When one thinks of hip arthroscopy, thoughts of labral
femoroacetabular impingement (FAI) may arise. But in the hip
trauma setting, a recent review article by Foulk and Mullis on hip dislocations
in the Journal of the American Academy of Orthopaedic Surgeons
mentions hip arthroscopy as being useful for the minimally invasive management
labral tears and
Several authors have found intra-articular fracture
fragments upon arthroscopic examination, even in the face of concentric
reductions and the absence of visualized loose bodies on preoperative
radiographs and thin-cut CT scans.
Third-body wear may be a major factor in the development of
the most common complication from hip dislocations, which is post-traumatic
coxarthrosis, not femoral head osteonecrosis. Although controversial whether
routine early surgical intervention is indicated after traumatic hip
dislocations, few would argue against the osteosynthesis of displaced major
weight-bearing fractures of the femoral head.
We recently published an article on the
arthroscopic osteosynthesis of a displaced
femoral head fracture and have since had other interesting
trauma cases that we have managed with hip arthroscopy. The following is a
review of four of them.
Dean K. Matsuda
Arthroscopic femoral head fracture osteosynthesis
An 18-year-old woman was ejected during a rollover motor
vehicle accident and had surprisingly few injuries other than a rare isolated
femoral head fracture without associated dislocation. She was referred to us
for consideration of arthroscopic removal of her fracture fragment. She had a
displaced large suprafoveal osteochondral fracture of the femoral head.
Essential preoperative planning included a critical assessment of the fracture
and an equally critical assessment of our arthroscopic hip experience.
Multiple images depicting a large displaced supra-foveal femoral
Postoperative views after arthroscopic reduction and internal
fixation using "chopstick" maneuver (shown intraoperatively in lower left
inset) and Herbert screw fixation
Images: Matsuda DK
We decided to attempt an
arthroscopic reduction and internal fixation after full
disclosure with the patient that this procedure had not yet been performed.
Moreover, we committed to an open reduction and internal fixation surgery if an
arthroscopic osteosynthesis failed rather than resort to arthroscopic removal
of a major weight-bearing fragment.
We performed supine arthroscopic hip surgery under
general anesthesia with intermittent hip distraction as an outpatient
procedure, utilizing our two standard portals (anterolateral viewing portal and
the modified mid-anterior working portal) plus an anterior portal.
Arthroscopic view of “clamshell” fracture being pried
open with microfracture awl prior to arthroscopic osteosynthesis. The two
cartilage surfaces of the folded-over fracture are represented by A and
Arthroscopic view of first headless screw being inserted after
angle of approach has been improved with arthroscopic rim trimming. Note
cannulated screw being inserted between trimmed acetabular rim and detached
view of osteochondral fracture after fixation with two headless cannulated
screws buried below femoral head chondral surface to level of subchondral bone
Cross-over techniques and creativity
Crossover techniques gained from experience with
arthroscopic FAI surgery, including comfort with 70° arthroscopic
visualization and adequate capsulotomies permitting instrument navigation and
fracture reduction, resulted in a successful surgery; anatomically based portal
placement with attention to traction time and intra-articular fluid pressure
led to a safe one.
Creative positioning of the operative extremity in
atypical positions, even adduction, aided fracture reduction and fixation. The
displaced osteochondral fragment was reduced using a “chopstick”
maneuver described in the original article and then fixated with Herbert screws
buried below the femoral head chondral surface while engaging subchondral bone.
Dynamic arthroscopic examination confirmed secure
internal fixation permitting early hip motion with protected weight-bearing. We
prefer radio-opaque metallic screws so that we may monitor possible early joint
encroachment on intermittent standard postoperative imaging studies.
This patient healed uneventfully and at 2 years out, is
asymptomatic and runs 3 miles daily.
Femoral head fracture with anterior dislocation
We have also managed a femoral head fracture associated
with an anterior dislocation in a 22-year-old man sustained while snowboarding.
A closed reduction had been performed within 4 hours of injury, and the patient
was referred to us for evaluation 1 week later.
The patient underwent supine arthroscopic hip surgery 2
weeks postinjury and was found to have an unusual fracture configuration
whereby the osteochondral fragment folded over on itself (presumably during the
closed hip reduction) with articular cartilage circumferentially surrounding
this “clamshell” fracture. We arthroscopically “pried open”
the fracture with a microfracture awl prior to osteosynthesis with headless
Arthroscopic rim reduction
It is important to note that this patient had
pre-existing abnormal hip morphology consistent with cam-pincer FAI. As part of
this outpatient procedure, an arthroscopic rim reduction was initially
performed to permit an improved angle of attack for screw placement followed by
labral re-fixation and femoral osteoplasty.
At 1-year postoperative, the patient is highly
satisfied, plays tennis and snowboards.
Arthroscopic femoral head malunion
An 18-year-old man presented to our clinic with a
malunion of a femoral head fracture sustained 9 months earlier from a gunshot
injury. His initial open reduction and internal fixation appeared promising
until his vertical fracture displaced with premature weight-bearing and
resulted in a malunion with more than 1 cm of inferior displacement with
secondary FAI of the intact lateral column of the femoral head against the
Preoperative radiograph showing femoral head malunion with
greater than 1 cm inferior translation of major head fragment (blue arrow) and
secondary impingement of proximal extension of lateral femoral head column with
lateral acetabulum (red arrow).
view of femoral head reduction after malunion takedown with main femoral head
segment (A) reduced into desired cephalad relationship to lateral column (B)
and prior to arthroscopic bone grafting with demineralized bone matrix putty
inserted via arthroscopic cannula and internal fixation.
3D CT scan of acetabulum with arrows noting the anterior acetabular fracture
image showing the internal fixation of the anterior acetabular fracture with a
second cannulated screw. Also note the rim-trimmed acetabulum with re-fixated
labrum (left) and femoral osteoplasty (right).
Because the patient had painful restriction of hip
motion and a noticeable leg length discrepancy, and because his young age
dictated an aggressive approach to forestall eventual total hip arthroplasty,
we opted for this arthroscopic approach. Moreover, we felt that by improving
the femoral head reduction, a future surface replacement could become a viable
Arthroscopic takedown, bone grafting and internal fixation
We addressed this challenging situation in six separate
steps. An arthroscopic takedown of the malunion was performed with small
straight and angled osteotomes. Arthroscopic reduction was achieved using a
combination of ipsilateral leg traction and mechanical translation with an
osteotome applying a cephalad-directed force against the retained broken screw
shaft, the latter permitting significant force to be distributed without
iatrogenic damage to the mobilized segment.
Arthroscopic bone grafting was performed with insertion
of demineralized bone matrix putty via an arthroscopic cannula. Percutaneous
screw fixation was performed under arthroscopic and fluoroscopic guidance.
A residual proximal osteophyte of the lateral column was
removed via arthroscopic burr resection. Finally, arthroscopic dynamic testing
confirmed resolution of lateral impingement and a stable fracture construct
permitting early motion.
Arthroscopic acetabular fracture osteosynthesis
Another recent case involved an 18-year-old man with a
gunshot injury with resultant anterior column and wall fractures with
intra-articular fracture fragments.
Preoperative imaging studies revealed FAI pathoanatomy.
Postoperative radiograph showing the reduced femoral head
fracture with percutaneous screw fixation. Also note the absence of secondary
Intraoperative fluoroscopic image under mild hip distraction
showing the anterior acetabular fixation with two screws prior to removal of
flexible guide pins.
We chose to stabilize his acetabular fracture as we did
not want another malunion case from postoperative compliance issues.
Arthroscopic placement of two cannulated screws was performed without incident.
We also performed extraction of small fracture fragments and the bullet, plus
rim trimming with labral re-fixation and femoral osteoplasty as part of this
Fluid extravasation into the intraperitoneal and
retroperitoneal spaces with resultant abdominal compartment syndrome is rare
but may occur, especially with acetabular fractures. Intermittent palpation of
the draped abdomen and monitoring of core body temperature are prudent
The last two cases were performed recently, therefore
outcomes of substance are yet to be reported.
The preceding examples give an interesting and exciting
glimpse into future possible applications of hip arthroscopy. An open procedure
done well trumps a minimally invasive one done poorly; all of us recognize
this. Anatomic reduction with secure internal fixation permitting early joint
motion remains the goal.
However, if the arthroscopic equivalent can be performed
in a safe manner, one can envision an expanding role of arthroscopy in select
cases of hip trauma … well beyond that of loose body removal.
- Foulk DM, Mullis. Hip dislocation: Evaluation and management.
J Am Acad Orthop Surg. 2010:18(4):199-209.
- Matsuda DK. A rare fracture, an even rarer treatment: The
arthroscopic reduction and internal fixation of an isolated femoral head
fracture. Arthroscopy. 2009;25(4):408-412.
- Dean K. Matsuda, MD,can be reached at Kaiser West Los Angeles
Medical Center, 6041 Cadillac Ave., Los Angeles, CA, 90034; 323-857-4477;