Triple Pelvic Osteotomy In The Treatment of Pincer Type Of Femoroacetabular Impingement Syndrome.

Purpose: Femoroacetabular impingement (FAI) syndrome is a dynamic cause of hip arthritis, and it is commonly diagnosed in young adults without any other causes of hip joint pain. Pincer type of FAI in this study, is typically present in active middle-aged females. Methods: Eighteen patients diagnosed only with pincer type FAI received triple pelvic osteotomy reverse in type between 2011 and 2020. The average age of the patients was 37.3 years (28.0-45.0). The joint preserving surgery consisted of open dislocation and trochanteric flip osteotomy. We chose to do in series of selected patients only a triple pelvic osteotomy reverse in type as a extraarticular procedure in order to safely address intraarticular arthritis. Results: After surgery, the Harris Hip Score increased from 55.1 to 91.4. The patients experienced a greater range of motion in the hip and less pain. Medium-term follow-up indicated that the surgeries were successful. In our series treated with triple pelvic osteotomy 22% (4 in 18 patients) after the operation appeared clinically rear pelvic FAI test. This result was not taken as significant due to small sample size (CI 95%). After the operation we used special guidelines and we postponed total hip replacement. We did no additional operation to selected patients.Conclusion: This technique is a safe procedure to restore hip mobility. This is an extraarticular operation, and therefore it helps this process inside the joint.

Osteosynthesis of Common Acetabular Fractures Operated on Through a Single Posterior (Kocher-Langenbeck) Approach with or without Trochanteric Flip Osteotomy. A Case Series

Background. The Kocher-Langenbeck approach is recommended in the majority of common posterior acetabular injuries. Trochanteric osteotomy can be used to extend the exposure of the Kocher-Langenbeck approach superiorly and anteriorly. We evaluated the functional outcome of common acetabular fractures operated on through the Kocher-Langenbeck approach with or without trochanteric flip osteotomy. Material and methods. This prospective study enrolled 42 patients with posterior wall, posterior column, transverse, posterior wall with posterior column, transverse with posterior wall and both column acetabular fractures. The Kocher-Langenbeck approach was used in 35 patients and trochanteric flip osteotomy was done in 7 patients. The radiological outcome was evaluated by Matta’s criteria and the functional outcome was evaluated using modified Merle d'Aubigné and Postel criteria. Results. D’Aubigne Postel scores at the final follow-up were excellent in 12 patients, good in 18, fair in 8 and poor in 4. Thirty-seven patients had congruent reduction (anatomical in 29, imperfect in 8) and 5 patients had non-congruent reduction on radiographs as per Matta’s criteria. Radiographic congruity (88.09%, 37 out of 42 cases) correlated fairly well with the functional outcome (excellent or good functional outcome in 71.4%, 30 out of 42 cases). The complications included traumatic nerve palsy (3 cases), iatrogenic nerve palsy (2 cases), deep venous thrombosis (2 cases), wound infection (3 cases), non-congruent reduction (5 cases), 8 cases of osteoarthritis of hip, 2 cases of avascular necrosis of femoral head and 3 cases of heterotrophic ossification. Conclusions. 1. Surgical treatment of common acetabular fractures with major posterior involvement can be attempted via a single posterior approach (Kocher-Langen­beck with or without trochanteric flip osteo­tomy) and leads to good-to-excellent results in a majority of the cases. 2. It is superior to conservative management, which has been found to be accompanied by a much higher rate of complications. 3. A thorough study of the pre-opera­tive radiographs, Judet’s views and 3D-reconstructed CT images helps in classifying the fracture and thereby assigning or not assigning it for the posterior approach.

Modified Hardinge approach is an alternative to trochanteric flip osteotomy for Pipkin type IV femoral head fracture

Background Pipkin type IV femoral head (FH) fractures generally have poor prognoses. Although several surgical approaches are used, the optimal procedure is still under debate. The purposes of this study were to compare two approaches, the modified Hardinge approach and trochanteric flip osteotomy, for the treatment of Pipkin type IV FH fractures. Methods This retrospective study included 20 patients who underwent surgical treatment for Pipkin type IV FH fractures between January 2011 and September 2017 at a level 1 trauma center. Thirteen were treated using the modified Hardinge approach (group A) and seven with trochanteric flip osteotomy (group B). All patients completed at least 1 year of follow-up. The clinical outcome of the Merle d’Aubigné-Postel score; and radiological outcomes including the quality of the fracture reduction, the osteonecrosis of the FH (ONFH), the hip joint osteoarthritis (OA), and heterotopic ossification (HO); were compared between the two groups. Conversion to THR was also recorded as an outcome measure, analyzed by Kaplan–Meier curve and log-rank test. Results The mean operative time was similar in the two groups. The estimated blood loss of group B (435.7 ± 307.8 ml) was nearly double that of group A (233.1 ± 116.8 ml), although not statistically significant (P = 0.135). Radiographic outcomes including the quality of fracture reduction, ONFH, hip joint OA, and HO did not differ significantly between the two groups. There were also no significant differences between the two groups in terms of mean Merle d’Aubigné-Postel score at 1 year after injury and the log rank test of conversion to THR. One patient in group A had recurrent dislocation and underwent revision surgery, while one patient in group B requested removal of the trochanteric screws due to discomfort. Conclusions For the management of Pipkin type IV FH fractures, the modified Hardinge approach results in reduced blood loss, similar clinical and radiological outcomes compared with trochanteric osteotomy. The modified Hardinge approach appears to be an acceptable alternative to trochanteric flip osteotomy.

Use of Trochanteric Flip Osteotomy Improves the Outcome of Pipkin I and II Femoral Head Fractures

Introduction: Annual incidence of femoral head fracture is constantly increasing due to increase in cases of road traffic accidents (RTA). Four to 17% of femoral head fractures are due to posterior dislocations of hip. Outcome of femoral head facture associated with posterior dislocation of hip, the pipkin I and II fracture, is unsatisfactory due to lack of universally accepted protocol for its management and treatment. Objective: To evaluate the patient outcome using relatively newer approach, the Trochanteric Flip (digastrics) Osteotomy (TFO), for the precise anatomical reduction of femoral head fractures associated with posterior dislocation of hip. Methods: Between 2013 and 2017, 21 patients with sustained isolated femoral head fracture were admitted at our hospital. We used TFO approach for the management and treatment of femoral head fractures. The patients were followed up for 42 months at different intervals. Clinical outcome were evaluated using Merle d’Aubigne Postel and Thompson-Epstein scale. Results: Retrospective analysis showed excellent, good, fair and poor results in five (23.8%) patients, 13 (61.9%) patients, two (9.5%) patients and one (4.7%) patient, respectively. Clinical outcomes included sciatic nerve injury (4.7%), moderate arthritis (95.3%), benign non-debilitating heterotrophic ossification (19%), avascular necrosis of femoral head (4.7%) and neuropraxia (4.7%). Conclusions: Use of trochanteric flip osteotomy gives the favorable outcome for the treatment of this type of fracture. Most importantly, the vascularity of femoral head remains intact which makes TFO a very useful technique for pipkin I and II fracture treatment.

Midterm results of trochanteric flip osteotomy technique for management of fractures around the hip

Introduction: In this study, we aimed to investigate safety and efficacy of the trochanteric flip osteotomy with surgical hip dislocation technique in selected displaced acetabular and femoral head fractures with clinico-radiological outcome and potential complications. Materials and methods: We retrospectively reviewed 32 patients from January 2009 to June 2014. Selected displaced acetabular fractures with comminution and/or cranial extension of posterior wall, marginal impaction, intraarticular fragment, femoral head fractures and hip fracture-dislocations were operated by this modified approach of trochanteric flip osteotomy and surgical hip dislocation. Patients were evaluated for fracture reduction, femoral head viability, trochanteric union, abduction power, and functional evaluation was done by Merle d’Aubigné-Postel scoring system. Minimum follow-up was 24 months. Results: Reduction was judged to be anatomical in 84.38% of cases, and within 1-3 millimetres in 9.38% of cases. All osteotomies healed in an anatomical position. Heterotopic ossification was found in 2 patients limited to Brooker class I. Osteonecrosis developed in 1 patient. 2 patients developed arthritis of the hip as sequelae of poor reduction. Abduction power was MRC 5/5 in all except in 1 patient (4/5). Mean Merle d’Aubigné-Postel score was 16.18; overall good to excellent result was achieved in 87.5% of cases. Conclusions: Trochanteric flip osteotomy with surgical dislocation allows better intraarticular assessment, control of intraarticular fragments, assists accurate reduction and the fixation of complex acetabular and femoral head fractures, without compromising femoral head vascularity and abductor strength. This technique has provided excellent midterm results in the management of complex injuries around the hip.

Complete Resection of a Massive Synovial Osteochondromatosis of the Hip Using an Anterior Approach: A Report of Two Cases

Arthroscopic excision of synovial osteochondromatosis of the hip is commonly performed. However, when the lesion extends to the extra-articular space of the hip joint, excision using arthroscopy becomes difficult. Although surgical dislocation of the hip with a trochanteric flip osteotomy is commonly used, manual access to the inferomedial portion of the acetabulum remains difficult. In this case report, we describe arthroscopic resection followed by open surgery using an anterior approach with or without surgical dislocation to excise a synovial osteochondromatosis of the hip that had extended to the extra-articular space and formed a herniation sac. Excision was completed without complications. An anterior approach with or without surgical dislocation should be considered as a surgical option for the treatment of a massive synovial osteochondromatosis of the hip joint.

Unstable Posterior Acetabular Fractures: Early Results of Delayed Reduction and Fracture Fixation Using the Kocher-Langenbeck Approach with Trochanteric Flip Osteotomy

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