Abstract
Aim
-
The aim of this study was to provide a comprehensive overview of floating hip injury and attempt to provide a management algorithm.
Methods
-
PubMed was searched using the terms ‘Floating hip’ or ‘acetabular fracture’ and ‘Ipsilateral femoral fracture’ or ‘pelvic fracture’ and ‘Ipsilateral femoral fracture’. One author performed a preliminary review of the abstracts and references of the retrieved articles.
Results
-
The mean injury severe score reported was higher than 20. Chest and abdominal injuries, as well as fractures at other sites, were the most common associated injuries. Despite the high disability rate, surgery remained the preferred option for managing these injuries. The surgical timing varied from a few hours to several days and was subjected to the principles of damage control orthopedics. Although, in most cases, fixation of femoral fractures took precedence over pelvic or acetabular fractures, there was still a need to consider the impact of damage control orthopedics, associated injuries, and surgeon's considerations and preferences. Posttraumatic arthritis, neurological deficits, heterotopic ossification, femoral head necrosis, femoral nonunion, and limb inequality were common complications of the floating hip injury.
Conclusions
-
The severity of such injuries often exceeds that of an isolated injury and often requires specialized multidisciplinary treatment. In the management of these complex cases, the complexity and severity of the injury should be fully assessed, and an appropriate surgical plan should be developed to perform definitive surgery as early as possible, with attention to prevention of complications during the perioperative period.
Introduction
The term ‘floating joint’ refers to a fracture that occurs both above and below the joint (1). It can be either extra-articular or intra-articular. In 1992, Liebergall et al. first used the term ‘floating hip’ to refer to a fracture of the pelvic ring or acetabulum and an ipsilateral femoral fracture (2). They described two types of floating hip: Type A, a pelvic fracture with an ipsilateral femoral fracture; Type B, an acetabular fracture with an ipsilateral femur fracture. In 1999, Müller et al. proposed a type C floating hip characterized by pelvic ring, acetabular, and femoral fractures (3).
High-energy violence is often required to generate these entities. Due to the abundant blood supply of the pelvis or acetabulum and femur, once these structures are fractured, they are prone to massive blood loss and serious complications such as traumatic shock, retroperitoneal hematoma, urinary system injury, and abdominal organ damage, which can cause death and disability. Cech et al. reported a mortality rate of approximately 3% for floating hip injury in their population (4). In particular, floating hip injury involving pelvic ring fracture has a higher mortality rate (3, 5) and tends to occur in the initial phase of treatment (3, 4).
Although there is broad consensus on the management of unstable pelvic ring fractures, acetabular fractures, and femoral fractures (6, 7, 8, 9, 10, 11), few reports have discussed the treatment protocols and outcomes of patients with simultaneous pelvic or acetabular and ipsilateral femoral fractures (2, 3, 12). At present, there are few relevant studies on this injury, and most of them are case reports (13, 14, 15, 16, 17, 18, 19). In addition, variations in the definition of floating hip and the scarcity of this injury have led to considerable heterogeneity of published studies. Nevertheless, the published literature has emphasized the severity, difficulty of management, and a high number of complications of this injury (2, 3, 5, 20, 21), which undoubtedly poses a continuous challenge to trauma orthopedic surgeons. Therefore, our aim was to provide a comprehensive overview of floating hip injury in order to raise awareness of this serious injury among the trauma orthopedic team and to try to provide an algorithm for the management of such injury.
Methods
PubMed was searched using the search items ‘Floating hip’, or ‘acetabular fracture’, and ‘Ipsilateral femoral fracture’, or ‘pelvic fracture’, and ‘Ipsilateral femoral fracture’. The search timeframe is until January 2023. One author screened the initially retrieved results. Those articles that were not in English were excluded unless their translated versions were available. The references of the selected articles were also reviewed to identify other valuable articles. A total of 22 articles were included in this review. (Fig. 1). The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
A flow diagram illustrating the process of including and excluding articles.
Citation: EFORT Open Reviews 9, 3; 10.1530/EOR-23-0013
Results
Report selection
The search strategy yielded 202 records that met the search criteria. After reviewing titles and abstracts, 182 studies were excluded. A review of the references of the remaining articles identified two references that met the inclusion criteria. A total of 22 articles were ultimately included in this review. These included eight case series and 14 case reports.
Results synthesis
Considering that case reports cannot summarize the commonalities of floating hip injury, we summarized the characteristics of the included case series studies in Tables 1 and 2 and present the postoperative complications in Table 3.
Details on the number of cases, injury severity, classification, and mean time from injury to surgery in the study are included in this review.
| Study | Cases, n | ISS | Classification (2, 3) | Mean time from injury to surgery | ||
|---|---|---|---|---|---|---|
| Type A | Type B | Type C | ||||
| Liebergall et al. (2) | 17 | NR | 14 | 3 | 6 (4–31) days | |
| Wu et al. (22) | 16 | NR | 16 | NR | ||
| Müller et al. (3) | 40* | 35 (14–50) | 12 | 25 | 5 | 5.5 (0–25) days |
| Liebergall et al. (12) | 20 | NR | 20 | |||
| 1-stage procedure | 7 cases: few hours; 6 cases: several days |
|||||
| Staged procedures | Femur: emergency; Acetabulum: few days |
|||||
| Burd et al. (21) | 57 | 20.1 (9–50) | 17 | 15 | 25 | 87 (6–430) h |
| Wu et al. (5) | 40 | NR | 40 | NR | ||
| Zamora-Navas et al. (23) | 25 | NR | 12 | 13 | NR | |
| Cech et al. (4) | 69 | 26.1 (9–53) | 52 | 3 | 14 | |
| Femur | 1.95 days | |||||
| Acetabulum | 8.3 days | |||||
| Pelvic ring | 3.7 days | |||||
*Includes 42 floating hip injuries and four cases of open femoral fracture.
NR, not reported; ISS, injury severity score.
Treatment procedures, mean follow-up time, and functional scores reported in the included studies.
| Study | Definitive treatment* | Mean follow-up | Functional score | ||
|---|---|---|---|---|---|
| Femur | Acetabulum | Pelvic ring | |||
| Liebergall et al. (2) | ORIF: 15; external fixation: 1; Hemiarthroplasty: 1 | ORIF: 3 | ORIF: 14; auxiliary fixation: 9 | 20 (6–35) months | NR |
| Wu et al. (22) | ORIF: 4; CRIF: 12 | ORIF: 17; non-surgery: 13 | 3.5 (2–8) years | Satisfactory results: 16 cases | |
| Müller et al. (3) | ORIF: 40; amputation: 1; non-surgery: 1 | ORIF: 17; non-surgery: 13 | ORIF: 10; non-surgery: 5 | 32.4 months; two PST deaths, five patients lost to follow-up | Work without limitations: 20 cases; change of occupation: eight cases; disabled: four cases; retired: one case |
| Liebergall et al. (12) | ORIF/CRIF: 20 | ORIF: 20 | 74 months (12–160); one death, one patient lost to follow-up | HHS – posterior acetabular fracture: 83.8 (63–100); central acetabular fracture: 89 (82–100) | |
| Burd et al. (21) | ORIF/external fixation: 53; amputation: 1; Spica casting: 1; non-surgery: 2 | ORIF: 32; non-surgery: 8 | ORIF: 23; non-surgery: 19 | 28 months | Return to employment: 32 cases (32/35); retired: seven cases; disabled: three cases; students: ten cases; incarcerated: one case; between jobs: one case |
| Wu et al. (5) | ORIF: 34; external fixation: 2 | ORIF: 27; external fixation: 8 | 32 (12–76) months | Satisfactory HHS: 34 cases (94%); satisfactory MKS: 30 cases (83%) | |
| Zamora-Navas et al. (23) | Initial ORIF: 25; Amputation later: 3 | ORIF: 13 | ORIF: 12 | NR | NR |
| Cech et al. (4) | Nail: 51; locking plate: 18 | ORIF: 9; THA: 3; non-surgery: 5 | Ant. lesion: 7; Post. lesion: 26; Ant. + Post. lesion: 33 | 5 ± 3 years, 19 cases lost to follow-up | OHS : 35.5 ± 10†; MJS: 71.5 ± 22.6‡ |
*Number of cases is provided for each procedure; †Scored by 12 patients with acetabulum lesions; ‡Scored by 47 patients with pelvic ring lesions.
CRIF, closed reduction and internal fixation; HHS, Harris hip score; MKS, Mize knee score; MJS, Majeed score; NR, not reported; ORIF, CRIF, open reduction and internal fixation; OHS, Oxford hip score; PST, post-traumatic.
Postoperative complications reported in the studies included.
| Study | Postoperative complications |
|---|---|
| Liebergall et al. (2) | Delayed wound healing: two cases; neurological injuries: eight cases; shortening of the affected leg: five cases; heterotopic ossification: one case |
| Wu et al. (22) | Incidence: 18.8% (3/16); OA: two cases; femoral nonunion: one case |
| Müller et al. (3) | DVT: three cases; neurological deficits: eight cases; wound infection: two cases; non-union: four cases; femur rotational malalignment: one case; femur significant shortening: one case. Acetabular secondary procedures: three cases; heterotopic ossification: eight cases; significant loss of hip motion (<100° flexion): seven cases |
| Liebergall et al. (12) | Posterior acetabular fracture: removal of metals: two cases; central acetabular fracture: delayed THA: three cases |
| Burd et al. (21) | DVT: seven cases; heterotopic ossification: 11 cases; femoral head AVN: one case; OA: nine cases; traumatic sciatic nerve palsy: 19 cases; femoral nonunion: two cases; Trendelenburg gait disturbance: eight cases |
| Wu et al. (5) | Femoral nonunion: two cases (5.6%); femoral malunion: one case (2.8%); pelvic malunion: five cases; wound infection: 11 cases; leg length discrepancies: one case |
| Zamora-Navas et al. (23) | Heterotopic ossification: seven cases; neurological deficit: two cases; OA and delayed THA: one case |
| Cech et al. (4) | Incidence: 65%; thrombo-embolism: 11 cases; peripheral nerve injuries: eight cases; heterotopic ossification: eight cases; non-union: four cases; malunion: five cases; delayed THA: three cases |
AVN, avascular necrosis; DVT, deep vein thrombosis; OA, osteoarthritis.
Discussion
Etiology
Floating hip injuries are most often caused by high-energy trauma, such as a high-energy automotive or motorcycle (2, 3, 5, 21). Cases due to falls from height have also been reported (3, 12).
Epidemiology
Current data on floating hip injuries are limited to anecdotal reports and a few clinical cohort studies. This combination of injuries is uncommon, with an estimated incidence of 1 in 10,000 fractures and occurring only two to eight times annually in trauma centers (2, 3, 5, 20, 21). Brainard et al. (24) reported an incidence of 13% in pedestrian motor vehicle trauma. Riemer et al. (25) identified 33 cases of ipsilateral pelvic ring fractures and 28 cases of ipsilateral acetabular/hip-related fractures in 153 femoral shaft fractures. This injury is commonly seen in yioung males (21). Although femoral fractures are easily detected in routine X-rays, more than 50% of hip dislocations may go unnoticed (26). Therefore, the incidence of floating hip injury is likely to be underestimated.
Injury mechanism
Liebergall et al. observed two major patterns of floating hip injury by retrospectively analyzing 25 patients with simultaneous ipsilateral fracture of the acetabulum and the femur. The first pattern is the posterior type, in which a longitudinal force along the femur causes a posterior acetabular fracture first, followed by a midshaft femoral fracture. The second pattern is the central type, in which a lateral blow on the greater trochanter causes a central fracture-dislocation of the acetabulum and a proximal fracture of the femur (12). In the former situation, there may be accompanying knee injuries with ligament rupture or patellar fracture, but supracondylar fractures of the femur are relatively rare (27, 28). This may be related to the fact that the residual force is insufficient to cause a supracondylar fracture (29).
Clinical presentation
The current reports on floating hip injury do not provide a board description of the clinical manifestations. Nevertheless, we can get a glimpse of the presentation of this injury from some literature (4, 19). This combined injury is mainly caused by high-energy violence and is mostly seen in multiple traumatic events. Thus, the various lesions and their consequences are more likely to exhibit a multiplicative effect rather than a purely additive one. In the acute phase, hemodynamic instability is the most common manifestation, requiring urgent fluid resuscitation (4, 30). Other manifestations include severe pain, inability to stand and walk, swelling of the thigh, deformity, and shortening of the affected limb. For open fractures, active bleeding and bone exposure may occur. If combined with a pelvic fracture, the pelvic compression test is positive. Sometimes, palpation of the dislocated femoral head at the buttock area is possible in a combined posterior hip dislocation. For floating hip injury with pelvic fracture or central fracture dislocation of hip, it is often combined with injury to pelvic or abdominal organs, showing corresponding abdominal signs, such as abdominal distension, abdominal pain, and blood in urine. Soft tissues, namely muscles and neurovascular structures, should also be closely evaluated (31), and the orthopedic surgeons must be aware of possible compartment syndrome (17), Morel-Lavallée lesion (32), and vascular lesion (33). If vascular compromise is suspected, it is manifested by enlarging pulsatile hematoma, bruit, thrill, hemorrhage, and acute ischemia. If the ankle-brachial index is <0.9, a CT angiography and vascular surgery consultation should be performed (33, 34).
Classification
Liebergall et al. initially classified floating hip injury into two types based on different combinations of fracture forms in 1992. Type A was characterized by a pelvic ring fracture combined with an ipsilateral femoral fracture, and type B involved an acetabular fracture combined with an ipsilateral femoral fracture (2). Subsequently, Müller et al. referred to pelvic ring, acetabular, and ipsilateral femoral fractures as type C floating hip injury (3). In 2002, Liebergall et al. conducted a retrospective analysis on the mechanism of 20 cases of type B floating hip injury and observed two main patterns, namely posterior acetabular fracture and central acetabular fracture-dislocation (12) (Table 4). In a retrospective study, a total of 33 type A floating hip injuries were included. These included 25 Tile B pelvic fractures (76%) and 8 Tile C pelvic fractures (24%) (5). In another single-center retrospective study, Tile B and Tile C pelvic fractures accounted for 42% and 38% of the included cases, respectively, while the incidence of simple versus complex complex acetabular fractures was comparable (53% vs 47%) (4). We, therefore, hypothesized that Tile B pelvic fractures were more prone to floating hip injuries, but this phenomenon needed to be further validated by multi-center studies with large sample sizes.
Classification of floating hip injury.
| Classification | Fracture | Subtypes based on mechanism | |||
|---|---|---|---|---|---|
| Pelvic ring | Acetabulum | Femur | First | Second | |
| Type A | + | + | – | – | |
| Type B | + | + | Posterior acetabular fracture + ipsilateral midshaft femoral fracture | Central fracture-dislocation of the acetabulum + ipsilateral proximal femoral fracture | |
| Type C | + | + | + | – | – |
+ indicates combination.
Management
There are no guidelines for the management of floating hip injuries. Several small cohort studies have investigated the efficacy of the different approaches, but no high-quality evidence exists for any one approach.
Floating hip injuries, as one of the critical illnesses in orthopedics and emergency department, are often accompained by injuries to the head, chest, abdomen, or other sites (Table 5). Managing such injuries should not focus solely on the skeletal muscular system while ignoring injuries to other systems and potential hemodynamic instability from bleeding. Therefore, the management of floating hip injury must be multidisciplinary and should ultimately be based on the patient's physiology and the anatomy of the injury. In daily clinical practice, initial decisions are based mainly on the theory of damage control orthopedics (DCO) (35), whose main objectives are bleeding control and stabilization of the hemodynamic status and prevention of complications (30). The main tasks include the management of combined injuries such as cephalothorax and abdomen, blood transfusion, fluid resuscitation, temporary fixation of unstable fractures, early debridement of open injuries, use of antibacterial drugs, reduction of dislocated joints, hemostasis of active bleeding, and early intervention of intensive care. Definitive fracture fixation will be performed after the patient is stabilized.
Associated injuries.
| Cases, n | Death, n | Associated injuries, n | |||||
|---|---|---|---|---|---|---|---|
| Head | Chest | Abd/Pel | MS† | Others | |||
| Liebergall et al. (2) | 17 | 0 | 1 | 4 | 3 | 10 | 5 cases of peripheral nerve injury and 2 cases of soft tissue injury |
| Wu et al. (22) | 16 | 0 | 1 | 1 | 0 | 10 | – |
| Müller et al. (3) | 40 | 2 | 6 | 16 | 3 | 38 | 2 cases of soft tissue injury |
| Liebergall et al. (12) | 20 | 12* | |||||
| Wu et al. (5) | 40 | 5 | 6 | 12 | 25 | 40 | – |
| Zamora-Navas et al. (23) | 25 | – | – | – | – | 4 | – |
| Cech et al. (4) | 69 | 2 | 43 | 49 | 44 | 12 | 33 cases of maxillo-facial injury; 22 cases of vascular (arterial) injury |
*The type of associated injuries was not specified; †Musculoskeletal injuries referred to other skeletal muscle injuries except floating hip injuries.
SF; spine fractures; MS, musculoskeletal; Abd/Pel, abdomen/pelvic.
The management strategy for this particular combined injury is still based on the treatment of the respective fracture. For example, indications for surgery included an acetabular fracture with 2 mm or more of displacement, hip instability, and incongruence (36). Secondarily, indications for definitive surgical fixation of pelvic ring injuries can be referred to Langford et al. (37) and Coccolini et al. (30). However, in the case of floating hip injuries, there are many considerations regarding surgical timing, surgical sequence, surgical approach, and selection of implants. The management strategy is described in Fig. 2.
Algorithm showing the management of floating hip injury.
Citation: EFORT Open Reviews 9, 3; 10.1530/EOR-23-0013
Surgical timing
The time from injury to the initial or definitive surgery can range from a few hours to several days. Surgical timing should be subjected to DCO (12, 21, 22, 23). Müller et al. reported 42 floating hip injuries, in which the mean time from injury to surgery was 5.5 days (3). Among the 24 patients admitted within 48 h after injury, half of them received surgical treatment on the day of admission. If the patient was hemodynamically stable, one-stage fixation of all fractures may be considered (19). Burd et al. reported that the time from injury to first surgery (fixation of femoral fracture) was 87 h (range: 6–430 h) for 57 floating hip injuries, with 20 patients receiving only one anesthetic period and 23 patients receiving multiple anesthetics periods. For patients who underwent staged procedures, the average delay between the first and second procedures was 129 h (range: 65–253 h) (21). Liebergall et al. recommended that acetabular fractures be operated on 3–5 days after injury, while femoral fractures be fixed on an emergency basis (12). Cech et al. reported that the mean time from injury to surgery was 2 days for the femur, 8.3 days for the acetabulum, and 3.7 days for the pelvic ring (4). It was found that pelvic ring fixation at 2–4 days post injury increased the incidence of post-injury complications, while the incidence of post-injury complications decreased when surgery was delayed until 6–8 days post injury (38). Many authors consider fluid resuscitation on the basis of initial external fixation for hemodynamically unstable pelvic ring injuries. When hemodynamically stable, delayed definitive internal fixation at day 4 is recommended (39, 40, 41, 42, 43, 44). In this regard, several observational cohort studies have shown that early pelvic fracture fixation in patients with stable or borderline resuscitation within 24 h of admission reduces the risk of complications and improves prognosis (45, 46, 47, 48).
Surgical sequence
The current main procedure for floating hip injuries endorsed by most scholars is the reduction and fixation of the femoral fracture, which is preferred over that of pelvic and acetabular fracture (4, 12, 18, 20, 21, 23). The basis to support this view is as follows: (i) a stable femur provides conditions for traction reduction of pelvic fracture, (ii) provides a fulcrum for the reduction of pelvic and acetabular fracture, and (iii) facilitates intraoperative exposure of bone fragments in the hip. Nevertheless, any protocol that attempts to determine the timing and sequence of pelvic and femoral fixation must yield to DCO, which emphasizes the patient's physiological status and associated injuries (12, 20, 21, 22, 31). If there is a fracture-dislocation of the femoral head that is difficult to reduce, and the patient is expected to tolerate one-stage fixation of all fractures, the acetabular fracture and the femoral head could be reduced first, and the femoral fracture could be treated simultaneously (17, 19). However, some investigators suggested that the proximal fracture should be managed prior to the femoral shaft fracture (49, 50).
Surgical approach
The choice of a surgical approach should meet the requirements of intraoperative exposure while minimizing surgical trauma. For type A floating hip injuries, surgical approaches for pelvic ring fracture and femur fractures still depend on the respective surgical protocol. For the posterior type of floating hip injury, all fractures can be managed in the lateral position through a single posterior approach (21, 51). For the central type of floating hip, in most cases, the acetabular fracture can be fixed through an anterior approach, while the femoral fracture can be fixed through another lateral incision. Of course, the choice of the surgical approach for acetabular fracture needs to consider other factors, such as the direction of fracture displacement, the presence of concomitant posterior wall fracture, the surgeon's personal preference, and the fixation method. If effective reduction and fixation cannot be achieved through a single surgical approach, a combined surgical approach may also be an option. Although there is no guidance on the surgical approach for type C floating hip injuries, the severity of the fracture, surgeon's preference, and associated injuries need to be taken into account.
Implants
For femoral shaft or distal fractures, locking plates or intramedullary nail fixation can be used (33, 52); Cancellous lag screw, dynamic hip screw, femoral neck system, and hip arthroplasty are used for femoral neck fracture (51, 53, 54, 55). For open femoral fracture treated with external fixation, late replacement with an internal fixation device is not mandatory if the functional reduction is acceptable. Alternative internal fixation devices for acetabular fractures include reconstruction plates and lag screws. If combined with poor prognostic factors, such as subcephalic fracture of femoral neck in the elderly, major cartilage impaction, severe femoral head damage, total hip arthroplasty (THA) combined with simultaneous internal fixation of the acetabulum is recommended (56, 57). For anterior pelvic ring fractures, external fixation, symphyseal plates, or subcutaneous pelvic fixator (INFIX) can be used (4). Among them, external fixation is mostly used as a temporary measure to control bleeding in the acute phase. INFIX is popular for fixing the anterior ring with definite efficacy and minimal surgical trauma, especially for overweight or obese patients (58). Optional internal plants for fixation of the posterior ring include sacroiliac screw, tension band plate, trans-iliac plate, and the percutaneous TightRope system (4, 59, 60, 61, 62).
Outcomes
Currently, there is a wide variation in the outcomes of floating hip injuries due to the heterogeneity of cases and variations in the definition. In this article, we use the classification proposed by Liebergall et al. (2) and Müller et al. (3) as a basis to explore the outcomes of floating hip injuries. Wu et al. retrospectively analyzed 16 patients with femoral shaft fractures combined with ipsilateral hip fracture-dislocations and showed satisfactory results in all patients (22). Twenty patients with type B floating hip injury treated by Liebergall et al. also achieved relatively satisfactory results (12), which were consistent with the findings of Wu et al. (5). In contrast, of the 40 cases of floating hip injuries studied by Müller et al., only 20 (50%) patients returned to work without restriction after surgery (3). Cech et al. found that only 30% of 69 patients with floating hip injuries were able to resume physical activities at the former level at a mean follow-up of 5 years (4) (Table 2).
Complications
The complications of floating hip injuries include early and late complications. These possible complications were detailed in Table 3. Early complications include wound infection, delayed healing, DVT, and neurological deficit (2, 3, 4, 5, 21). Late complications include heterotopic ossification, AVN of the femoral head, OA, femoral non-union or malunion, and shortening of the affected leg (2, 3, 4, 5, 12, 21, 22, 23) (Table 3). Anatomic reduction of the acetabulum, integrity of the pelvic ring, and normal femoral length and force line should be achieved to minimize postoperative complications.
Limitations
The quality of a systematic review depends on the level of evidence and methodological quality of the available literature. Only 22 retrospective studies were included in this review, of which only eight were retrospective studies of case series, with the remaining articles being case reports. This indicates relatively low methodological quality. Another important limitation was that the database searched for this review was limited to PubMed, and the search deadline was January 1, 2023, which may have missed some valuable reports. In the future, multicenter collaborative efforts are needed to conduct prospective cohort studies with large sample sizes to explore in-depth the epidemiology, injury mechanism, classification, and standardized treatment processes for floating hip injury.
Conclusion
In conclusion, floating hip injuries are usually severe injuries caused by high-energy violence. The management of such injuries focuses on multidisciplinary cooperation to achieve early hemodynamic stabilization. The overall principle is to assess the complexity of the injury on the basis of DCO, to perform definitive surgery as early as possible, and to reduce the incidence of perioperative complications.
ICMJE Conflict of Interest Statement
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the study reported.
Funding Statement
The authors received no financial support for the research, authorship, and/ or publication of this article.
Author contribution statement
YY provided the ideas of this study. YP collected the data. YY wrote the draft of the manuscript. BY critically reviewed and revised the manuscript for important intellectual content. All authors approved the final manuscript and agree to be accountable for all aspects of the work.
References
- 1↑
Simpson NS, & Jupiter JB. Complex fracture patterns of the upper extremity. Clinical Orthopaedics and Related Research 1995 318 43–53.
- 2↑
Liebergall M, Lowe J, Whitelaw GP, Wetzler MJ, & Segal D. The floating hip. Ipsilateral pelvic and femoral fractures. Journal of Bone and Joint Surgery 1992 74 93–100. (https://doi.org/10.1302/0301-620X.74B1.1732275)
- 3↑
Müller EJ, Siebenrock K, Ekkernkamp A, Ganz R, & Muhr G. Ipsilateral fractures of the pelvis and the femur--floating hip? A retrospective analysis of 42 cases. Archives of Orthopaedic and Trauma Surgery 1999 119 179–182. (https://doi.org/10.1007/s004020050385)
- 4↑
Cech A, Rieussec C, Kerschbaumer G, Seurat O, Corbet C, Vibert B, Tronc C, Ruatti S, Bouzat P, Tonetti J, et al.Complications and outcomes in 69 consecutive patients with floating hip. Orthopaedics and Traumatology, Surgery and Research 2021 107 102998. (https://doi.org/10.1016/j.otsr.2021.102998)
- 5↑
Wu CL, Tseng IC, Huang JW, Yu YH, Su CY, & Wu CC. Unstable pelvic fractures associated with femoral shaft fractures: a retrospective analysis. Biomedical Journal 2013 36 77–83. (https://doi.org/10.4103/2319-4170.110401)
- 6↑
Bone LB, Johnson KD, Weigelt J, & Scheinberg R. Early versus delayed stabilization of femoral fractures. A prospective randomized study. Journal of Bone and Joint Surgery 1989 71 336–340. (https://doi.org/10.2106/00004623-198971030-00004)
- 7↑
Tile M. Pelvic ring fractures: should they be fixed? Journal of Bone and Joint Surgery 1988 70 1–12. (https://doi.org/10.1302/0301-620X.70B1.3276697)
- 8↑
Tonetti J. Management of recent unstable fractures of the pelvic ring. An update Conference supported by the Club Bassin Cotyle. (Pelvis-Acetabulum Club). Orthopedics and Traumatology, Surgery and Research. 2013 99 S77–S86. (https://doi.org/10.1016/j.otsr.2012.11.013)
- 9↑
Kim WY. Treatment of unstable pelvic ring injuries. Hip Pelvis 2014 26 79–83. doi:10.5371/hp.2014.26.2.79)
- 10↑
Kelly J, Ladurner A, & Rickman M. Surgical management of acetabular fractures: a contemporary literature review. Injury 2020 51 2267–2277. (https://doi.org/10.1016/j.injury.2020.06.016)
- 11↑
Tornetta P. Displaced acetabular fractures: indications for operative and nonoperative management. Journal of the American Academy of Orthopaedic Surgeons 2001 9 18–28. (https://doi.org/10.5435/00124635-200101000-00003)
- 12↑
Liebergall M, Mosheiff R, Safran O, Peyser A, & Segal D. The floating hip injury: patterns of injury. Injury 2002 33 717–722. (https://doi.org/10.1016/s0020-1383(0100204-2)
- 13↑
Browne RS, & Mullan GB. Intertrochanteric fracture of the femur with ipsilateral central fracture of the acetabulum. Injury 1980 11 251–253. (https://doi.org/10.1016/s0020-1383(8080053-2)
- 14↑
Harper MC. Traumatic dislocation of the hip with ipsilateral femoral shaft fracture: a method of treatment. Injury 1982 13 391–394. (https://doi.org/10.1016/0020-1383(8290091-2)
- 15↑
Meinhard BP, Misoul C, Joy D, & Ghillani R. Central acetabular fracture with ipsilateral femoral-neck fracture and intrapelvic dislocation of the femoral head without major pelvic-column disruption: a case report. Journal of Bone and Joint Surgery 1987 69 612–615. (https://doi.org/10.2106/00004623-198769040-00020)
- 16↑
Mestdagh H, Butruille Y, & Vigier P. Central fracture-dislocation of the hip with ipsilateral femoral neck fracture: case report. Journal of Trauma 1991 31 1445–1447. (https://doi.org/10.1097/00005373-199110000-00027)
- 17↑
Tiedeken NC, Saldanha V, Handal J, & Raphael J. The irreducible floating hip: a unique presentation of a rare injury. Journal of Surgical Case Reports 2013 2013 2013(10):rjt075. (https://doi.org/10.1093/jscr/rjt075)
- 18↑
Irifune H, Hirayama S, Takahashi N, & Narimatsu E. Ipsilateral acetabular and femoral neck and shaft fractures. Case Reports in Orthopedics 2015 2015 351465. (https://doi.org/10.1155/2015/351465)
- 19↑
Rajasekaran RB, Jayaramaraju D, Palanisami DR, Perumal R, & Shanmuganathan R. Ipsilateral acetabular fracture with displaced femoral head and femoral shaft fracture: a complex floating hip injury. Case Reports in Orthopedics 2018 2018 4937472. (https://doi.org/10.1155/2018/4937472)
- 20↑
Suzuki T, Shindo M, & Soma K. The floating hip injury: which should we fix first? European Journal of Orthopaedic Surgery and Traumatology 2006 16 214–218. (https://doi.org/10.1007/s00590-006-0081-4)
- 21↑
Burd TA, Hughes MS, & Anglen JO. The floating hip: complications and outcomes. Journal of Trauma 2008 64 442–448. (https://doi.org/10.1097/TA.0b013e31815eba69)
- 22↑
Wu CC, Shih CH, & Chen LH. Femoral shaft fractures complicated by fracture-dislocations of the ipsilateral hip. Journal of Trauma 1993 34 70–75. (https://doi.org/10.1097/00005373-199301000-00013)
- 23↑
Zamora-Navas P, Estades-Rubio FJ, Cano JR, & Guerado E. Floating hip and associated injuries. Injury 2017 48(Supplement 6) S75–S80. (https://doi.org/10.1016/S0020-1383(1730798-2)
- 24↑
Brainard BJ, Slauterbeck J, & Benjamin JB. Fracture patterns and mechanisms in pedestrian motor-vehicle trauma: the ipsilateral dyad. Journal of Orthopaedic Trauma 1992 6 279–282. (https://doi.org/10.1097/00005131-199209000-00002)
- 25↑
Riemer BL, Butterfield SL, Burke CJ 3rd, & Mathews D. Immediate plate fixation of highly comminuted femoral diaphyseal fractures in blunt polytrauma patients. Orthopedics 1992 15 907–916. (https://doi.org/10.3928/0147-7447-19920801-07)
- 26↑
Helal B, & Skevis X. Unrecognised dislocation of the hip in fractures of the femoral shaft. Journal of Bone and Joint Surgery. British Volume 1967 49 293–300. (https://doi.org/10.1302/0301-620X.49B2.293)
- 27↑
Tile M. Describing the injury: classification of pelvic ring injuries. In Fractures of the Pelvis and Acetabulum, 3rd ed., pp. 130–167. Marvin T, Ed. Philadelphia: Lippincott Williams and Wilkins 2003.
- 28↑
Wiss DA, Tracy Watson J, & Johnson EE. Fractures of the knee. In Fractures in Adults, 4th ed., p. 1919. Rockwood CA Jr, & Gree DP, Eds. Philadelphia: Lippincott 1996.
- 29↑
Viano DC, & Stalnaker RL. Mechanisms of femoral fracture. Journal of Biomechanics 1980 13 701–715. (https://doi.org/10.1016/0021-9290(8090356-5)
- 30↑
Coccolini F, Stahel PF, Montori G, Biffl W, Horer TM, Catena F, Kluger Y, Moore EE, Peitzman AB, Ivatury R, et al.Pelvic trauma: WSES classification and guidelines. World Journal of Emergency Surgery 2017 12 5. (https://doi.org/10.1186/s13017-017-0117-6)
- 31↑
Zamora-Navas P, & Guerado E. Vascular complications in floating hip. Hip International 2010 20(Supplement 7) S11–S18. (https://doi.org/10.1177/11207000100200s703)
- 32↑
Singh R, Rymer B, Youssef B, & Lim J. The Morel-Lavallée lesion and its management: a review of the literature. Journal of Orthopaedics 2018 15 917–921. (https://doi.org/10.1016/j.jor.2018.08.032)
- 33↑
Mirza A, & Ellis T. Initial management of pelvic and femoral fractures in the multiply injured patient. Critical Care Clinics 2004 20 159–170. (https://doi.org/10.1016/s0749-0704(0300096-4)
- 34↑
Owers KL, Blewitt N, & Morse MH. Arterial injury complicating femoral shaft fracture: control of primary and secondary profunda femoral bleeding by transcatheter embolisation. Injury 1999 30 305–308. (https://doi.org/10.1016/s0020-1383(9900087-x)
- 35↑
Giannoudis PV. Surgical priorities in damage control in polytrauma. Journal of Bone and Joint Surgery. British Volume 2003 85 478–483. (https://doi.org/10.1302/0301-620x.85b4.14217)
- 36↑
Guyton JL, & Perez EA. Fractures of the acetabulum and pelvis. In Orthopaedics, 11 th ed. Canale ST, & Beaty JH, Eds. Philadelphia: Mosby 2007 3322–3323.
- 37↑
Langford JR, Burgess AR, Liporace FA, & Haidukewych GJ. Pelvic fractures: Part 2. Contemporary indications and techniques for definitive surgical management. Journal of the American Academy of Orthopaedic Surgeons 2013 21 458–468. (https://doi.org/10.5435/JAAOS-21-08-458)
- 38↑
Pape H, Stalp M, Griensven M, Weinberg A, Dahlweit M, & Tscherne H. Optimal timing for secondary surgery in polytrauma patients: an evaluation of 4,314 serious-injury cases. Chirurg 1999 70 1287–1293. (https://doi.org/10.1007/s001040050781)
- 39↑
Pape HC, Giannoudis P, & Krettek C. The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery. American Journal of Surgery 2002 183 622–629. (https://doi.org/10.1016/s0002-9610(0200865-6)
- 40↑
Katsoulis E, & Giannoudis PV. Impact of timing of pelvic fixation on functional outcome. Injury 2006 37 1133–1142. (https://doi.org/10.1016/j.injury.2006.07.017)
- 41↑
Spanjersberg WR, Knops SP, Schep NW, van Lieshout EM, Patka P, & Schipper IB. Effectiveness and complications of pelvic circumferential compression devices in patients with unstable pelvic fractures: a systematic review of literature. Injury 2009 40 1031–1035. (https://doi.org/10.1016/j.injury.2009.06.164)
- 42↑
Stahel PF, Mauffrey C, Smith WR, McKean J, Hao J, Burlew CC, & Moore EE. External fixation for acute pelvic ring injuries: decision making and technical options. Journal of Trauma and Acute Care Surgery 2013 75 882–887. (https://doi.org/10.1097/TA.0b013e3182a9005f)
- 43↑
Halawi MJ. Pelvic ring injuries: emergency assessment and management. Journal of Clinical Orthopaedics and Trauma 2015 6 252–258. (https://doi.org/10.1016/j.jcot.2015.08.002)
- 44↑
Chu CH, Tennakoon L, Maggio PM, Weiser TG, Spain DA, & Staudenmayer KL. Trends in the management of pelvic fractures, 2008–2010. Journal of Surgical Research 2016 202 335–340. (https://doi.org/10.1016/j.jss.2015.12.052)
- 45↑
Vallier HA, Cureton BA, Ekstein C, Oldenburg FP, & Wilber JH. Early definitive stabilization of unstable pelvis and acetabulum fractures reduces morbidity. Journal of Trauma 2010 69 677–684. (https://doi.org/10.1097/TA.0b013e3181e50914)
- 46↑
Nahm NJ, Moore TA, & Vallier HA. Use of two grading systems in determining risks associated with timing of fracture fixation. Journal of Trauma and Acute Care Surgery 2014 77 268–279. (https://doi.org/10.1097/TA.0000000000000283)
- 47↑
Vallier HA, Moore TA, Como JJ, Wilczewski PA, Steinmetz MP, Wagner KG, Smith CE, Wang XF, & Dolenc AJ. Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation. Journal of Orthopaedic Surgery and Research 2015 10 155. (https://doi.org/10.1186/s13018-015-0298-1)
- 48↑
Childs BR, Nahm NJ, Moore TA, & Vallier HA. Multiple procedures in the initial surgical setting: when do the benefits outweigh the risks in patients with multiple system trauma? Journal of Orthopaedic Trauma 2016 30 420–425. (https://doi.org/10.1097/BOT.0000000000000556)
- 49↑
Bucholz RW, & Rathjen K. Concomitant ipsilateral fractures of the hip and femur treated with interlocking nails. Orthopedics 1985 8 1402–1406. (https://doi.org/10.3928/0147-7447-19851101-13)
- 50↑
Koldenhoven GA, Burke JS, & Pierron R. Ipsilateral femoral neck and shaft fractures. Southern Medical Journal 1997 90 288–293. (https://doi.org/10.1097/00007611-199703000-00003)
- 51↑
Kregor PJ, & Templeman D. Associated injuries complicating the management of acetabular fractures: review and case studies. Orthopedic Clinics of North America 2002 33 73–95. (https://doi.org/10.1016/s0030-5898(0300073-7)
- 52↑
Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P, & Tscherne H. Minimally invasive plate osteosynthesis and vascularity: preliminary results of a cadaver injection study. Injury 1997 28(Supplement 1) A7–A12. (https://doi.org/10.1016/s0020-1383(9790110-8)
- 53↑
Patel S, Kumar V, Baburaj V, & Dhillon MS. The use of the femoral neck system (FNS) leads to better outcomes in the surgical management of femoral neck fractures in adults compared to fixation with cannulated screws: a systematic review and meta-analysis. European Journal of Orthopaedic Surgery and Traumatology 2023 33 2101–2109. (https://doi.org/10.1007/s00590-022-03407-8)
- 54↑
Kain MS, & Willier D 3rd. Hemiarthroplasty through a direct anterior approach for femoral neck fractures. Journal of Orthopaedic Trauma 2020 34(Supplement 2) S25–S26. (https://doi.org/10.1097/BOT.0000000000001820)
- 55↑
Florschutz AV, Langford JR, Haidukewych GJ, & Koval KJ. Femoral neck fractures: current management. Journal of Orthopaedic Trauma 2015 29 121–129. (https://doi.org/10.1097/BOT.0000000000000291)
- 56↑
Boudissa M, Ruatti S, Kerschbaumer G, Milaire M, Merloz P, & Tonetti J. Part 2: outcome of acetabular fractures and associated prognostic factors-a ten-year retrospective study of one hundred and fifty six operated cases with open reduction and internal fixation. International Orthopaedics 2016 40 2151–2156. (https://doi.org/10.1007/s00264-015-3070-6)
- 57↑
Boudissa M, Francony F, Drevet S, Kerschbaumer G, Ruatti S, Milaire M, Merloz P, & Tonetti J. Operative versus non-operative treatment of displaced acetabular fractures in elderly patients. Aging Clinical and Experimental Research 2020 32 571–577. (https://doi.org/10.1007/s40520-019-01231-5)
- 58↑
Steer R, Balendra G, Matthews J, Wullschleger M, & Reidy J. The use of anterior subcutaneous internal fixation (INFIX) for treatment of pelvic ring injuries in major trauma patients, complications and outcomes. SICOT-J 2019 5 22. (https://doi.org/10.1051/sicotj/2019019)
- 59↑
Khaleel VM, Pushpasekaran N, Prabhu N, Pandiyan A, & Koshy GM. Posterior tension band plate osteosynthesis for unstable sacral fractures: a preliminary study. Journal of Clinical Orthopaedics and Trauma 2019 10(Supplement 1) S106–S111. (https://doi.org/10.1016/j.jcot.2019.05.017)
- 60↑
Schweitzer D, Zylberberg A, Córdova M, & Gonzalez J. Closed reduction and iliosacral percutaneous fixation of unstable pelvic ring fractures. Injury 2008 39 869–874. (https://doi.org/10.1016/j.injury.2008.03.024)
- 61↑
Hao T, Changwei Y, & Qiulin Z. Treatment of posterior pelvic ring injuries with minimally invasive percutaneous plate osteosynthesis. International Orthopaedics 2009 33 1435–1439. (https://doi.org/10.1007/s00264-009-0756-7)
- 62↑
Gu F, Zhang J, Sui Z, Zhang K, Xie X, & Yu T. Minimally invasive percutaneous TightRope® system fixation for an unstable posterior pelvic ring: clinical follow-up and biomechanical studies. Orthopaedic Surgery 2022 14 1078–1092. (https://doi.org/10.1111/os.13261)
