Combined ipsilateral acetabular and femoral neck fractures are the
result of high-energy trauma. Satisfactory treatment for this injury pattern
remains a challenge, since traditional open reduction and internal fixation
(ORIF) is always accompanied by a high prevalence of posttraumatic arthritis
and avascular necrosis of the femoral head. Eight of 502 acetabular fractures
from 1990 to 2008 were diagnosed with combined ipsilateral femoral neck
fracture, in which 5 patients fractures were associated with hip
dislocation. These patients were injured from falls, traffic accidents, or
crushing accidents. Radiographs and computed tomography scans were taken to
check acetabular and femoral neck fractures. All of the patients underwent
surgery using appropriate approaches and techniques. Postoperative radiographs
demonstrated anatomic or satisfactory reduction for acetabular fractures as
well as excellent or good reduction for femoral neck fractures in all of the
patients. Follow-up radiographs showed femoral head necrosis in the 5 patients
with femoral head dislocations, but not in the other 3 patients. We have seen
few patients with this injury pattern, which makes us unable to detect
significant differences between the patients associated with femoral head
dislocation and those without femoral head dislocation. But by considering the
results of our study and those reported in the literature, we believe that for
patients with ipsilateral acetabular and femoral neck fractures without hip
dislocation, satisfactory results could be expected after ORIF. But for those
cases associated with hip dislocation, alternative methods such as acute THR as
primary treatment are worthy of consideration.
Combined ipsilateral acetabular and femoral neck fracture may be the
result of high-energy trauma. The incidence of this injury pattern among
acetabular factures in the literature ranged from 1.2% to 3.6%.1-3
Among the 502 acetabular fractures admitted to our department from 1990 to
2008, only 8 cases were diagnosed with combined ipsilateral femoral neck
fracture, yielding an incidence of 1.4% comparable to those of Judet et
al1 and Heeg et al.3
A few reports have described the clinical features of this injury
pattern.1-6 But how to treat it remains a great challenge.
Traditional open reduction and internal fixation (ORIF) is accompanied by a
high prevalence of posttraumatic arthritis and avascular necrosis of the
femoral head, resulting in a need for total hip replacement (THR). Furthermore,
part of this injury pattern may be associated with femoral head
dislocation,4 which makes treatment decision making even more
difficult. However, it is important that a preferable method be chosen if
better outcomes are expected. This study presents 8 consecutive patients
diagnosed with ipsilateral acetabular and femoral neck fractures between
October 1990 and January 2008.
Materials and Methods
Between October 1990 and January 2008, eight consecutive patients
suffered with ipsilateral acetabular and femoral neck fractures including 6 men
and 2 women with a mean age of 38 years (range, 22-55 years). Five injuries
resulted from a fall, 2 from traffic accidents, and 1 from a crushing
accident.7 Of these patients associated with brain or visceral
injuries, 5 were combined with shock, and 5 had other fractures. All patients
were checked radiographically with anteroposterior (AP) and Judet views of the
pelvis. Computed tomography (CT) scans and 3-D reconstructions were also taken.
According to Letournels classification for acetabular
fractures,8 2 posterior wall fractures, 1 posterior column, and 1
posterior wall fracture, 2 transverse and posterior wall fractures, 1
transverse fracture, and 2 column fractures were found. Femoral neck fractures
were classified using Gardens criteria,9 resulting in 2
patients classified as stage III and 6 as stage IV. Radiographs and CT scans
demonstrated ipsilateral superoposterior hip dislocations and femoral neck
fractures in 5 of 8 patients. All fractures underwent primary ORIF 5 to 21 days
after the injury following the treatment of concomitant life-threatening
injuries. The Table presents the detailed demographic data of the 8
All patients underwent skeletal traction preoperatively. We treat
femoral neck fractures using ORIF first, and then treat acetabular fractures
are treated using ORIF. This sequence was used in the hope that the retinacular
vessels of the femoral neck could be protected from further injury during
acetabular fracture reduction. If the femoral neck fracture and hip dislocation
had already been reduced satisfactorily via skeletal traction, the femoral neck
fracture was fixed using cannulated screws under C-arm surveillance. Next, the
patient was repositioned for ORIF of acetabular fractures. If the femoral neck
fracture and hip dislocation were not reduced satisfactorily by skeletal
traction, an appropriate approach fit for all fractures, if possible, was
chosen. Likewise, the hip dislocation and femoral neck fractures were reduced
and fixed first, followed by acetabular ORIF. As a rule, the Kocher-Langenbeck
approach was chosen for posterior column and posterior wall fractures. A
combined Kocher-Langenbeck and ilioinguinal approach was used for transverse
and both column fractures.
Prophylactic antibiotics were administered routinely pre- and
intraoperatively, and continued for 24 to 48 hours postoperatively. Suction
drains were used for 24 to 48 hours. All patients sat up 3 to 4 days
postoperatively. Moderately passive motion or static muscle contraction
exercises of the affected extremities were encouraged. After staying in bed for
7 to 12 days, walking on crutches with partial weight bearing was allowed for 6
to 8 weeks, and then a single crutch was allowed for 4 to 6 weeks until
Reduction quality of the acetabular and femoral neck fractures were
assessed, respectively, using criteria described by Matta10 and
Haidukewych et al.11 Follow-up radiographs were assessed for
fracture healing, posttraumatic arthritis, heterotopic ossification and
avascular necrosis of the femoral head. Heterotopic ossification was graded
according to the Brooker et al method.12 Long-term hip function and
follow-up radiographs were assessed according to DAubigné and
Postel13 and Epstein14 standards, respectively. To
minimize interobserver error, 2 orthopedic fellows not involved in the
management of the patients and blinded to the clinical and radiographic results
reviewed all of the radiographs.
No nerve or vascular complications, infections, or death occurred in
this group. Postoperative radiographs demonstrated that anatomical reductions
(no or <1 mm of displacement at the articular surface) of the acetabular
fracture were achieved in 6 patients (75%) and satisfactory reductions (no more
than 3 mm of displacement) in the remaining 2 (25%). All of the femoral neck
fractures were reduced as excellent or good. No patients were lost to follow-up
in this series. The patients were followed for an average of 9 years (range,
1-18 years), and the fractures in all patients healed eventually. All 5
patients with combined hip dislocations developed avascular necrosis of the
femoral head (100%) (Figure). The majority of them occurred as early as 1 year
postoperatively, and the others were ascertained 2 to 3 years postoperatively.
They underwent THR 1 to 4 years after the primary ORIF because of severe loss
of hip function.
|Figure: A 31-year-old man
involved in a traffi c accident who sustained ipsilateral acetabular and
femoral neck fractures combined with a dislocated hip. Preoperative AP (A) and
obturator oblique (B) radiographs of the hip. Radiographs taken immediately
after ORIF (AP view [C], obturator oblique view [D]). AP radiograph taken 6
months postoperatively (E). All fractures healed successfully. Radiograph taken
1 year postoperatively showing avascular necrosis of the femoral head (F).
As for the 3 patients without femoral head dislocation, no
radiographic signs of avascular necrosis or moderate or severe posttraumatic
arthritis were discovered until recent follow-up. Among them, 1 patient who
suffered from combined brain injury began to display Brooker stage III
heterotopic ossification 6 months postoperatively. Mild posttraumatic arthritis
signs were found on the latest radiographs for this patient, but hip functions
were good. The other 2 patients exhibited good clinical and radiographic
Mears et al7 reported that after ORIF, 14 of 15 patients
(93%) suffered from combined ipsilateral femoral neck and acetabular factures
developed into avascular necrosis of the femoral head. This incidence is higher
than those for displaced femoral neck fractures (Garden III or IV,
30%-40%)15 and displaced acetabular fractures
(5.6%),16 as well as acetabular fractures combined with hip
dislocations (7.5%-9.6%).8,17 Similarly, 5 of 8 patients (63%) in
the present study suffering with the same injury developed avascular necrosis
of the femoral head.
Displaced femoral neck fractures and fracture-disclocations of the hip
are always accompanied by a high incidence of avascular necrosis of the femoral
head, which may be caused by delayed reduction or the degree of the fracture
displacement.18-21 But Bhandari et al22 reported that the
avascular necrosis incidences were not influenced by the period from injury to
reduction. In this series, follow-up results showed that all of the patients
who developed avascular necrosis of the femoral head were those who suffered
with acetabular and femoral neck fractures combined with femoral head
dislocation, while the prognosis seems not related to the delay of 5 to 21 days
from injury to operation. Thus, we believe that the major reason for the high
necrosis rate in this series may be the high-energy trauma that damaged the
blood supply to the femoral head at the time of injury. Accordingly, we believe
that high necrosis incidence is the main clinical feature of this complex
As for the treatment of this injury pattern, considering the fact that
most of the patients suffering this sort of complex injury are relatively young
manual laborers, ORIF as primary treatment is the preferred method. If initial
ORIF is successful, the native joint, which is better than a prosthetic one,
could be used for a lifetime. If severe posttraumatic arthritis or avascular
necrosis of the femoral head develops, the primary ORIF can optimize acetabular
bone stock and minimize pelvic deformity and bone defect, which is beneficial
to the required THR.
Surgeons must keep in mind that the majority of patients may develop
avascular necrosis of the femoral head after ORIF and need eventual THRs. This
will increase not only trauma and suffering for patients, but also overall
medical costs. Additionally, scar tissue, heterotopic bones, retained internal
fixators, as well as possible infections after primary ORIF would present
challenges to surgeons and may increase the complications related to THR.
Thus, another method may be considered, which was to perform acute THR
under special conditions, including those acetabular fractures combined with a
displaced femoral neck fracture.23 The advantages of acute THR
include the potential of 1-stage treatment with quicker recovery and avoidance
of technical difficulties, as well as the possible complications related to the
primary ORIF. The distinct disadvantages of acute THR for acetabular fractures
are the major technical challenges of obtaining both socket and fracture
stability simultaneously.23,24 Another concern is that the majority
of orthopedic surgeons may be reluctant to accept an acute THR because of the
possible revision surgery later, especially for a young patient. But it is
interesting that Mears et al23 observed that the best late results
of THR after acetabular fracture have been documented when the arthroplasties
were performed acutely, and no convincing documented evidence that primary ORIF
improves the success of a subsequent THR exists. Although the authors did not
mean to advocate acute THR for acetabular fractures, it is a choice worthy of
We acknowledge that few patients were in this study as a result of the
rare incidence of this injury pattern. Thus we are unable to detect significant
differences between patients according to whether they had femoral head
dislocations. However, Mears et al23 reported that a small group of
displaced acetabular fractures patterns, including those combined with
displaced femoral neck fractures, as well as a delay between the injury and the
surgery, have a low likelihood for a favorable outcome after ORIF. These are
exactly the characteristics of the patients in the present study. By
considering the results of the present study and keeping in mind the
characteristics of such an injury pattern, we believe it is reasonable to
conclude that for those associated with hip dislocation, acute THR seems to be
a choice worthy of consideration, while for those without hip dislocation,
primary ORIF may be a suitable method.
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- Weber M, Berry DJ, Harmsen WS. Total hip arthroplasty after
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- Manninger J, Kazar C, Fekete G, et al. Significance of urgent
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Dr Wei is from First Peoples Hospital of Yibin, Yibin, and Mssrs
Sun, Wang, and Yang are from First Affiliated Hospital of Soochow University,
Dr Wei and Mssrs Sun, Wang, and Yang have no relevant financial
relationships to disclose.
Correspondence should be addressed to: Jun-Ying Sun, MS, First
Affiliated Hospital of Soochow University, 188 Shizi St, Suzhou, Jiangsu
215006, Peoples Republic of China.