title: Surgical hip dislocation is a reliable approach for treatment of femoral head fractures.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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).
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Level IV, therapeutic study.
authors.affiliation: Orthopaedic Department, University of Turin, Viale 25 aprile 137 int 6, 10133, Turin, Italy.|San Luigi Hospital of Orbassano, Turin, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Massè
authors.affiliation: Orthopaedic Department, University of Turin, Viale 25 aprile 137 int 6, 10133, Turin, Italy. ale_aprato@hotmail.com.|San Luigi Hospital of Orbassano, Turin, Italy. ale_aprato@hotmail.com.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Aprato
authors.affiliation: Orthopaedic Department, University of Turin, Viale 25 aprile 137 int 6, 10133, Turin, Italy.|San Luigi Hospital of Orbassano, Turin, Italy.
authors.forename: Caterina
authors.initials: C
authors.lastname: Alluto
authors.affiliation: Orthopaedic Department, University of Turin, Viale 25 aprile 137 int 6, 10133, Turin, Italy.|San Luigi Hospital of Orbassano, Turin, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Favuto
authors.affiliation: Department of Orthopaedic Surgery, University of Berne, Berne, Switzerland.
authors.forename: Reinhold
authors.initials: R
authors.lastname: Ganz
mesh_terms: D000328:Adult; D019644:Arthroplasty, Replacement, Hip; D001696:Biomechanical Phenomena; D001863:Bone Screws; D005260:Female; D005265:Femoral Neck Fractures / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D005271:Femur Head Necrosis / Q000209:etiology / Q000601:surgery; D005592:Fracture Fixation / Q000009:adverse effects / Q000295:instrumentation*; D017102:Fracture Healing; D006617:Hip Dislocation; D006621:Hip Joint / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009999:Ossification, Heterotopic / Q000209:etiology; D015207:Osteoarthritis, Hip / Q000209:etiology; D010027:Osteotomy; D011859:Radiography; D020127:Recovery of Function; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult