Trochanteric Flip Osteotomy Research Articles

Does digastric trochanteric flip osteotomy increase complications in treatment of complex acetabular fractures

Objective To observe the short-, mid- and long-term surgical complications of complex acetabular fractures treated by the Kocher-Langenbeck (K-L) approach combined with digastric trochanteric flip osteotomy (DTFO). Methods We reviewed the 40 cases of complex acetabular fracture that were treated at our department from December 2009 through December 2013. They were 34 men and 6 women, from 17 to 73 years of age (average, 47.6 years) . Of them, 19 were treated by K-L approach combined with DTFO, including 17 males and 2 females, with a mean age of 44.7±11.7 years. The other 21 controls were treated simply through the K-L approach, including 17 males and 4 females, with a mean age of 42.8±14.4 years. The 2 groups were compared in terms of intraoperative results, postoperative outcomes and surgical complications like infection, sciatic nerve injury, heterotopic ossification, femoral avascular necrosis, and post-traumatic arthritis. Results The 40 cases were followed up for an average of 29.7 months (range, from 18 to 59 months) . The operation time for the DTFO group (248.2±123.2 min) was significantly shorter than that for the control group (276.1±50.6 min) , the satisfactory reduction rate for the DTFO group (100.0%) was significantly higher than that for the control group (90.5%) , the hip intorsion (19.7°±3.5°) , hip extorsion (26.1°±4.3°) , and hip abduction (40.5°±4.7°) at one year postoperation in the DTFO group were significantly superior to those in the control group (14.3°±6.0°, 21.0°±7.2°, 31.9°±10.8°, respectively) , and the hospital stay for the for the DTFO group (19.0±7.1 d) was significantly longer than that for the control group (13.6±4.9 d) (P 0.05) . Infection or iatrogenic sciatic nerve injury occurred in none of the patients. There were no significant differences between the 2 groups in terms of positive Trendelenburg test, hip function, heterotopic ossification, femoral avascular necrosis, or post-traumatic arthritis at the last follow-ups (P>0.05). Conclusions In the surgical treatment of complex acetabular fractures, especially those involving the acetabular dome area and the femoral head, K-L approach combined with DTFO can obtain larger surgical exposure field, good fracture reduction and functional recovery, without obviously increasing surgical complications. This technique only slightly increases intraoperative bleeding and transfusion, and results in longer hospital stay. Key words: Acetabulum; Fractures, bone; Osteotomy; Postoperative complications

Surgical hip dislocation according to Ganz for excision of osteochondromas in patients with multiple hereditary exostoses.

We report a prospective cohort study of the midterm results of surgical dislocation of the hip (according to Ganz) to perform resection of osteochondromas involving the femoral neck in patients with multiple hereditary exostoses (MHE). Hip range of movement (ROM) was assessed pre- and post-operatively. Patients' judgment of post-operative reduction of pain, symptoms, the Rand 36-item Health Survey (RAND-36) and complications were analysed. Symptomatic osteochondromas of the femoral neck were removed in 20 hips (17 patients) between 2007 and 2012. There were nine men and eight women with a mean age at the time of surgery of 29 years (11 to 47). Mean follow-up was 46 months (26 to 73). At latest follow-up, mean ROM was significantly increased in all directions. Post-operatively the pain associated with the lesion was either significantly decreased or non-existent. There was a significant improvement in seven RAND-36 sub-domains. Encountered complications in four patients were pseudoarthrosis of the trochanteric osteotomy, traumatic separation of the trochanteric osteotomy, a pertrochanteric femoral fracture and avasvular necrosis. Histological analysis revealed osteochondromas in all hips. This study confirms the Ganz trochanteric flip osteotomy provided a reliable approach to osteochondromas of the femoral neck that are otherwise difficult to access for surgical resection. The procedure offered significant improvement in the quality of life, although one should be aware of the serious complications can arise despite the relatively safe procedure. When daily function and activities are affected, resection of osteochondromas of the proximal femur according to Ganz is indicated to significantly improve quality of life.

Application of Trochanteric Flip Osteotomy with Herbert Screw to Treat Pipkin I,II Fracture of the Femoral Head

There is no definite protocol in management of Pipkin fracture in relation to operation approach and internal fixations. The aim is to explore the therapeutic effects of internal fixation with Herbert screws for the treatment of Pipkin type I and type II femoral head fractures through the trochanteric flip osteotomy (TFO) approach. From January 2010 to December 2014, 12 cases of type I and II Pipkin fracture (including 8 type I,4 type II) treated through TFO approach and internal fixation with Herbert screws. All the patients were followed up 1-4 years with an average of 2.6 years. The whole osteotomies and acetabular fractures healed within 6 to 12 weeks. All patients achieved healing of femoral head fracture after 12-16 months without femoral head necrosis. Heterotopic ossification (HO) occurred in 1 cases after operation which were left untreated. At the last follow-up, excellent and good rate was 91.7%. Treatment of type I, II Pipkin fracture through TFO approach can provide good visualization and protect of the femoral head blood supply. The treatment of internal fixation with Herbert screws is effective for Pipkin type I and type II femoral head fracture.

Surgical Treatment of Synovial Osteochondromatosis of the Hip Using a Modified-Hardinge Approach with a Z-Shaped Capsular Incision.

Synovial osteochondromatosis of the hip is a rare condition, and the surgical treatment approach for this condition requires complete removal of loose bodies combined with synovectomy. While these, procedures are generally accepted as the optimal treatment method, this is still controversial topic. Recent studies have reported that open surgical procedures remain acceptable for synovial osteochondromatosis of the hip. These procedures include the dislocation of the femoral head, and complications such as femoral head necrosis and bursitis or great trochanter non-union due to trochanteric osteotomy have been reported. The present study reports a modified technique for surgical dislocation through a Z-shaped capsular incision without trochanteric flip osteotomy for the treatment of synovial osteochondromatosis of the hip.

Surgical hip dislocation for treatment of cam femoroacetabular impingement.

Background:Cam femoroacetabular impingement is caused by a misshapen femoral head with a reduced head neck offset, commonly in the anterolateral quadrant. Friction in flexion, adduction and internal rotation causes limitation of the hip movements and pain progressively leading to labral and chondral damage and osteoarthritis. Surgical hip dislocation described by Ganz permits full exposure of the hip without damaging its blood supply. An osteochondroplasty removes the bump at the femoral head neck junction to recreate the offset for impingement free movement.Materials and Methods:Sixteen patients underwent surgery with surgical hip dislocation for the treatment of cam femoroacetabular impingement by open osteochondroplasty over last 6 years. Eight patients suffered from sequelae of avascular necrosis (AVN). Three had a painful dysplastic hip. Two had sequelae of Perthes disease. Three had combined cam and pincer impingement caused by retroversion of acetabulum. All patients were operated by the trochanteric flip osteotomy with attachments of gluteus medius and vastus lateralis, dissection was between the piriformis and gluteus minimus preserving the external rotators. Z-shaped capsular incision and dislocation of the hip was done in external rotation. Three cases also had subtrochanteric osteotomy. Two cases of AVN also had an intraarticular femoral head reshaping osteotomy.Results:Goals of treatment were achieved in all patients. No AVN was detected after a 6 month followup. There were no trochanteric nonunions. Hip range of motion improved in all and Harris hip score improved significantly in 15 of 16 cases. Mean alpha angle reduced from 86.13° (range 66°–108°) to 46.35° (range 39°–58°).Conclusion:Cam femoroacetabular Impingement causing pain and limitation of hip movements was treated by open osteochondroplasty after surgical hip dislocation. This reduced pain, improved hip motion and gave good to excellent results in the short term.

Surgical hip dislocation is a reliable approach for treatment of femoral head fractures.

Femoral head fractures are rare injuries; incongruency and instability are indications for surgical intervention. Anterior, posterior, and transtrochanteric surgical approaches have been proposed, but the exposure is limited with classical approaches. Surgical hip dislocation allows for a 360° view of the head and may facilitate a reduction in selected head fractures, but to our knowledge, few studies have reported on the results with this technique. We therefore report on the (1) quality of fracture reduction; (2) modified Harris hip score at a minimum of 2 years (mean, 6 years, range, 26-122 months); and (3) frequency of complications, including avascular necrosis (AVN), arthritis development, and heterotopic ossification, in a case series of patients with femoral head fractures treated with this approach. The procedure involves digastric trochanteric flip osteotomy and safe dislocation of the femoral head, preserving its vessels. Using this technique we are able to reduce all displaced femoral head fractures under direct view. Definitive fixation is performed through this approach with 2.7-mm nonabsorbable screws. The same technique may be used also for Pipkin IV fractures to fix transverse, T-type, posterior wall, or posterior column acetabular fracture. Between 2004 and 2011, we used this approach to manage all displaced femoral head fractures in patients younger than 55 years old. A total of 17 patients were thus treated; of those three were lost to followup before 2 years, and one was excluded from study because of severe preoperative neurological impairment, leaving 13 for analysis here. Patient demographic, injury, and surgical variables as well as complications were recorded and retrospectively evaluated. Radiographic outcome was scored according to Matta's criteria on postoperative radiographs. Outcomes were evaluated with the modified Harris hip score. Minimum followup was 24 months (mean, 77 months; SD, 32.8 months). Fracture reduction was anatomic in eight hips and imperfect in five. Mean clinical score was 82 points (SD, 7.7). One patient developed symptomatic femoral head AVN and underwent total hip arthroplasty 4 years after the index procedure; no other patient underwent arthroplasty. Besides this patient, signs of arthritis (Grade I according to Tönnis classification) were found in one patient and heterotopic ossification was recorded in two patients, but neither was symptomatic. Our experience with surgical dislocation shows clinical results comparable to previously reported outcomes in femoral head fractures treated with common approaches; we also present a similar rate of AVN and a lower rate of posttraumatic arthritis, but a higher risk of heterotopic ossification. Further case-control studies are necessary to confirm these statements. Level IV, therapeutic study.

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 39.1years (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 31months (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.

Assessment of Femoral Head and Head-Neck Junction Perfusion Following Surgical Hip Dislocation Using Gadolinium-Enhanced Magnetic Resonance Imaging

The purpose of the present study was to quantify perfusion to the femoral head and head-neck junction using gadolinium-enhanced magnetic resonance imaging following three surgical dislocations of the hip (trochanteric flip osteotomy, standard posterior approach, and modified posterior approach). The medial femoral circumflex artery was cannulated in fifty fresh-frozen cadaveric hips (twenty-five pelvic specimens). One hip on each pelvic specimen was randomly chosen to undergo one of the three surgical dislocations, and the contralateral hip was used as a control. Gadolinium enhancement on the magnetic resonance imaging scan was quantified in both the femoral head and head-neck junction by volumetric analysis using custom magnetic resonance imaging analysis software. A polyurethane compound was then injected, and gross dissection was performed to assess the extraosseous vasculature. Magnetic resonance imaging quantification revealed that the trochanteric flip osteotomy group maintained almost full perfusion (mean, 96% for the femoral head and 98% for the head-neck junction). The standard posterior approach almost completely compromised perfusion (mean, 4% for the femoral head and 8% for the head-neck junction). Six specimens in the modified posterior approach group demonstrated partial perfusion (mean, 32% in the femoral head and 26% in the head-neck junction). Three specimens in the modified posterior approach group demonstrated almost full perfusion (mean, 96% in the femoral head and 97% in the head-neck junction). Gross dissection revealed that all specimens in the standard posterior approach group and seven of ten in the modified posterior approach group sustained disruption of the ascending branch of the medial femoral circumflex artery. All specimens in the standard posterior approach group demonstrated disruption of the inferior retinacular artery. The inferior retinacular artery remained intact in nine of ten specimens in the modified posterior approach group. One specimen in the modified posterior approach group that had disruption of both the ascending medial femoral circumflex artery and inferior retinacular artery demonstrated a substantial decrease in perfusion (7% in the femoral head and 5% in the head-neck junction). The trochanteric flip osteotomy preserves the vascular supply to the femoral head and head-neck junction. The standard posterior approach disrupts the vascular supply and should be completely abandoned for surgical hip dislocation. Despite reduced enhancement, substantial perfusion of the femoral head and head-neck junction was present in the modified posterior approach group, likely because of the preservation of the inferior retinacular artery. The modified posterior approach produced variable results, indicating that improvement to the modified posterior approach is needed. Our study provides previously unreported quantitative magnetic resonance imaging data on the perfusion to the femoral head and head-neck junction during common surgical approaches to the hip.

Surgical Dislocation Technique for the Treatment of Acetabular Fractures

Surgical hip dislocation allows for a 360° view of the acetabulum and may facilitate a reduction in selected acetabular fractures. To our knowledge there is no description in the literature of the different techniques used to reduce acetabular fractures through this approach. The aims of this study are to describe a technique of hip surgical dislocation to treat a variety of acetabular fracture patterns and to ascertain the early results with this technique, including the quality of fracture reductions achieved, clinical results, operative time, and complications such as avascular necrosis and heterotopic ossification. The procedure involves digastric trochanteric flip osteotomy and safe dislocation of the femoral head, preserving its vessels. T-type, transverse fractures alone or associated with posterior wall could be reduced with specific clamps and reduction adequacy can be judged by direct view. Anterior column fixation could be performed with one or two screws; the posterior column could be fixed with a single posterior plate or with two plates if a transverse fracture is associated with a posterior wall fracture. Between 2005 and 2011, we used this approach selectively to manage those types of fractures; during the period in question, we treated 312 acetabular fractures surgically, of which 31 (10%) were treated using this approach. Patient demographic, injury, and surgical variables as well as complications were recorded. Outcomes were evaluated with the Merle d'Aubigné and Postel system. Radiographic outcome was scored according to Matta's criteria on postoperative radiographs (AP and Judet views). Minimum followup was 24 months (mean, 43 months; range, 24-87 months). Fracture reduction was defined as anatomic in 65% cases, imperfect in 16%, and poor in 19%. Mean Merle d'Aubigné score was 15 points (out of 18, with higher scores being better). Two patients developed symptomatic femoral head avascular necrosis. In complex cases, surgical dislocation presents several advantages; a single approach may reduce surgical time, permit direct intraarticular assessment, and facilitate screw placement closer to the articular surface. It also presents several limitations; some difficulties with bone-reduction clamp positioning, limited fixation of the anterior column, and a small risk of greater trochanter malunion.

Pros and Cons of Surgical Hip Dislocation for the Treatment of Femoroacetabular Impingement

A more detailed understanding of the anatomy of the medial femoral circumflex artery enabled the development of the modern technique for surgical hip dislocation. Although the surgical hip dislocation is best known as an open method for treating femoroacetabular impingement, it allows the surgeon to address a variety of different hip pathologies, including femoral head and posterior wall acetabular fractures, chondral defects requiring cartilage restoration techniques, and excision of benign tumors. When the technique of an extended retinacular flap is added, surgeons are able to perform intra-articular osteotomies and open reduction of slipped capital femoral epiphysis while preserving the blood supply to the femoral head. The surgical hip dislocation allows direct observation of both intra-articular and extra-articular impingement and a means of correcting both during 1 procedure. The downsides of the surgical hip dislocation are largely related to the trochanteric flip osteotomy, with up to half of patients reporting mild residual lateral hip pain 1 year postoperatively. Trochanteric nonunion and residual abductor weakness are also potential complications of the surgical hip dislocation technique. Several studies have shown improved pain and functional outcomes in short-term and mid-term follow-up after treatment of femoroacetabular impingement. It has a low complication rate in the hands of experienced surgeons and is an important technique for addressing complex intra-articular hip pathology that would be technically challenging arthroscopically.

The Efficacy of Trochanteric Flip Osteotomy in Cases of Femoral Head Fracture

Purpose: The purpose of this study is to evaluate the clinical and radiological results of the trochanteric flip osteotomy in cases of femoral head fractures. Materials and Methods: Between May 2000 and January 2012, we evaluated 14 cases of femoral head fractures treated by trochanteric flip osteotomy in combination with the Kocher-Langenbeck approach after a minimum follow-up of one year. There were 13 men and one woman and the average follow-up period was 36.4 months. The clinical results were evaluated according to Merle d’Aubigne-Postel scores and the Thompson-Epstein scoring scale and the radiological results were evaluated according to time to union of fractures and osteotomy site. We also evaluated the incidence of complications. Results: At the last follow-up, mean Merle d’Aubigne-Postel score was 16.4 and 11 cases out of 14 patients presented with good to excellent, two cases presented with fair, and one case presented with a poor clinical result according to the Thompson-Epstein scoring scale. Radiologically all cases achieved union of fractures and osteotomy site and the mean time to union of the osteotomy site was 7.9 weeks. Complications included one case of heterotopic ossification which did not disturb hip function, two cases of avascular necrosis of the femoral head, and one case of post-traumatic osteoarthritis. Conclusion: The trochanteric flip osteotomy in the case of a femoral head fracture showed good clinical and radiological results through good visualization and accurate reduction of the fracture site. However, conduct of further studies including larger number of patients is needed in order to evaluate the incidence of complications such as avascular necrosis of the femoral head.

Rationales for the Bernese approaches in acetabular surgery

PurposeTo present two new approaches to acetabular surgery that were established in Berne, and which aim at enhanced visualization and anatomical reconstruction of acetabular fractures.MethodThe trochanteric flip osteotomy allows for surgical hip dislocation, and was introduced as a posterior approach for acetabular fracture management involving the posterior column and wall. For acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach is described.ResultsFull exposure of the hip joint, as provided by the trochanteric flip osteotomy, facilitates anatomical reduction of acetabular or femoral head fractures and safe positioning of the anterior column screw in transverse or T-shaped fractures. Additionally, the approach enables osteochondral transplantation as a salvage procedure for severe chondral femoral head damage and osteoplasty of an associated inadequate offset at the femoral head–neck junction. The Pararectus approach allows anatomical restoration with minimal access morbidity, and combines advantages of the ilioinguinal and modified Stoppa approaches.ConclusionsUtilization of the trochanteric flip osteotomy eases visualization of the superior aspect of the acetabulum, and enables the evaluation and treatment of chondral lesions of the femoral head or acetabulum and labral tears. Displaced fractures of the anterior column with a medialized quadrilateral plate can be addressed successfully through the Pararectus approach, in which surgical access is associated with minimal morbidity. However, long-term results following the two presented Bernese approaches are needed to confirm that in the treatment of complex acetabular fractures the rate of poor results in almost one-third of all cases (as currently yielded using traditional approaches) might be reduced by the utilization of the presented novel approaches.

Dislocated intra-articular femoral head fracture associated with fracture-dislocation of the hip and acetabulum: report of 12 cases and technical notes on surgical intervention

This report describes case series of the femoral head fractures associated with fracture-dislocation of the hip joint to evaluate the mid- and long-term outcomes and to highlight the surgical technique of fixation of the femoral head from the posterior trochanteric flip osteotomy approach. Twelve patients (6 men and 6 women) with dislocated femoral head fractures (mean age at the time of injury, 56 years; range, 23-80) were followed up for mean period of 9.7 years (range, 5-20). All dislocations were reduced within less than 6 h after the injury. The type of femoral head fracture was classified according to the Pipkin classification on radiographs and CT. Five patients were classified as type I, 2 as type II, 2 as type III, and 3 as type IV. The clinical and radiological outcomes were assessed by Thompson and Epstein's regimen. Excluding 2 patients with Pipkin type III, the outcome of 9 patients was excellent/good, and poor in 1. The latter patient sustained Pipkin type IV and developed osteoarthritis 1 year after surgery and consequently required total hip arthroplasty. We conclude that small fragment of the femoral head less than 1 cm can be removed, while larger fragments should be fixed by bioabsorbable screws or pins in all types of femoral head fractures. In Pipkin type IV fractures, surgeons should always take anatomical reduction in the acetabulum into consideration during surgery.

Surgical Hip Dislocation for Osteochondral Transplantation as a Salvage Procedure for a Femoral Head Impaction Fracture

Obturator anterior hip dislocation is very rare. Poor results are described in patients with additional large transchondral fractures and treatment of these injuries remains challenging. Appropriate treatment recommendations are missing in the literature. This case report introduces surgical hip dislocation for osteochondral autograft transplantation with graft harvest from the nonweightbearing area of the head-neck junction as a salvage procedure in a large femoral head defect. We report the treatment and outcome of a 48-year-old man who sustained an anterior dislocation of the left hip after a motorcycle accident. After initial closed reduction in the emergency room, imaging analysis revealed a large osteochondral defect of the femoral head within the weightbearing area (10 × 20 mm, depth: 5 mm). The hip was exposed with a surgical hip dislocation using a trochanteric osteotomy. An osteochondral autograft was harvested from a nonweightbearing area of the femoral head and transferred into the defect. The patient was prospectively examined clinically and radiologically. Two years postoperatively, the patient was free of pain and complaints. The function of the injured hip was comparable to that of the contralateral, healthy hip and showed satisfying radiologic results. Surgical hip dislocation with a trochanteric flip osteotomy is a simple, one-step technique that allows full inspection of the hip to treat osteochondral femoral defects by osteochondral transplantation. The presented technique, used as a salvage procedure in a large femoral head defect, yielded good clinical and satisfying radiologic outcomes at the midterm.

Surgical dislocation of the hip for a locked traumatic posterior dislocation with associated femoral neck and acetabular fractures

Traumatic posterior dislocation of the hip associated with a fracture of the posterior acetabular wall and of the neck of the femur is a rare injury. A 29-year-old man presented at a level 1 trauma centre with a locked posterior dislocation of the right hip, with fractures of the femoral neck and the posterior wall of the acetabulum after a bicycle accident. An attempted closed reduction had failed. This case report describes in detail the surgical management and the clinical and radiological outcome. Open reduction and fixation with preservation of the intact retinaculum was undertaken within five hours of injury with surgical dislocation of the hip and a trochanteric osteotomy. Two years after operation the function of the injured hip was good. Plain radiographs and MR scans showed early signs of osteoarthritis with some loss of joint space but no evidence of avascular necrosis. The patient had begun skiing and hiking again. The combination of fractures of the neck of the femur and of the posterior wall of the acetabulum hampers closed reduction of a posterior dislocation of the hip. Surgical dislocation of the hip with trochanteric flip osteotomy allows controlled open reduction of the fractures, with inspection of the hip joint and preservation of the vascular supply.

Letter to the Editor: Use of a Trochanteric Flip Osteotomy Improves Outcomes in Pipkin IV Fractures

To the Editor: We were interested to read the article by Solberg et al. [3] entitled “Use of a trochanteric flip osteotomy improves outcomes in Pipkin IV fractures.” The authors reported that combined fractures of the femoral head and acetabulum are relatively rare injuries and the debate continues regarding optimal surgical management of these injuries. We commend the authors on their excellent results and would like to add our support to their selection of this surgical approach. St George’s Healthcare NHS Trust provides a supraregional service for pelvic and actetabular trauma referrals. We corroborate the authors’ observation that a trochanteric flip osteotomy during the course of a posterior approach allows excellent access to the femoral head and acetabular fragments through one incision. However, we note some differences in our practice and wish to bring these to the authors’ attention. While describing the surgical approach, Solberg et al. explained that they tag and release the piriformis tendon but preserve the short external rotators. This contrasts with the approach originally described by Siebenrock et al. [2], which is the technique we tend to follow. Releasing the gemelli and obturator internus close to their insertion at the posterior trochanteric crest improves exposure of the posterior wall and facilitates application of a buttress plate for osteosynthesis. We do not believe this approach jeopardizes the vascularity of the femoral head. The retinacular vessels are identified and protected during surgery. The obturator externus and quadratus femoris, however, are not released, thus preserving the deep branch of the medial circumflex artery. Solberg et al. identified coexisting labral tears in all their patients and repaired seven of 12 tears by direct osteosynthesis. The technique of osteosynthesis is not described and a brief description would be appreciated. We also have found coexistent labral tears that we have repaired using Mitek suture anchors to exposed cancellous bone at the acetabular rim. We also administer low molecular weight heparin (eg, Fragmin) 6 hours postoperatively. Subsequently, warfarin is commenced with a loading regimen and is continued for 3 months. We do not routinely perform duplex ultrasound screening, although high-risk patients would be considered for a vena cava filter. Solberg et al. reported one case of wound dehiscence in their series and we would be interested to know if a cause was identified. Prophylaxis for heterotopic ossification remains controversial with a recent review [1] stating the benefit of prophylactic radiotherapy when compared with nonsteroidal antiinflammatory drugs. Another systematic review [4] however, concluded the opposite. In our practice, we reserve prophylactic radiation for high-risk patients, for example, those who have a coexisting head injury or a history of heterotopic ossification. We once again commend the authors on their contribution and look forward to their clarification of these issues.

Fixation of Femoral Head Fractures Using the Modified Heuter Direct Anterior Approach

Large displaced fractures of the femoral head require open reduction and internal fixation. If the displaced fragments are small, open reduction may not be possible and excision of the fragment or nonoperative care may be the treatment of choice. Surgical approaches that have been used for open reduction and internal fixation include the Smith-Petersen approach, Watson-Jones approach, Kocher-Langenbeck approach, a posterior approach with a trochanteric flip osteotomy, and surgical dislocation of the hip. Here, we describe the use of the modified Heuter direct anterior approach for open reduction and internal fixation of femoral head fractures in 2 patients.

Hip Resurfacing through a Modified Anterolateral Approach, as Compared with the Ganz Trochanteric Flip Osteotomy: A Two Year follow-up Study

Hip resurfacing arthroplasty has conventionally been undertaken through the posterior approach. There has been evidence in the recently published literature to suggest that the posterior approach may compromise the blood supply to the femoral head, by disruption of the posterolateral hip capsule. Ganz et al have proposed the trochanteric 'flip' osteotomy through a lateral approach, to permit surgical dislocation of the hip without damaging the blood supply. The disadvantages, however, are that early full weight bearing is not permitted and there is an incidence of trochanteric delayed or non-union, which may require further treatment. We describe a technique of hip resurfacing through a modified anterolateral approach preserving the posterolateral capsular blood supply. We describe our experience using this approach, and compare the results with our previously used Ganz trochanteric osteotomy. At a mean follow-up of two years, the outcome scores were not significantly different, and both groups had similar abductor strength. There were two cases of delayed union in the Ganz group, one of which required revision; there were no complications in the modified anterolateral group.

Digastric trochanteric flip osteotomy and surgical dislocation of hip in the management of acetabular fractures

To assess the efficacy and safety of digastric trochanteric flip osteotomy technique in the management of acetabular fractures and to evaluate surgical outcome in terms of fracture reduction, femoral head viability of selected acetabular fractures treated operatively using a digastric trochanteric flip osteotomy and a modified Kocher–Langenbeck approach with surgical dislocation of the femoral head. Prospective. Eighteen patients predominantly with combined transverse and posterior wall fractures or multifragmentary posterior wall fractures. OUTCOME EVALUATION: Clinical and radiographic analysis after a minimum 18 months follow-up. Methods A single modified approach involving digastric trochanteric flip osteotomy and a modified Kocher–Langenbeck approach with anterior (n = 14) or posterior (n = 4) surgical dislocation of the femoral head, was done for one or more of following reasons: intra-articular assessment of reduction in fractures with comminution, marginal impaction and involvement of the anterior column, removal of intra-articular fragments, and confirmation of extra-articular screw placement. At a mean follow-up of 26 months (18–40 months), the 17 patients presented with a good to excellent clinical result according to the d’Aubigné score. In all subjects, anatomical reduction was achieved during surgery. The osteotomy site healed at an average of 7 weeks and all the patients recovered abductor strength at 12 weeks. One avascular necrosis occurred in a case of posterior column plus wall fracture (who presented to us after 3 weeks). No heterotopic ossification interfering with hip function was found. This technique gives good exposure (especially in posterior wall, dome area, posterior fracture-dislocation with intra-articular fragments/femoral head fractures and T-fractures), preservation of abductor strength (which may be lost with excessive retraction of abductors to see dome area in classical posterior approach), reliable healing of osteotomy (in contrast to conventional trochanteric osteotomy) without risking the vascularity of femoral head.

Hip Resurfacing using the Trochanteric Flip Osteotomy

We report the early results and complications of resurfacing arthroplasty using the 'Trochanteric Flip Osteotomy' approach to the hip. There are no published clinical results of this approach used for resurfacing arthroplasty. One hundred consecutive patients were assessed prospectively for a minimum follow-up of 2 years (range 2-5 years). The Oxford Hip Score fell from a median of 30 pre-operatively to 5 at two years. Similar improvement was found in the UCLA Activity Score. There were no cases of component failure or fractures. However, nine patients had minor complications related to the osteotomy. Resurfacing Arthroplasty of the hip may be successfully performed through a trochanteric flip osteotomy. This surgical approach may avoid some of the complications associated with avascular necrosis of the femoral head.