Comparative outcomes of hip arthroscopy-assisted surgery and the direct anterior approach for Pipkin Type I and II femoral head fractures.

Abstract

Comparative evidence regarding the direct anterior approach and hip arthroscopy-assisted surgery for Pipkin type I and II fractures remains limited. This study compares these minimally invasive strategies and evaluates whether fragment excision or internal fixation yields superior functional outcomes. Thirty-nine patients with displaced Pipkin type I or II femoral head fractures treated between April 2010 and June 2023 were retrospectively analyzed, with a minimum follow-up of 2 years. Twenty-five underwent hip arthroscopy-assisted surgery and 14 underwent the direct anterior approach. Clinical outcomes were assessed using the modified Harris Hip Score (mHHS). Radiographic evaluation included Matta reduction criteria, osteonecrosis, heterotopic ossification (HO), and hip osteoarthritis (OA). Perioperative variables included operative time, blood loss, postoperative pain (VAS), and length of hospital stay. A secondary analysis compared fragment excision versus internal fixation. Hip arthroscopy-assisted surgery demonstrated significantly lower perioperative morbidity, with a shorter hospital stay (3.4 ± 1.4 vs. 8.6 ± 4.5 days, P < 0.001) and reduced blood loss (50.0 ± 0.0 vs. 195.0 ± 92.6 ml, P < 0.001) compared with the anterior approach. However, operative time was longer in the arthroscopy group (216.7 ± 48.6 vs. 165.0 ± 37.4 min, P = 0.007). At final follow-up, functional outcomes favored the arthroscopy-assisted group (mHHS: 97.4 ± 1.9 vs. 94.4 ± 4.4, P = 0.010). The anterior approach achieved a significant higher rate of anatomic reduction according to Matta criteria (P = 0.035). Regarding management strategy, fragment excision achieved equivalent excellent mHHS compared with internal fixation (98.0 ± 1.6 vs. 95.6 ± 3.6), though the difference was statistically significant (P = 0.010). Hip arthroscopy-assisted surgery significantly reduced perioperative morbidity and achieved equivalent, excellent clinical function compared with the anterior approach in the short- to mid-term, despite a higher rate of imperfect radiographic reductions. In carefully selected Pipkin type I fractures involving small, non-weight-bearing fragments, fragment excision was associated with favorable functional outcomes, supporting its role as a selective treatment option rather than a universal strategy. IV: Retrospective cohort study.