Lessons Learned from Long-Term Management of Hip Fracture in Patients with Osteopetrosis: A Report of Nine Hips in Five Patients

BACKGROUND: Treating patients with osteopetrosis is very challenging even in very skilled surgeons with many experiences. We present an account of 5 patients treated for hip fracture related problems occurring throughout their life due to this disease. Difficulties encountered during their treatment prompted us to present some general management principles. METHODS: From January 2003 to December 2016, 5 patients with osteopetrosis (9 hips; 3 men, 2 women), who underwent operative or conservative treatment were retrospectively reviewed. We evaluated their clinical features and rate of union, malunion and post-operative infection. RESULTS: Four of 5 patients (80%) suffered bilateral fracture, and 8 of 9 fractures (89%) are transverse and occurred at subtrochanteric area resulted from minor trauma. Among 9 hips, surgery was performed in seven hips. Nonunion were found in 3 hips (33%), malunion in 1 hip (11%) and oteomyelitis was developed in 2 hips (22%) at a median of 8.1 years. CONCLUSIONS: Clinical features of hip fracture in osteopetrosis are very similar to atypical subtrochanteric femoral fractures. Patients should be informed of the possibilities of several anticipated complications including the risk of nonunion and infection after surgery.

Preventive Effects of Low Parathyroid Hormone Levels on Hip Fracture in Patients with Vitamin D Deficiency

BACKGROUND: The objective of the current study is to determine the role of serum parathyroid hormone (PTH) on hip fracture development by retrospectively analyzing the relationship between vitamin D and PTH levels and hip fracture prevalence. METHODS: Among 288 patients over 50 years of age, 113 patients with hip fracture and 111 controls without fracture were analyzed after excluding patients with conditions affecting bone metabolism. Bone mineral density and serum biochemical markers were measured, while demographic data were obtained. Patients were divided into 4 groups according to serum 25-hydroxy-vitamin D (25-[OH]D) and PTH levels: LowD+LowP (low 25[OH]D and PTH); LowD+HighP, (low 25[OH]D and high PTH); HighD+LowP (high 25[OH]D and low PTH); and HighD+HighP, patients with (high 25[OH]D and PTH). Measured values and percentages of patients with hip fracture in each group were then determined and compared. RESULTS: The number of patients included in the LowD+LowP, LowD+HighP, HighD+LowP, and HighD+HighP groups was 116, 17, 87, and 4, while the percentages of patients with hip fracture in the same groups were 60.3%, 88.2%, 27.6%, and 100%, respectively. The percentage of hip fracture was significantly lower in the LowD+LowP than the LowD+HighP group (P=0.049). CONCLUSIONS: Patients with low serum 25(OH)D and PTH levels showed lower hip fracture prevalence, indicating the potential protective role of low PTH levels on bone health in patients with vitamin D deficiency. Therefore, clinicians should pay more attention to the possibility of fractures in patients with vitamin D deficiency who present with high PTH levels.

Effect of Preoperative Bisphosphonate Treatment on Fracture Healing after Internal Fixation Treatment of Intertrochanteric Femoral Fractures / 대한고관절학회지

PURPOSE: There are concerns that administration of bisphosphonate (BP) can substantially suppress bone turnover, potentially interfering with fracture healing. We investigated the effects of preoperative BP administration before internal fixation of intertrochanteric femoral fractures using fracture healing and clinical outcomes. MATERIALS AND METHODS: We retrospectively analyzed data from 130 patients who underwent internal fixation for osteoporotic intertrochanteric femoral fractures between March 2012 and July 2016. Patients previously treated with BPs for at least 3 months (BP group; n=29) were compared with the remaining patients (BP-naïve group; n=101). Radiographs were used to assess and compare fracture healing 3 months and 1 year postsurgery. The primary clinical outcome measure assessed was change in Koval score. RESULTS: Fracture union at 3 months after surgery was verified in 72.4% of patients (21/29) in the BP group and 90.1% of patients (91/101) in the BP-naïve group (P=0.027). Fracture union at 1 year postsurgery (BP group, 93.1% [27/29] vs. BP-naïve group, 97.0% [98/101], P=0.310) and change in Koval score (1.1 vs. 1.0, P=0.694) were not significantly different between the groups. Multivariable logistic regression analysis revealed that a history of BP administration was associated with an increased risk of delayed union at 3 months postsurgery (P=0.014). CONCLUSION: Preoperative administration of BP was associated with a decreased fracture healing rate 3 months after internal fixation, compared with BP-naïve patients. Therefore, patients previously treated with a BP should be carefully allowed to wean off walking aids and transition to full weight-bearing in the early postoperative period.

Risk Stratification for Avascular Necrosis of the Femoral Head After Internal Fixation of Femoral Neck Fractures by Post-Operative Bone SPECT/CT / 대한핵의학회잡지

PURPOSE: Avascular necrosis (AVN) of the femoral head is a major complication after internal fixation of a femoral neck fracture and determines the functional prognosis. We investigated postoperative bone single-photon emission computed tomography/computed tomography (SPECT/CT) for assessing the risk of femoral head AVN.METHODS: We retrospectively reviewed 53 consecutive patients who underwent bone SPECT/CT within 2 weeks of internal fixation of a femoral neck fracture and follow-up serial hip radiographs over at least 12 months.RESULTS: Nine patients developed femoral head AVN. In 15 patients who showed normal uptake on immediate postoperative SPECT/CT, no AVN occurred, whereas 9 of 38 patients who showed cold defects of the femoral head later developed AVN. The negative predictive value of immediate postoperative SPECT/CT for AVN was 100 %, whereas the positive predictive value was 24 %. Among 38 patients with cold defects, 1 developed AVN 3 months postoperatively. A follow-up bone SPECT/CT was performed in the other 37 patients at 2??0 months postoperatively. The follow-up bone SPECT/CT revealed completely normalized femoral head uptake in 27, partially normalized uptake in 8, and persistent cold defects in 2 patients. AVN developed in 3.7 % (1/27), 62.5 % (5/8), and 100 % (2/2) of each group, respectively.CONCLUSION: According to the time point of imaging, radiotracer uptake patterns of the femoral head on postoperative bone SPECT/CT indicate the risk of AVN after internal fixation of femoral neck fractures differently. Postoperative bone SPECT/CT may help orthopedic surgeons determine the appropriate follow-up of these patients.

Cobalt Intoxication Heart Failure after Revision Total Hip Replacement for Ceramic Head Fracture: A Case Report / 대한고관절학회지

In 1960s, toxic heart failure due to cobalt poisoning was firstly reported from Canadian industrial worker. Following development of bearing materials in hip arthroplasties, using cobalt-chrome alloy in bearing surface, there were rarely reported of systemic affect toxic cobaltism include toxic heart failure due to articulation wear in Western countries. It could be happened more easily by third body wear from ceramic particle especially revision total hip replacement (THR) surgery using cobalt-chrome alloy following ceramic articulation breakage which index surgery performed by ceramic on ceramic bearing. In Korea, due to many surgeons prefer ceramic on ceramic bearing in THR compared to Western countries, it might be more important issue within a time. However in our knowledge, there was no previous report about cobalt poisoning heart failure in Korea. It is still very rare and hard to diagnose cobalt intoxication heart failure after THR, so we report a case of fatal heart failure caused by cobalt intoxication after revision THR in 53-year old man who successfully underwent re-revision THR.

Generation and characterization of integration-free induced pluripotent stem cells from patients with autoimmune disease

Autoimmune diseases (AIDs), a heterogeneous group of immune-mediated disorders, are a major and growing health problem. Although AIDs are currently treated primarily with anti-inflammatory and immunosuppressive drugs, the use of stem cell transplantation in patients with AIDs is becoming increasingly common. However, stem cell transplantation therapy has limitations, including a shortage of available stem cells and immune rejection of cells from nonautologous sources. Induced pluripotent stem cell (iPSC) technology, which allows the generation of patient-specific pluripotent stem cells, could offer an alternative source for clinical applications of stem cell therapies in AID patients. We used nonintegrating oriP/EBNA-1-based episomal vectors to reprogram dermal fibroblasts from patients with AIDs such as ankylosing spondylitis (AS), Sjögren's syndrome (SS) and systemic lupus erythematosus (SLE). The pluripotency and multilineage differentiation capacity of each patient-specific iPSC line was validated. The safety of these iPSCs for use in stem cell transplantation is indicated by the fact that all AID-specific iPSCs are integrated transgene free. Finally, all AID-specific iPSCs derived in this study could be differentiated into cells of hematopoietic and mesenchymal lineages in vitro as shown by flow cytometric analysis and induction of terminal differentiation potential. Our results demonstrate the successful generation of integration-free iPSCs from patients with AS, SS and SLE. These findings support the possibility of using iPSC technology in autologous and allogeneic cell replacement therapy for various AIDs, including AS, SS and SLE.

The Role of Beta-Tricalcium Phosphate Graft in the Dynamic Hip Screw Fixation of Unstable Intertrochanter Fracture

PURPOSE: The purpose of this study was to introduce our method of stabilizing unstable intertrochanteric fractures by using the dynamic hip screw (DHS) with a beta-tricalcium phosphate (β-TCP) graft and to compare the outcomes of this procedure with those of the conventional DHS without β-TCP. MATERIALS AND METHODS: Patients who underwent surgery by using DHS between March 2002 and January 2016 were retrospectively reviewed for analysis of the outcomes. The inclusion criteria were: 1) age of 60 years and older; 2) low-energy fracture resulting from a fall from no greater than the standing height; 3) multifragmentary pertrochanteric fracture (AO classification 31-A2.2, 2.3); and 4) follow-up of over 3 months. We compared 29 patients (29 hips) who underwent surgery, using DHS without β-TCP, with 29 age-sex matched patients (29 hips) who underwent surgery using DHS with grafted β-TCP granules to empty the trochanter area after reaming. We investigated the fracture union rate, union time, and length of lag screw sliding. RESULTS: Bone union was achieved in all cases. The mean union time was 7.0 weeks in the β-TCP group and 8 .8 weeks in the non-β-TCP group. The length of lag screw sliding was 3.6 mm in the β-TCP group and 5 .5 mm in the non-β-TCP group. There were no implant failure cases in both groups. CONCLUSION: The β-TCP graft for reinforcement DHS acquired satisfactory clinical outcomes for treating unstable intertrochanteric fractures.

Aspergillus Septic Arthritis of the Hip in an Immunocompetent Middle-aged Female with Undiagnosed Recurrent Pulmonary Aspergillosis / 대한고관절학회지

We present a case of Aspergillus septic hip arthritis in an immunocompetent patient with undiagnosed recurrent pulmonary aspergillosis who underwent arthroscopic surgery. Biopsy specimens of synovium revealed fungal hyphae, confirming Aspergillus infection. Aspergillus septic hip arthritis can occur in immunocompetent patients, and arthroscopy can be a noninvasive surgical option in these cases.

Arthroscopic Treatment for External Snapping Hip / 대한고관절학회지

PURPOSE: The purpose of this study was to evaluate the clinical outcome of arthroscopic treatment for recalcitrant external snapping hip. MATERIALS AND METHODS: Between September 2011 and June 2013, we evaluated 7 patients (10 cases) with snapping hip who were refractory to conservative treatments for at least 3 months. Two patients (4 cases) were impossible to adduct both knees in 90degreesof hip flexion. Surgery was done in lateral decubitus position, under spinal anesthesia. We made 2 arthroscopic portals to operate the patients, and used cross-cutting with flap resection technique to treat the lesion. We performed additional gluteal sling release in those 2 patients (4 cases) with adduction difficulty. Average follow-up length was 19 months (range, 12-33 months). Clinical improvement was evaluated with visual analog scale (VAS), modified Harris hip score (mHHS), and also investigated for presence of limping or other complications as well. RESULTS: The VAS decreased from 6.8 (range, 6-9) preoperatively to 0.2 (range, 0-2) postoperatively, and the mHHS improved from 68.2 to 94.8 after surgery. None of the patients complained of post-operative wound problem or surgical complications. CONCLUSION: The clinical outcome of arthroscopic treatment for recalcitrant external snapping hip was encouraging and all patients were also satisfied with the cosmetic results.

The Character of Reverse Obliquity Intertrochanteric Fractures in Elderly Patients

PURPOSE: To discriminate the characteristics between reverse obliquity fractures in the elderly and that of young adults using three-dimensional computed tomography (3D CT). MATERIALS AND METHODS: Eighteen patients who had reverse obliquity intertrochanteric fractures were enrolled from January 2007 to March 2012. The fracture pattern was analyzed using the 3D CT. The area showing low density (bone defect) of trochanter and femoral neck region was measured. Patients were divided into two groups: Group I, less than 65 years old and Group 2, 65 years and over. RESULTS: In all 9 cases of group 1, the proximal fragment had a 'V' shape with an average of 5.6 cm below the vastus ridge; however, the fracture of 8 cases (88.97%) in group 2 had a 'Lambda' shape of the distal fragment at the level of vastus ridge and an additional fracture line extending to the greater trochanter tip. The bone defect volume of the trochanter and femoral neck region was larger significantly in group 2 than in group 1. CONCLUSION: Reverse obliquity intertrochanteric fracture in the elderly demonstrated a pattern of bursting fracture with 4 parts, which had different patterns from that of young patients. We believe that the larger volume of bone defects resulted in the difference of fracture patterns between the two groups.

Association of Bone Marrow Sphingosine 1-phosphate Levels with Osteoporotic Hip Fractures

BACKGROUND: Sphingosine 1-phosphate (S1P) has been discovered to be a critical regulator of bone metabolism. Very recently, we found that higher circulating S1P levels were associated with higher rate of prevalent osteoporotic fracture in human. METHODS: This was a cross-sectional study of 16 patients who underwent hip replacement surgeries. Bone marrow fluids were obtained during hip surgeries, and the S1P levels were measured using a competitive enzyme-linked immunosorbent assay (ELISA) assay. Bone mineral densities (BMDs) at various skeletal sites were obtained using dual energy X-ray absorptiometry. RESULTS: Among 16 patients, 4 patients were undergone operations due to hip fractures, and the others were done by any other causes. Bone marrow S1P levels were significantly lower in patients with hip fractures than in those without, before and after adjusting for confounding factors (P=0.047 and 0.025, respectively). We failed to demonstrate significant associations between bone marrow S1P levels and any BMD values (gamma=0.026-0.482, P=0.171-0.944). CONCLUSIONS: In conjunction with our previous findings, these suggest that the effects of gradient between peripheral blood and bone marrow, but not S1P itself, may be the most critical on bone metabolism.

Validation of a New Food Frequency Questionnaire for Assessment of Calcium and Vitamin D Intake in Korean Women

BACKGROUND: Validated simple calcium questionnaires are available to assess the intake of calcium and vitamin D in western countries, but they are not appropriate for Koreans since dairy products are not the major source of calcium and vitamin D in Korea. Thus, the objective of the present study was to develop and validate a simple and easy food frequency questionnaire (FFQ) of calcium and vitamin D for Korean. METHODS: Two hundred and fifty-six women were asked to complete the validated FFQ used by the Korean National Health and Nutrition Examination Survey (KNHANES) and a newly developed FFQ, the Korean Calcium Assessment Tool (KCAT), which contain the 7 food groups with 24 categories of 45 food items that are consumed frequently by Koreans. RESULTS: Calcium intake was not significantly different between the two methods; Pearson's correlation coefficient of 0.98 indicated a positive correlation, and Cohen's kappa coefficient of 0.78 indicated the subjects were correctly classified. Bland-Altman plot also showed that the mean differences of the calcium intake as assessed by the two methods were in high agreement. However, the vitamin D intake assessed by KCAT was significantly higher than that assessed by the FFQ used in KNHANES. The vitamin D intakes as assessed by the two methods were positively correlated but the two methods were in moderate agreement. CONCLUSIONS: The results suggested that the newly developed KCAT was a valid tool for assessing the calcium intake in Korean women, but it might overestimate the vitamin D intake.

Anatomical Study of Symphysis Pubis Using 3 Dimensional Computed Tomography in Koreans

PURPOSE: To acquire anatomical data for the normal pelvic bone structure using three-dimensional computed tomography (3D CT) and to propose the most appropriate angle and screw length for safe screw insertion during symphysis pubis plating. MATERIALS AND METHODS: We performed 3D CT analysis in 52 patients who required plating and selected a medial and lateral insertion point between the symphysis pubis and the pubic tubercle. Using a three-dimensional medical image analysis program, we evaluated the appropriate screw length, sagittal angle, and oblique angle at each point in this cohort. RESULTS: At the medial point, the sagittal angle was determined to be 49.1degrees with an average screw length of 49.4 mm. At the lateral point, we calculated an average screw length of 49.1 mm, oblique angle of 23.2degrees, and sagittal angle of 45.7degrees. The screw length was longer in men than in women (4.6 mm and 7.3 mm, respectively) at the medial and lateral point. CONCLUSION: At the symphysis pubis diastasis, we can insert the screw caudally at 49degrees with a minimal length of 37 mm at the medial point. We can insert the screw caudally at 46degrees, medially at 23degrees, with a minimal 34 mm length at the lateral point.

Serum Bisphenol A Concentration in Postmenopausal Women with Osteoporosis

OBJECTIVES: Bishphenol A (BPA) is a representative endocrine disruptor and is also known as a xenoestrogen. The objective of the present study is to investigate how many patients are exposed to BPA and to analyze the relationships between serum BPA concentration, bone mineral density (BMD) and biochemical bone markers in postmenopausal women with osteoporosis. METHODS: Total 51 patients were enrolled for measuring BPA and clinical variables including BMD and bone markers. The relationship between BPA and clinical variables were analyzed by the Pearson's correlation test and the Kruskal-Wallis test. Serum BPA concentration was measured by enzyme linked immunosorbent assay (ELISA). RESULTS: BPA was detected in all samples. The mean BPA concentration was 1.44 +/- 0.52 ng/mL. There was no statistically significant correlation between BPA and clinical variables. CONCLUSION: There was no statistical significance between serum BPA concentration and clinical variables related to bone metabolism. To clarify the effect of BPA on bone metabolism, further large scaled and high risk group investigation may be needed.

The Effects of Extracellular pH on Proliferation and Differentiation of human Bone Marrow Stem Cells

OBJECTIVES: The purpose of this study is to identify whether the change of pH affects the proliferation and the differentiation of human bone marrow stem cells (hBMSCs) and what mechanism is underlied. METHODS: To achieve objective of this study, hBMSCs were cultivated in the conditioned media adjusted to potential of hydrogen (pH) ranging from 6.4 to 8.0 using addition of hydrochloric acid (HCl) and sodium hydroxide (NaOH). The ratio of proliferation of hBMSCs according to the change of pH was measured for 24 h, 48 h, and 72 h using water-soluble tetrazolium salt (WST)-8 method. To elucidate the mechanism involved, hBMSCs was subjected to blocking extracellular signal-regulated kinases (ERK) and calcium sensing receptor (CaSR) activation. The Osteogenic-related genes and alkaline phosphatase (ALP) activity were tested under the conditioned media. RESULTS: The proliferation of hBMSCs was promoted under extracellular alkali conditions (pH 7.6~8.0) via CaSR/ERK pathway. On the other hand, the differentiation was inhibited/delayed via decreased ALP activity besides gene expression at pH 8.0. CONCLUSION: Extracellular alkali or acidic surrounding according to pH alteration can play a crucial role in hBMSC behavior including the proliferation and the differentiation.

The Effects of Extracellular pH on Proliferation and Differentiation of human Bone Marrow Stem Cells

OBJECTIVES: The purpose of this study is to identify whether the change of pH affects the proliferation and the differentiation of human bone marrow stem cells (hBMSCs) and what mechanism is underlied. METHODS: To achieve objective of this study, hBMSCs were cultivated in the conditioned media adjusted to potential of hydrogen (pH) ranging from 6.4 to 8.0 using addition of hydrochloric acid (HCl) and sodium hydroxide (NaOH). The ratio of proliferation of hBMSCs according to the change of pH was measured for 24 h, 48 h, and 72 h using water-soluble tetrazolium salt (WST)-8 method. To elucidate the mechanism involved, hBMSCs was subjected to blocking extracellular signal-regulated kinases (ERK) and calcium sensing receptor (CaSR) activation. The Osteogenic-related genes and alkaline phosphatase (ALP) activity were tested under the conditioned media. RESULTS: The proliferation of hBMSCs was promoted under extracellular alkali conditions (pH 7.6~8.0) via CaSR/ERK pathway. On the other hand, the differentiation was inhibited/delayed via decreased ALP activity besides gene expression at pH 8.0. CONCLUSION: Extracellular alkali or acidic surrounding according to pH alteration can play a crucial role in hBMSC behavior including the proliferation and the differentiation.

Study about Biodegradation of Hydroxyapatite and beta-tricalcium Phosphate Coating Layer

OBJECTIVE: Biodegradation of synthetic calcium phosphate depends on two mechanisms; dissolution in body fluid and a cellular reaction. The chemical dissolution process is well understood, but details of the cellular reaction are not yet fully understood. Thus, we investigated whether the resorption mechanisms of hydroxyapatite (HA) and beta-tricalcium phosphate (beta-TCP) coating layer were identical, and, if not, what differences were observed. METHODS: Titanium discs, 12 mm in diameter and 2 mm in thickness, were coated with HA (n = 40) or beta-TCP (n = 40) by a dip and spin method. In each group, specimens were divided into two subgroups; the Dissolution group (D) and the Osteoclast Culture group (C). Discs in the D group were immersed in the distilled water or cell culture medium for 5 days, whereas, in the C group, osteoclast-like cells, which were obtained from giant cell tumor of bone, were seeded onto specimens and cultured for 5 days. The degradation characteristics of the surface coating were observed by light microscopy and scanning electron microscopy. RESULTS: Extent of the cracks and denudations were much greater in the beta-TCP coating than the HA coating after dissolution. In the C groups, the mean area fraction of resorption lacunae in the HA-C group was 11.62%, which was significantly higher than the 0.73% noted in the beta-TCP-C group (P = 0.001). CONCLUSION: The resorption mechanism of HA and beta-TCP coating was different and the beta-TCP coating was degraded principally by dissolution and separation from the implant, but the HA coating was resorbed by osteoclastic activity.

The Effect of Cefazolin on Mechanical Properties and Antibacterial Reactions of Calcium Phosphate Cement / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to evaluate the change of mechanical properties and the effect of antibacterial reactions in calcium phosphate cement (CPC) mixed with cefazolin. MATERIALS AND METHODS: We made CPC and a sodium alginate solution and we mixed in variable dosages of cefazolin and then we made a standard sized cement mold. With that we performed compression stress tests, drug releasing tests and antibacterial tests. RESULTS: We found the typical appearance of hydroxyapatite (HA) in the cement mixed with cefazolin. The compressive strength of the cement mixed with cefazolin was higher than that of the cement not mixed with cefazolin and the higher strength cement had a smaller pore size and less porosity. The sodium alginate solution showed the maximum compressive strength at 2 & 4 wt%, but this was decreased at 6 wt%. Cefazolin was released in proportion to the concentration for the first 8 days on the drug releasing test and then a similar amount was released until the tenth day. An antibacterial effect was detected at all dosages of cefazolin on the antibacterial test. CONCLUSION: The compressive strength of the cement mixed with cefazolin was higher than that of the cement not mixed with cefazolin. The drug was released from the cement in a proper fashion and the antibacterial effect was preserved.

Clinical Results of Femoral Subtrochanteric Fractures

PURPOSE: This study examined the clinical course of subtrochanteric fractures of the femur as well as the risk factors of complications. MATERIALS AND METHODS: A retrospective study was performed on 56 patients with femoral subtrochanteric fractures who were treated at our hospital from 2004 to 2008. Risk factors, such as the type of fracture, type of implant, soft tissue dissection at the fracture site, communition of the medial cortex and degree of fracture displacement after the reduction, were compared to determine their effect on the rate of complications, such as nonunion and implant failure. Open reduction with a soft tissue dissection at the fracture site was performed in 34 cases, and a closed reduction was performed in 22 cases. Thirty five cases had medial cortex communition and 21 cases did not. RESULTS: There were 8 cases of nonunion(14.3%). There was a positive correlation between the degree of fracture displacement after the reduction and the union time (P=0.017). The union time was longer when there was communition of the medial cortex. A subtrochanteric fracture using an open reduction tended to have a long union time but this was not statistically significant. There was no correlation between the type of implant and union time. CONCLUSION: The union time is longer in subtrochanteric fractures with communition of the medial cortex. Therefore, it is important to preserve the blood supply at the fracture site using a closed reduction and restore the fracture reduction accurately.

Outcomes of Treatment for Femoral Head Fractures with Hip Dislocation: Review of 20 Cases

PURPOSE: We wanted to assess the clinical results and the complications of treating femoral head fractures. MATERIALS AND METHODS: Twenty patients with femoral head fractures and who had a minimum 1 year follow up were enrolled in this study from April 2004 to June 2008. The clinical outcomes were evaluated according to the mechanism of injury, the reduction time, the Pipkin classification, the treatment methods, the surgical approach and the complications. RESULTS: There were 5 cases of Pipkin type I and 2 cases of Pipkin type II, 1 case of Pipkin type III and 12 cases of Pipkin type IV. All the patients underwent operation except 1 patient; there were 5 excisions, 7 internal fixations, 1 prosthesis, and 6 internal fixations of combined acetabular fixation without surgery for the femoral head fractures. The average Harris hip score at 1 year after operation was 80.0 (range: 57~99): there were 4 excellent, 7 good, 5 fair and 4 poor results. The complications of the femoral head fractures were 2 cases of avascular necrosis and 2 cases of posttraumatic osteoarthritis. CONCLUSION: Internal fixation of the femoral head with using Herbert screws showed a favorable outcome, while excision of the femoral head fragments did not. Internal fixation of Pipkin type 1 or 2 fractures could be performed by the anterior approach. The posterior approach combined with surgical dislocation is especially useful in internal fixation of concurrent posterior acetabular fractures, and it has the advantage of preserving the blood supply to the femoral head.