Does Surgical Repair Benefit Pipkin Type I Femoral Head Fractures?: A Systematic Review and Meta-Analysis

Abstract

Background: Femoral head fractures are rare injuries with or without traumatic dislocations. The management of these fractures is crucial to prevent the development of severe complications and to achieve optimal functional outcomes. Wide treatment options for Pipkin 1 femoral head fractures range from fragment excision, fixation following open reduction with internal fixation, or conservative treatment such as close reduction alone after fracture dislocation. However, the best decision making remains controversial not only due to lack of large trials, but also inconsistent results reported. Therefore, we aim to compare the operative with nonoperative outcomes of Pipkin type 1 patients. Patients and Methods: We systemically searched MEDLINE, EMBASE, Cochrane library, In-Process & Other Non-Indexed Citations to identify studies assessing outcomes of Pipkin type 1 patients after conservative treatment, and open reduction with excision or fixation. Data on comparison of clinical outcomes of each management were extracted including arthritis, heterotopic ossification (HO), avascular necrosis (AVN), and functional scores (Thompson Epstein, Merle’ d Augine and Postel Score). We performed a meta-analysis with the available data. Results: Eight studies (7 case series and 1 RCT) were included in this study. In a pooled analysis, the overall rate of arthritis was 37% (95% CI, 2–79%), HO was 20% (95% CI, 2–45%), and AVN was 3% (95% CI, 0–16%). In comparison of management types, the excision group reached the best functional outcomes including Thompson Epstein Score (poor to worse, 9%; 95% CI, 0–27%) and Merle d’ Aubigne and Postel Score (poor to worse, 18%; 95% CI, 3–38%); ORIF group had the highest AVN rate (11%; 95% CI, 0–92%); conservative treatment had the highest arthritis rate (67%; 95% CI: 0–100%) and lowest HO rate (2%; 95% CI, 0–28%). Discussion: This meta-analysis demonstrates that different procedures lead to various clinical outcomes: fragment excision may achieve better function, conservative treatment may result in a higher arthritis rate, while ORIFs may have a higher AVN rate. These findings may assist surgeons in tailoring their decision-making to specific patient profiles. Future RCTs with multicenter efforts are needed to validate associations found in this study. Level of Evidence: II, systematic review and meta-analysis.

Pipkin Type I and II femoral head fractures: internal fixation or excision?—from the hip arthroscopy perspective

“…If surgery is selected, the surgical approach needs to be decided. A systematic review and meta-analysis of Pipkin Type I fracture suggested that surgical excision has the best functional outcomes and fixation may have a higher avascular necrosis rate [ 35 ]. Analysis of our outcomes after the application of hip scope–assisted surgery for the treatment of Pipkin Type I and II femoral head fractures demonstrated excellent and good results after either fragment excision or fixation.…”

Closed reduction and minimally invasive screw osteosynthesis of Pipkin femoral head fractures

“…Historically, femoral head fractures have been treated conservatively with closed reduction, prolonged bed rest, and inline traction (Butler, 1981;Epstein et al, 1985;Kristensen and Stougaard, 2009). Closed reduction alone (without stabilization of the fractured fragment) increases the rate of posttraumatic arthritis, may result in malunion, and lead to poor Merle d'Aubigne and Postel outcome scores (Leenen and van der Werken, 1990;Tsai et al, 2022). In the review of Giannoudis et al (2009), only 13% from 54 conservatively treated patients reached an excellent outcome according to Thompson and Epstein criteria, compared to 58% of patients in our group.…”

“…Similar results were reported in the Tsai et al ( 2022) meta-analysis, where fragment excision resulted in the best Thompson-Epstein and Merle d'Aubigne scores. Reduction and internal fixation of a Pipkin type I fracture is recommended if the fragment is larger (Giannoudis et al, 2009;Park et al, 2014;Tsai et al, 2022). Interestingly, no evidence is available for the method we used; minimal invasive fixation of the reduced head fragment with a lag screw inserted lateromedially through the femoral neck.…”

“…They are mostly caused by traffic accidents, falls from a height, and sports injuries. The optimal treatment of these so called Pipkin injuries is still under debate (Giannoudis et al, 2009;Menger et al, 2021;Scolaro et al, 2017;Tsai et al, 2022). Urgent reduction of hip dislocation should be performed, and the strategy of subsequent treatment depends on fracture patterns and the amount of displacement of the head fragment.…”

Safe Surgical Dislocation and Open Reduction, Internal Fixation with Herbert Screw for Pipkin's Fracture Head of Femur in an Obese Patient: An Interesting Case Report

“…Similarly, conservative management strategies have an increased possibility for the development of arthritis. These outcomes should be kept in mind prior to making an informed decision on the management strategy of a fractured head of femur [ 8 ]. Concentric reduction of the fracture associated with early diagnosis and management is imperative to ensure maximum recovery and healing [ 9 ].…”