One-stage hip arthroplasty and bone grafting for bilateral femoral head osteonecrosis

Evaluation of the predictive values of collapse and necrotic lesion boundary for osteonecrosis of the femoral head prognosis

OBJECTIVE

Osteonecrosis of the femoral head (ONFH) is a disabling and intractable orthopedic disease largely affecting young and middle-aged groups. Current standard of treatment relies on the collapse of femoral head as a predictor for prognosis. However, a wide range of variability in repair potentials is observed in patients with femoral head collapse. Therefore, the present study aimed to evaluate the accuracy of femoral head collapse as a predictor and to propose the necrotic lesion boundary as a novel yet reliable measure for ONFH prognosis.

METHODS

A retrospective cross-sectional study was conducted at the First Affiliated Hospital of Guangzhou University of Chinese Medicine, 203 hips with ONFH from 134 patients were included. The occurrences and progression of femoral head collapse were recorded. Necrosis lesion boundary was quantified and classified for each case based on anteroposterior view intact ratio (APIR) and the frog-leg view intact ratio (FLIR) as independent variables. Dependent variables were defined as progressive collapse or terminal collapse for Association Research Circulation Osseous (ARCO) stage II and III respectively. Logistic regression analysis, Receiver Operating Characteristic (ROC) curve and Kaplan-Meier (K-M) survival analysis was performed and results were interpreted.

RESULTS

Out of the 106 hips in ARCO stage II, 31 hips collapsed with further progression, while 75 hips had no collapse or collapse with repair of the necrotic areas. Out of the 97 hips in ARCO stage IIIA, the collapse continued to progress in 58 hips while the necrotic areas were repaired in 39 hips. Logistic regression analysis demonstrated that both APIR and FLIR, were independent risk factors. Further ROC curve analysis indicated that the cutoff values of APIR and FLIR could be considered as indications for evaluating the prognosis of ONFH. Contrary to the traditional view of poor prognosis after femoral head collapse, K-M survival analysis demonstrated a high value of APIR and FLIR for ONFH prognosis.

CONCLUSION

The present study found that the occurrence of collapse is an oversimplified predictor for ONFH prognosis. The collapse of the femoral head in ONFH does not predict a poor prognosis. The necrosis lesion boundary has a high value in predicting ONFH prognosis and informing clinical treatment strategies.

One-stage simultaneous hip-preserving surgeries for the management of bilateral femoral head osteonecrosis: a mean 7.0-year follow-up

Background

A retrospective study was conducted to evaluate and compare the clinical and radiological outcomes of one-stage fibular impaction allografting and vascularized greater trochanter flap autografting for the treatment of bilateral osteonecrosis of the femoral head (ONFH).

Methods

Patients who underwent one-stage aforementioned hip-preserving surgeries due to bilateral ONFH were retrospectively reviewed from January 2008 to December 2013. Sixty-nine patients (138 hips) with a mean age of 31.5 years and mean follow-up of 7.0 years were included. Hips that underwent fibular impaction allografting and vascularized greater trochanter flap autografting were assigned as group A and group B, respectively. Harris Hip Score (HHS) and Visual Analogue Scale (VAS) were used for clinical evaluation, and a series of X-ray images were used for radiological assessment. For inter-group analysis, the paired t test was used for continuous data, and the Wilcoxon rank sum test was used for non-parametric data, while the Mann-Whitney U test was used for intra-group analysis.

Results

The HHS and VAS in both groups A and B had a substantial advancement when compared with the preoperative level (p < 0.01). Fibular impaction allografting can achieve more pain relief (p < 0.01), though no clinical difference was found in terms of minimal clinically important difference (MCID < 10 points). Group A showed better radiological results than group B (p = 0.04). It was discovered that the appropriate indication for each procedure was patients with Association for Research on Osseous Circulation (ARCO) stages II and III, respectively.

Conclusion

One-stage hip-preserving surgeries for the management of bilateral ONFH could obtain good medium and long-term outcomes. It was recommended that fibular impaction allografting is more suitable for patients in ARCO stage II, while for patients in ARCO stage III, vascularized greater trochanter flap autografting is a better preference.

Trial registration

Retrospectively registered.

Comparison of mortality and complications between bilateral simultaneous and staged total hip arthroplasty: A systematic review and meta-analysis

BACKGROUND

Total hip arthroplasty (THA) relieves pain and restores function in patients with severe rheumatoid arthritis and osteoarthritis. Over the past few decades, several authors have attempted to assess the efficacy and safety of simultaneous bilateral THA compared with staged bilateral THA. The purpose of this meta-analysis is to compare the mortalities and complications between simultaneous bilateral THA and staged bilateral THA.

METHODS

A literature search to identify eligible studies was undertaken to identify all relevant articles published until August 2018. We included studies that compared simultaneous bilateral THA and staged bilateral THA and their effects on mortality and complications. The outcomes included mortality, the occurrence of deep venous thrombosis (DVT), the occurrence of pulmonary embolism (PE), respiratory complications, cardiovascular complications, digestive system complications and the occurrence of dislocation. Stata 12.0 was used for the meta-analysis.

RESULTS

Nineteen studies involving 59,257 patients were identified; among them, 16,758 patients were selected for treatment with simultaneous bilateral THA, and 42,499 patients were chosen for the purpose of staged bilateral THA. The meta-analysis results demonstrated that there was no significant difference between simultaneous bilateral THA and staged bilateral THA in terms of mortality (risk ratio [RR] = 1.15, 95% CI = 0.76, 1.74; P = .520). Compared with staged bilateral THA, simultaneous bilateral THA was associated with a reduction in the occurrence of DVT, PE and respiratory complications (P < .05). There were no significant differences in the cardiovascular complications, digestive system complications or the occurrence of dislocation and infection (P = .057).

CONCLUSIONS

We observed that the prevalence of DVT, PE and respiratory complications was considerably lower with the use of simultaneous bilateral THA than with the use of staged bilateral THA. Thus, simultaneous bilateral THA is a considerably safer procedure than staged bilateral THA in selected THA patients.

Hip osteonecroses treated with calcium sulfate-calcium phosphate bone graft substitute have different results according to the cause of osteonecrosis: alcohol abuse or corticosteroid-induced

INTRODUCTION

The aim of the study was to assess the factors influencing the final results of treatment of the femoral head osteonecrosis (ONFH) with core decompression and bone substitute grafting. The special interest was focused on comparison between alcohol- and steroid-induced ONFHs.

MATERIAL AND METHODS

In this prospective study, a total of 53 patients (58 hips) in the mean age of 35.5 years were included: 29 had a history of alcohol use (32 hips) and 24 of steroid use (26 hips). The mean follow-up was 4.2 years (minimum 3 years).

RESULTS

At last follow-up, significant improvements were noted in the Harris Hip Score (HHS) (mean 44.0 vs 55.9 points, p < 0.00002) and VAS scores (mean 7.0 vs 5.8 points, p < 0.0002) for the whole ONFH cohort, comparing to pre-operative status. The degree of improvement did not differ between Ficat and Arlet grade II and grade III (mean 14.9 vs 6.2 points, respectively, p = 0.1). No change was found between the final and initial results in this group in the steroid group (HHS mean 42.2 vs 45.5 points, p = 0.5 and VAS mean 6.8 vs 6.5 points, p = 0.5), but the improvement was noted in the alcohol group (HHS mean 45.5 vs 64.4 points, p < 0.0001; VAS mean 7.1 vs 5.2 points, p < 0.0001) comparing to pre-operative status.

CONCLUSIONS

Presented treatment of ONFH significantly improves hip function, offers pain reduction, and gives similar functional improvement for hips scoring grade II and III on the Ficat and Arlet scale. A good response to operative treatment is seen in patients with alcohol-induced ONFH, but not in those with steroid-induced ONFH.

One-sided hip-preserving and concurrent contralateral total hip arthroplasty for the treatment of bilateral osteonecrosis of the femoral head in different stages: short-medium term outcomes

Background

We aimed to evaluate the clinical and radiological short-medium term outcomes for the treatment of bilateral osteonecrosis of the femoral head (ONFH) with hip-preserving surgery of core decompression followed by tightly impaction bone grafting combining with non-vascularized fibular allografting in one hip and concurrent one-stage total hip arthroplasty (THA) in the contralateral side. We hypothesized the aforementioned surgery showed benefits of protecting the preserved hip from collapsing and thereafter THA was delayed or avoided.

Methods

We retrospectively reviewed a consecutive series of 18 non-traumatic bilateral ONFH patients (36 hips) who had undergone previous mentioned surgeries between July 2004 and June 2013. Preoperative and the last follow-up Harris Hip Score (HHS) and Visual Analogue Scale (VAS) Score were obtained for clinical outcomes evaluation and X-rays of antero-posterior and frog-leg lateral views of bilateral hips were compared for radiological outcomes assessment.

Results

All patients were telephone contacted for out-patient clinic return visit at an average follow-up time of 53.3 months (ranged from 20 months to 107 months). Of the 18 patients (15 men and 3 women), there were 5 patients were diagnosed preoperative IIB stages according to classification of the Association Research Circulation Osseuse classification (ARCO) and the remaining 13 patients were in ARCO IIIC stages. The mean age of the included patients was 40.7 years (range from 22 to 59 years). No age and followed-up time difference existed in genders. The postoperative HHS were 83.8 ± 17.9 points, and it revealed statistical significance when compared to preoperative 61.6 ± 17.0 points (p < 0.05). The VAS scores were reduced from preoperative 6.2 ± 2.0 points to postoperative 2.8 ± 2.3 points, which also manifested outcomes significance (p < 0.05). From radiological aspects, 14 patients acquired well repairmen of the necrotic areas of the femoral head. However, the other 4 patients ultimately suffered femoral head collapse, and the severe pain was gotten rid of after THA surgeries were performed.

Conclusions

The un-collapsed hip can achieve biological stability and sufficient blood supply through the hip-preserving surgery and obtain longtime repairmen of the necrotic bone as well as early non-weight-bearing function training, which benefits from distributing the whole body weight load to the hip of one-stage THA. Consequently, we recommend this sort of surgery for clinical practice trial when faced bilateral ONFH in different stages though longer time follow-up and larger samples are essentially needed to address its efficacy.

Combination treatment of biomechanical support and targeted intra-arterial infusion of peripheral blood stem cells mobilized by granulocyte-colony stimulating factor for the osteonecrosis of the femoral head: a randomized controlled clinical trial

The objective of this study was to determine the benefits of combination treatment with mechanical support and targeted intra-arterial infusion of peripheral blood stem cells (PBSCs) mobilized by granulocyte-colony stimulating factor (G-CSF) via the medial circumflex femoral artery on the progression of osteonecrosis of the femoral head (ONFH). Fifty-five patients (89 hips) with early and intermediate stage ONFH were recruited and randomly assigned to combination treatment or mechanical support treatment (control group). All hips received mechanical support treatment (porous tantalum rod implantation). Then, hips in the combination treatment group were performed targeted intra-arterial infusion of PBSCs. At each follow-up, Harris hip score (HHS) and Association Research Circulation Osseous (ARCO) classification were used to evaluate the symptoms and progression of osteonecrosis. Total hip arthroplasty (THA) was assessed as an endpoint at each follow-up. At 36 months, 9 of the 41 hips (21.95%) in the control group progressed to clinical failure and underwent THA whereas only 3 of the 48 hips (6.25%) in the combination treatment group required THA (p = 0.031). Kaplan-Meier survival analysis showed a significant difference in the survival time between the two groups (log-rank test; p = 0.025). Compared to the control group, combination treatment significantly improved the HHS at 36 months (p = 0.003). At the final follow-up examination, radiological progression was noted in 13 of 41 hips (31.71%) for the control group, but in only 4 of 48 hips (8.33%) for the combination treatment group (p = 0.005). The overall collapse rates were 15.15% (5/33 hips) and 8.11% (3/37 hips) in the control and combination treatment groups, respectively. Targeted intra-arterial infusion of PBSCs is capable of enhancing the efficacy of biomechanical support in the treatment of ONFH. This clinical trial confirmed that the combination treatment might be a safe and feasible choice for the treatment of early or intermediate stages of ONFH.

Are we evaluating osteonecrosis adequately?

PURPOSE

It is well recognised that to evaluate a patient with osteonecrosis of the femoral head (ONFH) adequately, it is necessary that the size of the infarct and the extent of femoral head joint involvement be indicated, in addition to the type or stage of the pathological process. The purpose of this study was to determine whether patients with ONFH are being evaluated adequately in studies published during the past 25 years and to see if any trends can be identified.

METHODS

Articles describing treatment of patients with ONFH, published between 1985 and 2011, were reviewed to determine the methods used to indicate the type and extent of pathology present on radiographs and magnetic resonance imaging (MRI) studies. The classification systems cited were identified and divided between those which indicated only the stage and those which indicated both stage and extent of involvement.

RESULTS

In 208 studies published between 1985 and 2011, specific classification systems were cited 237 times. During this period, non-quantitative systems, which only indicate stage, were cited 139 times (59 %) and quantitative systems, which indicate both stage and extent of involvement were cited 77 times (32 %). Between 2006 and 2011, non-quantitative systems were cited 30 times (48 %) and quantitative systems were cited 27 times (44 %).

CONCLUSIONS

During the past 25 years there has been a trend towards the use of more comprehensive and effective methods of evaluating patients with ONFH. However, during the past five years, approximately half of the published studies continued to use limited, non-quantitative methods of evaluation. This should be brought to the attention of the orthopaedic community. Future investigations and publications on ONFH should employ comprehensive methods of classification which include not only the stage of disease but also measurements of the size of the necrotic segment and the extent of femoral head and joint involvement.

Treatment of osteonecrosis of the femoral head in lymphoma patients by free vascularised fibular grafting

The purpose of this study was to assess the outcomes of treatment of femoral head osteonecrosis using free vascularised fibular grafting in patients with Hodgkin's disease and non-Hodgkin's lymphoma. We retrospectively reviewed seven patients (14 hips) with lymphoma who underwent free vascularised fibular grafting for osteonecrosis of the femoral head, evaluating pre- and postoperative Harris hip scores, visual analog scale (VAS) pain scores, hip range of motion and radiographs. Patients were followed up for a minimum of 1.5 years (mean, 3.3 years). All these patients exhibited good recovery without severe life-threatening complications. The mean Harris hip score improved from 69 to 88, while average VAS pain score decreased from 54 to 18. At the latest follow-up, we found improvement or unchanged radiographs in all three hips with initial Steinberg stage II osteonecrosis and in nine of 11 hips with stage III or IV osteonecrosis. No hips failed treatment and underwent total hip arthroplasty. The clinical data demonstrated that free vascularised fibular grafting can slow or even halt progression of necrosis, and improve the function of the hip and quality of life in lymphoma patients.

Treatment of femoral head osteonecrosis in patients with systemic lupus erythematosus by free vascularised fibular grafting

The purpose of this study was to review the radiographs of symptomatic femoral head osteonecrosis in patients with systemic lupus erythematosus (SLE) and to assess the results of treatment using free vascularised fibular grafting. We retrospectively reviewed 50 patients (80 hips) with SLE who underwent free vascularised fibular grafting for osteonecrosis of the femoral head. All patients were followed up for at least 2 or more years (average, 4.3 years). The mean Harris hip score improved from 72 to 88. At the latest follow-up, we found improved or unchanged radiographs in 12 of initially Stage II hips and in 60 of 64 Stage III or IV hips. No hips failed treatment and underwent total hip arthroplasty. The data suggest that free vascularised fibular grafting was successful in maintaining joint function and in delaying the need for joint replacement procedure.