articular fractures are
often referred by the trauma team to surgeons experienced in the management
of injuries to the joint in question. Therefore, across the world it is becoming
common for orthopaedic surgeons to specialize in treating fractures of only
one joint. This series is designed to fill a gap in the literature by presenting the
shared experience of surgeons skilled in the use of arthroscopic and open
techniques on individual joints.
In this specific book, Dr. Büchler and Dr. Keel, world renowned experts in
this field, developed a comprehensive table of contents regarding hip frac-
tures. Surgical anatomy and relevant radiology are described together with
different surgical approaches, including those that many surgeons are not
very familiar with. Then, acetabulum and proximal femur fracture manage-
ment is described in detail including conservative and surgical treatments.
The management (open and arthroscopic) of some common complications
(malunion, nonunion, loose bodies, etc.) is included as well. Experts from all
over the world were invited to participate in this project. The result is a practi-
cal reference guide for the hip surgeon, trauma surgeons and orthopaedic
resident approaching simple and complex fractures around the hip.

Torino, Italy Filippo Castoldi

Torino, Italy Davide Edoardo Bonasia

v
Preface

The series “Fracture Management Joint by Joint”, to which this volume

belongs, has introduced a new concept of up-to-date literature emphasizing
the importance to assess articular fractures in the context of the entire ana-
tomical region. Thus, the book is intended to be useful to the specialized
orthopaedic surgeon and general trauma surgeon alike.
A wide variety of approaches and surgical techniques are used to treat hip
fractures, and the selection of the best therapy is challenging. The purpose of
this book is to support the reader towards a broad understanding of the trau-
matized hip, including anatomy, biomechanics, diagnosis and surgical treat-
ment. As a result, the surgeon should be confident to choose the appropriate
treatment for a specific fracture in an individual patient, may this be conser-
vative, by osteosynthesis or through total hip arthroplasty.
We have assembled a group of renowned trauma surgeons from around the
world to present a comprehensive, up-to-date overview over their respective
field of expertise. The book is divided into three sections: Principles, includ-
ing anatomy, biomechanics, radiology and initial management, chapters on
surgical approaches and chapters on specific fracture types, pathological frac-
tures and complications.
It has been a tremendous pleasure to interact with such an excellent fac-
ulty, and we thank the authors for having dedicated their time and expertise.
We have learned a lot ourselves. Also, we would like to thank the editorial
staff at Springer. Without their great assistance and support, this project
would not have been possible.
We hope that the entire series, and this book in particular, will serve as a
valuable tool in the reader’s clinical practice.

Bern, Switzerland Lorenz Büchler

Zürich, Switzerland  Marius J.B. Keel

vii
Contents

1 Anatomy of the Hip Joint����������������������������������������������������������������   1

Michael Wyatt, Carl Freeman, and Martin Beck
2 Radiology of the Hip Joint��������������������������������������������������������������  19
Florian Schmaranzer, Till D. Lerch,
Inga A. S. Todorski, Moritz Tannast,
and Simon Steppacher
3 Initial Management of Hip Fractures Prior
to Surgical Intervention������������������������������������������������������������������  33
Mark Haimes and Michael Blankstein
4 Ilio-Inguinal Approach��������������������������������������������������������������������  43
Lorenz Büchler and Helen Anwander
5 Anterior Approaches to the Acetabulum ��������������������������������������  53
Claude H. Sagi
6 The Pararectus Approach to the Acetabulum ������������������������������  69
Johannes D. Bastian and Marius J.B. Keel
7 Lateral Approach to the Pelvis and Hip����������������������������������������  77
Joseph M. Schwab, Chad Beck, and Klaus A. Siebenrock
8 Extended Iliofemoral and Combined Approaches������������������������  89
Marius J.B. Keel
9 Traumatic Hip Dislocations������������������������������������������������������������  95
Mark Rickman and Lorenz Büchler
10 Acetabular Fractures���������������������������������������������������������������������� 105
Ippokratis Pountos and Peter V. Giannoudis
11 Pipkin Fractures������������������������������������������������������������������������������ 123
Benedikt J. Braun, Jörg H. Holstein, and Tim Pohlemann
12 Femoral Neck Fractures������������������������������������������������������������������ 139
Govind S. Chauhan, Mehool Acharya,
and Tim J. S. Chesser
13 Pathologic Fractures������������������������������������������������������������������������ 155
Frank M. Klenke, Attila Kollár, and Christophe Kurze

ix
x Contents

14 Acetabular and Femoral Neck Fracture Nonunion

and Malunion ���������������������������������������������������������������������������������� 169
Robert C. Jacobs, Craig S. Bartlett, and Michael Blankstein
15 The Use of Hip Arthroscopy in Trauma of the Hip���������������������� 189
Alessandro Aprato, Federico Bertolo, Alessandro Bistolfi,
Luigi Sabatini, and Alessandro Massè
 Anatomy of the Hip Joint
1
Michael Wyatt, Carl Freeman, and Martin Beck

Abstract to not only understand hip pathology but also to

The normal hip is often described as a synovial intervene safely with procedures such as surgi-
ball and socket joint but this hardly does it jus- cal hip dislocations. In this chapter we will
tice. The hip represents a remarkable coexis- explore both acetabulum and proximal femur
tence of stability married to versatility in from their development to final morphology.
motion. Furthermore this biomechanical phe- We shall delve into what is known about the
nomenon is built to sustain the demands of a labrum and other articular structures. Finally
lifetime and today such demands are ever we shall scrutinize the complex blood supply to
increasing. In broad terms the bony anatomy the hip for this is paramount to the prognosis of
with concave socket articulating with the femo- non-­arthroplasty treatment of intra-articular hip
ral head creates an incredibly stable joint chal- fractures and preventing complications.
lenged only in the most part by high-­energy
trauma. Its complex intra-articular structures Keywords
and lubrication system create a mobile and Hip · Anatomy · Embryology · Surface
durable couple, the secrets of which have not anatomy · Blood supply
yet fully been elucidated. The intricate arterial
anastomoses supplying the joint have only been
revealed in recent years. The application of this
anatomical knowledge has permitted surgeons 1.1 Landmarks of the Hip Joint

The most readily identifiable landmarks for the

hip and acetabulum are the greater trochanter and
M. Wyatt (*)
Department of Trauma and Orthopaedics, MidCentral the anterior superior iliac spine (ASIS). The ASIS
District Health Board, Palmerston North Hospital and lies superiorly and just laterally to the acetabu-
Massey University, Palmerston North, Manawatu, lum in the coronal plane and indicates the loca-
New Zealand
tion of the anterior column, the anterior wall, and
e-mail: [email protected]
the iliac crest. The lateral femoral cutaneous
C. Freeman
nerve lies between two and four centimeters
Jacksonville Orthopaedic Institute,
Jacksonville, FL, USA medial from the ASIS [1]. The anterior inferior
iliac spine (AIIS) lies directly anterior and supe-
M. Beck
Clinic for Orthopaedic and Trauma Surgery, Luzerner rior to the acetabulum (Fig. 1.1). The iliopectin-
Kantonsspital, Luzern, Switzerland eal eminence, which develops from the pubic

© Springer Nature Switzerland AG 2019 1

L. Büchler, M. J.B. Keel (eds.), Fractures of the Hip, Fracture Management Joint by Joint,
https://doi.org/10.1007/978-3-030-18838-2_1
2 M. Wyatt et al.

a b

Fig. 1.1 (a, b) Anatomy of the bony pelvis including muscular attachments. Reproduced with permission and copy-
right © of Acta Orthop Scand suppl. [2]

extension of the triradiate cartilage, is an internal the sixteenth (Fig.  1.2) [5, 6]. The hip anlage
landmark marking both the medial border of the forms from scleroblastema arranged in two lay-
acetabulum in the coronal plane [3] and the ilio- ers. The inner component is a spherical cluster of
pectineal bursa. The infracotyloid notch, which is primitive chondroblasts, which will form the
a notch on the posterior ischium, just posterosu- femoral head. The outer component consists of
perior to the ischial tuberosity and hamstring ori- three discoid masses which will form the ilium,
gin is an internal landmark. It denotes an area of ischium, and pubis [5, 6]. The region of the future
bone adjacent to the inferior acetabular rim. The joint space is characterized by a crescent of
ischial spine is a radiological landmark. Its spur densely packed cells between these two regions.
like appearance is formed by the sacrospinous By the end of the eighth week, the hip blood sup-
ligament and separates the greater and lesser sci- ply is established [5]. From weeks six to twelve,
atic notches. When visible on orthograde antero- the hip increases in size via interstitial growth,
posterior radiographs of the pelvis it may indicate and by the twelfth week the joint space has
retroversion of the acetabulum [4]. formed via apoptosis of cells between the anlage
acetabulum and the femoral head. Both the liga-
mentum capitis femoris, which forms in the
1.2 Development of the Hip region of the cotyloid notch, and the limbus,
which gives rise to the brim of the acetabulum
1.2.1 Embryology of the Hip and labrum, form at this time. By the sixteenth
week, the centers of ossification of the ilium,
The embryological development of the hip begins ischium, and pubis emerge, and the triradiate car-
at the fourth week and is essentially complete by tilage is created [5].
1  Anatomy of the Hip Joint 3

a b

c d

Fig. 1.2 (a) Around the sixth week, the hip begins to weeks six to twelve the acetabular anlage and femoral
form as a densely packed group of cells called a sclero- head increase in size via interstitial growth, and the joint
blastema, from which forms the acetabular anlage and the space begins to form. (d) By the twelfth week, the hip has
femoral head. (b) The region of the future joint space is formed the following: a joint space, the ligamentum capi-
marked by a crescent of densely packed cells, which will tis femoris, the cotyloid fossa, and the limbus. Reproduced
eventually undergo apoptosis to form a joint space, and with permission and copyright © Clinical Orthopaedics
formally separate the acetabulum from the head. (c) From and related research [5, 6]
4 M. Wyatt et al.

1.2.2 Development 1.2.3 Development of the Proximal

of the Acetabulum After Birth Femur After Birth

The acetabulum and labrum develop much of At birth the greater trochanter and femoral head
their final morphological features during child- share a common physis. During growth the
hood [7]. Between the innominate bones lies the medial part of the physis evolves into the physis
triradiate cartilage, which is responsible for the of the femoral head and the lateral part becomes
formation of the anterior wall, posterior wall, the physis of the greater trochanter (Fig. 1.3). The
and the dome of the acetabulum. It is the triradi- separation of the common physis into two dis-
ate cartilage that is most responsible for the final tinct ones occurs at the age of four. The physis of
depth of the acetabulum. Laterally, the triradiate the femoral head is responsible for the develop-
cartilage gives rise to a circumferential lip com- ment of the femoral neck. The growth of the neck
posed of hyaline cartilage centrally and fibrocar- occurs on the metaphyseal side of the physis con-
tilage on the periphery. This cartilaginous cup is tributing to most of the length of the femoral
the structure that will form the majority of the neck. This is in contrast to the greater trochanter,
mature acetabulum when growth is complete, where appositional growth at the periphery con-
and is the location where the acetabular epiphy- tributes to the size of the greater trochanter.
ses form, all under the constantly shaping stimu- Incomplete separation of the common physis
lus of the femoral head. The ilium and ischium may lead to widening of the femoral neck in the
contribute significantly to the final morphology anterosuperior area that eventually may predis-
of the dome and the posterior wall of the hip, pose to cam-type femoroacetabular impingement
respectively. The pubis contributes very little to [9]. The center of ossification in the femoral head
the final structure of the mature acetabulum. appears in females at the age of 4–7 months and
This is because the anterior wall is almost com- in males later at the age of 5–8 months. The ossi-
pletely formed by the os acetabuli, an epiphysis fication center of the greater trochanter develops
that forms adjacent to the pubis. The os acetabuli generally at the age of 4 years. The ossification
forms after age seven and has completed growth center in the lesser trochanter appears only much
and closed before the age of nine. The triradiate later at 12–14 years of age. Closure of the femo-
cartilage closes at 14–16 years old but the ace- ral head physis occurs at an age of approximately
tabular epiphyses can remain open as late as 18  years, the physis of the greater trochanter
18 years [8]. closes earlier at the age of 16–18 years.

a b c d

Fig. 1.3  Development of the center of ossification and the physis of the proximal femur. (a) age 4 months; (b) age
1 year; (c) age 4 years; (d) Modified and reproduced with permission and copyright © Acta Orthop Scand suppl. [2]
1  Anatomy of the Hip Joint 5

1.3 Osteology 6:00 refers to the midpoint of the fossa inferiorly,

and 12:00 refers to the superior part of the acetab-
1.3.1 The Acetabulum ulum directly across from the midpoint of the
fossa. The 3:00 position refers to the anterior
The bony acetabulum forms a concentric dome acetabulum on both right and left hips. The 3:00
over the femoral head. Its coverage of the femo- position can be identified by the superior margin
ral head is approximately 170°. The outer rim of the anterior labral sulcus, or “psoas-u” [11].
topography is independent of gender, but the The 9:00 position refers to the midpoint of the
male articular surface is larger than the female, posterior wall on both left and right hips. Four
where the acetabular fossa is wider. The average major regions of the bony acetabulum contribute
diameter of the native acetabulum is to coverage of the femoral head: the anterior
52 mm ± 4 mm [10]. wall, the posterior wall, the medial wall, and the
It is conventional to refer to points around the dome or tectum (latin for roof). The anterior wall
lateral acetabulum and labrum as positions on a is directly connected to the pubis, and the supe-
clock face (Fig.  1.4). Using this nomenclature, rior pubic ramus extends anteriorly from its

12:00

11:00 01:00

10:00 02:00

09:00 03:00
0˚

30˚

08:00 60˚ 04:00

90˚
07:00 05:00

06:00

Mean of acetabular rim Mean of acetabular fossa Mean + SD Mean - SD

Fig. 1.4  This figure shows mean and standard deviation gitude). 3:00 represents a point directly anterior on the
of rim and fossa values as a function of its geographical anterior wall in both right and left hips. The three promi-
reconstruction. 0° is at the pole of the acetabular hemi- nent areas are anterosuperior, anteroinferior, and postero-
sphere, 30°, 60°, and 90° are indicating the depth of the inferior. The two depressions along the anterior and
cup (latitude). The circle at 90° marks the equatorial level posterosuperior wall can clearly be distinguished.
of the hemisphere. The rim, fossa, and articular surface Modified and reproduced with permission and copyright
locations are indicated in a clockwise distribution, with © Clinical Orthopaedics and Related Research [10]
the acetabular notch as the caudal landmark for 6:00 (lon-
6 M. Wyatt et al.

medial border. The anterior wall and anterior rim Consequently, when loaded the posterior wall
of the acetabulum have a variable morphology. deforms substantially more than the anterior wall
Most acetabula have a prominence that extends [16]. This differential deformation is far more
from the anterior rim from about 12:30 to 3:00 pronounced at lower loads (30% body weight),
[10]. Proceeding medially along the anterior where the posterior wall deforms 40 times more
wall, the “psoas-u” is an indentation in the ante- than the anterior wall, and less pronounced at
rior wall adjacent to a prominent groove on the higher loads where the ratio approaches 3–1.
pelvic rim. This groove, just lateral to the iliopec- When carrying peak physiologic loads such as
tineal eminence, provides a track for the ilio- with gait, nearly full contact and global transmis-
psoas, and represents the most medial aspect of sion of force occurs [15]. Thus, the acetabulum
the anterior wall easily accessible with an arthro- including the anterior and posterior columns pro-
scope. The iliopectineal eminence lies just ante- gressively deform, increasing contact area during
rior to the inferior half of the anterior wall on the joint loading. The transverse ligament, connect-
pubic brim. ing anterior and posterior acetabular border,
The posterior wall is larger and projects more serves as a security chain against extreme defor-
laterally than the anterior wall. Its lateral edge mation and is supported by a connecting plate of
has a nearly vertical but curved route, with few bone, the quadrilateral plate, extending proxi-
prominences or grooves, and little variation mally forming a tension band between the two
between individuals [3, 12]. The posterior wall is columns. The quadrilateral plate is formed by the
a major bony contributor to the stability of the convergence of the three innominate bones and is
hip. Trauma research has shown that hip stability the location of the center of the closed triradiate
depends most on an intact posterior wall, and to cartilage.
lesser extent on an intact capsule. In a cadaver
study of hip stability, varying amounts of poste-
rior wall bone were osteotomized. Hundred per- 1.3.2 Fossa
cent of hips were stable with as much as 25% of
posterior wall disrupted, but with 33% of the pos- The medial part of the acetabulum has a central
terior wall disrupted only 75% of hips were sta- cavity, where no articulation occurs. This, the
ble. When 50% of the posterior wall was disrupted acetabular fossa, is filled with a fat pad called the
all specimens were found to be unstable [13]. pulvinar, and the ligamentum capitis femoris. The
Surrounding the acetabulum are two columns bony fossa and the fat pad both appear to be
of bone, the anterior and posterior column, which involved in evenly distributing forces across the
connect the acetabulum to the rest of the pelvis articular contact surfaces [17]. Its shape is vari-
and provide significant structural support [14]. able between individuals, from semicircular to
The acetabulum, which lies in the “concavity of cloverleaf in shape [3, 10]. Multiple foramina
the arch” created by the two columns, transmits serve as access for the small arterioles of the ace-
the load superiorly via this arch. tabular branch of the obturator artery which runs
The two columns in combination with the through the fat pad to both walls and to the dome
anterior and posterior walls allow for dynamic area [18]. The ligamentum capitis femoris (liga-
deformation of the acetabulum with differential mentum teres) is a small, synovial enclosed liga-
load bearing [15]. At lower loads, only the ante- ment averaging 30–35 mm in length, with a broad
rior and posterior walls transmit force, and the band at the distal border of the acetabular fossa.
dome does not contact the head. However, as Connecting the inferior acetabulum to the fovea
loading increases, the two columns increasingly capitis femoris just inferior to the center of the
separate and allow the walls to deform, thus per- femoral head, it originates on both the pubic and
mitting the acetabular dome to receive force ischial sides of the inferior fossa in the form of
transmission. The anterior wall is considerably two bands. In between these bands, the ligamen-
more rigid than the more flexible posterior wall. tum blends with the transverse ligament, and
1  Anatomy of the Hip Joint 7

attaches at a small section of the posteroinferior

fossa. The ligamentum has been theorized to be
involved in hip pain generation, stability, and
synovial fluid circulation [19, 20]. Furthermore
the ligamentum has a role in providing blood sup-
ply to the femoral head during growth. However
this role is temporary, for there is no avascular
necrosis (AVN) should the femoral head be surgi-
cally dislocated (as described in Sect. 1.6.2).

1.3.3 Acetabular Orientation

A description of the spatial orientation of the

acetabulum in relation to the pelvis and body
requires parameters which are difficult to Fig. 1.5  Pelvic tilt, δ, is defined as the angle between a
describe, and to some extent, difficult to measure. horizontal line and a line connecting the upper border of
In short, the most important spatial relationships the symphysis with the sacral promontory (PS-SP line).
Reproduced with permission and copyright © Skeletal
of the acetabulum to the pelvis are version and
Radiol. [21]
inclination, also called abduction. Version is
described as the angle between either a central
horizontal line connecting the anterior and poste- line placed on the posterior contour of the femo-
rior walls or the averaged opening plane of the ral condyles. If the axis of the neck inclines ante-
acetabulum and the sagittal plane [10]. Inclination riorly, the angle of torsion is called antetorsion.
is defined as the angle between either a central Similarly, if it points posteriorly, it is called ret-
vertical line connecting the superior-lateral ace- rotorsion. Differences in both techniques of
tabulum to the inferior-medial fossa or the open- examination, and populations may explain con-
ing plane of the acetabulum and the transverse trasting values that have been reported [23, 24].
plane. Average anteversion has been reported to On average, femoral anteversion ranges from 30°
be from 16° to 21° [10, 12]. Males tend to have to 40° at birth and decreases progressively
less anteversion than females, 12° to 20° versus throughout growth. According to Svenningsen
15° to 24°. The average inclination has been et al. femoral antetorsion has a regression rate of
reported to be 48°, with minimal differences about 1.5° (range 0.2°–3.1°) per year [24]. In the
between sexes. adult, mean femoral antetorsion is 10.5° ± 9.22°.
Acetabular orientation and its corresponding Antetorsion increases the range of motion in flex-
descriptive angles are affected by many variables, ion and internal rotation, and decreases external
such as pelvic tilt or rotation, acetabular tilt, and rotation in extension. Both increased femoral
the reference planes of the body. Version and antetorsion and retrotorsion can cause femoroac-
inclination can vary substantially when account- etabular impingement and have been associated
ing for differing degrees of pelvic tilt (Fig. 1.5) with early degenerative joint disease [25–27].
[10, 21, 22].
1.3.4.2 Neck-Shaft Angle
The neck-shaft angle is normally measured on
1.3.4 The Proximal Femur anteroposterior radiographs as the angle formed
by the axis of the femur and the axis of the neck
1.3.4.1 Antetorsion going through the center of the femoral head.
The femoral neck antetorsion is the inclination of Projected values are largely influenced by the
the axis of the femoral neck with reference to a rotation of the femur. The normal neck-shaft
8 M. Wyatt et al.

angle measures 125° with values ranging between perior area of the head-neck junction and can
121.4° and 137.5°. The average location of the tip add to cam-type femoroacetabular impinge-
of the greater trochanter is 3.4 ± 0.9 mm superior ment. A gender difference was observed, with
to the center of rotation (range from 20 mm supe- males having a significantly more prominent
rior to 10  mm inferior to the femoral head head neck junction anterosuperiorly [24]
center). (Fig. 1.6).

1.3.4.3 Lesser Trochanter 1.3.4.5 Alpha Angle

The lesser trochanter is positioned at a retrotor- The alpha angle was first described by Nötzli
sion angle (α) of −31.5° with a standard devia- et al. as an indicator of femoral head neck asphe-
tion of ±11.8°. In the same study an average ricity [24]. The alpha angle is the acute angle
antetorsion of the femoral neck (β) of 10.5° ± 9,22 between the neck axis and a line connecting the
was found. There was a high correlation between center of rotation with the point where the femo-
the antetorsion of the neck and the retrotorsion of ral head exits a circle around the femoral head.
the lesser trochanter [28]. The alpha angle measures the anterior aspheric-
ity; however, the individual maximum value can
1.3.4.4 Shape of the Femoral Neck be best determined with radial cuts of an
The femoral neck has an oval shape. The orien- MRI. Likewise although of less importance, the
tation of the greatest diameter of the femoral beta angle is measured posteriorly, the gamma
neck relative to the mechanical long axis of the angle superiorly, and the delta angle inferiorly
femur is defined with the angle ρ (rho). Angle ρ (Fig.  1.7). The position of the femoral head on
was reported to measure in a normal hip 21° ± 9° the femoral neck is defined by the AP and lateral
and in hips with an aspheric head neck junction physeal angles (Fig. 1.8). Based on several stud-
25° ± 8°, the difference is not significant [29]. ies the normal alpha angle is between 43° and
As a consequence of the oval cross section the 50°, but normal values up to 60° are discussed
modified alpha angle is reduced in the anterosu- [31–33].

a b

Fig. 1.6  Femoral head offset. (a) Shows the construction sion and copyright © Clinical Orthopaedics and Related
of the superior and inferior offset. (b) The construction of Research [30]
the anterior and inferior offset. Reproduced with permis-
1  Anatomy of the Hip Joint 9

a b

Fig. 1.7  Measurement of the asphericity of the head neck shows the gamma angle superiorly and delta angle inferi-
junction. (a) Shows the construction of the alpha anteri- orly. Reproduced with permission and copyright ©
orly and beta angle posteriorly. Correspondingly, (b) Clinical Orthopaedics and Related Research [30]

a b

Fig. 1.8  Definition of the position of the femoral head on the neck. (a) Shows the AP physeal angle. (b) Shows the
lateral physeal angle. Reproduced with permission and copyright © Clinical Orthopaedics and Related Research [30]

1.4 Cartilage cartilage surface results in the optimal distribu-

tion of articular contact forces and the elimina-
The acetabular socket is covered by a cartilagi- tion of peak stress areas [17]. The acetabular
nous surface. This surface has a crescent shape, cartilage surface is composed almost exclusively
as cartilage covers the anterior and posterior of hyaline cartilage, and averages about 1.5 mm
walls and the majority of the dome, but is absent in depth. However, the cartilaginous depth is not
medially and inferiorly. Mathematic investiga- uniform throughout the acetabulum. The region
tion has shown that the shape of the acetabular of greatest cartilage depth is the anterosuperior
10 M. Wyatt et al.

quadrant, where depth can exceed 3  mm. face of the acetabulum, is composed of a delicate
Cartilage is thinnest at the region surrounding the network of fibrocartilage with interposed chon-
acetabular fossa and inferiorly. In the most supe- drocytes. This thin, superficial layer contains
rior part of the dome, the cartilage surface often type II collagen in addition to I and III collagen,
will have a round imprint. This area has been and is usually continuous with the acetabular
named the “stellate crease,” and can be appreci- chondral surface at the labral-chondral junction.
ated most easily arthroscopically [34]. It is com- The second layer is composed of intersecting
posed of both hyaline and fibrocartilage, and is “lamellar-like collagen fibril bundles.” Finally,
present in 90% of the population [16]. Between the third and most peripheral layer is composed
the stellate crease and the fossa is the supra-­ of collagen fibrils which are oriented in a
acetabular fossa. This is not covered by hyaline circumferential direction. This layer is much
­
cartilage until maturity [35]. thicker than the other two, consisting of more
than 90% of the labrum, and is continuous with
the transverse acetabular ligament. Both the sec-
1.5 Labrum ond and third layers are composed of only type I
and III collagen.
The labrum is a ring of connective tissue continu- The labrum deepens the acetabular socket to
ous with the transverse acetabular ligament that the extent that it contributes 33% of the combined
surrounds the outer edge of the acetabulum [36]. acetabular and labral volume [36]. Additionally,
It is composed of three distinct layers (Fig. 1.9) the labrum increases the articular contact surface
[37]. The first layer, adjacent to the articular sur- by 22%, but controversy exists in regard to

a b

c d

Fig. 1.9 (a) The labrum has three layers. (b) Layer 1 con- circumferential fibrils continuous with the transverse
sists of a delicate network of fibrocartilage. (c) Layer 2 acetabular ligament. Reproduced with permission and
consists of intersecting “lamellar-like collagen fibril bun- copyright © Arch Orthop Trauma Surg [37]
dles.” (d) Layer 3 is the thickest layer, and is composed of
1  Anatomy of the Hip Joint 11

whether the labrum participates in load sharing motes an environment of readily available nutri-
of contact forces. The labrum varies in its size tion via maximal absorption of synovial fluid and
around its circumference. It is widest anteriorly water into cartilage surfaces [39]. Finally, the
and thickest superiorly. Inferiorly, the labrum is labrum contains nerve endings similar to the
indistinguishable from the transverse ligament. round ligament suggesting that the bumper effect
On its outer, superficial side, the labrum does not may be less mechanical but represents more an
connect with the joint capsule, but rather a alarm system to alert the musculature when joint
synovial-­lined recess 6–8 mm in depth is formed motion exceeds physiological limits [41].
as the capsule inserts directly onto the proximal
portion of bony acetabulum.
The labrum merges with the acetabular hya- 1.6 Blood Supply
line cartilage over a 1–2  mm transition zone.
Anteriorly, the labrum often has a cleft or recess 1.6.1 T
 he Blood Supply
separating it from the articular surface of the ace- of the Acetabulum
tabulum, and the collagen fibers in this area run
parallel to the chondro-labral junction [7]. This The acetabulum receives a large anastomotic
cleft has been reported in 20–75% of the popula- arterial network. The principal vessel is the nutri-
tion [37, 38]. Posteriorly, there is a “gradual and ent artery of the ilium, a branch of the iliolumbar
interdigitated” connection at the chondro-labral artery [18]. This ancillary vascular network is
junction, and collagen fibers in this area run per- composed of the superior gluteal, inferior gluteal,
pendicular to the transition zone [7]. The labrum and medial femoral circumflex arteries laterally,
is connected to the bony acetabulum over the area and the iliolumbar, obturator, and fourth lumbar
of a bony “tongue” that extends into the labrum arteries medially (Fig. 1.10).
from the acetabular brim [36]. On the articular-­ The iliolumbar artery originates from either
sided surface of this tongue the labrum attaches the posterior trunk of the internal iliac artery or
to the acetabular bone via a zone of calcified car- the obturator artery [18]. It divides into a superfi-
tilage with a clear tidemark. However, on the cial and a deep branch, the largest rami of which
outer surface of this tongue, the labrum inserts forms the nutrient artery to the ilium. In half of
without either calcified cartilage zone or a patients, the nutrient artery enters the ilium ante-
tidemark. rior to the iliosacral joint and lateral to the pelvic
The labrum has two immediately discernible brim. In the other half, the nutrient artery enters
biomechanical functions. The first function is the ilium medial to the pelvic brim. This anatomi-
that of a “suction seal” effect where the labrum cal variance is important to note because this
maintains and promotes negative pressure within artery is not readily accessible when medial to
the joint when distracted to increase stability the pelvic brim and can be quite large at times,
[39]. This role has been supported by research producing moderate bleeding when disrupted.
showing that venting and tearing of the labrum The obturator artery supplies a few branches
results in increased motion of the femur relative to the quadrilateral plate and superior pubic
to the acetabulum, and reduced force required to ramus before coursing through the obturator
displace the femur. The second and more impor- canal [18]. Together with branches from the
tant function is to seal the pressurized central medial femoral circumflex artery, it provides an
compartment to prevent synovial fluid from acetabular branch which enters the joint deep to
retreating to the peripheral compartment. This the transverse ligament. This vessel may be the
pressurization effect within the joint likely results final supply to the acetabulum if both the medial
in a more uniform fluid boundary across the artic- and lateral contributors are compromised. Thus,
ular surface, increasing the lubrication and low it should be protected when dissecting medial to
friction properties of the hip joint [39, 40]. the quadrilateral plate by strictly following a sub-
Additionally, this high pressure probably pro- periosteal plane.
12 M. Wyatt et al.

a b

Fig. 1.10 The blood supply of the acetabulum and rator, and fourth lumbar arteries medially (b). Reproduced
labrum is provided by a network of vessels composed of with permission and copyright © Surgical and Radiologic
the superior gluteal, inferior gluteal, and medial femoral Anatomy [18]
circumflex arteries laterally (a), and the iliolumbar, obtu-

The superior gluteal artery is the most impor- cumflex iliac vessels create an anastomotic ring
tant lateral contributor to the acetabular blood around the ilium at the level of the interspinous
supply. Initially, it divides into deep and superfi- crest and sciatic notch.
cial branches. The deep branch has four rami, the The inferior gluteal artery has two acetabular
superior, inferior, supra-acetabular, and acetabu- branches. One runs deep to the short external
lar. The superior ramus forms the anastomotic rotators to supply the posterior wall via several
network superiorly with the deep and superficial smaller vessels [42]. The other, distal acetabular
circumflex iliac vessels and the iliolumbar. The branch runs between the inferior gemellus and
supra-acetabular ramus runs deep to and/or the quadratus femoris to supply the posterior ace-
within the gluteus minimus near its origin along tabulum and anastomose with the medial femoral
its way to supply the acetabular roof [18]. The circumflex artery (MFCA). The acetabular
acetabular ramus runs inferior to the gluteus min- branches of the gluteal vessels create a periosteal
imus to supply the posterior-superior acetabulum anastomotic ring of around the lateral acetabu-
and acetabular roof. The acetabular and supra-­ lum, providing blood supply to the labrum
acetabular vessels then join, and the consolidated (Fig. 1.11). The labrum also receives a significant
vasculature continues to the interspinous crest to arterial supply from capsular vessels. The labrum
anastomose with the iliolumbar artery and the itself is poorly vascularized. Only the peripheral
ascending branch of the lateral femoral circum- one third of the labrum is penetrated by blood
flex artery. Thus, the superior gluteal artery and vessels, the largest of which run adjacent to the
its branches along with the iliolumbar and cir- outer brim of acetabular bone [36, 37]. The deep
1  Anatomy of the Hip Joint 13

Fig. 1.11  Posterior aspect of the acetabulum and the hip branch of the interior gluteal artery, 5  =  sciatic nerve,
joint after capsulotomy to show the acetabular branches of 6 = inferior gluteal artery, 7 = acetabular branch of the supe-
the gluteal arteries and anastomoses between them. rior gluteal artery, 8 = supra-acetabular branch of the supe-
1 = greater trochanter (osteotomized), 2 = deep branch of the rior gluteal artery, 9 = terminal vessel supplying the labrum,
medial femoral circumflex artery (intra-capsular part and cran = cranial, lat = lateral. Reproduced with permission and
retinacular arteries), 3 = lesser sciatic notch, 4 = acetabular copyright © Surgical and Radiologic Anatomy [18]

branch of the MFCA contributes a couple of yseal blood vessels. With the development of
branches to the anterior-inferior acetabulum in the femoral head physis, the lateral epiphyseal
addition to its anastomotic relationship with this vessels of the MFCA increasingly contribute to
network. the blood supply of the femoral epiphysis. At
birth, the major part of the common proximal
femoral physis is extraarticular. The lateral fem-
1.6.2 T
 he Blood Supply oral circumflex artery (LFCA) supplies the
of the Proximal Femur anterolateral physis, the majority of the greater
trochanter, and anteromedial parts of the femo-
In the adult the vascular blood supply of the ral head.
femoral head is secured through the retinacular The MFCA supplies the anteromedial physis,
arteries from the deep branch of the MFCA the posteromedial epiphysis, and the posterior
[43]. The evolution of the blood supply to the parts of the greater trochanter. By the age of
femoral head and proximal femur depends 18 months the blood supply of the femoral epiph-
largely on the development of the growth plates ysis mainly is provided through the lateral epiph-
and growth of femoral neck and greater trochan- yseal vessels of the MFCA. At birth there is an
ter. The blood supply of the growing proximal inconsistent anastomosis between the MFCA and
femur [44, 45] covering the entire growth period LFCA in the area of the greater trochanter.
until the end of adolescence is now discussed. In During growth of the femoral neck the LFCA
the initial stages of growth, before the develop- loses its contribution to the blood supply of the
ment of the ossification nuclei and growth plate, femoral epiphysis and physis and reduces its con-
the femoral head mainly is perfused by metaph- tribution to the greater trochanter and anterior
14 M. Wyatt et al.

femoral neck. At the age of three the blood sup-

ply of the entire epiphysis and physis comes
through the lateral and inferior retinacular ves-
sels of the MFCA. Blood vessels in the ligamen-
tum capitis femoris are observed at the age of
four, but this contribution to the femoral head
perfusion remains inconstant throughout growth
and rarely contributes significantly to the perfu-
sion of the epiphysis.

1.6.3 B
 lood Supply to the Adult
Femoral Head

Numerous publications investigated the blood

supply of the femoral head and the contribution
of the intraosseous terminations of the MFCA,
LCFA, the artery of the round ligament, the ves-
sels of the medial synovial fold (Ligament of
Weitbrecht), and the intramedullary blood ves-
sels [44].
The deep branch of the MFCA is the most
important contributor to the blood supply of the
femoral head. The extra-capsular course of the
medial femoral circumflex artery was investi-
gated in a cadaveric injection study [43]. After its Fig. 1.12 Course of the deep branch of the
MFCA.  Reproduced with permission and copyright ©
origin from the deep femoral artery and the divi- Surgical and Radiologic Anatomy [18]
sion of the ascending and superficial branches,
the deep branch of the MFCA runs dorsally
between the iliopsoas and the pectineus muscles piriformis, where it ramifies into 2–4 subsynovial
and continues proximal to the lesser trochanter at terminal branches, the lateral retinacular arteries
the base of the femoral neck along the inferior (Fig.  1.12). In addition to the work of Gautier
border of the obturator externus muscle. The ves- et al. [43] who described inconstant inferior reti-
sel runs anterior and cranial to the quadratus fem- nacular arteries, Kalhor et al. [42] found a con-
oris muscle toward the intertrochanteric crest and stant branch of the MFCA, which perforated the
emerges between the quadratus femoris and the capsule inferomedially, entered the joint, and
obturator externus muscle adjacent to their inser- continued as an inferior retinacular artery, and
tion at the proximal femur. At this point, one or was identified in all hips. This arterial branch ran
two branches are given off to the greater trochan- toward the femoral head in the ligament of
ter, the trochanteric branches. The main vessel Weitbrecht [42]. An important anastomosis exists
continues proximally along the intertrochanteric between the MFCA and a branch of the inferior
crest and crosses the tendon of the obturator gluteal artery, which runs along the inferior bor-
externus posteriorly and the tendon of inferior der of the piriformis, crosses posterior to the tri-
gemellus, internal obturator, and superior gemel- ceps coxae, and meets the deep branch in the
lus anteriorly. It obliquely perforates the capsule interval between quadratus and obturator exter-
just cranial to the insertion of the tendon of the nus muscle. Its size correlates inversely to the
superior gemellus and caudal to the tendon of the size of the deep branch. Kalhor et  al. [42]
1  Anatomy of the Hip Joint 15

Fig. 1.13 Superior
view on a left hip
showing a direct
anastomosis (∗) from the
inferior gluteal artery
supplying the femoral
head. JC joint capsule,
FH femoral head, GT
greater trochanter, QF
quadratus femoris
muscle, SN sciatic nerve.
Reproduced with
permission and
copyright © Surgical
and Radiologic Anatomy
[18]

described another anastomosis between the infe- 1.7 Surgical Implications

rior gluteal artery and the deep branch of the
MFCA at the level of the inferior sciatic notch By understanding the anatomy of the MFCA, it is
(Fig. 1.13). In two of 20 specimens this anasto- possible to dislocate the hip with an osteotomy of
mosis had replaced the deep branch. When pres- the greater trochanter without risking AVN [50].
ent, this branch of the inferior gluteal artery That the blood supply can be preserved by this
occupied the more common position of the technique was demonstrated by continuous laser
MFCA at the level of the greater trochanter [42, Doppler flowmetry measurement [51]. Tension
46]. The artery of the ligamentum capitis femoris on the retinacular arteries may obstruct the perfu-
usually originates from the obturator artery, sion to the femoral head. The knowledge of the
though occasionally it arises as a branch of the course of the MFCA with respect to the tendons
MFCA. Its contribution in adults is restricted to of the external rotators and the distance to the
the perifoveal area [45–47]. The intraosseous intertrochanteric crest are prerequisites to per-
branches of the first perforating artery and the form this type of surgery. This technique can be
intraosseous vascular system supply the proximal used to treat a variety of articular pathologies,
part of the shaft and the neck of the femur. They including femoroacetabular impingement (FAI),
anastomose with vessels within the femoral head, cartilage pathologies, intra-­articular deformities,
particularly in the caudal part of the head, but tumors and fractures of the acetabulum and fem-
their primary contribution is limited to the femo- oral head [52, 53]. Techniques such as femoral
ral neck. The combined contribution from epiph- neck osteotomies, femoral head reduction oste-
yseal and metaphyseal vessels that cross the otomies, and subcapital reorientation can be per-
physis after closure has been postulated by vari- formed safely without risk of AVN [54]. However,
ous authors [45, 47–49]. In the nonarthritic femo- the extra-capsular portion of the MFCA can be
ral head there is no relevant metaphyseal damaged during a posterior approach. Detaching
contribution to the femoral blood supply [50]. the short external rotators close to their insertion
16 M. Wyatt et al.

carries a high risk of iatrogenic damage to the tabular notch where it innervates the contents of
deep branch of the MFCA. It is recommended to the acetabular fossa, including the ligamentum.
divide the external rotators about 1.5  cm from The contents of the acetabular fossa have also
their trochanteric insertion, sparing completely been described as being innervated via branches
the tendon of the obturator externus [43]. AVN of from the sciatic nerve [59].
the femoral head in adolescence after antegrade The type of nerve endings, their location, and
intramedullary nailing of the femur is a rare com- their relative densities have been elucidated in
plication and most likely secondary to injury to regard to the contents of the fossa. The ligamen-
retinacular vessels of the deep branch of the tum capitis femoris contains only Type IVa nerves
MFCA at the time of insertion of the nail. Because and free nerve endings [20, 60]. Thus, the liga-
of the smaller diameter of the femoral neck, the mentum is not involved in mechanoreception or
insertion of the nail in the piriformis fossa puts proprioception, but rather senses only pain and
this vessel at risk. As a consequence, either ante- inflammatory stimuli. The fatty contents of the
grade femoral nailing should be avoided in the acetabular fossa have nerves located within the
adolescent or nail designs with the entry point at perivascular tissues. These nerve fibers contain
the tip of the greater trochanter should be used the neuropeptides substance P and calcitonin
[55, 56]. gene-related peptide, suggesting that they also
perform a pain nociception function [60]. The
labrum has a wealth of innervation. Eighty per-
1.8 Innervation cent of the nerves in the labrum lie in the superfi-
cial zone, alongside blood vessels. Free nerve
Most publications report that the hip is inner- endings are numerous in the labrum, especially in
vated by the femoral nerve, obturator nerve, the anterior and superior areas, which suggests
sacral plexus via the nerve to quadratus femoris, that the labrum is a powerful pain generator of
and sometimes by the accessory obturator nerve the hip. This may explain the early pain associ-
or directly by the sacral or sciatic plexuses [57]. ated with pincer impingement compared with
However, it is not clear which nerves are most that of cam impingement where labral involve-
significant in regard to the innervation of the ace- ment is late in the disease process [61].
tabular bone or fossa, as it has not been thor- Additionally, histologic examination has found
oughly investigated yet. Much controversy nerve end organs responsible for deep sensation,
remains on this subject. Dee, who researched the pressure, tactile sensation, and temperature
topic most closely, found three “primary articular within the labrum suggesting that the labrum also
nerves,” the posterior articular nerve, the medial plays a role in proprioception of the hip.
articular nerve, and the nerve to the ligamentum Furthermore nerve endings within the hip cap-
capitis femoris [58]. The posterior articular nerve sule provide important proprioceptive feedback
group included several short branches from the crucial for hip stability.
nerve to the quadratus femoris muscle. They fol-
low the ischium and the obturator internus tendon
to enter the posterior capsule. Once inside the References
joint, they run superiorly along the acetabular
1. Ray B, D’Souza AS, Kumar B, et  al. Variations in
rim. The medial articular nerve stems as a single
the course and microanatomical study of the lateral
branch from the anterior division of the obturator femoral cutaneous nerve and its clinical importance.
nerve near the obturator foramen. This nerve then Clin Anat. 2010;23:978–84. https://doi.org/10.1002/
forms multiple branches, which innervate the ca.21043.
2. Gray H, Lewis WH.  Anatomy of the human body.
anterior-medial, and inferior areas of the joint
Philadelphia: Lea & Febiger; 1918. https://doi.
capsule, and presumably the acetabulum as well. org/10.5962/bhl.title.20311.
The nerve to the ligamentum capitis femoris exits 3. Govsa F, Ozer MA, Ozgur Z.  Morphologic fea-
from the posterior division of the obturator nerve tures of the acetabulum. Arch Orthop Trauma
Surg. 2005;125:453–61. https://doi.org/10.1007/
near the obturator foramen. It then enters the ace-
s00402-005-0020-6.
1  Anatomy of the Hip Joint 17

4. Kalberer F, Sierra RJ, Madan SS, et  al. Ischial 19. Bardakos NV, Villar RN. The ligamentum teres of the
spine projection into the pelvis. Clin Orthop Relat adult hip. J Bone Joint Surg Br Vol. 2009;91-B:8–15.
Res. 2008;466:677–83. https://doi.org/10.1007/ https://doi.org/10.1302/0301-620x.91b1.21421.
s11999-007-0058-6. 20. Leunig M, Beck M, Stauffer E, et  al. Free nerve

5. Watanabe RS.  Embryology of the human hip. endings in the ligamentum capitis femoris.
Clin Orthop Relat Res. 1974;98:8–26. https://doi. Acta Orthop Scand. 2000;71:452–4. https://doi.
org/10.1097/00003086-197401000-00003. org/10.1080/000164700317381117.
6. Strayer LM.  Embryology of the human hip joint. 21. Tannast M, Murphy SB, Langlotz F, et al. Estimation
Clin Orthop Relat Res. 1971;74:221–40. https://doi. of pelvic tilt on anteroposterior X-rays—a compari-
org/10.1097/00003086-197101000-00029. son of six parameters. Skelet Radiol. 2005;35:149–
7. Cashin M, Uhthoff H, O’Neill M, Beaule 55. https://doi.org/10.1007/s00256-005-0050-8.
PE.  Embryology of the acetabular labral-chondral 22. Zilber S, Lazennec JY, Gorin M, Saillant G. Variations
complex. J Bone Joint Surg Br Vol. 2008;90-B:1019– of caudal, central, and cranial acetabular antever-
24. https://doi.org/10.1302/0301-620x.90b8.20161. sion according to the tilt of the pelvis. Surg Radiol
8. Liporace FA, Ong B, Mohaideen A, et  al. Anat. 2004;26:462–5. https://doi.org/10.1007/
Development and injury of the triradiate cartilage s00276-004-0254-y.
with its effects on acetabular development. J Trauma. 23. Jain AK, Maheshwari AV, Nath S, et al. Anteversion
2003;54:1245–9. https://doi.org/10.1097/01. of the femoral neck in Indian dry femora. J Orthop
ta.0000029212.19179.4a. Sci. 2003;8:334–40. https://doi.org/10.1007/
9. Siebenrock KA, Wahab KHA, Werlen S, et  al. s10776-003-0648-5.
Abnormal extension of the femoral head epiph- 24. Nakahara I, Takao M, Sakai T, et  al. Gender differ-
ysis as a cause of cam impingement. Clin ences in 3D morphology and bony impingement of
Orthop Relat Res. 2004;418:54–60. https://doi. human hips. J Orthop Res. 2010;29:333–9. https://
org/10.1097/00003086-200401000-00010. doi.org/10.1002/jor.21265.
10. Köhnlein W, Ganz R, Impellizzeri FM, Leunig
25.
Terjesen T, Benum P, Anda S, Svenningsen
M.  Acetabular morphology: implications for S.  Increased femoral anteversion and osteoarthritis
joint-preserving surgery. Clin Orthop Relat of the hip joint. Acta Orthop Scand. 1982;53:571–5.
Res. 2009;467:682–91. https://doi.org/10.1007/ https://doi.org/10.3109/17453678208992260.
s11999-008-0682-9. 26. Tönnis D, Heinecke A.  Diminished femoral ante-

11. Philippon MJ, Michalski MP, Campbell KJ, et  al. torsion syndrome: a cause of pain and osteoarthri-
An anatomical study of the acetabulum with clini- tis. J Pediatr Orthop. 1991;11:419–31. https://doi.
cal applications to hip arthroscopy. J Bone Joint org/10.1097/01241398-199107000-00001.
Surg Am. 2014;96:1673–82. https://doi.org/10.2106/ 27. Reikerås O, Høiseth A. Femoral neck angles in osteo-
JBJS.M.01502. arthritis of the hip. Acta Orthop Scand. 1982;53:781–
12. Maruyama M, Feinberg JR, Capello WN, Antonio 4. https://doi.org/10.3109/17453678208992292.
JAD.  Morphologic features of the acetabulum and 28. Herzberg W, Meitz R, Halata Z.  Antetorsion of the
femur. Clin Orthop Relat Res. 2001;393:52–65. femur neck. A variable of the trochanter minor?
https://doi.org/10.1097/00003086-200112000-00006. Unfallchirurg. 1991;94:168–71.
13. Vailas JC, Hurwitz S, Wiesel SW. Posterior acetabu- 29. Meyer DC, Beck M, Ellis T, et  al. Comparison

lar fracture-dislocations. J Trauma. 1989;29:1494–6. of six radiographic projections to assess femo-
https://doi.org/10.1097/00005373-198911000-00007. ral head/neck asphericity. Clin Orthop Relat Res.
14.
Letournel E, Judet R.  Fractures of the ace- 2006;445:181–5. https://doi.org/10.1097/01.
tabulum. Berlin: Springer; 1993. https://doi. blo.0000201168.72388.24.
org/10.1007/978-3-642-75435-7. 30. Toogood PA, Skalak A, Cooperman DR.  Proximal
15. Greenwald AS, O’Connor JJ. The transmission of load femoral anatomy in the normal human population.
through the human hip joint. J Biomech. 1971;4:507– Clin Orthop Relat Res. 2008;467:876–85. https://doi.
28. https://doi.org/10.1016/0021-9290(71)90041-8. org/10.1007/s11999-008-0473-3.
16. Lazennec JY, Laudet CG, Guérin-Surville H, et  al. 31. Nötzli HP, Wyss TF, Stoecklin CH, et  al. The con-
Dynamic anatomy of the acetabulum: an experi- tour of the femoral head-neck junction as a pre-
mental approach and surgical implications. Surg dictor for the risk of anterior impingement. J
Radiol Anat. 1997;19:23–30. https://doi.org/10.1007/ Bone Joint Surg. 2002;84:556–60. https://doi.
s00276-997-0023-9. org/10.1302/0301-620x.84b4.12014.
17. Daniel M, IgliC A, Kralj-IgliC V.  The shape of
32. Bealule P, Zaragoza E, Motamedi K, et  al. Three-­
acetabular cartilage optimizes hip contact stress dimensional computed tomography of the hip
distribution. J Anat. 2005;207:85–91. https://doi. in the assessment of femoroacetabular impinge-
org/10.1111/j.1469-7580.2005.00425.x. ment. J Orthop Res. 2005;23:1286–92. https://doi.
18. Beck M, Leunig M, Ellis T, et  al. The acetabular org/10.1016/j.orthres.2005.03.011.
blood supply: implications for periacetabular osteoto- 33.
Neumann M, Cui Q, Siebenrock KA, Beck
mies. Surg Radiol Anat. 2003;25:361–7. https://doi. M. Impingement-free hip motion: the “normal” angle
org/10.1007/s00276-003-0149-3. alpha after osteochondroplasty. Clin Orthop Relat
18 M. Wyatt et al.

Res. 2008;467:699–703. https://doi.org/10.1007/ 48. Freeman MAR. Some anatomical and mechanical con-
s11999-008-0616-6. siderations relevant to the surface replacement of the
34. Keene GS, Villar RN.  Arthroscopic anatomy of the femoral head. Clin Orthop Relat Res. 1978;134:19–24.
hip: an in  vivo study. Arthroscopy. 1994;10:392–9. https://doi.org/10.1097/00003086-197807000-00004.
https://doi.org/10.1016/s0749-8063(05)80189-6. 49.
Hulth A.  Circulatory disturbances in osteoar-
35. Byrd JWT. Portal anatomy. In: Operative hip arthros- thritis of the hip: a venographic study. Acta
copy. New York: Springer; 2005. p. 110–6. https://doi. Orthop Scand. 1958;28:81–9. https://doi.
org/10.1007/0-387-27047-7_7. org/10.3109/17453675808988610.
36. Seldes RM, Tan V, Hunt J, et  al. Anatomy, histo- 50. Ganz R, Gill TJ, Gautier E, et al. Surgical dislocation
logic features, and vascularity of the adult acetabular of the adult hip. J Bone Joint Surg. 2001;83:1119–24.
labrum. Clin Orthop Relat Res. 2001;382:232–40. https://doi.org/10.1302/0301-620x.83b8.11964.
https://doi.org/10.1097/00003086-200101000-00031. 51. Nötzli HP, Siebenrock KA, Hempfing A, et  al.

37. Petersen W, Petersen F, Tillmann B.  Structure and Perfusion of the femoral head during surgical dislo-
vascularization of the acetabular labrum with regard cation of the hip: monitoring by laser doppler flow-
to the pathogenesis and healing of labral lesions. Arch metry. J Bone Joint Surg. 2002;84:300–4. https://doi.
Orthop Trauma Surg. 2003;123:283–8. https://doi. org/10.1302/0301-620x.84b2.12146.
org/10.1007/s00402-003-0527-7. 52. Ellis TJ, Beck M.  Trochanteric osteotomy for ace-
38. McCarthy J, Noble P, Aluisio FV, et  al. Anatomy, tabular fractures and proximal femur fractures.
pathologic features, and treatment of acetabular labral Orthop Clin N Am. 2004;35:457–61. https://doi.
tears. Clin Orthop Relat Res. 2003;406:38–47. https:// org/10.1016/j.ocl.2004.05.002.
doi.org/10.1097/00003086-200301000-00008. 53. Tannast M, Kruger A, Mack PW, et al. Surgical dis-
39. Safran MR. The acetabular labrum: anatomic and func- location of the hip for the fixation of acetabular frac-
tional characteristics and rationale for surgical inter- tures. J Bone Joint Surg Br Vol. 2010;92-B:842–52.
vention. J Am Acad Orthop Surg. 2010;18:338–45. https://doi.org/10.1302/0301-620x.92b6.22994.
https://doi.org/10.5435/00124635-201006000-00006. 54.
Leunig M, Slongo T, Kleinschmidt M, Ganz
40. Ferguson SJ, Bryant JT, Ganz R, Ito K.  An in  vitro R.  Subkapitale Korrekturosteotomie bei der
investigation of the acetabular labral seal in hip joint Epiphyseolysis capitis femoris mittels chirurgischer
mechanics. J Biomech. 2003;36:171–8. https://doi. Hüftluxation. Oper Orthop Traumatol. 2007;19:389–
org/10.1016/s0021-9290(02)00365-2. 410. https://doi.org/10.1007/s00064-007-1213-7.
41. Kim YT, Azuma H. The nerve endings of the acetabu- 55. Orler R, Hersche O, Helfet DL, et  al. Avascular

lar labrum. Clin Orthop Relat Res. 1995;320:176–81. necrosis of the femoral head as a serious complica-
https://doi.org/10.1097/00003086-199511000-00029. tion following femoral nailing in children and ado-
42. Kalhor M.  Capsular and pericapsular contributions lescents. Unfallchirurg. 1998;101:495–9. https://doi.
to acetabular and femoral head perfusion. J Bone org/10.1007/s001130050301.
Joint Surg Am. 2009;91:409. https://doi.org/10.2106/ 56. Buford D, Christensen K, Weatherall P. Intramedullary
jbjs.g.01679. nailing of femoral fractures in adolescents. Clin
43. Gautier E, Ganz K, Krügel N, et al. Anatomy of the Orthop Relat Res. 1998;350:85–9. https://doi.
medial femoral circumflex artery and its surgical org/10.1097/00003086-199805000-00012.
implications. J Bone Joint Surg. 2000;82:679–83. 57. Gardner E.  The innervation of the hip joint. Anat
https://doi.org/10.1302/0301-620x.82b5.10426. Rec. 1948;101:353–71. https://doi.org/10.1002/
44. Lauritzen J.  The arterial supply to the femoral head ar.1091010309.
in children. Acta Orthop Scand. 1974;45:724–36. 58. Dee R. Structure and function of hip joint innervation.
https://doi.org/10.3109/17453677408989681. Ann R Coll Surg Engl. 1969;45:357–74.
45. Trueta J.  Vascular pattern of the femoral head
59. Saxler G, Löer F, Skumavc M, et al. Localization of
during growth. In: Studies of the development SP- and CGRP-immunopositive nerve fibers in the
and decay of the human frame. Philadelphia: JB hip joint of patients with painful osteoarthritis and of
Lippincott; 1968. p. 135–42. https://doi.org/10.1016/ patients with painless failed total hip arthroplasties.
b978-1-4831-6802-9.50024-9. Eur J Pain. 2007;11:67–74. https://doi.org/10.1016/j.
46. Grose AW, Gardner MJ, Sussmann PS, et  al.
ejpain.2005.12.011.
The surgical anatomy of the blood supply to 60. Sarban S, Baba F, Kocabey Y, et al. Free nerve end-
the femoral head: description of the anastomo- ings and morphological features of the ligamentum
sis between the medial femoral circumflex and capitis femoris in developmental dysplasia of the
inferior gluteal arteries at the hip. J Bone Joint hip. J Pediatr Orthop B. 2007;16:351–6. https://doi.
Surg Br Vol. 2008;90-B:1298–303. https://doi. org/10.1097/01.bpb.0000243830.99681.3e.
org/10.1302/0301-620x.90b10.20983. 61.
Gerhardt M, Johnson K, Atkinson R, et  al.
47. Letournel E, Judet R. Surgical anatomy. In: Fractures Characterisation and classification of the neural anat-
of the acetabulum. Berlin: Springer; 1981. p.  1–6. omy in the human hip joint. Hip Int. 2018;22:75–81.
https://doi.org/10.1007/978-3-662-02325-9_1. https://doi.org/10.5301/HIP.2012.9042.
 Radiology of the Hip Joint
2
Florian Schmaranzer, Till D. Lerch,
Inga A. S. Todorski, Moritz Tannast,
and Simon Steppacher

Abstract Keywords
The aim of this chapter is to describe the dif- Hip fracture · Acetabular fracture · Femur
ferent imaging modalities of the hip in the fracture · Trauma imaging · Conventional
trauma setting; this includes the conventional imaging · Computed tomography · Magnetic
radiography, which is still an essential modal- resonance imaging
ity for fracture evaluation due to fast acquisi-
tion, cost effectiveness, and the good overview 2.1 Conventional Radiography
on hip morphology. However, the acquisition
technique has a direct implication on radio- Despite the continuously increasing availability of
graphic anatomy of the hip and, therefore, this multidetector CT, plain radiographs are still the
chapter also aims to demonstrate the different standard imaging modality for assessment of the
technical principles and views of conventional hip joint in the trauma setting. Conventional imag-
imaging of the hip. In the trauma setting com- ing is widely available, cost-effective and the
puted tomography (CT) has emerged as an acquisition is very fast. In addition, it gives a good
indispensable tool for detailed preoperative overview on the radiographic morphology of the
planning with the possibility of hip and allows fracture detection in the early eval-
3D-reconstruction and multiplanar reformat- uation of trauma. Serial radiographic imaging of
ting. Magnetic resonance imaging (MRI) of the hip allows detection of secondary displace-
the hip is of minor significance in acute hip ment or confirmation of healing of a hip fracture.
trauma but is very helpful to detect occult Furthermore, it serves as the basis for preoperative
fractures, assess soft tissue injuries, or evalu- planning of total hip arthroplasty or correction
ate posttraumatic deformities. osteotomy of posttraumatic deformities [1, 2].
The acquisition technique and the different
views have a direct implication on the radio-
graphic anatomy of the hip. Therefore, the tech-
nical principles including film-tube distance,
centering and direction of the central X-ray beam,
F. Schmaranzer (*) · T. D. Lerch · I. A. S. Todorski · and pelvic orientation during acquisition are
M. Tannast · S. Steppacher described in detail. The anteroposterior (AP) pel-
Department of Orthopaedic Surgery and vic view and an axial view serve as the basis of
Traumatology, Inselspital, Bern University Hospital,
Bern, Switzerland conventional imaging; additional views include
e-mail: [email protected] Judet views [3, 4].

© Springer Nature Switzerland AG 2019 19

L. Büchler, M. J.B. Keel (eds.), Fractures of the Hip, Fracture Management Joint by Joint,
https://doi.org/10.1007/978-3-030-18838-2_2
20 F. Schmaranzer et al.

2.1.1 Technical Principles 2.1.1.1 Film-Tube Distance

of Conventional Radiography In contrast to CT scans, radiographs are based on
a conical projection that originates from a point-­
Technical principles with implications on the shaped X-ray source. The more anterior an ana-
radiographic anatomy of the hip include: film-­ tomic structure is located, the more lateral it will
tube distance, centering of the central X-ray be projected on the film. For example, with
beam, direction of the central X-ray beam, and increasing film-tube distance the acetabulum will
pelvic orientation [5]. appear more anteverted (Fig. 2.1) [5]. Therefore,

Anterior wall

Posterior wall

PW
AW
AW
PW

a b

Fig. 2.1  Impact of film-tube distance on pelvic anatomy. lap of the crossover sign (anterior wall [AW] projecting
(a) Compared to the regular film-tube distance (b) a more laterally than the posterior wall [PW]). (a, b)
decrease in the distance leads to a decrease in apparent Schematic drawing shows that structures that are located
acetabular anteversion, respectively, an increase in acetab- more anteriorly are visualized more laterally on the film
ular retroversion. This is indicated by a more distal over- than posterior anatomic structures
2  Radiology of the Hip Joint 21

standardization of the film-tube distance is [5]. Similarly, centering the central beam over
important. In the countries with the metric sys- one hip leads to a decrease of acetabular antever-
tem the standard film-tube distance usually is sion compared to the pelvic-centered view
120 cm and 40 inches (101.6 cm) in the countries (Fig. 2.3) [5]. Furthermore, the acetabular socket
with the imperial system. appears deeper in hip-centered views (Fig.  2.3)
[5]. The depth of the acetabular socket can vary
2.1.1.2 Centering of the Central X-Ray and has to be considered since safety zones for
Beam screw placement in acetabular fractures depend
The centering of the central beam has a major on acetabular morphology. For definite preopera-
influence on the projected anatomy of the hip tive assessment of safe zones, CT is very helpful
joint. On a standard AP pelvic view the central (Fig. 2.4).
beam should point at the midpoint between the
upper border of the symphysis and a line which 2.1.1.3 Pelvic Orientation
connects the superior anterior iliac spines. Pelvic orientation can vary regarding oblique-
Lowering of the central beam, which is often ness, rotation, and pelvic tilt [2]. For correction
used for planning of total hip arthroplasty, leads of measurement errors due to pelvic obliqueness,
to an increase in acetabular anteversion (Fig. 2.2) anatomic reference lines such as the teardrop line

a b

Fig. 2.2  Impact of the level of centration of the central (PW) and a prominent projection of the ischial spine (IS)
beam (white cross) on the projected hip anatomy. (a) AP into the pelvic inlet. (b) On the low-centered AP pelvic
pelvic radiograph centered over the pelvis shows a retro- view, the apparent acetabular anteversion increases as the
verted acetabulum indicated by a more lateral projection ischial-spine sign and the crossover between the anterior
of the anterior wall (AW) compared to the posterior wall and posterior acetabular disappears
22 F. Schmaranzer et al.

a b

Fig. 2.3  Impact of the centration of the central beam on distance between the anterior (AW) and posterior wall
the projected hip anatomy. (a) Compared to the film cen- (PW) is greater. Furthermore in (b) the femoral head and
tered over the midpoint of the pelvis, (b) the hip-centered the acetabular fossa are projected more medially toward the
view shows more apparent acetabular anteversion as the ilioischial line (IL) compared to the pelvic-centered view

a b

Fig. 2.4  Impact of acetabular depth on safety zones for the ilioischial line) no infraacetabular screw was used for
screw placement after pelvic trauma. (a) An infraacetabu- fixation (dashed lines). Axial CT scans show that in
lar screw was used for fixation in a hip with normal ace- severely overcovered hips (d) the acetabular walls, espe-
tabular depth. (b) By contrast in this patient with bilateral cially the medial acetabular facet is much thinner than in
protrusio acetabuli (overlap between he femoral head and hips with normal coverage (c)
2  Radiology of the Hip Joint 23

c d

Fig. 2.4 (continued)

can be drawn. Malrotation of the pelvis affects Knowledge of the key radiographic landmarks of
acetabular anteversion and is present if the sacro- the hip is the prerequisite for accurate image
coccygeal joint is not aligned with the center of interpretation and includes: the anterior acetabu-
the symphysis. Rotation to one side leads to an lar wall, the posterior acetabular wall, the acetab-
ipsilateral decrease in acetabular anteversion. ular roof, the teardrop, the iliopectineal line, and
Pelvic tilt can be indirectly assessed with the dis- the ilioischial line (Fig. 2.5). On radiographs the
tance between the sacrococcygeal joint and the iliopectineal line corresponds to the anterior col-
upper border of the symphysis. Anterior pelvic umn of the pelvis, which is defined as the bony
tilt, i.e. an increase in the sacrococcygeal-­ structure that runs from the sacroiliac joint down
symphyseal distance leads to an decrease in ace- to the ipsilateral pubic ramus. The anterior col-
tabular version, and vice versa [2]. umn includes the superior pubic ramus,
anterosuperior/-inferior iliac spines, the anterior
half of the acetabulum, and the anterior iliac crest
2.1.2 Different Views [6]. The ilioischial line corresponds to the radio-
of Conventional Imaging graphic projection of the anatomic posterior col-
umn and runs from the posterosuperior iliac spine
The different views of conventional imaging of down to the ischial tuberosity. The posterior col-
the hip in the trauma setting and their applica- umn includes the part of the ischium which
tions are described in detail. extends from the ischiopubic junction to the
greater sciatic notch and the posterior half of the
2.1.2.1 AP Pelvic View acetabulum [6].
AP pelvic views are part of the initial screening For acquisition of AP pelvic views, patients
for detection of femoral and acetabular fractures. are positioned supine with both legs 15° inter-
24 F. Schmaranzer et al.

Fig. 2.5  Six lines

according to Letournel
in a normal hip joint

Anterior acetabular wall

Posterior acetabular wall

Acetabular roof

Teardrop

IIiopectineal line

IIioischial line

Fig. 2.6  Acquisition of

AP pelvic views.
Patients are positioned
supine, with both legs
15° internally rotated.
The tube-film distance is
1.2 m and the central
beam points at the
midpoint between the
upper border of the
symphysis and a line
which connects the left
and right superior
anterior iliac spine

nally rotated. The tube-film distance is 120  cm 2.1.2.2 Lateral Views: Axial Cross-Table
and the central beam points at the midpoint View
between the upper border of the symphysis and a A secondary view of the hip is mandatory for eval-
line which connects the left and right superior uation of hip. For femoral fractures this is done
anterior iliac spine (Fig. 2.6) [2]. with an axial view. Different techniques exist
2  Radiology of the Hip Joint 25

Fig. 2.7  Acquisition of

axial crosstable views.
Patients are positioned
supine, with the
ipsilateral leg 15°
internally rotated to
compensate for femoral
torsion. The central
beamed is angled 45°
and points to the
inguinal fold

which include the cross-table axial, Dunn view, “obturator view,” left iliac oblique or right obtu-
Lauenstein view, or frog-leg lateral view. For the rator oblique) projections were the basis of radio-
acetabulum and its fracture evaluation the Judet graphic classification of acetabular fractures [6].
views have been described (see Sect. 2.1.2.3). Based on these views, the Letournel classifi-
The axial cross-table view enables visualiza- cation was developed which differentiates
tion of the anterior and posterior contour of the between ten types of acetabular fractures [8].
femoral head and neck and is invaluable for pre- Among these, three elementary fractures can be
liminary conformation and further assessment of identified: Wall fractures, column fractures, and
displacement of a suspected fracture visible on AP transverse fractures. The iliac oblique view shows
pelvic views. Patients are positioned supine, with the ipsilateral ilioischial line, the entire iliac
the ipsilateral leg 15° internally rotated to compen- wing, and the anterior wall of the acetabulum.
sate for femoral torsion. The central beam is The obturator oblique view shows the ipsilateral
angled 45° and points to the inguinal fold (Fig. 2.7). iliopectineal line and the posterior wall.
Alternatives of axial views include the Dunn view For acquisition of right posterior oblique and
(AP view with 90° of flexion and 20° abduction in left posterior oblique views, the patient is posi-
the hips), the modified Dunn view (45° of flexion tioned supine at 45° of rotation to the right and to
instead of 90°), Lauenstein view (45° of flexion the left on the radiographic table (Fig. 2.8). The
and 34° of abduction in the hip) or Frog-Leg lat- central beam is centered over the hip. We recom-
eral views (bilateral Lauenstein view) can be mend the standard acquisition of CT scans with
obtained [7]. Among all these views only the axial subsequent 3D reconstruction of the pelvis and
cross-table view enables assessment in a true sec- femur and acquisition of Judet views to get an
ondary plane of the acetabulum while the remain- overview of pelvic anatomy and for postoperative
ing views are all based on an AP projection. comparison.

2.1.2.3 Judet Views

Before the advent of CT, Judet views, i.e. right 2.1.3 Fluoroscopy
posterior oblique (RPO) (also known as: “ala
view,” right iliac oblique or left obturator oblique) Fluoroscopy is an important intra-operative
and left posterior oblique (LPO) (also known as: modality in the trauma setting. In contrast to
26 F. Schmaranzer et al.

a b

c d

Fig. 2.8 (a, b) Right posterior oblique view of the right side. (b) Ipsilateral posterior column and the anterior ace-
hip (“ala view,” right iliac oblique view) and (c, d) left tabular wall (AW) are nicely outlined. (c) Schematic
posterior oblique view of the right hip (“obturator view,” drawing shows patient rotated 45° to the left side. (d)
right obturator oblique view) of a 54-year-old patient. (a) Ipsilateral anterior acetabular column and the posterior
Schematic drawing shows patient rotated 45° to the right acetabular wall (PW) fracture are nicely outlined
2  Radiology of the Hip Joint 27

standard pelvic views it is based on a postero-­ special software, CT has become a standard tool
anterior projection and is centered over one hip. for surgical decision making and treatment plan-
One has to be aware of the fact that this leads to ning in hip and pelvic trauma. The reliability of the
an increase in the projected acetabular antever- Letournel classification was improved based on the
sion while resulting measurements for acetabular evaluation of CT images [3, 13].
coverage do not change [9].

2.3 Magnetic Resonance

2.2 Computed Tomography (CT) Imaging (MRI)

Although conventional radiographs are the diag- Conventional radiographs and especially CT are
nostic basis in hip trauma, CT imaging has the primary diagnostic tools for assessment of
emerged as an indispensable tool for detailed pre- hip in trauma setting. In the elderly patient, a hip
operative planning with the possibility of fracture may not be visible in 3–5% of cases with
3D-reconstruction and multiplanar reformatting. conventional radiographs. MRI is the modality of
In fractures of the femur, CT imaging can be per- choice to exclude undislocated femoral fractures
formed for detailed evaluation of the fracture pat- (Fig. 2.9) in patients with high clinical suspicion
tern and to aid in choosing the implant for and negative radiographs or CT scans [14, 15].
osteosynthesis. Multiplanar and Furthermore the excellent soft tissue contrast of
3D-reconstruction is very helpful for the surgeon MRI enables assessment of other pathologies
to plan the steps needed for reduction and osteo- such as muscular injuries (for instance, hamstring
synthesis of the fracture. This is especially true in injuries) which may explain the symptoms. The
comminuted fractures or when surgery is per- standard trauma MRI protocol of the pelvis
formed through a minimal invasive approach. For includes [1]: coronal and axial: T1-/T2-weighted
fractures of the acetabulum, CT imaging is per- turbo/fast spin-echo without fat saturation (T1-w
formed routinely. The complex anatomy of the TSE, T2-w TSE), and fluid-sensitive sequences
acetabulum and pelvis and the very different (T2-w/PD-w with fat saturation or short-tau
courses of acetabular fractures make it difficult inversion recovery) over the entire pelvis. On
for evaluation of the fracture using conventional MRI a fracture appears as a hypointense (“dark”)
imaging only (Fig. 2.4). Postoperative CT imag- line on all pulse sequences which is surrounded
ing can be performed to verify anatomic reduc- by a hyperintense (“bright”) bone marrow edema
tion of the fracture and correct placement of on the fluid-sensitive sequences, respectively,
screws. Since a non-anatomic reduction in articu- with low intensity on T1-w images (Fig.  2.9).
lar fractures of the hip is associated with increased Only rarely application of contrast is needed for
risk of secondary osteoarthritis of the joint, CT inconclusive cases with a suspect hip fracture to
imaging can be indicated following surgery [10]. further improve visualization of the non-­
Integration of a whole-body CT (non-contrast vascularized fracture line [1].
head, contrast-enhanced: spine, chest, abdomen, In the setting of an acute traumatic posterior
and pelvis) into the acute trauma care algorithm hip dislocation, MRI can be used to assess the
enables fast recognition or exclusion of life-­ integrity of the external obturator muscle which
threatening injuries and facilitates treatment is the anatomic landmark for the deep branch of
planning. An early whole-body CT in polytrau- the medial femoral circumflex artery. This vessel
matized patients reportedly increases the survival maintains vascularization of the femoral head.
rate [11, 12]. Hence an intact external obturator muscle is a
Due to its almost universal availability and the morphologic MRI predictor for a preserved blood
possibilities of fast acquisition of multiplanar refor- supply to the femoral head [16] (Fig. 2.10).
matted 2D images, 3D reconstructions of the pelvis In young patients with femoral and acetabular
and the reconstruction of virtual radiographs using fractures, traumatic sequelae have to be considered
28 F. Schmaranzer et al.

a b

c d

Fig. 2.9 (a) AP pelvic- and (b) modified Dunn views of a image without fat saturation and (d) coronal STIR image
48-year-old man with recurrent groin pain 4 weeks after show a hypointense fracture line (arrows) and adjacent
arthroscopic offset correction for correction of a cam bone marrow edema (arrows) corresponding to a stress
deformity without a history of trauma. (a, b) Plain radio- fracture of the femoral neck
graphs show no apparent fractures. (c) Coronal T1-w TSE

in primary fixation and/or in the follow-up after pri- trauma MR protocol. Direct MR arthrography
mary surgery (Fig. 2.11). Posttraumatic deformities is the current modality of choice for assess-
can lead to femoroacetabular Impingement (FAI) ment of chondrolabral lesions and superior to
and eventually to the development of osteoarthritis non-­contrast MRI [21, 22]. Direct MR arthrog-
[17]. MR imaging in the posttraumatic setting raphy can be further combined with axial trac-
includes the assessment of the proximal-femoral tion to achieve a distinct visualization of the
neck junction, femoral torsion, labrum tears cartilage layers and the ligamentum teres [23–
(Fig.  2.12), intraarticular loose bodies, osteochon- 26]. Based on the institutional preferences
dral injuries, and ligamentum teres lesions (Fig. 2.13) T1-w or PD-w images with or without fat-satu-
[18]. Accurate identification and localization of ration in coronal, axial/axial-oblique, and sag-
these lesions and the underlying bony pathomor- ittal planes are acquired using a small field of
phologies is important to refer these patients to sur- view (16–20  cm) [18]. Since radial slices
gical treatment. This may be either hip arthroscopy which rotate around the femoral neck axis are
for more focal, anterior lesions or surgical hip dislo- the gold-standard for imaging of the cam
cation for more complex corrections and reconstruc- deformity, either 2D radial images or radial
tions related to femoral malalignment [2, 19, 20]. reformats from gradient-echo sequences (GRE)
Assessment of FAI and intraarticular lesions should be acquired [27]. The availability of
requires a different imaging approach than the high-field scanners at 3  T, high performance
2  Radiology of the Hip Joint 29

a b

Fig. 2.10 (a) AP pelvic view of a 45-year-old woman femoral head. (c) MRI was performed to assess the vital-
who had a traumatic posterior dislocation and a resulting ity of the femoral head. Axial STIR image of the pelvis
acetabular fracture. (b) Schematic drawing shows the shows hyperintense signal indicating edema and hemor-
course of the medial circumflex femoral artery which rhagia of the periarticular musculature. The obturator
passes through the obturator foramen, runs on the external extensor muscle is intact. The patient did not develop
obturator muscle, and maintains the blood supply to the avascular necrosis of the femoral head

a b

Fig. 2.11 (a) AP pelvic view of a 45-year-­old patient with a in the anterior femoral neck. (c) Open reduction and fixation
posteriorly displaced, valgus-impacted medial femoral neck with an angular stable plate and (d) offset correction to pre-
fracture. (b) Axial view shows a resulting bony spur (circle) vent secondary posttraumatic FAI
30 F. Schmaranzer et al.

c d

Fig. 2.11 (continued)

a b

c d

Fig. 2.12  A 28-year-old woman who sustained a hyper- sented with groin pain with prolonged sitting and stand-
extension and external rotation trauma. (a–c) AP pelvic-, ing. Radial direct MR arthrograms show anterior partial
crosstable lateral-view, and an axial CT scan show a non-­ tear of the labrum with intrasubstance degeneration (cir-
displaced fracture of the posterior acetabular wall cle) and the posterior fracture of the acetabular wall
(arrows). (d) Three months after the injury patient pre-

gradients, dedicated multi-channel coils have ble or higher resolution to CT scans within rea-
paved the way for the routine acquisition of 3D sonable imaging time. Using this 3D volume
GRE sequences. These sequences enable thin, multiplanar reformation according to patient-
multiplanar image reformation with compara- specific anatomy is possible. This enables
2  Radiology of the Hip Joint 31

a b

c d

Fig. 2.13 (a) AP pelvic view of a 25-year-old man with to the femoral head. (c) Consecutive coronal PD-w TSE
excessive femoral antetorsion who sustained a hip sublux- image shows complete rupture of one bundle of the liga-
ation of the left hip via a hyperextension-adduction mentum teres (circle). (d) Coronal TIRM image shows
trauma. A radiolucent structure in the acetabular fossa is hyperintense signal suggesting partial rupture of the sec-
suggestive for a loose body (arrows), the opposing femo- ond bundle of the ligamentum teres (circle) and bone mar-
ral head appears deformed and with subtle inhomoge- row edema in the fovea capitis (arrows). (e) Postoperative
neous radiolucency. (b) Coronal proton density-weighted AP pelvic view following an extension wedge-osteotomy
(PD-w) turbo spin-echo (TSE) images show an osteo- of the femoral neck via a surgical hip dislocation and fixa-
chondral loose body in the acetabular fossa (asterisk) and tion of the central osteochondral fragment
a perifoveal osteochondral fragment still partly attached

reduction of out-of-plane artifacts and partial manual MRI and manual CT segmentations.
volume averaging [28]. Furthermore prelimi- The increasing use of machine learning appli-
nary in-house data shows excellent correlation cations will probably allow fully automated
between the mean surface distance (<1 mm) of MR segmentation in the future.
32 F. Schmaranzer et al.

References in evaluation of occult fracture of the proximal femur.

Injury. 2015;46:1557–61.
16. Tannast M, Pleus F, Bonel H, Galloway H, Siebenrock
1. Karantanas AH. What’s new in the use of MRI in the
KA, Anderson SE.  Magnetic resonance imaging in
orthopaedic trauma patient? Injury. 2014;45:923–33.
traumatic posterior hip dislocation. J Orthop Trauma.
2. Tannast M, Siebenrock KA, Anderson 2010;24:723–31.
SE.  Femoroacetabular impingement: radiographic 17. Leunig M, Beaulé PE, Ganz R. The concept of femoro-
diagnosis–what the radiologist should know. AJR Am acetabular impingement: current status and future per-
J Roentgenol. 2007;188:1540–52. spectives. Clin Orthop Relat Res. 2009;467:616–22.
3. Clarke-Jenssen J, Øvre SA, Røise O, Madsen 18. Schmaranzer F, Todorski IAS, Lerch TD, Schwab

JE. Acetabular fracture assessment in four different pel- J, Cullmann-Bastian J, Tannast M.  Intra-articular
vic trauma centers: have the Judet views become super- lesions: imaging and surgical correlation. Semin
fluous? Arch Orthop Trauma Surg. 2015;135:913–8. Musculoskelet Radiol. 2017;21:487–506.
4. Ricci WM, Mamczak C, Tynan M, Streubel P, 19. Steppacher S, Schwab J, Siebenrock K, Tannast

Gardner M. Pelvic inlet and outlet radiographs rede- M. Actual management of femoroacetabular impinge-
fined. J Bone Joint Surg Am. 2010;92:1947–53. ment. Minerva Ortopedica e Traumatologica.
5. Steppacher SD, Albers CE, Tannast M, Siebenrock 2012;63:365–78.
KA. Plain radiographic evaluation of the hip. In: Nho 20.
Lerch TD, Todorski IAS, Steppacher SD,
S, Leunig M, Kelly B, Bedi A, Larson C, editors. Schmaranzer F, Werlen SF, Siebenrock KA, Tannast
Hip arthroscopy and hip joint preservation surgery. M.  Prevalence of femoral and acetabular version
New York: Springer; 2014. p. 1–22. abnormalities in patients with symptomatic hip dis-
6. Lawrence DA, Menn K, Baumgaertner M, Haims ease: a controlled study of 538 hips. Am J Sports
AH. Acetabular fractures: anatomic and clinical con- Med. 2018;46:122–34.
siderations. Am J Roentgenol. 2013;201:W425–36. 21. Saied AM, Redant C, El-Batouty M, El-Lakkany MR,
7. Meyer DC, Beck M, Ellis T, Ganz R, Leunig El-Adl WA, Anthonissen J, Verdonk R, Audenaert
M.  Comparison of six radiographic projections to EA.  Accuracy of magnetic resonance studies in the
assess femoral head/neck asphericity. Clin Orthop detection of chondral and labral lesions in femoroac-
Relat Res. 2006;445:181–5. etabular impingement: systematic review and meta-­
8. Letournel E.  Acetabulum fractures: classifica- analysis. BMC Musculoskelet Disord. 2017;18:83.
tion and management. Clin Orthop Relat Res. 22. Smith TO, Hilton G, Toms AP, Donell ST, Hing

1980;151:81–106. CB.  The diagnostic accuracy of acetabular labral
9. Büchler L, Schwab JM, Whitlock PW, Beck M, tears using magnetic resonance imaging and magnetic
Tannast M.  Intraoperative evaluation of acetabular resonance arthrography: a meta-analysis. Eur Radiol.
morphology in hip arthroscopy comparing standard 2011;21:863–74.
radiography versus fluoroscopy: a cadaver study. 23. Schmaranzer F, Klauser A, Kogler M, Henninger B,
Arthroscopy. 2016;32:1030–7. Forstner T, Reichkendler M, Schmaranzer E. Improving
10. Tannast M, Najibi S, Matta JM. Two to twenty-year visualization of the central compartment of the hip with
survivorship of the hip in 810 patients with opera- direct MR arthrography under axial leg traction: a fea-
tively treated acetabular fractures. J Bone Joint Surg sibility study. Acad Radiol. 2014;21:1240–7.
Am. 2012;94:1559–67. 24. Schmaranzer F, Klauser A, Kogler M, Henninger

11. Huber-Wagner S, Lefering R, Qvick L-M, Körner M, B, Forstner T, Reichkendler M, Schmaranzer
Kay MV, Pfeifer K-J, Reiser M, Mutschler W, Kanz E.  Diagnostic performance of direct traction MR
K-G, Working Group on Polytrauma of the German arthrography of the hip: detection of chondral and
Trauma Society. Effect of whole-body CT during labral lesions with arthroscopic comparison. Eur
trauma resuscitation on survival: a retrospective, mul- Radiol. 2015;25:1721–30.
ticentre study. Lancet. 2009;373:1455–61. 25. Schmaranzer F, Klauser A, Kogler M, Henninger B,
12. Huber-Wagner S, Mand C, Ruchholtz S, Kühne CA, Forstner T, Reichkendler M, Schmaranzer E.  MR
Holzapfel K, Kanz K-G, van Griensven M, Biberthaler arthrography of the hip with and without leg traction:
P, Lefering R, Trauma Register DGU.  Effect of the assessing the diagnostic performance in detection of
localisation of the CT scanner during trauma resusci- ligamentum teres lesions with arthroscopic correla-
tation on survival – a retrospective, multicentre study. tion. Eur J Radiol. 2016;85:489–97.
Injury. 2014;45(Suppl 3):S76–82. 26. Schmaranzer F, Lerch TD, Strasser U, Vavron P,

13. Ohashi K, El-Khoury GY, Abu-Zahra KW, Berbaum Schmaranzer E, Tannast M.  Usefulness of MR
KS. Interobserver agreement for letournel acetabular frac- arthrography of the hip with and without leg traction
ture classification with multidetector ct: are standard judet in detection of intra-articular bodies. Acad Radiol.
radiographs necessary? Radiology. 2006;241:386–91. 2018. https://doi.org/10.1016/j.acra.2018.10.008.
14. Collin D, Geijer M, Göthlin JH.  Computed tomog- 27. Agten CA, Sutter R, Buck FM, Pfirrmann CWA. Hip
raphy compared to magnetic resonance imaging in imaging in athletes: sports imaging series. Radiology.
occult or suspect hip fractures. A retrospective study 2016;280:351–69.
in 44 patients. Eur Radiol. 2016;26:3932–8. 28. Naraghi A, White LM.  Three-dimensional MRI of
15. Haubro M, Stougaard C, Torfing T, Overgaard
the musculoskeletal system. AJR Am J Roentgenol.
S. Sensitivity and specificity of CT- and MRI-scanning 2012;199:W283–93.
 Initial Management of Hip
Fractures Prior to Surgical 3
Intervention

Mark Haimes and Michael Blankstein

Abstract 3.1 Introduction

Initial deliberate management of hip fractures
is imperative to set the stage for a successful This chapter will focus on the initial manage-
hospital course and surgical treatment. The ment of patients with hip fractures. Hip fractures
hip fracture population can be separated into should be separated into two populations, elderly
two groups: elderly patients that sustained patients following a low energy fall and young
low energy osteoporotic fractures and young patients who sustained high energy trauma, each
patients following high-energy trauma. Low with different management strategies.
energy hip fracture patients require a focus on When evaluating the low-energy osteoporotic
medical comorbidities with consultation of hip fractures, the focus should be on a thorough
the appropriate services for perioperative history, physical exam, and metabolic/nutritional
optimization. The primary goal is early oper- workup, with early involvement of family, physi-
ative intervention in order to mobilize patients cal therapy, social work, nutrition, and medicine/
as quickly as possible. Regional nerve blocks geriatric co-management teams. The ultimate
may be beneficial, but traction is not. High-­ goal is surgery within 24–48  h to allow early
energy hip fracture management differs with mobilization.
a focus on resuscitation, identification of con- The high-energy hip fractures usually occur
comitant injuries, and emergent reduction. In in a younger population and are associated
both groups, attention should be paid to with other concomitant trauma requiring emer-
appropriate anticoagulation. gent attention and resuscitation. The initial
focus is the history, thorough physical and
Keywords acute stabilization by the general surgery/
Hip fracture · Emergency · Initial management · trauma teams. The orthopedic goals are to sta-
Preoperative · Low energy · High energy bilize the patient and surgically treat when safe
to proceed. Principles of damage control ortho-
pedics should be applied. Ultimately, the
patient should undergo urgent operative inter-
M. Haimes (*) · M. Blankstein vention if the joint is concentrically reduced,
Department of Orthopaedic Surgery, University of
Vermont Medical Center, Burlington, VT, USA but emergent surgery otherwise.
e-mail: [email protected]

© Springer Nature Switzerland AG 2019 33

L. Büchler, M. J.B. Keel (eds.), Fractures of the Hip, Fracture Management Joint by Joint,
https://doi.org/10.1007/978-3-030-18838-2_3
34 M. Haimes and M. Blankstein

3.2  ow Energy Elderly

L On physical exam, the affected extremity is
Osteoporotic Hip Fractures classically shortened and externally rotated, but
this may not always be the case. It is important to
3.2.1 Presentation logroll the unaffected and affected side to help
confirm the diagnosis. A Stinchfield exam (resisted
The osteoporotic hip fracture patient presents straight leg raise) is a more sensitive test to help
most often after a fall from standing height. It determine intra-articular pathology [2]. With sub-
is important to assess for concomitant injuries tle intra-articular hip pathologies and osteoarthri-
and differentiate the nature of the fall: mechan- tis, the Stinchfield test is less sensitive [3], but in a
ical, neurological, or cardiopulmonary. It is hip fracture population it approaches 100% sensi-
also important to inquire about antecedent hip tivity. A good cardiopulmonary exam is important
pain, which could be a clue of a pathologic as well, as many of these patients have multiple
fracture. cardiopulmonary medical comorbidities that need
to be identified to assist the internal medicine and
anesthesia colleagues [1]. In demented patients
3.2.2 History and Physical especially, or those that cannot provide a thorough
history, it is important to examine the head, chest,
The medical history is extremely important with abdomen, and all extremities in the usual head-to-
this elderly population. Due to the high preva- toe fashion to detect other injuries. Finally, a good
lence of medical comorbidities [1], the osteopo- dermatologic exam should be performed in all
rotic hip fracture population is relatively difficult patients, ideally with the help of nursing, to iden-
to manage and has a variable prognosis. tify skin lesions or tears, and pressure ulcers as
Worldwide, the 1-year mortality rate of this pop- they are a significant cause of morbidity and can
ulation can be up to 30%, with even more experi- be prevalent in 10–60% of patients [4–6].
encing significant functional deficits [1]. Along
with the medical history and other medical
comorbidities, it is also important to gauge the 3.2.3 Diagnostic Testing
patient’s functional status and social history, spe-
cifically ambulatory status, living situation, level Radiographs are the predominant imaging modal-
of function, and activities of daily living (ADLs). ity of choice. An anteroposterior (AP) pelvis, iso-
Support from family and other healthcare profes- lated hip AP and cross table lateral, and
sionals is extremely important to help guide the completion images of the entire femur are impor-
decision for surgery. tant for surgical planning. A standardized marker
All medications, allergies, past medical/surgi- should be used to correct for magnification error
cal/family history should be reviewed, including and subsequent calibration for implant sizing. A
any anticoagulation, complications with anesthe- traction view can be useful, as it assists in identi-
sia, or family history of hematological or cardio- fication of fracture pattern. A traction view is per-
pulmonary disorders. Prior to admission, it is formed by obtaining an AP radiograph of the hip
important to discuss code status with these while the operator pulls axial traction and inter-
patients, as well as the code status specifically nal rotation through the affected lower extremity.
surrounding the perioperative period. The An assistant will need to hold counter-traction by
patient’s code status addresses their wishes the axillae during the X-ray. An AP chest X-ray
should they undergo cardiopulmonary arrest and may be obtained at this point if clinically relevant
possibly require resuscitation or other long-term based on history and preoperative planning for
life-sustaining measures. It is best to involve the anesthesia or medicine teams.
family early regarding the gathering of history In rare instances, a patient’s history and physi-
and direction of management, especially in those cal exam correlates with a hip fracture, however,
patients that cannot provide a thorough and there may be no findings on plain radiographs. In
detailed history themselves. this case, an MRI of the hip can assist in ruling out
3  Initial Management of Hip Fractures Prior to Surgical Intervention 35

an occult hip fracture. This is in concordance with 3.3  anagement of Low Energy
M
the American Academy of Orthopedic Surgeons Hip Fractures in the
(AAOS) guidelines that provide moderate support Emergency Department
for using MRI to assist in the diagnosis [7].
Management is controversial regarding the occult After the patient has been evaluated, further opti-
fracture, however, both operative and non-opera- mization can be performed in the emergency
tive intervention may be appropriate after an in- department. A Foley catheter is recommended
depth conversation and informed decision making due to the significant pain and immobilization
with the patient and families (Case 1). that will occur until surgery. Two peripheral IVs
Laboratory data is obtained to assess overall are placed to assist with fluids and medication
medical condition and comorbidities, as well as and minimize delay in the operative room.
nutritional deficits and endocrinopathies. Traction is rarely applied for osteoporotic hip
Standard laboratory orders include a complete fracture patients. A prospective randomized con-
blood count (CBC), basic metabolic profile trol trial of 100 consecutive elderly patients with
(BMP), prothrombin time, INR, and partial femoral neck and intertrochanteric femur frac-
thromboplastin time. For osteoporotic hip frac- tures compared use of cutaneous traction with
ture patients, calcium, magnesium, phosphorus, five pounds versus no traction and only place-
alkaline phosphatase, albumin, prealbumin, para- ment of a pillow. The authors concluded that pre-
thyroid hormone (PTH), vitamin D, and hemo- operative skin traction in patients with hip
globin A1c should be used to assist with nutrition fractures does not provide significant pain relief,
and endocrine status. An electrocardiogram and as compared with pillow placement under the
urinalysis are ordered due to the high prevalence injured extremity, and thus should not be rou-
of abnormal cardiac pathologies and high risk of tinely performed [15]. A 2011 Cochrane Review,
urinary tract infections. In the USA, nasal swab including 11 trials and 1654 patients compared
to detect methicillin-resistant Staphylococcus skin traction to no traction in elderly patients
aureus (MRSA) is also performed, as MRSA with hip fractures. There was no difference of
colonization could compromise the surgical relief of pain, ease of fracture reduction, or qual-
recovery, increase cost, and contribute to poten- ity of fracture reduction at the time of surgery
tial postoperative infection [1, 8–11]. [16]. Furthermore, a digital subtraction angiogra-
phy study of nine patients with femoral neck
fractures demonstrated a decrease in femoral
3.2.4 Consulting Additional head perfusion when placed in 3  kg of traction
Services compared to the contralateral side. Perfusion was
further decreased with 5  kg of traction, which
Internal medicine co-management services have suggests that traction decreases blood flow to the
shown to improve outcomes, including, but not femoral head in patients with hip fractures [17].
limited to, in-hospital mortality, long-term mor- Therefore, we advocate against the use of trac-
tality, and length of stay [1, 12]. Economic cost-­ tion in the elderly hip fracture population. This is
effective analyses demonstrate reduction of costs in concordance with the recommendations of the
with a dedicated elderly hip fracture team, con- AAOS which states there is moderate evidence
sisting of orthopedic, internal medicine, physical that does not support the use of routine preopera-
therapy, and social work [13]. Due to the benefit tive traction in patients with a hip fracture [7].
of early surgical management [7, 14], the focus Pain medication should be limited to non-­
should be to expedite optimization of the patient narcotics, as narcotics in the elderly may be associ-
for surgery with appropriate risk stratification. ated with adverse outcomes [18]. Acetaminophen,
Anesthesia may be consulted early if there is a tramadol, and methocarbamol are the mainstays of
concern for difficulty providing anesthesia with treatment for pain at our institution. Anticoagulation
the patient’s medical comorbidities, depending on should be provided to all patients with hip fractures
the institution’s anesthesia preoperative protocol. and this can begin prior to surgery if surgery will be
36 M. Haimes and M. Blankstein

delayed. The American College of Chest Physicians Overall, a regional anesthetic may be beneficial
recommends use of heparin or low molecular and should be considered part of the standard pro-
weight heparin if there is likely to be a delay to tocol for patients with hip fractures in the preop-
surgery [19]. If admitted patients are already on erative period. There is difficulty in implementing
anticoagulants due to a history of atrial fibrillation a hip fracture protocol which incorporates an
or other indications, anticoagulation reversal FICB due to inadequate staff, other resumption of
should be initiated. INR <1.5 should be achieved anesthetics, and misperception of benefit [27].
by administering vitamin K or prothrombin com- The discussion for surgery should happen
plex concentrate [20]. Fresh frozen plasma is rarely early, and in the presence of family if possible.
used with vitamin K antagonist reversal due to its The risks, benefits, and non-operative treatment
delay and incomplete reversal [20]. Other novel options should be discussed in detail. Surgical
oral anticoagulants such as thrombin and direct treatment is the preferred method of choice for
factor Xa inhibitors should be held. New reversal most patients with the goal of giving patients the
agents have been developed to expedite surgery for best chance at returning to their baseline func-
patients on these medications, but it is unclear how tional status. Chlebeck et al. in a retrospective
long the surgeon should wait before considering matched cohort study of 154 operative and 77
safe surgical intervention. Aspirin and clopidogrel nonoperative patients with hip fractures, found
should not change hip fracture management proto- significantly higher percent in-hospital (28.6 vs
cols and delay a trip to the operating room. Studies 3.9; p<0.0001), 30-day (63.6 vs. 11.0; <0.0001)
and systematic review have shown no difference in and one-year (84.4 vs 36.4;p<0.0001) mortality.
bleeding complications, blood loss or transfusion Their mean life expectancy after a hip fracture for
requirements, overall mortality and hospital length the nonoperative cohort was significantly shorter
of stay when comparing patients who underwent than the operative group (221 vs. 1024 days;
hip fracture surgery with antiplatelet therapy and p<0.0001) [44]. According to the AAOS guide-
those without [20, 21]. Furthermore, there is an lines, it is important to get hip fracture patients to
increase in thromboembolic and infectious compli- surgery within 24–48  h due to the significant
cations if surgery is delayed in the population on improved outcomes [7]. A recent retrospective
antiplatelet therapy. The American Society of analysis of 42,230 patients with hip fractures dem-
Regional Anesthesia does not recommend neuro- onstrated an increased risk of complications and
axial anesthesia in this population, although there even a higher 30-day mortality rate when wait
are cases of the use of platelet transfusion in times were greater than 24 h [14]. This newer evi-
patients on clopidogrel and aspirin leading to safe dence, although retrospective, attempted to match
use of spinal anesthesia [20]. patients based on medical comorbidities and other
Regional nerve blocks have been shown to have known confounders. Furthermore, a linear relation-
some benefit in pain reduction and even a reduc- ship is demonstrated between 1-year-mortality rate
tion in delirium in patients at moderate risk [22– and timing to surgery with a 5% increase per 10-h
26]. A prospective randomized control trial of 50 delay [30]. Assuming the patient is stable, a 24-h
patients with femoral neck fractures treated with a goal for surgery, and even an urgent time sensitive
bupivacaine femoral nerve block and IV morphine protocol similar to management of stroke and myo-
versus IV morphine alone, demonstrated faster cardial infarction may be appropriate.
time to lowest pain score, 2.88 h vs. 5.81 h, as well
as requiring less morphine per hour than controls
[22]. Results are similar with multiple fracture pat- 3.4 High Energy Hip Fractures
terns and even superior when fascia iliaca com-
partment blocks (FICB) were used with fewer side 3.4.1 Presentation
effects of systemic anesthetics like opioids [23,
27–29]. Further studies show a decrease in delir- As with most orthopedic injuries, there is a
ium in moderate risk patients and even a decreased bimodal distribution of age when referring to
time to achieving spinal anesthesia [25, 26]. patients with fractures about the hip. The younger
3  Initial Management of Hip Fractures Prior to Surgical Intervention 37

patients with hip fractures are more likely to be a sonography for trauma (FAST) exam is per-
result of high-energy mechanisms such as motor formed followed by a CT scan of the cervical
vehicle collisions or falls from extreme heights. spine, chest, abdomen, and pelvis if indicated.
The first presentation of these patients should Patients with a diaphyseal femur fracture have a
be addressed using the advanced traumatic life 1–9% rate of having a concomitant femoral neck
support (ATLS) algorithm. The orthopedic fracture, and historically up to one-third of these
assessment can be extremely valuable but should are missed or diagnosed on a delayed basis [32].
not interfere with the ATLS treatment by the Therefore, a fine-cut CT of the pelvis should be
emergency and general surgery trauma teams. considered with a high energy diaphyseal femur
When assessing the patient’s circulation, external fracture [33, 34] (Case 2). Blood work is obtained
hemorrhage from extremity trauma or intra-­ with a CBC, BMP, coagulation studies, and type
pelvic hemorrhage from pelvic trauma are and screen.
extremely important to identify as early potential
sites for volume loss.
3.5  anagement of High Energy
M
Hip Fractures
3.4.2 History and Physical in the Emergency
Department
Unlike the osteoporotic population, imaging may
not be obtained prior to the orthopedic consulta- Once the patient is appropriately evaluated and
tion and physical exam, so the physical exam is injuries identified, a treatment plan should be
extremely important to identify injuries. implemented. In the high-energy traumatic inju-
Concomitantly with the general surgery trauma or ries, fractures are more variable and dislocations
emergency medical teams, a thorough orthopedic have a much higher incidence. High-energy hip
evaluation is performed as part of the secondary fractures include the intertrochanteric/sub tro-
survey. The orthopedic surgeon should perform a chanteric region, femoral neck, femoral head,
head-to-toe evaluation. Special attention is given acetabular fracture, and these may be associated
to all extremities, the back, perineum, and pelvis. with a dislocation or subluxation of the hip.
The skin, major long bone deformities, and neuro- These injuries may be also associated with inju-
vascular status should be assessed for each extrem- ries of the pelvic ring that may require a pelvic
ity. All clothing, traction, and splints used for sheet or binder acutely.
stabilization should be removed for the physical All hip reductions should be addressed emer-
exam, as a significant portion is applied inappro- gently to help preserve cartilage and blood sup-
priately and with minimal proven benefit in the ply to femoral head. If a suspected hip dislocation
poly-trauma patient [31]. The back and spine or subluxation is present, it should be confirmed
should be inspected to assess for any skin defects with plain radiographs, and acute emergent inter-
and palpated to assess for tenderness, bogginess, vention is necessary. These should be closed
or step-offs. A rectal exam is performed to assess reduced gently under good sedation and post
neurologic status and to identify pelvic/rectal inju- reduction radiographs should be obtained.
ries with gross blood after digital rectal exam. Traction assists in reduction of fractures or
Assessing stability of the pelvis and a thorough hip dislocations, helps maintain length and align-
exam should be performed. ment, decreases muscle spasms, and allows tam-
ponade of bleeding [35]. Isolated native hip
dislocations have a wide range of treatment; how-
3.4.3 Diagnostic Testing ever, traction has not been shown to have a clear
benefit. A retrospective analysis of isolated native
After the physical exam, an AP chest radiograph hip dislocations treated with skeletal traction ver-
and AP pelvis radiograph are obtained according sus early partial weight bearing shows no differ-
to the ATLS protocol. A focused assessment with ence in outcomes with earlier return to work [36].
38 M. Haimes and M. Blankstein

If there is an associated hip fracture, the use of regarded as more urgent than the osteoporotic hip
skeletal traction may be indicated. Traction fractures. A survey of 540 orthopedic surgeons
through the hip is thought to prevent pressure from the USA and Canada was performed regard-
necrosis of the articular cartilage and viability of ing urgency of young femoral neck fractures.
the femoral head and acetabulum [35]. About one-quarter indicated their preference to
Skeletal traction should be considered follow- operate within 8 h and about two-thirds indicated
ing a hip fracture dislocation. Skeletal traction that fractures were typically treated within 8–24 h
may be placed in the distal femur or proximal tibia [42]. The young patient with a high-energy hip
prior to the reduction to assist in stability immedi- fracture is difficult to manage. They have a high
ately after reduction. A threaded pin is used as it incidence of concomitant injuries, AVN, non-
decreased the likelihood of loosening, although is union, and need for re-operation [32, 43]. Their
more likely to bend [37]. Skeletal traction may be injuries are more urgent and there is a strong pref-
used with 5–10 kg, and even reports of up to 15 kg erence to operate within 24 h.
for months of treatment. A proximal tibial or distal
femoral traction pin may be used with a few excep-
tions. A proximal tibial traction pin should not be 3.6 Conclusion
used in patients with injuries about the knee
including suspected ligamentous knee injuries or Hip fractures are very common injuries. It is
proximal tibia fractures. A distal femoral traction important to utilize a collaborative approach when
pin is most often used. The disadvantage is the managing these injuries. The osteoporotic hip
<1% risk of infection [38], and the placement of fracture management team consists of orthope-
the pin may occupy the space for an intramedul- dics, internal medicine, physical therapy, nutrition,
lary femoral nail if the pin is not anterior or poste- and social work. In patients with high-energy hip
rior enough. The distal femoral traction pin is fractures, the collaborative approach involves the
placed medial to lateral, >0.7 cm proximal to the general surgery trauma and emergency teams with
adductor tubercle near the metaphyseal flare. and initial stabilization as the primary goal. Other pre-
<2 cm proximal to the superior pole of the patella operative management includes a regional anes-
[45]. The goal is to avoid the femoral artery as it thetic block, FICB or femoral nerve, which has
passes through the adductor hiatus and to avoid shown some benefit in pain and even delirium
intra-articular placement of the pin within the knee reduction. Traction should not be used in the
[35]. A proximal tibial traction pin may be placed osteoporotic hip fracture population, as it does not
from lateral to medial, 2.5  cm distal and 2.5  cm reduce pain compared to placement of a pillow.
posterior to the tibial tubercle, parallel to the joint However, in the younger high-energy population,
line. The goal is to avoid the peroneal nerve [35]. traction plays an important role in maintaining
If the joint is unable to be reduced or a fracture reduction and preserving cartilage. Anticoagulation
fragment remains in the incongruous joint, open is important in preventing DVT and anticoagula-
reduction should be performed on an emergent tion reversal should be implemented in specific
basis [39]. Surgery may be delayed otherwise after cases. Recent data suggests improved outcomes
initial stabilization, however, should be performed with operative treatment within 24 h.
urgently within 24 h. A prospective cohort of 107
patients aged 18–55 with femoral neck fractures Case 1
found that fracture displacement, quality of reduc- Occult intertrochanteric femur fracture: 90-year-­
tion, and nonunion were associated with a poor old female with history of a ground level fall and
physical component outcome score [40]. persistent pain with weight bearing, pain with log
Furthermore, in a systematic review of 1558 young roll on physical exam and pain with any hip range
femoral neck fractures, avascular necrosis (AVN) of motion. An MRI was obtained which showed an
and nonunion were the most common complica- intertrochanteric femur fracture. After a long dis-
tions leading to re-operation in about 20% of cussion, the patient was treated non-operatively
cases. This was associated with degree of fracture with protected weight bearing and the fracture
displacement [41]. These injuries are classically healed without further displacement (Fig. 3.1).
3  Initial Management of Hip Fractures Prior to Surgical Intervention 39

Case 2 ipsilateral diaphyseal and femoral neck frac-

Ipsilateral diaphyseal and femoral neck fracture: tures. A thin sliced 1  mm CT scan is shown,
26-year-old male who presented after a high-­ which better visualizes the femoral neck fracture
speed motor vehicle accident and sustained an (Fig. 3.2).

a b

Fig. 3.1 (a) An AP radiograph of the right hip demonstrates degenerative changes with no fracture identified. (b)
Coronal slice of T1-weighted MRI demonstrates hypointensity along the intertrochanteric line which confirms the
diagnosis of a non-displaced, standard obliquity, intertrochanteric femur fracture

a b

Fig. 3.2  (a) An AP radiograph of the left proximal femur demonstrates a completely displaced transverse diaphyseal
femur fracture. The femoral neck is difficult to visualize. There is a radioluceny along the femoral neck. (b) Thin sliced
axial CT of the femoral neck confirms left femoral neck fracture
40 M. Haimes and M. Blankstein

References 16. Handoll HH, Queally JM, Parker MJ.  Pre-operative

traction for hip fractures in adults. Cochrane Libr.
2011;12:CD000168.
1. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen
17. Lin J, Yang H.  DSA observation of hemodynamic
AB.  Incidence and mortality of hip fractures in the
response of femoral head with femoral neck fracture
United States. JAMA. 2009;302:1573–9.
during traction: can traction really increase the risk of
2. Mcgrory BJ. Stinchfield resisted hip flexion test. Hosp
osteonecrosis of the femoral head? J Orthop Trauma.
Physician. 1999;35:41–2.
2012;26:E168.
3. Maslowski E, Sullivan W, Harwood JF, et al. The diag-
18. Abou-Setta AM, Beaupre LA, Rashiq S, et  al.

nostic validity of hip provocation maneuvers to detect
Comparative effectiveness of pain management inter-
intra-articular hip pathology. PM R. 2010;2:174–81.
ventions for hip fracture: a systematic review. Ann
4. Beaupre LA, Allyson Jones C, Duncan Saunders L,
Intern Med. 2011;155:234–45.
Johnston DWC, Buckingham J, Majumdar SR.  Best
19. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention
practices for elderly hip fracture patients. J Gen Intern
of venous thromboembolism: American College of
Med. 2005;20:1019–25.
Chest Physicians evidence-based clinical practice
5. Houwing R, Rozendaal M, Wouters-Wesseling W,
guidelines. Chest. 2008;133:381s–453s.
Beulens J, Buskens E, Haalboom J.  A randomised,
20. Yassa R, Khalfaoui MY, Hujazi I, Sevenoaks H,

double-blind assessment of the effect of nutritional
Dunkow P.  Management of anticoagulation in hip
supplementation on the prevention of pressure ulcers
fractures: a pragmatic approach. EFORT Open Rev.
in hip-fracture patients. Clin Nutr. 2003;22:401–5.
2017;2:394–402.
6. Baumgarten M, Margolis D, Berlin JA, et  al. Risk
factors for pressure ulcers among elderly hip fracture 21. Soo CG, Della Torre PK, Yolland TJ, Shatwell

patients. Wound Repair Regen. 2003;11:96–103. MA.  Clopidogrel and hip fractures, is it safe?
7. American Academy of Orthopaedic Surgeons. A systematic review and meta-analysis. BMC
Management of Hip Fractures in the Elderly - Musculoskelet Disord. 2016;17:136.
Evidence Based Clinical Practice Guideline. https:// 22. Fletcher AK, Rigby AS, Heyes FL.  Three-in-one

www.aaos.org/research/guidelines/HipFxGuideline. femoral nerve block as analgesia for fractured neck
pdf. Published September 5, 2014. of femur in the emergency department: a randomized,
8. Thyagarajan D, Sunderamoorthy D, Haridas S, controlled trial. Ann Emerg Med. 2003;41:227–33.
Beck S, Praveen P, Johansen A.  Mrsa colonisation 23. Foss NB, Kristensen BB, Bundgaard M, et al. Fascia
in patients admitted with hip fracture: implications iliaca compartment blockade for acute pain control in
for prevention of surgical site infection. Acta Orthop hip fracture patientsa randomized, placebo-controlled
Belg. 2009;75:252–7. trial. Anesthesiology. 2007;106:773–8.
9. Shukla S, Nixon M, Acharya M, Korim M, Pandey 24. Haddad F, Williams R. Femoral nerve block in extra-
R.  Incidence of MRSA surgical-site infection in capsular femoral neck fractures. Bone Joint Journal.
MRSA carriers in an orthopaedic trauma unit. J Bone 1995;77:922–3.
Joint Surg Br. 2009;91:225–8. 25.
Mouzopoulos G, Vasiliadis G, Lasanianos N,
10. Nixon M, Jackson B, Varghese P, Jenkins D, Taylor Nikolaras G, Morakis E, Kaminaris M. Fascia iliaca
G.  Methicillin-resistant staphylococcus aureus on block prophylaxis for hip fracture patients at risk for
orthopaedic wards: incidence, spread, mortality, cost delirium: a randomized placebo-controlled study. J
and control. J Bone Joint Surg Br. 2006;88:812–7. Orthop Traumatol. 2009;10:127–33.
11. Prokuski L.  Prophylactic antibiotics in orthopaedic 26. Yun M, Kim Y, Han M, Kim J, Hwang J, Do

surgery. J Am Acad Orthop Surg. 2008;16:283–93. S.  Analgesia before a spinal block for femoral neck
12. Grigoryan KV, Javedan H, Rudolph V. Ortho-geriatric fracture: fascia iliaca compartment block. Acta
care models and outcomes in hip fracture patients: Anaesthesiol Scand. 2009;53:1282–7.
a systematic review and meta-analysis. J Orthop 27. Miller GW, Godrey JJ, Sagmeister ML, Lewis

Trauma. 2014;28:E49. TL.  Provision of fascia iliaca compartment block in
13. Swart E, Vasudeva E, Makhni EC, Macaulay W, Bozic the acute management of proximal femoral fractures:
KJ.  Dedicated perioperative hip fracture comanage- a national observational study of UK hospitals. Injury.
ment programs are cost-effective in high-volume cen- 2016;47:2490–4.
ters: an economic analysis. Clin Orthop Relat Res. 28. Haines L, Dickman E, Ayvazyan S, et al. Ultrasound-­
2016;474:222–33. guided fascia iliaca compartment block for hip frac-
14. Pincus D, Ravi B, Wasserstein D, et  al. Association tures in the emergency department. J Emerg Med.
between wait time and 30-day mortality in 2012;43:692–7.
adults undergoing hip fracture surgery. JAMA. 29. Pinson S.  Fascia iliaca (Ficb) block in the emer-

2017;318:1994–2003. gency department for adults with neck of femur
15. Rosen JE, Chen FS, Hiebert R, Koval KJ.  Efficacy fractures: a review of the literature. Int Emerg Nurs.
of preoperative skin traction in hip fracture patients: 2015;23:323–8.
a prospective, randomized study. J Orthop Trauma. 30. Maheshwari K, Planchard J, You J, et  al. Early sur-
2001;15:81–5. gery confers 1-year mortality benefit in hip-fracture
patients. J Orthop Trauma. 2018;32:105–10.
3  Initial Management of Hip Fractures Prior to Surgical Intervention 41

31. Wood SP, Vrahas M, Wedel SK.  Femur fracture

head fractures associated with hip dislocations. Clin
immobilization with traction splints in multisystem Orthop Relat Res. 2000;377:44–56.
trauma patients. Prehosp Emerg Care. 2003;7:241–3. 40. Slobogean GP, Stockton DJ, Zeng B, Wang D, Ma
32. Hak DJ, Mauffrey C, Hake M, Hammerberg EM, B-T, Pollak AN.  Femoral neck fractures in adults
Stahel PF.  Ipsilateral femoral neck and shaft frac- treated with internal fixation: a prospective mul-
tures: current diagnostic and treatment strategies. ticenter Chinese cohort. J Am Acad Orthop Surg.
Orthopedics. 2015;38:247–51. 2017;25:297–303.
33. Zettas JP, Zettas P.  Ipsilateral fractures of the
41.
Slobogean G, Sprague S, Scott T, Bhandari
femoral neck and shaft. Clin Orthop Relat Res. M.  Complications following young femoral neck
1981;160:63–73. fractures. Injury. 2015;46:484–91.
34. Tornetta P III, Kain MSH, Creevy WR.  Diagnosis 42. Slobogean G, Sprague S, Scott T, Mckee M, Bhandari
of femoral neck fractures in patients with a femoral M. Management of young femoral neck fractures: is
shaft fracture: improvement with a standard protocol. there a consensus? Injury. 2015;46:435–40.
J Bone Joint Surg Am. 2007;89:39–43. 43. Damany D, Parker MJ, Chojnowski A. Complications
35. Matullo KS, Gangavalli A, Nwachuku C.  Review
after intracapsular hip fractures in young adults: a
of lower extremity traction in current orthopaedic meta-analysis of 18 published studies involving 564
trauma. J Am Acad Orthop Surg. 2016;24:600–6. fractures. Injury. 2005;36:131–41.
36. Schlickewei W, Elsässer B, Mullaji A, Kuner E. Hip 44. Chlebeck JD, Birch CE, Blankstein M, Kristiansen
dislocation without fracture: traction or mobilization T, Bartlett CS, Schottel PC. Nonoperative Geriatric
after reduction? Injury. 1993;24:27–31. Hip Fracture Treatment is Associated with Increased
37. Althausen PL, Hak DJ.  Lower extremity traction
Mortality: A Matched Cohort Study. J Orthop Trauma.
pins: indications, technique, and complications. Am J 2019 Feb.
Orthop (Belle Mead NJ). 2002;31:43–7. 45. McElvany M, Benninger B, Smith S, Mirza A,

38. Austin DC, Donegan D, Mehta S. Low complication Marshall L, Friess D. Are distal femoral traction pins
rates associated with the application of lower extremity intra-articular? A cadaveric study. J Orthop Trauma.
traction pins. J Orthop Trauma. 2015;29:E259–E65. 2013;27(11):e250–3.
39.
Stannard JP, Harris HW, Volgas DA, Alonso
JE.  Functional outcome of patients with femoral
 Ilio-Inguinal Approach
4
Lorenz Büchler and Helen Anwander

Abstract Keywords
The ilio-inguinal approach is an anterior approach Acetabulum · Fractures · Ilio-inguinal ·
to the pelvis, introduced by Letournel in 1965. Anterior pelvic approach · Letournel
With its use, the results of surgical treatment of
acetabular fractures with the main dislocation in
the anterior column were greatly improved. The
anatomical dissection leads to a low complication 4.1 Introduction and History
rate and fast recovery of the patient. Three ana-
tomical windows are developed: The first exposes Before the groundbreaking work from Letournel
the anterior sacro-iliac joint and iliac fossa, the and Judet in the early 1960s, fractures of the ace-
second exposes the anterior column, the anterior tabulum were mainly treated conservatively.
wall, and the quadrilateral surface, and the third Results were generally poor due to persisting dis-
exposes the superior pubic ramus. The main location, femoral head necrosis, and early progres-
advantage of the ilio-inguinal approach is that by sion to osteoarthritis. In his thesis under the
using all three windows, an extended direct view supervision of Judet in 1961, Letournel classified
on the entire inner side of the pelvis can be the fractures of 75 cases and suggested surgical
achieved for fracture reduction and plate posi- approaches according to the specific fracture pat-
tioning. Main disadvantages are the lack of direct terns [1, 2]. The postero-lateral approach had been
visualization of the acetabular surface, the the one most frequently used. Two cases (trans-
impaired view on the posterior column, and the verse fracture, anterior column/post-­
need to open the inguinal canal. hemitransverse fracture) were treated with a
modification of the ilio-femoral approach devel-
oped by Smith-Petersen [3, 4]. It was however
mentioned that the approach caused great difficul-
ties, as the large vessels prevented access to the
L. Büchler (*) quadrilateral plate [2]. To improve the access, ana-
Department of Orthopaedic Surgery, Kantonsspital tomical studies were performed for a new anterior
Aarau, Aarau, Switzerland
e-mail: [email protected]
approach where the distal part of the incision was
curved upwards towards the midline and the entire
H. Anwander
Department of Orthopaedic Surgery and
internal iliac fossa as well as the pelvic brim was
Traumatology, Inselspital, Bern University Hospital, exposed. This research culminated in the ilio-
Bern, Switzerland inguinal approach to the pelvis, an anatomical

© Springer Nature Switzerland AG 2019 43

L. Büchler, M. J.B. Keel (eds.), Fractures of the Hip, Fracture Management Joint by Joint,
https://doi.org/10.1007/978-3-030-18838-2_4
44 L. Büchler and H. Anwander

muscle-sparing approach with extended visualiza- mation provided by intraoperative fluoroscopy or

tion of the anterior column, ideally exposing the CT.  Acetabular fractures are mainly addressed
inner aspect of the ilium and pubic bone from the using the second window, with extensions proxi-
sacro-iliac joint to the pubic symphysis [5]. Since mal or distal for plate fixation.
1965, this new approach was frequently and suc- The direct anterior visualization of the sacro-­
cessfully used by Judet and Letournel and has iliac joint and the inner aspect of the ilium
become the gold standard in the treatment of ante- through the first window can be used for reduc-
rior column fractures [5–7]. The surgical exposure tion and internal stabilization of sacro-iliac inju-
allows the development of three working win- ries such as sacro-iliac dislocation in a type C
dows: The first (lateral) window extends between pelvic ring fracture, reposition and internal fixa-
the sacro-iliac joint and the iliopsoas, providing tion of a transiliac fracture (crescent fracture) as
access to the sacro-iliac joint, the internal iliac well as a fracture of the wing of the ilium and
fossa, and the proximal pelvic brim. The second treatments of infections of the sacro-iliac joint or
(middle) window extends between the iliopsoas abscesses and hematomas of the iliopsoas. Over
and the external iliac vessels, providing access to the second window, a fracture of the quadrilateral
the distal pelvic brim, the quadrilateral surface, the surface can be reduced and fixated. This may
acetabular roof, the greater sciatic notch, and the occur in the case of an internal luxation of the hip
anterior acetabular wall. The third (medial) win- or in an intrapelvic protrusion of the acetabular
dow extends between the iliac vessels and the component following total hip prosthesis. Injuries
symphysis, providing access to the space of to the anterior pelvic ring, such as transpubic
Retzius, the pubic symphysis, the superior pubic fractures and disruptions of the symphysis can be
ramus from the pubic tubercle to the pectineus addressed using the third window (Fig. 4.1).
recess and includes the spermatic cord (male) or
round ligament (female) [8]. Limitations are the
limited access to the posterior column and the
inferior quadrilateral surface as well as the lack of
direct visualization of the acetabular surface.

4.2 Indications

The ilio-inguinal approach is the gold standard

for anterior wall and anterior column fractures as
an excellent, direct visualization of the anterior
column can be achieved [9]. The posterior col-
umn and the quadrilateral plate can be visualized
indirectly through the second window; subse-
quently, this approach can also be used for more
complex acetabular fractures with the main dis-
placement in the anterior column, such as two
column fractures, anterior column-posterior
hemitransverse fractures as well as some t-type
Fig. 4.1  Overview of the three windows of the ilio-­inguinal
and transverse fractures. Articular reduction is approach with the relevant anatomical structures. (1)
done indirectly based on the extraarticular anat- Anterior superior iliac spine, (2) Inguinal ligament, (3) N.
omy, as the joint cannot be directly visualized. cutaneus femoris lateralis, (4) Ala ossis ilii, (5) ilio-­sacral
joint, (6) M. iliopsoas, (7) N. femoralis, (8) A. femoralis
Consequently, the quality of the articular reduc- communis, (9) V. femoralis communis, (10) Ductus sper-
tion relies on the quality of cortical osseous maticus/Lig. rotundum. Adopted and reproduced with per-
reductions of the innominate bone and the confir- mission and copyright © of Der Unfallchirurg, Springer [9]
4  Ilio-Inguinal Approach 45

4.3 Technique the ASIS, and then slightly curved medially fol-
lowing the inguinal ligament to the midline 2 cm
4.3.1 Preparation, Patient proximal to the symphysis. After skin incision,
Positioning the subcutaneous fat is dissected (Fig. 4.2).

The patient is put under general anesthesia with

complete muscle relaxation. Due to the often pro- 4.3.3 Exposure of the First Window
longed operation time and wide exposures, tem-
perature regulation is important to prevent a After releasing the external oblique muscle inser-
decrease of core temperature of the patient. tion from the lateral iliac crest, the inner side of
Intraoperative blood salvage with the use of cell the ilium is exposed through subperiosteal eleva-
savers and reinfusion after processing should be tion of the M. iliacus from the internal iliac fossa
considered. A urinary catheter should be inserted to the anterior sacro-iliac joint posteriorly and the
to empty the bladder. The patient is placed in pelvic brim inferiorly. Medial retraction of the M.
supine position with the greater trochanter at the iliopsoas requires placement of retractors on the
rim of a radiolucent table. The leg of the fractured quadrilateral surface and flexion of the hip to
side is draped freely to enable hip flexion during release muscle tension. Bleeding from the nutri-
surgery for relaxation of the iliopsoas and traction ent foramina can be controlled using bone wax
via a subtrochanteric pin for fracture reduction. and temporary packing the iliac fossa. The first
The fluoroscope is tested for unrestricted posi- window provides access to the sacro-iliac joint,
tioning for AP, ala- and obturator images as well the internal iliac fossa, and the proximal pelvic
as 3D reconstructions if available. brim (Fig. 4.3).

4.3.2 Incision 4.3.4 Exposure of the Second

Window
The landmarks are the crista iliaca, the anterior
superior iliac spine (ASIS), and the pubic sym- The aponeurosis of the external oblique is incised
physis. The incision follows the crista iliaca to from the ASIS to the lateral border of the rectus

Fig. 4.2  Skin incision

for the ilio-inguinal
approach (red line). The
incision begins cranially
at the posterior superior
iliac spine (PSIS) and
follows the iliac crest to
the anterior superior iliac
spine (ASIS). The
incision is then slightly
curved medially towards
the midline proximal of
the symphysis. Adopted
and reproduced with
permission and copyright
© of Der Unfallchirurg,
Springer [9]
46 L. Büchler and H. Anwander

Fig. 4.3 Intraoperative
view of the first
ilio-inguinal window
(right hip). (1) M.
iliopsoas, (2) lateral
femoral cutaneous
nerve, (3) Spina iliaca,
(4) Iliac fossa, (5) Pelvic
brim

sheath, passing 1 cm cranial to the inguinal canal, to the sacro-iliac joint is opened. This exposes the
identifying and protecting the lateral femoral iliopectineal eminence, the acetabular roof, and
cutaneous nerve, which usually lies on the lateral the quadrilateral space (Fig. 4.5). To expose the
border of the iliacus muscle and passes 1–2 cm greater sciatic notch and the entire quadrilateral
medial of the ASIS below the inguinal ligament space to the sciatic spine, the pectineus and the
into the compartment of the sartorius muscle. internal obturator muscles are elevated subperi-
The conjoint tendon of the internal oblique and osteally. Anteriorly, the anastomoses between the
the transversus abdominis muscles is incised two obturator vessels and either the inferior epigastric
to three millimeters cranial of the inguinal liga- or external iliac vessels (the corona mortis) have
ment and the ilio-inguinal nerve is identified. It to be ligated. If torn, they can lead to major
emerges from the lateral border of the psoas bleeding.
major muscle, passes across the iliacus muscle,
the anterior part of the iliac crest and the internal
oblique muscle to follow the spermatic cord/ 4.3.5 Exposure of the Third Window
round ligament. Next, the spermatic cord/the
round ligament is identified and mobilized. The plane between the pubic symphysis and the
To develop the second window, the iliopectin- bladder (space of Retzius) is bluntly dissected.
eal arch, a thickened band of fused iliac and psoas The bladder can be identified by palpating the
fascia that separates the inguinal canal, is incised urinary catheter bulb. In acute trauma, wound
(Fig. 4.4). On the lateral side, the lacuna muscu- hematoma frequently dilates this space and is
lorum contains the M. iliopsoas, the femoral easily removed. In revision surgery significant
nerve and the lateral femoral cutaneous nerve. On adhesions have to be expected, which render
the medial side, the lacuna vasorum contains the the dissection more difficult with the risk of
external iliac artery and vein and the surrounding injuries to the bladder or peritoneum.
lymphatics. The M. iliopsoas and the femoral Mobilizing the bladder cranially provides visu-
nerve are mobilized laterally, the external iliac alization of the space between the rectus and
vessels medially. The iliopectineal arch is divided the spermatic cord/round ligament. Infra-
distally and the fascia following the terminal line pectineal dissection carefully proceeds along
4  Ilio-Inguinal Approach 47

Fig. 4.4 Intraoperative
view of the iliopectineal
arch. The lateral femoral
cutaneus nerve is
identified and marked
with a red rubber strap.
(1) M. iliopsoas, (2)
lateral femoral
cutaneous nerve, (3)
iliopectineal arch

a b

Fig. 4.5 (a) Intraoperative view of the second ilio-­ the transparent rubber strap) retracted medially to expose
inguinal window. The M. iliacus and femoral nerve are the quadrilateral plate. (b) close-up view of a dislocated
retracted laterally and the inguinal vessels (marked with fracture of the anterior column

the medial surface of the pubic ramus and pos- expanded to allow direct, intrapelvic access to
teriorly following the pelvic brim. The iliopec- the entire quadrilateral surface and the poste-
tineal fascia has already been released allowing rior column (Fig. 4.6).
elevation of the external iliac vessels. The third If a visualization of the contralateral side of
window provides access to the space of Retzius, the symphysis is required, the ipsilateral rectus
the pubic symphysis, the superior pubic ramus insertion is released or the linea alba between the
and includes the spermatic cord (male) or round two rectus heads is split in the midline similar to
ligament (female). The third window can be the Stoppa approach (fourth window) (Fig. 4.7).
48 L. Büchler and H. Anwander

4.3.6 Fracture Reduction

Simultaneous exposure of all three windows is

not possible. The iliopsoas with the femoral
nerve, the external inguinal vessels with the
surrounding lymphatics and the spermatic
cord/round ligament are mobilized and
retracted alternating. Fractures are reduced
sequentially, usually working from dorsal to
ventral using the appropriate clamps or ball
spike pushers. In medially displaced fractures,
lateral traction of the femur can be applied
with the help of a pin inserted in the proximal
femur or femoral neck. Preshaped plates can be
inserted and fixed from anterior to posterior
with the alternating use of the different win-
dows. Anatomical reduction and correct screw
placement is verified with the fluoroscope
using different image settings.

4.3.7 Wound Closure

Fig. 4.6  Intraoperative view of the third ilio-inguinal Before closure, drains are placed in the space of
window. (1) Inguinal artery (2) Inguinal vein, (3) sper-
matic cord
Retzius and along the quadrilateral surface.

Fig. 4.7  Far medial

dissection of the
ilio-inguinal approach
(fourth window). The
left and right portions of
the M. rectus abdominis
and the spermatic cord
are retracted with
Hohmann-retractors
placed on the superior
pubic ramus. The
bladder is retracted
cranially using a
malleable retractor. In
this case, a laminar
spreader is placed in the
symphysis to facilitate
fracture reduction
4  Ilio-Inguinal Approach 49

Closure of the different wound layers begins path of the primary lymphatic trunk to the lower
with reattachment of the conjoint tendon of the extremity, which passes medial to the vein.
internal oblique and the transversus abdominis Damage to the iliac vessels or corona mortis can
muscles to the inguinal ligament. The roof of the lead to severe bleeding and ischemia of the leg.
inguinal canal is repaired by closure of the apo- Prolonged excessive retraction of the vessels
neurosis of the external oblique muscle and the should be avoided to prevent thrombosis and pul-
rectus sheath, followed by secure reattachment of monary embolism [11].
the abdominal wall origin to the iliac crest. A
hernia-­free repair and avoidance of entrapment of
the spermatic cord and the inguinal nerve should 4.4.3 Spermatic Cord
be achieved. The iliopectineal fascia is not
repaired. Finally, closure of the subcutaneous tis- The spermatic cord contains the vas deferens and
sue and skin is performed. the testicular artery. Damage can cause testicular
ischemia or infertility.

4.4  tructures at Risk

S
and Complications 4.4.4 Heterotopic Ossification

4.4.1 Nerves There is a strong association between the opera-

tive approach and the prevalence and severity of
The overall risk of an intervention-related nerve ectopic bone formation. Letournel noted in a
injury is 2–20% [10–12]. Damage to the lateral study of 195 acetabular fractures treated with the
femoral cutaneous nerve is the most common ilio-inguinal approach that no cases of hetero-
complication of the ilio-inguinal approach. topic ossification occurred [7]. Matta reported a
Transient neuropraxia can result from tension of rate of 2% heterotopic ossifications following an
the nerve with retractors. Due to its anatomical ilio-inguinal approach, versus 20% after an ilio-­
proximity, damage frequently occurs during the femoral and 8% after a Kocher-Langenbeck
incision of the conjoint tendon or during closure approach [12].
of the aponeurosis of the internal oblique muscle
due to its anatomical proximity, leading to vari-
ous degree of dysesthesia or anesthesia in the lat- 4.4.5 Inguinal Hernia
eral thigh. Damage to the femoral or obturator
nerves are rare but can lead to significant impair- Closure of the inguinal canal must be conducted
ment with weakened hip flexion and knee exten- carefully to avoid hernias. 2–3.5% suffer of an
sion or weakened hip adduction and anesthesia of inguinal hernia after the ilio-inguinal approach
the medial thigh, respectively. The inguinal nerve [5, 7]. Current inguinal or femoral hernias or
follows the spermatic cord/round ligament and is previous hernia surgery may complicate the
mainly at risk when closing the inguinal canal. surgical approach, particularly in older individ-
uals. In these cases, it may be prudent to limit
or omit the second window exposure, and
4.4.2 Blood Vessels and Lymphatics expand visualization through the first and third
windows.
Dissection of the perivascular tissue around the
inguinal vessels should be minimized. This limits Case Report (Figs. 4.8, 4.9, 4.10 and 4.11)
the risk of vascular injury and also preserves the
50 L. Büchler and H. Anwander

Fig. 4.8  36 year old

polytraumatized male
patient after a high-­
energy base-jump
accident. The AP-pelvis
X-ray shows a
dislocated anterior
column fracture
extending in the ilium,
an undislocated
hemitransverse fracture,
and a pelvic ring
fracture type B (open
book with rupture of the
symphysis and
transforaminal fracture
of the sacrum left)

a b c

Fig. 4.9  Pre-operative CT scan of the same patient. Axial Open reduction and internal fixation of the fractures was
(a, b) and coronal (c) planes of the fractured acetabulum. performed via the ilio-inguinal approach
4  Ilio-Inguinal Approach 51

Fig. 4.10 Postoperative
AP-pelvis view after
fixation of the anterior
column with a plate,
reduction of the
symphysis with a plate
and fixation of the ala
fracture with two free
3.5 mm cortical screws

a b c

Fig. 4.11  The postoperative CT scan shows anatomical reduction of the fractures in the axial (a), coronal (b), and
sagittal (c) planes. Compared to Fig. 4.9, the fracture lines are anatomically reduced

3. Smith-Petersen MN. A new supra-articular subperios-

References teal approach to the hip joint. JBJS. 1917;s2–15:592–5.
4. Smith-Petersen MN.  Treatment of malum coxae
1. Judet R, Judet J, Letournel E. Fractures of the acetabu- senilis, old slipped upper femoral epiphysis,
lum: classification and surgical approaches for open intrapelvic protrusion of the acetabulum, and
reduction. Preliminary report. J Bone Joint Surg Am. coxa plana by means of acetabuloplasty. JBJS.
1964;46:1615–46. 1936;18:869–80.
2. Letournel E. Fractures of the cotyloid cavity, study of 5. Letournel E, Judet R.  Fractures of the acetabulum.
a series of 75 cases. J Chir (Paris). 1961;82:47–87. Berlin: Springer; 1993.
52 L. Büchler and H. Anwander

6. Letournel E.  Acetabulum fractures: classifica- 10. Lehmann W, Hoffmann M, Fensky F, et al. What is the
tion and management. Clin Orthop Relat Res. frequency of nerve injuries associated with acetabular
1980;151:81–106. fractures? Clin Orthop Relat Res. 2014;472:3395–403.
7. Letournel E.  The treatment of acetabular fractures 11. Mardian S, Schaser KD, Hinz P, et  al. Fixation

through the ilioinguinal approach. Clin Orthop Relat of acetabular fractures via the ilioinguinal versus
Res. 1993;292:62–76. ­pararectus approach: a direct comparison. Bone Joint
8. Tosounidis TH, Giannoudis VP, Kanakaris NK, et al. J. 2015;97-B:1271–8.
The Ilioinguinal approach: state of the art. JBJS 12. Matta JM.  Fractures of the acetabulum: accuracy of
Essent Surg Tech. 2018;8:e19. reduction and clinical results in patients managed
9. Keel MJ, Bastian JD, Buchler L, et  al. Anterior operatively within three weeks after the injury. J Bone
approaches to the acetabulum. Unfallchirurg. Joint Surg Am. 1996;78:1632–45.
2013;116:213–20.
 Anterior Approaches
to the Acetabulum 5
Claude H. Sagi

Abstract tion of surgical techniques that continue to

A number of surgical approaches exist to drive the progress and improve the outcomes
allow surgeons the ability to access, reduce, of fracture surgery and the art of medicine.
and stabilize acetabular fractures from both This chapter will focus on the historical and
the anterior and posterior aspects of the pelvis technical aspects of the “modern” and com-
innominate bone. The anterior approaches in monly used anterior surgical exposures for
particular have evolved substantially since acetabular fracture surgery.
their inception to the extent that modern ace-
tabular fracture surgery will frequently employ Keywords
one or more approaches in isolation or in com- Anterior · Surgical exposure · Acetabulum ·
bination. Importantly, while separate camps Ilioinguinal · Iliofemoral · Stoppa · Anterior
may exist that favor one “philosophy” or intrapelvic
“style,” surgeons should recognize the impor-
tance and value of each approach such that
maximal access can be obtained to optimally
expose reduce and stabilize the acetabulum. 5.1 Iliofemoral Approach
For example, many surgeons that would con- to the Acetabulum
sider themselves “purists” in their use of the
ilioinguinal approach have come to utilize 5.1.1 Introduction and Historical
some form of the “Modified Stoppa” or Perspective
Anterior Intrapelvic Approach as a more func-
tional medial window for access to the quadri- As time passes, colloquial usage of various terms
lateral surface and posterior column. This tends to overcome the recollection of historical
does not represent any form of heresy or devi- facts; the Iliofemoral and Smith-Petersen
ation; rather, the normal and necessary evolu- approaches are no exception. The anterior
approach to the hip joint as originally described
by Marius Nygard Smith-Petersen [1] was an
inter-nervous surgical exposure for “mold arthro-
C. H. Sagi (*) plasty of the hip,” not an approach for reduction
Division of Trauma, Department of Orthopaedics and fixation of acetabular fractures. While the
and Sports Medicine, University of Cincinnati
College of Medicine, Cincinnati, OH, USA distal extent of this approach (between the
e-mail: [email protected] Sartorius and tensor fascia) is similar to other

© Springer Nature Switzerland AG 2019 53

L. Büchler, M. J.B. Keel (eds.), Fractures of the Hip, Fracture Management Joint by Joint,
https://doi.org/10.1007/978-3-030-18838-2_5
54 C. H. Sagi

“versions” of the iliofemoral approach, the proxi- padded triangle or stack of towels under the knee.
mal portion of the exposure involved elevation of Ensure that access to the greater trochanter is
the tensor fascia lata (TFL) and gluteal mass possible following draping to allow for lateral
from the outer table of the ilium. The iliofemoral traction during the course of reduction should it
approach for the surgical treatment of acetabular be required. The skin incision is placed along the
fractures, however, elevates the iliacus muscle iliac crest curving distally at the ASIS to proceed
(instead of the gluteals and TFL from the outer longitudinally to the lateral aspect of the patella
table) to expose the inner table of the ilium, thus along the interval between Tensor Fascia Lata
being ideally suited for treatment of fractures (TFL) and Sartorius for a distance of approxi-
involving the anterior column. mately 10  cm. Should proximal extension be
The following chapter describes the surgical required, the incision is turned longitudinally at
techniques used to optimize visualization and approximately the mid-axillary line to accommo-
access using the Iliofemoral approach for reduc- date the iliac crest which starts to turn back
tion and fixation acetabular fractures requiring an towards the midline posteriorly (Fig. 5.1).
anterior surgical approach. Proximally, the internervous interval between
the external oblique (segmental intercostal
nerves) and the TFL/Gluteal mass (superficial
5.1.2 Indications gluteal nerve) is identified. Recall that from the
iliac tubercle posteriorly, the external oblique
The iliofemoral approach is useful for accessing usually drapes over the crest to varying degrees.
the ilium form the iliac crest to the pelvic brim. The external oblique should be pulled proximally
When combined with either an osteotomy of the to reveal the interval so that the dissection pro-
anterior superior iliac spine (ASIS) or soft-tissue ceeds straight to bone and does not cut through
“sleeve” release of the external oblique, sartorius any muscle fibers of the TFL or external oblique.
and inguinal ligament, the anterior column, ante- Adhering to this principle minimizes post-­
rior wall and lateral half of the superior pubic operative pain and facilitates a more reliable fas-
ramus can be visualized. In isolation, the iliofem- cial closure at the conclusion of the case
oral approach can be used to treat high anterior (Fig. 5.2). The external oblique is then released
column fractures with or without an associated from its insertion on the iliac crest to expose the
anterior wall component. In combination with the fibers of the iliacus muscle on the inner table of
Anterior Intra-Pelvic approach (see Sect. 5.2) it the ilium, which is then elevated with a Cobb or
can be used to successfully treat the Associated other periosteal elevator down to the SI joint pos-
Both Column or Anterior plus Posterior
Hemitransverse fractures where the cranial extent
of the anterior column fracture exits the iliac
crest or near the ASIS. This surgical exposure is
also very helpful in combined injuries of the ace-
tabulum and pelvic ring when open reduction of
the sacro-iliac (SI) joint is required with the
patient in the supine position.

5.1.3 Surgical Technique

The patient is positioned flat in the supine posi-

tion with the lower extremity ipsilateral to the Fig. 5.1  Intraoperative positioning and incision used for
fractured acetabulum draped free. The hip is iliofemoral approach. Circle delineates the anterior supe-
flexed to approximately 30–45° with a sterile rior iliac spine (ASIS)
5  Anterior Approaches to the Acetabulum 55

Fig. 5.2 Intraoperative demonstration of the interval

between external oblique and tensor fascia (TFL). The Fig. 5.3  Demonstration of the lateral femoral cutaneous
forceps are pointing to the ASIS.  Note the overhanging nerve at the level of the ASIS. An incision has been made
nature of the external oblique more posteriorly with the in the fascia over the lateral border of the sartorius so that
arrows pointing to the inferior margin the interval between it and the tensor fascia can be devel-
oped allowing the nerve to move medially with the sarto-
rius without tension. Sartorius and External Oblique are
attached to the ASIS as a digastric ostetomy
teriorly, and to the pelvic brim anteriorly. A small
portion (2  cm) of the external oblique insertion
just proximal to the ASIS is left attached to the
iliac crest so that a “digastric” osteotomy can be
performed with the opposing Sartorius if needed
(see later).
From the ASIS, an incision is made in the
Fascia Lata overlying the TFL and Sartorius mus-
cles taking care to avoid injury to the Lateral
Femoral Cutaneous Nerve (LFCN), which has
variable anatomic relations to the ASIS and inser-
tion of the Inguinal Ligament. The LFCN should
be dissected distally allowing it to be mobilized
from the TFL as the Sartorius is retracted medi-
ally (Fig. 5.3).
The TFL is then elevated from the external
surface of the ilium just enough that the inter-­
spinous notch between the ASIS and Anterior Fig. 5.4  Sawbones model demonstrating a retractor in
the interspinous notch serving as a target for the osteot-
Inferior Iliac Spine (AIIS) can be palpated and omy which begins on the crest approximately two centi-
localized. A small clamp is placed in the inter-­ meters posterior to the ASIS
spinous notch to serve as a “target” for the oste-
otomy, and a curved osteotome is used to
osteotomize the ASIS taking care to avoid propa- curvilinear path. Alternatively, the external
gating a crack or fracture line down toward the oblique and sartorius can be mobilized as a single
acetabulum (Fig.  5.4). When the osteotomy is sleeve of tissue without an osteotomy if the ingui-
completed both the External Oblique and nal ligament is released from its insertion on the
Sartorius muscles should still be attached to the ASIS and the LFCN is dissected as described
ASIS to provide opposing muscle tension in above [2].
digastric fashion after the repair (Fig.  5.5). The With the osteotomy complete, the abdominal
osteotomy may take the form of a 90° “step” or wall and iliacus can be retracted medially to a
56 C. H. Sagi

Fig. 5.5  Osteotomy has been performed with sartorius

and external oblique remaining attached to the ASIS. The
LFCN can be seen moving medially with sartorius and the
ASIS, thus protecting it
Fig. 5.6  Retractors are positioned over the pelvic brim
greater extent, giving improved visualization and (A), into the sacral ala lateral to the SI joint (B), and over
the iliac crest under the ilio-lumbar ligament (C)
access to the inner table of the ilium. The LFCN
moves with the ASIS and abdominal wall medi-
ally and injury is prevented by releasing the fas- the purpose for reducing the SI joint from an
cia over the TFL distally so that the nerve is not anterior approach. A 3.5 mm screw is placed into
tethered and can move freely. the ilium just lateral to the SI joint, directed from
Within the pelvis, the iliacus and iliopsoas the brim posteriorly into the posterior inferior
tendon are elevated from the psoas gutter/pubic iliac spine (PIIS). A second screw is placed into
root and retracted medially to expose the lower the sacral ala just medial to the SI joint and
aspect of the anterior column and pelvic brim directed distally along the length of the sacrum
down to the lateral aspect of the superior pubic paralleling the SI joint lateral to the sacral foram-
ramus and the base of the anterior wall. If desired, ina (Fig. 5.7).
the origin of the direct head of the Rectus Femoris
can be detached from the AIIS (leaving a stump 5.1.4.2 Anterior Column (Cranial Extent
of rectus tendon attached to the AIIS for later to Iliac Crest)
repair) to provide complete exposure of the ante- A small window is created by detaching a small
rior wall of the acetabulum. Key retractors and portion of the TFL from the iliac crest and a
their respective positions are as follows: a sharp Farabeuf clamp is placed around the iliac crest to
Hohmann underneath the iliolumbar ligament at manipulate the ilium (Fig. 5.8).
the posterior iliac crest, a sharp Hohmann into
the sacral ala just medial to the SI joint, a narrow 5.1.4.3 Anterior Column (Distal Extent
malleable over the pelvic brim, or a sharp to Pelvic Brim)
Hohmann at the base of the anterior wall or Blunt dissection over the brim, down the quadri-
medial to the pubic root (Fig. 5.6). lateral surface to the lesser sciatic notch lateral to
the obturator nerve is undertaken with a perios-
teal elevator. The distal tine of an angled jaw
5.1.4 Reduction Clamp clamp (quad clamp) is then guided down the
Opportunities Through quadrilateral surface into the lesser sciatic notch
the Iliofemoral Approach while the proximal tine of the clamp is placed
onto the pelvic brim lateral to the anterior column
5.1.4.1 Sacroiliac Joint fracture line or onto the outer table of the ilium
A two-screw technique utilizing a Jungbluth or under the abductors and TFL depending on the
Farabeuf reduction clamp generally best serves vector required (Fig.  5.9). Similarly, the angled
5  Anterior Approaches to the Acetabulum 57

a b

Fig. 5.7 (a) Jungbluth retractor reducing the SI joint with reduction of the SI joint from anterior through the ilio-
screw fixation into the sacral ala and iliac wing. (b) Intra-­ femoral approach
operative fluoroscopic image demonstrating Jungbluth

repaired with a single 3.5 mm lag screw directed

from the tip of the ASIS posteriorly into the iliac
tubercle after reduction and compression with
pointed reduction forceps keeping the opposing
external oblique and Sartorius muscles attached
(Fig. 5.10). A single drain is placed into the inter-
nal iliac fossa. The External Oblique muscle is
reattached to the crest by suturing it to the fascial
attachment of the TFL/Gluteal mass onto the iliac
crest. The superficial and deep fascial layers of
Fig. 5.8  Farabeuf clamp placed through a small window the thigh can be closed in a single layer with
in the tensor fascia to manipulate and facilitate reduction absorbable suture then subcutaneous tissue and
of the iliac wing and cranial portion of the anterior skin in layers. Hip precautions are not necessary
column
for the ASIS osteotomy.

jaw clamp can be placed under the abductors

onto a posterior and superior wall fragment that 5.2 Anterior Intra-Pelvic
is frequently encountered with an associated both Approach to the Acetabulum
column type fracture pattern (Fig. 5.9).
5.2.1 Introduction and Historical
Perspective
5.1.5 Closure
The Anterior Intra-Pelvic (AIP) surgical
The direct head of the Rectus femoris is repaired approach for reduction and fixation of acetabular
back to the AIIS using a heavy braided non-­ fractures as we know it today evolved from a
absorbable suture to re-attach the tendon back to technique described by Rives and Stoppa for
the residual stump of its insertion left behind at applying Dacron mesh in the repair of inguinal
the time of tenotomy. The ASIS osteotomy is herniae [3]. The approach utilized a midline ver-
58 C. H. Sagi

a b

Fig. 5.9 (a) Reduction clamp placed around interspinous posterior wall fragment with an associated both column
notch onto the outer table of the ilium to reduce the ante- fracture. (b) Intra-operative fluoroscopic image demon-
rior column, or similarly placed to reduce a high superior strating clamp reduction described in (a)

buttress and infra-pectineal plating, respectively.

While some attention was paid to the more distal
aspects of the quadrilateral surface and posterior
column, the initial descriptions of this technique
did not focus on manipulation and instrumenta-
tion of these areas as such.
Over the last two decades there have been a
number of refinements to the surgical technique
which have led to improved visualization and
access for the placement of reduction clamps and
Fig. 5.10  Repair of the ASIS osteotomy with clamp fixation [6]. Recent publications reporting results
reduction and single lag screw placement into the iliac and complications of acetabular fracture reduc-
tubercle. A 2 mm Kirschner wire is placed to help stabi-
tion using the AIP approach are similar to those
lize the fragment while clamping and compressing
reported using the more traditional ilio-inguinal
approach, with 70–80% anatomic reductions and
tical split in the rectus abdominis followed by complication rates between 8% and 13% [7–9].
dissection along the superior pubic ramus and The potential benefits of the AIP approach are:
anterior ­pelvic brim to expose the inner surface
of the anterior abdominal wall. Separate reports 1. Improved access to comminuted fractures of
by Hirvensalo [4] and Cole/Bolhofner [5], in the quadrilateral surface.
1993 and 1994 respectively, reported on the 2. Improved access to the posterior column from
results of acetabular reduction and fixation uti- the sciatic notch to the ischial spine.
lizing an extension of the surgical dissection 3. Avoiding dissection of the inguinal canal,

described by Rives and Stoppa to include expo- femoral nerve, and external iliac vessels.
sure along the entire course of the pelvic brim 4. Avoiding dissection through scarred tissue

posteriorly to the sacro-iliac joint. These early and mesh from previous herniorraphy.
descriptions of the “Modified Stoppa” described
access to the lower portion of the anterior col- The following chapter describes the surgical
umn and pelvic brim from the symphysis to the techniques used to optimize visualization and
SI joint. This allowed for reduction and stabili- access using the AIP approach for reduction and
zation of the caudal portion of the anterior col- fixation of acetabular fractures requiring an ante-
umn as well as the quadrilateral surface with rior surgical approach.
5  Anterior Approaches to the Acetabulum 59

5.2.2 Indications

The AIP surgical approach can be used for ace-

tabular fractures that require (either in isolation
or in combination with other staged approaches)
anterior exposure and access to the pelvis and
acetabulum. This would include the following
fracture patterns: anterior column, anterior col-
umn/anterior wall, anterior plus poster hemi-­
transverse, associated both column, T-shaped
fractures (staged and combined with posterior
approach), transtectal transverse +/− posterior Fig. 5.11  Supine positioning of the patient with ipsilat-
wall (staged and combined with posterior eral leg draped free and hip flexed to ~40°
approach), and acetabular fractures associated
with symphyseal and/or sacro-iliac joint disrup-
tion. Finally, geriatric acetabular fractures or making the dissection more difficult and placing
insufficiency fractures associated with osteope- the neurovascular structures at greater risk.
nia/osteoporosis where quadrilateral surface Depending on various patient factors such as
comminution and dome impaction are present are previous incisional scars, exploratory laparotomy
well suited to this surgical approach for reduction or the presence of herniae, the skin incision can
and fixation. be either midline vertical or horizontal in the
style of a Pfannenstiel incision. The anterior rec-
tus fascia is exposed to visualize the midline
5.2.3 Surgical Technique linea alba and decussation of the recuts fascial
fibers, but care is taken to avoid excessive under-
The patient is positioned supine on the operative mining of the subcutaneous fatty layer and exces-
table. A urinary catheter is placed to deflate the sive lateral dissection which can place the
bladder helping to avoid injury, improve visual- spermatic cord and round ligament at risk.
ization, and monitor urine output/fluid balance Optimal exposure is NOT contingent upon a wide
during the course of the procedure. The leg ipsi- lateral dissection in the superficial layers, it is
lateral to the fractured acetabulum is placed over dependent upon mobilization of the rectus
a padded triangle to flex the hip approximately abdominis muscle which requires a high proxi-
35–45°, relaxing the iliacus/psoas muscles, the mal split along the linea alba and a low distal
femoral vein, and the external iliac vessels release of the rectus insertion off of the anterior
(Fig. 5.11). The surgeon is positioned on the side aspect of the pubic body. Reluctance to adhere to
of the patient contralateral to the injury. Contrary this principle will significantly diminish the oper-
to popular belief, the patient should NOT be ating surgeon’s field of view and access for
tilted on to the affected side to improve visualiza- reduction clamps/maneuvers. If the midline split
tion through the AIP window as this places pres- of the linea alba proceeds too proximal and the
sure on the greater trochanter, which pushes the peritoneal cavity is entered, simply take 3-0 chro-
femoral head medially into the pelvis and dis- mic suture to repair the peritoneum and place a
places the fracture. Lateral traction via the greater single figure eight suture in the anterior rectus
trochanter is applied to extract the femoral head fascia to prevent further proximal splitting. The
from the pelvis and provide some provisional rectus abdominis has a broad insertion along the
reduction of the anterior and posterior columns entire superior and anterior aspect of the ipsilat-
(Fig. 5.12). Longitudinal traction is NOT recom- eral pubic body and should be released (but not
mended because this tensions the iliacus and completely detached) anteriorly and lateral to the
femoral/external iliac neurovascular structures pubic tubercle (Fig. 5.13).
60 C. H. Sagi

a b

Fig. 5.12 (a) Lateral traction applied with Schanz pin operative fluoroscopic view of the acetabulum following
through the greater trochanter. (b) Intra-operative fluoro- lateral traction showing lateralization of the femoral head
scopic view of the acetabulum prior to lateral traction and improved positioning of the anterior and posterior
showing intra-pelvic position of the femoral head and dis- columns via capsulotaxis
placement of the anterior and posterior columns. (c) Intra-­

a b

Fig. 5.13 (a) Intra-operative clinical photograph show- the rectus abdominis down the anterior aspect of the
ing proximal release of the rectus abdominis. (b) Intra-­ pubic body from the pubic tubercle (A) to the lower
operative clinical photograph showing distal release of symphysis (B)
5  Anterior Approaches to the Acetabulum 61

Apart from a single thin layer of transversalis Further dissection along the superior ramus and
fascia, there is no posterior rectus fascia below pelvic brim lateral to the iliopectineal fascia requires
the umbilicus and arcuate line. The simplest way releasing the fascia of the iliacus muscle from the
to enter the true pelvis and stay out of the perito- pelvic brim so that a retractor can be placed under
neal cavity is to make a small incision in the the iliacus. The external iliac vein and artery are
transversalis fascia just behind the pubic sym- located on the medial edge of the iliacus muscle. In
physis to enter the potential space of Retzius. order to prevent injury to the external iliac vein, it
With blunt dissection, sweep the index finger should be retracted ­superiorly and laterally along
between the bladder and posterior surface of the with the rectus and iliacus muscles to expose the
pubic body, then distal to proximal between the internal iliac fossa. In order to accomplish this
superior/anterior surface of the bladder and under safely, the surgeon must address two issues:
surface of the rectus to break down any adhe- Firstly, the surgeon needs to determine if there is
sions. This is important because as the exposure a distal branching of the internal iliac vessels. The
is developed, the rectus will be turned and AIP approach takes place essentially within the
retracted toward the ipsilateral injured side. The axilla created by the branching of the internal and
pelvic contents and bladder need to be retracted external iliac vessels from the common iliac.
away from the injured side to allow visualization Occasionally, the internal iliac has a very distal
of the quadrilateral surface and posterior column, branching with an “axilla” at the level of the pelvic
if the adhesions to the undersurface of the rectus brim. When this situation occurs, it limits the poste-
are not cleared then the pelvic viscera will be rior and distal exposures along the brim and quadri-
pulled into the visual field, hampering the expo- lateral surface respectively, necessitating an alternate
sure and access to the acetabulum. If during the exposure such as the ilioinguinal (Fig. 5.14).
course of exposure or reduction/fixation the sur-
geon finds that the bladder is injured, a simple
repair with absorbable suture is undertaken. If,
however, an injury to the base of the bladder in
the region of the trigone, urinary sphincter or ure-
thra is identified then urological consultation is
recommended.
A narrow Deaver retractor is placed under the
rectus to retract it laterally and a sharp Hohmann
retractor is placed lateral to the pubic tubercle
anterior to the superior pubic ramus while a lap
sponge is placed into the space of Retzius with a
malleable retractor to protect the bladder. Care
should be taken to avoid excessive downward
pressure on the malleable as it can cause damage
to the bladder neck and urethra. Similar to the ilio-
inguinal approach, the ilio-pectineal fascia needs
to be released from the superior pubic ramus to
allow communication between the true and false
pelvis. With the AIP approach this communication
is simply developed in the reverse direction: from
the true pelvis into the false pelvis. After the ilio-
pectineal fascia is released the underlying muscle
fibers of the pectineus muscle come into view and
Fig. 5.14  Intraoperative photograph of a low-branching
these can be elevated from the superior ramus with iliac system occurring sitally along the brim (with permis-
a Cobb or other periosteal elevator. sion Marcus Sciadini, MD)
62 C. H. Sagi

Fig. 5.16  Intra-operative photograph showing retractor

Fig. 5.15  Intra-operative clinical photograph showing
placed anterior to SI joint on the pelvic brim (A), under-
the anastomotic vessels, noting the improved access to
neath the iliacus muscle to expose the internal iliac fossa
these vessels with this approach
and protect the external iliac vessels (B) and into the psoas
gutter (C) to give a surgeon’s view of the pelvic brim from
symphysis to SI joint and lower third of internal iliac fossa
Secondly, the surgeon needs to determine if an
anastomosis between the external iliac and obtu-
rator vessels (the so-called corona mortise) exists. iliopsoas tendon fibers away from the pubic root
Exposure of the internal iliac fossa by elevation and into the psoas gutter. A second sharp
of the external iliac vessels along with the iliacus Hohmann retractor is then placed into the psoas
muscle will not be possible if the external iliac gutter lateral to the pubic root to retract the ilio-
vessels are tethered to the obturator vessels since psoas tendon, thus completing the more cranial
retraction and elevation will tear the anastomotic portion of the AIP exposure which allows visual-
or obturator vessels. If these vessels are identified ization of the entire lower half of the internal iliac
during the course of the dissection, they must be fossa back to the SI joint and lower aspect of the
ligated prior to proceeding farther posteriorly anterior column from anterior inferior iliac spine
along the brim and underneath the iliacus distally (Fig. 5.16).
(Fig. 5.15). The lower portion of the AIP approach
With the anastomotic vessels ligated, the involves exposure of the quadrilateral surface and
external iliac vessels can be retracted farther lat- medial surface of the posterior column. At this
erally to expose the underlying iliacus muscle point, the next order of business is to identify,
and fascia. A malleable retractor is then gently mobilize, and protect the obturator nerve, which
pushed along the pelvic brim back to the lateral can be found in the fatty tissue immediately
aspect of the SI joint to retract the pelvic viscera below the pelvic brim along the upper portion of
away from the acetabulum. While gently retract- the quadrilateral surface laying on the origin of
ing the external iliac vein way from the medial the obturator internus muscle fascia. Acetabular
edge of the iliacus muscle and pelvic brim, the fractures that require anterior approaches often
fascia along the brim is incised from just lateral have central dislocation of the femoral head with
to the SI joint forward to the pubic root to allow intra-pelvic intrusion of the quadrilateral surface
elevation of the iliacus muscle away from the and posterior column, which places the obturator
internal iliac fossa. Once this plane is developed, neurovascular bundle under tension. The surgeon
a malleable or other flat retractor is placed under- will frequently find that unless the femoral head
neath the iliacus to protect the external iliac ves- has been retracted laterally, it can be difficult to
sels for the duration of the case. isolate and safely mobilize the obturator nerve,
With the iliacus being retracted laterally, sharp making another good case for lateral femoral
dissection is required to continue to release the traction at the beginning of the case. The nerve is
5  Anterior Approaches to the Acetabulum 63

traced from the obturator foramen posteriorly to Releasing the obturator membrane and mobiliz-
its exit from the lumbosacral plexus so that it can ing the obturator nerve from its tunnel also
be manipulated easily and the surgeon can work exposes and excellent location for reduction
both medial and lateral to the nerve as needed clamp placement (see below).
without tension and iatrogenic neuropraxia An important point should be made about the
(Fig.  5.17). Carefully release the upper lateral obturator artery and vein at this stage. These ves-
portion of the obturator membrane to un-tether sels are located immediately inferior to the nerve
and further mobilize the obturator nerve. that they accompany and are often traumatically
disrupted with fracture patterns that are addressed
via an anterior approach. If, however, they are
not, they should be isolated and ligated to avoid
injury and bleeding during difficult reduction
maneuvers involving the quadrilateral surface
and distal posterior column. Unlike the obturator
nerve, the vessels send many branches into the
floor of the pelvis and cannot be mobilized and
manipulated as easily as the nerve.
Once the nerve has been mobilized and pro-
tected, exposure of the quadrilateral surface and
medial aspect of the posterior column is accom-
plished by elevating the obturator internus mus-
cle from the brim distally to the ischial spine and
posteriorly to the greater sciatic foramen
(Fig.  5.18). Recall that the hip is flexed during
Fig. 5.17  Intra-operative clinical photograph showing
anterior exposures, so the sciatic nerve is under
mobilization of the obturator nerve so that the surgeon can
work both medial and lateral to the nerve. In this photo- some tension. Careless plunging into the greater
graph the malleable (A) is in the greater sciatic foramen sciatic foramen can injure the sciatic nerve in
resting on the posterior medial aspect of the posterior col- addition to the superior gluteal neurovascular
umn, medial to the obturator nerve to expose the quadri-
bundle. A malleable retractor can be placed
lateral surface without any tension on the nerve. Retractors
(B) and (C) are under the iliacus and in the psoas gutter, medial to the obturator nerve but lateral to the
respectively obturator internus muscle to safely expose the

a b

Fig. 5.18 (a) Intra-operative clinical photograph show- with no tension on the obturator nerve. (b) Schematic
ing retraction of the obturator internus muscle medial demonstrating the visible and accessible territory follow-
exposing the quadrilateral surface and posterior column, ing complete AIP exposure
64 C. H. Sagi

entire quadrilateral surface and posterior column

form the brim and sciatic notch down to the ischial
spine. To keep the pelvic viscera retracted to the
contralateral pelvis, retractors can be placed gen-
tly into the greater or lesser sciatic foramina.
Should exposure of the upper portion of the
anterior column be required to address the full
extent of the fracture, a separate lateral surgical
window (Ilio-inguinal window #1, or ilio-­
femoral) along the iliac crest will need to be uti-
lized as discussed above in Sect. 5.1.

5.2.4 Reduction Clamp

Opportunities Through
the AIP
Fig. 5.19 Intra-operative fluoroscopic image demon-
5.2.4.1 Anterior Column strating clamp placement for reduction of the lower more
Reduction of the anterior column generally pro- caudal portion of an anterior column fracture through the
ceeds from cranial to caudal and from posterior to AIP window
anterior. If the cranial extent exits the iliac crest or
in the region of the interspinous notch, then a sepa-
rate lateral will be required (see Sect. 5.1).
Reduction of the posterior (brim portion) and cau-
dal/anterior (ramus or pubic root) aspects of the
anterior column can be accomplished through the
AIP window with various pointed reduction for-
ceps (such as a Weber clamp) or an angled-jaw
clamp as follows: For the posterior aspect of the
anterior column reduction along the brim, one tine
of the reduction clamp can be placed over the brim
posteriorly into the internal iliac fossa while the
other tine can be placed into a drill hole in the
quadrilateral surface or the posterior column. For
reduction of the caudal or anterior aspect of the
anterior column fracture that frequently exits in
the region of the pubic root or lateral ramus, one
Fig. 5.20 Intra-operative fluoroscopic image demon-
tine can be placed into the psoas gutter while the strating clamp placement for reduction of a high anterior
other tine is placed into the obturator foramen just column fracture (A) requiring use of lateral window for
lateral to the obturator nerve, taking care to visual- cranial portion of the fracture and “queen tong” place-
ize the nerve the entire time. Release of the obtura- ment, and reduction of the lower more caudal portion of
the anterior column with a pointed reduction clamp
tor membrane as mentioned above is helpful in through the AIP window (B)
mobilizing the nerve to allow clamp placement in
this fashion (Figs. 5.19 and 5.20).
characteristics of the fracture pattern [10]. If the
5.2.4.2 Posterior Column fracture into the posterior column is high (above
Reduction maneuvers and clamp placement for or into the greater sciatic notch), then the pur-
the posterior column will depend upon various chase into the posterior column can be the greater
5  Anterior Approaches to the Acetabulum 65

a b

Fig. 5.21 (a) Model demonstrating clamp placement for greater notch. (b) Intra-operative fluoroscopic image dem-
reduction of a high posterior column fracture with the onstrating clamp placement for reduction of a high poste-
clamp tine in the greater sciatic notch. (A) Tyne into the rior column fracture with lower tine in greater sciatic notch

a b

Fig. 5.22 (a) Model demonstrating clamp placement for eral surface. (b) Intra-operative fluoroscopic image dem-
reduction of an intermediate posterior column fracture onstrating clamp placement for reduction of an
with the lower clamp tine on the quadrilateral surface. intermediate posterior column fracture with lower clamp
Tine (A) over brim, and tine (B) in drill hole in quadrilat- tine on the quadrilateral surface

notch itself (Fig. 5.21). If the fracture line exits linear reduction clamp through the lateral win-
the ­posterior column between the sciatic notch dow) will need to be placed into the lesser sciatic
and the ischial spine (intermediate), then a drill foramen with the other tine on the brim of the
hole in the posterior column or quadrilateral sur- pelvis (Fig. 5.23). Finally, fractures of the poste-
face can be used as a point of purchase for the rior column can have a more atypical orientation
clamp’s tine with the other tine up over the brim running along the length of the column. In this
in the internal iliac fossa (Fig. 5.22). For fractures scenario, a clamp can be placed perpendicular to
that exit low in the posterior column around the this fracture line with one tine in the obturator
level of the ischial spine, reduction clamps (such foramen and the other tine in the greater sciatic
as an angled jaw clamp through the AIP or col- foramen (Fig. 5.24).
66 C. H. Sagi

Fig. 5.23 (a) Model

a b
demonstrating clamp
placement for reduction
of a low posterior
column fracture with the
collinear reduction
clamp in the lesser
sciatic notch (applied
through lateral window).
(b) Intra-operative
fluoroscopic image
demonstrating clamp
placement for reduction
of a low posterior
column fracture with
collinear reduction
clamp in the lesser
sciatic notch

a b

Fig. 5.24 (a) Model demonstrating clamp placement for demonstrating clamp placement for reduction of a vertical
reduction of a vertical oblique posterior column fracture oblique posterior column fracture with clamp tines in the
with the clamp tines in the obturator foramen and greater obturator foramen and greater sciatic foramen
sciatic foramen. (b) Intra-operative fluoroscopic image

5.2.5 Closure References

A single drain is placed into the retropubic 1. Smith-Petersen MN. Approach to and exposure of the
space anterior to the bladder. Either a running hip joint for mold arthroplasty. J Bone Joint Surg Am.
1949;31A(1):40–6.
or interrupted #1 suture is used to re-approxi-
2. Sagi HC, Bolhofner B.  Osteotomy of the anterior
mate the anterior rectus fascia. Closure of the superior iliac spine as an adjunct to improve access
single layer of transversalis fascia posterior to and visualization through the lateral window. J Orthop
the rectus is not necessary. Subcutaneous tis- Trauma. 2015;29(8):e266–9.
3. Stoppa RE, Rives JL, Warlaumont CR, Palot JP,
sues are closed to assure no dead space remains
Verhaeghe PJ, Delattre JF. The use of Dacron in the
where a hematoma or seroma may form repair of hernias of the groin. Surg Clin North Am.
post-operatively. 1984;64(2):269–85.
5  Anterior Approaches to the Acetabulum 67

4. Hirvensalo E, Lindahl J, Böstman O. A new approach 8. Elmadağ M, Güzel Y, Acar MA, Uzer G, Arazi
to the internal fixation of unstable pelvic fractures. M.  The Stoppa approach versus the ilioinguinal
Clin Orthop Relat Res. 1993;297:28–32. approach for anterior acetabular fractures: a case
5. Cole JD, Bolhofner BR.  Acetabular fracture fixa- control study assessing blood loss complications
tion via a modified Stoppa limited intrapelvic and function outcomes. Orthop Traumatol Surg Res.
approach. Description of operative technique and 2014;100(6):675–80.
preliminary treatment results. Clin Orthop Relat Res. 9. Ma K, Luan F, Wang X, Ao Y, Liang Y, Fang Y,
1994;305:112–23. Tu C, Yang T, Min J.  Randomized, controlled
6. Sagi HC, Afsari A, Dziadosz D.  The anterior intra-­ trial of the modified Stoppa versus the ilioingui-
pelvic (modified stoppa) approach for acetabular frac- nal approach for acetabular fractures. Orthopedics.
ture fixation. J Orthop Trauma. 2010;24(5):263–70. 2013;36(10):e1307–15.
7. Shazar N, Eshed I, Ackshota N, Hershkovich O, 10. Kistler BJ, Sagi HC. Reduction of the posterior col-
Khazanov A, Herman A.  Comparison of acetabular umn in displaced acetabulum fractures through the
fracture reduction quality by the ilioinguinal or the anterior intrapelvic approach. J Orthop Trauma.
anterior intrapelvic (modified Rives-Stoppa) surgical 2015;29:S14–9.
approaches. J Orthop Trauma. 2014;28(6):313–9.
 The Pararectus Approach
to the Acetabulum 6
Johannes D. Bastian,
and Marius J. B. Keel

Abstract 6.1 Introduction and History

The appearance of acetabular fractures involv-
ing predominantly the anterior column has The gold standard for anterior surgical treatment
changed following an increase in elderly of acetabular fractures is the ilioinguinal approach,
trauma. In elderly, a greater prevalence of providing extrapelvic access as described more
quadrilateral plate fractures and acetabular than 50 years ago [1]. In the 1990s, the modified
dome impaction due to medial protrusion of Stoppa approach was introduced, for the first time
the femoral head is noticed. The Pararectus providing intrapelvic access to the anterior ace-
approach provides distinct and safe surgical, tabulum [2, 3]. Subsequently, the modified Stoppa
intrapelvic, extraperitoneal access from ante- approach was established as a valuable alternative
rior directly above the hip joint. The Pararectus with comparable results to the ilioinguinal
approach combines the advantages of the ilio- approach [2–13]. The modified Stoppa approach
inguinal approach and Stoppa approach with avoids dissection within the inguinal canal, which
access through the second window, however, requires time-­consuming wound closure with risk
without the need to dissect the inguinal canal of postoperative hernia. Additionally, the modi-
(ilioinguinal approach) and without losing any fied Stoppa approach reduces operative time,
direct access to the hip joint (Stoppa approach). blood loss, and the amount of blood transfusion
compared to the ilioinguinal approach.
Keywords However, the modified Stoppa approach has
Acetabulum · Fracture · Anterior column · some limitations. The second ilioinguinal window
Dome impaction · Quadrilateral plate · is not dissected but only retracted cephalad. Due to
Exposure · Anterior · Intrapelvic · this limited access, the first window of the ilioin-
Extraperitoneal guinal approach is dissected frequently. Therefore,
the surgeon has to switch between the first, third,
and fourth windows during fracture reduction and
J. D. Bastian (*) fixation at the level of the hip joint. Traction inju-
Department of Orthopaedic and Trauma Surgery, ries, especially of the obturator nerve, and postop-
Inselspital, University Hospital, Bern, Switzerland
e-mail: [email protected] erative hernia are possible complications. In
addition, the appearance of acetabular fractures
M. J. B. Keel
Trauma Center Hirslanden, Clinic Hirslanden, involving the anterior column has changed within
Zürich, Switzerland the last decades. Due to d­emographic changes

© Springer Nature Switzerland AG 2019 69

L. Büchler, M. J.B. Keel (eds.), Fractures of the Hip, Fracture Management Joint by Joint,
https://doi.org/10.1007/978-3-030-18838-2_6
70 J. D. Bastian and M. J. B. Keel

with a significant increase of geriatric patients, column, associated anterior column-­posterior hemi-
new and demanding fracture patterns such as ace- transverse, associated both-­ column) as a single
tabular dome impaction, disruption of the quadri- approach. The Pararectus approach is further used
lateral plate and intrapelvic protrusion of the in combination with posterior approaches (digastric
femoral head in elderly patients are current and trochanteric flip osteotomy, surgical hip disloca-
future challenges [12, 14–17]. These specific frac- tion) in complex acetabular fractures (T-shaped
ture patterns are all located within the second win- fracture, associated anterior column-posterior
dow of the ilioinguinal approach. hemitransverse fracture, or both-column fracture)
Accordingly, an ideal surgical approach with an additional severe displacement in the poste-
allows for reduction and fixation of these com- rior column and/or in the dome, which is not reduc-
plex fracture patterns by sufficient visualization ible through the anterior approach alone.
of fracture lines through an access directly above
the hip joint, comparable to that obtained by the
second window of the ilioinguinal approach but 6.3 Description of Surgical
without dissection of the inguinal canal. These Technique
needs based the concept of the Pararectus
approach as initially reported in 2012 [18]. 6.3.1 Surgical Access
Following the initial published description, fur-
ther scientific articles confirmed the safety and The patient is placed in supine position on a
efficiency of the Pararectus approach [19–21, 22] radiolucent operating room table with a Foley
or describe the technique in detail using a video catheter in situ. Intravenous antibiotics should be
publication [23]. administered preoperatively. The patient is
The potential benefits of the Pararectus draped with the ipsilateral leg draped freely to
approach are: allow for reduction maneuvers. The surgeon and
scrub nurse are positioned on the contralateral
• Sufficient access to the inner hemipelvis, the side of the acetabular fracture. The image intensi-
acetabular dome, the quadrilateral plate, the fier is positioned over the injured hip joint, as are
posterior column, and the sacroiliac joint. the surgical assistants. The landmarks for inci-
• Screw placement less limited by soft-tissue sion are identified as presented in Fig.  6.1. The
tension resulting in a twofold increase in skin incision runs along the lateral border of the
length of the posterior column screws. rectus abdominis muscle and is curved from the
• Single approach without the need to change lateral to the medial third of the triangle that is
windows. built by lines connecting the navel, the anterior
• No dissection of the inguinal canal. superior iliac spine (ASIS) and the pubic sym-
• Short incision length. physis. Superficial dissection develops the rectus
• Simple wound closure. sheath, which is incised at the lateral border of
• Vascular control (iliolumbar vessels, external the rectus abdominis muscle (Fig. 6.2). Deep dis-
and internal iliac vessels). section is located within the “false” and “true”
• Safe to use in cases with inguinal hernia or pelvis (Fig. 6.3) to develop the intrapelvic expo-
previous hernia repair. sure (Figs. 6.4 and 6.5) with the five surgical win-
• Safe to use after suprapubic catheter. dows of the Pararectus approach. Deep dissection
starts anteriorly and proceeds posteriorly. The
first key structures are the inferior epigastric ves-
6.2 Indications sels that are identified easily and circumvented.
The next structure is the vas deferens in males or
The Pararectus approach is used for acetabular frac- the round ligament in females. Lateral retraction
tures involving the anterior column (anterior wall, of these structures and posterior retraction of the
anterior column, transverse and T-shaped fractures bladder using a malleable retractor facilitates
with displacement predominantly in the anterior access to the retroperitoneal space in the fourth
6  The Pararectus Approach to the Acetabulum 71

window. This window visualizes the symphysis

and the superior pubic ramus. The periosteum is
incised and a Hohmann-retractor placed on the
superior pubic ramus. Before visualization of the
fractured anterior column and further dissections
posteriorly, the third and second windows are
developed. The third and fifth windows are
located between the inferior epigastric vessels
and the external iliac vessels. Accordingly, the
next key structures are the external iliac vessels
that are digitally identified and mobilized. Before
further incision of the periosteum, the Corona
Mortis (anastomosis of the obturator and external
iliac systems) has to be ligated or clamped in the
third window at the level of the superior pubic
branch. In the fifth window, the key structure is
the obturator neurovascular bundle. Tension to
Fig. 6.1  Landmarks for skin incision: The navel, the the obturator nerve should be avoided. The peri-
anterior superior iliac spine (ASIS), and the symphysis are
connected (dashed red line). The skin incision (red line) osteum at the quadrilateral plate is incised and
starts cranial at the border between the lateral and middle the obturator internus muscle is mobilized until
third of the line connecting the navel with the ASIS. The the lesser sciatic notch is visible. The second
incision is curved and directed towards the border between window is located between the iliopsoas muscle
the middle and medial third of the line connecting the
ASIS with the symphysis. An extension of the incision is and the external iliac vessels. Before deep dissec-
possible as presented (dotted lines). Reproduced with per- tion proceeds with incision of the periosteum
mission and copyright © of the British Editorial Society in  the second window, the iliolumbar vessels
of Bone and Joint Surgery [18]

Fig. 6.2 (a) Schematic cross-sectional anatomy of the neum (black line), IP intraperitoneal space. (b) Schematic
operative field with direction of dissection (red arrows): (1) overview of the operative field: (1) Subcutaneous tissue,
Subcutaneous tissue, fascia of Camper, (2) deep layer of fascia of Camper, (2) deep layer of the anterior abdominal
the anterior abdominal wall (green line), fascia of Scarpa, wall, fascia of Scarpa, (3) rectus sheath, rectus abdominis
(3) rectus sheath (blue line), rectus abdominis muscle muscle (star), (4) transversalis fascia. Reproduced with
(star) (4) transversalis fascia (orange line), (5) inferior epi- permission and copyright © of the British Editorial Society
gastric vessels. EP extraperitoneal space, parietal perito- of Bone and Joint Surgery [18]
72 J. D. Bastian and M. J. B. Keel

Fig. 6.3 (a) Schematic drawings showing the cross-­section (b) Schematic drawings showing the cross-­section at the
at the level of the sacroiliac joint as illustrated by the picto- level of the hip joint as illustrated by the pictogram. Red
gram. Red arrows indicating the dissection planes within arrows indicating the dissection planes within the “true”
the “false” pelvis: (1) Rectus abdominis muscle, (2) exter- pelvis: (1) Pectineus and (2) obturator internus muscles.
nal and internal oblique and transverse abdominis muscles, Reproduced with permission and copyright © of the British
(3) iliacus muscle, (4) psoas major muscle, P peritoneal sac. Editorial Society of Bone and Joint Surgery [18]

Fig. 6.4  Exposure: (1) Ilioinguinal nerve, (2) lateral

femoral cutaneous nerve, (3) genitofemoral nerve with
femoral and genital branches, (4) external iliac artery/
vein, (5) anterior superior iliac spine (ASIS), (6)
iliopsoas muscle, (7) roof of the acetabulum, (8)
inferior epigastric vessels, (9) anastomosis between
obturator and inferior epigastric or external iliac
vessels, (10) obturator nerve and vessels (obturator
canal), (11) obturator internus muscle, (12) vas
deferens, (13) obturator nerve. Reproduced with
permission and copyright © of the British Editorial
Society of Bone and Joint Surgery [18]
6  The Pararectus Approach to the Acetabulum 73

(vascular connection between the internal iliac 6.3.2 Fracture Reduction

vessels with the deep circumflex iliac vessels and Fixation
originating from the external iliac vessels) need
to be controlled and ligated. The next key struc- Once all windows are developed safely, the frac-
tures at the border to the first window are the ture lines are visualized and cleaned. Lateral
genitofemoral nerve, the lateral cutaneous femo- traction of the femur supports fracture reduc-
ral nerve, and the iliacus muscle. tion. Fracture reduction begins at the level of the
joint, proceeds with reduction of the anterior
column followed by the quadrilateral plate. In
presence of an impacted acetabular dome frag-
ment, this can be disimpacted directly through
the fracture using a raspatorium, which is a cru-
cial step to obtain anatomic reduction in these
articular fractures (Fig. 6.6). The void generated
by the disimpaction has to be filled with bone
graft to avoid secondary displacement of the
reduced dome fragment. An anatomical, pre-
shaped, suprapectineal plate can be used for
direct reduction (Fig. 6.7). This plate is inserted
from anterior to posterior, fixed preliminary
using 2.5  mm threaded K-wires and correct
positioning of the plate is confirmed using the
Fig. 6.5  Intraoperative photograph presenting an intra-
pelvic view from medial to lateral after surgical exposure image intensifier. A ball-spiked pusher placed
by the Pararectus approach with the five “surgical win- on the plate assists in reduction of the anterior
dows,” essential landmarks (LM) and key structures: (KS column. The plate is fixed posteriorly using
1) inferior epigastric vessels, (KS 2) vas deferens, (KS 3)
3.5  mm cortical screws. A Verbrugge clamp is
external iliac vessels, (KS 4) obturator nerve, (KS 5) ilio-
psoas muscle, (KS 6) genitofemoral nerve, (KS 7) iliacus used for fixation of the plate to the superior
muscle, (KS 8) lateral cutaneous femoral nerve pubic ramus. A curved ball-spiked pusher placed

a b

Fig. 6.6 (a) Intraoperative photographic showing the yellow arrow fracture gap with access to acetabular dome,
medial to lateral intrapelvic view in the third and fifth white arrow raspatorium inserted for disimpaction of the
window obtained by the Pararectus approach in the left acetabular dome. (b) Three-dimensional reconstruction of
hemipelvis in a 79-year-old male patient who sustained an the left-hemipelvis showing the bony structures in corre-
acetabular fracture (compare Fig.  6.8); LM 1 landmark spondence to (a)
1  =  ASIS, AC anterior column, ∗ superior pubic ramus,
74 J. D. Bastian and M. J. B. Keel

on the quadrilateral portion of the suprapectin- In fractures with involvement of the posterior
eal plate reduces the breakout of the quadrilat- column (especially in anterior column posterior
eral plate. The plate is then fixed anteriorly. A hemitransverse fractures), an infra-acetabular
Collinear clamp is used (Fig. 6.7) for compres- screw, a posterior column screw or both should
sion of the posterior column to the anterior col- be placed for fixation of the posterior column
umn. The clamp must be hooked into the lesser depending on fracture lines and comminution.
sciatic notch and compressed against the plate. Case example presented in Fig. 6.8.

a b

Fig. 6.7  Model showing an intrapelvic view of the quad- reduction of the quadrilateral plate and a Collinear clamp
rilateral plate and the posterior pelvic brim (a). A curved (2) for direct reduction of the posterior column (hocked
ball spiked pusher (1) on the quadrilateral portion on the into the lesser sciatic notch and compression against the
anatomical, preshaped, suprapectineal plate for direct plate). (b) Same model, view from proximal-lateral

A B C

Fig. 6.8 (a) Preoperative radiographs with (A) anteroposte- views showing an anatomic reduction with disimpaction of
rior, (B) iliac oblique, and (C) obturator oblique views the dome fragment. A supra-acetabular screw (unfilled yel-
showing an acetabular fracture (anterior column/ posterior low arrow) was placed in horizontal direction to buttress the
hemitransverse) in a 74-year-old female patient with dome disimpacted dome fragment (unfilled yellow arrow). A pos-
impaction (yellow arrow), breakout of the quadrilateral plate terior column screw was used for compression of the poste-
and intrapelvic protrusion of the femoral head. (b) rior column to the anterior column (filled yellow arrow). (d)
Preoperative CT scans with (A) axial (dome level), (B) coro- Postoperative CT scans with (A) axial (dome level), (B)
nal, and (C) sagittal reconstruction planes showing the ace- coronal, and (C) sagittal reconstruction planes show an ana-
tabular fracture (anterior column/posterior hemitransverse) tomic reduction with disimpaction of the dome fragment (B,
of the same patient. (c) Postoperative radiographs with (A) yellow arrow). (C): supra-acetabular screw (unfilled yellow
anteroposterior, (B) iliac oblique, and (C) obturator oblique arrow), posterior column screw (filled yellow arrow)
6  The Pararectus Approach to the Acetabulum 75

A B C

A B C

A B C

Fig. 6.8 (continued)

6.3.3 Closure
References
A suction drain is placed in the Retzius space rou- 1. Judet R, Judet J, Letournel E. Fractures of the acetabu-
tinely. After wound irrigation, hemostasis and clear lum: classification and surgical approaches for open
urine output, the anterior lamina of the rectus sheath reduction. Preliminary report. J Bone Joint Surg Am.
is sutured using absorbable sutures. A layered clo- 1964;46:1615–46.
2. Hirvensalo E, Lindahl J, Bostman O. A new approach
sure of the subcutaneous tissues follows, and the skin to the internal fixation of unstable pelvic fractures.
is closed using staples or an intracutaneous suture. Clin Orthop Relat Res. 1993;297:28–32.
76 J. D. Bastian and M. J. B. Keel

3. Cole JD, Bolhofner BR.  Acetabular fracture fixa- 13. Ma K, Luan F, Wang X, et al. Randomized, controlled
tion via a modified Stoppa limited intrapelvic trial of the modified Stoppa versus the ilioingui-
approach. Description of operative technique and nal approach for acetabular fractures. Orthopedics.
preliminary treatment results. Clin Orthop Relat Res. 2013;36(10):e1307–e15.
1994;305:112–23. 14.
Ferguson TA, Patel R, Bhandari M, Matta
4. Ponsen KJ, Joosse P, Schigt A, Goslings JC, Luitse JM. Fractures of the acetabulum in patients aged 60
JS.  Internal fracture fixation using the Stoppa years and older: an epidemiological and radiological
approach in pelvic ring and acetabular fractures: study. J Bone Joint Surg Br. 2010;92(2):250–7.
technical aspects and operative results. J Trauma. 15. Anglen JO, Burd TA, Hendricks KJ, Harrison P. The
2006;61(3):662–7. “Gull sign”: a harbinger of failure for internal fixation
5. Jakob M, Droeser R, Zobrist R, Messmer P, Regazzoni of geriatric acetabular fractures. J Orthop Trauma.
P. A less invasive anterior intrapelvic approach for the 2003;17(9):625–34.
treatment of acetabular fractures and pelvic ring inju- 16. Bastian JD, Giannoudis PV.  Central acetabular frac-
ries. J Trauma. 2006;60(6):1364–70. ture dislocations: are existing classifications compre-
6. Sagi HC, Afsari A, Dziadosz D.  The anterior intra-­ hensive? Injury. 2014;45(12):1807–15.
pelvic (modified Rives-Stoppa) approach for fixa- 17. Prasartritha T, Chaivanichsiri P. The study of broken
tion of acetabular fractures. J Orthop Trauma. quadrilateral surface in fractures of the acetabulum.
2010;24(5):263–70. Int Orthop. 2013;37(6):1127–34.
7. Andersen RC, O’Toole RV, Nascone JW, Sciadini MF, 18. Keel MJ, Ecker TM, Cullmann JL, et al. The Pararectus
Frisch HM, Turen CW.  Modified Stoppa approach approach for anterior intrapelvic management of
for acetabular fractures with anterior and posterior acetabular fractures: an anatomical study and clinical
column displacement: quantification of radiographic evaluation. J Bone Joint Surg Br. 2012;94(3):405–11.
reduction and analysis of interobserver variability. J 19. Bastian JD, Savic M, Cullmann JL, Zech WD, Djonov
Orthop Trauma. 2010;24(5):271–8. V, Keel MJ. Surgical exposures and options for instru-
8. Laflamme GY, Hebert-Davies J, Rouleau D, Benoit mentation in acetabular fracture fixation: Pararectus
B, Leduc S.  Internal fixation of osteopenic acetabu- approach versus the modified Stoppa. Injury.
lar fractures involving the quadrilateral plate. Injury. 2016;47:695.
2011;42(10):1130–4. 20. Keel MJ, Tomagra S, Bonel HM, Siebenrock KA,
9. Khoury A, Weill Y, Mosheiff R. The Stoppa approach Bastian JD.  Clinical results of acetabular fracture
for acetabular fracture. Oper Orthop Traumatol. management with the Pararectus approach. Injury.
2012;24(4–5):439–48. 2014;45(12):1900–7.
10. Shazar N, Eshed I, Ackshota N, Hershkovich O,
21. Mardian S, Schaser KD, Hinz P, Wittenberg S, Haas
Khazanov A, Herman A.  Comparison of acetabular NP, Schwabe P.  Fixation of acetabular fractures via
fracture reduction quality by the ilioinguinal or the the ilioinguinal versus Pararectus approach: a direct
anterior intrapelvic (modified Rives-Stoppa) surgical comparison. Bone Joint J. 2015;97-B(9):1271–8.
approaches. J Orthop Trauma. 2014;28(6):313–9. 22. von Rüden C, Wenzel L, Becker J, Thannheier A,
11.
Isaacson MJ, Taylor BC, French BG, Poka Augat P, Woltmann A, Bühren V, Perl M.  The para-
A.  Treatment of acetabulum fractures through the rectus approach for internal fixation of acetabular
modified Stoppa approach: strategies and outcomes. fractures involving the anterior column: evaluating
Clin Orthop Relat Res. 2014;472:3345–52. the functional outcome. International orthopaedics.
12. Bastian JD, Tannast M, Siebenrock KA, Keel
2018. https://doi.org/10.1007/s00264-018-4148-8
MJ. Mid-term results in relation to age and analysis 23. Keel MJB, Siebenrock KA, Tannast M, Bastian

of predictive factors after fixation of acetabular frac- JD.  The Pararectus approach: a new concept. JBJS
tures using the modified Stoppa approach. Injury. Essent Surg Tech. 2018;8(3):e21.
2013;44(12):1793–8.
 Lateral Approach to the Pelvis
and Hip 7
Joseph M. Schwab, Chad Beck,
and Klaus A. Siebenrock

Abstract Keywords
Lateral-based surgical approaches to the hip Kocher-Langenbeck · Surgical hip dislocation ·
and pelvis are critical to treatment of both Acetabular fracture · Femoroacetabular
traumatic and developmental conditions of the impingement · Trochanteric flip osteotomy
adult hip. This chapter focuses on two lateral-­
based approaches that can treat a wide array of
conditions: The Kocher-Langenbeck approach 7.1 Kocher-Langenbeck
popularized by Judet and Letournel, and the Approach
safe surgical hip dislocation popularized by
Ganz. The Kocher-Langenbeck approach has 7.1.1 Introduction
been described over 70 years ago but remains
a workhorse approach for certain types of ace- Classically described as a posterior approach,
tabular trauma. Ganz’ safe surgical hip dislo- the Kocher-Langenbeck approach is a work-
cation has been described within the past horse approach to the hip and acetabulum that
20  years but has been shown to be safe and allows complete visualization of the posterior
effective in the treatment of both traumatic column, as well as palpation of the quadrilat-
and developmental pathologies. Both eral surface all the way to the pelvic brim. This
approaches are technically challenging and approach, in its current form, was described by
require attention to detail, but with adequate Judet and Lagrange in 1958 [1]. Judet and
study and practice can be mastered. Letournel described additional extensions to
this approach to gain further access to the ante-
rior column in the superior acetabular region.
These techniques include splitting the tendi-
nous insertion of the gluteals or extending the
J. M. Schwab (*) · C. Beck incision similar to a triradiate approach.
Department of Orthopaedic Surgery, Medical College Siebenrock also described expanding anatomic
of Wisconsin, Milwaukee, WI, USA access through a trochanteric flip osteotomy
e-mail: [email protected]
[2]. Despite these extensions, the Kocher-
K. A. Siebenrock Langenbeck approach in use today remains
Department of Orthopaedic and Trauma Surgery,
Inselspital, Bern University Hospital, very similar to the technique described by
Bern, Switzerland Judet.

© Springer Nature Switzerland AG 2019 77

L. Büchler, M. J.B. Keel (eds.), Fractures of the Hip, Fracture Management Joint by Joint,
https://doi.org/10.1007/978-3-030-18838-2_7
78 J. M. Schwab et al.

7.1.2 Indications eral position (see below), rather than the tradi-
tional prone position.
The Kocher-Langenbeck approach is still pre-
dominantly used for open reduction and internal
fixation of fractures about the acetabulum where 7.1.3 Setup
the fracture pattern is posterior dominant.
Specifically, this approach is indicated for the The setup for the Kocher-Langenbeck approach
following fracture patterns [3]: may occur in the lateral position or in the prone
position.
• Posterior wall acetabular fractures.
• Posterior column acetabular fractures. 7.1.3.1 Lateral Position [3, 4]
• Posterior column and posterior wall acetabu- The patient is placed in the lateral decubitus posi-
lar fractures. tion on a flat, radiolucent table, with the operative
• Transverse and posterior wall acetabular extremity up, and draped free. This positioning is
fractures. similar to the posterior approach used in total hip
• Transverse acetabular fractures with the major arthroplasty, with the major difference being that
displacement occurring at the posterior the drapes need to extend proximally above the
column. level of the iliac crest and posteriorly to the mid-
• Posterior element reduction and fixation in line. This allows for palpation of the posterior
T-type acetabular fractures. superior iliac spine as a landmark. The down
extremity needs to be appropriately padded to
While this approach provides excellent visual prevent pressure-related complications.
access to the posterior acetabulum and posterior
column, as well as palpation access to the quadri- 7.1.3.2 Prone Position [5]
lateral surface, it does not provide any adequate For the prone position, traditionally a pelvic table
access to the anterior elements of an acetabular is used to help maintain proper position. Chest
fracture. Therefore, the following fracture pat- rolls are place so that the patient’s breasts and
terns are considered a contraindication to the areolas are free. Additional padding is placed on
Kocher-Langenbeck approach: the anterior superior iliac spine to help support
the pelvis, and a well-padded perineal post is
• Anterior wall acetabular fractures. placed. A distal femoral traction pin is placed
• Anterior column acetabular fractures. preoperatively on the operative extremity and
• Transverse acetabular fractures with the major attached to an in-line traction component of the
displacement occurring at the anterior table. The foot is placed into the foot holder to
column. allow for positioning the knee in flexion. The
• Associated both-column acetabular fractures. table is then adjusted until there is slight exten-
• Anterior element reduction and fixation in sion at the hip and the knee is flexed. This allows
T-type acetabular fractures. tension to be taken off the sciatic nerve for safe
• Anterior column and posterior hemitransverse retraction during the exposure (Fig. 7.1).
acetabular fractures. An alternative to a pelvic specialty table is
• Anterior column and anterior wall acetabular using a completely radiolucent flat top table. For
fractures. this variation in positioning chest rolls should be
placed similar to the pelvic specialty top. Once
Finally, when an acetabular fracture is com- the patient is in the prone position the hip needs
bined with a femoral head fracture, or when it is to be slightly extended and the knee flexed. This
anticipated that a trochanteric osteotomy would can be accomplished prior to prepping the patient
be helpful in gaining exposure to an isolated with pillows under the knee and a stack of
posterior-­
superior acetabular wall fracture, it ­blankets at the level of the patient’s anterior tibia
may be preferable to perform the approach in lat- to hold this position. This can also be accom-
7  Lateral Approach to the Pelvis and Hip 79

Fig. 7.1  The patient is in the prone position on a fully Fig. 7.2  The skin incision is marked. One limb is in line
radiolucent table. A distal femoral traction pin and foot with the femoral diaphysis to the top of the greater tro-
holder are used on the operative side to hold the hip in chanter. The second limb then curves towards the poste-
slight extension and the knee in flexion. The extremity is rior superior iliac spine after passing the level of the
draped widely to allow access to all necessary bony land- greater trochanter
marks. Any catheters, chest tubes, or other drains are posi-
tioned under the table to be out of the way of fluoroscopy
7.1.4.4 Optional
• Intraoperative autologous blood transfusion
plished intra-operatively with an assistant hold- (cell-saver).
ing the knee flexed while a stack of surgical • Intraoperative imaging with fluoroscopy,
towels is placed under the anterior thigh allowing O-arm, or CT.
for hip extension. • Additional implants, as needed, such as spring
plates, mini-screws, or percutaneous screw
sets.
7.1.4 Instruments/Equipment/
Implants Required
7.1.5 Procedure
7.1.4.1 Surgical Table
• A specialty pelvic top traction table is required 7.1.5.1 Exposure
for the prone position. Bony landmarks first need to be located. These
• A flat-top Jackson-type table, or imaging table include the femoral diaphysis, the posterior supe-
that allows for C-arm fluoroscopy is required rior iliac spine, and the greater trochanter. The
for the lateral position. skin incision is made in line with the femoral
diaphysis, then from distal to proximal, curves
7.1.4.2 Instruments towards the posterior superior iliac spine after
• Pelvic retractor set including long curved sci- passing the level of the greater trochanter
atic nerve retractor. (Fig. 7.2). In general, the surgeon’s palm can be
• For fracture reduction, there are specialized used as a guide for the length of the limbs of this
reduction tools, including pelvic reduction incision. One palm length for the part of the inci-
clamps and forceps, ball-spike pushers, and sion along the femoral shaft to the tip of the
bone hooks. greater trochanter and two palm widths from the
tip of the greater trochanter curving towards the
7.1.4.3 Implants posterior superior iliac spine. This makes the dis-
• 3.5  mm cortical screws, 3.5  mm locking tal limb of the incision from the gluteus maximus
screws, and 3.5  mm pelvic reconstruction tendon to the greater trochanter and the proximal
plates portion double that length. In obese patients or
80 J. M. Schwab et al.

more muscular patients the portion towards the obturator internus and the gemelli is found deep
posterior superior iliac spine may have to be to the muscle bellies. With these tagged you can
increased for easier visualization. now use them as a guide to clear off the retro
The deeper dissection carries through the acetabular surface back to the level of the greater
subcutaneous fat until you reach the iliotibial and lesser sciatic notches. The gemelli/obtura-
band. Be careful to only clear off enough fat tors can be used to protect the sciatic nerve by
from the iliotibial band to allow visualization.
Too much cleared off the iliotibial band can
cause a large deep space for fluid collection after
closure. From here incise the iliotibial band in
line with the fibers and in line with your incision.
Carry this proximal to the tip of the greater tro-
chanter. From here curve towards the posterior
superior iliac spine with incising the gluteus
maximus fascia. By following this direction for
incising the gluteus fascia you should be in line
with the muscle fibers deep to the fascia
(Fig. 7.3). The gluteus maximus is now split in-
line with its fibers. This should start at the greater
trochanter and end once you reach the first neu-
rovascular bundle. This will allow access to the
short external rotators. Clear the fat and bursa
overlying the tendon insertions of the short
Fig. 7.4  The iliotibial band and gluteus maximus fascia
external rotators. A blunt retractor placed under-
and muscle have been split revealing the posterior struc-
neath the gluteus medius muscle belly helps with tures of the acetabulum and proximal femur. The vastus
visualization (Fig.  7.4). Once the two tendons lateralis tendon and muscle are clearly visible coming off
are identified tag both using a strong suture for of the greater trochanter. The sciatic nerve can be seen
coursing from proximal to distal (right to left) deep in the
control. This should be performed 1 cm off the
wound. At this point in the operation, the short external
femoral insertions to avoid damage to the femo- rotators are still intact
ral head blood supply running up the posterior
femur (Fig. 7.5). The confluent tendon from the

Fig. 7.5 The short external rotators are tagged and

reflected off their insertions on the femur. The piriformis
tendon (proximal) and confluent tendon of the obturator
Fig. 7.3  Once the skin and subcutaneous tissues have internus/gemelli (distal) should be transected 1 cm from
been incised, the fascial incision follows a similar path as their insertion on the femur in order to protect proximal
the skin incision femoral blood supply
7  Lateral Approach to the Pelvis and Hip 81

placing a retractor in the lesser sciatic notch aspect of the exposure, the quadratus femoris
under the muscle bellies (Figs. 7.6 and 7.7). The muscle can be elevated off the ischial tuberosity.
superior aspect of the dissection will require This muscle belly should never be elevated off
clearing off the gluteus minimus muscle belly. In the femur during this approach as the blood sup-
the setting of a fracture this should be debrided ply to the femoral head travels along the femur
as well as the short external rotator bellies that deep to this muscle attachment.
look damaged/necrotic. They will be a source of
heterotopic ossification if left in the wound. If 7.1.5.2 Wound Closure
further visualization is needed in the inferior A thorough debridement of necrotic muscle, with
special attention paid to the gluteus minimus,
must occur prior to closure. This is followed by a
thorough irrigation of the surgical wound. The
short external rotators are repaired to their attach-
ments. Be careful not to suture close to the femur
as this repair could accidentally ligate the blood
supply to the femoral head. One drain is placed
deep to the iliotibial band closure and one deep to
the skin closure.

7.1.6 Postoperative Regimen

For most fractures about the hip the patient can be

made toe touch weight bearing. This will help
reduce the forces across the post-surgical hip. If
the patient had a hip dislocation associated with
Fig. 7.6  The sciatic nerve typically runs posterior to the
confluent tendon. By reflecting this tendon posteriorly, the their injury, posterior hip precautions are used for
sciatic nerve can be protected from direct contact with the first 6 weeks post operatively. These precau-
retractors placed in the lesser sciatic notch tions include limiting hip flexion to less than 90°,
not allowing combined adduction with hip flexion
(such as crossing the legs in a seated position),
and not allowing the patient to sleep on their side.
In addition, a knee immobilizer can sometimes be
helpful to prevent the patient from excessively
flexing their hip. Heterotopic ossification (HO)
prophylaxis is a topic of debate but currently is
not used if an adequate debridement of damaged
or necrotic musculature, particularly the gluteus
minimus muscle, was performed. Increased non-
union rates have been seen with the use of high
dose Nonsteroidal anti-inflammatory drugs
(NSAID) [6]. Radiation therapy has been shown
to reduce rates of clinically relevant (Brooker
III-IV) HO when combined with adequate muscle
debridement, but it has not clearly been shown to
Fig. 7.7  Once the tip of the sciatic nerve retractor is in
the lesser sciatic notch, the sciatic nerve can safely be
be superior to other forms of prophylaxis [7, 8]. In
retracted, allowing excellent visualization of the retroac- addition, radiation therapy carries the risk of radi-
etabular space ation-induced sarcoma [9, 10].
82 J. M. Schwab et al.

7.2 Trochanteric Flip pathology. The following is a list of conditions

and Surgical Hip Dislocation that can be treated through a surgical hip
dislocation:
7.2.1 Introduction
• Femoroacetabular impingement [14, 15]
Ganz et al. began using a technique for safe sur- • Trauma including femoral head and/or acetab-
gical dislocation of the hip in 1992, and subse- ular wall fractures [22]
quently published the technique, along with • Slipped capital femoral epiphysis (acute and
results on 213 cases, in 2001 [11]. This technique chronic) [19, 21]
was based on careful anatomic study of the blood • Legg-Calve-Perthes disease, and Perthes-like
supply to the femoral head, with particular focus deformities [18, 23]
on the medial femoral circumflex artery being the • Synoproliferative disorders such as synovial
dominant blood supply to the adult femoral head chondromatosis and pigmented villonodular
[12]. This technique uses a trochanteric osteot- synovitis [24]
omy to gain access to the hip capsule, preserving
the course of the medial femoral circumflex
artery to the retinacular vessels of the femoral 7.2.3 Setup
head in the process. This technique has led to a
greater understanding of hip pathologies such as The setup for a surgical hip dislocation is similar
femoroacetabular impingement, slipped capital to that for a traditional posterior-approach total
femoral epiphysis, Legg-Calve-Perthes disease, hip arthroplasty [11, 25]. The patient is placed in
and other potential causes of “idiopathic” degen- the lateral decubitus position with the entire
erative changes to the hip [13–21]. operative extremity draped free. The patient
should be stabilized in the lateral position to
allow intraoperative hip flexion beyond 90°. A
7.2.2 Indications tunnel cushion placed over the non-operative
extremity protects it from injury and provides a
Surgical hip dislocation provides wide access supportive surface for the operative extremity
to the proximal femoral and acetabular articular during the procedure (Fig. 7.8). A sterile bag, or
surfaces. This makes it a very powerful pocket, on the anterior side of the patient is used
approach for a wide variety of intraarticular hip while the hip joint is dislocated.

Fig. 7.8  The patient is

secured in the lateral
decubitus position and a
tunnel cushion is placed
over the down extremity
to provide protection to
the extremity and act as
a stable surface for the
surgical limb.
Reproduced with
permission and copyright
© of Springer [26]
7  Lateral Approach to the Pelvis and Hip 83

7.2.4 Instruments/Equipment/
Implants Required

7.2.4.1 Surgical Table

• A flat-top Jackson-type table, or imaging table
with padded positioners to hold the patient in
the lateral decubitus position.

Instruments Fig. 7.9  Perforating vessels are a relatively constant ana-

• Langenbeck-style, curved spoon-style, and tomic indicator of the anterior border of the gluteus maxi-
mus. After identifying these vessels, the fascia can be
double bent Hohmann retractors are helpful incised, anterior to the vessels, in line with femur
for atraumatic soft-tissue retraction.
• A long, curved scissors is helpful to transect
the ligamentum teres during hip dislocation. is approached through a Gibson interval [11, 25,
• Curved osteotomes and/or a high-speed burr 27], just anterior to gluteus maximus muscle.
can be used for femoral head and acetabular Branches of the inferior gluteal artery run within
rim trimming. the fascia between the gluteus medius and the
• An arthroscope can be used to provide close- gluteus maximus and perforate the fascia lata at
­up inspection of the joint during dislocation, the anterior border of the gluteus maximus [25]
without the need for a fluid pump. (Fig. 7.9). These vessels continue into the subcu-
• Plastic hemispherical femoral head templates taneous fat after perforating the fascia lata. This
of multiple sizes are helpful for determining is most easily identified by starting the dissection
when adequate femoral head resection has distally, identifying the fascia lata, and proceed-
been performed in cases of cam-type femoro- ing proximally until the perforating vessels are
acetabular impingement. encountered. The fascia overlying the gluteus
medius muscle is incised at the anterior border of
Implants the gluteus maximus muscle. The gluteus maxi-
• 3.5 mm cortical screws for trochanteric frag- mus muscle is retracted posteriorly keeping the
ment fixation overlying fascia of the gluteus medius with it.
• Suture anchors for labral repair, refixation, or This helps to protect the superior cluneal nerves,
reconstruction. as well as branches of the superior gluteal artery,
• Mini-screws or headless screws for articular which can run in that fascia.
surface fixation (i.e., femoral head fracture, The leg is then internally rotated to expose the
head reduction osteotomy, etc.) gluteus minimus, piriformis, and short external
• Proximal femoral fixations plates for fixation rotators. Care must be taken at this point to avoid
of femoral derotational osteotomies. disrupting these posterior structures as they pro-
tect the medial femoral circumflex artery
Optional (MFCA), the major blood supply to the femoral
• Arthroscopic shaver for synovial debridement head [12].
(e.g. PVNS, synovial chondromatosis).
7.2.5.2 Trochanteric Osteotomy
An osteotomy of the greater trochanter is then
7.2.5 Procedure performed. This can either be a flat-cut or step-­
cut osteotomy depending on the goals of surgery
7.2.5.1 Exposure specific to that patient. For instance, if a trochan-
The skin incision is typically 20–25 cm long and teric advancement or relative neck lengthening is
is centered over the tip of the greater trochanter in indicated, a flat-cut osteotomy is recommended.
line with the anterior third of the femur. The hip Step-cut osteotomy provides greater resistance to
84 J. M. Schwab et al.

superior migration secondary to pull from the distal end of the first cut, approximately 6  cm
gluteus medius and may allow for more acceler- more medial. A 6 mm osteotome is then passed to
ated rehabilitation [28, 29]. Whether performing connect the two ends of the step and the trochan-
a flat or stepped osteotomy, the femur should be teric fragment is mobilized.
internally rotated approximately 15°–20° to com-
pensate for femoral anteversion. Before perform- 7.2.5.4 Variation: Flat-Cut Osteotomy
ing the osteotomy, mark a line from the tip of the (Fig. 7.11)
greater trochanter to the posterior border of the Pass an oscillating saw from posterior to anterior
vastus lateralis ridge with electrocautery. This along the cauterized line. If anatomic fixation is
also cauterizes the trochanteric branch of the desired, the anterior, or anterosuperior portion of
MFCA, which can otherwise cause bleeding dur- cortical bone can be left intact and fractured by
ing the osteotomy. It is also important to avoid prying the fragment up. This would provide an
cutting the trochanter too medial proximally, as area to “key in” when fixing the osteotomy.
this can damage the retinacular vessels from the Otherwise, if mobility of the fragment is desired
medial femoral circumflex artery as they course (as in the case of a trochanteric advancement),
into the femoral head. This could lead to iatro- the osteotomy should be completed with the saw.
genic avascular necrosis, a devastating Thickness of the mobilized trochanteric fragment
complication. is approximately 1.5 cm.

7.2.5.3 Variation: Step-Cut Osteotomy 7.2.5.5 Capsular Exposure

[26, 28, 29] (Fig. 7.10) Once the trochanteric osteotomy has been per-
Pass a narrow oscillating saw from posterior to formed, the leg is taken out of internal rotation
anterior starting at the tip of the greater trochan- while the trochanteric fragment is mobilized
ter and extending approximately ½ of the length anteriorly. Fibers of the vastus lateralis muscle
of the osteotomy. The blade is left in the osteot- are released from the femur down to the midpoint
omy and used as a plane of reference. A broad of the insertion of the gluteus maximus tendon to
oscillating saw is then passed starting just distal achieve mobilization of the fragment. Proximally
to the vastus lateralis ridge and extending to the 1–2 mm of gluteus medius tendon remains on the

Fig. 7.10  Step cut trochanteric osteotomy is performed by more medial, along the distal 2/5 of the osteotomy. The two
first (A) passing the saw blade from the proximal tip to limbs are connected with the use of a narrow (approximately
approximately 3/5 the length of the osteotomy. A second 6 mm) osteotome to complete the osteotomy. Reproduced
saw blade is used to place a second limb of the osteotomy, with permission and copyright © of Springer [26]
7  Lateral Approach to the Pelvis and Hip 85

stable portion of the greater trochanter and must 7.2.5.6 Capsulotomy (Fig. 7.12)
be released to mobilize the fragment anteriorly. Z-shaped capsulotomy is performed starting with
Often a few fibers of the piriformis tendon remain the anterolateral capsule in-line with the femoral
attached to the mobile fragment and must be neck. After initial capsule penetration with the
carefully released to allow mobilization. scalpel, an “inside-out” capsulotomy helps pro-
Dissection is then carried out between the glu- tect the cartilage and labrum from iatrogenic
teus minimus and piriformis muscles, which injury. The capsulotomy is extended to the rim of
allows visualization of the joint capsule. To facil- the acetabulum proximally and to the anterolat-
itate exposure of the capsule, the hip should now eral tip of the stable trochanter distally. An antero-
go into slight flexion and external rotation while inferior limb of the capsulotomy is then performed,
the gluteus medius and minimus are retracted and care must be taken to stay anterior to the
superiorly. lesser trochanter to protect the MFCA. The supe-

Fig. 7.11  Flat cut a

trochanteric osteotomy
(a) is designed to be
approximately 15 mm in
depth and extend from
the medial border of the
tip of the greater
trochanter to just distal
to the vastus lateralis
ridge. A saw blade is
passed most of the way
through the greater
trochanter with care not
to aim to medial
proximally. (b) Once the
osteotomy is complete
the trochanteric
fragment can be
reflected anteriorly and
fibers of the vastus
lateralis released from
the femur to allow
fragment mobilization.
Reproduced with
permission and
copyright © of Springer b
[26]
86 J. M. Schwab et al.

Fig. 7.12  Capsulotomy is performed along the femoral The proximal portion of the capsulotomy is extended poste-
neck starting at the junction where the trochanter meets the riorly along the acetabular rim, and the distal portion is
femoral neck anteriorly. This capsulotomy is performed in extended medially towards the lesser trochanter. Reproduced
an “inside-out” fashion to protect the cartilage and labrum. with permission and copyright © of Springer [26]

rior limb of the capsulotomy is then developed tibial band are then closed with a running absorb-
along the rim of the acetabulum posteriorly until it able suture. Subcutaneous tissue and skin are
reaches the retracted piriformis tendon. closed in routine fashion.
Both deep and superficial drains can be used
7.2.5.7 Dislocation to reduce hematoma formation and allow for
Bringing the hip into flexion and external rotation more comfortable early passive motion.
leads to dislocation. We routinely use a bone
hook around the inferior neck to gently apply the
appropriate force to the proximal femur to aid in 7.2.6 Postoperative Regimen
dislocation. A curved scissors is used to transect
the ligamentum teres, allowing full dislocation. Postoperatively patients are placed in a continu-
Once dislocated, the operative leg is placed in the ous passive motion machine to minimize intraar-
sterile bag anterior to the patient. The proximal ticular adhesions. Mechanical and pharmacologic
femur and acetabulum can now be circumferen- DVT prophylaxis are maintained while in the
tially inspected. The remaining ligamentum teres hospital, and pharmacologic prophylaxis is con-
is excised from the fovea capitis. tinued for at least 30 days following surgery.
Patients with a flat-cut trochanteric osteotomy
7.2.5.8 Wound Closure are made touchdown weight bearing and
The capsulotomy is closed anatomically with advanced to full weight bearing between 6 and
absorbable suture. A watertight closure of the 8  weeks postoperatively. Once they are full
capsule is not necessary as efflux of the hemar- weight bearing, they may begin abductor
throsis may reduce the risk of iatrogenic osteone- strengthening [25].
crosis secondary to increased joint pressure. Patients with a step-cut osteotomy are made
After capsule closure the mobile trochanteric 50% body weight bearing and may advance to
fragment is reduced and fixed with two to three full weight bearing between 3 and 6 weeks post-
3.5 or 4.5 mm cortical screws aimed towards the operatively depending upon the clinical situation
inferior neck and lesser trochanter (Fig.  7.13). [28, 29]. Abductor strengthening may begin after
The gluteus maximus fascia and proximal ilio- the patient is full weight bearing.
7  Lateral Approach to the Pelvis and Hip 87

Fig. 7.13  Fixation of the

trochanteric osteotomy is
performed with two
3.5 mm cortical screws
aimed towards the lesser
trochanter. While this
image depicts the
step-cut osteotomy, the
same fixation can be used
for a flat-cut osteotomy.
Reproduced with
permission and copyright
© of Springer [26]

9. Farris MK, Chowdhry VK, Lemke S, et  al.

References Osteosarcoma following single fraction radia-
tion prophylaxis for heterotopic ossifica-
1. Judet R, Judet J, Lagrange J. Gibson's postero-­external tion. Radiat Oncol. 2012;7:140. https://doi.
approach without section of the trochanter in surgery org/10.1186/1748-717X-7-140.
of femur neck fractures and in osteotomies. Presse 10. Mourad WF, Packianathan S, Shourbaji RA, et  al.
Med. 1958;66:263–4. Radiation-induced sarcoma following radiation pro-
2. Siebenrock KA, Gautier E, Ziran BH, Ganz phylaxis of heterotopic ossification. Pract Radiat
R.  Trochanteric flip osteotomy for cranial extension Oncol. 2012;2:151–4. https://doi.org/10.1016/j.
and muscle protection in acetabular fracture fixa- prro.2011.06.005.
tion using a Kocher-Langenbeck approach. J Orthop 11. Ganz R, Gill TJ, Gautier E, et al. Surgical dislocation
Trauma. 1998;12:387–91. of the adult hip a technique with full access to the fem-
3. Tosounidis TH, Giannoudis VP, Kanakaris NK, oral head and acetabulum without the risk of avascu-
Giannoudis PV.  The Kocher-Langenbeck approach: lar necrosis. J Bone Joint Surg Br. 2001;83:1119–24.
state of the art. JBJS Essent Surg Tech. 2018;8:e18. 12. Gautier E, Ganz K, Krügel N, et al. Anatomy of the
https://doi.org/10.2106/JBJS.ST.16.00102. medial femoral circumflex artery and its surgical
4. Negrin LL, Benson CD, Seligson D.  Prone or lat- implications. J Bone Joint Surg Br. 2000;82:679–83.
eral? Use of the Kocher-Langenbeck approach to 13. Beck M, Kalhor M, Leunig M, Ganz R.  Hip mor-
treat ­acetabular fractures. J Trauma. 2010;69:137–41. phology influences the pattern of damage to the
https://doi.org/10.1097/TA.0b013e3181b28ba6. acetabular cartilage: femoroacetabular impinge-
5. Letournel E, Judet R. Surgical approaches to the ace- ment as a cause of early osteoarthritis of the hip. J
tabulum. In: Elson RA, editor. Fractures of the acetab- Bone Joint Surg Br. 2005;87:1012–8. https://doi.
ulum. Berlin: Springer; 1993. p. S-363–97. org/10.1302/0301-620X.87B7.15203.
6. Sagi HC, Jordan CJ, Barei DP, et  al. Indomethacin 14. Clohisy JC, St John LC, Schutz AL.  Surgical treat-
prophylaxis for heterotopic ossification after acetabu- ment of femoroacetabular impingement: a sys-
lar fracture surgery increases the risk for nonunion of tematic review of the literature. Clin Orthop Relat
the posterior wall. J Orthop Trauma. 2014;28:377–83. Res. 2010;468:555–64. https://doi.org/10.1007/
https://doi.org/10.1097/BOT.0000000000000049. s11999-009-1138-6.
7. Davis JA, Roper B, Munz JW, et al. Does postopera- 15. Espinosa N, Rothenfluh DA, Beck M, et  al.

tive radiation decrease heterotopic ossification after Treatment of femoro-acetabular impingement: pre-
the Kocher-Langenbeck approach for acetabular liminary results of labral refixation. J Bone Joint
fracture? Clin Orthop Relat Res. 2015;474:1430–5. Surg Am. 2006;88:925–35. https://doi.org/10.2106/
https://doi.org/10.1007/s11999-015-4609-y. JBJS.E.00290.
8. Rath EMS, Russell GV, Washington WJ, Routt 16. Ganz R, Parvizi J, Beck M, et  al. Femoroacetabular
MLC. Gluteus minimus necrotic muscle debridement impingement: a cause for osteoarthritis of the hip.
diminishes heterotopic ossification after acetabular Clin Orthop Relat Res. 2003;417:112–20. https://doi.
fracture fixation. Injury. 2002;33:751–6. org/10.1097/01.blo.0000096804.78689.c2.
88 J. M. Schwab et al.

17. Ross JR, Schoenecker PL, Clohisy JC.  Surgical

23. Albers CE, Steppacher SD, Schwab JM, et  al.

dislocation of the hip: evolving indications. Relative femoral neck lengthening improves pain
HSS J. 2013;9:60–9. https://doi.org/10.1007/ and hip function in proximal femoral deformities
s11420-012-9323-7. with a high-riding trochanter. Clin Orthop Relat
18. Siebenrock KA, Anwander H, Zurmühle CA, et  al. Res. 2015;473:1378–87. https://doi.org/10.1007/
Head reduction osteotomy with additional contain- s11999-014-4032-9.
ment surgery improves Sphericity and containment 24. Sink EL, Beaulé PE, Sucato D, et  al. Multicenter
and reduces pain in Legg-Calvé-Perthes disease. study of complications following surgical dislocation
Clin Orthop Relat Res. 2014;473:1–10. https://doi. of the hip. J Bone Joint Surg Am. 2011;93:1132–6.
org/10.1007/s11999-014-4048-1. https://doi.org/10.2106/JBJS.J.00794.
19. Slongo T, Kakaty D, Krause F, Ziebarth K. Treatment 25. Espinosa N, Beck M, Rothenfluh DA, et al. Treatment
of slipped capital femoral epiphysis with a modi- of femoro-acetabular impingement: preliminary
fied Dunn procedure. J Bone Joint Surg Am. results of labral refixation. Surgical technique. J Bone
2010;92:2898–908. https://doi.org/10.2106/ Joint Surg Am. 2007;89(Suppl 2 Pt.1):36–53. https://
JBJS.I.01385. doi.org/10.2106/JBJS.F.01123.
20. Steppacher SD, Huemmer C, Schwab JM, et  al.
26. Tannast M, Siebenrock KA.  Die offene Therapie

Surgical hip dislocation for treatment of femoroac- des femoroazetabulären Impingements. Oper Orthop
etabular impingement: factors predicting 5-year sur- Traumatol. 2010;22:3–16. https://doi.org/10.1007/
vivorship. Clin Orthop Relat Res. 2014;472:337–48. s00064-010-3001-7.
https://doi.org/10.1007/s11999-013-3268-0. 27. Gibson A. Posterior exposure of the hip joint. J Bone
21. Ziebarth K, Zilkens C, Spencer S, et  al. Capital
Joint Surg Br. 1950;32-B:183–6.
realignment for moderate and severe SCFE using 28. Bastian JD, Wolf AT, Wyss TF, Nötzli HP.  Stepped
a modified Dunn procedure. Clin Orthop Relat osteotomy of the trochanter for stable, anatomic
Res. 2009;467:704–16. https://doi.org/10.1007/ refixation. Clin Orthop Relat Res. 2009;467:732–8.
s11999-008-0687-4. https://doi.org/10.1007/s11999-008-0649-x.
22. Haefeli PC, Marecek GS, Keel MJB, et  al. Patients 29. Schoeniger R, LaFrance AE, Oxland TR, et al. Does
undergoing surgical hip dislocation for the treatment trochanteric step osteotomy provide greater stability
of acetabular fractures show favourable long-term than classic slide osteotomy? A preliminary study.
outcome. Bone Joint J. 2017;99-B:508–15. https:// Clin Orthop Relat Res. 2009;467:775–82. https://doi.
doi.org/10.1302/0301-620X.99B4.37681. org/10.1007/s11999-008-0668-7.
 Extended Iliofemoral
and Combined Approaches 8
Marius J. B. Keel

Abstract Surgical hip dislocation · Intrapelvic

The indications for the extended iliofemoral approach · Pararectus approach · Floppy
(EIF) approach are transverse, T-shaped, or lateral position
both-column acetabular fracture types with
some complicating factors such as the transtec-
tal transverse fracture subtype, associated ante- 8.1  xtended Iliofemoral (EIF)
E
rior pelvic ring pathologies, sacroiliac joint Approach
injuries, a separate sciatic notch fragment,
extended posterior wall fractures, separate dome 8.1.1 Concept of EIF Approach
fracture or impaction or the late reconstruction
(>3 weeks after accident) of complex acetabular The extended iliofemoral (EIF) approach was
fractures. Due to the high incidence of compli- developed by Letournel [1]. The idea was to
cations of the EIF approach such as ectopic achieve both columns simultaneously through
ossifications and fair or poor functional out- one single anatomic approach. It provides direct
come combined approaches become more pop- access to the entire external aspect of the innomi-
ular. The simultaneous intrapelvic Pararectus nate bone from the crest to the ischial tuberosity.
approach and trochanteric flip osteotomy with In addition the internal iliac fossa can also be
surgical hip dislocation allow anatomic recon- exposed to the iliopectineal eminence and psoas
struction of complex acetabular fractures with a tendon as medial border. The dissection follows
lower incidence of complications. an interval between the muscles innervated by
the femoral nerve, which are retracted medially,
Keywords and the muscles innervated by the superior and
Complex acetabular fractures · Extended inferior gluteal neural vascular bundles, which
iliofemoral approach · Combined approaches · are retracted postero-laterally [2].

8.1.2 Surgical Technique of EIF

Approach
M. J. B. Keel (*) The patient is placed in the lateral decubitus posi-
Trauma Center Hirslanden, Clinic Hirslanden, Zürich,
Switzerland tion with a mobile leg or on a skeletal traction
e-mail: [email protected] table. The skin incision begins posteriorly at the

© Springer Nature Switzerland AG 2019 89

L. Büchler, M. J.B. Keel (eds.), Fractures of the Hip, Fracture Management Joint by Joint,
https://doi.org/10.1007/978-3-030-18838-2_8
90 M. J. B. Keel

posterior superior iliac spine and courses anteri- released. After reduction and fixation, all dis-
orly along the iliac crest. At the level of the ante- sected tendons are reattached in sequence or the
rior superior iliac spine, the distal arm of the greater trochanter and/or the ASIS are attached
incision is directed toward the supero-lateral pole with screws.
of the patella at the medial border of the tensor
muscle. The gluteal muscles and the tensor fascia
lata are subperiosteally released from the exter- 8.1.3 Indication for EIF Approach
nal aspect of the iliac wing. The sheath of the ten-
sor fascia lata is opened and the tensor muscle The indications for the EIF approach are trans-
belly is retracted laterally. The anterior superior verse, T-shaped, or both-column fracture types
spine is dissected from both arms of the expo- with some complicating factors [2]. These factors
sure. The tensor-gluteal myocutaneous flap is are the transtectal subtype in transverse or
completed by abductor tenotomy or by an oste- T-shaped fractures, associated anterior pelvic ring
otomy of the greater trochanter. The greater sci- pathologies, sacroiliac joint injuries (Fig. 8.2), a
atic notch is visualized under careful control of separate sciatic notch fragment (Fig.  8.3),
the superior gluteal neurovascular bundle. After extended posterior wall fractures or separate
identification of the sciatic nerve the short exter-
nal rotator tendons are released according to the
Kocher-Langenbeck approach. The rectus mus-
cle belly is retracted medially. Distally the
ascending branches of the lateral femoral circum-
flex vessels are ligated. The reflected head of the
rectus is dissected off the hip capsule. The exter-
nal oblique insertion on the crest is released with
the attachment of the sartorius and inguinal liga-
ment at the anterior spine. Alternatively an oste-
otomy of the anterior superior iliac spine (ASIS)
can be carried out. Finally the iliac fossa is devel-
oped completely. A marginal capsulotomy can be
made over the posterior and cranial aspect of the
joint (Fig. 8.1). As extension of the approach the Fig. 8.2  AP pelvis of a transtectal T-shaped acetabular
femoral insertion of the gluteus maximus can be fracture with an associated ipsilateral sacroiliac joint injury

Fig. 8.1  Extended iliofemoral approach in a cadaver dis-

section. The tensor-gluteal myocutaneous flap is com-
pletely mobilized with osteotomy of the greater trochanter Fig. 8.3  AP 3D computed tomography image of a both-­
and a marginal capsulotomy is done. The internal iliac column acetabular fracture with a separate sciatic notch
fossa is not yet exposed fragment
8  Extended Iliofemoral and Combined Approaches 91

dome fracture or impaction. In addition late 8.2 Combined Approaches

reconstruction (>3 weeks after accident) of com-
plex acetabular fractures is also a classic indica- 8.2.1 Concept and Indications
tion for the EIF approach. The use of the EIF of Combined Approaches
approach was decreased in the series of Matta by
the increased experiences for single approaches As alternative to the EIF approach anterior and
like the ilioinguinal or the Kocher-­Langenbeck posterior approaches can be combined for com-
approaches [3]. In a retrospective study, increase plex approaches. This can be carried out sequen-
in single approach surgery resulted in shorter tially or simultaneously. If the anterior approach
mean surgical time, significant increase in ana- is followed by the posterior approach or vice
tomical reduction, and reduction of frequency of versa in the same operation or in two separate
intra- and postoperative complications [4]. operations the fixation of the anterior or posterior
column should not block the opposite column in
a malposition. The indications for combined
8.1.4 Complications and Outcome approaches are the similar like for the EIF
of EIF approach.

The advantage of the EIF for complex acetabular

fractures is the concept of one single anatomic 8.2.2 Techniques of Combined
approach. However the approach is at risk for Approaches
infections, heterotopic ossifications, total flap
necrosis, and prolonged postoperative morbidity Routt described the open reduction and internal
due to the devascularization of the innominate bone fixation through combined anterior and poste-
and the gluteus medius and minimus muscles [2]. rior exposures during the same period of anes-
In a series of Matta with 106 patients involving thesia in a sequential procedure [7]. The
in 60% both-column fractures, 64% good or excel- simultaneous use of the ilioinguinal and Kocher-
lent results could be observed 6.3  years (2–17) Langenbeck approaches in floppy lateral posi-
postoperatively [5]. 36% developed fair or poor tion was primarily described in 1989 by Goulet
results. Functional outcome correlated significantly [8]. However these simultaneous approaches are
with the accuracy of the reduction. The reduction technically complicated by the limitations of
was graded as anatomical (0–1  mm of displace- both approaches in the semi-lateral position.
ment) in 72%, imperfect (2–3  mm) in 22%, and The combination of an intrapelvic approach, the
poor (>3 mm) in 6%. Operation was undertaken in modified Stoppa or especially the Pararectus
less than 3 weeks after injury in 67% and in 33% approach [9], with the trochanteric flip osteot-
the procedure was carried out later. Significant het- omy and surgical hip dislocation is easier to
erotopic ossification developed in 30% and was proceed and allows an absolute anatomic reduc-
associated with a worse outcome. tion because of the full exposure of the joint and
In a series of 50 cases published by Stöckle in the verification of the anatomic reduction [10].
2002 complications included 8% loss of reduc- The success of the c­ombined approaches
tion, 13% significant heterotopic ossifications, depends on the experience of the surgeon carry-
and 4% avascular femoral head necrosis [6]. At ing out each single approach.
the two-year follow-up there were 74% good or
excellent radiographic and clinical results. Four
patients had already total hip replacements. In 8.2.3 Complications and Outcome
summary, between 30% and 40% of complex of Combined Approaches
acetabular fractures operated through the EIF
approach ended in fair or poor results with a high Goulet showed in his series of 31 cases excellent
incidence of ectopic ossifications. The use of the in 35% and good results in 42% [8]. Routt
EIF approach is finally a risk for poor outcome achieved in 24 cases anatomic reduction in 88%.
with implantation of a total hip arthroplasty [3]. Significant ossifications developed in 16%. In
92 M. J. B. Keel

another series of ten patients with sequential ilio- rate of anatomical reduction in 28% [12]. Clinical
inguinal and Kocher-Langenbeck approaches, and radiological results of combined intrapelvic
only in three patients of seven patients anatomic and posterior approaches are missing. However,
reduction could be achieved [11]. Moroni pub- first experiences as shown by the presented cases
lished 18 patients affected by both-column frac- (Figs. 8.4 and 8.5) demonstrate excellent results
tures operated on by staged combined ilioinguinal with a low incidence of complications.
and Kocher-Langenbeck approaches with a low

a b

Fig. 8.4  46 year old man with transtectal T-shaped frac- with retractors and reduction clamps in situ (e) and into
ture and a femoral head impaction on the left side after ski the joint after anatomic reduction and fixation (f) in the
accident. AP pelvis (a) and axial CT cuts on the dome floppy lateral position. Postoperative AP pelvis (g) and
level (b) and distally with the displacement in the poste- axial CT cut on the dome level (h) with demonstration of
rior column and impaction of the femoral head (c). the anatomic reconstruction. AP pelvis (i) 2  years after
Intraoperative views on the femoral head impaction dur- surgery of the pain-free patient
ing surgical hip dislocation (d), the Pararectus approach
8  Extended Iliofemoral and Combined Approaches 93

g h

Fig. 8.4 (continued)

a b

Fig. 8.5  62 year old man with juxtatectal T-shaped frac- of the reduction maneuver of the sacroiliac joint on the
ture on the left side, a posterior hip dislocation on the right right side with a Jungbluth clamp (c) and the plates on the
side with a transtectal transverse fracture and associated anterior column and the symphysis through the Pararectus
sacroiliac joint dislocation on the right side and symphy- approach on the right side (d) in the second operation in
sis dislocation after a bicycle accident. AP pelvis after the same anesthesia. AP pelvis postoperatively (e) and
closed reduction of the right hip (a). Intraoperative view 8 months after surgery with equal bilateral hip functions
of the floppy lateral position for the reconstruction of the however with some ectopic ossifications (f)
left hip joint (b) in the first operation. Intraoperative views
94 M. J. B. Keel

c d

e f

Fig. 8.5 (continued)

7. Routt ML Jr, Swiontkowski MF. Operative treatment

References of complex acetabular fractures. Combined anterior
and posterior exposures during the same procedure. J
1. Letournel E.  Les fractures du còtyle. Etude d’une Bone Joint Surg Am. 1990;72:897–904.
serie de 75 cas. J Chir. 1961;87:83–92. 8. Goulet JA, Bray TJ.  Complex acetabular fractures.
2. Mayo KA.  Surgical approaches to the acetabulum. Clin Orthop Relat Res. 1989;240:9–20.
Tech Orthip. 1990;4:24–35. 9. Keel MJB, Ecker TM, Cullmann JL, Bergmann M,
3. Tannast M, Najibi S, Matta JM. Two to twenty-year Bonel HM, Büchler L, Siebenrock KA, Bastian
survivorship of the hip in 810 patients with opera- JD.  The Pararectus approach for anterior intrapelvic
tively treated acetabular fractures. J Bone Joint Surg management of acetabular fractures. An anatomical
Am. 2012;94:1559–67. study and clinical evaluation. J Bone Joint Surg Br.
4. Gusic N, Sabalic S, Pavic A, Ivkovic A, Sotosek-­ 2012;94-B:405–11.
Tokmadzic V, Cicvaric T.  Rationale for more con- 10. Keel MJB, Ecker TM, Siebenrock KA, Bastian
sistent choice of surgical approaches for acetabular JD. Rationales for the Bernese approaches in acetabular
fractures. Injury. 2015;46S:S78–86. surgery. Eur J Trauma Emerg Surg. 2012;38:489–98.
5. Griffin DB, Beaulé PE, Matta JM. Safety and efficacy 11. Guerado E, Cano JR, Cruz E.  Simultaneous ilioin-
of the extended iliofemoral approach in the treatment guinal and Kocher-Langenbeck approaches for the
of complex fractures of the acetabulum. J Bone Joint treatment of complex acetabular fractures. Hip Int.
Surg (Br). 2005;87-B:1391–6. 2010;20(Suppl 7):S2–S10.
6. Stöckle U, Hoffmann R, Südkamp NP, Reindl R, 12. Moroni A, Caja VL, Sabato C, Zinghi G.  Surgical
Haas NP. Treatment of complex acetabular fractures treatment of both-column fractures by staged
through a modified extended iliofemoral approach. J combined ilioinguinal and Kocher-Langenbeck
Orthop Trauma. 2002;16:220–30. approaches. Injury. 1995;26:219–24.
 Traumatic Hip Dislocations
9
Mark Rickman and Lorenz Büchler

Abstract anesthesia to assess stability aids planning and

Pure hip dislocations are relatively unusual, but early post-operative mobility is probably benefi-
represent an injury with significant capacity for cial. Surgery is reserved for irreducible disloca-
resulting in long-term disability. The femoral tions, associated fractures, incongruence after
head most commonly dislocates posteriorly reduction, or significant instability found at
(80–90%), typically caused by axial force on examination under anesthesia (EUA).  Long-
the femur with the hip flexed as seen in dash term hip outcomes are mostly excellent or good,
board injuries. Concomitant pathomorphologies but avascular necrosis (AVN) and post-injury
of the hip such as cam-type impingement, or arthritis affect up to 20% of cases. Associated
femoral retrotorsion are a risk factor for poste- injuries are common in this group, and often
rior dislocation. Anterior dislocations are not determine the overall patient outcome.
that unusual, forming approximately 10% of
most series. Other forms of pure dislocation are Keywords
very unusual, i.e. obturator and central disloca- Hip · Joint dislocation · Traumatic dislocation ·
tion and are mostly a fracture dislocation. Early Obturator dislocation · Femoral head · Open
reduction is essential to improve outcome, and reduction · Closed reduction · Hip outcome
certainly within 12 h of injury, although as early
as is safely possible is ideal. CT scanning is the
current standard imaging; examination under
9.1 Epidemiology, Mechanism
of Injury

The hip is an intrinsically stable joint, with the

femoral head typically well seated within the
M. Rickman (*) acetabulum. Stability is further improved by sur-
Centre for Orthopaedic and Trauma Research, rounding musculature, as well as the labrum,
Discipline of Orthopaedics and Trauma, University of
capsule and associated thickenings/ligaments
Adelaide, Adelaide, SA, Australia
(especially iliofemoral ligament and zona orbicu-
Department of Orthopaedics and Trauma, Royal
laris), and the ligamentum teres. The energy
Adelaide Hospital, Adelaide, SA, Australia
e-mail: [email protected] required to dislocate a native hip joint therefore is
immense, and as a result concomitant life-­
L. Büchler
Department of Orthopaedic Surgery, Kantonsspital threatening injuries and fractures are reported to
Aarau, Aarau, Switzerland occur in up to 95% of cases [1]. Apart from ace-
© Springer Nature Switzerland AG 2019 95
L. Büchler, M. J.B. Keel (eds.), Fractures of the Hip, Fracture Management Joint by Joint,
https://doi.org/10.1007/978-3-030-18838-2_9
96 M. Rickman and L. Büchler

tabular fractures, imaging must therefore be care- Post-traumatic arthritis is the commonest
fully scrutinized to identify femoral head or neck long-term complication of hip dislocation, pri-
fractures, and patients carefully examined look- marily as a result of the joint surface damage sus-
ing for distant injuries. Posterior dislocations tained, combined with effects from retained loose
commonly occur in conjunction with knee inju- bodies and subtle post-injury instability.
ries and are most frequently seen in drivers of Avascular necrosis is the second most common
vehicles, prompting the theory of a dashboard and severe complication. The exact incidence of
strike as the mechanism; however, other theories AVN remains unclear in the literature, and AVN
have been put forward including a brake-pedal rates are reported in the range of 1–15% [11–14].
injury [2]. Sciatic nerve injuries are seen in In the past treatment involved a long period of
around 10% of posterior dislocations [3], and traction but it is now recognized that there seems
more likely to occur with delayed reduction [4] . to be no correlation between the period of traction
As well as direct injuries, the blood supply to the and the incidence of either avascular necrosis or
femoral head can be compromised by this injury, recurrent instability following hip dislocation. It
resulting in avascular necrosis. remains unknown whether early weight bearing
Epstein et  al. postulated that posterior affects outcome [5, 15]. The importance of imme-
impingement at the extreme of external rotation diate reduction of the dislocation is also difficult to
acts as a lever, to force the femoral head anteri- state with any certainty. The purest series, that is
orly [5]. Upadhyay et  al. found a decrease in with the longest follow-­up, is that published by
femoral anteversion in a group of patients who Upadhyay and Moulton in 1981 [16]. They had 53
had suffered a posterior dislocation, suggesting posterior dislocations without fracture, in a series
that the hip would impinge during internal rota- of over 80 cases. The follow-up was greater than
tion and posterior dislocation would then occur 10  years in 55 of these cases, and the avascular
[6]. More recently several authors have linked necrosis rate of the whole series was 6%, which is
cam-type femoro-acetabular impingement to in the midrange of other authors on the topic. The
posterior dislocation through a similar postulated numbers of avascular necrosis in Upadhyay’s
mechanism [7–10]. paper were too small to give any indication regard-
No matter what the exact mechanism, there is ing the timing of relocation and avascular necrosis
significant contact between the femoral head and rate although in both dislocations that were missed
acetabular rim at the time of dislocation, with a avascular necrosis developed and subsequently
combination of compression and shear forces; had a poor outcome. However, Reigstad reported
this frequently results in either an acetabular rim no incidences of AVN in hips reduced within 6 h,
fracture or chondral damage to the femoral head and Hougard similarly showed poorer results in
or acetabulum. It is generally believed that an hips dislocated for longer than this in a series of
anterior dislocation will fare worse than a poste- 127 cases. Kellam and Ostrum [17] published a
rior one, in view of the femoral head damage systematic review of the literature on this issue in
typically being posterior in these cases—how- 2015, and concluded that AVN was approximately
ever there is a paucity of evidence in the literature twice as likely to occur after posterior dislocations
either to confirm or refute this. compared to anterior, and that reduction before
As the femoral head dislocates, the ligamen- 12 h has a significant effect on the likely risk of
tum teres is necessarily rendered incompetent. AVN overall. There is no evidence that anything
True ligament ruptures occur, but frequently less than 6 h has a significant effect, thus reduction
there is a bony avulsion from either the femoral should be planned as soon as is feasible, but not
head (which can lead to a significant femoral rushed in an unsafe manner. Any dislocation that is
head injury) or from the foveal surface; these missed for a significant period will result in a
bony avulsions often come to lie in the joint after poorer outcome with a higher incidence of avascu-
reduction, causing incongruence and further lar necrosis, osteoarthritis, and subsequent require-
damage if not retrieved. ment for arthroplasty.
9  Traumatic Hip Dislocations 97

9.2 Clinical and Radiographic It is critical to examine the patient at this stage

Assessment for signs of neurological or vascular compro-
mise, and to document these findings; the discov-
Most orthopedic surgeons are familiar with ery of sciatic nerve palsy after a closed reduction
patients presenting with dislocated total hip of a dislocated hip is impossible to interpret with-
replacements, and the position of the leg; dislo- out sound knowledge of the pre-reduction state,
cated native hips are little different from a clini- and can lead to unnecessary urgent surgery.
cal perspective, with the exception of the higher In most hospitals, the initial imaging will
energy involved. Posterior dislocations (Fig. 9.1) involve a simple plain AP pelvic radiograph. The
will tend to result in the lower limb becoming vast majority of dislocations are easily identified
fixed in internal rotation with or without flexion on plain films, but both the direction of disloca-
and adduction, and anterior dislocations (Fig. 9.2) tion and associated injuries can be much more
typically result in external rotation, abduction, difficult to elucidate. CT scanning allows a more
and extension. Obturator dislocations have a formal assessment of the injury; if one studies
more variable position, but the main defining fac- pre-operative radiographs and CT scans care-
tor is typically that the leg rests in a degree of fully, it is often possible to identify small poste-
abduction. rior wall flake fractures and hence these really

a b

Fig. 9.1 (a) AP radiograph of a posterior hip dislocation at presentation. (b) CT scan of the same case, showing the
femoral head locked behind the posterior acetabulum

a b

Fig. 9.2 (a) AP radiograph of an anterior hip dislocation at presentation. (b) CT scan of the same case, showing the
direction of dislocation more clearly
98 M. Rickman and L. Büchler

Fig. 9.3  Classification of Traumatic Hip Dislocations lum, with or without major fragment. (4) With fracture of
from Thompson & Epstein. (1) With or without minor acetabular rim and floor. (5) With fracture of femoral
fracture. (2) With large single fracture of posterior acetab- head. Reproduced with permission and copyright © of
ular rim. (3) With comminuted fracture of rim of acetabu- Springer [19]

need to be classified as wall fractures rather than (Fig. 9.3). Only Type 1 was said to be “with or with-
pure dislocations. out minor fracture.” Nevertheless, this is a useful
The role of MRI scanning remains controver- and widely applied classification, and their results
sial. Whilst it may add useful information regard- show nicely that from 116 cases, the anterior dislo-
ing the vascularity of the femoral head [18] as cations fared well, and 20 of 30 Type 1 posterior
well as identify labral or chondral damage, its dislocations had good or excellent outcomes com-
main role remains as an adjunct to follow-up, or pared to only 13 of 68 Types 2–5. It must be noted
for investigation of the incongruent hip after though that a good result in this report allowed for a
reduction, especially in skeletally immature 25% decrease in range of motion with minimal
patients. X-ray changes (at a mean of 3 years and 9 months),
and it is likely that these cases would deteriorate and
become arthritic in time.
9.2.1 Classification

Classification of hip dislocation can either be 9.3 Reduction and Assessment/

done based on direction or associated injuries. In Decision Making
its pure form (i.e., without any associated acetab-
ular or femoral head fractures) the dislocated hip All pure dislocations will require reduction. In the
can be classified as being posterior, anterior, or absence of a femoral neck fracture this is gener-
obturator in decreasing order of frequency. ally possible using manual maneuvers, but
Central fracture-dislocations are also often requires muscle relaxation in the form of either
described, but these represent an acetabular frac- heavy sedation or general anesthesia. In addition,
ture with medial displacement of the femoral immediate confirmation of reduction using image
head, rather than a true dislocation. This descrip- intensifier is necessary, and some assessment of
tive classification helps the treating surgeon when the level of instability is helpful, and for these rea-
thinking about reduction maneuvers, and has sons it is desirable for reduction to be performed
some prognostic information with regard to AVN where possible in the operating theater. However,
rates and possibly long-term outcomes. a balance needs to be struck between these desires
The most commonly used injury related classifi- and the need for rapid reduction. If immediate or
cation is that of Thompson and Epstein [11], very early access to an environment where image
although all five of their categories potentially had intensifier is available is not p­ ossible, then reduc-
associated fractures, types 2–4 had acetabular frac- tion in the emergency department is reasonable
tures and type 5 had femoral head fractures provided safe sedation is available.
9  Traumatic Hip Dislocations 99

9.3.1 Reduction Methods 9.3.2 Failed Reduction

In basic terms, reduction of a dislocated joint If closed reduction is not possible, then open
requires traction with or without rotational reduction is mandated. This situation requires
maneuvers, and some form of counter-traction. careful planning around the surgical skills avail-
Regardless of the direction of dislocation, man- able—not only is the surgical approach more dif-
ual in line traction will reduce many dislocations. ficult due to displaced structures, but ideally any
Two more advanced methods for reduction of a associated injuries should be dealt with at the same
dislocated hip have been described. time. This situation confers a poorer prognosis—
Allis [20] described his technique over McKee et al. [27] recorded a series of 25 patients
100 years ago. The patient is supine, and counter-­ with high-energy dislocations that could not be
traction applied to the pelvis—in the original reduced closed. Not surprisingly there were a high
report this was done with bandages passed incidence of other injuries including sciatic nerve
through hooks in the floor, running up and over palsy (28%), femoral head or neck fractures
the pelvis, more commonly an assistant will place (36%), and only 6 of the 25 patients had a good or
each hand on an anterior superior iliac spine and excellent outcome. Canale and Manugian [28]
hold the pelvis still. With the hip and knee both also discussed the irreducible hip, and described
flexed to 90° traction is applied in a vertical direc- the causes as being the femoral head button-holed
tion, with the addition after a few seconds of sus- through the capsule, or piriformis being displaced
tained traction of slight adduction/rotation in across the acetabulum. In cases with associated
order to facilitate the femoral head clearing the fractures, a large intra-­ articular bone fragment
lip of the acetabulum. In order to gain mechanical may prevent reduction; in addition, if there is a
advantage the surgeon must be above the large posterior wall fracture, then reduction can be
patient—this is typically achieved either by the unstable enough that it appears impossible to
patient being very close to (or on) the floor or by reduce the hip, whereas reduction is in fact
the surgeon standing on the bed; this maneuver is achieved but stability is impossible.
very difficult if not impossible to do with the sur- If an open reduction is necessary, then a CT is
geon standing on the floor and the patient in bed mandated prior to surgery; this will give essential
at a routine height. information regarding associated injuries and
Stimson [21] described a gravity assisted possible causes for failed reduction which may
method even earlier—in 1889. This technique impact directly on the proposed procedure.
involves having the patient lie prone, with the
affected leg hanging off the side of the bed. The
hip and knee are again flexed to 90°, and traction 9.3.3 Assessment of Reduction
applied this time to the back of the calf. This
maneuver is in fact the same as the Allis maneu- After closed reduction, careful assessment of the
ver, but as it is gravity assisted it is mechanically imaging is required to assess congruence. In
easier to perform. It has the disadvantage how- some cases, a plain film will show a perfect
ever of requiring a prone patient, which in the reduction, and it is safe to plan further manage-
trauma situation is rarely possible in a safe ment; however in a number of cases, although the
manner. hip will be relocated, incongruence is seen as a
Numerous other techniques have been result of either bone, cartilage or labrum typically
described [22–26], most of which in various being interposed between the joint surfaces
forms attempt to increase the mechanical advan- (Figs.  9.4, 9.5 and 9.6). Any doubt regarding
tage of the surgeon, using either a fulcrum or ­congruence should lead to further imaging. CT
assistants. scanning will show incongruent reductions and
100 M. Rickman and L. Büchler

a b

Fig. 9.4 (a) AP radiograph of a hip showing posterior hip dislocation. (b) AP radiograph after reduction showing an
incongruent joint with a slightly increased joint space

Fig. 9.5  CT scanning revealed a loose fragment in the

joint

bone fragments well, is typically more readily

available but involves radiation; MRI scanning
whilst being less easy to organize in most institu- Fig. 9.6  The loose body was retrieved arthroscopically—
tions will give additional information regarding the AP film subsequently shows a congruent hip joint
the labrum, and any other associated soft tissue
damage that may be causing incongruence. The meaning that the role of MRI scanning remains
accuracy of MRI scanning for assessment of predominantly in the follow-­up phase, or rarely
chondral injuries however appears less good, for cases where CT has demonstrated no cause
with Tannast et al. [18] reporting observed chon- for post-reduction incongruence.
dral injuries in only 16–21% of cases, whereas Of note—there are a number of cases where
surgery on the same cases revealed damage in reduction is congruent, but CT scanning shows a
67%. In practice, CT scanning gives more rele- small fragment of bone sitting in the acetabular
vant information and is simpler to organize, fossa. Provided the fragment is definitely not
9  Traumatic Hip Dislocations 101

interposed between the articular surfaces, then it “remind” patients of their injury, as symptoms
is safe for this small fragment to be left alone; in subside over the early weeks.
most cases, it will be seen to be resorbed and dis-
appear over time, after having become locked in
place in the fossa by early scar tissue. 9.5 Operative Treatment

The only absolute indications for operative man-

9.3.4 Assessment of Stability agement of a pure hip dislocation are the irreduc-
ible hip and the incongruent reduction. Relative
After reduction (whether open or closed), an indications are instability demonstrated at EUA,
assessment of instability is helpful for further repair of large soft tissue lesions identified on
management decisions. Typically the hip is flexed MRI scanning, and surgery to assess chondral
to 90°, then internal rotation/abduction applied impaction identified on CT scanning.
until the hip is seen to start to sublux (or external The irreducible hip is an emergency situation,
rotation/adduction for anterior dislocations). whereas the incongruent hip can be delayed for a
After a closed reduction, a very unstable hip day or two if necessary; most surgeons would
requires careful consideration of surgical explo- apply traction in the meantime to avoid further
ration and repair; in most cases, there is a signifi- articular damage as a result of the interposed
cant tear in the capsule, as well as labral structures. Surgery for instability, soft tissue
detachment. Again, these are well visualized on lesions or femoral head damage can be planned
MRI scanning, although the decision is aided more leisurely, but should still ideally be per-
more by stability testing than imaging. Stable, formed within a few days.
congruent hips can be managed non-operatively The choice of surgical approach is made based
with the expectation of good results, even in the on injury factors as well as the skills of the sur-
presence of soft tissue damage. geon; most pure dislocations with or without
femoral head damage can be safely approached
via lateral or posterior approach, and a trochan-
9.4 Conservative Treatment teric osteotomy added if necessary. This will give
access to the entire posterior capsule and labrum,
Until fairly recently these injuries were managed as well as the entire femoral head if chondral
with differing amounts of bed rest and traction, injuries are to be addressed. However, for irre-
with the presumed benefit of avoiding re-­ ducible anterior dislocations an anterior approach
dislocation, allowing the soft tissues to heal, and (e.g. Smith-Petersen) is recommended, as the
limiting joint damage by avoiding weight bearing block to reduction is more likely to be out of the
in this potentially unstable phase. However, if the field of view of a posterior approach, even after a
hip is proven to be stable on testing, then careful trochanteric osteotomy. In all approaches per-
activity management should avoid re-dislocation; formed for irreducible dislocations, extreme care
more recent papers have shown no disadvantage must be taken as structures are displaced from
to early weight bearing, and in fact the opposite their usual positions, and often under tension.
may in fact be true [29]. Femoral head impaction lesions or abrasion of
Patients with pure dislocations that have the cartilage are difficult to manage, and undoubt-
been reduced anatomically and shown on exam- edly have a negative effect on overall long-term
ination under anesthetic to be stable can there- outcomes. Management options are the same as
fore be managed simply with full weight discussed in Chap. 11, Pipkin Fractures. As well
bearing as soon as the patient is comfortable. It as achieving anatomic joint reduction, the soft
is prudent to avoid flexion beyond 90° for tissues should be repaired as far as possible, in
6  weeks, and internal rotation beyond 10°. A order to achieve stability. This involves repairing
pair of crutches for 6 weeks may also serve to the labrum where torn, as well as closing the
102 M. Rickman and L. Büchler

damaged capsule and reattaching any torn ten- 9.6 Overall Outcomes
dons when possible.
The two largest series of anterior dislocation of
the hip were reported by Epstein in 1980 and
9.5.1 H
 ip Arthroscopy After Brav in 1962. There were 54 cases with a mean
Dislocation follow-up of 17 months in Epstein’s series and 34
cases with a mean follow-up of 18  months in
In recent years, interest has increased in the role Brav’s—88 cases in all. Drainhoffer et al. in 1994
of hip arthroscopy after hip dislocations. Use of have reported a further 12 cases with a mean fol-
hip arthroscopy can be divided into early (pre- low-­up of 8 years.
dominantly removal of loose bodies or labral The overall incidence of an excellent or good
repair) or late (similar indications, but also allow- result (using Thompson/Epsteins method) was
ing assessment of healed chondral surfaces). 76%, with a quarter being fair or poor. There was a
Keene and Villar [30] were the first to publish 5% avascular necrosis rate. Post-traumatic arthritis
two case reports of arthroscopic loose body was 17% and myositis ossificans was seen in 4%.
removal after hip relocation—they also stressed Thompson & Epstein’s series and classifica-
the importance of careful joint distraction to avoid tion of posterior dislocation types I, II, III, IV,
further damaging the femoral head blood supply. and V are difficult to interpret as they are almost
Mullis and Dahners [31] reported 36 patients combining posterior dislocation with some form
undergoing hip arthroscopy after dislocated hips of acetabular fracture in three of the five
at a mean of 15  days, with no specific clinical injuries.
indication. They found loose bodies in 92% of Upadhyay described the long-term (mean
cases, but no patient outcomes were provided. 14.5 years) outcome of 74 simple posterior dislo-
Wylie et al. [32] performed arthroscopies on cations, presumably managed by only closed
12 cases of dislocation (11 within 30  days of methods. 56 (76%) hips had good or excellent
injury), performed for ongoing hip symptoms, results, but six hips had developed AVN by
and found eight patients to have loose bodies 3 years, and a further 16% developed osteoarthri-
and the same number to have labral injuries. tis. Manual laborers fared much worse, with the
Patient outcomes however were again not given incidence of osteoarthritis in patients injured in
in the paper. mining accidents as high as 45%.
A summary of the available literature regard- CT scanning was not widely available at the
ing hip arthroscopy after dislocation would be time of any of these reports, and one of the rea-
that it is possible to treat specific lesions identi- sons for the poor results is the fact that although
fied on imaging, and routine arthroscopy may the acetabular rim does not break, the femoral
identify previously unappreciated pathology, but head will be indented and impacted; these inju-
whether this translates into any clinical benefit ries would have gone undetected, whereas today
for the patient is yet to be proven. they are more likely to be seen and addressed.
One of the concerns regarding early hip However, no large series of patients exist using
arthroscopy after dislocation is the possibility of modern imaging and treatment methods.
fluid extravasation and the development of com-
partment syndrome. Whilst case reports [33] of
abdominal compartment syndrome exist, there References
are none within the literature at the present time
related to post-traumatic hip arthroscopies; nev- 1. Hak DJ, Goulet JA.  Severity of injuries associated
ertheless, it remains a theoretical risk, and one with traumatic hip dislocation as a result of motor
vehicle collisions. J Trauma. 1999;47(1):60–3.
which surgeons must bear in mind. Mullis stated 2. Monma H, Sugita T. Is the mechanism of traumatic pos-
that extravasation was commonly seen, but had terior dislocation of the hip a brake pedal injury rather
not resulted in any clinical problems. than a dashboard injury? Injury. 2001;32(3):221–2.
9  Traumatic Hip Dislocations 103

3. Cornwall R, Radomisli TE.  Nerve injury in trau- 18. Tannast M, Pleus F, Bonel H, Galloway H, Siebenrock
matic dislocation of the hip. Clin Orthop Relat Res. KA, Anderson SE.  Magnetic resonance imaging in
2000;377:84–91. traumatic posterior hip dislocation. J Orthop Trauma.
4. Hillyard RF, Fox J.  Sciatic nerve injuries associated 2010;24(12):723–31.
with traumatic posterior hip dislocations. Am J Emerg 19. Kanakaris NK, Giannoudi MP. Fractures-dislocations
Med. 2003;21(7):545–8. of the hip. In: Lasanianos NG, Kanakaris NK,
5. Epstein HC.  Traumatic dislocations of the hip. Clin Giannoudis PV, editors. Trauma and orthopaedic
Orthop Relat Res. 1973;92:116–42. classifications. A comprehensive overview. London:
6. Upadhyay SS, Moulton A, Burwell RG.  Biological Springer; 2014. p. 293–8.
factors predisposing to traumatic posterior dislocation 20. Allis OH. XI. Everted dorsal dislocations of the hip.
of the hip. A selection process in the mechanism of Ann Surg. 1911;54(3):371–80.
injury. J Bone Joint Surg. 1985;67(2):232–6. 21. Stimson LA. Five cases of dislocation of the hip. Clin
7. Steppacher SD, Albers CE, Siebenrock KA, Tannast Orthop Relat Res. 1988;231:3–6.
M, Ganz R.  Femoroacetabular impingement pre- 22. Dahners LE, Hundley JD.  Reduction of posterior

disposes to traumatic posterior hip dislocation. Clin hip dislocations in the lateral position using traction-­
Orthop Relat Res. 2013;471(6):1937–43. countertraction: safer for the surgeon? J Orthop
8. Berkes MB, Cross MB, Shindle MK, Bedi A, Kelly Trauma. 1999;13(5):373–4.
BT. Traumatic posterior hip instability and femoroac- 23. Lefkowitz M. A new method for reduction of hip dis-
etabular impingement in athletes. Am J Orthop (Belle locations. Orthop Rev. 1993;22(2):253–6.
Mead NJ). 2012;41(4):166–71. 24. Marya SK, Samuel AW.  Piggy back technique for
9. Manner HM, Mast NH, Ganz R, Leunig M. Potential relocation of posterior dislocation of the hip. Injury.
contribution of femoroacetabular impingement to 1994;25(7):483–4.
recurrent traumatic hip dislocation. J Pediatr Orthop 25. Nordt WE 3rd. Maneuvers for reducing dislocated
B. 2012;21(6):574–8. hips. A new technique and a literature review. Clin
10. Krych AJ, Thompson M, Larson CM, Byrd JW,
Orthop Relat Res. 1999;360:260–4.
Kelly BT. Is posterior hip instability associated with 26. Schafer SJ, Anglen JO. The East Baltimore lift: a sim-
cam and pincer deformity? Clin Orthop Relat Res. ple and effective method for reduction of posterior hip
2012;470(12):3390–7. dislocations. J Orthop Trauma. 1999;13(1):56–7.
11. Thompson VP, Epstein HC. Traumatic dislocation of 27. McKee MD, Garay ME, Schemitsch EH, Kreder HJ,
the hip; a survey of two hundred and four cases cover- Stephen DJ.  Irreducible fracture-dislocation of the
ing a period of twenty-one years. J Bone Joint Surg hip: a severe injury with a poor prognosis. J Orthop
Am. 1951;33-a(3):746–78. Trauma. 1998;12(4):223–9.
12. Upadhyay SS, Moulton A, Srikrishnamurthy K.  An 28. Canale ST, Manugian AH.  Irreducible traumatic

analysis of the late effects of traumatic posterior dislo- dislocations of the hip. J Bone Joint Surg Am.
cation of the hip without fractures. J Bone Joint Surg. 1979;61(1):7–14.
1983;65(2):150–2. 29. Schlickewei W, Elsasser B, Mullaji AB, Kuner

13.
Paus B.  Traumatic dislocations of the hip; EH. Hip dislocation without fracture: traction or mobi-
late results in 76 cases. Acta Orthop Scand. lization after reduction? Injury. 1993;24(1):27–31.
1951;21(2):99–112. 30. Keene GS, Villar RN.  Arthroscopic loose body

14. Stewart MJ, Milford LW.  Fracture-dislocation of
retrieval following traumatic hip dislocation. Injury.
the hip; an end-result study. J Bone Joint Surg Am. 1994;25(8):507–10.
1954;36(A:2):315–42. 31. Mullis BH, Dahners LE. Hip arthroscopy to remove
15. Brav EA.  Traumatic dislocation of the hip. JBJS.
loose bodies after traumatic dislocation. J Orthop
1962;44-A:1115–34. Trauma. 2006;20(1):22–6.
16. Upadhyay SS, Moulton A.  The long-term results of 32. Wylie JD, Abtahi AM, Beckmann JT, Maak TG,

traumatic posterior dislocation of the hip. J Bone Joint Aoki SK.  Arthroscopic and imaging findings after
Surg. 1981;63b(4):548–51. traumatic hip dislocation in patients younger than
17. Kellam P, Ostrum RF.  Systematic review and meta-­ 25 years of age. J Hip Preserv Surg. 2015;2(3):303–9.
analysis of avascular necrosis and posttraumatic 33. Fowler J, Owens BD.  Abdominal compartment

arthritis after traumatic hip dislocation. J Orthop syndrome after hip arthroscopy. Arthroscopy.
Trauma. 2016;30(1):10–6. 2010;26(1):128–30.
 Acetabular Fractures
10
Ippokratis Pountos and Peter V. Giannoudis

Abstract 10.1 Epidemiology

Acetabular fractures are the result of high-­ and Mechanism of Injury
energy trauma in young individuals or low-­
energy impacts in elderly. They are rare Acetabular fractures are rare injuries that are
injuries and can be associated with morbidity associated with significant morbidity and mortal-
and mortality. These injuries constitute a chal- ity. Their incidence in the USA and Europe has
lenging joint-reconstruction problem. The remained unchanged over the years. The annual
goal of surgery is to restore the congruency of incidence of pelvic fractures is approximately
the joint and minimize or prolong the appear- 35–40 cases per 100,000 population. Acetabular
ance of arthritis. A step or gap of more than fractures are only seen in about 10% of these
2  mm is regarded an indication for surgery. cases [1, 2].
Our armamentarium includes a variety of The epidemiology of acetabular fractures
approaches and implants for the fixation of shows a bimodal age distribution. The first peak
these injuries. Primary arthroplasty has a role represents young adults sustaining high-energy
in the management of acetabular fractures trauma following motor vehicle collisions or falls
especially in elderly individuals with pre-­ from height. The second peak corresponds to
existing osteoarthritis, and severe impaction older patients with decreased bone density and
with a compromised bone stock. low-energy injuries. It has been previously esti-
mated that approximately 80% of acetabular
Keywords fractures are the result of motor vehicle collisions
Acetabular fractures · Pelvis · Trauma · and 11% the outcome of falls [3]. The implemen-
Triradiate cartilage · Internal fixation · Total tation of strict road safety regulations has
hip arthroplasty decreased the incidence of high-energy acetabu-
lar fractures, but on the other hand, low-energy
fractures are becoming increasingly common due
to the increased life expectancy together with a
more active lifestyle [4]. Some studies quantify
the incidence of low energy acetabular fracture to
25% of all acetabular fractures [5–7]. It is possi-
I. Pountos · P. V. Giannoudis (*) ble that the observed increase in the incidence of
Academic Department of Trauma & Orthopaedics,
School of Medicine, University of Leeds, Leeds, UK acetabular fractures in elderly is also due to
e-mail: [email protected] increased diagnosing, as computed tomography

© Springer Nature Switzerland AG 2019 105

L. Büchler, M. J.B. Keel (eds.), Fractures of the Hip, Fracture Management Joint by Joint,
https://doi.org/10.1007/978-3-030-18838-2_10
106 I. Pountos and P. V. Giannoudis

(CT) scans are readily available in the assessment 10.2 Clinical and Radiological
of hip pain after simple low energy falls. Evaluation
There is a male preponderance to the acetabu-
lar fractures, which is evident in the elderly as An acetabular fracture can be the result of signifi-
well. This later finding contrasts with common cant trauma and can be associated with other life-­
fragility fractures like distal radius and hip frac- threatening injuries. Consequently, trauma
tures which have a strong female predominance patients should be initially assessed and managed
[2, 5]. Common associated injuries in high-­ according to Advanced Trauma Life Support
energy acetabular fractures include pelvic and (ATLS) principles. The primary aim is to stabi-
lower limb fractures as well as head, chest, and lize the patient, identify, and treat life-threatening
abdominal life-threatening injuries [3, 8]. Not conditions and initiate supportive treatment.
uncommonly, bone fragments can injure adjacent Only once the patient is stable, further evaluation
neurovascular structures or penetrate the bowel of the injuries can be commenced together with
or the genitourinary tract. plans for the operative or non-operative manage-
The fracture configuration depends on the ment of the acetabular fractures.
position of the femoral head at the time of impact, The major cause of mortality within the first
magnitude, and vector of the causative force as 24 h following pelvic and acetabular fractures is
well as the underlying strength of the bone. In acute blood loss. Thereafter, multiorgan failure is
young individuals they occur as a result of high the commonest cause of death. The patient’s age,
energy trauma and most commonly associated early physiologic derangement, and presence of
with multiple injuries. Internal rotation of the other injuries (head or trunk) are negative predic-
femoral head at the time of impact is associated tors for survival [10]. Unstable acetabular frac-
with a posterior column fracture while anterior tures are likely to receive blood transfusions. In
column fractures occur with external rotation. one study the average transfusion requirement for
Equally, abduction of the femoral head can lead “both column” acetabular fractures was 8.8 units
to fractures of the inferior aspect of the dome, while anterior column posterior hemitransverse
while adduction leads to fracture of the acetabu- was 6.4 units [10]. The ideal volumes of plasma,
lar roof. The fracture-dislocation of the femoral platelets, cryoprecipitate, and other coagulation
head is closely related to the magnitude of the factors in relationship to the red blood cell trans-
causative force. Likewise, the degree of commi- fusion volume are currently unknown [9, 11].
nution and articular impaction are also associated Current data incline towards a target ratio of
with the amount of the transmitted energy and the plasma: red blood cell: platelet transfusions of
strength of the underlying bone. 1:1:1 [11]. Transfusion of blood and blood prod-
In elderly, fracture characteristics show a ucts should be guided by clotting profiles and an
higher degree of variability. Lower energy is assessment of the degree of coagulopathy.
transmitted with the force vector applied from the Conventional clotting tests are still used as stan-
greater trochanter and directed towards the dard but other markers like thromboelastography
anteromedial aspect of the acetabulum. Fractures and rotational thromboelastometry could allow
with a quadrilateral-plate component or roof real time assessment of clotting. At present, the
impaction as well as those configurations causing transfusion of fluids, blood, and blood products is
medial displacement are more common in elderly guided by local protocols as a joint effort and
patients [5]. Fractures involving the anterior wall agreement between trauma physicians.
of the acetabulum are more prevalent in elderly Clinical evaluation requires a thorough history
as well as the anterior column with a posterior together with a systematic clinical examination.
hemitransverse extension and the both column Establishing the past medical history and current
patterns [5, 9]. medications is essential. Effective analgesia is
10  Acetabular Fractures 107

always required to reduce patient suffering and patient following trauma and should be always
facilitate the clinical examination. The primary obtained under the ATLS protocol. During the
or secondary surveys can identify the personality evaluation of patient with pelvic injuries, the AP
of the injury, for example leg position after poste- view can give information of the congruency of
rior hip dislocation. The presence of a hip dislo- several structures. The six fundamental land-
cation requires a prompt reduction. Closed marks visible in this view include the anterior
reduction should be performed under sedation in and posterior wall of the acetabulum, the tear-
the emergency department. In cases where this is drop, the roof, and the iliopectineal (anterior col-
unsuccessful, CT scanning is required to estab- umn) and ilioischial (posterior column) lines
lish the obstruction to reduction and the formula- (Fig. 10.2). The iliac oblique view provides an en
tion of an operative plan. Occasionally general face view of the iliac wing and profile of the
anesthesia and fluoroscopy are required, how- obturator ring, hence it brings the posterior col-
ever, if the surgeon’s experience in open reduc- umn and anterior wall into relief. For this view
tion is limited, transfer of the patient to a center the patient is rolled 45° towards the injured side.
capable in dealing with these injuries is recom- The obturator oblique view, on the other hand, is
mended. In patients with sciatic nerve injury fol- used to assess the obturator ring, posterior wall
lowing posterior hip dislocation, prompt and anterior column and requires the patient to be
reduction is associated with better outcomes. rotated 45° towards the uninjured side on the
The radiographic examination provides the radiographic table.
essential information for acetabular fracture clas- CT is useful in showing the finer details [12].
sification and CT with or without multiplanar The entire pelvis should be included and axial
reconstruction is always recommended. X-ray cuts with thin 1.5–3  mm intervals and corre-
examination should include three main views: sponding slice thicknesses should be acquired
anteroposterior, iliac oblique, and obturator (Fig. 10.3) [13]. CT allows the visualization of
oblique (Judet views), (Fig. 10.1). The anteropos- additional fragments and obscure fracture lines
terior (AP) view is essential in evaluating a not previously visible with plain films. CT can

a b

Fig. 10.1  Pelvic radiographs: AP (A) and Judet views: Obturator oblique (B) and iliac oblique view (C). Arrow illus-
trates fracture location
108 I. Pountos and P. V. Giannoudis

show the number and size of bony fragments,

the presence of articular c­ omminution, impac-
tion or incongruency (steps of the articular car-
tilage), the extent of displacement and the
rotation of the columns, and the presence of
retained bony fragments inside the joint
(Fig. 10.4). It can also identify associated inju-
ries in the pelvis like sacral fractures, injuries of

Fig. 10.2  Radiological landmarks of acetabulum: Pink

line  =  Iliopectineal line (anterior column), Light blue
line  =  Ilioischial line (posterior column), Dark blue
line  =  Posterior wall, Red line  =  Anterior wall, Green Fig. 10.4  Axial cut demonstrating marginal impaction
line = Teardrop, Yellow line = Roof, White line = Iliac wing (white arrow) of right acetabulum

a b c

d e f

g h i

Fig. 10.3  A–I: Axial cuts demonstrating a two-column fracture of the left acetabulum, showing the complete separa-
tion of the joint from the proximal pelvic ring
10  Acetabular Fractures 109

the sacroiliac joint, soft tissues injuries, and the include fractures of the posterior wall, posterior
presence of hematoma. An artificial pelvic column, anterior wall, anterior column, and
model is often helpful to draw and understand transverse fractures. The associated fracture
the fracture patterns and template the fracture types are of more complex configuration and
fixation. 3D reconstruction or the more recent include T-type fractures, combined fracture of
advance of 3D printing can be of great assis- the posterior column and posterior wall, combi-
tance to the surgeon. nation of transverse and posterior wall fracture,
A 3-dimentional CT (3D CT) reconstruction anterior column fracture with hemitransverse
transforms the scanned CT data into standard posterior fracture and both column fractures.
coordinates to create a 3D-image. Current soft- The classification of Letournel and Judet is
ware may help better visualize the major fracture based on the morphological characteristics of the
lines by the disarticulation of the femoral head innominate bone. The authors realized that the
from the acetabulum and removing rectal or acetabulum was located centrally between two
intravenous contrast material [14]. Several stud- columns, an anterior and a posterior, which acted
ies have shown that 3D reconstructions improve as struts to provide stability. The iliac crest, iliac
the surgeons understanding for fracture configu- spines, pubis, and the anterior aspect of the
ration however, caution is required as during the ­acetabulum compose the anterior column while
process some vital information could be elimi- the posterior column consists of the ischium, pos-
nated by the software, for example minimally terior half of the acetabulum till the bone of the
displaced fractures [15–17]. An alternative sciatic notch. As result, anterior column fractures
approach which is gaining popularity is the rapid disrupt the iliopectineal line while posterior ones
prototyping and 3D printing technology [18, 19]. disrupt the ilioischial lines. In addition to the col-
This technology can allow the fabrication of umns, the acetabular walls or rims represent only
complex real models based on CT scans. The sur- the anterior or posterior articular surface of the
geon could be assisted not only by the model but acetabulum. The transverse acetabular fractures
also by the fabrication of guiding templates but are limited to the acetabulum with the fracture
also pre-bended or custom metalwork [18, 19]. line involving both the anterior and posterior
This aims to improve the placement accuracy and aspects of the acetabulum. The fracture line is on
safety of the metalwork [18, 19]. a transverse plane relative to the acetabulum,
with the fracture components coursing medially
and superiorly from the acetabulum. On X-rays,
10.3 Classification both the iliopectineal and ilioischial lines are dis-
rupted and the obturator ring is intact. Both col-
The accurate classification of acetabular frac- umn fractures represent fractures that divide the
tures is crucial to guide the appropriate manage- ilium so that the sacroiliac joint is not connected
ment. Early classification systems initially by any articular segment (see Fig.  10.3).
described the direction of hip dislocation, fol- Characteristic of both column fractures is the
lowed by the “clock face” classification of spur sign seen on the obturator oblique view,
Knight and Smith and the “triradiate” of Rowe which represents the posterior displacement of
and Lowell [20, 21]. In 1961, the Letournel and the sciatic buttress, in essence disconnecting the
Judet classification was developed which repre- roof of the acetabulum from the axial skeleton.
sents the most comprehensive and widely Finally, T-type acetabular fractures represent a
adopted system to date [22]. combination of a transverse fracture that extends
Letournel and Judet divided acetabular frac- inferiorly into the obturator ring. Similarly, to
tures into simple and associated types (Fig. 10.5) both column fractures, these fractures disrupt the
[22]. The simple fractures are isolated fractures obturator ring causing discontinuity of both the
of one wall or one column along with transverse iliopectineal and ilioischial lines during roent-
fractures; the five subtypes of simple fractures genographic evaluation. These fractures do not
110 I. Pountos and P. V. Giannoudis

a b c d e

i ii iii iv v

Fig. 10.5  Judet-Letournel fracture classification of ace- posterior column, (II) transverse with posterior wall, (III)
tabular fractures. Elementary fractures include the (A) T-shaped fracture, (IV) anterior wall/column hemitrans-
posterior wall, (B) posterior column, (C) anterior wall, verse, and (V) both column fractures. Reproduced with
(D) anterior column, and (E) transverse fractures. permission and copyright © of Springer [23]
Associated fractures include the (I) posterior wall with

involve the iliac wing, hence can be differentiated umn. Type B fractures are partially articular
from the both column fractures. transverse oriented fractures including the trans-
Attempts to expand and improve the classifi- verse and posterior wall (B1), T-type (B2) and
cation of Letournel and Judet have been reported. anterior and posterior hemitransverse fracture
Among them, Harris classification utilized a CT types (B3). Finally, type C injuries include frac-
based scheme able to classify more fracture sub- tures of both columns with all articular segments,
types and introduce more symmetry between the including the roof, detached from the ilium. This
walls and columns [24, 25]. The two main differ- is also referred to as “floating acetabulum.”
ences of this classification is firstly the way of Qualifiers aiming to add information and docu-
definition of walls and columns (lips of the ace- ment the condition of the articular surfaces were
tabulum referred to as walls while medial aspect added in an attempt to improve the predictive
referred to as columns) and secondly the shorten- value of the classification. Such qualifiers include
ing of anterior column that reaches only to the the femoral head dislocation/subluxation and the
top of the iliopectineal line. Harris et al. catego- presence of chondral lesions, osteochondral and
rized the fractures according to the involved col- impacted fractures.
umns with subcategories for the fracture line
extension.
The AO group has also developed an alphanu- 10.4 Conservative Treatment
meric classification system adopting and expand-
ing the Letournel and Judet classification. The For many decades the management of acetabular
AO classification aims to describe the severity fractures was purely conservative. Operative
and predict the final outcome. Type A fractures management was initiated by the fundamental
include partial articular of a single wall or col- studies of Judet et  al., reinforced by improve-
10  Acetabular Fractures 111

ments in radiologic interpretations and estab- femoral head. Medial displacement of the femo-
lished following long follow-up studies ral head and gaps without stem between the frag-
demonstrating that even small residual incongru- ments are known to occur. This phenomenon is
ency in the weight-bearing surface of the acetab- referred to as “secondary congruency” but is
ulum leads to arthritis in contrast to similar rarely found to occur in 5% of both column frac-
fractures where anatomical reduction was tures [34]. Magu et al. reported good to excellent
achieved with internal fixation [26, 27]. functional outcome in 88.8% of both column
The indications for conservative management fractures with secondary congruence despite
of acetabular fractures are shrinking. Undisplaced medial subluxation [36].
fractures or those displaced up to 2  mm can be Patient related factors play a vital role in the
treated conservatively. The patient has to remain decision between operative and conservative
non-weight-bearing for a period of 6–8  weeks management. In many cases the severity of the
with X-rays obtained at regular intervals to assess associated injuries mandates the delay of surgery
that articular congruency is maintained. Similar while medical contraindications to surgery are
management can be utilized for fractures sparing not uncommon. Some authors advocate early
the anatomic biomechanical weight-bearing sur- percutaneous fixation in severely injured patients.
face of the acetabulum. The criteria, however, Skeletal traction can be used in such cases to pro-
vary. In the study of Oslon and Matta, the criteria tect the articular cartilage. Other factors include
used were (1) intact superior 10 mm of the articu- condition that disrupts or threatens the soft tissue
lar acetabular surface on CT (equivalent to roof envelope including the presence of open frac-
arc measurements of 45°), (2) congruency of the tures, infected wounds, and soft tissue lesions
femoral head with the superior acetabulum out of from blunt trauma. In some patients the presence
traction on anteroposterior and Judet views, and of Morel-Lavallee (closed degloving injury asso-
(3) more than 50% of posterior wall intact [28]. ciated with a hemolymphatic mass) can signifi-
With regard to the minimal roof arc measure- cant delay surgery as operating through it
ments, subsequent experimental studies have increases the infection rate significantly. The
reported different angle values. In the biome- presence of a suprapubic catheter is anecdotally
chanical study on cadaveric pelvises, Vrahas considered a contraindication through the ilioin-
et  al. suggested that operative management is guinal approach due to the potential bacterial
required with less than 45°, 25°, and 55° of colonization of the catheter. Finally, patient’s age
medial, anterior, and posterior acetabular roof arc was long considered a defining factor for the
angles [29]. Other clinical and experimental stud- choice of surgery with patients over 60 years old
ies have reported comparative measurements to be allocated to conservative management.
with the exception of anterior angle which Current literature supports the view that older
reported between 42° and 52° [30, 31]. As far as patients should not be precluded from a fixation,
the posterior wall fractures are concerned, several but instead, factors including the comorbidities,
authors have proposed that fractures involving up the presence of symptomatic arthritis, the activity
to 20% of the posterior wall are stable, while in level, poor bone stock with high risk for loss of
those involving more than 40% dynamic clinical reduction should be considered in the decision-­
instability can exist [32, 33]. Fluoroscopic stress making process [7].
views while the hip comes into flexion can be
acquired to rule out instability (joint space wid-
ening suggests instability). 10.5 Operative Treatment
Conservative management has been previ-
ously proposed for some both column fracture The achievement of anatomical reduction of the
configurations [13, 34–36]. In these fractures, the articular surface combined with a rigid internal
labrum and articular capsule remained intact fixation, which will allow early mobilization, is
allowing the molding of the fragments over the the rationale behind the surgical treatment of
112 I. Pountos and P. V. Giannoudis

acetabular fractures. Fractures resulting in more 10.5.1.1 Kocher-Langenbeck

than 2  mm displacement of the weight-bearing Approach
surface and those resulting in subluxation of the The Kocher-Langenbeck approach is indicated
femoral head should be treated surgically. for posterior wall and column injuries. Structures
Posterior wall fractures involving more than 40% at risk with this approach include the sciatic
of the wall do require fixation [28, 32, 33]. nerve, medial circumflex femoral artery, and
Injuries resulting in trapped bony fragments in superior gluteal artery and nerve. The superior
the hip joint or those associated with avulsion of gluteal artery can be a significant source of bleed-
the ligamentum teres lodged between the articu- ing when injured. In such cases packing can con-
lar surfaces generally require excision. Another trol it, however, direct ligation or even
indication of operative management in severely embolization is required. The incidence of het-
comminuted fractures is the preservation of ade- erotopic ossification with the Kocher-Langenbeck
quate bone stock and avoidance of non-union that approach is higher compared to the other
will improve the chances of a favorable outcome approaches used to fix acetabular fractures.
following a subsequent hip reconstructive A trochanteric osteotomy or a trochanteric flip
surgery. osteotomy can increase the access provided by the
Kocher-Langenbeck approach. These osteotomies
provide better access to the dome and some lim-
10.5.1 Choice of Surgical Approach ited access to the anterior column. Detaching the
greater trochanter carries a high non-union rate,
The type and configuration of the fracture deter- can result in abductor weakness, and requires
mines the choice of the surgical approach experience and additional implants to reattach the
(Table 10.1). The Kocher-Langenbeck, ilioingui- trochanter. To overcome these problems the flip
nal, and modified Stoppa are most commonly osteotomy has been popularized. A slice of the
used. Combined approaches can be performed greater trochanter is created that leaves intact the
for more complex and comminuted fractures. tendinous attachment of the gluteus muscles and
the tendinous origin of the vastus lateralis.
Therefore, a neutralizing force is created keeping
Table 10.1  Approaches for the management of acetabu- the trochanteric slice in place and preventing any
lar fractures
proximal migration of the trochanter.
Fracture type Approach
Posterior wall Kocher-Langenbeck 10.5.1.2 Iliofemoral Approach
Posterior column Kocher-Langenbeck or
mod. Stoppa or Pararectus
The iliofemoral approach provides access to the
Anterior wall Ilioinguinal or Iliofemoral iliac wing, anterior aspect of sacroiliac joint, and
or mod. Stoppa or the entire internal iliac fossa. It also provides digi-
Pararectus tal access to the quadrilateral surface and greater
Anterior column Ilioinguinal or Iliofemoral sciatic notch. The structures at risk include the
or mod. Stoppa or
Pararectus
superior gluteal neurovascular bundle, sciatic
Both columns Ilioinguinal or extensile or nerve, lateral femoral cutaneous nerve, and the
combined perforating branches of the femoral artery.
Transverse or T-type Kocher-Langenbeck
(posterior wall or 10.5.1.3 Ilioinguinal Approach
displacement)
The ilioinguinal approach allows exposure to the
Transverse or T-type Ilioinguinal or Stoppa
(anterior displacement) internal iliac fossa, pelvic brim, anterior wall and
Hemitransverse Ilioinguinal column and quadrilateral plate and sacroiliac joint.
Quadrilateral plate Ilioinguinal or Iliofemoral Thus, fractures of the anterior wall, anterior col-
or mod. Stoppa or umn, anterior column with posterior hemitrans-
Pararectus verse and some both column fractures can be
10  Acetabular Fractures 113

treated through this approach. Structures at risk include cerclage wiring, special reduction tools
include the femoral nerve, femoral and external and implants, traction, and disimpaction tech-
iliac blood vessels, the lateral cutaneous nerve of niques for depressed osteochondral fragments.
the thigh, the obturator nerve, and spermatic cord. Reduction tools designed specifically for pel-
Also, the corona mortis (vascular anastomosis vic and acetabular surgery exist and they play a
between the external iliac artery or deep inferior vital role in the reduction of the fragments.
epigastric artery with the obturator artery) should Pointed reduction clamps with their tips intro-
be identified and ligated otherwise can be a signifi- duced in drill holes or on washers can facilitate
cant source of bleeding if accidentally damaged. stronger fixation. Farabeuf or Jungbluth clamps
attached on bi-cortical screws is an alternative
10.5.1.4 Modified Stoppa Approach option. Surgeon’s armamentarium includes offset
An alternative to the ilioinguinal approach is the clamps for the posterior column fracture reduc-
modified Stoppa approach [37]. It is an anterior tion or single- or double-pronged clamps for both
intrapelvic extraperitoneal approach though the column fracture reduction. Cerclage wires placed
rectus abdominis [38]. It provides access to the on the greater or lesser sciatic notch can facilitate
pubis, posterior aspect of ramus, pubic eminence, reduction and could be even retained to improve
sciatic buttress, and notch as well as the anterior fixation.
aspect of the sacroiliac joint [37–39]. Structures Traction is often essential intraoperatively.
at risk include the obturator nerve and vessels, Traction can be applied on the extremity through
corona mortis, external iliac vessels, and urinary the traction table. The traction table should allow
bladder. application of traction in every direction. Instead
of a traction table, manual traction can be applied
10.5.1.5 Pararectus Approach by the use of assistants. Direct traction to the
The pararectus approach is an alternative to the femoral head or pelvis can be applied during
Stoppa approach [40]. The indications include reduction maneuvers. A Schanz screw placed
fractures involving the anterior column and the directly into the femoral head or a hook over the
quadrilateral plate. The pararectus approach is greater trochanter can assist the distraction of the
versatile and can be extended without an addi- joint. In addition, the use of Schanz pins could
tional incision in cases where the fixation of the provide strong lever to reduce fracture and de-­
posterior pelvis is required. Structures at risk rotate large bony fragments.
include the peritoneum, inferior epigastric ves- The restoration of the articular surface con-
sels, spermatic cord, and external iliac vessels. gruency often requires the disimpaction of osteo-
chondral fragments (Fig.  10.6). Once such

10.5.2 Techniques of Open

Reduction and Fixation

The reduction of acetabular fractures is often the

most difficult element of their surgical manage-
ment. When possible, surgery should be per-
formed early as fracture reduction can be difficult
or even impossible if surgery is delayed for three
or more weeks. A thorough preoperative plan
with provisions for the difficulties, materials, and
instruments that may be required during the fixa-
tion of the fracture is essential. Intraoperatively, Fig. 10.6  Marginal impaction of acetabulum exposed via
several strategies can be employed to restore the a Kocher-Langenbeck posterior approach. (A) Impaction
anatomy and fix the fractures. Such techniques articular fragment; (B) Femoral head; (C) Acetabulum joint
114 I. Pountos and P. V. Giannoudis

fragments are lifted, subchondral voids are cre- bent 90 degrees and used to secure the fragment)
ated which could require grafting. Autologous (Figs.  10.7 and 10.8) [41]. The 3.5  mm recon-
tricortical bone graft harvested from the iliac struction plate (straight or curved) fixed with
crest is currently the gold standard, however, syn- 3.5 mm cortical screws is the implant of choice.
thetic void filling materials can also be used like Great care should be taken to ensure that the
hydroxyapatite granules or calcium phosphate. screws do not penetrate into the joint space.
Often the disimpaction of the articular fragments
can be performed through the preexisting frac-
ture. In cases where the direct visualization of the 10.5.3 Minimal Invasive Techniques
fragment is not feasible, reduction can be and Navigation
achieved through a cortical window or balloon
osteoplasty followed by bone grafting. In com- Intraoperative navigation has been implemented
plex circumscribed impacted fractures, fragment in the management of acetabular fractures. It
elevation and molding over the intact femoral requires a specific image intensifier, which allows
head can be implemented. 3D reconstruction. This technology has several
The fixation of the acetabular fracture requires advantages over conventional approaches. Firstly,
an array of screw sizes and lengths together with it can provide advanced resolution that could
reconstruction plates that can be contoured in all facilitate a better understanding and control of
three dimensions. The AO principles of anatomic the quality of articular reduction during and after
reduction and stable fixation with interfragmen- fracture fixation [42]. Secondly, the use of screw
tary lag screw and neutralizing plates apply. navigation allows the insertion of “high risk”
Alternatively, plates can be used to secure or but- screw safely in the periarticular space. Thirdly, it
tress fragments (most commonly a posterior wall allows percutaneous or minimally invasive met-
fracture) or as a “spring plate” (modified one-­ alwork placement. These advantages were shown
third tubular plate, cut through distal hole, tines in cases of percutaneous iliosacral screw place-

A C

Fig. 10.7 (a) Pre-operative radiographs (A: AP pelvis; B: CT coronal, C: CT axial cuts) of a two-column right acetabu-
lum fracture. (b) Postoperative radiographs following reconstruction (A: Pelvic inlet view, B: Obturator oblique,
C: Iliac oblique)
10  Acetabular Fractures 115

A C

Fig. 10.7 (continued)

A B

A B C

Fig. 10.8 (a) Pre-operative AP pelvis (A) and CT images oblique, and (C) Iliac oblique view demonstrating recon-
(B) of a transverse posterior wall left acetabulum fracture. struction of the fracture
(b) Postoperative images (A) AP pelvis, (B) Obturator
116 I. Pountos and P. V. Giannoudis

ment and percutaneous acetabular fracture fixa- meta-analysis has shown that 79% of the patients
tion and the reported results were favorable report a favorable outcome [62]. This figure, how-
[43–46]. In regards to the radiation exposure, ever, varies according to the specific outcome
available studies suggest that is comparable or instrument used [62]. Factors that are associated
even lower to that of conventional fluoroscopy with poor outcome included delays in treatment,
[43, 44]. The main limitation of navigation is the the presence of articular incongruence, the pres-
need of a substantial financial investment in the ence of associated injuries and osteonecrosis [54].
operating room, in addition to the mobile imag- Complications are not uncommon. They include
ing system, the navigator and ancillary [43]. iatrogenic nerve palsy, infection, DVT, and avascu-
Arthroscopic techniques for the fixation of lar necrosis of the femoral head [26, 54, 56]. The
acetabular fractures exist. Arthroscopy is mini- incidence of heterotopic ossification varies between
mally invasive, offers superior visualization of the studies and is associated with the surgical
the hip joint, facilitates the diagnosis, and even approach as well as the fracture configuration [56].
allows fracture reduction. The removal of loose The clinical and radiologic outcomes are favorable
osteochondral fragments, joint debridement or in the majority of the patients. Gait analysis studies
lavage can be performed reducing the risk of highlight that although the walking velocity of the
osteoarthritis [47]. It is however technically patients will recover, the gait, muscle strength, and
demanding, so significant experience in both hip outcome will deteriorate [53, 63]. Similarly, the
arthroscopy and acetabular fracture management forward tilt of the pelvis and the peak hip abduction
is essential. Several authors have reported good moment show incomplete recovery [53]. It is rec-
to excellent results following arthroscopic reduc- ommended that with maximizing muscle strength
tion of acetabular fractures even in cases of femo- early, the gait and functional recovery are likely to
ral head fractures or dislocations [48–50]. improve further [53, 63].
Yamamoto et al. reported, through a case series
study, that arthroscopy was capable of detecting
small free osteochondral or chondral fragments 10.5.5 Influence of Associated Pelvic
that were not detectable on either plain radio- and Femoral Fractures
graphs or computed tomography scans in 70% of
the cases [50]. Similar finding were reported A combination of pelvic and acetabular injury is
when arthroscopy was used to evaluate symp- a devastating dyad. Such patients are polytrau-
tomatic hip pathologies following injury. Loose matized and present with a high injury severity
bodies, labral tears, step deformities, and osteo- score, which often represents a resuscitative chal-
chondral lesions were injuries difficult to diag- lenge. Patients with combined injury have higher
nose with CT or MRI scans, but can be easily transfusion requirements and lower systolic
identified and managed with arthroscopy [51]. blood pressure at presentation [64]. Their inci-
Complications of hip arthroscopy are rare. dence vary, however, reported incidence can be
Reported complications include venous throm- as high as 16% [64]. The fracture patterns differ
boembolism, peripheral nerve injury, septic from those observed in isolated injuries; poste-
arthritis, instrument failure, and extravasation of rior acetabular fractures are less common and
fluid leaking in the abdomen or causing compart- anterior–posterior compression pelvic injuries
ment syndrome [52]. seem much more frequent in cases of combined
injuries [65]. Mortality rates are high ranging
from 1.5 to 13% between different studies [64,
10.5.4 Operative Results 65]. Once the patient is stable, a detailed analysis
of the injuries is required together with the for-
The outcomes of the surgical management of ace- mulation of an overall treatment strategy to
tabular fractures are good to excellent in the major- address the injuries [64]. Ideally, an initial accu-
ity of the cases (Table 10.2) [26, 53–62]. A recent rate reduction of the pelvic injuries is required,
10  Acetabular Fractures 117

Table 10.2  Selected recent studies presenting the outcome of the operative management of acetabular fractures
Patient
Nrs
Study (gender) Age (range) Fracture type Conclusions and outcomes
Ochs 858 49.4 (range Elementary fracture •  Complications occurred in 20% of patients
et al. [26] 12–92 years) patterns 42.5% and • Complications included nerve palsy (5.6%),
associated fracture infection (2.3%), thrombosis (2.7%),
patterns 57.5% hematoma (1.9%), and multiple organ
failure (0.7%)
Kubota 19 (15 52.5 (range, Twelve partial • Pelvic forward tilt and peak hip abduction
et al. [53] M) 26–77 years) articular 1-column moment showed incomplete recovery at
fractures 12 months after ORIF
Two partial articular, • Improvement of hip abductor muscle
transversely oriented strength in the early postoperative period
fractures; could improve the functional outcome
Five both column
fractures
Dunet 72 (56 41.6 (range Simple fractures is 45 • 25 THRs were performed, with a mean
et al. [54] M) 16–75 years) (62.5%) patients, time to surgery of 3.7 years
complex 27 (37.5%) • Factors associated with poor outcome
included no functional treatment, initial
traction, anterior and posterior congruency
defect, initial traction, VAS, osteoarthritis,
and osteonecrosis
Meena 118 (99 38.75 (range Elementary fracture • The clinical outcome was good-­excellent in
et al. [55] M) 16–65 years) patterns 45.8% and 79 (67%), good in 52 (33%)
associated fracture • Poor reduction, associated injuries, fracture
patterns 54.2% displacement of >20 mm, joint dislocation
and late surgery definitely carry poor
prognosis
Anizar-­ 30 (23 39.9 (range 17 (56.7%) were • 20 (66.7%) patients had excellent/good
Faizi et al. M) 14–81 years) elementary fractures results (Harris hip score > 80)
[56] and 13 cases (43.3%) • Postoperative complications were deep
associated type infection (6.7%), iatrogenic sciatic nerve
fractures injury (10.0%), avascular necrosis (16.7%),
heterotopic ossification (3.3%),
degenerative changes in hip joint (43.3%)
and loss of reduction (3.3%)
Bhat et al. 59 (45 38.35 (range Associated in 15 • Radiological evaluation revealed excellent
[57] M) 18–60 years) (60%) and elementary outcome in 16% hips, good in 54% hips,
in 35 (40%) fair in 20% hips, and poor in 10% hips
• Good to excellent results were achieved in
42 cases (70%)
• Complications included implant back-out,
postoperative dislocation, iatrogenic nerve
palsy, superficial wound infection,
intraoperative bleeding and osteoarthritis
Borg and 101 (76 49, (range Associated in 61 • Postoperative complications included deep
Hailer M) 17–83 years) (60%) and elementary infections in four patients, and
[58] in 40 (40%) thromboembolic complications in six
• The hip joint was preserved in 78 (77%)
patients whereas 21 patients received a THA
and the remaining two had a Girdlestones
Iqbal 50 (36 44.20 ± 11.65 years Elementary fracture • The clinical outcome was good to excellent
et al. [59] M) patterns 84% and in 35 (70.0%)
associated fracture • The radiological outcome was anatomical in
patterns 16% 39 (78.0%) cases, congruent in 5 (10.0%)
cases, incongruent in 6 (12.0%) cases
(continued)
118 I. Pountos and P. V. Giannoudis

Table 10.2 (continued)
Patient
Nrs
Study (gender) Age (range) Fracture type Conclusions and outcomes
Clarke-­ 253 42 years Elementary fracture •  THR in 36 patients (14%)
Jenssen (197 (12–78 years). patterns in 99 (39%) •  The presence of injury to the femoral head
et al. [60] M) and 154 (61%) and acetabular impaction proved to be strong
associated fracture predictors of failure
types
Negrin 167 41.8 (range, Sixty five posterior •  Posttraumatic arthritis was found in 36
and (111 14–85 years) wall (38.9%), 34 patients (21.6%) and THR in17 patients
Seligson M) posterior column •  Nine cases of iatrogenic damage (three
[61] (20.4%), 51 permanent), eight patients (4.8%) sustained
transverse (30.5%), an infection, postoperative hemorrhagic
and 17 T-shaped shock was detected in 26 patients (15.6%)
(10.2%) •  Revision surgery due to secondary loss of
reduction was indicated in five patients

followed by the reconstruction of the acetabulum ios; firstly, acutely in acetabular fractures deemed
[66]. The amount of residual pelvic displace- to conclude in a poor outcome following fixa-
ment, patient’s age, and the presence of T-shaped tions and secondly in patients that develop osteo-
acetabular fractures are predictors of residual arthritis from either conservative or surgical
acetabular displacement [66, 67]. management.
Femoral head fractures occur frequently with The indications of THR in the acute setting are
acetabular fractures. Beckmann et  al. quantified placed in the context of the severity of the injury
this incidence to approximately 18% of acetabu- and the reported outcomes following ORIF.  It
lar fractures [68]. Most commonly occur with allows early full weight bearing and eliminates
posterior wall fractures (56.3%), while their inci- the need of a second procedure for THR. Reported
dence with anterior and posterior hip dislocation indications include complex or non-­
is 66.7% and 71.9%, respectively [68]. Acetabular reconstructable fractures, concurrent hip osteoar-
fractures occurring in association with femoral thritis, associated femoral head fractures, and
fractures carry a poor prognosis [68, 69]. It was poor bone quality (Table 10.3) [72–79]. Studies
previously suggested that even the mildest grade have reinforced THR with cable fixation, rein-
of femoral head fracture carries a greater than forcement rings, bone grafting, and antiprotru-
10% risk for poor outcome [68]. Devastating sion cages [72, 73, 75, 77–79]. In one study THR
results are also known to occur with combination prosthesis was used alone [76].
of acetabular fracture combined with ipsilateral The indications of THR in the management of
femoral neck fracture. Such injury combination post-traumatic arthritis are similar to those of
carries a 93% risk of avascular necrosis of the end-stage hip disease. Pain and stiffness that
femoral head [1]. This incidence is much higher interfere with daily activities together with
to that of Garden III and IV that is known to radiologic signs are the cardinal findings.
range between 30–40% [70]. It has been hypoth- Challenges are anticipated and pre-operative
esized that there is extensive damage to the vas- preparations are essential. Such challenges
culature at the time of injury, preventing include bone loss, retained material, prominent
revascularization even with good reduction [71]. metalwork, pelvic deformity, and osteonecrosis.
Dealing with bone loss during a THR can be
daunting. Voids or even total absence of the ante-
10.5.6 Primary Arthroplasty rior or posterior walls or defect of the acetabular
roof could require extensive grafting. Special
Total hip replacement (THR) after an acetabular THR revision implants (rings, cages, meshes),
fracture can be indicated in two distinct scenar- impaction grafting or structural grafts fixed with
10  Acetabular Fractures 119

Table 10.3  Selected studies presenting the outcomes and complications of THR after acetabular fractures
Nr of Revision
Author patients Outcome Complications rate Authors comments
Mears and 57 Good to •  DVT 5% 5% • Substantial experience in both
Velyvis [72] excellent in • Heterotopic acetabular trauma and hip
79% ossification 10% arthroplasty required
Tidermark 10 Good to •  DVT 10% 10% • All patients able to walk
et al. [73] excellent 60% • Heterotopic independently (three with walking
ossification 40% aids)
Mouhsine 18 Good outcome •  Dislocation 6% 0% • Cable fixations and early THR
et al. [74] in 17/18 provides good primary fixation,
patients stabilizes acetabular fractures,
and permits early mobilization
Sarkar et al. 19 n/a •  Infection 16% 42% • Complications are not infrequent
[75] • Cup loosening 16% and a solid buttress is crucial
•  Stem loosening 5%
•  Dislocation 10%
• Ceramic head
fracture 5%
Sermon et al. 54 Good to • Heterotopic 8% • Acute THR resulted in a lower
[76] excellent ossification 28% revision rate and incidence of
results in 58% heterotopic ossifications
Herscovici 22 Average Harris • Heterotopic 22% • Combined ORIF and THR is
et al. [77] hip score 74 ossification 18% valid option in elderly patients
(range 42–86) • Wound dehiscence
4%
• Hip dislocation in
six patients (27%)
Enocson and 15 Average Harris •  No complications 0% • Primary reinforcement ring, bone
Blomfeldt hip score 88 graft and acute THR is a safe
[78] option with good functional
outcome

plates and screws can be used [80]. In addition to stage reconstruction, following the eradication of
bone loss, pelvic deformity can distort normal the infection, can be then performed.
anatomy and can jeopardize the correct place- The results of delayed THR following an ace-
ment of the acetabular component leading to tabular fracture vary significantly. Romnes et al.
early wear or dislocation. A detailed pre-opera- reported a revision rate of 13.7% with radiologic
tive planning is essential and intraoperative acetabular loosening of 53% at the 7.3-year fol-
X-rays are helpful to d­ etermine the ideal cup low-­up. Subsequent studies have shown survival
abduction and anteversion angles. rates ranging from 70 to 97% [76, 81–84]. The
One scenario with potential devastating conse- most common complications included the devel-
quences is the presence of low-grade infection in opment of heterotopic ossification, infection,
cases of previous open reduction and internal fixa- early loosening, and dislocation [81].
tion (ORIF). This should be strongly suspected in
cases of rapid deterioration of the joint space or in
cases of mismatch between radiologic and clinical References
symptoms. Baseline investigations include blood
tests (white cell count, neutrophils, C-reactive pro- 1. Mears DC, Velyvis JH, Chang CP. Displaced acetabu-
tein, and erythrocyte sedimentation rate) followed lar fractures managed operatively: indicators of out-
come. Clin Orthop Relat Res. 2003;407:173–86.
by a joint aspiration if the suspicion is strong. In 2. Mauffrey C, Hao J, Cuellar DO 3rd, Herbert B, Chen
cases where infection is confirmed, removal of the X, Liu B, Zhang Y, Smith W. The epidemiology and
implants and joint debridement is required. A two- injury patterns of acetabular fractures: are the USA
120 I. Pountos and P. V. Giannoudis

and China comparable? Clin Orthop Relat Res. 19. Chen X, Chen X, Zhang G, Lin H, Yu Z, Wu C, Li
2014;472:3332–7. X, Lin Y, Huang W.  Accurate fixation of plates and
3. Giannoudis PV, Grotz MR, Papakostidis C, screws for the treatment of acetabular fractures using
Dinopoulos H. Operative treatment of displaced frac- 3D-printedguiding templates: an experimental study.
tures of the acetabulum. A meta-analysis. J Bone Joint Injury. 2017;48:1147–54.
Surg Br. 2005;87:2–9. 20. Knight RA, Smith H. Central fractures of the acetabu-
4. Al-Qahtani S, O’Connor G.  Acetabular fractures lum. J Bone Joint Surg Am. 1958;40-A:1–16.
before and after the introduction of seatbelt legisla- 21. Rowe CR, Lowell JD.  Prognosis of fractures of the
tion. Can J Surg. 1996;39:317–20. acetabulum. J Bone Joint Surg Am. 1961;43:30–59.
5. Ferguson TA, Patel R, Bhandari M, Matta 22. Judet R, Judet J, Letournel E. Fractures of the acetab-
JM. Fractures of the acetabulum in patients aged 60 ulum: classification and surgical approaches for open
years and older: an epidemiological and radiological reduction—preliminary report. J Bone Joint Surg Am.
study. J Bone Joint Surg Br. 2010;92:250–7. 1964;46:1615–46.
6. Toro JB, Hierholzer C, Helfet DL.  Acetabular frac- 23. Kanakaris NK, Giannoudi MP. Fractures-dislocations
tures in the elderly. Bull Hosp Jt Dis. 2004;62:53–7. of the hip. In: Lasanianos NG, Kanakaris NK,
7. Guerado E, Cano JR, Cruz E.  Fractures of the Giannoudis PV, editors. Trauma and orthopaedic
acetabulum in elderly patients: an update. Injury. classifications. A comprehensive overview. London:
2012;43(suppl 2):S33–41. Springer; 2015. pp. 285, 289.
8. Kregor PJ, Templeman D.  Associated injuries com- 24.
Harris JH Jr, Lee JS, Coupe KJ, Trotscher
plicating the management of acetabular fractures: T.  Acetabular fractures revisited: part 1, redefini-
review and case studies. Orthop Clin North Am. tion of the Letournel anterior column. AJR Am J
2002;33:73–95. Roentgenol. 2004;182:1363–6.
9. Culemann U, Holstein JH, Köhler D, Tzioupis CC, 25.
Harris JH Jr, Coupe KJ, Lee JS, Trotscher
Pizanis A, Tosounidis G, Burkhardt M, Pohlemann T. Acetabular fractures revisited. 2. A new CT-based
T.  Different stabilisation techniques for typical classification. AJR. 2004;182:1367–75.
acetabular fractures in the elderly--a biomechanical 26. Ochs BG, Marintschev I, Hoyer H, Rolauffs B,

assessment. Injury. 2010;41:405–10. Culemann U, Pohlemann T, Stuby FM.  Changes in
10. Magnussen RA, Tressler MA, Obremskey WT,
the treatment of acetabular fractures over 15 years:
Kregor PJ.  Predicting blood loss in isolated pelvic analysis of 1266 cases treated by the German Pelvic
and acetabular high-energy trauma. J Orthop Trauma. Multicentre Study Group (DAO/DGU). Injury.
2007;21:603–7. 2010;41:839–51.
11. Kaur P, Basu S, Kaur G, Kaur R. Transfusion protocol 27. Judet R, Judet J, Letournel E. Fractures of the acetab-
in trauma. J Emerg Trauma Shock. 2011;4:103–8. ulum. Acta Orthop Belg. 1964;30:285–93.
12.
Jouffroy P, Sebaaly A, Aubert T, Riouallon 28. Olson SA, Matta JM. The computerized tomography
G. Improved acetabular fracture diagnosis after train- subchondral arc: a new method of assessing acetabu-
ing in a CT-based method. Orthop Traumatol Surg lar articular continuity after fracture (a preliminary
Res. 2017;103:325–9. report). J Orthop Trauma. 1993;7:402–13.
13. Tornetta P 3rd. Displaced acetabular fractures: indica- 29. Vrahas MS, Widding KK, Thomas KA. The effects
tions for operative and nonoperative management. J of simulated transverse, anterior column, and pos-
Am Acad Orthop Surg. 2001;9:18–28. terior column fractures of the acetabulum on the
14. Geijer M, El-Khoury GY. Imaging of the acetabulum stability of the hip joint. J Bone Joint Surg Am.
in the era of multidetector computed tomography. 1999;81:966–74.
Emerg Radiol. 2007;14:271–87. 30. Harnroongroj T, Suangyanon P, Tharmviboonsri T,
15. Scheinfeld MH, Dym AA, Spektor M, Avery LL,
Harnroongroj T. Posterior acetabular arc angle of the
Dym RJ, Amanatullah DF. Acetabular fractures: what femoral head assesses instability of posterior fracture-­
radiologists should know and how 3D CT can aid dislocation of the hip. Int Orthop. 2013;37:1141–5.
classification. Radiographics. 2015;35:555–77. 31. Harnroongroj T, Wattanakaewsripetch M, Sudjai N,
16. Garrett J, Halvorson J, Carroll E, Webb LX.  Value Harnroongroj T. Acetabular roof arc angles and ana-
of 3-D CT in classifying acetabular fractures dur- tomic biomechanical superior acetabular weight bear-
ing orthopedic residency training. Orthopedics. ing area. Indian J Orthop. 2014;48:484–7.
2012;35:e615–20. 32. Vailas JC, Hurwitz S, Wiesel SW. Posterior acetabu-
17. Kickuth R, Laufer U, Hartung G, Gruening C,
lar fracture-dislocations: fragment size, joint capsule,
Stueckle C, Kirchner J. 3D CT versus axial helical CT and stability. J Trauma. 1989;29:1494–6.
versus conventional tomography in the classification 33. Keith JE Jr, Brashear HR Jr, Guilford WB. Stability of
of acetabular fractures: a ROC analysis. Clin Radiol. posterior fracture-dislocations of the hip. Quantitative
2002;57:140–5. assessment using computed tomography. J Bone Joint
18. Chana-Rodríguez F, Mañanes RP, Rojo-Manaute J, Surg Am. 1988;70:711–4.
Gil P, Martínez-Gómiz JM, Vaquero-Martín J. 3D sur- 34. Matta JM.  Operative indications and choice of sur-
gical printing and pre contoured plates for acetabular gical approach for fractures of the acetabulum. Tech
fractures. Injury. 2016;47:2507–11. Orthop. 1986;1:13.
10  Acetabular Fractures 121

35. Sen RK, Veerappa LA.  Long-term outcome of con- 50. Yamamoto Y, Ide T, Ono T, Hamada Y. Usefulness of
servatively managed displaced acetabular fractures. J arthroscopic surgery in hip trauma cases. Arthroscopy.
Trauma. 2009;67:155–9. 2003;19:269–73.
36. Magu NK, Rohilla R, Arora S. Conservatively treated 51. Khanna V, Harris A, Farrokhyar F, Choudur HN,

acetabular fractures: a retrospective analysis. Indian J Wong IH.  Hip arthroscopy: prevalence of intra-­
Orthop. 2012;46:36–45. articular pathologic findings after traumatic injury of
37. Cole JD, Bolhofner BR.  Acetabular fracture fixa-
the hip. Arthroscopy. 2014;30:299–304.
tion via a modified Stoppa limited intrapelvic 52. Ladner B, Nester K, Cascio B.  Abdominal fluid

approach. Description of operative technique and extravasation during hip arthroscopy. Arthroscopy.
preliminary treatment results. Clin Orthop Relat Res. 2010;26:131–5.
1994;305:112–23. 53. Kubota M, Uchida K, Kokubo Y, Shimada S, Matsuo
38. Guy P. Evolution of the anterior intrapelvic (Stoppa) H, Yayama T, Miyazaki T, Takeura N, Yoshida A, Baba
approach for acetabular fracture surgery. J Orthop H.  Changes in gait pattern and hip muscle strength
Trauma. 2015;29(Suppl 2):S1–5. after open reduction and internal fixation of acetabular
39. Archdeacon MT, Kazemi N, Guy P, Sagi HC.  The fracture. Arch Phys Med Rehabil. 2012;93:2015–21.
modified Stoppa approach for acetabular fracture. J 54. Dunet B, Tournier C, Billaud A, Lavoinne N, Fabre T,
Am Acad Orthop Surg. 2011;19:170–5. Durandeau A. Acetabular fracture: long-term follow-
40. Bastian JD, Savic M, Cullmann JL, Zech WD, Djonov ­up and factors associated with secondary implantation
V, Keel MJ. Surgical exposures and options for instru- of total hip arthroplasty. Orthop Traumatol Surg Res.
mentation in acetabular fracture fixation: Pararectus 2013;99:281–90.
approach versus the modified Stoppa. Injury. 2016 55. Meena UK, Tripathy SK, Sen RK, Aggarwal S,

Mar;47(3):695–701. Behera P.  Predictors of postoperative outcome for
41. Richter H, Hutson JJ, Zych G.  The use of spring acetabular fractures. Orthop Traumatol Surg Res.
plates in the internal fixation of acetabular fractures. J 2013;99:929–35.
Orthop Trauma. 2004;18:179–81. 56. Anizar-Faizi A, Hisam A, Sudhagar KP, Moganadass
42. Wu X, Chen W, Zhang Q, Su Y, Guo M, Qin D, Wang M, Suresh C.  Outcome of surgical treatment for
L, Zhang Y. The study of plate-screw fixation in the displaced acetabular fractures. Malays Orthop J.
posterior wall of acetabulum using computed tomog- 2014;8:1–6.
raphy images. J Trauma. 2010;69:423–31. 57. Bhat NA, Kangoo KA, Wani IH, Wali GR, Muzaffar
43. Coste C, Asloum Y, Marcheix PS, Dijoux P, Charissoux N, Dar RA.  Operative management of displaced
JL, Mabit C. Percutaneous iliosacral screw fixation in acetabular fractures: an institutional experience with
unstable pelvic ring lesions: the interest of O-ARM a midterm follow-up. Ortop Traumatol Rehabil.
CT-guided navigation. Orthop Traumatol Surg Res. 2014;16:245–52.
2013;99:S273–8. 58. Borg T, Hailer NP.  Outcome 5 years after surgical
44. He J, Tan G, Zhou D, Sun L, Li Q, Yang Y, Liu treatment of acetabular fractures: a prospective clini-
P.  Comparison of isocentric C-arm 3-dimensional cal and radiographic follow-up of 101 patients. Arch
navigation and conventional fluoroscopy for percuta- Orthop Trauma Surg. 2015;135:227–33.
neous retrograde screwing for anterior column frac- 59. Iqbal F, Taufiq I, Najjad MK, Khan N, Zia

ture of acetabulum: an observational study. Medicine OB. Functional and radiological outcome of surgical
(Baltimore). 2016;95:e2470. management of acetabular fractures in tertiary care
45. Ruan Z, Luo CF, Zeng BF, et al. Percutaneous screw hospital. Hip Pelvis. 2016;28:217–24.
fixation for the acetabular fracture with quadrilateral 60. Clarke-Jenssen J, Røise O, Storeggen SAØ, Madsen
plate involved by three-dimensional fluoroscopy navi- JE. Long-term survival and risk factors for failure of
gation: surgical technique. Injury. 2012;43:517–21. the native hip joint after operatively treated displaced
46. Jacob AL, Suhm N, Kaim A, et  al. Coronal acetab- acetabular fractures. Bone Joint J. 2017;99-B:834–40.
ular fractures: the anterior approach in computed 61. Negrin LL, Seligson D.  Results of 167 consecu-

tomography-­navigated minimally invasive percutane- tive cases of acetabular fractures using the Kocher-­
ous. Cardiovasc Intervent Radiol. 2000;23:327–31. Langenbeck approach: a case series. J Orthop Surg
47. Yang JH, Chouhan DK, Oh KJ.  Percutaneous screw Res. 2017;12:66.
fixation of acetabular fractures: applicability of hip 62. Dodd A, Osterhoff G, Guy P, Lefaivre KA. Assessment
arthroscopy. Arthroscopy. 2010;26:1556–61. of functional outcomes of surgically managed ace-
48. Kim H, Baek JH, Park SM, Ha YC.  Arthroscopic tabular fractures: a systematic review. Bone Joint J.
reduction and internal fixation of acetabular frac- 2016;98-B:690–5.
tures. Knee Surg Sports Traumatol Arthrosc. 63. Engsberg JR, Steger-May K, Anglen JO, Borrelli J Jr.
2014;22:867–70. An analysis of gait changes and functional outcome
49. Park MS, Her IS, Cho HM, Chung YY. Internal fixa- in patients surgically treated for displaced acetabular
tion of femoral head fractures (Pipkin I) using hip fractures. J Orthop Trauma. 2009;23:346–53.
arthroscopy. Knee Surg Sports Traumatol Arthrosc. 64. Halvorson JJ, Lamothe J, Martin CR, Grose A,

2014;22:898–901. Asprinio DE, Wellman D, Helfet DL. Combined ace-
122 I. Pountos and P. V. Giannoudis

tabulum and pelvic ring injuries. J Am Acad Orthop 75. Sarkar MR, Wachter N, Kinzl L, Bischoff M. Acute
Surg. 2014;22:304–14. total hip replacement for displaced acetabular frac-
65. Osgood GM, Manson TT, O’Toole RV, Turen
tures in older patients. Eur J Trauma. 2004;30:296.
CH. Combined pelvic ring disruption and acetabular 76. Sermon A, Broos P, Vanderschot P.  Total hip

fracture: associated injury patterns in 40 patients. J replacement for acetabular fractures. Results in 121
Orthop Trauma. 2013;27:243–7. patients operated between 1983 and 2003. Injury.
66. Suzuki T, Smith WR, Hak DJ, Stahel PF, Baron AJ, 2008;39:914–21.
Gillani SA, Morgan SJ. Combined injuries of the pel- 77. Herscovici D Jr, Lindvall E, Bolhofner B, Scaduto
vis and acetabulum: nature of a devastating dyad. J JM.  The combined hip procedure: open reduction
Orthop Trauma. 2010;24:303–8. internal fixation combined with total hip arthroplasty
67. Hess AE, Johal HS, O’Toole RV, Nascone JW. Early for the management of acetabular fractures in the
postoperative displacement of combined pelvic elderly. J Orthop Trauma. 2010;24:291–6.
ring injury with acetabular fracture. Orthopedics. 78. Enocson A, Blomfeldt R. Acetabular fractures in the
2017;40:163–8. elderly treated with a primary Burch-Schneider rein-
68. Beckmann NM, Chinapuvvula NR, Cai C. Association forcement ring, autologous bone graft, and a total hip
of femoral head and acetabular fractures on computer- arthroplasty: a prospective study with a 4-year follow-
ized tomography: correlation with the Judet-Letournel ­up. J Orthop Trauma. 2014;28:330–7.
classification. Emerg Radiol. 2017;24(5):531–9. 79. Malhotra R, Singh DP, Jain V, Kumar V, Singh

69. Tannast M, Najibi S, Matta JM. Two to twenty-year R. Acute total hip arthroplasty in acetabular fractures
survivorship of the hip in 810 patients with opera- in the elderly using the Octopus System: mid term to
tively treated acetabular fractures. J Bone Joint Surg long term follow-up. J Arthroplasty. 2013;28:1005–9.
Am. 2012;94:1559–67. 80. Choplin RH, Henley CN, Edds EM, Capello W,

70. Asnis SE, Wanek-Sgaglione L. Intracapsular fractures Rankin JL, Buckwalter KA.  Total hip arthroplasty
of the femoral neck. Results of cannulated screw fixa- in patients with bone deficiency of the acetabulum.
tion. J Bone Joint Surg Am. 1994;76:1793–803. Radiographics. 2008;28:771–86.
71. Wei L, Sun JY, Wang Y, Yang X. Surgical treatment 81. Makridis KG, Obakponovwe O, Bobak P, Giannoudis
and prognosis of acetabular fractures associated PV.  Total hip arthroplasty after acetabular fracture:
with ipsilateral femoral neck fractures. Orthopedics. incidence of complications, reoperation rates and
2011;34:348. functional outcomes: evidence today. J Arthroplast.
72. Mears DC, Velyvis JH. Acute total hip arthroplasty for 2014;29:1983–90.
selected displaced acetabular fractures: two to twelve-­ 82. Berry DJ, Halasy M.  Uncemented acetabular com-
year results. J Bone Joint Surg Am. 2002;84-A:1–9. ponents for arthritis after acetabular fracture. Clin
73. Tidermark J, Blomfeldt R, Ponzer S, Söderqvist A, Orthop Relat Res. 2002;405:164–7.
Törnkvist H.  Primary total hip arthroplasty with a 83.
Lizaur-Utrilla A, Sanz-Reig J, Serna-Berna
Burch-Schneider antiprotrusion cage and autolo- R. Cementless acetabular reconstruction after acetab-
gous bone grafting for acetabular fractures in elderly ular fracture: a prospective, matched-cohort study. J
patients. J Orthop Trauma. 2003;17:193–7. Trauma Acute Care Surg. 2012;73:232–8.
74. Mouhsine E, Garofalo R, Borens O, Blanc CH,
84. Lai O, Yang J, Shen B, Zhou Z, Kang P, Pei F. Midterm
Wettstein M, Leyvraz PF.  Cable fixation and early results of uncemented acetabular reconstruction for
total hip arthroplasty in the treatment of acetabu- posttraumatic arthritis secondary to acetabular frac-
lar fractures in elderly patients. J Arthroplast. ture. J Arthroplast. 2011;26:1008–13.
2004;19:344–8.
 Pipkin Fractures
11
Benedikt J. Braun, Jörg H. Holstein,
and Tim Pohlemann

Abstract • Pipkin classification most common; Brumback

Femoral head fractures are rare, but associated classification also includes anterior
with a high complication risk. Appropriate dislocations.
treatment can significantly reduce complica- • Nonsurgical treatment associated with
tions and improve outcome. Pearls and pitfalls improved outcome only in Pipkin I fractures
of the entire treatment from diagnostics –– If <2 mm dislocation, stable hip joint, and
through therapy and aftercare are presented no interposed fragments
within this chapter and the effect on overall • If closed reduction succeeds, surgery during
outcome discussed with the current literature. delayed primary care phase recommended.
In short: • Main blood supply to femoral head from
medial femoral circumflex artery
• Younger patients (average around 40 years). –– Cave: posterior approaches.
• Most commonly observed during automobile • No significant outcome differences between
collisions (>80%). approaches; should be tailored to fracture
• Fracture commonly results from posterior hip pattern.
dislocation (10%). –– Increased avascular necrosis in posterior
• Fracture results from chiseling mechanism; approaches.
pattern depending on hip position during –– Increased rate of heterotopic ossification in
trauma. trochanteric flip osteotomy.
• Early closed reduction improves outcome • Decision fragment excision vs. fixation based on:
(<6 h) –– Residual fragment displacement <2 mm
–– Immediate open reduction if closed reduc- –– Fragment outside weight bearing region
tion fails. –– Free range of motion, no interposition
• Post-reduction/Preoperative CT scan • Management/approach depends on fracture
recommended. type
–– Pipkin I: non-operative/fragment excision.
–– Pipkin II: Fixation with either countersunk
interfragmentary compression screws,
B. J. Braun · J. H. Holstein · T. Pohlemann (*) headless self-compression screws, and bio-­
Department of Trauma, Hand and Reconstructive absorbable pins and screws.
Surgery, Saarland University Hospital, Homburg,
Germany –– Pipkin III: Emergency surgery, open reduc-
e-mail: [email protected] tion favored.

© Springer Nature Switzerland AG 2019 123

L. Büchler, M. J.B. Keel (eds.), Fractures of the Hip, Fracture Management Joint by Joint,
https://doi.org/10.1007/978-3-030-18838-2_11
124 B. J. Braun et al.

–– Pipkin IV: If fracture pattern allows tro- (84.3%), followed by motorcycle accidents
chanteric flip shows better outcome. (5.1%) and falls (4.3%).
• Postoperative care: early functional treatment; While it was classically assumed that the typi-
minimum of 6 weeks partial weight bearing; cal fracture pattern in femoral head fractures was
avoid high degrees of hip flexion. a result of the pull of the foveal ligament (“stay-
• Common complications are nerve injury (20% ing effect”) newer studies have shown that the
sciatic nerve in posterior dislocations), avas- ligament can only pull out a small osteocartilagi-
cular necrosis, heterotopic ossification, and nous fragment. The typical fracture pattern is
osteoarthritis. explained as a chiseling mechanism of the ace-
• Depending on fracture type about 50% good tabular wall on the femoral head [8]. The exact
to excellent results can be expected. fracture pattern during dorsal hip dislocation then
depends on the hip position during the trauma: If
Keywords the hip is flexed below 60° and adducted, typi-
Femoral head fractures · Epidemiology · cally a Pipkin type I injury results as the medial
Classification · Nonsurgical management · part of the femoral head is pressed against the
Operative treatment · Aftercare very solid posterior acetabular wall. Abduction
with the same flexion will likely result in a type II
injury. If the hip is flexed >60° the femoral head
is pressed against a thinner portion of the poste-
11.1 Epidemiology, Mechanism rior acetabular wall more likely resulting in ace-
of Injury tabular fractures and cartilaginous damage, or
cortical depression fractures, of the femoral head
The fracture of the femoral head was first [9]. Pipkin type III fractures usually occur in
described in 1869 by Birkett who saw this injury cases with prolonged exposure to different forces:
during an autopsy of a patient who fell from the The first impact dislocates the femoral head from
second story of a building [1]. These fractures are the joint and causes a part of the femoral head to
rare and almost exclusively occur after hip joint shear-off. Prolonged adduction force then leads
dislocations. The resulting femoral head shearing to a femoral neck fracture with the posterior ace-
fractures are encountered in about 10% of all tabular rim acting as a hypomochlion [10].
posterior hip dislocations and less frequently in Occasionally the femoral neck fracture can also
anterior hip dislocations [2]. The exact frequency occur during the reduction maneuver. It is
varies from study to study between 7% and 18% assumed however that the majority of mechanical
[3]. Apart from the complete shearing fractures, damage to the femoral neck region results from
cortical depression fractures are described. the initial trauma, and initially non-displaced
Before the routine use of computed tomography, fractures that were simply not noted on the pri-
cortical depression fractures of the femoral head mary X-ray dislocate during the reduction
without fragment dislocation were virtually never maneuver [8].
detected. Due to improved imaging modalities
the incidence rate for cortical depression frac-
tures has been shown to be over 80% for anterior 11.2 Clinical and Radiographic
hip dislocations [4], 60% for posterior disloca- Assessment
tions [5], and even to occur in patients without
dislocations [6]. In a systematic review by As the majority of femoral head fractures are
Giannoudis et  al. the average age for over 450 associated with high-energy trauma and multiple
patients with femoral head fractures was reported injured patients it is important to identify the
as 38.9 years [7]. The most commonly observed fracture amongst concomitant injuries. Especially
injury mechanism was an automobile collision in unconscious patients careful history taking and
11  Pipkin Fractures 125

reports about the mechanism of injury from the head in relation to the contralateral, uninjured
emergency medical personnel present on the femur: Increased head size indicates that the
scene of the accident can assist in determining femur is closer to the X-ray source, thus anteri-
the risk for such fractures. While the clinical pre- orly dislocated; while posterior dislocations are
sentation can be misleading, fractures with poste- closer to the radiographic film, thus appear
rior hip dislocation generally appear with the leg smaller. Careful review of the femoral neck
in flexion, adduction, and internal rotation giving region is advisable to assess the existence of a
the impression of an overall shortened extremity. Pipkin Type III situation that could dislocate dur-
In fractures with anterior dislocation the leg is ing the reduction process. Furthermore oblique
generally abducted and externally rotated. These ala and obturator views can be used to determine
classic malpositions can be missing in the case of acetabular fractures, while inlet and outlet views
concomitant femoral neck fractures. Careful can be performed to detect pelvic ring injuries.
examination of the integument is needed to iden- Especially in the polytraumatized patient these
tify skin damages associated with high-energy views are commonly replaced by an immediate,
trauma (Morel-Lavallée lesions). A detailed neu- pre-reduction computed tomography (CT).
rological examination should be performed in the CT is considered routine following closed
conscious patient to determine sciatic nerve inju- reduction of the hip to correctly identify the frac-
ries associated with posterior dislocations or ture pattern and to decide upon the appropriate
femoral nerve injuries associated with anterior therapy (Fig.  11.1). In cases of irreducible hip
dislocations. In the unconscious patient this dislocation, CT can be performed to determine
examination should be performed as early as fea- the presence of intraarticular fragments that
sible; special attention needs to be paid to the might prevent reduction before surgery. In gen-
neurovascular structures on the imaging. eral, CT can determine size, number, and location
Conventional radiographs are the primary of fracture fragments as well as concomitant
means of determining the direction of dislocation injuries. Some studies have recommended a spe-
and extent of gross bony injuries. The fracture cial CT patient positioning to allow for
dislocation of the hip is routinely recognized in CT-directed pelvic oblique conventional radio-
anteroposterior (ap) radiographs by the disrup- graphs [11]. This has been shown to be an effec-
tion of Shenton’s line (Fig.  11.1). In ap pelvic tive method to determine the extent of fracture
radiographs, the direction of dislocation can be displacement and congruity of the joint and is
determined by evaluating the size of the femoral still recommended in current textbooks. However

a b

Fig. 11.1  The conventional ap radiograph shows a Pipkin dislocation of the femoral head and associated posterior
IV fracture left with concomitant posterior hip dislocation acetabular wall fracture (b)
(a). The CT scan after closed reduction shows fragment
126 B. J. Braun et al.

with the available technical ability to manually 11.3 Classification

adjust the CT plain and three-dimensional CT
reconstructions, these radiographs have no added As femoral head fractures are commonly associ-
value during primary diagnostics and should be ated with hip dislocations this is represented in
used for follow-up purposes only. the existing classification systems. The most
Magnetic resonance imaging (MRI) is primar- common classification system was introduced by
ily used to determine the cartilage and vascular Pipkin in 1957 [13] (Fig. 11.2): Type I fractures
integrity of the femoral head. As such it has been are fractures where the fracture line ends caudal
suggested during the initial examination. Due to to the Fovea capitis femoris, whereas in Type II
time constraints during the emergency treatment fractures the line ends cranial to the Fovea. This
however its main value is during follow-up visits helps distinguish between fractures outside
in determining the existence of early forms of (Type I) and within (Type II) the load-bearing
avascular necrosis (AVN) [12]. If an injury to the portion of the femoral head. In Type III fractures
external obturator muscle is suspected MRI can the femoral head fracture of either kind is associ-
discover injuries to the anatomically close medial ated with a femoral neck fracture. In Type IV
femoral circumflex artery and determine future fractures it is associated with acetabular wall
risk of AVN. fractures.

Type I Type II Type III Type III

Type IV

Fig. 11.2  Pipkin classification of femoral head fractures; either kind associated with acetabular wall fractures
Type I: Fracture line ends caudal to the Fovea capitis fem- (Haas, Norbert P., and Christian Krettek, eds. Tscherne
oris; Type II: Fracture line ends cranial to the Fovea; Type Unfallchirurgie: Hüfte und Oberschenkel. Springer-­
III: Femoral head fracture of either kind associated with Verlag, 2011. Adapted and reproduced with permission
femoral neck fracture; Type IV: Femoral head fracture of and copyright © of Springer)
11  Pipkin Fractures 127

1A 1B 3A 3B

2A 2B 4A 4B 5

Fig. 11.3  Brumback classification of femoral head frac- tures associated with hip dislocations. Clin Orthop Relat
tures. (Stannard JP, Harris HW, Volgas DA, Alonso JE: Res 2000;377:44–56. Adapted and reproduced with per-
Functional outcome of patients with femoral head frac- mission and copyright © of Springer)

In this system, only the more common dorso-­ combined femoral head and femoral neck frac-
cranial dislocations (90%) are classified. Brumback tures as C3 (Fig. 11.4).
introduced a modification of the original classifica-
tion 30  years later to incorporate all directions of
dislocation and also therapeutic and prognostic esti- 11.4 Conservative Treatment
mations (Fig. 11.3) [14]: Type I and Type II frac-
tures are defined like Pipkin I and II fractures, but 11.4.1 General Considerations
divided into two subgroups. Subgroup A are frac-
tures with minimal, or no acetabular rim damage The clinical and radiographic outcome of femo-
and stable joint conditions after reduction. Subgroup ral head fractures with concomitant hip disloca-
B fractures show significant acetabular rim damage tion is directly linked to the time of reduction [17,
along with hip joint instability. Brumback III frac- 18] and should thus be considered as a true ortho-
tures are posterior hip dislocations with femoral pedic trauma emergency. Several studies have
neck fractures without (subgroup A) or with associ- shown superior results if the hip is reduced within
ated femoral head fractures (subgroup B). Type IV 6 h [19], or even 3 h [20]. While many reduction
fractures result from anterior hip dislocations and maneuvers for hip dislocations have been pro-
either show an osteocartilaginous indentation (sub- posed, they all incorporate common mechanisms
group A), or a transchondral shear fracture (sub- for both anterior and posterior dislocations. In
group B). The final Type V fractures are central hip anterior dislocations, the reduction is generally
dislocations with femoral head fractures. While this performed by axial pull with the hip and knee in
classification system has been used in several larger neutral flexion/extension. For posterior disloca-
studies [15, 16] and shown to be a valuable tool to tions, knee and hip are flexed to around 90° and
assist outcome measurements, the clinical use of axial pull in the direction of the femur is applied.
this classification is rare, in part due to its increased Adequate pain management and sedation/relax-
complexity when compared to the original Pipkin ation is required prior to reduction to keep the
classification. occurring stresses to the femoral head as low as
The AO fracture classification system accounts possible. Post-reduction CT scan should be per-
for femoral head fractures within the classifica- formed to guide the ensuing management. Closed
tion of proximal femoral fractures. All femoral reduction is contraindicated in patients with con-
head fractures are classified under 31-C. Pipkin comitant femoral neck fractures. If closed reduc-
Type I and II fractures are further classified as tion is technically not possible, immediate open
C1, osteochondral depression fractures as C2 and reduction is recommended. A CT scan should be
128 B. J. Braun et al.

C 1.1 C 1.2 C 1.3

C 2.1 C 2.2 C 2.3

C 3.1 C 3.2 C 3.3

Fig. 11.4  AO classification system for femoral head frac- Springer-Verlag, 2011. Adapted and reproduced with per-
tures. (Haas, Norbert P., and Christian Krettek, eds. mission and copyright © of Springer)
Tscherne Unfallchirurgie: Hüfte und Oberschenkel.

performed beforehand to assess the fracture situ- largely abandoned due to relatively poor results
ation in detail if this does not lead to substantial [21] and the associated socioeconomic conse-
delays until final reduction is achieved. quences. Non-operative treatment however can
be considered especially in Pipkin I fractures
under certain conditions: Near anatomic reduc-
11.4.2 Nonsurgical Treatment tion with fragment dislocation below 2  mm, a
stable hip joint and congruent joint surfaces with-
The historically predominant conservative frac- out interposed fragments [22]. When applying
ture treatment with bed rest and traction has been these criteria studies with limited patient num-
11  Pipkin Fractures 129

bers have shown satisfactory outcomes [23]. be performed during the delayed primary care
Even if the fragment does not completely reduce phase ideally between the sixth and tenth day
after closed reduction, non-operative treatment [25]. If the definitive surgery is performed after
can be performed if the hip range of motion is not the 14th day post reduction, significantly worse
compromised by it [24], as even necrotic changes operative results have to be expected.
to the fragment outside the weight bearing zone
seem to have no effect on the clinical outcome 11.5.1.2 General Considerations:
[18]. The same criteria can be applied to Pipkin Vascular Anatomy
Type II fractures. However as they are located in Before committing to any approach and treat-
the weight bearing portion of the femoral head ment clear visualization of the approaches anat-
surface these fractures are exposed to increased omy and associated vascular supply of the
direct pressure and shear forces that can prevent femoral head and neck is advisable to avoid iatro-
adequate closed reduction [23]. Furthermore genic damage to the important vessels. The most
these fractures usually contain large areas of the important blood supply of the femoral head
femoral head, thus a high likelihood for an unsta- weight bearing cartilage is provided by the termi-
ble hip joint and osteoarthritis in case of incon- nal branches of the medial femoral circumflex
gruity or osteonecrosis is given. artery [26]. The medial circumflex artery origi-
If nonsurgical treatment is chosen, the patient nates from the deep femoral artery and runs
should be limited to partial weight bearing with between the iliopsoas and pectineus muscles
crutches for at least 6 weeks. Adduction and exces- along the basal part of the femoral neck. From
sive internal rotation of the hip should be avoided. there it continues around the inferior border of
Follow-up radiographs after 3 and 6 weeks should the external obturator muscle, runs posterior to
be performed to determine the maintenance of its tendon and anterior to the gemellus muscles
adequate reduction. The CT-directed pelvic and into the hip capsule just superior to the supe-
oblique radiograph technique originally published rior gemellus muscle insertion. From there the
by Moed et al. can be used to determine the posi- terminal branches of the artery lie within the peri-
tioning angle of the patient to allow for a standard- osteum and enter the bone postero-superiorly just
ized, perpendicular fracture line visualization [11]. lateral to the joint cartilage. As a result of this
course the main risk of injuring the medial cir-
cumflex artery is during posterior approaches
11.5 Operative Treatment [27]. Important medial blood supply from the
vessels within Weibrecht’s ligament [28] is fur-
11.5.1 Approaches thermore at risk during reduction of femoral head
fractures and care should be taken not to injure
11.5.1.1 General Considerations: the medial synovial fold, as it is often attached to
Time to Surgery the fragment. The lateral circumflex artery has
As with other fracture entities around the proxi- barely any contribution to the femoral heads
mal femur the time to surgery can have signifi- blood supply.
cant implications on the long-term outcome. The
most time sensitive and outcome predicting fac- 11.5.1.3 Anterior Approaches
tor is early joint reduction. In cases of technically Traditionally anterior approaches such as the
impossible reduction the time to surgery should Smith-Petersen approach were unpopular due to
thus ideally be below the 6 h threshold if comor- misinterpreted anatomical considerations. The
bidities and concomitant injuries permit. believe was that the more common posterior hip
Likewise in cases with a Pipkin III type injury dislocation injures the posterior blood supply so
early reduction and femoral neck fixation is that an anterior approach with possible damage
needed especially if a head preserving therapy is to the ascending branch of the lateral circumflex
planned. If closed reduction is accomplished cur- artery would then cut all blood supply from the
rent opinion is that the definitive surgery should femoral head [21]. With the above-mentioned
130 B. J. Braun et al.

anatomical considerations in mind however ante- directly address the posterior structures in irreduc-
rior approaches have gained considerably in pop- ible fracture dislocations as well as in cases with
ularity. Studies have shown that this approach is associated posterior acetabulum fractures (Pipkin
associated with decreased operating time and IV) the Kocher-Langenbeck approach is recom-
blood loss [23]. Furthermore the rate of avascular mended [31]. To manage femoral head damages
necrosis of the femoral head seems to be through a posterior approach a combination of the
decreased [29]. In cases of isolated femoral head approach with a trochanteric flip osteotomy surgi-
fracture the associated fragment is most com- cal hip dislocation is suggested. The advantage of
monly anteromedial. The Smith-Petersen this approach was demonstrated in a cadaver study
approach thus offers direct visualization of most by Gautier et al. that provided insight into the fem-
fragments in Pipkin I and II fractures without oral heads blood supply [27]. Through this tech-
compromising the vascular integrity of the femo- nique the obturator externus muscle is kept intact,
ral head. A radial capsulotomy at the beginning thus preserving blood supply to the femoral head
of the acetabulum usually offers sufficient frac- through the medial femoral circumflex artery [32].
ture visualization. If improved exposure is Patient positioning and initial exposure are per-
needed, the iliac rectus femoris origin can be formed analogue to the Kocher-Langenbeck
released. Without dislocating the hip most frac- approach, with the actual transmuscular approach
tures can then be visualized by extension, abduc- going through the Gipson Interval. A trochanteric
tion, and external rotation. The anterolateral step cut osteotomy is then performed from the
Watson Jones approach offers less soft tissue superior edge of the greater trochanter distally to
trauma, but also less adaptability when it comes the posterior end of the vastus ridge and mobilized
to extending the approach. Pipkin III fractures anteriorly. Afterwards the capsule is incised and
can be addressed by an anterolateral approach to the foveal ligament transected and excised with
manage both the femoral neck fracture with open the hip joint in a flexed and externally rotated posi-
reduction and also the femoral head fracture tion. The hip can now be anteriorly dislocated and
through a single incision. the complete femoral head can be surgically
Some older studies have seen higher incidence addressed. To facilitate anatomical refixation of
for heterotopic ossifications for anterior the greater trochanter with two cortical screws
approaches. Swiontkowski et al. have shown an drilling should be performed prior to the
increased overall (58% vs. 25%) rate of hetero- osteotomy.
topic ossifications when comparing anterior with In their original study of patients with surgical
posterior approaches in the treatment of Pipkin I anterior hip dislocation Ganz et  al. experienced
and II fractures [23]. Of the ossifications 29% no cases of avascular necrosis in 213 patients
were functionally significant in anterior [32]. In a further study Kloen et  al. compared
approaches while none were functionally signifi- patients treated either with an anterior, anterolat-
cant in posterior approaches. In a follow-up study eral, isolated posterior, or trochanteric flip
the author has thus recommended to only use the approach [30]. They found that around 80% of
distal, gluteal musculature sparing part of the the patients with trochanteric flip osteotomy had
Smith-Petersen approach. Newer studies have either excellent or good results. Again they
thus shown not only similar, but lower incidence noticed no avascular necrosis but a high rate
rates of heterotopic ossifications for the anterior (60%) of functionally significant heterotopic
approach [29, 30]. ossification. As such the excellent exposure of
this approach is limited by the extensive soft tis-
11.5.1.4 Posterior Approaches sue trauma and should be used in cases with pos-
Posterior fracture dislocations are often associated terior bony acetabulum injury combined with
with posterior soft tissue damage to structures anterior femoral head fractures. Careful operative
such as the piriformis tendon. These structures technique is needed to protect the femoral heads
most commonly block closed reduction. To vasculature.
11  Pipkin Fractures 131

Table 11.1  Common treatment options in relation to the Pipkin classification

Pipkin Conservative
classification optiona Surgical treatment Approach
I Yes   (1) Fragment excision Anterior preferred, depending
  (2) Internal fixation on fragment location
  (3) Arthroplasty
II Possible   (1) Internal fixation Anterior preferred, depending
  (2) Fragment excision on fragment location
  (3) Arthroplasty
III No   (1) (Open) Reduction internal fixation of the neck Anterolateral/anterior
  (2) Internal fixation of the head
  (3) Fragment excision
  (4) No head treatmenta
  (5) Arthroplasty
IV Yes   (1) Internal fixation of the acetabulum Posterior/trochanteric flip
  (2) Internal fixation of the head Separate anterior
  (3) Fragment excision Anterior with Smith-Petersen
  (4) Arthroplasty extension
Conservative treatment if: closed reduction is possible, residual fragment dislocation <2 mm and fragment outside of
a

weight bearing region

11.5.2 Techniques of Open sion compared to nonsurgical treatment [35]. In

Reduction and Fixation light of these results Pipkin Type I fractures
(Table 11.1) should mainly be treated with fragment excision.
Pipkin Type II fractures and larger fragments have
As the surgical technique is dependent on the however been shown to significantly interfere
fracture morphology the treatment options are with normal hip joint function if excised [34].
discussed using the more common Pipkin After excision the contact area was increased,
classification: mean pressures higher and displaced centrally.
This is thought to increase the chance of chondral
11.5.2.1 Pipkin Type I/II deterioration and ultimately osteoarthritis. If tech-
If the above-mentioned criteria for nonsurgical nical operability is given, these fracture fragments
management are not met (Sect. 11.4.2), the surgi- should be addressed by osteosynthesis. The
cal treatment can be performed either by internal approach should be tailored to the fragment loca-
fixation or fragment excision. Earlier studies have tion as determined on the preoperative CT scan
generally advised for fragment excision as long as and temporal fixation after open reduction can be
the fragment size was less than one third of the achieved with Kirschner wires. Definitive frag-
femoral head, as this has been shown to have a ment fixation then depends on fragment size and
superior outcome compared to fragment fixation surgeon preference. In larger fragments extra-
[33]. Further criteria advocating excision are the articularly introduced lag screws can be an option
degree of fracture comminution and thus techni- [36]. Most fractures however require fixation
cal operability, exact fragment size, and fracture from within the joint. Treatment options are coun-
location in a non-weight bearing area of the femo- tersunk interfragmentary compression screws
ral head. A cadaveric study by Holmes et  al. [37], headless self-compression screws [38], and
showed that fragment excision in Pipkin Type I bio-absorbable pins and screws [39]. Studies
fractures does not change the peak load and load comparing the outcome between these treatment
distribution on the acetabulum surface [34]. A methods in a randomized, controlled fashion do
recent randomized controlled trial has shown not exist and all studies with these fixation meth-
superior functional outcome scores in patients ods suggest comparable outcomes. Only one
with Pipkin Type I fractures and fragment exci- study using 3-mm cannulated screws with wash-
132 B. J. Braun et al.

ers has shown a high failure rate due to dissocia- has been shown to improve outcome in Pipkin
tion between screw and washer [29]. type IV fractures [16]. Pipkin IV fractures with
In cases of technically impossible anatomic anterior acetabular involvement can be addressed
fixation of fragments in the weight bearing either by the ilioinguinal or the Stoppa approach
region, as well as in older patients, hemi- and with a Smith-Petersen extension [22]. The indi-
total hip arthroplasty is a treatment option [40]. cations for hemi- or total hip arthroplasty are the
Especially in the geriatric patient this enables same as for the previously reported Pipkin I-III
early rehabilitation without the risk of secondary fractures.
complications such as avascular necrosis or trau-
matic osteoarthritis.
11.5.3 Results
11.5.2.2 Pipkin III
This rare fracture type has to be addressed by 11.5.3.1 Postoperative Care
emergency surgery to allow for successful reduc- Regardless of surgical or nonsurgical treatment
tion and fixation of both the femoral neck and several studies have shown that early mobiliza-
head with adequate outcome. Internal fixation of tion yields equivalent, if not superior results to
the femoral neck and hip reduction can be per- prolonged bed rest and extension treatment if the
formed by the Watson Jones approach, or any hip joint is stable [9, 30]. Early functional treat-
approach of the surgeon’s preference. Open ment with 20% body weight partial weight bear-
reduction decreases the risk of vascular compro- ing with crutches is thus recommended for a
mise [7]. If the Watson Jones approach is used the minimum of 6 weeks. Early mobilization can be
approach can subsequently serve as the approach assisted by continuous passive motion devices as
to the femoral head in adequately located fracture early as the first postoperative day. Especially in
situations. Whether or not surgical fixation of the posterior hip dislocations flexion above 70–90°
femoral head is needed is dependent on the frag- should be avoided, to decrease the load on the
ment size and position after reduction. In princi- structurally weak part of the posterior acetabular
ple the same criteria apply as mentioned above rim. Careful, repeated physical therapy instruc-
(Sect. 11.4.2). Fragments smaller than 2  mm, tions on the correct postoperative behavior as
outside the weight bearing region with near nor- well as aids such as wedge-shaped bolster should
mal hip range of motion can be left untreated. be used. If radiographic signs of fracture healing
Primary hemi- or total hip arthroplasty can be a are evident after 6 weeks careful, assisted weight
treatment option in elderly patients and femoral bearing increases combined with low impact
neck fractures with large displacements [41]. training should be begun. Full weight bearing is
generally achieved after 3 months.
11.5.2.3 Pipkin IV
The treatment and approach to these fractures is 11.5.3.2 Complications
dictated by the location and severity of the ace- The most common early complication associated
tabular fracture. Small, well-reduced fragments with posterior hip dislocations is sciatic nerve
without interposed loose bodies can be treated injury (Fig.  11.5). This injury is seen in up to
conservatively in the same fashion as Pipkin I 20% of all fracture dislocations. The nerve dam-
fractures. Especially in younger patients however age is either caused by entrapment of the nerve
fixation should be performed in larger and dis- between the femoral head or fracture fragments
placed fragments. The most common posterior and the ischium, rupture on a fracture surface, or
wall fractures can be addressed through the indirect pull and stretch [42]. In the majority of
Kocher-Langenbeck approach and possibly a cases the damage results from direct compression
separate anterior approach depending on the fem- through fracture fragments. The most commonly
oral head fragment location or through a single injured part of the sciatic nerve are the peroneal
approach with a trochanteric flip osteotomy. This nerve fibers, as they are most susceptible to isch-
11  Pipkin Fractures 133

Common signs are edema, wavy, low signal lines

with fatty centers, the double line sign, and later
on osteochondral fragmentation. Prolonged com-
promise of the initial vascularity of the femoral
head is regarded as a main risk factor for osteone-
crosis [46]. In this regard early reduction of an
associated hip dislocation is the key element to
reduce this risk. However several studies have
shown that despite early reduction osteonecroses
were seen [47], suggesting that the etiology is
multifactorial. A major risk factor is direct osteo-
chondral trauma from the initial injury, as well as
the reduction [17]. Therefore multiple, unsuc-
cessful closed reduction maneuvers have to be
avoided. Current studies also suggest that the
medial femoral circumflex artery can be dam-
aged if the obturator externus muscle is injured.
Older studies have suggested that anterior surgi-
cal approaches might compromise vascular integ-
rity [17]. This was however soon refuted by
Fig. 11.5  Injury mechanism for sciatic nerve damages: newer studies [33].
Over-stretch and direct pressure damage. (Haas, Norbert
P., and Christian Krettek, eds. Tscherne Unfallchirurgie:
The second most common long-term compli-
Hüfte und Oberschenkel. Springer-Verlag, 2011. Adapted cation is heterotopic ossification (Fig.  11.6)
and reproduced with permission and copyright © of which some authors have seen in as many as
Springer) 80% of all cases [47]. Associated risk factors are
pronounced muscle damage, traumatic brain
­
emic damage and have less stretching reserve due injury, and insufficient soft tissue management.
to the fixed course around the fibular head [43]. Furthermore fracture patterns requiring exten-
Immediate hip reduction is thus the most impor- sive approaches with long operating times seem
tant method to reduce the pressure on the nerve. to be associated with more heterotopic ossifica-
Letournel et al. have shown that in more than 2/3 tions. Some studies report the incidence of het-
of all patients with symptomatic sciatic nerve erotopic ossification to be higher in anterior
injuries no macroscopic injury can be observed approaches possibly due to aggressive muscle
[44]. Partial to total symptomatic recovery can be stripping from the ilium during this approach
expected in about 70% of all patients [45]. [22]. The underlying exact mechanism remains
In their 2009 meta-analysis Giannoudis et al. unknown. To prevent this complication either
have shown that the postoperative infection rate oral non-steroidal anti-inflammatory (NSAR)
for all femoral neck fractures is 3.2% [7]. They drugs or single dose radiation with seven Gray is
have furthermore shown that the three most com- suggested. Radiation is however hard to per-
mon long-term complications after these frac- form, especially in multiple injured, hemody-
tures are femoral head necrosis (11.8%), namically unstable patients. Radiation therapy
heterotopic ossification (16.8%), and posttrau- has to be performed immediately preoperative,
matic arthritis (20%). or within the first postoperative hours. Common
Femoral head avascular necrosis typically oral NSAR regimes are either 50 mg twice daily
occurs within the first 2 years after femoral head or 25 mg of Indomethacin three times a day over
fractures. Long before conventional radiographic 6 weeks postoperatively. It was shown that this
changes can be noticed, the MRI can determine effectively reduces the risk of severe heterotopic
early changes associated with avascular necrosis. ossification [46]. As some studies have shown
134 B. J. Braun et al.

Fig. 11.6  Heterotopic ossification (Brooker III; <1 cm between ossifications) 10 years after treatment of a Pipkin II
fracture through an anterior approach

that prolonged NSAR treatment can compromise 11.6 Results

bone healing [48], newer studies suggest this
prophylaxis only in the presence of extensive Due to the rarity of the injury many of the pub-
muscle damage, traumatic brain injury, or pro- lished studies report case series with small patient
longed mechanical ventilation [22]. numbers, different treatment options, inhomoge-
By far the most common complication after neous follow-up, non-standardized outcome mea-
hip dislocations with or without associated sures and different classification systems, thus
fractures is posttraumatic osteoarthritis. The limiting the comparability of the reported results.
development of posttraumatic osteoarthritis is In one of the earliest larger studies Thompson and
associated with the severity of the initial trauma Epstein reported <10% of good results in patients
[49], the amount of direct injury to the joint with femoral head fractures [5]. Within this article
cartilage [50], and the postoperative congruity they introduced an outcome measure for radio-
of the articular surface [51]. Accordingly the graphic, as well as clinical results that include
risk of osteoarthritis development is different gross radiographic appearance, as well as pain,
among the various fracture types: While some range of motion, and walking ability. In order to
degree of osteoarthritis is seen in almost all achieve good or excellent results only minimal
patients with Pipkin III fractures, or ventral dis- joint line narrowing and osteophyte formation is
locations, only as much as 50% of patients with allowed radiographically while clinically at least
Pipkin I, II, or IV fractures show this complica- 75% range of motion have to be achievable with-
tion [14, 46]. out any associated pain (Table 11.2).
11  Pipkin Fractures 135

Table 11.2  Outcome classification according to Thompson and Epstein [5]

Radiographic criteria
Excellent (normal) Good (minimal changes)
  1. Normal relationship between head and acetabulum   1. Normal relationship between head and acetabulum
  2. Normal articular cartilaginous space   2. Minimal narrowing of cartilaginous space
  3. Normal density of the femoral head   3. Minimal de-ossification
  4. No spur formation   4. Minimal spur formation
  5. No calcification of the capsule   5. Minimal capsular calcification
Fair (moderate changes) Poor (severe damages)
  1. Normal relationship between head and acetabulum   1. Almost complete obliteration of cartilaginous space
Any one or more of the following   2. Relative increase in density of femoral head
  1. Moderate narrowing of cartilaginous space   3. Subchondral cyst formation
  2. Mottling of head, sclerotic areas, decreased density   4. Formation of sequestrate
  3. Moderate spur formation   5. Gross deformity of femoral head
  4. Moderate to severe capsular calcification   6. Severe spur formation
  5. Depression of subchondral cortex of femoral head   7. Acetabular sclerosis
Clinical criteria
Excellent (all of the following) Good
  1. No pain   1. No pain
  2. Full range of hip motion   2. Free motion (75% of normal hip motion)
  3. No limp   3. Not more than slight limp
  4. No radiographic evidence of progressive changes   4. Minimal radiographic changes
Fair (any one or more of the following) Poor (any one or more of the following)
  1. Pain, but not disabling   1. Disabling pain
  2. Limited motion of hip; no adduction deformity   2. Marked limitation of motion or adduction deformity
  3. Moderate limp   3. Re-dislocation
  4. Moderately severe radiographic changes   4. Progressive radiographic changes

This score is the most predominant score in increased odds ratio for heterotopic ossification,
the current literature and has been used to stratify while posterior approaches had a higher inci-
the outcome in larger reviews. Studies applying dence of avascular necrosis. Due to this trend
the modern management principles mentioned towards better outcome and less complication
above have shown some improvements in the some authors favor the anterior approaches in the
clinical and radiographic outcome when com- current literature [22]. It should be noted how-
pared to the earlier treatment results. Intermediate ever that the primary decision on the approach is
term follow-up studies (mean follow-up of dictated by the fracture pattern. Interestingly only
33 months) with sufficient patient numbers (>30 one study has used a validated, patient centered
patients) have shown good and excellent results health status survey (SF-12) to quantify the out-
in over 55% of all patients [30, 33]. These num- come after femoral head fractures [29]. No rela-
bers are confirmed by current reviews [7, 52]. In tionship between the SF-12 score and time to
these studies the incidence of poor outcome surgery, surgical approach, or treatment method
increased with increasing fracture type (Pipkin I was seen, in part due to the low patient number
through IV). A non-significant tendency towards (n = 17).
better outcome in surgically treated fractures was For future studies the use of validated, compa-
seen, however limited data suggest better out- rable outcome measures (Thompson Epstein
come for Pipkin Type I fractures with conserva- score, Merle d’Aubigne and Postel Score, Harris
tive treatment. No statistically significant Hip Score, SF-35, EQ 5d) paired with a multi-
outcome differences were seen between anterior, center approach is needed to generate sufficient
posterior, and trochanteric flip approaches. statistical power required to truly evaluate treat-
Trochanteric flip osteotomy presented with an ment and fracture specific outcome.
136 B. J. Braun et al.

References 17. 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.
1. Birkett J. Description of a dislocation of the head of
18. Hougaard K, Thomsen PB.  Traumatic posterior dis-
the femur, complicated with its fracture; with remarks.
location of the hip--prognostic factors influencing the
Med Chir Trans. 1869;52:133–8.
incidence of avascular necrosis of the femoral head.
2. Duquennoy A, Decoulx J, Capron JC, Torabi DJ. Les
Arch Orthop Trauma Surg. 1986;106(1):32–5.
luxations traumatiques de la hanche avec fracture de
19. Schweikert CH, Weigand
la tête fémorale. À propos de 28 observations. Rev
H.  Hüftkopfkalottenfrakturen. Hefte Unfallheilkd.
Chir Orthop. 1975;61:209–19.
1979;140:188–200.
3. Yang RS, Tsuang YH, Hang YS, Liu TK. Traumatic
20. Schiedel F, Rieger H, Joosten U, Meffert R.  Wenn
dislocation of the hip. Clin Orthop Relat Res.
die Hüfte nicht “nur” luxiert. Unfallchirurg.
1991;265:218–27.
2006;109(7):538–44.
4. DeLee JC, Evans JA, Thomas J. Anterior dislocation
of the hip and associated femoral-head fractures. J 2
1. Epstein HC.  Posterior fracture-dislocations of the
Bone Joint Surg Am. 1980;62(6):960–4. hip; long-term follow-up. J Bone Joint Surg Am.
5. Thompson VP, Epstein HC. Traumatic dislocation of 1974;56(6):1103–27.
the hip; a survey of two hundred and four cases cover- 2
2. Droll KP, Broekhuyse H, O’Brien P.  Fracture
ing a period of twenty-one years. J Bone Joint Surg of the femoral head. J Am Acad Orthop Surg.
Am. 1951;33-A(3):746–78; passim. 2007;15(12):716–27.
6. Yoon PW, Jeong HS, Yoo JJ, Koo KH, Yoon KS, 23. Swiontkowski MF, Thorpe M, Seiler JG, Hansen
Kim HJ.  Femoral head fracture without dislocation ST. Operative management of displaced femoral head
by low-energy trauma in a young adult. Clin Orthop fractures: case-matched comparison of anterior versus
Surg. 2011;3(4):336–41. https://doi.org/10.4055/ posterior approaches for Pipkin I and Pipkin II frac-
cios.2011.3.4.336. tures. J Orthop Trauma. 1992;6(4):437–42.
7. Giannoudis PV, Kontakis G, Christoforakis Z, 2
4. Thannheimer A, Gutsfeld P, Buhren V. Current ther-
Akula M, Tosounidis T, Koutras C.  Management, apy options for fractures of the femoral head. Chirurg.
complications and clinical results of femoral head 2009;80(12):1140–6. https://doi.org/10.1007/
fractures. Injury. 2009;40(12):1245–51. https://doi. s00104-009-1738-4.
org/10.1016/j.injury.2009.10.024. 25. Pape HC, Rice J, Wolfram K, Gansslen A, Pohlemann
8. Goulet JA, Levin PE.  Hip dislocations. In: Skeletal T, Krettek C. Hip dislocation in patients with multiple
trauma: basic science, management, and reconstruc- injuries. A followup investigation. Clin Orthop Relat
tion, vol. 3. Philadelphia: Saunders; 2003. p. 1657–69. Res. 2000;377:99–105.
9. Lang-Stevenson A, Getty CJ.  The Pipkin fracture-­ 2
6. Harrison MH, Schajowicz F, Trueta J.  Osteoarthritis
dislocation of the hip. Injury. 1987;18(4):264–9. of the hip: a study of the nature and evolution of the
10. Brumback RJ, Holt ES, McBride MS, Poka A, Bathon disease. J Bone Joint Surg. 1953;35-B(4):598–626.
GH, Burgess AR.  Acetabular depression fracture 27. Gautier E, Ganz K, Krugel N, Gill T, Ganz
accompanying posterior fracture dislocation of the R. Anatomy of the medial femoral circumflex artery
hip. J Orthop Trauma. 1990;4(1):42–8. and its surgical implications. J Bone Joint Surg.
11. Moed BR, Maxey JW. Evaluation of fractures of the 2000;82(5):679–83.
femoral head using the CT-directed pelvic oblique 28. Gojda J, Bartonicek J.  The retinacula of Weitbrecht
radiograph. Clin Orthop Relat Res. 1993;296:161–7. in the adult hip. Surg Radiol Anat. 2012;34(1):31–8.
12. Henle P, Kloen P, Siebenrock KA. Femoral head inju- https://doi.org/10.1007/s00276-011-0829-3.
ries: which treatment strategy can be recommended? 29. Stannard JP, Harris HW, Volgas DA, Alonso
Injury. 2007;38(4):478–88. https://doi.org/10.1016/j. JE.  Functional outcome of patients with femoral
injury.2007.01.023. head fractures associated with hip dislocations. Clin
13. Pipkin G. Treatment of grade IV fracture-dislocation Orthop Relat Res. 2000;377:44–56.
of the hip. J Bone Joint Surg Am. 1957;39-A(5):1027– 30. Kloen P, Siebenrock KA, Raaymakers ELFB, Marti
42; passim. RK, Ganz R. Femoral head fractures revisited. Eur J
14. Brumback RJ, Kenzora JE, Levitt LE, Burgess
Trauma. 2002;28(4):221–33.
AR, Poka A.  Fractures of the femoral head. Hip. 31. McKee MD, Garay ME, Schemitsch EH, Kreder HJ,
1987;1987:181–206. Stephen DJ.  Irreducible fracture-dislocation of the
15. Prokop A, Helling HJ, Hahn U, Udomkaewkanjana hip: a severe injury with a poor prognosis. J Orthop
C, Rehm KE. Biodegradable implants for Pipkin frac- Trauma. 1998;12(4):223–9.
tures. Clin Orthop Relat Res. 2005;432:226–33. 32. Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N,

16. Solberg BD, Moon CN, Franco DP. Use of a trochan- Berlemann U.  Surgical dislocation of the adult hip
teric flip osteotomy improves outcomes in Pipkin IV a technique with full access to the femoral head and
fractures. Clin Orthop Relat Res. 2009;467(4):929– acetabulum without the risk of avascular necrosis. J
33. https://doi.org/10.1007/s11999-008-0505-z. Bone Joint Surg. 2001;83(8):1119–24.
11  Pipkin Fractures 137

3 3. Marchetti ME, Steinberg GG, Coumas 43.

Trojan E.  Gefäß-und Nervenverletzungen bei
JM.  Intermediate-term experience of Pipkin Frakturen und luxationen im Beckenbereich. Hefte
fracture-­ dislocations of the hip. J Orthop Trauma. Unfallheilkd. 1979;140:44–8.
1996;10(7):455–61. 44. Letournel E, Judet R.  Fractures ofthe acetabu-

34. Holmes WJ, Solberg B, Bay BK, Laubach JE, Olson lum (Translated and edited by Elson RA). Berlin:
SA.  Biomechanical consequences of excision of Springer; 1981.
displaced Pipkin femoral head fractures. J Orthop 45. Cornwall R, Radomisli TE.  Nerve injury in trau-

Trauma. 2000;14(2):149–50. matic dislocation of the hip. Clin Orthop Relat Res.
35. Chen ZW, Lin B, Zhai WL, Guo ZM, Liang Z, Zheng 2000;377:84–91.
JP, et al. Conservative versus surgical management of 46. Hougaard K, Thomsen PB.  Traumatic posterior

Pipkin type I fractures associated with posterior dis- fracture-dislocation of the hip with fracture of the
location of the hip: a randomised controlled trial. Int femoral head or neck, or both. J Bone Joint Surg Am.
Orthop. 2011;35(7):1077–81. https://doi.org/10.1007/ 1988;70(2):233–9.
s00264-010-1087-4. 47. Schwarzkopf SR, Dreinhofer KE, Haas NP, Tscherne
36. Mostafa MM.  Femoral head fractures. Int Orthop. H.  Isolated hip dislocation of traumatic origin.
2001;25(1):51–4. Unfallchirurg. 1996;99(3):168–74.
37. Ross JR, Gardner MJ.  Femoral head fractures. Curr 48. Burd TA, Hughes MS, Anglen JO. Heterotopic ossi-
Rev Musculoskelet Med. 2012;5(3):199–205. https:// fication prophylaxis with indomethacin increases
doi.org/10.1007/s12178-012-9129-8. the risk of long-bone nonunion. J Bone Joint Surg.
38. Murray P, McGee HM, Mulvihill N. Fixation of fem- 2003;85(5):700–5.
oral head fractures using the Herbert screw. Injury. 49. Upadhyay SS, Moulton A.  The long-term results of
1988;19(3):220–1. traumatic posterior dislocation of the hip. J Bone Joint
39. Jukkala-Partio K, Partio EK, Hirvensalo E, Rokkanen Surg. 1981;63B(4):548–51.
P.  Absorbable fixation of femoral head fractures. A 50. Borrelli J Jr. Chondrocyte apoptosis and posttraumatic
prospective study of six cases. Ann Chir Gynaecol. arthrosis. J Orthop Trauma. 2006;20(10):726–31.
1998;87(1):44–8. https://doi.org/10.1097/01.bot.0000249882.77629.5c.
40. Roeder LF Jr, DeLee JC.  Femoral head fractures
51.
Bhandari M, Matta J, Ferguson T, Matthys
associated with posterior hip dislocation. Clin Orthop G.  Predictors of clinical and radiological out-
Relat Res. 1980;147:121–30. come in patients with fractures of the acetabulum
41. Kozin SH, Kolessar DJ, Guanche CA, Marmar
and concomitant posterior dislocation of the hip. J
EC. Bilateral femoral head fracture with posterior hip Bone Joint Surg. 2006;88(12):1618–24. https://doi.
dislocation. Orthop Rev. 1994;Suppl:20–4. org/10.1302/0301-620X.88B12.17309.
42. Rehm KE.  Acetabulumfrakturen–posttraumatische 52. Akula M, Giannoudis P, Gopal S, Pagoti R.  Pipkin
und postoperative Nervenschäden. Hefte Unfallheilkd. fractures–clinical outcomes. J Bone Joint Surg Br.
1985;174:472–6. 2010;92(SUPP IV):543.
 Femoral Neck Fractures
12
Govind S. Chauhan, Mehool Acharya,
and Tim J. S. Chesser

Abstract 12.1 Mechanism of Injury

Fractures of the proximal femur, commonly and Epidemiology
termed hip fracture, is a devastating injury for
any age of patient. The injury carries a high 12.1.1 Mechanism of Injury
mortality as well as significant morbidity and
impact of function. They can be divided into The vast majority of hip fractures present as a
intracapsular (also called subcapital) fractures result of low energy trauma in elderly patients
and extracapsular fractures. Extracapsular with weakened osteoporotic bone. These are
fractures are further subdivided into basicervi- termed fragility fractures and generally result
cal, trochanteric, and subtrochanteric frac- from falls from a standing height. As well as hav-
tures. In this chapter we will discuss the ing weaker bone, the elderly are at high risk of
epidemiology, assessment, classification, falls due to multiple factors including co-­
management, and outcome for patients of morbidities, side effects of medications, reducing
intracapsular (subcapital) fractures. mobility, and poorer balance and co-ordination
[1, 2]. Femoral neck fractures usually occur from
Keywords a direct fall onto the lateral aspect of the hip
Intracapsular femoral neck fracture · Garden · around the greater trochanter, and may also occur
Pauwels · Internal fixation · Hemiarthroplasty · from a twisting injury with a planted, fixed foot.
Total hip replacement · Arthroplasty In some low energy hip fractures, there are pre-­
existing pathological lesions in the femoral neck,
and these pathological fractures are covered in
Chap. 13.
In patients with normal bone, a large force is
required to fracture the femoral neck, and these
patients present after high-energy trauma such as
motor vehicle accidents and falls from heights. A
G. S. Chauhan femoral neck fracture in these cases usually
The Knowledge Hub, The Royal Orthopaedic occurs from axial loading of the femur with the
Hospital, Birmingham, UK
hip in an abducted position. If the hip is adducted
M. Acharya · T. J. S. Chesser (*) and flexed at the time of impact, dislocation of
Department of Trauma and Orthopaedics, Brunel
Building, Southmead Hospital, Bristol, UK the hip is the commoner injury. These high-­
e-mail: [email protected] energy injuries occur in younger patients, and the

© Springer Nature Switzerland AG 2019 139

L. Büchler, M. J.B. Keel (eds.), Fractures of the Hip, Fracture Management Joint by Joint,
https://doi.org/10.1007/978-3-030-18838-2_12
140 G. S. Chauhan et al.

principles for treating them differ from the affected hip and the majorities are unable to
elderly, and are described later in this chapter. mobilize. On examination, these patients may
have a shortened, externally rotated limb if the
fracture has displaced. There may or may not be
12.1.2 Epidemiology any signs of external bruising, particularly with
intracapsular fractures as the hematoma is con-
Worldwide, with improvements in medical care, tained within the capsule of the hip joint. Due to
nutrition and quality of life, the population con- the high prevalence of cognitive impairment in
tinues to live longer, and thus there are more the geriatric population, an accurate clinical
patients living with diseases of the elderly, assessment is often difficult, and thus a low
including osteoporosis. This has led to increasing threshold for radiological investigation is
numbers of patients with hip fractures. In 1990, required. Both anteroposterior and lateral views
there were approximately 1.66 million hip frac- should be obtained and displacement in either
tures, with projections for 2050 estimating over 6 plane can influence treatment [2]. Between 5%
million hip fractures, and over half of these are and 10% have an occult fracture that is not recog-
expected to be in Asia [3]. The current incidence nized on initial radiological screening. Any
of hip fracture in the Western world is approxi- elderly patient who suffers a fall and has pain on
mately one per thousand, but there remains sig- weight bearing, with negative initial radiographs,
nificant variation between studies, as well as requires further imaging. Magnetic resonance
between countries [4]. scans are thought to be the gold standard [8, 9],
yet many will perform CTs due to ease of access.
This imaging should be performed within 24 h of
12.1.3 Risk Factors admission in order to prevent delay to surgery
should it be required [2].
The major risk factors for femoral neck fractures A key part of the assessment of the elderly
are falls and osteoporosis, which show an increas- patient with low energy trauma is identifying
ing prevalence with age [5]. Twenty-five percent potential causes for the fall. Medical emergen-
of patients presenting with femoral neck fractures cies, such as myocardial infarction, sepsis, stroke,
will have had a previous fragility fracture [6]. etc., must be considered and promptly treated if
Women are at a significantly higher risk of hip present. As well as a thorough history, a full sys-
fracture, making up 75% of the patients. A third of temic examination must be performed. It is well
patients presenting with hip fractures have been recognized that the majority of falls in the elderly
shown to have a significant degree of cognitive are multifactorial, and these should be addressed
impairment [7]. Other risk factors that have a during the patient’s admission. Early evaluation
higher incidence of hip fracture include lower of the patients’ hydration status is also vital, and
socioeconomic status, cardiovascular disease, a proportion of the patients will have spent a sig-
renal disease, diabetes, and polypharmacy. It is nificant amount of time on the floor before being
the significant frailty of the geriatric population, able to obtain help. The assessing doctor must
which increases the complexity of treatment. also actively look for any other injuries, in par-
ticular associated osteoporotic fractures, com-
monly distal radius or proximal humeral
12.2 Clinical and Radiological fractures.
Assessment Most units have developed fast track services
allowing rapid radiological diagnosis and early
12.2.1 Clinical Assessment: Low medical optimization of the patients so not to
Energy Trauma delay surgical treatment [7]. Appropriate investi-
gations should be undertaken on admission with
Patients who have fractured their hip following a the aim of immediate optimization, ensuring sur-
low energy fall will complain of pain in the gery is not delayed by anemia, volume depletion,
12  Femoral Neck Fractures 141

electrolyte imbalance, correctable cardiac the injured limb. The motor and sensory func-
arrhythmias, uncontrolled diabetes, uncontrolled tions of the sciatic nerve should be assessed
heart failure, acute chest infections, nor exacer- through both its tibial and common peroneal
bation of chronic chest conditions. All units branches. Additional CT imaging is now rou-
should have policies in place for the reversal of tinely performed as part of the initial trauma
anticoagulants, and in particular, surgery should assessment, allowing better understanding of the
not be delayed because of antiplatelet therapy fractures.
[2]. A balance must be sought between avoiding It is also important to undertake imaging of
excessive delays and inadequate optimization. the femoral neck in patients who have femoral
Prolonged delays to surgery causing ongoing shaft fractures as a result of high-energy trauma,
pain and greater time to weight bearing, which in with up to 6% patients having ipsilateral femoral
turn is associated with the complications of inac- neck fractures [11].
tivity such as pressure ulcers, respiratory tract
infections, thromboembolism, etc. Conversely,
inadequate optimization places the patient at risk 12.3 Classification
of perioperative complications. To date, there
remains a paucity of good evidence regarding the There are numerous classification systems
impact of timing of surgery; however no study which exist for proximal femoral fractures,
has shown an advantage by delaying surgery [2]. however the most important things to determine
Early surgery has been shown to result in reduced are whether the fracture is intracapsular or
mortality, reduced pain, shorter length of stay, extracapsular, and whether it is displaced or
and reduced incidence of significant complica- undisplaced (Fig. 12.1).
tions. Acute medical physicians or specialist This is of importance due to the retrograde
orthogeriatricians, and anesthetists are increas- blood supply to the femoral head. At the base of
ingly being involved preoperatively to provide the femoral neck, retinacular vessels branch off
assistance and support to optimize what is often a the medial femoral circumflex artery and pene-
long, complex list of co-morbidities. Surgery trate the head at the 11 o’clock position to supply
should be performed as soon as possible, ideally it [13]. As well as this, the intracapsular femoral
on the day of, or day after injury. neck has little cancellous bone and a thin perios-
Structured multidisciplinary management and teum. Displaced intracapsular fractures are at
pathways have shown to significantly reduce
mortality and improve patient outcomes whilst
reducing complications and length of stay [2, 7].

12.2.2 Clinical Assessment: High-­

Energy Trauma

The assessment of patients with high-energy

trauma differs greatly from that in the elderly
described above. The initial assessment of these
patients is guided by resuscitation and lifesav-
ing interventions, with the help of a trauma
team [10].
Once the patient has been resuscitated and sta-
bilized, the orthopedic surgeon can then assess Fig. 12.1  Classification of proximal femoral fractures by
the injured hip. It is important to accurately site. Reproduced with permission and copyright © of
assess and document the neurovascular status of Elsevier [12]
142 G. S. Chauhan et al.

high risk of disrupting the blood supply to the • Type 1—Incomplete fracture, with valgus
femoral head, thus putting it at risk of avascular impaction.
necrosis. Intracapsular fractures are also associ- • Type 2—Complete fracture, but undisplaced.
ated with higher rates of non-union and • Type 3—Complete fracture with partial
mal-union. displacement.
Commonly used classification systems include • Type 4—Complete fracture with full
Garden, Pauwels, and AO/OTA, all of which have displacement.
their own significant limitations. The simple clas-
sification into undisplaced and displaced is
thought to help with surgical decision-making 12.3.2 Intracapsular Fractures:
and prognosis. Pauwels’ Classification [16, 17]

Pauwels’ classification of intracapsular frac-

12.3.1 Garden Classification tures is a biomechanical classification system,
(Intracapsular Fractures) [14] dividing intracapsular fractures into three cat-
egories based on the angle between the fracture
The Garden classification is a widely used sys- line and the horizontal on an AP radiograph. It
tem based on the descriptions by British orthope- was first described in 1935 by Friedrich
dic surgeon Robert Symon Garden. It is based Pauwels, a German orthopedic surgeon, with
purely on the AP radiograph, and is divided into the original text in German. This was then re-
four categories based on fracture completeness published in 1976  in English. Over the years,
and displacement. It can be useful in determining there have been misinterpretations of Type 3 in
treatment strategies, but is flawed in that it does Pauwels’ classification system which have
not consider the appearances on the lateral radio- been repeated and printed in multiple highly
graph, nor does it consider the underlying quality regarded texts [18]. The angle is measured
of the bone (Fig. 12.2). between the fracture line of the distal fragment

1 2

Fig. 12.2  Garden classification. Types 1-4. Reproduced with permission and copyright © of Springer [15]
12  Femoral Neck Fractures 143

3 4

Fig. 12.2 (continued)

Fig. 12.3  Original images for Pauwels’ classification. Type 1: Less than 30°; Type 2: Between 30° and 50°; Type 3:
Greater than 50°. Reproduced with permission and copyright © of Springer [19]

and the horizontal line, to determine shearing In Pauwels’ Type 1, the forces are compres-
stresses and compressive force. The correct sive across the fracture site. In Type 2 fractures,
system is described below (Fig. 12.3). some shear forces are also present, having a neg-
ative impact on fracture healing. In Type 3 frac-
• Type 1—less than 30° tures, shear forces are dominant, causing varus
• Type 2—between 30° and 50° collapse and displacement of the fracture. Again,
• Type 3—greater than 50° similar to Garden’s classification, Pauwels’ sys-
144 G. S. Chauhan et al.

tem is limited by the fact that it too does not con- AO/OTA classification is for intracapsular frac-
sider the lateral radiograph and nor the bone tures, and there are seven subtypes as described
quality. below (Fig. 12.4),

• 31-B1—subcapital with slight displacement

12.3.3 AO/OTA Classification [20] • 31-B1.1—Valgus impacted fracture
• 31-B1.2—Non-displaced fracture
The Arbeitsgemeinschaft für Osteosynthesefragen • 31-B1.3—Displaced fracture
(AO)/Orthopaedic Trauma Association (OTA) • 31-B2—Transcervical
has an extensive long bone classification system • 31-B2.1—Simple fracture
which includes hip fractures. These come under • 31-B2.2—Multifragmentary fracture
section 31 of the system (3 = femur, 1 = proxi- • 31-B2.3—Shear fracture
mal). This has been updated in 2018. 31-B of the • 31-B3—Basicervical fracture

Fig. 12.4  AO/OTA Classification: 31-B. Reproduced with permission and copyright © of Wolters Kluwer Health, Inc.
[20]
12  Femoral Neck Fractures 145

All three of these classification systems have 12.5 Operative Treatment

significant limitations with intra-observer and
inter-observer reliability. This is likely due to vari- The main aims of surgical intervention differ
ation in identifying the angle of the primary frac- between the high and low energy trauma groups
ture line, as there is often rotation and overlap of of patients with hip fractures, and this must be
the fragments obscuring the view. Many surgeons considered when assessing the patient and deter-
opt to simply describe the fracture as either dis- mining the surgical plan.
placed or undisplaced, but there is widespread dis- For the young patient with a high-energy hip
agreement about what is defined an undisplaced fracture, the aim is to preserve the femoral head if
intracapsular fracture [21, 22]. The Garden classi- at all possible. These patients can usually tolerate
fication is the most widely used in literature. restrictions on mobility for a period of time
whilst the fracture heals.
For the elderly patient with a low energy hip
12.4 Conservative Treatment fracture, the primary aim is to restore mobility as
quickly as possible. These patients should have
12.4.1 Initial Treatment one definitive surgical procedure to treat their
injury allowing them to mobilize weight bearing
Once a hip fracture is suspected, patients must be without restrictions [2].
provided with analgesia. This can often be over- In any surgical approach where fixation is to
looked, particularly in patients with cognitive be undertaken, the critical step is reduction. An
impairment who are unable to communicate their accurate reduction will restore the mechanics of
pain. The majority of these patients will require the hip joint, promote fracture healing, and dis-
opiate analgesia, and this can be provided in oral, tribute the forces to avoid excess stress on the
intramuscular, or intravenous form, taking care to implant.
avoid potential complications such as respiratory
depression and delirium. Following diagnosis,
analgesia can also be supplemented with regional 12.5.1 Undisplaced Subcapital
nerve blocks, such as fascia iliaca block or femo- Fractures
ral nerve block [2].
Undisplaced, subcapital fractures are generally
treated with internal fixation. There is signifi-
12.4.2 Definitive Non-Operative cant variation in what surgeons classify as
Treatment undisplaced. With more tilt and valgus collapse
there is more of a tendency to replacement,
Definitive, non-operative treatment of hip frac- though the evidence for this is currently lack-
tures is reserved for a very small minority of ing. The two commonest fixation methods
patients (less than 2%) [7]. It should only be con- available to the surgeon are either cannulated
sidered in either patients who are not expected to screw fixation or sliding hip screw. Recently,
survive 24  h, those at extremely high risk from more fixed angle implants have been intro-
surgical intervention, non-ambulatory patients duced, but with limited published evidence
who are not in pain, or those who present late with comparing them against traditional separate
partially healed fractures not affecting function. screw or sliding hip screw ­fixation [23–25]. A
Patients in the terminal stages of illness should not recent large randomized trial studied 1108
be denied surgery if it can help to improve their patients with low-energy femoral neck frac-
quality of life by providing pain relief, ease of tures, who were randomized to internal fixation
nursing and mobility, even if only temporarily [2]. with a sliding hip screw or cancellous screws.
146 G. S. Chauhan et al.

Fig. 12.5  Cannulated screw fixation of a marginally displaced fracture of the femoral neck (Garden Type 1)

Fig. 12.6  Sliding hip screw fixation of a varus displaced femoral neck fracture (Pauwels Type 3)

The results show no significant difference in the the patient in the lateral position, again taking
rate of re-operation between the sliding hip care not to displace the fracture.
screw (19.7%; 107/542) and the cancellous Following internal fixation of undisplaced
screw (21.8%; 117/537), groups (p = 0.18), and fractures, there remains great variation in re-­
no difference in any measure of quality of life operation rates reported in the literature (4–19%).
up to 2  years [26]. This suggests either tech- The commonest causes for re-operation are frac-
nique can be used (Figs. 12.5 and 12.6). ture non-union (0.7–11%), avascular necrosis of
For fixation, the patient can be positioned the femoral head (2.5–10.8%), localized pain
either supine or in the lateral position. In the from metalwork prominence (1.3–5%), and peri-­
supine position, the patient is carefully positioned prosthetic fracture (0.3–1.7%) [27–33].
on the traction table with the contralateral leg
flexed and abducted. It is important to remember
that as the fracture is undisplaced, no traction 12.5.2 Displaced Intracapsular
should be applied to the limb, and great care Fractures in the Elderly
should be taken on transferring the patient to
ensure the fracture is not displaced iatrogenically. Internal fixation of displaced intracapsular frac-
Alternatively, these fractures can be fixed with tures is associated with a significant re-operation
12  Femoral Neck Fractures 147

rate (14–53%) when compared to initial arthro- (9–23% vs. 0–13%) [35, 39, 43]. More recent
plasty (0–16%) [33–37]. Complication rates fol- studies suggest this dislocation rate can be reduced
lowing fixation of intracapsular fractures also with anterior and anterolateral approaches.
remain high, with literature reporting 10–38% Guidelines in the UK advise offering total hip
non-union, 0–19% avascular necrosis, and 4–6% replacement to those who were able to walk inde-
localized pain [35, 36, 38]. Studies have also pendently out of doors with no more than the use
shown improved functional recovery and less pain of one stick prior to the fall, who are not cogni-
with arthroplasty compared to fixation [37–39]. tively impaired, and who are medically fit [2].
Given the level 1 evidence and meta-analysis There remains concern regarding the more
that is available for this topic, arthroplasty is the elderly patient, and currently many patients are
treatment of choice recommended by most guide- not offered total hip replacement for logistical
lines for displaced intracapsular fractures in the reasons, with a lack of experienced surgeons [7].
elderly [34, 35].
Internal fixation does however have a lower 12.5.2.2 Cemented or Uncemented
blood loss, length of surgery, and risk of deep There remains worldwide variation in the use of
wound infection [35]. cement in replacement arthroplasty for hip frac-
The anterolateral approach has been shown to tures, usually depending on the individual coun-
have a lower dislocation rate compared to a pos- tries practice. Most larger studies and database
terior approach, and in this frail group where the publications have shown advantages with cement
aim is to avoid complications, this is the approach with decreased mortality, improved function, and
recommended for UK surgeons [2]. The anterior lower peri-prosthetic fracture rate. Many of these
approach provides another alternative. Both uni- studies looked at older type prosthesis, such as
polar and bipolar hemiarthroplasty have been the Austin-Moore and Thompsons implants, now
recommended, yet there is no evidence that bipo- not commonly used. There have been reports of
lar heads give any improvement in any measured bone cement implantation syndrome, or a drop-
outcomes and function, hence unipolar hemiar- ping of blood pressure, associated with cement
throplasty is advised, due to lower costs [40]. insertion and implantation of the femoral stem.
Strategies to avoid this include adequate resusci-
12.5.2.1 Hemiarthroplasty or Total tation and medical optimization of the patient,
Hip Replacement lavage of the femoral canal and not to over-­
The published literature to help surgeons decide pressurize in those as risk [44–47].
which of these two operations is best for the
patient has not yet clearly defined which popula-
tion of patients will benefit from total hip replace- 12.5.3 Displaced Intracapsular
ment over hemiarthroplasty. It is accepted that Fractures in the Young
those with pre-existing symptomatic osteoarthri-
tis and patients with rheumatoid arthritis should The aim of surgery in the young patient is to pre-
be considered for a total hip replacement. serve the femoral head. This is achieved by
The evidence for total hip replacement reduction, either closed or open, and internal fix-
remains relatively limited. In the selected patient ation, with either cannulated screws or sliding
groups studied, total hip replacement is found to hip screw [48].
be associated with improved functional status at
3 months and 1 year, more cost effective and have 12.5.3.1 Time to Surgery
a lower re-operation rate (2–8% versus 0–24%) The urgency of theater for the treatment of dis-
than hemiarthroplasty [34, 41, 42]. placed femoral neck fractures remains a topic of
Total hip replacement does however have a debate, with inconclusive, poor quality evidence
higher rate of dislocation than hemiarthroplasty in the literature. The advantages of early surgery
for displaced intracapsular fractures in the elderly are argued as by allowing early reduction and
148 G. S. Chauhan et al.

capsular decompression, it allows vessels to then checked with image intensifier on AP and lat-
unkink and relieves the pressure on them, giving eral views. If an adequate closed reduction cannot
the femoral head the best chance of revascular- be achieved, multiple reduction attempts should be
ization. Some studies have shown delays in fixa- avoided as they have been reported to show
tion beyond 12  h to be associated with higher increased rates of avascular necrosis [48].
rates of osteonecrosis, whilst others have shown
no difference when comparing delays of 24  h 12.5.3.3 Open Reduction
[48]. Open reduction of the femoral neck can be
achieved through a number of different tech-
12.5.3.2 Closed Reduction niques and approaches. One technique is to posi-
An initial closed reduction can be attempted by tion temporary wires or pins into the proximal
using the Leadbetter technique [49]. The hip is fragment by passing them anteriorly, utilizing
flexed whilst in abduction, and then traction applied. them as a joystick to mobilize the fragment and
The hip is then slightly internally rotated and then achieve reduction, before then passing further
extended whilst traction is maintained. Reduction is lateral wires to maintain the reduction (Fig. 12.7).

Fig. 12.7  Open reduction of intracapsular fracture with k-wires and bone hook [50]
12  Femoral Neck Fractures 149

lized as a minimum, though no advantage has

been shown from utilizing four or more screws.
Following internal fixation in these healthy
patients, the majority of surgeons would advo-
cate limiting weight bearing for up to 12 weeks
post-operatively in order to allow healing without
excessive collapse or displacement of the frac-
ture. Whilst the traditional teaching has been to
allow compression of the fracture, evidence in
younger patients shows that collapse greater than
10 mm can start to affect function [53].
Fig. 12.8  Temporary bridging plate to maintain femoral
A 2015 meta-analysis of the available research
neck reduction analyzed the complications of re-operation, avascu-
lar necrosis, non-union, implant failure, and infec-
tion following internal fixation of intracapsular
Alternatively, reduction can be achieved fol- fractures in young (aged 16–60 years old) patients.
lowing direct visualization of the femoral neck It reported an 18% overall re-operation rate from 28
through either a Smith-Petersen or a Watson-­ studies, with displaced fractures (17.8%, 95% CI
Jones approach [51]. The approach chosen is 12.4–24.9) having a much higher incidence of re-
usually dependent on the surgeons’ experience, operation than undisplaced fractures (6.9%, 95% CI
but care must be taken to prevent injury to the 2.6–17.1%), however this was not statistically sig-
vessels supplying the femoral head, in particular nificant. For avascular necrosis, there was an overall
the medial femoral circumflex artery. 14.3% incidence, with displaced fractures (14.7%,
Achieving reduction, especially rotationally, 95% CI 12.3–17.5%) at greater risk than undis-
can be difficult and various strategies are employed placed fractures (6.4%, 95% CI 3.4–11.8%). Non-
including joystick wires, clamps or temporary union occurred in 9.3% of patients, and again the
plates bridging the fracture (Fig. 12.8) [50]. point estimates showed a large difference between
displaced (10.0%, 95% CI 6.9–14.3%) and undis-
12.5.3.4 Capsulotomy placed (5.2%, 95% CI 2.0–13.1%) fractures, but not
Some surgeons advocate performing a capsulot- demonstrating statistical significance due to wide
omy to decompress the hip and reduce the tam- confidence intervals. The authors noted that there
ponade effect. An alternative is to perform an were few studies which reported mal-union, implant
aspiration. Studies however have only been on failure and infection rates, thus only providing an
small scales, and to date have failed to show a overall incidence rate without comparing undis-
significant impact on clinical outcome. No study placed and displaced fractures. The incidence of
has shown a disadvantage to performing capsu- mal-union was 7.1%, implant failure 9.7%, and
lotomy, and it can be performed during open sur- infection 5.1% [54].
gery, or percutaneously under image guidance in A previous 2005 meta-analysis of the available
closed procedures [48]. research analyzed the complications of avascular
necrosis and non-union following internal fixa-
12.5.3.5 Internal Fixation Techniques tion of intracapsular fractures in young (aged
Once an anatomical reduction has been achieved, 15–50 years old) patients. It reported a 23% inci-
the fracture is fixed with either a dynamic hip dence of avascular necrosis, with displaced frac-
screw or cannulated screws. When positioning tures having a significantly higher incidence than
cannulated screws, there should be parallel and undisplaced fractures. After excluding an outlying
as wide a spread in the femoral neck as possible, study, they could not identify a statistically sig-
and an inverted triangle distribution along the nificant difference in avascular necrosis incidence
calcar provides a stronger fixation with higher between those treated with open and closed reduc-
loads to failure [52]. Three screws should be uti- tions. The incidence of non-union was 8.9%, and
150 G. S. Chauhan et al.

again a higher incidence was observed in the dis- nificant morbidity. When quality of life was
placed fracture group. For non-union, those looked at, the majority of patients recovered to
patients treated with open reduction had a higher their optimum at 4  months, but all suffered
incidence than those treated by closed reduction. approximately a 20% loss of quality of life [58].
There was no difference in incidence of avascular In the elderly population, up to a third of patients
necrosis, or non-union, between early (less than require a change of residence on discharge, with
12 h) and late (after 12 h) reduction [55]. even more being unable to perform all activities
of daily living independently. Also, the majority
12.5.3.6 Arthroplasty require a mobility aid following their recovery
Should reduction be unachievable due to the frac- and there is also a significant rate of hospital re-­
ture pattern or severity, arthroplasty should be con- admission in the first 6  months following hip
sidered as the primary treatment [56]. For the active fracture [7, 59, 60].
patient, total hip replacement is the procedure of
choice, as it has lower re-operation rates and
improved functional scores than hemiarthroplasty 12.7.2 Mortality in the Elderly
[41, 57]. The other advantage of arthroplasty over
fixation is that patients are able to mobilize fully The implementation of national audits and stan-
weight bearing from day one post-operatively. dards has seen the mortality rate following hip
It must be acknowledged, however, that total fracture improve, but the condition is still associ-
hip replacement in trauma is associated with a ated with one of the highest death rates amongst
significantly higher risk of dislocation than hemi- orthopedic patients. Latest data puts the 30-day
arthroplasty [39], and measures must be taken to mortality rate in the Western world around 7.5%,
reduce this, such as using larger head sizes, and rising to around 20% at 1 year. Excess mortality
the anterolateral or direct anterior approach. following hip fracture has been shown to persist
for at least 10  years following the injury, with
males having higher mortality rates than females
12.6 Post-Operative Treatment at all intervals following hip fracture [61–63].
The relative hazard for death following hip frac-
Post-operatively, the importance of the multidis- ture at 3  months post-injury was calculated at
ciplinary approach to hip fracture care becomes 5.75  in females and 7.95  in males in a meta-­
even more prominent [2]. The team are vital in analysis [62]. The risk of death following hip
identifying and meeting the patients’ medical, fracture is also higher in those admitted from an
cognitive, analgesic, nutritional, social, and reha- institution, significant cognitive impairment,
bilitation needs as early as possible. These multiple medical co-morbidities, an admission
patients should no longer be managed by trauma hemoglobin <100 g/l, and age over 85. Of these,
surgeons acting alone. Ideally, hospitals should age over 85 is the single biggest risk factor [64].
have a tailored orthopedic hip fracture program,
and especially in the Western world, we are
increasingly seeing specialist orthogeriatricians 12.7.3 Recurrent Fracture (Falls
taking the lead for the post-operative manage- and Bone Health)
ment of these complex patients [2].
A key part in femoral neck fracture care for
elderly patients is falls prevention and bone
12.7 Results health [2].
Over a third of over 65s in the community suf-
12.7.1 Morbidity fer a fall each year, with the frequency increasing
with age [65]. Epidemiological studies have
Outcomes following hip fractures remain poor, shown that up to a quarter of elderly patients who
with those who survive the injury faced with sig- fall suffer either a fracture or an injury that
12  Femoral Neck Fractures 151

requires admission to hospital [66]. In the elderly, 8. Cannon J, Silvestri S, Munro M. Imaging choices in
occult hip fracture. J Emerg Med. 2009;37(2):144–52.
the cause for these falls is seldom a solitary find- 9. Lubovsky O, Liebergall M, Mattan Y, Weil Y, Mosheiff
ing, and is more often due to multiple causative R. Early diagnosis of occult hip fractures: MRI versus
factors. One of the greatest contributors to falls CT scan. Injury. 2005;36(6):788–92.
risk is disability of the lower limbs [65], such as 10. ATLS. Advanced trauma life support (ATLS) student
course manual. 10th ed. Chicago: American College
when in the recovery phase from hip fracture. As of Surgeons; 2018.
well as this added risk, these patients have pre- 11. Tornetta P, Kain MS, Creevy WR. Diagnosis of femo-
sented as a result of a fall, and investigations and ral neck fractures in patients with a femoral shaft frac-
assessment must be carried out to identify all ture. J Bone Joint Surg Am. 2007;89(1):39–43.
12. Chesser T, Chauhan G, Kelly M.  Management

reducible risks. Polypharmacy is one such risk of hip fractures in the elderly. Surgery (Oxford).
which can be addressed during the inpatient stay, 2016;34(9):440–3.
together with therapy assessment of the patient’s 13. Gautier E, Ganz K, Krügel N, Gill T, Ganz

mobility and living environment, highlighting the R. Anatomy of the medial femoral circumflex artery
and its surgical implications. J Bone Joint Surg Br.
importance of a multidisciplinary approach to the 2000;82(5):679–83.
care of hip fracture patients [2, 7]. 14. Garden RS. Low-angle fixation in fractures of the fem-
It is well evidenced that patients with fragility oral neck. J Bone Joint Surg Br. 1961;43(4):647–63.
fractures are at high risk of future fractures [67, 15. Bandeira-Rodrigues E, Vasta S, Leitão JC, Monllau
JC. Femur fractures. In: Espregueira-Mendes J, et al.,
68], and the opportunity to identify these vulnera- editors. Injuries and health problems in football.
ble patients and reduce their risk should be utilized Berlin: Springer; 2017. p. 247.
when they present with femoral neck fractures. 16. Pauwels F. Der schenkelhalsbruch ein mechanisches
This increased fracture risk is greatest during the problem. Z Orthop Ihre Grenzgeb. 1935;63:1–135.
17. Pauwels F, Furlong RJ, Maquet P.  Biomechanics of
first year after the injury, but is still present the normal and diseased hip, theoretical foundation,
10  years later [69]. To reduce the risk of future technique and results of treatment an atlas. Berlin:
osteoporotic fractures, these patients should have Springer; 1976.
their Vitamin D and Calcium levels corrected, and 18. Bartonicek J. Pauwels’ classification of femoral neck
fractures: correct interpretation of the original. J
be assessed for anti-resorptive therapy. Orthop Trauma. 2001;15:358–60.
19. Pauwels F. Der Schenkelhalsbruch. In: Gesammelte
Abhandlungen zur funktionellen Anatomie des
Bewegungsapparates. Berlin: Springer; 1965. p. 28.
References 20. Meinberg E, Agel J, Roberts C, et  al. Fracture and
dislocation classification compendium. J Orthop
1. Grisso JA, Kelsey JL, Strom BL, Chiu GY, Maislin Trauma. 2018;32(1):S1–S10.
G, O’Brien LA, Hoffman S, Kaplan F.  Risk factors 21. Blundell CM, Parker MJ, Pryor GA, Hopkinson-­

for falls as a cause of hip fracture in women. The Woolley J, Bhonsle SS. Assessment of the AO clas-
Northeast Hip Fracture Study Group. N Engl J Med. sification of intracapsular fractures of the proximal
1991;324(19):1326–31. femur. J Bone Joint Surg Br. 1998;80(4):679–83.
2. National Institute for Health and Care Excellence 22. Zlowodzki M, Bhandari M, Keel M, Hanson BP,

(NICE). Hip fracture; the management of hip fracture Schemitsch E.  Perception of Garden’s classification
in adults CG124. NICE, London. 2011. https://www. for femoral neck fractures: an international survey
nice.org.uk/guidance/cg124. Accessed Dec 2018. of 298 orthopaedic trauma surgeons. Arch Orthop
3. Cooper C, Campion G, Melton LJ.  Hip fractures in Trauma Surg. 2005;125(7):503–5.
the elderly: a world-wide projection. Osteoporos Int. 23. Parker MJ, Blundell C.  Choice of implant for inter-
1992;2:285–9. nal fixation of femoral neck fractures: meta-analysis
4. Dhanwal DK, Dennison EM, Harvey NC, Cooper of 25 randomised trials including 4925 patients. Acta
C.  Epidemiology of hip fracture: worldwide geo- Orthop Scand. 1998;69(2):138–43.
graphic variation. Indian J Orthop. 2011;45(1):15–22. 24. Walsum AD, Vroemen J, Janzing HM, Winkelhorst T,
5. Melton LJ, Wahner HW, Richelson LS, O’Fallon WM, Kalsbeek J, Roerdink WH. Low failure rate by means
Riggs BL.  Osteoporosis and the risk of hip fracture. of DLBP fixation of undisplaced femoral neck frac-
Am J Epidemiol. 1986;124(2):254–61. tures. Eur J Trauma Emerg Surg. 2016;19:1–6.
6. Kanis JA. Diagnosis of osteoporosis and assessment of 25. Parker M, Cawley S, Palial V.  Internal fixation of
fracture risk. Lancet. 2002;359:1929. intracapsular fractures of the hip using a dynamic
7. The National Hip Fracture Database (NHFD) Annual locking plate. Bone Joint J. 2013;95(10):1402–5.
Report 2015. http://www.nhfd.co.uk/nhfd/nhf- 26.
Fixation using Alternative Implants for the
d2015reportPR1.pdf. Accessed Apr 2016. Treatment of Hip fractures (FAITH) Investigators.
152 G. S. Chauhan et al.

Fracture fixation in the operative management 41. Baker RP, Squires B, Gargan MF, Bannister GC. Total
of hip fractures (FAITH): an international, mul- hip arthroplasty and hemiarthroplasty in mobile,
ticentre, randomised controlled trial. Lancet. independent patients with a displaced intracapsular
2017;389(10078):1519–27. fracture of the femoral neck. J Bone Joint Surg Am.
27. Lapidus LJ, Charalampidis A, Rundgren J, Enocson 2006;88(12):2583–9.
A.  Internal fixation of garden I and II femoral neck 42. Hedbeck CJ, Enocson A, Lapidus G, Blomfeldt R,
fractures: posterior tilt did not influence the reopera- Törnkvist H, Ponzer S, Tidermark J.  Comparison of
tion rate in 382 consecutive hips followed for a mini- bipolar hemiarthroplasty with total hip arthroplasty
mum of 5 years. J Orthop Trauma. 2013;27(7):386–90. for displaced femoral neck fractures. J Bone Joint
28. Murphy DK, Randell T, Brennan KL, Probe RA,
Surg Am. 2011;93(5):445–50.
Brennan ML.  Treatment and displacement affect 43. Avery PP, Baker RP, Walton MJ, Rooker JC, Squires
the reoperation rate for femoral neck fracture. Clin B, Gargan MF, Bannister GC. Total hip replacement
Orthop Relat Res. 2013;471(8):2691–702. and hemiarthroplasty in mobile, independent patients
29. Conn KS, Parker MJ.  Undisplaced intracapsular hip with a displaced intracapsular fracture of the femoral
fractures: results of internal fixation in 375 patients. neck. J Bone Joint Surg Br. 2011;93(8):1045–8.
Clin Orthop Relat Res. 2004;421:249–54. 44. White SM, Moppett IK, Griffiths R.  Outcome by

30. Gjertsen JE, Fevang JM, Matre K, Vinje T, Engesaeter mode of anaesthesia for hip fracture surgery. An
LB. Clinical outcome after undisplaced femoral neck observational audit of 65 535 patients in a national
fractures. Acta Orthop. 2011;82:268–74. dataset. Anaesthesia. 2014;69(3):224–30.
31. Bjorgul K, Reikeras O. Outcome of undisplaced and 45. Costa ML, Griffin XL, Pendleton N, Pearson M,

moderately displaced femoral neck fractures. Acta Parsons N.  Does cementing the femoral compo-
Orthop. 2007;78(4):498–504. nent increase the risk of peri-operative mortality
32. Parker MJ, White A, Boyle A. Fixation versus hemiar- for patients having replacement surgery for a frac-
throplasty for undisplaced intracapsular hip fractures. ture of the neck of femur? Data from the National
Injury. 2008;39(7):791–5. Hip Fracture Database. J Bone Joint Surg Br.
33. Rogmark C, Flensburg L, Fredin H.  Undisplaced
2011;93(10):1405–10.
femoral neck fractures--no problems? A consecutive 46. Gjertsen JE, Lie SA, Vinje T, Engesæter LB, Hallan
study of 224 patients treated with internal fixation. G, Matre K, Furnes O. More re-operations after unce-
Injury. 2009;40(3):274–6. mented than cemented hemiarthroplasty used in the
34. Rogmark C, Johnell O. Primary arthroplasty is better treatment of displaced fractures of the femoral neck:
than internal fixation of displaced femoral neck frac- an observational study of 11,116 hemiarthroplas-
tures: a meta-analysis of 14 randomized studies with ties from a national register. J Bone Joint Surg Br.
2,289 patients. Acta Orthop. 2006;77(3):359–67. 2012;94(8):1113–9.
35. Parker MJ, Gurusamy KS.  Internal fixation ver-
47. Griffiths R, et al. Safety guideline: reducing the risk
sus arthroplasty for intracapsular proximal femoral from cemented hemiarthroplasty for hip fracture
fractures in adults. Cochrane Database Syst Rev. 2015. Anaesthesia. 2015;70:623–6.
2006;4:CD001708. 48. Ly TV, Swiontkowski MF. Treatment of femoral neck
36. Parker MJ, Pryor G, Gurusamy K. Hemiarthroplasty fractures in young adults; an instructional course lec-
versus internal fixation for displaced intracapsular hip ture. JBJS Am. 2008;90-A(10):2253–66.
fractures: a long-term follow-up of a randomised trial. 49.
Leadbetter GW.  Closed reduction of fractures
Injury. 2010;41(4):370–3. of the neck of the femur. J Bone Joint Surg Am.
37.
Frihagen F, Nordsletten L, Madsen 1938;20(1):108–13.
JE. Hemiarthroplasty or internal fixation for intracap- 50. Hoffman R, Haas NP.  Fractures of the femo-

sular displaced femoral neck fractures: randomised ral neck (31-B) in AO Principles of Fracture
controlled trial. BMJ. 2007;335(7632):1251–4. Management. Biel/Bienne: Arbeitsgemeinschaft
38. Johansson T, Jacobsson SA, Ivarsson I, Knutsson A, für Osteosynthesefragen (AO) Foundation.
Wahlström O. Internal fixation versus total hip arthro- https://www2.aofoundation.org/wps/portal/!ut/p/
plasty in the treatment of displaced femoral neck frac- a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_
tures: a prospective randomized study of 100 hips. A0M3D2DDbz9_UMMDRyDXQ3dw9wMDAzMjf
Acta Orthop Scand. 2000;71(6):597–602. ULsh0VAbWjLW0!/?bone=Femur&segment=Proxi
39. Ravikumar KJ, Marsh G.  Internal fixation versus
mal&showPage=D&contentUrl=srg/popup/further_
hemiarthroplasty versus total hip arthroplasty for reading/PFxM2/31/661_32-Neck_fxs_surg_treat.jsp.
displaced subcapital fractures of femur—13 year Accessed Dec 2018.
results of a prospective randomised study. Injury. 51. Molnar RB, Routt ML Jr. Open reduction of intracap-
2000;31(10):793–7. sular hip fractures using a modified Smith-Petersen
40. Liu Y, Tao X, Wang P, Zhang Z, Zhang W, Qi
surgical exposure. J Orthop Trauma. 2007;21(7):490.
Q.  Meta-analysis of randomised controlled trials 52.
Selvan VT, Oakley MJ, Rangan A, Al-Lami
comparing unipolar with bipolar hemiarthroplasty MK. Optimum configuration of cannulated hip screws
for displaced femoral-neck fractures. Int Orthop. for the fixation of intracapsular hip fractures: a biome-
2014;38(8):1691–6. chanical study. Injury. 2004;35(2):136–41.
12  Femoral Neck Fractures 153

53. Zlowodzki M, Brink O, Switzer J, Wingerter S,

61. The National Hip Fracture Database (NHFD) 2015
Woodall J, Petrisor BA, Kregor PJ, Bruinsma DR, Annual report supplement—An analysis of 30-day
Bhandari M. The effect of shortening and varus col- mortality in 2014.
lapse of the femoral neck on function after fixation of 62. Haentjens P, Magaziner J, Colón-Emeric CS, et  al.
intracapsular fracture of the hip. J Bone Joint Surg Br. Meta-analysis: excess mortality after hip fracture
2008;90(11):1487–94. among older women and men. Ann Intern Med.
54. Slobogean GP, Sprague SA, Scott T, Bhandari
2010;152:380.
M.  Complications following young femoral neck 63. Huddleston JM, Whitford KJ.  Medical care of

fractures. Injury. 2015;46(3):484–91. elderly patients with hip fractures. Mayo Clin Proc.
55. Damany DS, Parker MJ, Chojnowski A. Complications 2001;76:295.
after intracapsular hip fractures in young adults: a 64. Moppett IK, Parker M, Griffiths R, Bowers T, White
meta-analysis of 18 published studies involving 564 SM, Moran CG.  Nottingham hip fracture score:
fractures. Injury. 2005;36(1):131–41. longitudinal and multi-assessment. Br J Anaesth.
56. McKinley JC, Robinson CM. Treatment of displaced 2012;109(4):546–50.
intracapsular hip fractures with total hip arthroplasty: 65. Tinetti ME, Speechley M, Ginter SF. Risk factors for
comparison of primary arthroplasty with early salvage falls among elderly persons living in the community.
arthroplasty after failed internal fixation. J Bone Joint N Engl J Med. 1988;319(26):1701–7.
Surg. 2002;84(11):2010–5. 66. Campbell AJ, Borrie MJ, Spears GF, Jackson SL,
57. Blomfeldt R, Törnkvist H, Eriksson K, Söderqvist A, Brown JS, Fitzgerald JL.  Circumstances and conse-
Ponzer S, Tidermark J. A randomised controlled trial quences of falls experienced by a community popula-
comparing bipolar hemiarthroplasty with total hip tion 70 years and over during a prospective study. Age
replacement for displaced intracapsular fractures of Ageing. 1990;19(2):136–41.
the femoral neck in elderly patients. J Bone Joint Surg 67. Klotzbuecher CM, Ross PD, Landsman PB, Abbott
Br. 2007;89(2):160–5. TA, Berger M.  Patients with prior fractures have an
58. Griffin XL, Parsons N, Achten J, Fernandez M, Costa increased risk of future fractures: a summary of the
ML.  Recovery of health-related quality of life in a literature and statistical synthesis. J Bone Miner Res.
United Kingdom hip fracture population. Bone Joint 2000;15(4):721–39.
J. 2015;97(3):372–82. 68. Kanis JA, Johnell O, De Laet C, Johansson H, Odén
59. Van Balen R, Steyerberg EW, Polder JJ, Ribbers
A, Delmas P, Eisman J, Fujiwara S, Garnero P,
TL, Habbema JD, Cools HJ.  Hip fracture in elderly Kroger H, McCloskey EV.  A meta-analysis of pre-
patients: outcomes for function, quality of life, vious fracture and subsequent fracture risk. Bone.
and type of residence. Clin Orthop Relat Res. 2004;35(2):375–82.
2001;390:232–43. 69.
British Orthopaedic Association and British
60. Wolinsky FD, Fitzgerald JF, Stump TE. The effect of Geriatrics Society. The care of patients with fragil-
hip fracture on mortality, hospitalization, and func- ity fracture ‘blue book’. London: British Orthopaedic
tional status: a prospective study. Am J Public Health. Association; 2007.
1997;87:398–403.
 Pathologic Fractures
13
Frank M. Klenke, Attila Kollár,
and Christophe Kurze

Abstract 13.1 Epidemiology

A bone fracture is termed pathologic when the
fracture occurs through a region of a preexist- Metastatic bone disease is the most frequent cause
ing bone pathology weakening the bony archi- for pathologic fractures of the acetabulum and the
tecture. Such pathologies include metabolic proximal end of the femur. It has been reported
bone diseases such as Paget’s disease, osteo- that 9–29% of patients with metastatic bone dis-
genesis imperfecta, and osteoporosis as well ease will develop pathological fractures out of
as local alterations of the bone structure due to which more than 90% require surgical interven-
tumorous processes and tumor-like bone tion [1, 2]. Bone is the third most common site
lesions. affected by metastatic disease, outnumbered only
This chapter discussed pathologic fractures by metastases to the lung and the liver. Bone
of the hip caused by the processes leading to metastases may arise from any solid cancer. They
local bone destruction including tumor-like are observed most frequently in prostate, breast,
lesions as well as primary and secondary (i.e., lung, kidney, and thyroid cancer [3]. Patients with
metastases) bone tumors. prostate and breast cancer are affected by bone
metastases and skeletal related events (SRE, i.e.
Keywords bone pain, pathological fractures, spinal cord
Pathologic fracture · Bone · Tumor · compression, palliative radiotherapy, and surgery)
Metastasis · Tumor-like lesion · Sarcoma · with particular frequency. This is due to the high
Surgery · Osteosynthesis · Arthroplasty incidence of bone metastases in these tumors and
a relatively long survival time after diagnosis of
bone metastases ranging between 7 and 28 months
[3–6]. Within 5  years after the initial diagnosis
10–17% of patients with prostate and breast can-
cer will develop bone metastases and more than
F. M. Klenke (*) · C. Kurze 70% of the patients with advanced prostate and
Department of Orthopaedic Surgery and breast cancer will develop bone metastases during
Traumatology, Inselspital, Bern University Hospital, the course of the disease.
Bern, Switzerland
e-mail: [email protected] Pathologic fractures associated with tumor-­
like bone lesions, benign bone tumors, and malig-
A. Kollár
Department of Medical Oncology, Inselspital, Bern nant bone tumors are markedly less frequent.
University Hospital, Bern, Switzerland Multiple myeloma, which is the most frequent

© Springer Nature Switzerland AG 2019 155

L. Büchler, M. J.B. Keel (eds.), Fractures of the Hip, Fracture Management Joint by Joint,
https://doi.org/10.1007/978-3-030-18838-2_13
156 F. M. Klenke et al.

primary bone tumor, accounts for 1% of all 13.2 Tumor-Like Lesions

malignancies [7]. Approximately 30% of patients
with multiple myeloma will be diagnosed with Historically, tumor-like lesions have been defined
the disease due to a pathologic fracture and as non-neoplastic bone lesions by Lichtenstein,
approximately 80% experience a pathologic frac- which include non-ossifying fibroma (NOF),
ture during the course of the disease [8, 9]. The simple bone cysts (SBC), aneurysmal bone cysts
vast majority of pathologic fractures occur at (ABC), fibrous dysplasia (FD), osteofibrous dys-
spine and ribs. Only 5% of the pathologic frac- plasia (OFD), and eosinophilic granuloma (EG).
tures associated with multiple myeloma involve However, it is known today that some of these
the pelvis or the proximal femur [8]. In chondro- lesions are indeed neoplastic. For example, NOF
sarcoma, the second most frequent primary has been classified as a benign fibrohistiocytic
malignancy of bone in adults, the rate of patho- tumor by the World Health Organization (WHO).
logic fractures of the proximal femur was shown EG is a neoplastic proliferation of Langerhans
to range between 25% and 28% [10, 11]. cells and has been classified as a tumor of unde-
Although chondrosarcomas frequently involve fined neoplastic nature.
the pelvis, pathologic fractures of the acetabulum Due to their benign behavior, tumor-like
are usually not observed [11, 12]. The rate of lesions do not require surgical treatment per se
osteosarcoma or Ewing’s sarcoma presenting but they often require surgical treatment due to
with a pathological fracture is significantly lower pathological fractures. At the proximal femur and
and ranges between 4% and 13% [11, 13–15]. In at the acetabulum, surgical treatment should also
contrast to multiple myeloma and chondrosar- be considered when a lesion is discovered inci-
coma, osteosarcoma and Ewing’s sarcoma typi- dentally without fracture. This is due to the high
cally occur in children and young adults. The risk of pathologic fractures and the severity of
same is true for the majority of tumor-like lesions complications associated with the fractures such
and benign bone tumors including solitary bone as femoral head necrosis, medial head migration,
cysts (SBC), aneurysmal bone cysts (ABC), and persistent deformity [18]. It should be
fibrous dysplasia (FD), eosinophilic granuloma stressed that, in case of suspicion of ABC, biopsy
(EG), and chondroblastoma. Thus, pathologic should be performed prior to definitive treatment
fractures associated with these bone lesions most to rule out teleangiectatic osteosarcoma, which
often affect young patients. Solitary bone cysts may resemble ABC on imaging studies [19].
show a specific risk of pathologic fractures. Surgery for pathological fractures of tumor-­
These lesions are the most common cause of like lesions has to address the fracture as well as
pathologic fractures in children. Approximately the lesion itself in order to prevent persistence of
70% of these bone lesions are diagnosed due to a the lesion and re-fracture [20–29]. Surgery
pathologic fracture [16]. The fracture rate at the involves open reduction and internal fixation
proximal femur has been shown to be 52% [16]. using intramedullary nails, plates, and screws.
In children under 18  years of age, pathologic To induce healing of the lesion, curettage plus
fractures of the proximal femur account for high-­speed burring followed by bone void filling
approximately 35% of all fractures of the proxi- with autogenous or allogeneic bone grafts or
mal femur [17]. bone graft substitutes should be performed. In
Pathologic fractures around the hip are a result general, studies have shown equivalent results
of a wide variety of underlying diseases. The independent of whether bone grafts or bone graft
causes of fracture have to be taken into consider- substitutes were used. In fibrous dysplasia how-
ation when deciding which type of fracture treat- ever, there is an increased risk of graft resorp-
ment needs to be applied in the individual tion. In adult patients with monostotic disease,
situation. bone grafting is indicated but the use of cortical
13  Pathologic Fractures 157

a b instead of cancellous autologous bone grafts or

impacted allogeneic bone has been recom-
mended [24, 27, 28]. In young patients with
polyostotic fibrous dysplasia, high graft resorp-
tion rates have been observed. Therefore, some
authors have recommended abandoning bone
grafting in this group of patients [30, 31]. We
usually perform impacted allogeneic bone graft-
ing in polyostotic fibrous dysplasia but have
abandoned autologous bone grafting in these
patients (Figure 13.1). In unicameral bone cysts,
perforation of the inner cyst wall and creation of
a communication with the bone marrow has been
shown to stimulate cyst ossification and should
be performed by standard [32, 33]. In non-ossi-
fying fibroma, curettage of the lesion is not
imperative because these lesions often heal after
a fracture without specifically treating the lesion
c d [20, 34]. However, the authors recommend curet-
tage and grafting of the lesion in order to acceler-
ate bony healing and prevent failure of the
osteosynthesis.

13.3 Benign and Intermediate

Bone Tumors

The vast majority of primary bone tumors are

benign. Since many are not clinically apparent
they usually remain undiscovered or are discov-
ered incidentally at radiographic examinations
for other reasons. Therefore, the true incidence of
benign bone tumors has not been determined pre-
cisely. Despite their frequency, benign bone
tumors are usually not associated with pathologic
fractures [35]. Enchondroma, which is the sec-
Fig. 13.1  25 year old male diagnosed with polyostotic
ond most frequent benign bone tumor carries the
fibrous dysplasia. The patient developed progressive hip
pain with ambulation. X-ray and CT scans demonstrated highest risk of pathologic fractures [36].
an extensive osteolytic lesion and an un-displaced frac- However, these fractures usually involve the
ture at the calcar (marked with arrowheads, (a, b). The small bones of the hand and feet [37, 38].
patient was treated with curettage through an anterior
Enchondroma of the femoral neck or the acetabu-
cortical window, bone grafting with impacted allogeneic
bone and plate osteosynthesis of the proximal femur. lum is extremely rare and may be associated with
The postoperative course was uneventful with complete enchondromatosis, i.e. Ollier’s disease or
bone reconstitution of the proximal femur after 2 years Maffucci syndrome [39, 40]. Furthermore, suspi-
(c). Plate removal was performed 27  months after the
cion of a cartilaginous tumor necessitates the
index surgery (d)
exclusion of chondrosarcoma, which is a much
158 F. M. Klenke et al.

more common finding in the proximal femur and 13.4 P

 rimary Malignant Bone
the pelvis [41]. Pathologic fractures of the ace- Tumors
tabulum and the proximal femur are more fre-
quently found in giant cell tumor of bone The treatment of primary malignant bone tumors
(GCTB). Histologically, GCTB is a benign neo- such as osteosarcoma, chondrosarcoma, and Ewing
plastic lesion. It has been classified as an sarcoma may be complicated by a pathologic frac-
­intermediate tumor due to its clinically aggres- ture. Pathologic fractures through primary malig-
sive behavior and its potential to seed pulmonary nant bone tumors have been linked to an increased
metastases [36]. Approximately 11–15% of risk of local recurrences and decreased survival.
GCTB occur in the proximal femur and the pelvis However, the exact impact of pathologic fractures
[42, 43]. The rate of pathologic fractures ranges on local recurrence and survival is unclear. Some
between 9% and 30% with fractures of the proxi- studies found a correlation between pathologic
mal femur being markedly more frequent than fracture and limited survival, whereas other studies
those of the acetabulum [44–49]. failed to demonstrate such association [11, 15, 57–
Surgical treatment of pathologic fractures due 62]. Similarly, previous studies have shown con-
to benign and intermediate bone tumors is similar flicting results in finding an association of
to that of tumor like lesions and involves removal pathologic fracture and an increased risk of local
of the tumor and open reduction and internal fixa- recurrence [11, 15, 59, 60]. Around the hip, patho-
tion of the fracture. The standard treatment proto- logic fractures through primary malignant bone
col for tumor removal at our institution includes tumors seem to be associated with a particular poor
curettage and high-speed burring of the lesion prognosis [15, 63]. This may be due to the lack of
plus thermocoagulation of the tumor void with containment of the fracture hematoma resulting in
argon beam as adjunctive therapy [50, 51]. We widespread contamination of the surrounding soft
have omitted adjunctive local phenol application tissues with tumor cells [63]. Furthermore, the
due to its limited therapeutic effect and the asso- pathologic fracture may be a sign for a more
ciated toxicity [52, 53]. Open reduction and fixa- aggressive biologic behavior of sarcomas as dem-
tion of pathologic fractures of the proximal femur onstrated by the finding that such tumors are asso-
and the acetabulum should be combined with ciated with a high rate of synchronous pulmonary
autogenous or allogeneic bone grafts, or bone metastasis [11, 63]. It is important to note that local
graft substitutes in order to fill the bone recurrence and survival are not affected by the type
void created with the tumor removal. of surgical treatment, viz. limb preserving surgery
Polymethylmethacrylate (PMMA) bone cement or amputation as long as adequate surgical margins
has been recommended as bone void filler pro- can be obtained [11, 58, 62].
viding immediate structural stability and an With this in mind, the general principles of
effective adjunctive therapy for GCTB [42, 52, tumor surgery apply to primary malignant bone
54]. However, in case of a pathologic fracture the tumors independent of whether they present with
non-resorbable nature of PMMA may prevent a pathologic fracture or not. Not recognizing a
biologic fracture healing and limit long-term fracture as being of pathologic nature may result
mechanical stability of the fractured bone. It has in inappropriate treatment, e.g. by open reduction
been shown that joint salvage through curettage and internal fixation. This again will result
and internal fixation is a reasonable option for in local tumor spread necessitating a more exten-
patients with pathologic fractures due to GCTB sive and morbid surgery for tumor removal and
since functional outcomes and recurrence rates will worsen the prognosis of tumor treatment. As
are similar GCTB without fracture [54–56]. On a standard of care, wide resection with negative
the other hand, extensive joint destruction or soft surgical margins has to be aimed for in bone
tissue extension may warrant wide resection and sarcoma with and without pathologic
total hip arthroplasty. fracture [64]. The only exception is low-grade
13  Pathologic Fractures 159

chondrosarcoma, which can be treated with intra- consequences of a pathologic fracture through a
lesional surgery without worsening recurrence- primary malignant bone tumor around the hip,
free survival and overall prognosis [65–68]. early surgery prior to chemotherapy should be
However, in case of pathologic fracture, indicat- considered if there is an extensive lytic process
ing a more aggressive local behavior we recom- likely to lead to fracture following biopsy.
mend wide resection also for low-grade
chondrosarcoma [67, 68]. This is especially true
for periacetabular tumors due to the dramatic 13.5 Bone Metastases
consequence of a local recurrence in this location
[69, 70]. 13.5.1 General Considerations
Options for limb reconstruction after resection
of primary malignant bone tumors around the hip The primary goals of the treatment of metastases
include tumor endoprosthesis, allograft-­prosthetic around the hip include sufficient and durable hip
constructs, and extracorporeal irradiation and joint function, rapid return to full weight bearing,
reimplantation [71–77]. The choice of the type of and immediate pain relief. Furthermore, local
reconstruction should be individualized to the tumor control should be achieved to prevent pro-
location and extent of the tumor resection but is gressive bone destruction, re-fracture, or implant
independent of the presence of a pathologic frac- failure [79, 80].
ture. For primary malignant bone tumors with the Bone metastases are classified into osteolytic
indication for neo-adjuvant chemotherapy (e.g., and osteoblastic lesions. Invasion of the skeleton
osteosarcoma, Ewing sarcoma), pathologic frac- by cancer cells causes an imbalance in the activi-
tures should be treated by non-­operative means ties of bone resorbing osteoclasts and bone form-
whenever possible and wide tumor resection ing osteoblasts resulting in pathologic bone
should be performed after completion of the pre- destruction or bone formation [81]. Patients may
operative portion of chemotherapy. This approach exhibit osteolytic and osteoblastic lesions at a
is feasible in stable pathologic fractures through time and metastases are often heterogeneous con-
bone tumors of the periacetabular region. However, taining both osteolytic and osteoblastic compo-
in pathologic fractures of the proximal femur, nents [82]. Bone metastases without fracture,
immobilization is difficult if not impossible with especially when located at the acetabulum may be
non-surgical treatment. A joint spanning external treated non-surgically with local radiation and/or
fixator may achieve sufficient immobilization of systemic therapy whereas the majority of patho-
the fracture site in such cases but is poorly toler- logic fractures require surgical intervention.
ated and prone to secondary complications over Due to the dysregulation of bone (re-)model-
the extended period of several cycles of preopera- ing in bone metastases fracture healing of patho-
tive chemotherapy. Therefore, adaption of the che- logic fractures is altered. In a study of 129
motherapy protocol should be considered. pathologic fractures originating from different
Adaption may consist in a curtailed preoperative tumor entities, Gainor and Buchert [83] showed
induction chemotherapy or transition to an adju- that the overall fracture healing rate was only
vant setting allowing rapid surgical treatment of 35%. In those patients that survived longer than
the local tumor disease and the fracture [63, 78]. 6  months the healing rate was 74% indicating
Taken together, pathologic fracture through that fracture healing through metastases is pro-
primary malignant bone tumors at the hip wors- longed but does occur in principle. Tumor entity,
ens prognosis but does not necessarily implicate duration of survival, internal fracture fixation,
amputation. If adequate surgical margins can be postoperative irradiation, and chemotherapy cor-
obtained, limb preserving surgery can be per- related with fracture healing. Metastases origi-
formed, especially when the tumor responds well nating from multiple myeloma, renal and breast
to preoperative chemotherapy. Due to the severe carcinoma showed the highest fracture healing
160 F. M. Klenke et al.

rates of 67%, 44% and 37%, respectively, shown to be effective in decreasing secondary
whereas none of the fractures due to metastases surgical interventions due to local progression of
from lung carcinoma healed and none of these metastases arising from breast, lung, prostate,
patients survived longer than 6 months. and colorectal cancer [91]. In solitary metastases
The major clinical challenges arising from of tumors with slow and moderate progression
skeletal metastases are pain and bone destruction, including hormone (in)dependent breast and
ultimately leading to pathologic fractures. Pain prostate cancer, thyroid cancer, multiple
and bone destruction limit the patients’ quality of myeloma, malignant lymphoma, renal cell carci-
life dramatically. During the past 25  years, noma, endometrial and ovarian cancer and in
improvements in cancer treatment have signifi- metastatic disease arising from tumors with poor
cantly increased the life expectancy of patients radiation sensitivity, especially renal cell carci-
with bone metastases and thus, the treatment of noma wide resection of the metastasis may be
bone metastases has gained increasing impor- recommended [86, 88, 92].
tance [84, 85]. According to a recent systemic
review by Errani et al. the general indication for
surgery of an impending or a pathologic fracture 13.5.2 Metastases of the Proximal
is a life expectancy of ≥6 weeks [86]. The type of Femur
the primary tumor and its response to chemo- and
radiotherapy, the presence of visceral metastases The femur is the most commonly affected long
and multiple skeletal metastases, abnormal labo- bone in metastatic bone disease [93].
ratory data such as CRP and LDH levels or plate- Approximately 80% of femoral metastases are
let count, and general health status, e.g. the located in the proximal femur. Out of those, 35%
ECOG performance score are the most important involve the femoral neck and 65% the inter- and
factors for survival [87–89]. In this regard, subtrochanteric region. Due to the immediate con-
Katagiri et al. introduced a scoring system to pre- sequences on ambulation, surgical intervention is
dict survival of patients with bone metastases and usually indicated in pathologic fractures of the
help clinicians with their decision-making on the proximal femur whereas bone metastases without
treatment of bone metastases and pathologic fracture may be treated non-surgically [94]. Mirels
fractures [88]. introduced a scoring system to predict the patho-
Before initiating the surgical treatment of a logic fracture risk and guide physicians in their
pathologic fracture, a diagnosis needs to be estab- decision on how to treat femoral bone metastases
lished to rule out bone sarcoma, metabolic bone [95]. The score is based on four variables: degree
disease, and osteomyelitis. According to Rougraff of pain, lesional size, lytic versus blastic nature,
et al. the standard diagnostic workup for patients and anatomic location. Treatment recommenda-
without a definite primary tumor should include tions generated by Mirels were prophylactic stabi-
an X-ray of the affected limb, a whole-body bone lization of patients with a total score of 9 points or
scan, laboratory studies, and CT scans of the more and consideration of prophylactic stabiliza-
chest, abdomen, and pelvis [90]. If the diagnosis tion at a borderline score of 8 points. The Mirels’
cannot be established despite adequate workup score has been shown to be reproducible and valid
biopsy should be performed. [96]. However, it seems to overestimate the actual
Surgical treatment options include intramed- occurrence of a pathological fracture. Thus, strict
ullary nailing, compound osteosynthesis, and adherence to Mirels’ recommendations would
prosthetic joint replacement. Besides the actual result in a large proportion of patients with a lim-
fracture treatment, the tumor tissue should be ited life expectancy to undergo unnecessary pro-
removed—usually by intralesional curettage—to phylactic stabilization [96, 97]. We therefore
improve local tumor control and the efficiency of recommend to include additional factors into the
postoperative adjuvant therapy. Adjuvant therapy decision making of whether to stabilize femoral
most often includes local irradiation, which was metastases prophylactically such as the Katagiri
13  Pathologic Fractures 161

score and an axial cortical involvement of greater a b

than 30 mm [88, 97, 98].
Fractures involving the different regions of the
proximal femur are addressed with different
forms of stabilization or endoprosthetic replace-
ment. Prior to selecting the type of treatment,
imaging studies of the entire femur should be
obtained to exclude additional sites of metastatic
involvement in the same bone. If present, addi-
tional metastases should be addressed with the
same surgery.
There is evidence that the treatment of patho-
logic or impending femoral neck fractures with
endoprosthetic reconstruction is superior to that
with internal fixation [99] (Figure  13.2).
Advantages of endoprosthetic reconstruction
over internal fixation include rapid return to full c d
weight-bearing ambulation, reduced pain, and
the ability to perform en-bloc resection minimiz-
ing the risk local recurrence [100]. Furthermore,
the need of repeat surgical intervention is lower
after endoprosthetic reconstruction. The rate of
repeat surgeries has been reported to range from
16 to 42% after internal fixation and 3–8% after
endoprosthetic reconstruction [101–103]. In a
study including 142 patients with proximal femo-
ral metastases Wedin and Bauer reported that the
risk of re-surgery was twice as high in the osteo-
synthesis group (16%) compared to the arthro-
plasty group (8%). However, three periprosthetic
pathologic fractures occurred in the arthroplasty
group distal to the femoral component. To
decrease the risk of secondary fractures, the use Fig. 13.2  Metastatic bone disease of the proximal femur
of a long femoral stem has been recommended with a pathologic femoral neck fracture through an exten-
[102]. There is no evidence in favor for or against sive mixed osteoblastic/osteolytic prostate cancer metas-
using PMMA for fixation of the femoral compo- tasis in a 54 year old male (a). Resection of the affected
bone and reconstruction with a modular tumor endopros-
nent. However, one has to consider that cortical thesis was performed (b). Pathologic subtrochanteric frac-
tumor growth may result in stem loosening when ture in a 39 year old male due to a previously unknown
using uncemented implants [99]. Due to negative multiple myeloma (c). The fracture was treated with com-
effects of radiation on bone ingrowth, cemented pound osteosynthesis (d) followed by local irradiation
(total dose 30 Gy) and high-dose chemotherapy
implants should be favored when postoperative
radiotherapy is planned [104].
Impending and pathologic inter-/subtrochan- have been recommended in order to avoid femo-
teric fractures may be treated with intramedullary ral neck fractures in case of progression of meta-
nailing, plating, or arthroplasty. For successful static disease. However, there is no scientific
intramedullary nailing, sufficient proximal nail evidence that a cephalomedullary nail would pre-
fixation is essential. Furthermore, distal locking vent femoral neck fracture or re-operation [105,
is mandatory. Usually, cephalomedullary nails 106]. In large defects, PMMA may be used to
162 F. M. Klenke et al.

improve structural support and prolong implant classification based treatment algorithm. Class 1
survival [79]. Miller et  al. found that hardware metastatic lesions stem from tumors with slow
failure, non-union, tumor progression, and sur- and moderate progression, class 2 lesions are
geon error were reasons for failure of intramedul- metastases of the periacetabular region with
lary nailing of pathologic femoral fractures [107]. pathologic fractures, class 3 are supra-acetabular
Due to the critical consequences of implant fail- osteolytic metastases with impending fractures
ure, arthroplasty should be preferred in case of (Fig. 13.3), and class 4 are metastatic lesions not
poor bone stock of the proximal femur [99]. compromising the mechanical stability in situa-
However, endoprosthetic reconstruction is asso- tions that cannot be classified under class 1.
ciated with a longer surgery time as well as a Surgical treatment has been recommended for
higher rate of peri- and postoperative complica- classes 1–3, whereas situations that are classified
tions such as cardiac failure, cerebrovascular as class 4 should be treated non-surgically by
incidents, and dislocation [100, 102]. irradiation, systemic therapy, or with minimally
Alternatively, compound osteosynthesis, a invasive procedures including cryoablation and
PMMA augmented combination of an intramed- radiofrequency ablation [92]. For classes 1–3, the
ullary placed small fragment plate and a condylar surgically treatment needs further stratification.
blade plate, may be used to address both patho- In class 1 situations, wide resection viz. internal
logic and impeding femoral fractures [85, 108, hemipelvectomy of a solitary metastasis and
109]. The loading strength of a compound osteo- endoprosthetic reconstruction with saddle/socket
synthesis equals the strength of an intact femur endoprosthesis or custom-made triflange implants
and has a higher mechanical strength than intra- should be considered. Previous studies reported
medullary nailing even if cement augmentation is that curettage of single metastatic lesions is asso-
used [108, 110–112]. Rompe et al. reported that ciated with decreased survival as compared to
the functional outcome was superior to endopros- wide resection [80, 116]. Furthermore, wide
thetic reconstruction with respect to range of resection of solitary periacetabular metastases
motion and gait pattern [113]. The authors attrib- may decrease the rate of secondary local compli-
uted this finding to the integrity of the gluteal cations such as local metastatic progression and
insertion, which was not altered by the compound implant failure [116]. Thus, wide resection seems
osteosynthesis. This technique has been used at to be justified to achieve local tumor control in
our institution for over 30 years and has proven to class 1 situations despite the higher risk of surgi-
be a viable option in cases with bone destruction cal complications associated with internal hemi-
where proximal locking of intramedullary nails is pelvectomy. In cases of an impending or a
difficult to achieve [114]. pathologic fracture (class 2 and 3), the surgical
treatment can be further stratified applying
Harrington’s criteria [117]. In Harrington group 1
13.5.3 Periacetabular Metastases lesions, without destruction of the subchondral
bone of the acetabulum, curettage and void filling
The pelvis is the second most frequent site of with bone cement (cementoplasty) provides a
metastatic bone disease, only outnumbered by minimal invasive solution achieving rapid pain
the spine [115]. According to the treatment of relief, ambulation, and improvement of quality of
metastases of the femur, the treatment of periace- life [118–120]. Greater acetabular deficiencies
tabular metastases should be adapted to the local (medial wall, Harrington group 2/acetabular roof
situation, i.e. osteolytic versus osteoblastic and rim, Harrington group 3) require total hip
lesions, single or multiple lesions, size of the arthroplasty with acetabular stabilization using
lesion(s), as well as the stage and the overall reinforcement rings with or without cement/
prognosis of the tumor disease. Recently, Müller Steinman pin augmentation (Harrington tech-
and Capanna [92] published a classification sys- nique) [117, 121–124]. In cases of expected sur-
tem for metastatic disease of the pelvis and a vival times greater than 24 months or metastatic
13  Pathologic Fractures 163

a b c

Fig. 13.3  51 year old female with metastatic lung cancer. heads (a, b)) was treated with bone cement reinforced total
An impending fracture due to a Harrington class 3 meta- hip arthroplasty with the use of a Ganz acetabular rein-
static lesion of the right acetabulum (marked with arrow- forcement ring (Zimmer Biomet Inc., Switzerland) (c)

disease with poor response to adjuvant therapy References

more extensive surgical procedures involving
saddle/socket endoprosthesis or custom-made tri- 1. Aaron AD.  Treatment of metastatic adenocarcinoma
of the pelvis and the extremities. J Bone Joint Surg
flange implants should be considered [72, 92, Am. 1997;79(6):917–32.
119, 125]. Similar treatment considerations apply 2. Harrington KD. Orthopaedic management of extrem-
to metastatic disease with unrestorable acetabular ity and pelvic lesions. Clin Orthop Relat Res.
collapse (Harrington group 4). 1995;312:136–47.
3. Coleman RE.  Metastatic bone disease: clinical fea-
tures, pathophysiology and treatment strategies.
Cancer Treat Rev. 2001;27(3):165–76.
13.6 Conclusion 4. Harries M, Taylor A, Holmberg L, et  al. Incidence
of bone metastases and survival after a diagnosis of
bone metastases in breast cancer patients. Cancer
The treatment options of impending and patho- Epidemiol. 2014;38(4):427–34.
logic fractures around the hip are manifold and 5. Jensen AO, Jacobsen JB, Norgaard M, Yong M,
require careful analysis of the underlying disease. Fryzek JP, Sorensen HT. Incidence of bone metastases
The treatment has to be individualized to the and skeletal-related events in breast cancer patients:
a population-based cohort study in Denmark. BMC
pathology of the bone lesion, the location, the Cancer. 2011;11:29.
extent of local bone destruction, the stage of the 6. Norgaard M, Jensen AO, Jacobsen JB, Cetin K, Fryzek
disease and its overall prognosis and involves a JP, Sorensen HT. Skeletal related events, bone metas-
multidisciplinary team of radiologists, patholo- tasis and survival of prostate cancer: a population
based cohort study in Denmark (1999 to 2007). J Urol.
gists, radiation-oncologists, oncologists, and 2010;184(1):162–7.
orthopedic surgeons familiar with the diagnosis 7. Becker N. Epidemiology of multiple myeloma. Recent
and treatment of bone pathologies. Results Cancer Res. 2011;183:25–35.
164 F. M. Klenke et al.

8. Melton LJ 3rd, Kyle RA, Achenbach SJ, Oberg AL, term results of curettage and bone-grafting and
Rajkumar SV.  Fracture risk with multiple myeloma: mechanical realignment. J Bone Joint Surg Am.
a population-based study. J Bone Miner Res. 1998;80(5):648–58.
2005;20(3):487–93. 25. Krishnan H, Yoon TR, Park KS, Yeo JH. Eosinophilic
9. Riccardi A, Gobbi PG, Ucci G, et al. Changing clini- granuloma involving the femoral neck. Case Rep
cal presentation of multiple myeloma. Eur J Cancer. Orthop. 2013;2013:809605.
1991;27(11):1401–5. 26. Mankin HJ, Hornicek FJ, Ortiz-Cruz E, Villafuerte J,
10. Albergo JI, Gaston CL, Jeys LM, et al. Management Gebhardt MC. Aneurysmal bone cyst: a review of 150
and prognostic significance of pathological fractures patients. J Clin Oncol. 2005;23(27):6756–62.
through chondrosarcoma of the femur. Int Orthop. 27. Ortiz EJ, Isler MH, Navia JE, Canosa R. Pathologic
2015;39(5):943–6. fractures in children. Clin Orthop Relat Res.
11. Bramer JA, Abudu AA, Grimer RJ, Carter SR, Tillman 2005;432:116–26.
RM. Do pathological fractures influence survival and 28. Tong Z, Zhang W, Jiao N, Wang K, Chen B, Yang
local recurrence rate in bony sarcomas? Eur J Cancer. T. Surgical treatment of fibrous dysplasia in the proxi-
2007;43(13):1944–51. mal femur. Exp Ther Med. 2013;5(5):1355–8.
12. Andreou D, Ruppin S, Fehlberg S, Pink D, Werner 29. Wai EK, Davis AM, Griffin A, Bell RS, Wunder

M, Tunn PU. Survival and prognostic factors in chon- JS.  Pathologic fractures of the proximal femur sec-
drosarcoma: results in 115 patients with long-­term ondary to benign bone tumors. Clin Orthop Relat Res.
follow-up. Acta Orthop. 2011;82(6):749–55. 2001;393:279–86.
13. Bacci G, Ferrari S, Longhi A, et  al. Nonmetastatic 30. Leet AI, Boyce AM, Ibrahim KA, Wientroub S,

osteosarcoma of the extremity with pathologic frac- Kushner H, Collins MT.  Bone-grafting in poly-
ture at presentation: local and systemic control by ostotic fibrous dysplasia. J Bone Joint Surg Am.
amputation or limb salvage after preoperative chemo- 2016;98(3):211–9.
therapy. Acta Orthop Scand. 2003;74(4):449–54. 31. Stanton RP, Ippolito E, Springfield D, Lindaman

14. Fuchs B, Valenzuela RG, Sim FH. Pathologic fracture L, Wientroub S, Leet A.  The surgical management
as a complication in the treatment of Ewing’s sar- of fibrous dysplasia of bone. Orphanet J Rare Dis.
coma. Clin Orthop Relat Res. 2003;415:25–30. 2012;7(Suppl 1):S1.
15. Scully SP, Ghert MA, Zurakowski D, Thompson RC, 32. Hou HY, Wu K, Wang CT, Chang SM, Lin WH, Yang
Gebhardt MC. Pathologic fracture in osteosarcoma : RS. Treatment of unicameral bone cyst: surgical tech-
prognostic importance and treatment implications. J nique. J Bone Joint Surg Am. 2011;93(Suppl 1):92–9.
Bone Joint Surg Am. 2002;84-A(1):49–57. 33. Kadhim M, Thacker M, Kadhim A, Holmes L Jr.
16. Ahn JI, Park JS. Pathological fractures secondary to Treatment of unicameral bone cyst: systematic review
unicameral bone cysts. Int Orthop. 1994;18(1):20–2. and meta analysis. J Child Orthop. 2014;8(2):171–91.
17. Azouz EM, Karamitsos C, Reed MH, Baker L,
34. Easley ME, Kneisl JS.  Pathologic fractures through
Kozlowski K, Hoeffel JC.  Types and complications nonossifying fibromas: is prophylactic treatment war-
of femoral neck fractures in children. Pediatr Radiol. ranted? J Pediatr Orthop. 1997;17(6):808–13.
1993;23(6):415–20. 35. Hakim DN, Pelly T, Kulendran M, Caris JA. Benign
18. Papagelopoulos PJ, Choudhury SN, Frassica FJ, Bond tumours of the bone: a review. J Bone Oncol.
JR, Unni KK, Sim FH. Treatment of aneurysmal bone 2015;4(2):37–41.
cysts of the pelvis and sacrum. J Bone Joint Surg Am. 36. Fletcher CD.  The evolving classification of soft tis-
2001;83-A(11):1674–81. sue tumours - an update based on the new 2013 WHO
19. Mascard E, Gomez-Brouchet A, Lambot K.  Bone
classification. Histopathology. 2014;64(1):2–11.
cysts: unicameral and aneurysmal bone cyst. Orthop 37. Haase SC.  Treatment of pathologic fractures. Hand
Traumatol Surg Res. 2015;101(1 Suppl):S119–27. Clin. 2013;29(4):579–84.
20. Arata MA, Peterson HA, Dahlin DC.  Pathological 38. Sassoon AA, Fitz-Gibbon PD, Harmsen WS, Moran
fractures through non-ossifying fibromas. Review of SL.  Enchondromas of the hand: factors affecting
the Mayo Clinic experience. J Bone Joint Surg Am. recurrence, healing, motion, and malignant transfor-
1981;63(6):980–8. mation. J Hand Surg Am. 2012;37(6):1229–34.
21. Bali K, Sudesh P, Patel S, Kumar V, Saini U, Dhillon 39. Khoo RN, Peh WC, Guglielmi G.  Clinics in diag-
MS. Pediatric femoral neck fractures: our 10 years of nostic imaging (124). Multiple enchondromatosis in
experience. Clin Orthop Surg. 2011;3(4):302–8. Ollier disease. Singap Med J. 2008;49(10):841–845;
22. De Mattos CB, Binitie O, Dormans JP.  Pathological quiz 846.
fractures in children. Bone Joint Res. 40. Singh P, Kejariwal U, Chugh A. A rare occurrence of
2012;1(10):272–80. enchondroma in neck of femur in an adult female: a
23. Dormans JP, Hanna BG, Johnston DR, Khurana
case report. J Clin Diagn Res. 2015;9(12):RD01–3.
JS.  Surgical treatment and recurrence rate of aneu- 41. Murphey MD, Flemming DJ, Boyea SR, Bojescul JA,
rysmal bone cysts in children. Clin Orthop Relat Res. Sweet DE, Temple HT.  Enchondroma versus chon-
2004;421:205–11. drosarcoma in the appendicular skeleton: differenti-
24. Guille JT, Kumar SJ, MacEwen GD.  Fibrous dys- ating features. Radiographics. 1998;18(5):1213–37;
plasia of the proximal part of the femur. Long-­ quiz 1244-1215.
13  Pathologic Fractures 165

42. Balke M, Schremper L, Gebert C, et  al. Giant cell clinical outcomes for patients with osteosarcoma.
tumor of bone: treatment and outcome of 214 cases. J BMC Musculoskelet Disord. 2016;17(1):503.
Cancer Res Clin Oncol. 2008;134(9):969–78. 58. Moradi B, Zahlten-Hinguranage A, Lehner B,

43. Klenke FM, Wenger DE, Inwards CY, Rose PS, Sim Zeifang F.  The impact of pathological fractures
FH. Recurrent giant cell tumor of long bones: analy- on therapy outcome in patients with primary
sis of surgical management. Clin Orthop Relat Res. malignant bone tumours. Int Orthop. 2010;34(7):
2011;469(4):1181–7. 1017–23.
44. Balke M, Streitbuerger A, Budny T, Henrichs M,
59. Schlegel M, Zeumer M, Prodinger PM, et al. Impact
Gosheger G, Hardes J.  Treatment and outcome of pathological fractures on the prognosis of primary
of giant cell tumors of the pelvis. Acta Orthop. malignant bone sarcoma in children and adults: a
2009;80(5):590–6. single-center retrospective study of 205 patients.
45. Blackley HR, Wunder JS, Davis AM, White LM,
Oncology. 2018;94(6):354–62.
Kandel R, Bell RS. Treatment of giant-cell tumors of 60. Sun L, Li Y, Zhang J, Li H, Li B, Ye Z.  Prognostic
long bones with curettage and bone-grafting. J Bone value of pathologic fracture in patients with high
Joint Surg Am. 1999;81(6):811–20. grade localized osteosarcoma: a systemic review
46. Campanacci M, Baldini N, Boriani S, Sudanese
and meta-analysis of cohort studies. J Orthop Res.
A. Giant-cell tumor of bone. J Bone Joint Surg Am. 2015;33(1):131–9.
1987;69(1):106–14. 61. Zeifang F, Sabo D, Ewerbeck V. [Pathological frac-
47. Larsson SE, Lorentzon R, Boquist L. Giant-cell tumor ture in primary malignant bone tumors]. Chirurg.
of bone. A demographic, clinical, and histopathologi- 2000;71(9):1121–5.
cal study of all cases recorded in the Swedish Cancer 62. Zuo D, Zheng L, Sun W, Hua Y, Cai Z.  Pathologic
Registry for the years 1958 through 1968. J Bone fracture does not influence prognosis in stage IIB
Joint Surg Am. 1975;57(2):167–73. osteosarcoma: a case-control study. World J Surg
48. Sung HW, Kuo DP, Shu WP, Chai YB, Liu CC, Li Oncol. 2013;11:148.
SM.  Giant-cell tumor of bone: analysis of two hun- 63. Chandrasekar CR, Grimer RJ, Carter SR, Tillman

dred and eight cases in Chinese patients. J Bone Joint RM, Abudu A, Buckley L.  Modular endoprosthetic
Surg Am. 1982;64(5):755–61. replacement for tumours of the proximal femur. J
49. Turcotte RE, Wunder JS, Isler MH, et  al. Giant cell Bone Joint Surg Br. 2009;91(1):108–12.
tumor of long bone: a Canadian Sarcoma Group 64. Kawaguchi N, Ahmed AR, Matsumoto S, Manabe J,
study. Clin Orthop Relat Res. 2002;397:248–58. Matsushita Y. The concept of curative margin in sur-
50. Benevenia J, Patterson FR, Beebe KS, Abdelshahed gery for bone and soft tissue sarcoma. Clin Orthop
MM, Uglialoro AD. Comparison of phenol and argon Relat Res. 2004;419:165–72.
beam coagulation as adjuvant therapies in the treat- 65. Chen X, Yu LJ, Peng HM, et al. Is intralesional resec-
ment of stage 2 and 3 benign-aggressive bone tumors. tion suitable for central grade 1 chondrosarcoma: a
Orthopedics. 2012;35(3):e371–8. systematic review and updated meta-analysis. Eur J
51. Lewis VO, Wei A, Mendoza T, Primus F, Peabody T, Surg Oncol. 2017;43(9):1718–26.
Simon MA. Argon beam coagulation as an adjuvant 66. Chen YC, Wu PK, Chen CF, Chen WM. Intralesional
for local control of giant cell tumor. Clin Orthop Relat curettage of central low-grade chondrosarcoma:
Res. 2007;454:192–7. a midterm follow-up study. J Chin Med Assoc.
52. Klenke FM, Wenger DE, Inwards CY, Rose PS,
2017;80(3):178–82.
Sim FH.  Giant cell tumor of bone: risk factors for 67. Meftah M, Schult P, Henshaw RM. Long-term results
recurrence. Clin Orthop Relat Res. 2011;469(2): of intralesional curettage and cryosurgery for treat-
591–9. ment of low-grade chondrosarcoma. J Bone Joint
53. Mittag F, Leichtle C, Kieckbusch I, et  al. Cytotoxic Surg Am. 2013;95(15):1358–64.
effect and tissue penetration of phenol for adju- 68. Weber KL, Raymond AK.  Low-grade/dedifferenti-

vant treatment of giant cell tumours. Oncol Lett. ated/high-grade chondrosarcoma: a case of histo-
2013;5(5):1595–8. logical and biological progression. Iowa Orthop J.
54. van der Heijden L, Dijkstra PD, Campanacci DA, 2002;22:75–80.
Gibbons CL, van de Sande MA. Giant cell tumor with 69. Deloin X, Dumaine V, Biau D, et  al. Pelvic chon-
pathologic fracture: should we curette or resect? Clin drosarcomas: surgical treatment options. Orthop
Orthop Relat Res. 2013;471(3):820–9. Traumatol Surg Res. 2009;95(6):393–401.
55. Deheshi BM, Jaffer SN, Griffin AM, Ferguson PC, 70.
Pring ME, Weber KL, Unni KK, Sim FH.
Bell RS, Wunder JS. Joint salvage for pathologic frac- Chondrosarcoma of the pelvis. A review of sixty-
ture of giant cell tumor of the lower extremity. Clin four cases. J Bone Joint Surg Am. 2001;83-A(11):
Orthop Relat Res. 2007;459:96–104. 1630–42.
56. Zheng K, Yu X, Hu Y, Wang Z, Wu S, Ye Z. Surgical 71. Brown TS, Salib CG, Rose PS, Sim FH, Lewallen
treatment for pelvic giant cell tumor: a multi-center DG, Abdel MP. Reconstruction of the hip after resec-
study. World J Surg Oncol. 2016;14:104. tion of periacetabular oncological lesions: a system-
57. Chung LH, Wu PK, Chen CF, Weng HK, Chen
atic review. Bone Joint J. 2018;100-B(1 Supple A):
TH, Chen WM.  Pathological fractures in predicting 22–30.
166 F. M. Klenke et al.

72. Bus MP, Szafranski A, Sellevold S, et al. LUMiC((R)) 87. Forsberg JA, Eberhardt J, Boland PJ, Wedin R,
endoprosthetic reconstruction after periacetabular Healey JH. Estimating survival in patients with oper-
tumor resection: short-term results. Clin Orthop able skeletal metastases: an application of a Bayesian
Relat Res. 2017;475(3):686–95. belief network. PLoS One. 2011;6(5):e19956.
73. Hong AM, Millington S, Ahern V, et al. Limb pres- 88. Katagiri H, Okada R, Takagi T, et al. New prognostic
ervation surgery with extracorporeal irradiation factors and scoring system for patients with skeletal
in the management of malignant bone tumor: the metastasis. Cancer Med. 2014;3(5):1359–67.
oncological outcomes of 101 patients. Ann Oncol. 89. Ratasvuori M, Wedin R, Hansen BH, et  al.
2013;24(10):2676–80. Prognostic role of en-bloc resection and late onset of
74. Liang H, Ji T, Zhang Y, Wang Y, Guo W. bone metastasis in patients with bone-seeking carci-
Reconstruction with 3D-printed pelvic endoprosthe- nomas of the kidney, breast, lung, and prostate: SSG
ses after resection of a pelvic tumour. Bone Joint J. study on 672 operated skeletal metastases. J Surg
2017;99-B(2):267–75. Oncol. 2014;110(4):360–5.
75. Sharma DN, Rastogi S, Bakhshi S, et  al. Role of 90. Rougraff BT, Kneisl JS, Simon MA.  Skeletal
extracorporeal irradiation in malignant bone tumors. metastases of unknown origin. A prospective study
Indian J Cancer. 2013;50(4):306–9. of a diagnostic strategy. J Bone Joint Surg Am.
76. Sun W, Li J, Li Q, Li G, Cai Z. Clinical effectiveness 1993;75(9):1276–81.
of hemipelvic reconstruction using computer-aided 91. Wolanczyk MJ, Fakhrian K, Adamietz IA.
custom-made prostheses after resection of malignant Radiotherapy, bisphosphonates and surgical stabi-
pelvic tumors. J Arthroplast. 2011;26(8):1508–13. lization of complete or impending pathologic frac-
77. Thambapillary S, Dimitriou R, Makridis KG, tures in patients with metastatic bone disease. J
Fragkakis EM, Bobak P, Giannoudis PV.  Implant Cancer. 2016;7(1):121–4.
longevity, complications and functional outcome fol- 92. Muller DA, Capanna R.  The surgical treat-
lowing proximal femoral arthroplasty for musculo- ment of pelvic bone metastases. Adv Orthop.
skeletal tumors: a systematic review. J Arthroplasty. 2015;2015:525363.
2013;28(8):1381–5. 93. Nilsson J, Gustafson P. Surgery for metastatic lesions
78. Goorin AM, Schwartzentruber DJ, Devidas M, et al. of the femur: good outcome after 245 operations in
Presurgical chemotherapy compared with immedi- 216 patients. Injury. 2008;39(4):404–10.
ate surgery and adjuvant chemotherapy for nonmeta- 94. Morishige M, Muramatsu K, Tominaga Y,
static osteosarcoma: Pediatric Oncology Group Study Hashimoto T, Taguchi T.  Surgical treatment of
POG-8651. J Clin Oncol. 2003;21(8):1574–80. metastatic femoral fractures: achieving an improved
79. Choy WS, Kim KJ, Lee SK, et al. Surgical treatment quality of life for cancer patients. Anticancer Res.
of pathological fractures occurring at the proximal 2015;35(1):427–32.
femur. Yonsei Med J. 2015;56(2):460–5. 95. Mirels H.  Metastatic disease in long bones. A
80. Issack PS, Kotwal SY, Lane JM.  Management of proposed scoring system for diagnosing impend-
metastatic bone disease of the acetabulum. J Am ing pathologic fractures. Clin Orthop Relat Res.
Acad Orthop Surg. 2013;21(11):685–95. 1989;249:256–64.
81. Mundy GR.  Metastasis to bone: causes, conse- 96. Damron TA, Morgan H, Prakash D, Grant W,
quences and therapeutic opportunities. Nat Rev Aronowitz J, Heiner J. Critical evaluation of Mirels’
Cancer. 2002;2(8):584–93. rating system for impending pathologic fractures.
82. Roudier MP, Vesselle H, True LD, et  al. Bone his- Clin Orthop Relat Res. 2003;415:S201–7.
tology at autopsy and matched bone scintigraphy 97. Van der Linden YM, Dijkstra PD, Kroon HM, et al.
findings in patients with hormone refractory pros- Comparative analysis of risk factors for pathological
tate cancer: the effect of bisphosphonate therapy fracture with femoral metastases. J Bone Joint Surg
on bone scintigraphy results. Clin Exp Metastasis. Br. 2004;86(4):566–73.
2003;20(2):171–80. 98. Menck H, Schulze S, Larsen E.  Metastasis size in
83. Gainor BJ, Buchert P.  Fracture healing in meta- pathologic femoral fractures. Acta Orthop Scand.
static bone disease. Clin Orthop Relat Res. 1988;59(2):151–4.
1983;178:297–302. 99. Issack PS, Barker J, Baker M, Kotwal SY, Lane
84. Bohm P, Huber J.  The surgical treatment of bony JM.  Surgical management of metastatic disease of
metastases of the spine and limbs. J Bone Joint Surg the proximal part of the femur. J Bone Joint Surg
Br. 2002;84(4):521–9. Am. 2014;96(24):2091–8.
85. Jacofsky DJ, Haidukewych GJ.  Management of 100. Peterson JR, Decilveo AP, O’Connor IT, Golub
pathologic fractures of the proximal femur: state of I, Wittig JC.  What are the functional results and
the art. J Orthop Trauma. 2004;18(7):459–69. complications with long stem hemiarthroplasty in
86. Errani C, Mavrogenis AF, Cevolani L, et  al. patients with metastases to the proximal femur? Clin
Treatment for long bone metastases based on a Orthop Relat Res. 2017;475(3):745–56.
systematic literature review. Eur J Orthop Surg 101. Steensma M, Boland PJ, Morris CD, Athanasian
Traumatol. 2017;27(2):205–11. E, Healey JH.  Endoprosthetic treatment is more
13  Pathologic Fractures 167

durable for pathologic proximal femur fractures. 114. Merckaert S, Siebenrock K, Tannast M. Compound
Clin Orthop Relat Res. 2012;470(3):920–6. osteosynthesis of the proximal femur as a choice
102. Wedin R, Bauer HC. Surgical treatment of skeletal for the treatment of pathological proximal femo-
metastatic lesions of the proximal femur: endopros- ral fractures. American Academy of Orthoppaedic
thesis or reconstruction nail? J Bone Joint Surg Br. Surgerons (AAOS) Annual Meeting, San Diego,
2005;87(12):1653–7. USA; 2017.
103. Yazawa Y, Frassica FJ, Chao EY, Pritchard DJ, Sim 115. Picci P, Manfrini M, Fabbri N, Gambarotti M, Vanel
FH, Shives TC. Metastatic bone disease. A study of D.  Atlas of musculoskeletal tumors and tumorlike
the surgical treatment of 166 pathologic humeral lesions. Berlin: Springer; 2014.
and femoral fractures. Clin Orthop Relat Res. 116. Yasko AW, Rutledge J, Lewis VO, Lin PP. Disease-
1990;251:213–9. and recurrence-free survival after surgical resec-
104. Capanna R, Campanacci DA.  The treatment of tion of solitary bone metastases of the pelvis. Clin
metastases in the appendicular skeleton. J Bone Joint Orthop Relat Res. 2007;459:128–32.
Surg Br. 2001;83(4):471–81. 117. Harrington KD.  The management of acetabu-
105. Alvi HM, Damron TA.  Prophylactic stabilization lar insufficiency secondary to metastatic malig-
for bone metastases, myeloma, or lymphoma: do we nant disease. J Bone Joint Surg Am. 1981;63(4):
need to protect the entire bone? Clin Orthop Relat 653–64.
Res. 2013;471(3):706–14. 118. Cotten A, Deprez X, Migaud H, Chabanne B,
106. Scarborough MT. CORR Insights (R): Intramedullary Duquesnoy B, Chastanet P.  Malignant acetabular
nailing of femoral diaphyseal metastases: is it neces- osteolyses: percutaneous injection of acrylic bone
sary to protect the femoral neck? Clin Orthop Relat cement. Radiology. 1995;197(1):307–10.
Res. 2015;473(4):1503–4. 119. Guzik G. Treatment of metastatic lesions localized in
107. Miller BJ, Soni EE, Gibbs CP, Scarborough the acetabulum. J Orthop Surg Res. 2016;11(1):54.
MT. Intramedullary nails for long bone metastases: 120. Scaramuzzo L, Maccauro G, Rossi B, Messuti
why do they fail? Orthopedics. 2011;34(4):274. L, Maffulli N, Logroscino CA.  Quality of life in
108. Friedl W. [Double plate compound osteosynthe- patients following percutaneous PMMA acetabulo-
sis. A procedure for primary stress-stable manage- plasty for acetabular metastasis due to carcinoma.
ment of problem injuries of the subtrochanteric to Acta Orthop Belg. 2009;75(4):484–9.
supracondylar femoral area]. Aktuelle Traumatol. 121. Clayer M.  The survivorship of protrusio cages for
1992;22(5):189–96. metastatic disease involving the acetabulum. Clin
109. Gruber G, Zacherl M, Leithner A, et  al. [Surgical Orthop Relat Res. 2010;468(11):2980–4.
treatment of pathologic fractures of the humerus and 122. Ho L, Ahlmann ER, Menendez LR.  Modified
femur]. Orthopade. 2009;38(4):324, 326–8, 330–4. Harrington reconstruction for advanced peri-
110. Friedl W, Ruf W, Mischkowsky T. [Compound dou- acetabular metastatic disease. J Surg Oncol.
ble plate osteosynthesis in subtrochanteric patho- 2010;101(2):170–4.
logic fractures. A clinical and experimental study]. 123. Marco RA, Sheth DS, Boland PJ, Wunder JS,
Chirurg. 1986;57(11):713–18. Siegel JA, Healey JH.  Functional and oncological
111. Ganz R, Fernandez D. [Treatment of patho- outcome of acetabular reconstruction for the treat-
logical fractures in metastases]. Ther Umsch. ment of metastatic disease. J Bone Joint Surg Am.
1973;30(4):307–9. 2000;82(5):642–51.
112. Schottle H, Sauer HD, Jungbluth KH. [Measurements 124. Tillman RM, Myers GJ, Abudu AT, Carter SR,
of stability of operative osteosynthesis on the proxi- Grimer RJ.  The three-pin modified ‘Harrington’
mal femur (author’s transl)]. Arch Orthop Unfallchir. procedure for advanced metastatic destruction of
1977;89(1):87–100. the acetabulum. J Bone Joint Surg Br. 2008;90(1):
113. Rompe JD, Eysel P, Hopf C, Heine J.  Metastatic 84–7.
instability at the proximal end of the femur. 125. Kitagawa Y, Ek ET, Choong PF. Pelvic reconstruc-
Comparison of endoprosthetic replacement and tion using saddle prosthesis following limb salvage
plate osteosynthesis. Arch Orthop Trauma Surg. operation for periacetabular tumour. J Orthop Surg
1994;113(5):260–4. (Hong Kong). 2006;14(2):155–62.
 Acetabular and Femoral Neck
Fracture Nonunion and Malunion 14
Robert C. Jacobs, Craig S. Bartlett,
and Michael Blankstein

Abstract Keywords
Nonunion and malunion are uncommon com- Acetabular · Acetabulum · Nonunion ·
plications following femoral neck fracture and Malunion · Fracture · Femoral neck
even more rarely reported after a fracture of
the acetabulum. These complications can be
difficult to diagnose but can be successfully 14.1 Acetabular Fractures
treated with a large number of patients experi-
encing good to excellent outcomes. 14.1.1 Introduction
Algorithmic approaches for each are included
including the conversion to total hip arthro- 14.1.1.1 Incidence
plasty after unsuccessful open reduction inter- Open reduction with internal fixation (ORIF) is
nal fixation of an acetabular fracture. the gold standard of treatment for most displaced
With respect to the acetabulum, malunion acetabular fractures. Nonunion is a rare compli-
is likely more common than previously cation after ORIF with a rate less than 5% [1–4],
thought. Case examples for conversion to total occurring most commonly after transverse or
hip arthroplasty after acetabular malunion and associated transverse fracture patterns [1, 3, 5].
open reduction internal fixation after acetabu- Malunion after an acetabular fracture is seen in
lar nonunion are included. Due to their less than 6% of cases [4]. The incidences of these
bimodal demographics of young and old, frac- two complications vary by the approach and the
tures of the femoral neck have significant dif- type of fracture as classified by Judet and
ferences with respect to both their etiology Letournel [1]. Unfortunately, most large series
and treatment. A case example for conversion presenting clinical and functional results of ace-
of nonunion to total hip arthroplasty is tabular fractures do not elaborate on their occur-
included. rence or treatment [6–14].
The incidence of acetabular malunion may be
loosely inferred using reported reduction quality
after ORIF from post-operative or follow-up
imaging as a surrogate measure. There are many
subjective and different objective methods of
reporting reduction quality. Most recent authors
R. C. Jacobs (*) · C. S. Bartlett · M. Blankstein
University of Vermont, Burlington, VT, USA use the criteria of Matta [2] to define the reduc-
e-mail: [email protected] tion as anatomic (0–1 mm), imperfect (2–3 mm)

© Springer Nature Switzerland AG 2019 169

L. Büchler, M. J.B. Keel (eds.), Fractures of the Hip, Fracture Management Joint by Joint,
https://doi.org/10.1007/978-3-030-18838-2_14
170 R. C. Jacobs et al.

or poor (>3 mm) based on the residual displace- suggests that indomethacin treatment in posterior
ment noted on plain radiograph (AP and Judet wall acetabular fractures may be associated with
views) [15]. If a malunion is defined as a healed rates of nonunion approaching 62% [20]. The use of
fracture with >3  mm of residual displacement indomethacin may explain some of the of nonunions
plain radiographs, then the real incidence of ace- reported during conversion to total hip arthroplasty
tabular malunion is likely significantly higher (THA), however the rates vary depending on the
with ranges between 4.0% and 32.6% [1–4, 6–8, series and are subject to study design biases [5].
10–14, 16]. In his landmark paper, Letournel did Despite anatomical reduction, rapid progres-
not report specific measurements but did have sion to arthritis can occur within the first few
“imperfect reductions” in 26% of 417 operatively months following ORIF of a displaced acetabular
treated cases [1]. fracture. Articular malreduction resulting in mal-
Determining the incidence of malunion is fur- union or nonunion further compounds the signifi-
ther complicated by the fact that plain radiographs cant damage to the osteochondral surface at the
overestimate reduction quality due to the complex time of injury and is almost uniformly associated
anatomy of the acetabulum, especially in fractures with poor functional outcomes [2, 4]. Studies
involving the posterior wall. In a study of 100 have shown that THA after attempted ORIF
patients, Moed et al. noted 97 anatomic reductions occurs at rates at 6–35%, though this depends on
by plain radiographs despite recognizing gaps of fracture pattern [3, 11, 14]. It is interesting that
>3 mm intraoperatively in 41 cases [9]. younger patients frequently have more compli-
The definitions of a malunion or nonunion can cated fracture patterns, more severe injuries and
also be challenging as they are not universally worse radiographs but have similar or better func-
agreed upon and are constantly evolving [17]. tional outcomes [2]. They also tend to progress to
Unlike long bone fractures, obtaining quality THA more rapidly than the elderly patients, per-
imaging is more challenging and it is difficult to haps in part to the increased functional demands
apply plain radiographic criteria to assess for they place on their reconstructions [21, 22], how-
multiple healed cortices. ever this is not born out in all studies [19].

14.1.1.2 O  ther Complications After

ORIF of Acetabular Fractures 14.1.2 Outcomes After Non-­
One of the most common complications follow- operative Treatment
ing displaced acetabular fractures treated with of Acetabular Fractures
ORIF is osteoarthritis. Giannoudis et al. reported
a rate of severe osteoarthritis of almost 20% in a Displaced acetabular fractures (>3  mm diastasis
2005 meta-analysis [18] with more recent authors or step-off) have significantly decreased outcomes
reporting similar results [6]. There is also evi- when treated nonoperatively when compared to
dence that the rates of post-traumatic arthritis those treated with modern techniques of open
after ORIF of an acetabular fracture decrease reduction and internal fixation [23]. This discrep-
with surgical specialization, increased experi- ancy in outcomes has limited non-­operative treat-
ence and treatment in a tertiary referral setting ment of acetabular fractures to those with near
[18]. Risk factors negatively affecting outcomes anatomic alignment, the elderly with secondary
include: increasing patient age [2, 4, 6, 9, 10, 19], congruence, the severely poly traumatized patient
fracture pattern complexity [2, 6, 18, 19], who has significant medical comorbidities [23]
increased time to surgery [1, 2, 6, 9, 16], local and those with stable posterior wall fractures after
complications (including infection and avascular exam under anesthesia [24]. Patients with mini-
necrosis) [2, 10, 18], and heterotopic ossification mally displaced acetabular fractures with ≤2 mm
(HO) [2, 3, 10, 18]. of step-off have reported 10-year hip survival
The use of indomethacin for prevention of HO rates of 94% without arthroplasty intervention
following acetabular surgery has been common- and functional outcomes of good to excellent in
place for decades. Nevertheless, recent literature 88% and 89% of patients [25].
14  Acetabular and Femoral Neck Fracture Nonunion and Malunion 171

14.1.3 Outcomes of ORIF approaches are often required and carry signifi-
of Acetabular Fractures cant additional morbidity; with increased compli-
cations including infection, HO, avascular
When operatively treated with an ORIF, reduc- necrosis of the femoral head, and need for conver-
tions of ≤3 mm have been associated with good sion to total hip arthroplasty [1, 2, 12, 13, 16, 19].
to excellent radiographic and functional out-
comes in up to 70% of cases [2–4, 6, 9, 10, 18,
19]; even in the setting of extended approaches 14.1.5 Evolution of the Conversion
[13] and elderly patients [26]. Acetabular frac- to THA
tures with good to excellent functional out-
comes after 2 years can usually expect to have Conversion to total hip arthroplasty is the salvage
good long-term outcomes at 10 and 20 years [6, operation of choice for most patients with arthri-
19, 25]. However, there are many fractures that tis of the hip joint following ORIF or non-­
progress rapidly to joint space loss, pain, and operative treatment of a displaced acetabular
debilitating arthritis and require additional sur- fracture [28–30]. Some of the first efforts in this
gical intervention in an effort to provide a more field met with poor results and high levels of
functional joint [11, 19]. A predictive nomo- morbidity. These studies showed significant rates
gram was developed based on the experience of of acetabular component failure and higher than
Matta that helps predict the patients who will expected revision rates of both acetabular and to
most likely need a THA after ORIF of acetabu- a lesser extent, femoral components [21].
lar fracture [19]. However, with improved understanding of the
There are few select series that report on the treatment of these complex patients, so have the
delayed treatment of acetabular fractures and results [22].
treatment of acetabular nonunions using ORIF
[1, 16, 27]. These all report worse functional and
radiographic outcomes of patients undergoing 14.1.6 Outcomes After Conversion
delayed ORIF compared to patients who receive to THA
operative intervention within 3 weeks of injury.
Short- and long-term outcomes of patients after
conversion to THA after a displaced acetabular
14.1.4 Outcomes of Revision ORIF fracture show significant functional improve-
of Acetabular Fractures ments with better functional scores in younger
patients [29, 31–34]. Regarding outcomes, most
Less frequently reported in the literature are the results are not comparable to age matched
results of revision ORIF of displaced acetabular patients undergoing primary THA [35] with com-
fractures. If re-operated on within 3 weeks, 59% plication rates more comparable to those expected
can still achieve good-excellent clinical results, after revision THA [28, 36]. However, there are
however the outcomes are significantly worse for some authors who report mid-term survivorship
those treated beyond 12  weeks (29% good to rates approaching the levels seen after primary
excellent outcomes) [16, 27]. The need for sur- THA with the only major differences being
gery in most cases was the result of hardware increased operative time, blood loss, and post-­
failure with resulting redisplacement or surgical operative complications [22, 28, 31].
malreductions [5, 27]. Overall, most recent studies report improved
Quality literature regarding revision ORIF for mid-term revision rates between 0 and 32% [28,
displaced acetabular fractures is scarce and often 29]. The literature is relatively sparse regarding
combines patients treated in both the acute and the long-term outcomes in these patients with
delayed fashion, the latter group overlapping with 20-year acetabular survival rates at 57% [34].
malunion and nonunion cohorts [5, 16]. In either Younger patients undergoing delayed arthro-
case of revision or delayed ORIF, extensile plasty after ORIF of an acetabular fracture can
172 R. C. Jacobs et al.

also expect a shorter time to revision THA [21, entire pelvis is helpful to allow comparison with
35]. Regardless, patients requiring conversion to the normal hip.
THA after ORIF of a displaced acetabular frac- All operative notes should be obtained and the
ture are at increased risk for nerve injury, disloca- patient examined so that previous incisions and
tion, infection, HO formation, loosening, and surgical intervals can be utilized when possible.
hardware failure [29, 35]. This will also help develop an appropriate plan to
address hardware for possible removal. Lastly,
the expected outcomes of conversion THA after
14.1.7 Preoperative Evaluation failed acetabular ORIF need to be weighed
against the expected outcomes of revision
When evaluating a patient for a potential nonunion ORIF.  In most circumstances of nonunion or
or malunion following a previous acetabular frac- malunion, conversion to THA is recommended
ture, care should be taken to spend adequate time over revision ORIF due to its better overall out-
on achieving a complete history and performing a comes in a wider selection of patients.
detailed physical exam. The previous rationale for
treatment of the acetabular fracture should be care-
fully reviewed. The course of initial recovery 14.1.8 Surgical Planning of Revision
should also be scrutinized to help rule out addi- ORIF
tional hip pathology, especially infection.
If infection is on the differential diagnosis, A successful surgical outcome starts with the
then inflammatory markers should be drawn and development of a thorough surgical plan with
repeated as necessary. If there is a high clinical contingencies in place for the major intraopera-
suspicion, synovial fluid should be aspirated and tive hurdles. This is built upon a detailed history,
sent for gram stain/culture, synovial cell count, physical exam, and discussions with the patient.
differential and crystal analysis. As mentioned previously, the surgeon should
A thorough endocrine workup should also be understand why the malunion or nonunion
considered as a part of the preoperative evalua- occurred and what critical steps will restore joint
tion. In patients with an unexplained nonunion, reduction and stability. Revision ORIF usually
Brinker et  al. found that 84% had a treatable requires an extensile approach which carries sig-
endocrine abnormality. Furthermore, 8/37 nificant morbidity [16]. The approach chosen
patients eventually healed their nonunion with should be matched to the nonunion or malunion
correction of the abnormality and non-opera- deformity to be corrected and stabilized. Existing
tive treatment [37]. Smoking cessation should hardware should be evaluated for retention vs.
also be attempted as it is associated with an removal and existing bone stock should be ana-
increased time to union, as well as surgical lyzed for quality and quantity. If multiple incisions
complications, delayed healing, and need for will be required, the morbidity of these approaches
multiple surgeries [38]. should be weighed against the expected outcomes
Regardless if a patient has undergone previous from a single approach conversion to THA.
ORIF or non-operative treatment, complete An infectious and metabolic work-up should
imaging radiographs (AP and Judet views) of the proceed as mentioned in the previous section.
pelvis are minimum requirements. Thin slice Previous operative reports, implant records, and
computed tomography (CT) scans are also gener- skin incisions should be evaluated to see if revi-
ally recommended. Other helpful adjuncts are sion ORIF is feasible. Specific plans for dealing
metal suppression CT scans with 3D reconstruc- with the location of hardware to be encountered,
tion imaging. Magnetic resonance imaging bone stock and instability should be in place,
(MRI) can also be considered to identify possible with backup options as needed.
occult infection and femoral head avascular The expectation of possible intraoperative
necrosis. This too can be performed with specific complications and potential inability to achieve
metal suppression sequences and imaging of the bony stability and/or anatomic acetabular joint
14  Acetabular and Femoral Neck Fracture Nonunion and Malunion 173

congruence should be addressed. If the goals underlying revision total hip arthroplasty [39,
listed above of surgery cannot be achieved intra- 40]. Metal augments are increasingly being used
operatively, then the procedure should be con- in the revision arthroplasty setting to deal with
verted to a total hip arthroplasty. A non-anatomic large areas of bone loss, especially with a defi-
reduction in the setting of delayed revision ORIF cient posterior wall [33]. Other prosthetic consid-
is associated with a poor outcome [16]. erations include porous titanium cups with
A separate preoperative plan for both revi- multihole designs and cup/cage constructs [41].
sion ORIF and intraoperative conversion to These allow screw fixation through the acetabu-
THA should be prepared including under which lar component into the ilium, ischium, and even
conditions the procedure would be completed pubis. While they can be employed successfully
in a multi-approach or staged fashion. All nec- with less than 50% native bony contact with the
essary equipment for both procedures should acetabular component, there is a trend to
be readily available before surgery. A surgical improved mid-term outcomes with more than
team with the appropriate skill set is critical. 50% host bone contact [42].
This will likely include an orthopedic trauma- There is still a role for using autograft and/or
tologist comfortable in treatment of complex allograft to restore bone stock in the acetabular
acetabular fractures and an orthopedic recon- malunion or nonunion with bone loss [5, 28, 33,
structive surgeon comfortable in revision of 43]. The stability of the grafts must be ensured with
complex total hip arthroplasty if the primary plate and screw fixation or incorporation into the
surgeon is not facile in all portions of both final acetabular component [5, 43]. As discussed
procedures. previously, cemented acetabular components can
provide good outcomes in certain patients [22],
Case Example 1 however more recent uncemented revisions have
A 19 year old male was the driver in a motor been shown to have improved results [32].
vehicle crash and sustained an isolated right hip The workhorse approach for addressing a con-
posterior wall fracture dislocation. He was version THA after acetabular fracture remains
reduced successfully in the emergency depart- the Kocher-Langenbeck (KL) approach. If a pre-
ment (Fig. 14.1a–e). vious posterior approach has been performed,
then the original hardware the fracture will be
more readily accessible should the need arise.
14.1.9 Surgical Planning Intra-articular hardware can be removed with the
of Conversion to THA use of a metal-cutting burr and ultrasound gel in
the setting of a buried screw [44].
A successful surgical outcome starts with the Recreation of the hip center can be assisted
development of a thorough surgical plan with with the use of computer navigation and preop-
contingencies in place for the major intraopera- erative computer assisted design templating.
tive hurdles. The most common patient to present Additional methods for increasing stability after
for conversion to THA is one with a posterior placement of the acetabular construct include the
wall component to the fracture pattern. These use of lipped liners and dual-mobility head com-
patients also have the worst outcomes amongst ponents [28–31].
the 10 acetabular fracture patterns [1, 2, 11]. The Kocher-Langenbeck approach also allows
Fortunately most posterior wall patients have for an easier extensile view of both the acetabu-
intact bone stock and do not require bone graft- lum and femoral shaft if needed. It can also
ing. Restoration of native hip center should be a accommodate partial or complete release of the
priority. Those patients with a hip center greater gluteus maximus, digastric osteotomy, and an
than 20 mm from normal after THA have extended trochanteric osteotomy more easily
increased rates of revision [22, 31]. than other approaches. As such, the subsequent
In the setting of bone loss, bony stability can operative plan and imaging will focus on the KL
be achieved by several principles similar to those approach for treatment (Table 14.1).
174 R. C. Jacobs et al.

a b

Fig. 14.1 (a) AP pelvis radiograph demonstrating right right acetabular nonunion. (d) T2 fat-saturated weighted
hip dislocation with posterior wall acetabular fracture. The MRI showing the sciatic nerve (white arrow) and piriformis
patient declined admission and was subsequently lost to tendon (red arrow) entrapped within the nonunion. The
follow-up. He represented to our clinic 9 months later after posterior wall fragment (black arrow) is lateral to the nerve.
a fall from standing onto his knees with subsequent feeling The patient was subsequently taken to the operating room
of right hip subluxation and instability. He had been notic- for exploration of the right sciatic nerve and ORIF of the
ing increasing pain and paresthesias in a distribution con- right acetabular nonunion through a Kocher-Langenbeck
sistent with the right sciatic nerve for several months. approach. The sciatic nerve was identified and freed from
Radiographs, CT scans, and MRI were obtained confirm- the nonunion. A femoral distractor was used assist in direct
ing right acetabular nonunion with the sciatic nerve visualization of the hip joint; grade 2 cartilage wear was
entrapped within the fracture site. (b) Obturator oblique noted on the femoral head. The posterior wall fragment was
radiograph demonstrating heterotopic bone formation anatomically reduced and secured with a plate and screws.
about the displaced posterior wall acetabular fragment (e) Ten-year follow-up AP pelvis radiograph demonstrating
(white arrow). (c) A representative axial CT image demon- intact fixation, preserved joint space with pain free range of
strating the entrapped sciatic nerve (white arrow) within the motion without any activity limitations
Table 14.1  Algorithm for conversion THA after unsuccessful ORIF of femoral neck fractures or acetabular fracture
Indication  – Nonunion
 – Malunion
 – Avascular necrosis of the femoral head
 – Post-traumatic osteoarthritis of the hip
Goals  – Confirm the absence of infection
 – Restore pelvis/acetabular stability to receive the THA
 – Stable hip postoperatively with restoration of hip center if possible
 – Functional, pain free ambulation and ROM
Preoperative General Radiograph Acetabular bone stock Femoral hardware
algorithm  • Ensure appropriate  • Critical evaluation of  • Adequate or minimal loss:  • Not present:
indications for surgery imaging (XR and CT)    – Without nonunion: proceed proceed
• Preop. rule out of •  Acetabular hardware    – With nonunion: Hardware removal as necessary to allow for  • Hardware present
infection   – Absent → proceed revision ORIF with bone grafting and restoration of stability (compression hip
   – Ruled out → proceed    – Hardware present prior to THA screw, cannulated
   – If infected; then requires removal  • Inadequate screws,
patient is not ready for     If accessible for    – Use AAOS or Paprosky classifications and principles for cephalomedullary
THA, plan should be primary removal dealing with bone loss as in revision THA [45, 46] nail)
changed to appropriate through KL    – Nonunion or Malunion    – Surgically
treatment of infection approach: KL    Augmentation dislocate hip
   – MRSA screen approach with plan     Trabecular metal augment to restore posterior wall and/or prior to
    Positive: Povidone to remove minimal column support hardware
nasal swabs amount of    Multihole porous metal revision cup removal
14  Acetabular and Femoral Neck Fracture Nonunion and Malunion

preoperatively and hardware as    Cup/cage construct    – Reduce hip and

vancomycin necessary to     Maintains ability to place screws into ilium and ischium remove
intraoperatively complete THA    Bone graft (autograft ± allograft) with ORIF ± augment hardware
    Negative: Standard     If not accessible     Type I (posterior wall deficiency): Buttress with femoral
preoperative primarily, buried head or iliac crest
antibiotics hardware will need     Type II (contained cavitary): Morcelize and impact
 • Critical evaluation of to be removed     Type III (column/wall deficiency): Strut allograft ± femoral
previous operative reports from the head or iliac crest
   – Skin incision acetabulum during
   – Deep interval the course of
   – Hardware applied and preparation
manufacturer
identified, removal
tools available
(continued)
175
Table 14.1 (continued)
176

Approach/  • KL in lateral decubitus position

positioning   – Extensile
   – Can incorporate trochanteric slide osteotomy for improved visualization
 • Other approaches not recommended
   – Increased difficulty to address posterior wall and/or column deficiencies intraoperatively
   – Increased difficulty to address intraoperative femur fracture
   – Subsequent revision surgery is more challenging
Intraoperative Surgical exposure Culture/sonication Stability Closure
 • KL approach and bone cut  • Intraoperative rule out  • Revision acetabular ORIF with autograft ± structural allograft (if  • Multiple layers
for removal of femoral of infection needed)  • Drains as
head and neck  • Minimum two  • Fill contained cavitary bone defects with femoral head necessary
 • Identification and cultures for gram autograft ± allograft (if needed)
protection of sciatic nerve stain, culture for  • Ream for line to line sizing of the acetabular component
 • Address femoral hardware anaerobes, aerobes  • Application of acetabular hardware
if necessary  • Native section for   – Augments
 • Address acetabular histology    – Multihole revision cup
hardware if necessary  • Frozen section to    – Cup/cage construct
 • Hardware removal pathology STAT  • Ensure stability of the acetabulum before proceeding to the
   – Minimum necessary    – Less than 5 femoral component
with stable bone stock neutrophils per  • Stability adjuncts
   – Buried: Metal- cutting high power field:    – Medialization of acetabulum to ensure host bony support
burr and ultrasound gel proceed    – Additional screw fixation into ilium, ischium, pubis
   – More than 5     Awareness of safe zones is critical
neutrophils per    – Lipped liner (10–20°)
high power field:    – Lateralized liner in setting of medialized acetabular
convert to component
antibiotic    – Dual mobility cup
articulating hip    – Larger heads
spacer or    – Increased offset through increased neck length modularity
Gridlestone  • Femoral component stability
   – Consider sonication    – Press fit stem
and culture of     Younger patient with good bone quality
hardware    – Cemented stem:
   Older patient
   Poor bone stock
   Previous instrumentation
   – Anteversion can be increased to improve stability
R. C. Jacobs et al.
Post- Weight bearing Mobility Pain control DVT prophylaxis/
operative antibiotics
 • As tolerated  • Ambulation post-  • Multimodal oral medications preferred  • Per institutional
   – If preoperative bony operative day 1 with protocol
stability verified assistive device  • Antibiotics × 24 h
 • Toe touch weight bearing  • Daily physical or drains removed
   – If bony pelvis unstable therapy/occupational
preoperatively therapy for gait
   – If bony instability training, ROM, stairs
recognized  • Posterior hip
intraoperatively precautions
   – Advance weight    – For 3 months post
bearing at 8 weeks operatively
   – Limit flexion to 90°
   – Avoid internal
rotation beyond
neutral
   – Avoid adduction
past neutral
14  Acetabular and Femoral Neck Fracture Nonunion and Malunion
177
178 R. C. Jacobs et al.

Case Example 2 sule before arborizing within the periosteum of

A 23 year old male involved in a motor vehicle the superior femoral neck [54].
accident presents with right hip dislocation and Femoral neck fractures are intracapsular and
comminuted posterior wall acetabular fracture lack a periosteal blood supply thereby increasing
with a nondisplaced transverse component. His the risk of nonunion even after stabilization. This
hip was reduced in the emergency department challenging complication occurs even more fre-
under conscious sedation within 7  h of injury quently than malunion [49].
(after transfer from outside hospital where staff The morphology of the fracture also plays a
were unable to reduce his hip). His sciatic nerve significant role in the development of a nonunion.
function was preserved pre and post reduction In young patients the high energy mechanism can
(Figs. 14.2a–e). generate fracture lines that tend to be more verti-
cally oriented [50] and classified as Pauwels’
type III (above 50°) [55]. The shearing forces
14.2 Femoral Neck Fractures seen across the fracture site predispose to varus
angulation and nonunion rather than healing
14.2.1 Introduction under compression [56]. Since the early charac-
terizations of femoral neck fractures by Pauwels
Femoral neck nonunion is the most common [55], the Garden classification has become com-
complication following surgical fixation of a dis- monly used and relies on the displacement of the
placed femoral neck fracture with recent studies femoral head relative to the neck [57]. Garden
reporting rates of 10–30% [47–49]. When com- stages III and IV are considered displaced and are
bined with avascular necrosis of the femoral at higher risk for nonunion after fixation than
head, these two complications affect up to stages I and II [57].
20–50% of patients [47–49]. The recently published “fracture fixation in
Femoral neck fractures have a bimodal distri- the operative management of hip fractures”
bution occurring primarily due to high-energy (FAITH) trial compared the effect of using a slid-
mechanisms in the young population and lower ing hip screw against cannulated screws for fixa-
energy mechanisms in the elderly cohort [47, tion of femoral neck fractures in the elderly
50, 51]. However, they are uncommon in population [58]. It did not find a difference in the
patients younger than age 50, encompassing nonunion rate between the different groups based
only 3% of total hip fractures [51]. In contrast, on the Garden or Pauwels’ classifications (though
their incidence rises substantially in the elderly, it was not specifically powered to identify this
with 27.7 and 63.3 per 1000 patients for men parameter). It also did not find a difference in
and women, respectively [52]. They make up reoperation rate between fixation methods [58].
approximately half of the proximal femur frac-
tures in the geriatric population after fall from
standing height [51]. 14.2.2 Definition and Diagnosis
Displaced femoral neck fractures are associ-
ated with significant morbidity in the young The absence of obvious radiographic union and a
patient cohort as they most commonly occur in patient with ongoing pain and limp for several
the setting of a high energy mechanism [47, 53]. months after operative fixation should prompt
In these cases, there is often significant damage the surgeon to have a high suspicion for femoral
to the proximal femoral soft tissues and perios- neck nonunion. The patient with progressive
teum. The neck area is a watershed for blood sup- hardware failure on sequential radiographs, late
ply where the main contribution from the medial fracture migration or femoral neck shortening
femoral circumflex artery ascends posteriorly should also be evaluated for nonunion [59]. The
within the quadratus femoris. It stays ventral to differential diagnosis should also include mal-
the piriformis tendon and penetrates the hip cap- union, delayed union with inadequate fixation,
14  Acetabular and Femoral Neck Fracture Nonunion and Malunion 179

a b

c d

Fig. 14.2 (a) Obturator oblique view demonstrating the ing concentric reduction. (d) AP pelvis radiograph 5 years
nondisplaced transverse fracture (red arrow). There are later demonstrates complete joint space loss of the right
multiple posterior wall fragments. The largest measures hip with intact hardware. No evidence of hardware failure
approximately 35 × 35 mm (white arrow). (b) A Kocher- or displacement of the transverse posterior wall fractures
Langenbeck approach was used to treat the acetabular was noted. There was sufficient retained posterior wall
fracture. There was cartilage loss on the femoral head side and no hardware expected within the area of expected
and several non-viable pieces of comminuted posterior acetabular reaming, therefore a CT scan was deferred. (e)
wall bone and cartilage were removed. Retroacetabular AP pelvis radiograph 4  months after THA.  Good bone
congruence was obtained under direct visualization and stock was noted intraoperatively and no hardware was
intraoperative fluoroscopy demonstrated a near anatomic encountered with acetabular reaming. Multiple acetabu-
reduction. A post-operative CT was taken demonstrating lar screws were placed and excellent purchase was noted.
5 mm of gapping at the fracture site related to the bone The patient has returned to work as a laborer and has hip
loss but without step-off. (c) AP pelvis radiograph show- range of motion equal to the uninjured side
180 R. C. Jacobs et al.

and infection. Ultimately, the diagnosis of non- (ORIF), data regarding the rate of femoral neck
union is multifactorial and takes into account the nonunion in the elderly are more challenging to
ongoing clinical findings, physical examination, interpret than in the younger cohort.
and radiographic data.
The definition of a femoral neck nonunion 14.2.3.2 Young Patients
can be challenging, in part due to the lack of con- In a recent meta-analysis, patients younger than
sensus regarding imaging findings, time at which age 50 had a nonunion rate of 8.9% after ORIF
nonunion is declared and location of the fracture [47]. It does not appear to be higher if surgery is
[17]. In 2013 the Radiographic Union Score for delayed more than 12 h (or even as many as 48 h)
Hip (RUSH) was published as a validated scor- [66], although there are conflicting reports in a
ing checklist system that for predicting radio- number of studies [47]. Displaced fractures at
graphic hip fracture union [60–62]. It has shown presentation are more likely to go on to nonunion
improved intra- and interobserver reliability in after ORIF (compared to nondisplaced fractures)
accurately predicting union [62] and was recently with rates between 6 and 33% [47, 67]. Femoral
used on a cohort of patients from the FAITH trial neck fractures fixed in varus angulation or those
where it was able to accurately predict radio- fixed with increasing fracture displacement are
graphic nonunion with 100% specificity and more likely to fail to unite compared to those
positive predictive values for a specific threshold with anatomical reductions [66]. This is of par-
scoring level [63]. ticular importance in the young population as
Finally, computed tomography can be used to these fractures most often present with signifi-
help diagnose nonunions but can have limited cant posterior and inferior comminution (80%)
specificity (62%) even with 100% sensitivity [64]. and vertically oriented fracture lines in excess of
60° [50]. They are shortened and externally
rotated with varus coronal alignment, and apex
14.2.3 Incidence of Femoral Neck anterior axial fracture orientation [50]—precisely
Nonunion the orientation associated with increased rates of
nonunion [66]. Regardless of open or closed
14.2.3.1 Elderly Patients reduction and the treatment method employed,
In the physiologically elderly population, dis- better union rates are achieved after an anatomic
placed femoral neck fractures (Garden III/IV) are reduction [68].
usually treated with some form of arthroplasty
whereas nondisplaced fractures (Garden I/II) are
typically treated with cannulated hip screws or a 14.2.4 Management Principles:
sliding hip screw construct [58]. The definition of Non-operative Treatment
“elderly” is vague and is intentionally not defined
here as a 45 year old with end stage renal disease The work-up of any suspected nonunion begins
on dialysis may receive a hemiarthoplasty and a with the history and physical exam. A patient
healthy, active 60 year old may undergo ORIF for with a femoral neck nonunion will often present
the same displaced femoral neck fracture. with ongoing deep groin pain and difficulty
Recent literature has suggested also that the ambulating without an assistive device [59, 69].
nonunion rate in the elderly may vary according They will also often fail to progress with physical
to the treatment methods with a 19% rate for can- therapy and can have difficulty weaning from
nulated screws and an 8% for a fixed angle device narcotic medications. A cause for the nonunion
[65], though this was not supported by the FAITH can likely be related to patient or surgeon-­
trial with a 6% nonunion rate for both devices controlled factors, however infection and sys-
[58]. Since a significant portion of the fractures temic causes should be considered.
have been treated by methods (e.g., arthroplasty) Infection should be ruled out early during the
other than open reduction internal fixation work-up as discussed in Sect. 14.1.7.
14  Acetabular and Femoral Neck Fracture Nonunion and Malunion 181

Smoking cessation and discontinuation of are approximately 7% with females, patients

anti-inflammatory medications should be encour- treated for acute fracture or nonunion, and
aged as nicotine and NSAIDs have been associ- patients older than 70 being more likely to dislo-
ated with increased rates of nonunion, revision cate than patients receiving THA for osteoarthri-
surgery, and decreased patient outcomes [38, 53]. tis [73].
Diabetes is a common and potentially modifi- Total hip arthroplasty has been associated
able risk factor and is associated with increased with higher rates of dislocation than hemiarthro-
risk of infection, as well as delayed fracture heal- plasty after femoral neck fracture but provides a
ing and nonunion [70]. In the absence of obvi- more durable long-term solution with lower over-
ously modifiable risk factors referral to an all reoperation rate and better functional out-
endocrine clinic may be of significant benefit. As comes [74].
discussed in Sect. 14.1.7, evaluation of the other Removal of the femoral hardware is best
metabolic components of nonunion can be of sig- addressed in a step-wise fashion to prevent
nificant value in non-operative management. unnecessary complications. This process begins
Radiographs may not clearly demonstrate a with a review of the previous operative report(s),
nonunion of the femoral neck but can be used to knowledge of the previous implant system, and
easily determine angulation of the femoral neck appropriate removal tools. A careful review of
and hardware failure. Other radiographic factors imaging is also important to confirm the diagno-
associated with poor outcomes in these patients sis with radiographs and CT as needed. However,
include varus angulation of the fracture and cal- a nonunion should be suspected from the clinical
car comminution [71]. Computed tomographic history, absence of clear bony union on AP and
imaging can demonstrate progressive failure of lateral radiographs, and progressive hardware
hardware or sclerosis at the level of the previous failure [59]. It is also important to radiographi-
fracture with variable amounts of femoral head cally examine the integrity of the greater trochan-
avascular necrosis [59] (see Case Example 3). ter and clinically evaluate the function of the hip
Unlike long-bone nonunions, treatment abductors.
options for a femoral neck nonunion are more
limited. The blood supply to the femoral head is Conversion to Total Hip Arthroplasty
retrograde and the nonunion site is intra-articular Abductor damage is more important in the femo-
with synovial fluid disrupting bone graft healing. ral neck nonunion patient initially treated with a
The femoral neck is also difficult to address using cephalomedullary nail (CMN) than one treated
conventional techniques used for long-bone non- with a sliding hip screw or cannulated screws.
unions due to limited bone on either side of the The starting point for the CMN is frequently a
nonunion inhibiting stable fixation. trochanteric entry location and involves the cre-
ation of a 15 mm hole through the insertion of the
gluteus medius and greater trochanter. Patients
14.2.5 Management Principles: with previous CMN and femoral neck nonunion
Operative Treatment may require some degree of abductor repair at the
time of revision surgery. In addition to hip abduc-
14.2.5.1 Elderly Patient tor damage, the entry reamer creates a stress riser
The decision making regarding operative versus in the greater trochanter increasing the risk of its
non-operative treatment of a geriatric femoral fracture during revision surgery.
neck nonunion is simplified due to the superior Most implants used to treat the initial femoral
results that can be achieved with hip arthroplasty neck fracture are placed through a laterally based
relative to ORIF [72]. Generally, older patients incision. Therefore, to readily access this hard-
with nonunion can expect good long-term out- ware and allow for extensile visualization to the
comes when treated with total hip arthroplasty proximal femur, a posterior approach to the hip is
(THA). Dislocation rates at 25  years follow-up preferred. Following the surgical approach, the
182 R. C. Jacobs et al.

hip should be dislocated then reduced with the (HbA1c of 8.1), hypothyroidism, and hyperten-
hardware left in situ. If the proximal femoral sion (Figs. 14.3a–e).
hardware is removed before the dislocation, then
an iatrogenic fracture may occur through the 14.2.5.2 Young Patient
newly exposed screw hole(s). After the hardware The evaluation of a femoral neck nonunion is more
has been removed, prophylactic cabling of the complicated in the young patient compared to the
proximal femoral shaft can be performed (if indi- elderly, as joint preservation in the former remains
cated). The proximal femur is then re-dislocated the priority. Though the upper limit of when
in preparation for the femoral neck cut. patients are considered as “young” continues to
Occasionally a patient will have femoral hard- decrease as long-term arthroplasty options
ware cut out and an associated acetabular defect. improve, most do not consider a patient for an
Cemented acetabular components can still be arthroplasty over a salvage procedure under the
used in primary and revision arthroplasty with 40- 50-year-old age range [69]. This was recently
good long-term outcomes [22]. However, these supported by Swart et al. who found it more cost
have been increasingly replaced by bone-stock effective to perform a THA than an ORIF for a
preserving, noncemented metal backed acetabu- patient with a femoral neck fracture between the
lar components with improving outcome superi- ages of 45–65 [77]. Those with increased comor-
ority since the mid-1990s [17]. The noncemented bidities and increased risk of fixation failure would
acetabular components have excellent track also benefit from THA at a younger ages com-
records with higher retention rates in primary pared with age adjusted healthy patients [77]. Joint
THA than cemented acetabular components at preservation seeks to primarily address the lack of
10-year follow up (94% vs. 85%) [75]. a proper biomechanical loading environment
The author’s preferred choice for the femoral through reorientation of loading vectors [69].
component is a cemented stem, which is backed
by good results with cementation of the femoral Mechanical Environment and Results
component in primary hip arthroplasty and in the of Valgus Intertrochanteric Osteotomy
setting of femoral neck fracture [76]. The The shearing forces produced with ambulation
cemented femoral stem also has the benefit of on a vertically oriented femoral neck fracture
increased flexibility to adjust femoral anteversion are believed to be one of the primary causes of
compared to press fit systems. Bearing surface femoral neck nonunion. The inability to control
selection for the conversion THA is a controver- these forces biomechanically with current fixa-
sial topic and should be evaluated by the surgeon tion methods results in hardware failures which
on a case by case basis. occur more often in the setting of a high
The decision to convert a femoral neck non- Pauwels’ angle fracture [65]. A valgus produc-
union to a THA or hemiarthroplasty is multifac- ing intertrochanteric osteotomy as originally
torial. Patients with a femoral neck nonunion described by Pauwels and subsequently modi-
have additional deconditioning due to their fied by Muller is selected and functions by con-
inability to return to preambulatory function. version of shearing into compression forces to
Although no studies exist directly comparing promote bony union [55, 56].
hemiarthroplasty with THA for the treatment of a Retention of the fibrous tissue and compres-
femoral neck nonunion, it is reasonable to use the sion through the nonunion can achieve union and
acute geriatric femoral neck fracture population is used effectively in other locations of the body
instead. [78]. The valgus intertrochanteric osteotomy has
reliable outcomes without removal of the inter-
Case Example 3 vening fibrous tissue when treated appropriately
A 70 year old male fell from ground level onto with extensive preoperative planning and a fixed
his right hip and sustained a subcapital femoral angle device such as a blade plate [79]. These
neck fracture. He ambulates independently and osteotomies have success rates approaching 90%,
his medical history is significant for diabetes but are technically demanding [80].
14  Acetabular and Femoral Neck Fracture Nonunion and Malunion 183

a b

c d

Fig. 14.3 (a) AP pelvis radiograph demonstrating a right varus femoral neck nonunion after removal of the cannu-
subcapital femoral neck fracture. The patient was subse- lated hip screws. Treatment with total hip arthroplasty was
quently treated with three partially threaded 7.3 mm can- recommended. During surgery, the acetabulum was initially
nulated screws in an inverted triangle configuration. (b) AP reamed for a 56 mm diameter multihole uncemented com-
intraoperative fluoroscopic image demonstrating final hard- ponent and secured with 4 acetabular screws. The acetabular
ware placement. The patient eventually returned to inde- bone stock was osteoporotic and the screws had poor pur-
pendent ambulation with a cane. However, he had continued chase. During subsequent trialing of the femoral neck
right hip pain, which was attributed to trochanteric bursitis length, the metal acetabular component displaced and was
from screw prominence. Sixteen months later the patient removed with subsequent revision to a cemented all-poly-
received a CT scan for evaluation of abdominal pain that ethylene acetabular component. This intraoperative chal-
noted an “incompletely healed femoral neck fracture”. (c) lenge might have been anticipated by considering that the
Coronal CT image 16 months after initial fixation. A verti- patient had been using an assistive device to unload his pain-
cally oriented nonunion with sclerotic margins is present. ful right hip. To some degree, this likely produced a func-
The patient was taken to surgery 1 month later for removal tional disuse osteopenia of the subchondral bone about the
of his “symptomatic hardware” in the setting of presumed acetabulum. The patient made a full recovery and three-year
trochanteric bursitis. The treating physician was unaware of follow-up radiographs were taken in clinic without change
the CT scan demonstrating nonunion. A metabolic work-up in femoral or acetabular component location. The patient
was not obtained prior to his second right hip surgery. The has pain free range of motion, ambulates without assistive
patient followed up in clinic 1  week later where he was device and has returned to all activities. (e) AP radiograph
noted to have significant displacement of his femoral neck demonstrating cemented acetabular and femoral compo-
nonunion. (d) AP radiograph demonstrating a displaced nents with restoration of offset and leg length
184 R. C. Jacobs et al.

to reorient the femoral neck nonunion angle while

e
appreciating how this selection will affect osteot-
omy stability and limb length [81]. An appropri-
ately selected fixed angle device is then templated
and applied to allow restoration of a more normal
femoral neck shaft angle while gaining compres-
sion across the osteotomy site [56, 79, 81].

Results of Total Hip Arthroplasty

in the Young Patient
Although no epidemiologic study of young
patients with a femoral neck nonunion exists,
most patients are presumed to be treated with val-
gus intertrochanteric osteotomy. Native articular
Fig. 14.3 (continued) cartilage and an altered gait are generally consid-
ered preferable to the relative activity restrictions
and higher risks of future revision surgery accom-
The advantages of more normal hip joint bio- panying THA. This may change as THA becomes
mechanics through restoration of femoral offset a more cost-effective option with immediate
and leg length must be weighed against the ben- weight bearing as both revision and primary
efits of preserving the native femoral and acetab- results continue to improve [77].
ular articulation. Femoral neck nonunion patients Young patients requiring conversion to THA
typically exhibit abnormal hip biomechanics in resemble the younger population with AVN
addition to pain due to significant amounts of requiring primary THA. Should THA be selected,
femoral neck shortening [69]. However, while a management of pre-existing femoral hardware
successful valgus intertrochanteric osteotomy should be addressed similar to that previously
can eliminate the painful nonunion and poten- described for elderly patients. The use of prophy-
tially increase leg length, it cannot improve fem- lactic cerclage wiring should be considered in the
oral offset and patients are left with an altered setting of a press fit stem in this situation given
gait [69]. A successful valgus intertrochanteric the hoop stresses that will be imparted during the
osteotomy is generally accepted as “in most seating of the final implant. Cemented femoral
cases, moderately suboptimal hip biomechanics fixation is used frequently in Europe for primary
are accepted as the trade-off to gain good bone arthroplasty with an excellent track record [75].
apposition in a stable position and fracture union” It is less frequently used in the USA for primary
[69]. Subsequent conversion to THA after a joint arthroplasty, but could be considered in the revi-
preserving osteotomy is more challenging (due to sion setting given the added benefits of antibiotic
the altered proximal femoral anatomy and in situ delivery, improved anteversion control, and
hardware) though this should not preclude an improved management of the stress risers from
attempt at a joint salvage procedure in a young previous fixation efforts.
patient.
The technique for a valgus intertrochanteric
osteotomy is classically described by Muller [56] References
and Marti [79] and more recently updated by
Mayo [81]. It begins with thorough preoperative 1. Letournel E.  Acetabulum fractures: classification and
management. Clin Orthop Relat Res. 1980;151:81–106.
planning beginning with comparing the injured 2. Matta JM.  Fractures of the acetabulum: accuracy of
and uninjured sides in both the coronal and sagit- reduction and clinical results in patients managed
tal planes to quantify the deformity [81]. Based on operatively within three weeks after the injury. J Bone
the initial measurements an osteotomy is planned Joint Surg Am. 1996;78:1632–45.
14  Acetabular and Femoral Neck Fracture Nonunion and Malunion 185

3. Mayo KA.  Open reduction and internal fixation of nonunion of the posterior wall. J Orthop Trauma.
fractures of the acetabulum. Results in 163 fractures. 2014;28:377–83.
Clin Orthop Relat Res. 1994;305:31–7. 21. Berry DJ, Halasy M.  Uncemented acetabular com-
4. Mears DC, Velyvis JH, Chang CP. Displaced acetabu- ponents for arthritis after acetabular fracture. Clin
lar fractures managed operatively: indicators of out- Orthop Relat Res. 2002;405:164–7.
come. Clin Orthop Relat Res. 2003;407:173–86. 22. Schreurs BW, Zengerink M, Welten ML, et al. Bone
5. Mohanty K, Taha W, Powell JN. Non-union of acetab- impaction grafting and a cemented cup after acetabu-
ular fractures. Injury. 2004;35:787–90. lar fracture at 3-18 years. Clin Orthop Relat Res.
6. Briffa N, Pearce R, Hill AM, et al. Outcomes of ace- 2005;437:145–51.
tabular fracture fixation with ten years’ follow-up. J 23. Sen RK, Veerappa LA.  Long-term outcome of con-
Bone Joint Surg Br. 2011;93:229–36. servatively managed displaced acetabular fractures. J
7. Hull JB, Raza SA, Stockley I, et al. Surgical manage- Trauma. 2009;67:155–9.
ment of fractures of the acetabulum: the Sheffield 24. Mcnamara AR, Boudreau JA, Moed BR. Nonoperative
experience 1976-1994. Injury. 1997;28:35–40. treatment of posterior wall acetabular fractures after
8. Matta JM. Operative treatment of acetabular fractures dynamic stress examination under anesthesia: revis-
through the ilioinguinal approach. A 10-year perspec- ited. J Orthop Trauma. 2015;29:359–64.
tive. Clin Orthop Relat Res. 1994;305:10–9. 25. Clarke-Jenssen J, Wikeroy AK, Roise O, et al. Long-­
9. Moed BR, Willsoncarr SE, Watson JT.  Results term survival of the native hip after a minimally dis-
of operative treatment of fractures of the poste- placed, nonoperatively treated acetabular fracture. J
rior wall of the acetabulum. J Bone Joint Surg Am. Bone Joint Surg Am. 2016;98:1392–9.
2002;84-A:752–8. 26. Carroll EA, Huber FG, Goldman AT, et al. Treatment
10. Murphy D, Kaliszer M, Rice J, et al. Outcome after of acetabular fractures in an older population. J
acetabular fracture. Prognostic factors and their inter-­ Orthop Trauma. 2010;24:637–44.
relationships. Injury. 2003;34:512–7. 27. Mayo KA, Letournel E, Matta JM, et al. Surgical revi-
11. Saterbak AM, Marsh JL, Nepola JV, et  al. Clinical sion of malreduced acetabular fractures. Clin Orthop
failure after posterior wall acetabular fractures: the Relat Res. 1994;305:47–52.
influence of initial fracture patterns. J Orthop Trauma. 28. Bellabarba C, Berger RA, Bentley CD, et  al.

2000;14:230–7. Cementless acetabular reconstruction after
12. Starr AJ, Watson JT, Reinert CM, et al. Complications acetabular fracture. J Bone Joint Surg Am.
following the “T extensile” approach: a modified 2001;83-A:868–76.
extensile approach for acetabular fracture surgery-­ 29. Makridis KG, Obakponovwe O, Bobak P, et  al.

report of forty-three patients. J Orthop Trauma. Total hip arthroplasty after acetabular fracture: inci-
2002;16:535–42. dence of complications, reoperation rates and func-
13. Stockle U, Hoffmann R, Sudkamp NP, et al. Treatment tional outcomes: evidence today. J Arthroplast.
of complex acetabular fractures through a modified 2014;29:1983–90.
extended iliofemoral approach. J Orthop Trauma. 30. Weber M, Berry DJ, Harmsen WS. Total hip arthro-
2002;16:220–30. plasty after operative treatment of an acetabular frac-
14. Wright R, Barrett K, Christie MJ, et  al. Acetabular ture. J Bone Joint Surg Am. 1998;80:1295–305.
fractures: long-term follow-up of open reduction and 31.
Lizaur-Utrilla A, Sanz-Reig J, Serna-Berna
internal fixation. J Orthop Trauma. 1994;8:397–403. R. Cementless acetabular reconstruction after acetab-
15. Judet R, Judet J, Letournel E. Fractures of the acetab- ular fracture: a prospective, matched-cohort study. J
ulum: classification and surgical approaches for open Trauma Acute Care Surg. 2012;73:232–8.
reduction. Preliminary report. J Bone Joint Surg Am. 32. Salama W, Ditto P, Mousa S, et al. Cementless total
1964;46:1615–46. hip arthroplasty in the treatment after acetabular frac-
16. Johnson EE, Matta JM, Mast JW, et al. Delayed recon- tures. Eur J Orthop Surg Traumatol. 2017;28:59.
struction of acetabular fractures 21-120 days follow- 33. Sermon A, Broos P, Vanderschot P.  Total hip

ing injury. Clin Orthop Relat Res. 1994;305:20–30. replacement for acetabular fractures. Results in 121
17. Morshed S. Current options for determining fracture patients operated between 1983 and 2003. Injury.
union. Adv Med. 2014;2014:708574. 2008;39:914–21.
18. Giannoudis PV, Grotz MR, Papakostidis C, et  al.
34. Von Roth P, Abdel MP, Harmsen WS, et  al. Total
Operative treatment of displaced fractures of the hip arthroplasty after operatively treated acetabular
acetabulum. A meta-analysis. J Bone Joint Surg Br. fracture: a concise follow-up, at a mean of twenty
2005;87:2–9. years, of a previous report. J Bone Joint Surg Am.
19. Tannast M, Najibi S, Matta JM. Two to twenty-year 2015;97:288–91.
survivorship of the hip in 810 patients with opera- 35. Morison Z, Moojen DJ, Nauth A, et  al. Total hip
tively treated acetabular fractures. J Bone Joint Surg arthroplasty after acetabular fracture is associated
Am. 2012;94:1559–67. with lower survivorship and more complications. Clin
20. Sagi HC, Jordan CJ, Barei DP, et  al. Indomethacin Orthop Relat Res. 2016;474:392–8.
prophylaxis for heterotopic ossification after 36. O’toole RV, Hui E, Chandra A, et al. How often does
acetabular fracture surgery increases the risk for open reduction and internal fixation of geriatric ace-
186 R. C. Jacobs et al.

tabular fractures lead to hip arthroplasty? J Orthop 52. Egol KA, Koval KJ, Zuckerman JD.  Handbook of
Trauma. 2014;28:148–53. fractures. Philadelphia: Wolters Kluwer Health; 2015.
37. Brinker MR, O’connor DP, Monla YT, et al. Metabolic 53. Haidukewych GJ, Rothwell WS, Jacofsky DJ, et  al.
and endocrine abnormalities in patients with non- Operative treatment of femoral neck fractures in
unions. J Orthop Trauma. 2007;21:557–70. patients between the ages of fifteen and fifty years. J
38. Lindstrom D, Sadr Azodi O, Wladis A, et al. Effects Bone Joint Surg Am. 2004;86-A:1711–6.
of a perioperative smoking cessation intervention on 54. Seeley MA, Georgiadis AG, Sankar WN. Hip vascu-
postoperative complications: a randomized trial. Ann larity: a review of the anatomy and clinical implica-
Surg. 2008;248:739–45. tions. J Am Acad Orthop Surg. 2016;24:515–26.
39. Paprosky WG, O’rourke M, Sporer SM.  The treat- 55. Pauwels F. Der Schenkelhalsbruch. Ein mechaizisches
ment of acetabular bone defects with an associ- problem: Grundagen des Heilungsvorganges Prognose
ated pelvic discontinuity. Clin Orthop Relat Res. und kausale Therapie. Beilagheft Z. Orthop. Chir. 63
2005;441:216–20. Stuttgart, Enke. 1935.
40. Paprosky WG, Perona PG, Lawrence JM. Acetabular 56. Muller M.  Intertrochanteric osteotomy: indications,
defect classification and surgical reconstruction in preoperative planning, technique. In: Schatzker J,
revision arthroplasty. A 6-year follow-up evaluation. editor. The trochanteric osteotomy. Berlin: Springer;
J Arthroplast. 1994;9:33–44. 1984.
41. Solomon LB, Studer P, Abrahams JM, et  al. Does 57. Garden R. Low-angle fixation in fractures of the fem-
cup-cage reconstruction with oversized cups provide oral neck. J Bone Joint Surg Br. 1961;48-B:647–63.
initial stability in THA for osteoporotic acetabular 58. Fixation Using Alternative Implants for the Treatment
fractures? Clin Orthop Relat Res. 2015;473:3811–9. of Hip Fractures Investigators. Fracture fixation in
42. Sternheim A, Backstein D, Kuzyk PR, et  al. Porous the operative management of hip fractures (FAITH):
metal revision shells for management of contained an international, multicentre, randomised controlled
acetabular bone defects at a mean follow-up of six trial. Lancet. 2017;389:1519–27.
years: a comparison between up to 50% bleeding host 59. Stockton DJ, Lefaivre KA, Deakin DE, et  al.

bone contact and more than 50% contact. J Bone Joint Incidence, magnitude, and predictors of shortening
Surg Br. 2012;94:158–62. in young femoral neck fractures. J Orthop Trauma.
43. Veerappa LA, Tripathy SK, Sen RK. Management of 2015;29:e293–8.
neglected acetabular fractures. Eur J Trauma Emerg 60. Bhandari M, Chiavaras M, Ayeni O, et al. Assessment
Surg. 2015;41:343–8. of radiographic fracture healing in patients with
44. Mcgrory AC, Replogle L, Endrizzi D.  Ultrasound
operatively treated femoral neck fractures. J Orthop
gel minimizes third body debris with partial hard- Trauma. 2013;27:e213–9.
ware removal in joint arthroplasty. Arthroplast Today. 61. Bhandari M, Chiavaras MM, Parasu N, et  al.

2017;3:29–31. Radiographic union score for hip substantially
45. Paprosky WG, O’Rourke M, Sporer SM.  The treat- improves agreement between surgeons and radiolo-
ment of acetabular bone defects with an associ- gists. BMC Musculoskelet Disord. 2013;14:70.
ated pelvic discontinuity. Clin Orthop Relat Res. 62. Chiavaras MM, Bains S, Choudur H, et  al. The

2005;441:216–20. Radiographic Union Score for Hip (RUSH): the use of
46. D’Antonio JA. Periprosthetic bone loss of the acetab- a checklist to evaluate hip fracture healing improves
ulum. Classification and management. Orthop Clin agreement between radiologists and orthopedic sur-
North Am. 1992;23(2):279–90. geons. Skelet Radiol. 2013;42:1079–88.
47. Damany DS, Parker MJ, Chojnowski A. Complications 63. Frank T, Osterhoff G, Sprague S, et  al. The

after intracapsular hip fractures in young adults. A Radiographic Union Score for Hip (RUSH) identifies
meta-analysis of 18 published studies involving 564 radiographic nonunion of femoral neck fractures. Clin
fractures. Injury. 2005;36:131–41. Orthop Relat Res. 2016;474:1396–404.
48.
Slobogean GP, Sprague SA, Scott T, et  al. 64. Bhattacharyya T, Bouchard KA, Phadke A, et  al.

Complications following young femoral neck frac- The accuracy of computed tomography for the diag-
tures. Injury. 2015;46:484–91. nosis of tibial nonunion. J Bone Joint Surg Am.
49. Slobogean GP, Stockton DJ, Zeng B, et  al. Femoral 2006;88:692–7.
neck fractures in adults treated with internal fixation: 65. Liporace F, Gaines R, Collinge C, et al. Results of inter-
a prospective multicenter Chinese cohort. J Am Acad nal fixation of Pauwels type-3 vertical femoral neck
Orthop Surg. 2017;25:297–303. fractures. J Bone Joint Surg Am. 2008;90:1654–9.
50. Collinge CA, Mir H, Reddix R.  Fracture morphol- 66. Upadhyay A, Jain P, Mishra P, et  al. Delayed inter-
ogy of high shear angle “vertical” femoral neck nal fixation of fractures of the neck of the femur in
fractures in young adult patients. J Orthop Trauma. young adults. A prospective, randomised study com-
2014;28:270–5. paring closed and open reduction. J Bone Joint Surg
51. Thorngren KG, Hommel A, Norrman PO, et  al.
Br. 2004;86:1035–40.
Epidemiology of femoral neck fractures. Injury. 67. Lu-Yao GL, Keller RB, Littenberg B, et al. Outcomes
2002;33(Suppl 3):C1–7. after displaced fractures of the femoral neck. A meta-­
14  Acetabular and Femoral Neck Fracture Nonunion and Malunion 187

analysis of one hundred and six published reports. J 75. Hailer NP, Garellick G, Karrholm J.  Uncemented

Bone Joint Surg Am. 1994;76:15–25. and cemented primary total hip arthroplasty in the
68. Swiontkowski MF. Intracapsular fractures of the hip. Swedish Hip Arthroplasty Register. Acta Orthop.
J Bone Joint Surg Am. 1994;76:129–38. 2010;81:34–41.
69. Haidukewych GJ, Berry DJ.  Salvage of failed treat- 76. Parker MI, Pryor G, Gurusamy K.  Cemented ver-
ment of hip fractures. J Am Acad Orthop Surg. sus uncemented hemiarthroplasty for intracapsular
2005;13:101–9. hip fractures: a randomised controlled trial in 400
70. Beam HA, Parsons JR, Lin SS. The effects of blood patients. J Bone Joint Surg Br. 2010;92:116–22.
glucose control upon fracture healing in the BB 77. Swart E, Roulette P, Leas D, et  al. ORIF or arthro-
Wistar rat with diabetes mellitus. J Orthop Res. plasty for displaced femoral neck fractures in patients
2002;20:1210–6. younger than 65 years old: an economic decision
71. Alho A, Benterud JG, Ronningen H, et al. Prediction analysis. J Bone Joint Surg Am. 2017;99:65–75.
of disturbed healing in femoral neck fracture. 78.
Rodriguez-Merchan EC, Gomez-Castresana
Radiographic analysis of 149 cases. Acta Orthop F.  Internal fixation of nonunions. Clin Orthop Relat
Scand. 1992;63:639–44. Res. 2004;419:13–20.
72. Blomfeldt R, Tornkvist H, Ponzer S, et al. Comparison 79.
Marti RK, Schuller HM, Raaymakers
of internal fixation with total hip replacement for EL.  Intertrochanteric osteotomy for non-union
displaced femoral neck fractures. Randomized, con- of the femoral neck. J Bone Joint Surg Br.
trolled trial performed at four years. J Bone Joint Surg 1989;71:782–7.
Am. 2005;87:1680–8. 80. Magu NK, Singla R, Rohilla R, et  al. Modified

73. Berry DJ, Von Knoch M, Schleck CD, et  al. The Pauwels’ intertrochanteric osteotomy in the man-
cumulative long-term risk of dislocation after primary agement of nonunion of a femoral neck fracture
Charnley total hip arthroplasty. J Bone Joint Surg Am. following failed osteosynthesis. Bone Joint J.
2004;86-A:9–14. 2014;96-B:1198–201.
74. Burgers PT, Van Geene AR, Van Den Bekerom MP, 81. Mayo K, Kuldjanov D.  Generic preoperative plan-
et  al. Total hip arthroplasty versus hemiarthroplasty ning for proximal femoral osteotomy in the treatment
for displaced femoral neck fractures in the healthy of nonunion of the femoral neck. J Orthop Trauma.
elderly: a meta-analysis and systematic review of ran- 2018;32(Suppl 1):S46–54.
domized trials. Int Orthop. 2012;36:1549–60.
 The Use of Hip Arthroscopy
in Trauma of the Hip 15
Alessandro Aprato, Federico Bertolo,
Alessandro Bistolfi, Luigi Sabatini,
and Alessandro Massè

Abstract arthroscopy such as fluid extravasation into the

Hip arthroscopy may be used to treat selected gluteal compartment, scrotal or perineal pres-
intra-articular lesions even in trauma cases. sure wounds, nerve injuries, iatrogenic carti-
Although most of the published studies are lage injury, and cardiac arrest resulting from
small case series, results are encouraging. On abdominal compartment syndrome are rare.
the other hand, there is consensus about the In this chapter we review the indications
importance of surgeon’s experience in hip for hip arthroscopy in trauma cases and the
arthroscopy and about the limitations of this current evidence for these arthroscopic
technique. Intra-articular injuries are not lim- techniques.
ited to hip dislocations only, but can be associ-
ated with femur head fractures, acetabular Keywords
fractures, and even soft tissue injuries not Hip arthroscopy · Loose bodies · Traumatic
associated with a fracture. During arthroscopic hip dislocation · Arthroscopic reduction · Hip
treatment of these affections care must be fractures
taken in mobilizing, translating, and reducing
fracture fragment(s), considering fluoroscopic
guidance and the use of chopstick technique
where indicated. Allowing early mobilization 15.1 Introduction
of hip and protected weight bearing as well as
performing interval postoperative radio- Hip arthroscopy permits a direct visualization of
graphic assessment is mandatory. hip articular surface (femoral head and acetabu-
Arthroscopic treatment of traumatic events lum) without the tissues disruption of the open
is conditioned to the amount of articular dam- surgery techniques [1] and has gained consider-
age suffered and to the time the hip has been able popularity in the past decade. Although at
dislocated before reduction. Complications present non-traumatic pathologies are the most
directly related to the performance of hip common indications for hip arthroscopy, several
traumatic intra-articular conditions are also
treated. Indications for arthroscopy in hip trauma
cases are acetabular fractures, hip dislocation,
A. Aprato (*) · F. Bertolo · A. Bistolfi · L. Sabatini · and femoral head fractures and their sequelae,
A. Massè
University of Turin, Turin, Italy although only selected cases may be treated with-
e-mail: [email protected] out concomitant open procedures.

© Springer Nature Switzerland AG 2019 189

L. Büchler, M. J.B. Keel (eds.), Fractures of the Hip, Fracture Management Joint by Joint,
https://doi.org/10.1007/978-3-030-18838-2_15
190 A. Aprato et al.

Initially only extraction of loose bodies or

small intra-articular fragments after hip fracture
dislocation and bullet extraction have been
described; with the advances in arthroscopic
techniques, reduction and fixation of femoral
head or posterior wall fractures have been
reported in literature. Furthermore labral suture,
chondral injuries fixation, and capsulorrhaphy in
traumatic hip dislocation sequelae have been
described. Finally, arthroscopic cam resection in
neck fracture sequelae is now a standard
treatment.
Standard arthroscopic principles have been
applied to facilitate visualization and navigation
within the hip joint for these traumatic cases
incorporating infusion pumps, specific hip por-
Fig. 15.1  Intra-operative image of a loose osteochondral
tals with multiple cannulas and leg traction. On
fragment in a right hip joint: view from the mid anterior
the other hand, the advantage of arthroscopic portal toward the fovea
techniques should always be balanced with the
possible complications: They include fluid
extravasation into the gluteal compartment; scro- fracture-­dislocation should be treated with open
tal or perineal pressure wounds; lateral femoral debridement. Even in simple hip dislocations,
cutaneous nerve injury; traction nerve palsies of traumatic arthritis is a common complication
the peroneal, pudendal, sciatic, and femoral (prevalence rate of 24%), probably because of
nerves; iatrogenic cartilage injury caused by unrecognized intra-articular loose bodies [3, 4].
instruments and cardiac arrest resulting from The prevalence rate rises as high as 54% when
abdominal compartment syndrome. Although there’s evidence of more complex injuries, such
these complications are described as rare, sur- as fracture-dislocations [5–7]. In these cases the
geon should be familiar with hip arthroscopy in increased rate of traumatic arthritis would be
non-traumatic patients in order to minimize them. attributed mainly to the femoral and/or acetabular
Hereby we described the most common fracture instead of the presence of loose bodies.
trauma related indications and their treatment Retained loose bodies can cause damage to
techniques. the articular surface through a third-body wear
mechanism, leading to premature degenerative
changes and chronic synovitis.
15.2 R
 emoval of Loose Bodies or It’s important to obtain standard radiographs
Foreign Objects after hip dislocation, including AP pelvis and CT
scans (not only axial scans but also sagittal and
Loose body removal is one of the primary indica- coronal scans), in order to evaluate the three-­
tions for hip arthroscopy (Fig. 15.1). During a dimensional nature of the osteochondral injury
traumatic event involving the hip joint such as hip and the degree of articular surface involvement.
dislocation or hip fracture-dislocation, loose bod- Sometimes it can be difficult to recognize
ies originate by the femoral head shearing against intra-articular loose bodies, especially if they con-
the acetabular lip. The incidence of loose body sist of cartilaginous tissue. Presence of
formation however is unknown [2]. intra-­
­ articular unrecognized loose bodies can
Epstein et al. first described the importance of cause an incomplete or non-concentric reduction.
removal of loose bodies. According to Epstein, Although non-concentric reduction and pres-
loose bodies were so common that all hip ence of osteochondral fragments in the weight-­
15  The Use of Hip Arthroscopy in Trauma of the Hip 191

bearing area of the acetabulum are absolute 15.3 Fixation of Posterior Wall
indications for removal of loose bodies, there is Fractures
less general consensus regarding the necessity of
loose bodies removal in concentric reductions, Arthroscopic-assisted percutaneous osteosynthe-
specially if loose bodies are located in or below sis has facilitated the surgeon’s ability to closely
the fovea [8]. observe the fracture site, helping in the reduction
According to authors’ personal experience, and to diagnose and treat associated chondral
loose bodies’ removal may be easily performed injuries. Although arthroscopic-assisted percuta-
in arthroscopy and may be performed either in neous osteosynthesis are well documented in
supine or in lateral decubitus. Authors’ per- tibia plateau fractures and ankle disorders, only
sonal choice is lateral position because floating small case series of acetabular fractures treat-
bodies usually fall in the fovea and are easily ment are reported. That said, several authors have
removed. described either arthroscopic removal of small
Hip arthroscopy can be useful to remove intra-­ fragment of posterior wall (Fig.  15.3) or
articular bullets too (Fig.  15.2). Singleton et  al. arthroscopic treatment for traumatic hip fracture-­
have recently proposed a safe and useful method dislocations [2, 10–14]. The first successful per-
to remove bullets from hip joint by using a cutaneous fixation of acetabular fracture was
threaded pin. Instead of risking further trauma to carried out by Gay et al. by using CT guidance
the articular surface by removing with osteo- [15]. Yamamoto et al. reported reduction and per-
tomes or using curettes, the bullet is engaged cutaneous fixation in patients with acetabular
end-on with a 3.2-mm threaded tipped guide pin fracture [12]; Yang et  al. reported arthroscopic
from the dynamic hip screw set, that is inserted guided percutaneous screw fixation of minimal
through the anterior portal. Then the pin is displaced acetabular fractures [13]. In these
advanced into the bullet under fluoroscopic guid- cases, percutaneous screw fixation of the anterior
ance and when is firmly seated is simply pulled column of the acetabulum was performed under
out through the anterior portal [9]. guidance of hip arthroscopy to enable direct

Fig. 15.2  X-rays showing a bullet inside the hip joint

192 A. Aprato et al.

a b

c d

Fig. 15.3 (a) AP-pelvis x-ray showing a posterior hip fragment of the posterior wall. (d) intra-operative view of
dislocation. (b) X-ray of the same patient after reduction. the fragment from the mid anterior portal
(c) CT scan of the same patient showing an intra-articular

visual confirmation of the quality of the reduc- 15.4 Fixation of Pipkin Fractures
tion and avoid any violation of the medial wall of
the acetabulum with the screws. Femoral head fractures are relatively uncommon
Recently Kim et  al. [14] have described two injuries and occur in 5–15% of traumatic hip dis-
cases of arthroscopic reduction and internal fixa- locations and are more common in posterior dis-
tion of acetabular fractures. In particular one of locations than anterior dislocations [4, 16–19].
these was a displaced posterior wall fracture of Pipkin classified these fractures according to the
the acetabulum: in this case hip arthroscopy was morphology of the fracture and their occurrence
performed with the affected limb in traction to in conjunction with femoral neck or acetabular
obtain a sufficient distraction of 10–12  mm. fractures [20]. Arthroscopically assisted treat-
Access was through an antero-lateral, anterior ment of Pipkin Type 1 fractures, caudal to the
and postero-lateral portal; after hematoma evacu- fovea, has been reported; Lansford et al. described
ation and detection of the bony fragment, they two cases of displaced Pipkin type 1 fractures,
reduced anatomically and temporarily fixed the caused both by posterior hip dislocation, treated
fragment with two K wires. Finally they used two with excision of the fragments and debriding of
4.0-mm-diameter cannulated screws to fix the the fracture bed [21]. Recently, Park et  al.
fragment under direct arthroscopic visualization. described some cases of displaced infra-foveal
On the other hand, the indications for Pipkin Type 1 fractures, treated 7 days after the
arthroscopically assisted percutaneous fixation of trauma with arthroscopically assisted percutane-
acetabular fractures are limited and this tech- ous fixation through temporary K-wires fixation
nique has to be performed only in cases with and then definitive 3.5-mm cortical screw fixa-
minimal and moderate displaced fractures. tion. They performed an accessory distal anterior
15  The Use of Hip Arthroscopy in Trauma of the Hip 193

portal and a T-shaped capsulotomy; they used fragment removal) if arthroscopic method
metallic screws instead of bio-absorbable screws fails
because the metallic screws are more easily visu- • Consider fluoroscopic templating technique to
alized on radiographic images and decrease the standardize pelvic position under hip
risk of implant breakage [22, 23]. distraction
Matsuda [11] recently reported a case of • Pay careful attention to safe portal placement
supra-foveal fracture (Pipkin type II) with dis- (may require several accessory portals), cap-
tally displaced osteochondral fracture fragment sulotomies, intra-articular fluid pressure, and
and no evidence of hip dislocation; once the frag- distraction amount and time in order to avoid
ment was identified through direct arthroscopic side effects like nerve injuries or fluid
view, it was translated toward the fracture site. extravasation
Using an additional anterior portal, the surgeon • Mobilize, translate, and reduce fracture
was able to use two thin guide pins in a chopstick fragment(s); consider use of chopstick tech-
manner to de-rotate the fragment and reduce the nique where indicated
fracture; then he used a cannulated Herbert screw • Consider arthroscopic fixation using radi-
to fixate the central portion of the fragment and a opaque screw(s) or pin(s) visible under inter-
mini-Herbert screw to fixate the proximal pole. mittent fluoroscopic guidance, instead of
According to the literature [4, 6, 11, 16, 17], bio-absorbable implants
surgical indications for hip arthroscopy in femo- • Consider removal of osteochondral bone not
ral head fractures are: (1) displaced, large femo- essential to weight bearing or structural integ-
ral head fracture configuration, (2) severely rity of fracture construct
limited range of motion and impingement signs • Confirm accurate reduction and stable fixation
following conservative treatment, and (3) femo- by arthroscopic and fluoroscopic dynamic
ral head fracture associated with intra-articular testing (such as anterior impingement test and
lesions, such as loose bodies, labral tears, or liga- Patrick test)
mentum teres injury. Possible contraindications • Allow early mobilization of hip and protected
to arthroscopic surgery for femoral head fractures weight bearing commensurate with assessed
include: (1) hip instability with recurrent disloca- fracture fixation.
tion following closed reduction and (2) acetabu- • Perform postoperative radiographic progres-
lar fractures with column fractures that can cause sive investigations, with special attention to
fluid extravasation during hip arthroscopy. If the joint space narrowing and/or hardware migra-
femoral head fractures can’t be reduced by tion/violation of hip joint [11]
arthroscopic methods, open reduction and inter-
nal fixation may be the most appropriate approach
to achieve anatomic femoral head contours [11]. 15.5 C
 apsular Re-tension After
Unfortunately the decision regarding whether Traumatic Instability
fragments should be internally fixed or simply
excised remains controversial [24]. Traumatic hip instability can be due to frank dis-
In conclusion the cornerstones for arthroscopic locations following major trauma, hip sub-­
reduction and internal fixation of femoral head luxation from more minor trauma, and
fractures are: microtrauma following repetitive impinging
movements [25].
• Perform accurate preoperative fracture Recognizing the various patterns of hip insta-
assessment bility after trauma is complicated, and therefore
• Perform accurate preoperative self-assessment management and outcome of these disorders are
of surgical experience and arthroscopic skills quite variable.
• Be willing to perform possible open reduc- The evaluation of hip instability is important,
tion–internal fixation (rather than arthroscopic especially if it is associated with evidence of gen-
194 A. Aprato et al.

eralized ligament laxity. This can be associated the head–neck junction comes in contact with
with bone-collagen type disorders, including the acetabular rim on flexing the hip within nor-
Ehlers-Danlos syndrome, Down syndrome, mal range, especially when the leg is rotated
arthrochalasis multiplex congenita, developmen- internally. With further motion of the hip, the flat
tal dysplastic hip, and idiopathic type. As pub- head–neck junction is jammed against the ante-
lished by Bellabarba et  al. [26], capsular laxity rior acetabular cavity, causing damage not only
may be the underlying cause of dynamic hip to the undersurface of the labrum, but also to the
instability. While previously managed by thermal anterior acetabular cartilage [31]. Anteroposterior
capsulorrhaphy, capsular laxity is currently hip or pelvic radiographs are indicative of
addressed through suture-based plication tech- impingement only when the fracture has healed
niques [27]. in varus. Axial radiographs and MRI scans may
There are several different techniques to show retrotorsion and the lack of offset on the
incise, repair, or remove the capsule during hip anterior part of the femoral head and neck con-
arthroscopy; Capsulectomy, extensile interportal tour. MRI is also helpful in showing the sequelae
capsulotomy with or without repair, or a of chronic impingement: degeneration and tear-
T-capsulotomy with partial or complete repair. ing of the labrum and defects of the adjacent
Capsular plication (capsulorrhaphy) can limit acetabular cartilage.
capsular redundancy; it’s performed with the hip Although osteotomies and arthroplasties play
in 45° flexion, so that side-to-side stitches take a major role in the treatment of those post-­
larger bites to reduce extraneous capsular tissue traumatic deformations, in slight to moderate
and decrease capsular volume [28]. deformity cases resection osteoplasty of the fem-
Arthroscopic thermal modification of collagen oral head and neck junction may be performed
in the hip capsular tissue appears to be a treat- arthroscopically (Fig. 15.4). The aim of this pro-
ment option for patients with hip instability. The cedure is to improve the anterior head–neck off-
hip joint capsule is predominantly type 1 colla- set in order to improve the clearance of the joint.
gen, and the mechanism of tissue shrinkage The technique is similar to a standard cam resec-
through type 1 collagen alteration is well docu- tion. To confirm impingement, performing an
mented in the literature [29]. Short-term results extended anterior capsulotomy allows full visual-
appear promising. However, more studies are ization of the joint and testing for impingement.
required to determine the long-term efficacy of Creation of an improved femoral head–neck off
this procedure in the treatment of this challeng- set is performed by resection osteoplasty of the
ing disorder. femoral neck. Damage to the cartilage cannot be
reversed; this explains why most of patients com-
plain of some persisting groin pain especially
15.6 C
 am Deformity in Neck with the impingement test. The mean goal of
Fracture Sequelae treatment must therefore be early diagnosis and
treatment of impingement to prevent further
Posttraumatic femoroacetabular impingement damage to the cartilage and subsequent osteoar-
(FAI) can be a cause of hip pain in patients who throsis. Prevention of impingement is possible by
sustained a fracture of the neck of the femur initial anatomic reduction, not only in the antero-
[30]. Impingement can develop when the head posterior plane, but also in the axial plane. This
heals in retrotorsion or varus position. may be difficult to achieve with closed or semi-
Retrotorsion of the head is a position often seen open techniques and is much easier with open
after cervical fractures. In these malpositions, techniques [32].
15  The Use of Hip Arthroscopy in Trauma of the Hip 195

a b

Fig. 15.4 (a) X-ray showing a consolidated subcapital bone callus in a consolidated neck fracture. (c) X-ray
neck femur fracture 2 years after the fracture and 1 year showing the result of arthroscopic resection of the callus
after screws’ removal. (b) X-ray showing an excessive

8. Svoboda SJ, Williams DM, Murphy KP.  Hip

References arthroscopy for osteochondral loose body removal
after a posterior hip dislocation. Arthroscopy.
1. Burman MS.  Arthroscopy for direct visualization of 2003;19(7):777–81.
joints. J Bone Joint Surg. 1931;13:669–95. 9. Singleton SB, Joshi A, Schwartz MA, Collinge
2. Mullis BH, Dahners LE.  Hip arthroscopy to remove CA.  Arthroscopic bullet removal from the acetabu-
loose bodies after traumatic dislocation. J Orthop lum. Arthroscopy. 2005;21(3):360–4.
Trauma. 2006;20(1):22–6. 10. Ilizaliturri VM Jr, Gonzalez-Gutierrez B, Gonzalez-­
3. Hc E. Posterior fracture dislocations of the hip. J Bone Ugalde H, Camacho-Galindo J.  Hip arthroscopy
Joint Surg Am. 1974;56:1103–27. after traumatic hip dislocation. Am J Sports Med.
4. Epstein HC, Wiss d, Cozen L. Posterior fracture dis- 2011;39(Suppl):50S–7S.
location of the hip with fractures of the femoral head. 11. Matsuda DK.  A rare fracture, an even rarer treat-
Clin Orthop. 1985;201:9–17. ment: the arthroscopic reduction and internal fixation
5. Armstrong JR. Traumatic dislocation of the hip joint: of an isolated femoral head fracture. Arthroscopy.
review of 101 dislocations. J Bone Joint Surg Br. 2009;25(4):408–12. https://doi.org/10.1016/j.
1948;30:430–5. arthro.2009.01.011.
6. Steward MJ, McCarroll HR Jr, Mulhollan 12. Yamamoto Y, Ide T, Ono T, Hamada Y. Usefulness of
JS. Fracture-dislocation of the hip. Acta Orthop Scand. arthroscopic surgery in hip trauma cases. Arthroscopy.
1975;46:507–25. 2003;19:269–73.
7. Brav CE.  Traumatic dislocation of the hip. J Bone 13. Yang JH, Chouhan DK, Oh KJ.  Percutaneous screw
Joint Surg Am. 1962;44:1115–34. fixation of acetabular fractures: applicability of hip
196 A. Aprato et al.

arthroscopy. Arthroscopy. 2010;26(11):1556–61. 23. Park MS, Yoon SJ, Choi SM.  Arthroscopic reduc-
https://doi.org/10.1016/j.arthro.2010.04.068. tion and internal fixation of femoral head fractures.
14. Kim H, Baek JH, Park SM, Ha YC. Arthroscopic reduc- J Orthop Trauma. 2014;28(7):e164–8. https://doi.
tion and internal fixation of acetabular fractures. Knee org/10.1097/BOT.0000000000000048.
Surg Sports Traumatol Arthrosc. 2014;22(4):867–70. 24. Ross JR, Gardner MJ.  Femoral head fractures. Curr
https://doi.org/10.1007/s00167-013-2799-y. Rev Musculoskelet Med. 2012;5:199–205.
15. Gay SB, Sistrom C, Wang GJ, et  al. Percutaneous 25. Boykin RE, Anz AW, Bushnell BD, Kocher MS,

screw fixation of acetabular fractures with CT Stubbs AJ, Philippon MJ. Hip Instability. J Am Acad
­guidance: preliminary results of a new technique. AJR Orthop Surg. 2011;19(6):340–9.
Am J Roentgenol. 1992;158:819–22. 26. Bellabarba C, Sheinkop MB, Kuo KN. Idiopathic hip
16. Hougaard K, Thomsen PB.  Traumatic posterior
instability. An unrecognized cause of coxa saltans in
fracture-dislocation of the hip with fracture of the the adult. Clin Orthop Relat Res. 1998;355:261–71.
femoral head or neck, or both. J Bone Joint Surg Am. 27. Bedi A, Galano G, Walsh C, Kelly BT.  Capsular

1988;70:233–9. management during hip arthroscopy: from femoro-
17. Roeder LF, Delee JC. Femoral head fractures associ- acetabular impingement to instability. Arthroscopy.
ated with posterior hip dislocation. Clin Orthop Relat 2011;27(12):1720–31. https://doi.org/10.1016/j.
Res. 1980;147:121–30. arthro.2011.08.288.
18. Sahin V, Karankas ES, Aksu S, et  al. Traumatic hip 28. Kuhns BD, Weber AE, Levy DM, Bedi A, Mather
dislocation and fracture-dislocation of the hip. A long RC 3rd, Salata MJ, Nho SJ.  Capsular management
term follow up study. J Trauma. 2003;54:520–9. in hip arthroscopy: an anatomic, biomechanical and
19. Gillespie P, Aprato A, Bircher M.  Hip dislocation technical review. Front Surg. 2016;3:13. https://doi.
and femoral head fractures. In: Bentley G, editor. org/10.3389/fsurg.2016.00013.
European surgical orthopaedics and traumatology. 29.
Philippon MJ.  The role of arthroscopic ther-
Berlin: Springer; 2014. p.  2179–202. https://doi. mal capsulorrhaphy in the hip. Clin Sports Med.
org/10.1007/978-3-642-34746-7_114. 2001;20(4):817–29. Review.
20. Pipkin G. Treatment of grade IV fracture dislocation 30. Ganz R, Bamert P, Hausner P, et al. Zervikoazetabuläres
of the hip. J Bone Joint Surg Am. 1957;39:1027–42. Impingement nach Schenkelhalsfraktur. Unfallchirurg.
21. Lansford T, Munns SW.  Arthroscopic treatment of 1991;94:172–5.
Pipkin type I femoral head fractures: a report of 2 31. Klaue K, Durnin C, Ganz R. The acetabular rim syn-
cases. J Orthop Trauma. 2012;26(7):e94–6. https:// drome. A clinical presentation of dysplasia of the hip.
doi.org/10.1097/BOT.0b013e3182323f4f. J Bone Joint Surg Br. 1991;73:423–9.
22. Park MS, Her IS, Cho HM, Chung YY. Internal fixa- 32. Eijer H, Myers SR, Ganz R.  Anterior femoroac-

tion of femoral head fractures (Pipkin I) using hip etabular impingement after femoral neck fractures. J
arthroscopy. Knee Surg Sports Traumatol Arthrosc. Orthop Trauma. 2001;15(7):475–81.
2014;22(4):898–901. https://doi.org/10.1007/
s00167-013-2821-4.