Acetabular Fractures Associated with Femoral Head Fractures(Pipkin IV Injuries): Treatment Utilizing Ganz Trochanteric Flip Osteotomy

Session VII - Pelvis

Fri., 10/6/06 Pelvis, Paper #37, 3:24 pm

Acetabular Fractures Associated with Femoral Head Fractures (Pipkin IV Injuries): Treatment Utilizing Ganz Trochanteric Flip Osteotomy

Philip J. Kregor, MD¹(a-Synthes); Alexander R. Vap¹(n);
Michael Zlowodzki, MD³(n); Andrew Thomson, MD¹(n);
George V. Russell, MD²(n);
¹Vanderbilt Orthopaedic Institute, Nashville, Tennessee, USA;
²University of Mississippi, Jackson, Mississippi, USA;
³University of Minnesota, Minneapolis, Minnesota, USA

Purpose: Treatment of the Pipkin IV injury requires optimal visualization of both injuries, thorough debridement of the hip joint, fixation of the posterior wall (unless low), and fixation of the femoral head (unless low and minimally displaced). The purpose of this prospective analysis is to delineate the surgical findings and clinical outcome of Pipkin IV injuries treated via open reduction and internal fixation with the Ganz trochanteric flip osteotomy.

Methods: All acetabular fractures operated on by the senior author were entered into an IRB-approved database. Between 2001 and 2005, 610 acetabular fractures were operatively treated. In this series, 18 Pipkin IV injuries underwent treatment with the Ganz trochanteric flip osteotomy as the surgical approach. Surgical indication included an unstable or irreducible hip joint, a displaced (1-2 mm) hip posterior wall fracture, and femoral head displacement >2 mm.

Results: The acetabular fracture pattern was 16/18 posterior wall fractures and 2/18 transverse-posterior wall fractures. 3/18 cases had irreducible dislocations. The acetabular fracture was treated with plate and screw fixation in all cases. In 16/18 cases, the femoral head was treated with 2.7-mm lag screws. In 2 cases the femoral head fractures were not reconstructable. The hip capsule and labral pathology was repaired, if possible, using soft-tissue anchors. Postoperative reductions qualified as anatomic in 17/18 cases, and imperfect in 1 (revised in secondary surgery). However, chondral loss of >2 mm was seen in 17/18 cases. At an average follow-up of 19 months (range, 9-39), Postel d'Aubigne clinical scores were excellent in 5, good in 9, and poor in 4. Secondary surgical procedures included: heterotopic ossification resection for Brooker IV ossification in 2 cases, irrigation and debridement for a delayed MRSA infection in one case, and a reoperation for a malreduction of a transverse-posterior wall acetabular fracture in one case. Three total hip arthroplasties were performed at an average of 18 months postinjury.

Conclusion/Significance: Our clinical impression is that the visualization of both injuries is challenging, even with combined approaches. Our case series demonstrates that with use of the Ganz trochanteric flip osteotomy: (1) Acceptable results (14 of 18 good/excellent: 78%) can be obtained at an average follow-up of 19 months, and (2) Significant heterotopic ossification can occur (n = 2), but with excision the clinical result can be acceptable.

If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.

· The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an "off label" use). · · FDA information not available at time of printing.