Operative treatment of displaced Pipkin type I and II femoral head fractures

The optimal surgical approach for the treatment of femoral head fracture remains controversial. We retrospectively reviewed patients with Pipkin type I and II femoral head fractures managed surgically through posterior Kocher–Langenbeck approach and Ganz trochanteric flip approach aiming to define the best approach with the least morbidity.

Between May 1995 and November 2010, 23 patients (14 men and 9 women) with an average age of 39.1 years (range 27–62) were treated by open reduction and internal fixation of femoral head fractures (5, Pipkin type I; and 18, type II) through Kocher–Langenbeck approach in 11 patients and trochanteric flip (digastric) osteotomy in 12. The two approaches were compared regarding operative time, difficulty of reduction and fixation, amount of blood loss, occurrence of femoral head osteonecrosis or heterotopic ossification and the final functional outcome. The scale of Brooker was used to document heterotopic ossification. The modified Merle d’Aubigne and Postel as well as Thompson and Epstein scores were used for final evaluation.

Trochanteric flip approach was associated with less operative time, less blood loss and improved visualization facilitating direct screw fixation compared with Kocher–Langenbeck approach. Non-union of the trochanteric osteotomy developed in one patient. Heterotopic ossification was seen more in trochanteric flip-approached cases. Avascular necrosis of the femoral head occurred in one patient (8.1 %) of trochanteric flip-approached group and two (18.1 %) of posterior approach group. All patients were followed up for an average of 31 months (range 24–84). Except for one patient, the final outcomes were equal in the two groups.

Despite the limited number of patients, we can conclude that good final outcome does not necessarily follow a specific approach.