Transtrochanteric anterior rotational osteotomy for avascular necrosis of the femoral head. Long-term results

Variability in the classification, management, and outcome reporting for avascular necrosis of the femoral head: A systematic review

Introduction

There is no universally-utilized classification system for avascular necrosis of the femoral head (AVNFH), a debilitating condition that arises due to impaired blood supply resulting in cortical collapse. AVNFH may require early intervention to prevent irreversible damage leading to total hip arthroplasty. The purpose of this study is to assess the variability in classification, management, and outcomes reported in randomized controlled trials (RCTs) related to AVNFH.

Methods

PubMed, Embase, and Medline were queried for RCTs on the treatment of AVNFH (2010-2023). The number of patients, number of femoral heads, minimum follow-up, AVNFH classification system, treatment interventions, and outcome measures were extracted. Variability in classification, management approach, and reporting of outcomes was evaluated.

Results

A total of 30 RCTs met inclusion criteria, encompassing 1891 total patients. The mean number of patients in each study was 63 (SD = 41), with a mean minimum follow-up of 30 months (SD = 17). The Association Research Circulation Osseous classification system was utilized in 63 % (n = 19) of studies, Ficat and Arlet in 20 % (n = 6) of studies, Steinberg in 10 % (n = 3), Mitchell in 3 % (n = 1), and the China-Japan Friendship Hospital classifications in 3 % (n = 1). There were 61 treatment interventions, stratified into nine categories. Radiographic imaging was most commonly used to evaluate patients at follow-up.

Conclusion

There are a variety of classification systems, treatments, and outcome measures utilized in the literature to categorize and quantify AVNFH. The utilization of a universally-accepted classification system and standardized outcome reporting may help to ensure reproducibility and accuracy given a continued lack of consensus.

Bilateral same-day transtrochanteric rotational osteotomy using computed tomography-based navigation: a case report

BACKGROUND

Transtrochanteric rotational osteotomy (TRO) for osteonecrosis of the femoral head (ONFH) is considered technically demanding, with varying results among institutions. This is due to the complex soft tissue exposure and determination of the osteotomy line. We report a case in which the osteotomy line was assessed using the Stryker OrthoMap® three-dimensional (3D) computed tomography (CT)-based navigation system and determined as preoperatively planned.

CASE PRESENTATION

The patient was a 24-year-old male with alcohol-related ONFH. Japanese Investigation Committee Classification Type C2/C2 Stage 3b/3b was confirmed through magnetic resonance imaging, and TRO was performed bilaterally on the same day using the Stryker OrthoMap® 3D CT-based navigation system. The patient was hospitalized for 55 days, and full loading was allowed at 6 months postoperatively. Eight months after surgery, the patient could return to work at his previous job in the restaurant industry relatively quickly. One and a half years postoperatively, the functional score improved from a preoperative visual analog scale of 90 to 12 mm at and the Japanese Hip Society Hip Evaluation Questionnaire improved from 31 points preoperatively to 59 points.

CONCLUSIONS

This is the first report of a bilateral TRO for bilateral ONFH performed on the same day using CT-based navigation. For osteonecrosis, which is often bilateral, accurate determination of the osteotomy line as planned preoperatively using CT-based navigation contributes to shorter operative time, less intraoperative blood loss, and allows for bilateral same-day surgery. This may improve situations in which patients are hesitant to undergo bone-preserving surgery because of the long period of time required to return to work, thereby facilitating their early reintegration into society.

Spherical varus rotational osteotomy of the femur using a navigation system as extra-articular surgery for extensive osteonecrosis of femoral head: a case control study

BACKGROUND

Curved varus osteotomy (CVO) is an effective femoral head-preserving surgical procedure for osteonecrosis of the femoral head (ONFH) classified as type B or C1 according to the Japanese Investigation Committee (JIC) classification; it reportedly provides better postoperative outcomes than transtrochanteric rotational osteotomy (TRO). We have developed a new procedure called spherical varus rotational osteotomy (SVRO) in which osteotomy of the femur into a spherical shape is followed by varus and anterior rotation using navigation to increase indications and improve postoperative outcomes.

METHODS

Nine joints of eight patients who underwent SVRO and could be followed up for > 1 year were included in the study. Disease types determined preoperatively according to the JIC classification were type C1 for four joints and type C2 for five joints. Preoperative disease JIC classification stages were 3a for eight joints and 1 for one joint. SVRO was performed using OrthoMap® 3D Navigation software, and the following variables were measured: surgery time, intraoperative blood loss, difference between preoperative and postoperative angles of anteversion, postoperative lower limb length discrepancy, and postoperative intact area occupancy. The Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) was used for clinical evaluation. Visual Analog Scale and JHEQ scores were evaluated preoperatively and at the final follow-up.

RESULTS

The measurement results were as follows: surgery time, 130 min; blood loss, 200 ml; angle of varus, 20°; angle of anterior rotation, 30°; preoperative angle of anteversion, 15°; postoperative angle of anteversion, 22°; lower limb shortening, 11 mm; preoperative intact area occupancy, 0%; and postoperative intact area occupancy, 74.2%. There were no cases of progression in the postoperative stages or re-collapse.

CONCLUSION

SVRO allows for the repositioning of the exterior and posterior intact areas, providing a broader intact region postoperatively. This technique is particularly beneficial for young patients with ONFH and extensive necrosis and is a less invasive alternative to TRO. This procedure has been shown to be effective in achieving favorable outcomes in patients with extensive necrosis who would have otherwise required rotational osteotomy, depending on the necrosis location. Further longitudinal studies are necessary to validate these findings and establish long-term benefits.

Acidity and oxidative potential of atmospheric aerosols over a remote mangrove ecosystem during the advection of anthropogenic plumes

To investigate the acidity and the water-soluble oxidative potential of PM10, during the continental biomass-burning plume transport, a three-year (2018-2020) winter-time campaign was conducted over a pristine island (21.35°N, 88.32°E) of Sundarban mangrove ecosystem situated at the shore of Bay of Bengal. The average PM10 concentration over Sundarban was found to be 98.3 ± 22.2 μg m-3 for the entire study period with a high fraction of non-sea-salt- SO42- and water-soluble organic carbons (WSOC) that originated from the regional solid fuel burning. The thermodynamic E-AIM(IV) model had estimated that the winter-time aerosols over Sundarban were acidic (pH:2.4 ± 0.6) and mainly governed by non-sea-salt-SO42-. The volume and mass normalized oxidative potential of PM10 was found to be 1.81 ± 0.40 nmol DTT min-1 m-3 and 18.4 ± 6.1 pmol DTT min-1 μg-1 respectively which are surprisingly higher than several urban atmospheres across the world including IGP. The acid-digested water-soluble transition metals (Cu, Mn) show higher influences in the oxidative potential (under high aerosol acidity) compared to the WSOC. The study revealed that the advection of regional solid fuel burning plume and associated non-sea-salt-SO42- is enhancing aerosol acidity and oxidative stress that in turn alters the intrinsic properties of aerosols over such marine ecosystems rich in ecology and bio-geochemistry.

Intertrochanteric curved varus osteotomy for subchondral fracture of the femoral head: a case series

Although favorable results have been reported with total hip arthroplasty, joint-preserving treatment should be the first choice for subchondral fracture of the femoral head (SFF) in young patients. This study reviewed four young male patients with SFF who underwent intertrochanteric curved varus osteotomy (CVO). The patients had a mean age of 32.3 years (range: 18-49 years). Conservative treatment was initially attempted in all cases, but failed to alleviate the pain, leading to surgical intervention at an average time of 6 months (range: 4-10 months) after symptom onset. As the fracture sites were located medial to the lateral edge of the acetabulum in all cases, CVO was performed to achieve a postoperative intact ratio of ≥ 34% in the weight-bearing region of the femoral head. The average follow-up period after surgery lasted 4.3 years (range: 2-7 years). Clinical and radiographic assessments were performed pre- and postoperatively. At the latest follow-up, the mean Harris hip score improved from 67.3 preoperatively to 99.5 postoperatively. The average preoperative intact ratio of the weight-bearing region of the femoral head was 12.3%, which increased to 44.3% postoperatively. No progression to femoral head collapse or joint space narrowing was observed on the plain radiographs. CVO is a simple, less-invasive, and beneficial approach for treating SFF in young patients whose fractures occur medial to the lateral edge of the acetabulum.

Clinical outcomes of autologous platelet-rich plasma and bone marrow mononuclear cells grafting combined with core decompression for Association Research Circulation Osseous II-IIIA stage non-traumatic osteonecrosis of the femoral head

PURPOSE

This study aimed to investigate the efficacy and safety of autologous platelet-rich plasma (PRP) and bone marrow mononuclear cells (BMMCs) grafting combined with core decompression (CD) in the treatment of Association Research Circulation Osseous (ARCO) II-IIIA stage non-traumatic osteonecrosis of the femoral head (ONFH).

METHODS

The clinical data of 44 patients (44 hips) with non-traumatic ONFH from December 2018 to December 2019 were retrospectively reviewed. Twenty-four patients underwent CD combined with autologous PRP and BMMCs grafting (PRP+BMMCs group), and 20 patients underwent core decompression alone (CD group). During a minimum follow-up of 36 months, radiographic outcomes were evaluated using X-ray, radiographic failure rates were compared, and Harris hip score (HHS) and visual analog scale (VAS) were selected to evaluate clinical outcomes. The percentage of patients with minimal clinically important difference (MCID) in both groups was analyzed. Clinical failure was defined as further total hip arthroplasty (THA) with Kaplan-Meier survival analysis. Surgical complications were recorded.

RESULTS

All patients had well healed wounds, and no complications such as infection and thrombosis occurred. HHS and VAS scores in both the PRP+BMMCs and CD groups were better than those preoperatively (P<0.05). At the last follow-up, the HHS and VAS scores of the PRP+BMMCs group were significantly better than those of the CD group (P<0.05). In ARCO II-IIIA stage, 66.7% of the PRP+BMMCs group and 30.0% of the CD group achieved the MCID (P<0.05). The clinical and imaging failure rates in the PRP+BMMCs group were 12.5% and 20.8%, respectively, compared with 40.0% and 50.0% in the CD group (P<0.05). In ARCO II stage, the MCID, clinical and imaging failure rates of PRP+BMMCs group and CD group were 66.7% and 33.3% (P<0.05), 4.8% and 33.3% (P<0.05), 14.3% and 44.4% (P<0.05), respectively. The PRP+BMMCs group had better hip survival rate compared with CD group (P<0.05).

CONCLUSION

CD combined with autologous PRP and BMMCs grafting is a safe and effective method for the treatment of ARCO II-IIIA stage non-traumatic ONFH, especially for ARCO II stage, effectively reducing the collapse rate of the femoral head and delaying or even avoiding THA.

A review and meta-analysis of the survival rate of adult with osteonecrosis of the femoral head treated with transtrochanteric rotational osteotomy

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a progressive disease, and transtrochanteric rotational osteotomy (TRO) is a promising option to treat hip preservation. Compared with outcomes of non-Asian patients, those of Asian patients are different. Once ONFH has progressed to the stage of collapse, total hip arthroplasty (THA) is an unavoidable surgical procedure. However, patients treated with TRO still have a certain rate of femoral head collapse. A meta-analysis was done to comprehensively understand the outcome of TRO surgery for ONFH, in which conversion to THA was used as an endpoint event or the survival rate of patients with ONFH after TRO surgery as an indicator.

METHODS

We retrieved electronic databases from the inception of the study until June 2022, using the survival rate after TRO surgery or that after conversion to the endpoint event of THA as the effect indicator. The Risk Difference Independent unmatched samples of counting information with 95% confidence intervals (CI) were used to calculate the outcome. Also, subgroup analysis was carried out for Asian and non-Asian patients. Heterogeneity and publication bias analyses were also done for the included studies.

RESULTS

We pooled 19 studies, all of which were about applying TRO procedure for ONFH. There were 15 cohort studies, 4 case-control studies, and no randomized controlled studies. Based on the information extracted from the reported above (we extracted the relevant independent effect values separately for the case-control studies), this meta-analysis was performed based on a fixed-effect model, and META analysis was performed for an independent unpaired group of the samples. The total hip survival rate after TRO in ONFH was 0.58(95% CI = 0.45-0.72), The survival rate for Asians was: 0.68 (95% CI = 0.51-0.85) and for non-Asians was: 0.41 (95% CI = 0.17-0.64), respectively.

CONCLUSIONS

The application of TRO surgery in ONFH can effectively relieve patients' symptoms and they enjoy n a high survival rate, especially for Asian patients. This makes it a promising surgical technique.

Hip preserving procedures for osteonecrosis of the femoral head after collapse

Osteonecrosis of the femoral head (ONFH) affects mainly young patients and causes secondary hip osteoarthritis if remains untreated. Several operative treatments have been introduced with successful outcomes in the early stages. However, in late stages of ONFH treatment may be challenging due to the progressive nature of disease and many surgeons prefer arthroplasty option after collapse. Considering the size, age and etiology an effort should be made to preserve hip joint selected patients with early collapse or minimal arthritic changes. The purpose of the current review is to discuss the results of joint preserving procedures for late stages of ONFH.

Osteonecrosis of the hip: is there a difference in the survivorship of total hip arthroplasty with or without previous vascular iliac bone grafting?

Background

Osteonecrosis of the femoral head (ONFH) is a debilitating condition. Vascularized iliac bone graft (VIBG) is a joint-preserving surgery to improve blood supply to the avascular portion of the femoral head which may delay secondary osteoarthritis and total hip arthroplasty (THA). However, whether VIBG will affect the subsequent THA survivorship and outcomes are still uncertain.

Methods

Implant survivorship and clinical outcomes were compared between 27 patients who had undergone prior VIBG and 242 patients who had only undergone THA for ONFH. Baseline characteristics and the postoperative Harris Hip Score (HHS) were also recorded and compared between the two groups. Implant survivorship was determined using Kaplan-Meier survival analysis.

Results

The overall implant survival for all patients who had a primary diagnosis of ONFH and eventually underwent THA was 92.9%. There was no significant difference in the implant survivorship between the group who directly received THA (survivorship of 93%) and the group which failed VIBG and was subsequently converted to THA (survivorship of 91.9%) (p = 0.71). In addition, higher THA revision rates were associated with smokers and drinkers.

Conclusions

VIBG may be a reasonable option as a “buy-time” procedure for ONFH. Even if conversion to THA is eventually required, patients may be reassured that the overall survivorship and clinical outcomes may not be compromised. Patients are recommended to give up smoking and binge drinking prior to THA to increase implant survival rate.

Treatment of aseptic osteonecrosis of the femoral head: Historical aspects

The treatment of aseptic osteonecrosis (ON) of the femoral head has been the subject of numerous therapeutic and surgical proposals due to the absence of medical treatment with proven efficacy. For many years, the goal of surgical treatment was to avoid total hip replacement (THR) with uncertain survival in patients considered too young (30-50 years) for this procedure. Numerous conservative treatments were thus proposed: core decompression with numerous variants, non-vascularized and vascularized bone grafts, intertrochanteric and rotational transtrochanteric osteotomies, cementing. The lack of a common classification and a lack of knowledge of natural history complicated the interpretation of the results for a long time. Nevertheless, it appeared that these treatments were effective only in the very early stages and among these in the limited ONs, medial rather than central and especially lateral, with discrepancies according to etiologies apart from sickle cell disease recognized by all as being pejorative. For the same reason, partial arthroplasties have been attempted and abandoned in turn: femoral head total and partial resurfacing and femoral prosthesis. The most recent advances are stem-cell-enhanced core decompression and progress in total arthroplasty, whose reliability has made it possible to extend the indications to increasingly younger patients seeking treatment with guaranteed or near-guaranteed efficacy. Most of the other interventions have disappeared or almost disappeared because of their lack of effectiveness especially in extensive and post-fracture ONs, sometimes because of their complexity and the length of their post-operative management, and also because they complicate and penalize a future total arthroplasty. This argues for early detection of ON at an early stage where the "head can be saved" by stem cell augmented core decompression, a minimally invasive treatment that leaves the chances of success of a THR intact.

Concentrated autologous bone marrow aspirate transplantation versus conservative treatment for corticosteroid-associated osteonecrosis of the femoral head in systemic lupus erythematosus

Objective: To compare the outcomes of steroid-associated osteonecrosis of the femoral head in patients with systemic lupus erythematosus who underwent conservative treatment and concentrated autologous bone marrow aspirate transplantation

Methods: Osteonecrosis of the femoral head was classified according to the Japanese Investigation Committee system. Concentrated autologous bone marrow aspirate transplantation was performed by aspirating the bone marrow from both iliac crests and then transplanting it to the necrotic area after the core decompression. Patients with >2-year follow-up after the concentrated autologous bone marrow aspirate transplantation in our institution (Group I) and those with >2-year follow-up after the first hospital visit in a cooperative institution (Group II) were included in this study. After a randomized matching based on age, sex, type, stage, and etiology, the collapse rate in pre-collapsed stages and total hip arthroplasty conversion rate in all stages were compared between the two groups.

Results: After the matching adjustment, 33 pairs of hips were included. Preoperatively, 1, 2, 16, and 14 hips were classified as types A, B, C1, and C2, respectively, and 15, 13, 2, and 3 hips were classified as stages 1, 2, 3A, and 3B, respectively. The collapse rates in the pre-collapsed stages were 68% and 39% in Groups I and II, respectively. Total hip arthroplasty conversion rates were 33% and 45% in Groups I and II, respectively. However, Group I had significantly higher and lower conversion rates in stages 1 and 3, respectively (both P<0.05).

Conclusion: Conservative treatment may be preferable in stage 1 hips. In addition, concentrated autologous bone marrow aspirate transplantation may prevent further collapse in stage 3.

Study on the outcome of patients with aseptic femoral head necrosis treated with percutaneous multiple small-diameter drilling core decompression: a retrospective cohort study based on magnetic resonance imaging and equivalent sphere model analysis

Background

Aseptic necrosis of the femoral head (ANFH) has a high incidence in the community and causes substantial problems with health as well as economic and social stress. Core decompression is the most commonly used treatment for early ANFH. Although many studies have reported on the efficacy of femoral head core decompression surgery for ANFH, there are still some shortcomings in assessing the severity of femoral head necrosis, the location distribution, and changes in necrotic lesions before and after surgery. Magnetic resonance imaging (MRI) and equivalent sphere model analysis were used to further clarify the clinical efficacy of percutaneous multiple small-diameter drilling core decompression in patients with ANFH.

Methods

From July 2013 to November 2016, 24 patients (32 cases of the hip joint) with ANFH who underwent percutaneous multiple small-diameter drilling core decompression were selected, and a retrospective analysis was conducted. MRI as well as VAS, OHS-C, and HHS scores were used to evaluate joint function in all patients before and 6, 12, and 24 months after the operation.

Results

Twenty-four months after the operation, 10 hips were amputated. The survival rates of alcoholic femoral head necrosis (AFNH), idiopathic femoral head necrosis (IFHN), and steroid-induced femoral head necrosis (SIFHN) patients at 24 months were 100%, 85.7% (− 2 hips), and 0.0% (− 8 hips), respectively. The MRI and equivalent sphere analysis results revealed that the anterior superior medial quadrant was the area most prone to osteonecrosis, and the posterior superior medial quadrant was the area second most prone to necrosis. After the operation, the average percentage of the AFHN necrosis area in the total volume of the femoral head decreased from 14.5 to 10.3%, and the average percentage of the IFHN necrosis area decreased from 16.3 to 9.2%; however, the average percentage of the necrosis area for SIFHN increased from 30.4 to 33.1%.

Conclusion

Percutaneous multiple small-diameter drilling core decompression significantly reduced the lesion volume for AFHN and IFHN, but the effect on SIFHN was not good.

Hip survival rate in the patients with avascular necrosis of femoral head after transtrochanteric rotational osteotomy: a systematic review and meta-analysis

Supplemental Digital Content is available in the text

Background:

The clinical outcome of transtrochanteric rotational osteotomy (TRO) for osteonecrosis of the femoral head (ONFH) remains controversial, and the promising clinical results of several Japanese studies could not be reproduced in American and European studies. Trying to solve controversies on TRO for ONFH rising from apparently conflicting studies, a meta-analysis was conducted to assess the 5- and 10-year hip survival rates (with conversion to artificial joint replacement and radiographic failure as endpoints) after TRO.

Methods:

All eligible studies were searched in seven comprehensive databases including PubMed, Web of Science, Embase, Cochrane Library, VIP Database, China Knowledge Resource Integrated Database, and Wan Fang Database prior to June 2019. The outcomes evaluated were 5- and 10-year hip survival rates after TRO. The odds ratio and risk difference for the non-comparative binary data with the 95% confidence intervals (CIs) were calculated for each outcome. The included studies were assessed for methodologic bias and potential reasons for heterogeneity were explored.

Results:

Nineteen studies of TRO for ONFH were eligible for this meta-analysis according to inclusion criteria. Based on the previous report, two calculation methods (Methods 1 and 2) were adopted in this meta-analysis. Furthermore, we performed a sub-group analysis of the 5- and 10-year hip survival rates (Method 1) after TRO for ONFH: Asian sub-population and non-Asian sub-population. Taking conversion to artificial joint replacement as the endpoint, 5- and 10-year hip survival rates (Method 1) after TRO for ONFH in the Asian population were 0.86 (95% CI = 0.82–0.89) and 0.72 (95% CI = 0.65–0.78), respectively, and 5- and 10-year hip survival rates after TRO for ONFH in the non-Asian population were 0.55 (95% CI = 0.43–0.67) and 0.42 (95% CI = 0.28–0.55), respectively. The 5- and 10-year hip survival rates (Method 2) after TRO for ONFH were 0.90 (95% CI = 0.79–0.95) and 0.89 (95% CI = 0.81–0.94), respectively. Taking radiographic failure as the endpoint, 5- and 10-year hip survival rates after TRO for ONFH were 0.70 (95% CI = 0.64–0.76) and 0.53 (95% CI = 0.46–0.61), respectively.

Conclusions:

The 5- and 10-year hip survival rates after TRO for ONFH were satisfactory in the Asian population, and were acceptable in the non-Asian population despite high early failure rates.

Total knee arthroplasty in achondroplasia without deformity correction: A case report with 11 years' follow-up

Knee osteoarthritis in patients with achondroplasia is rare. Bowleg deformity is typical but corrective surgery is limited. Thus, primary total knee arthroplasty (TKA) might be challenging due to the particular anatomy. We report on a patient with 11 year's follow-up after a TKA performed maintaining bowleg alignment, using a posterior stabilized, fixed-bearing design. Sequential X-rays showed radiolucencies on the femoral component within two years postoperatively, slightly increasing over time but stable at last follow-up. The Oxford Knee Score showed an excellent result at 11 years. Despite the peculiarities of a case report, TKA without concomitant osteotomies might be an option for such patients. Nevertheless, a thorough discussion about pros and cons is paramount.

Mid- to long-term results of modified non-vascularized allogeneic fibula grafting combined with core decompression and bone grafting for early femoral head necrosis

Purpose

The aim of this study was to determine mid-and-long term follow-up results of patients with early femoral head osteonecrosis who were treated by modified free vascularized fibular grafting combined with core decompression and bone grafting.

Methods

Forty-four patients at early ONFH were included in this study. Visual analog scale (VAS) pain scores, range of hip motion (ROM), and Harris hip score (HHS) were recorded to assess the clinical outcome; Western Ontario McMaster Osteoarthritis index (WOMAC) scores and Short Form 36 health survey (SF-36) were conducted to measure the living quality; X-ray film or magnetic resonance imaging (MRI) was used to evaluate radiographic progression; survivorship was defined as patients did not undergo the total hip arthroplasty (THA) or fusion at the last follow-up. Median follow-up was 7.4 years (6–8.2 years).

Results

The mean VAS score, ROM, and HHS were significantly improved at the final follow-up compared with preoperative values (p < 0.001). Health assessment including WOMAC scores and SF-36 were also better than those preoperatively (p < 0.001). Seven patients progressed to Ficat III and the four patients progressed to Ficat IV with osteoarthritis. Eight patients who cannot tolerate the pain and had poor living quality underwent THA.

Conclusion

Modified non-vascularized allogeneic fibula Grafting combined with core decompression and bone grafting could improve the clinical outcomes and enhance the quality of life for patients with early ONFH.

[Hip preservation experience of avascular necrosis of femoral head according to China-Japan Friendship Hospital classification]

OBJECTIVE

To sum up staging treatment experiences of hip preservation for avascular necrosis of the femoral head (ANFH) according to China-Japan Friendship Hospital Classification (CJFH Classification).

METHODS

The literature about hip preservation of ANFH was extensively reviewed, and a staging treatment method for ANFH was set up base on CJFH Classification and the 28 years of clinical experience in this research group.

RESULTS

According to CJFH Classification, the ANFH can be rated as types M, C, and L. And the type L is rated as L1, L2, and L3 subtypes. The staging treatment method for ANFH based on CJFH Classification is set up. Conservative treatment was selected for CJFH-M patients because the necrotic area is small and in the medial non-weight-bearing area. Minimally invasive sequestrum clearance, impacting bone graft, and supporting allogenic fibular graft is selected for CJFH-C patients because the necrotic area is also small and in the lateral non-weight-bearing area. If patients are in CJFH-L1, normal bone area is less than 1/3 on hip abduction radiograph, the sequestrum clearance and impacting bone graft via surgical hip dislocation approach can be selected. If patients are in CJFH-L1, normal bone area is more than 1/3 on hip abduction radiograph, the transtrochanteric curved varus osteotomy can be selected. The rotational osteotomy on the base of femoral neck via surgical hip dislocation approach is for CJFH-L2 patients. Total hip arthroplasty via direct anterior approach is for CJFH-L3 patients.

CONCLUSION

The staging treatment method for ANFH according to CJFH Classification has good short-term effectiveness. But the long-term effectiveness needs further follow-up.

Ten-year results of concentrated autologous bone marrow aspirate transplantation for osteonecrosis of the femoral head: a retrospective study

BACKGROUND

Idiopathic osteonecrosis of the femoral head (ONFH) occurs at a relatively younger age. It is therefore important to prevent the resultant femoral head collapse and requirement of total hip arthroplasty in these patients. In 2003, we initiated concentrated autologous bone marrow aspirate transplantation (CABMAT), a joint-preserving treatment for ONFH, at our institution. Here, we report the long-term results of CABMAT treatment.

METHODS

We retrospectively collated and analyzed the demographic and treatment data of 69 patients (109 hips) with idiopathic ONFH treated with CABMAT between April 2003 and April 2008.

RESULTS

Totally, 44 patients (21 men, 23 women, 80 hips) completed the 10-year follow-up. The follow-up rate was 73.4%, and the mean follow-up period was 12.0 (range, 10.0-15.4) years. The mean age of the patients was 42.2 (range, 16.3-70.5) years. Using the Association Research Circulation Osseous (ARCO) classification system for preoperative analysis, 12, 31, 32, and 5 hips were classified as stages 1, 2, 3, and 4, respectively. The overall rate of conversion to total hip arthroplasty (THA) was 34% (27/80 hips). In a multivariate regression analysis, the preoperative stage of ONFH and the body mass index were found to correlate significantly with conversion to THA. Totally, 43 hips (of 80) were classified as belonging to the pre-collapse stage (i.e., stages 1 or 2). The overall collapse rate and the THA-conversion rate of these hips were estimated to be 49% (21/43) and 14% (6/43), respectively.

CONCLUSIONS

On the basis of our long-term findings, the minimally invasive and feasible CABMAT therapy can be utilized as one of a joint-preserving treatment for ONFH.

Which Osteotomy for Osteonecrosis of the Femoral Head and Which Patient for the Osteotomy?

Transtrochanteric curved varus osteotomy (TCVO) and transtrochanteric rotational osteotomy (TRO) are joint-preserving procedures for osteonecrosis of the femoral head. The purpose of this review is to provide up-to-date guidelines for the osteotomies. One retrospective comparison revealed that TCVO has shorter operation time, less bleeding, lower incidence of osteophyte formation, and lower rate of secondary collapse. To obtain successful results of the osteotomy, the patient should be younger than 40 years and should have a body mass index of less than 24 kg/m². The osteotomy should be performed in early stages of femoral head osteonecrosis before marked collapse of the femoral head. The patient should have a medium-size lesion and an enough viable bone to restore the intact articular surface and subchondral bone in the weight-bearing area.

[Effectiveness comparison between impacting bone graft and rotational osteotomy via surgical hip dislocation approach for avascular necrosis of femoral head at ARCO stage ]

OBJECTIVE

To compare effectiveness between sequestrum clearance and impacting bone graft and rotational osteotomy on the base of femoral neck via surgical hip dislocation approach for avascular necrosis of femoral head (ANFH) at Association Research Circulation Osseous (ARCO ) stage Ⅲ.

METHODS

A clinical data of 24 patients (27 hips) with ANFH at ARCO stage Ⅲ, who met the inclusion criteria between June 2012 and November 2017, was retrospectively analysed. Of all patients, 12 patients (14 hips) were treated with sequestrum clearance and impacting bone graft via surgical hip dislocation approach (group A); and 12 patients (13 hips) were treated with rotational osteotomy on the base of femoral neck via surgical hip dislocation approach (group B). There was no significant difference in gender, age, disease duration, and affected side, type, and stage of the ANFH between 2 groups ( P>0.05). The operation time of each hip and hospitalization stays of each patient in 2 groups were recorded and compared. Imaging examination was performed to observe the blood supply around femoral head, healing of the osteotomy, and the femoral head collapsed. The function of the hip was evaluated by Harris score.

RESULTS

There was no significant difference in operation time and hospitalization stays ( t=-0.262, P=0.797; t=-0.918, P=0.411). All patients were followed up, the follow-up time of group A was 12-28 months (mean, 19.7 months), and the follow-up time of group B was 14-24 months (mean, 17.8 months). The Harris score in groups A and B increased significantly at 6 months and 12 months after operation when compared with preoperative ones ( P<0.05). There was no significant difference between 2 groups at 6 months and 12 months ( P>0.05). At 12 months after operation, according to the Harris scoring, there were 3 hips of excellent, 7 hips of good, and 4 hips of poor, with the excellent and good rate of 71.4% in group A; there were 5 hips of excellent, 7 hips of good, and 1 hip of poor, with the excellent and good rate of 92.3% in group B. Digital substraction angiography was performed at 1 week after operation and indicated that the blood supply around the femoral head was not destroyed during the operation. Imaging examination after operation showed that the osteotomy of the greater trochanter all healed in 2 groups and the osteotomy of the femoral neck healed in group B. Hip collapse occurred in 2 patients (2 hips) of group A at 12 months after operation. No hip collapse occurred in group B.

CONCLUSION

The rotational osteotomy on the base of femoral neck via surgical hip dislocation approach is superior to sequestrum clearance and impacting bone graft in delaying the collapse and improving the hip function for patients with ANFH at ARCO stage Ⅲ.

Classification systems of hip osteonecrosis: an updated review

PURPOSE

Osteonecrosis of the femoral head (ONFH) typically impacts middle-aged patients who are typically more active and in whom many surgeons would try to delay performing a total hip arthroplasty (THA). This poses a clinical decision-making challenge. Therefore, several options for joint preservation have been advocated, but varying indications and success rates have led to debate on when to use the various procedures. This is due in part to the lack of a generalized system for assessing ONFH, as well as the absence of a standardized method of data collection for patient stratification. Due to the paucity of studies, in this review, we aimed to provide an up-to-date review of the most widely utilized classification systems and discuss the characteristics of each system.

METHODS

A comprehensive literature review was conducted. Studies published between January 1st, 1975 and March 1st, 2018 were reviewed. The following key words were used in combination with Boolean operators AND or OR for the literature search: "osteonecrosis," "avascular necrosis," "hip," "femoral head," "classification," "reliability," and "validity." We defined the inclusion criteria for qualifying studies for this review as follows: (1) studies that reported on the classification systems for hip osteonecrosis, (2) studies that reported on the inter-observer reliability of the classification systems, and (3) studies that reported on the intra-observer reliability of any ONFH classification systems. In addition, we employed the following exclusion criteria: (1) studies that assessed classification systems for traumatic osteonecrosis, (2) Legg-Calvé-Perthes disease, or (3) Developmental Dysplasia of the Hip. Additionally, we excluded case reports and duplicate studies among searched databases.

RESULTS

The following classification systems were the most commonly utilized: The Ficat and Arlet, Steinberg, the Association Research Circulation Osseous (ARCO), and the Japanese Investigation Committee (JIC) classification systems. The details of each system have been discussed and their inter- and intra-observer reliability has been compared.

CONCLUSION

To this date, there is a lack of consensus on a universal and comprehensive system, and the use of any of the previous classification systems is a matter of dealer's choice. The Ficat and Arlet system was the earliest yet remains the most widely utilized system. Newer classification systems have been developed and some such as the JIC shows promising prognostic value while maintaining simplicity. However, larger validating studies are needed. While all of these systems have their strengths, the lack of a unified classification and staging system is still a problem in the diagnosis and prognosis ONFH. Further multi-center collaborative efforts among osteonecrosis experts are needed to adopt a universal classification system that may positively reflect on patient's outcomes.

Analysis of early stage osteonecrosis of the human femoral head and the mechanism of femoral head collapse

We explored the mechanism of early stage osteonecrotic femoral head collapse by analyzing and comparing different regions in human osteonecrotic femoral head samples. Eight osteonecrotic femoral heads (ARCO II-III) were obtained from patients undergoing total hip arthroplasty. Bone structure was observed and evaluated by micro-computed tomography (CT) scans and pathology. Osteoblast and osteoclast activities were detected by tartrate-resistant acid phosphatase, alkaline phosphatase, and immunofluorescent staining. Some trabeculae had microfractures in the subchondral bone and necrotic region, which had lower bone mineral density, as well as trabecular thickness and number, but greater osteoclast activity. A sclerotic band had already appeared in certain samples which had greater trabecular thickness and number, bone mineral density, and osteoblast activity. The appearance of the femoral head did not change significantly in the early stage of osteonecrosis of the femoral head. However, osteoblast and osteoclast activities had already changed in different regions of the osteonecrotic femoral head, which may lead to eventual collapse of the femoral head. Therefore, osteonecrosis of the femoral head must be treated during the early stage. In addition, osteoblast activity should be promoted and osteoclast activity inhibited as early as possible to prevent collapse of an osteonecrotic femoral head.

Total Hip Arthroplasty After Transtrochanteric Rotational Osteotomy for Osteonecrosis of the Femoral Head: A Mean 10-Year Follow-Up

BACKGROUND

The objective of the present study was to investigate clinical, quality of life, and radiographic outcomes of patients who underwent total hip arthroplasty (THA) after transtrochanteric rotational osteotomy (TRO) for osteonecrosis of the femoral head (ONFH).

METHODS

We performed a case-control study. The participants were 29 patients (34 hips) who underwent THA after TRO (TRO group). These patients had a mean age at surgery of 51.6 years (range, 30-72 years) and underwent postoperative follow-up for a mean period of 10.5 years (range, 3-19 years). For the control group (primary group), we included 58 patients (68 hips) who underwent primary THA for ONFH, matching for age and gender.

RESULTS

The Harris Hip Scores at the last follow-up were significantly poorer in the TRO group than in the primary group. Similarly, preoperative and postoperative hip range of motion was significantly poorer in the TRO group than in the primary group. Quality of life (Short Form-36, Oxford Hip Score, and Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire) and complication rates were not significantly different between the groups. The survival rates at 10 years, with revision for any reason as the endpoint, were 81% in the TRO group and 91% in the primary group, showing no significant difference between the groups. The TRO group had a larger average postoperative leg length discrepancy and a higher rate of stem malalignment than the primary group.

CONCLUSION

The clinical outcomes of THA after TRO for ONFH were poorer than those of primary THA.

Comparison of Surgical Parameters and Results between Curved Varus Osteotomy and Rotational Osteotomy for Osteonecrosis of the Femoral Head

Background

Various osteotomies have been introduced to treat osteonecrosis of the femoral head. The purpose of this study was to compare surgical parameters, postoperative limb length discrepancy, and minimum 5-year clinical and radiological results between transtrochanteric curved varus osteotomy (TCVO) and transtrochanteric rotational osteotomy (TRO) for osteonecrosis of the femoral head.

Methods

From 2004 to 2009, 103 consecutive TROs (97 patients) followed by 72 consecutive TCVOs (64 patients) were performed for the treatment of osteonecrosis of the femoral head. Of these, 85 patients (91 hips) in the TRO group and 58 patients (65 hips) in the TCVO group completed minimum 5-year clinical and radiological follow-up. The Kaplan-Meier product-limit method was used to estimate survival.

Results

The TCVO group had shorter operation time (p < 0.05) and less estimated blood loss (p = 0.026). Postoperative collapse developed in 26 hips (28.6%) in the TRO group and 7 hips (10.8%) in the TCVO group (p = 0.007). Osteophyte formation was observed in 34 hips (37.4%) in the TRO group and 13 hips (20%) in the TCVO group (p = 0.020). Fifteen hips (16.5%) in the TRO group and 7 hips (10.8%) in the TCVO group underwent conversion total hip arthroplasty (THA). The survival rate at 9 years with radiographic collapse as the endpoint was 68.7% (95% confidence interval [CI], 58.1% to 79.3%) in the TRO group, and 84.7% (95% CI, 71.5% to 97.9%) in the TCVO group. With conversion to THA as the endpoint, the survival rate was 82.2% (95% CI, 73.1% to 91.3%) in the TRO group and 89.2% (95% CI, 81.7% to 96.7%) in the TCVO group.

Conclusions

The comparison indicates that TCVO was better than TRO in terms of surgical parameters including operation time and estimated blood loss while the 9-year survival rates were similar.

Long-term outcomes of transtrochanteric rotational osteotomy for non-traumatic osteonecrosis of the femoral head

AIMS

Transtrochanteric rotational osteotomy (TRO) is performed for young patients with non-traumatic osteonecrosis of the femoral head (ONFH) to preserve the hip. We aimed to investigate the long-term outcomes and the risk factors for failure 15 years after this procedure.

PATIENTS AND METHODS

This study included 95 patients (111 hips) with a mean age of 40 years (21 to 64) who underwent TRO for ONFH. The mean follow-up was 18.2 years (3 to 26). Kaplan-Meier survivorship analyses were performed with conversion to total hip arthroplasty (THA) and radiological failure due to secondary collapse of the femoral head or osteoarthritic changes as the endpoint. Multivariate analyses were performed to assess risk factors for each outcome.

RESULTS

Survival rates at 15 years with conversion to THA and radiological failure as the endpoint were 59% (95% confidence interval (CI) 49 to 67) and 30% (95% CI 22 to 39), respectively. Necrotic type C2 ONFH (lesions extending laterally to the acetabular edge) (hazards ratio (HR) 3.9) and age > 40 years (HR 2.5) were risk factors for conversion to THA. Stage > 3a ONFH (HR 2.0) and age > 40 years (HR 1.9) were risk factors for radiological failure.

CONCLUSION

The 15 year outcomes after TRO for ONFH are unfavorable because osteoarthritic changes occur after five years post-operatively. Cite this article: Bone Joint J 2017;99-B:175-83.

Patient-reported outcomes of femoral osteotomy and total hip arthroplasty for osteonecrosis of the femoral head: a prospective case series study

Background

Patient-reported scoring systems have recently been used after surgical procedures. The purpose of this prospective study was to evaluate the patient-reported outcomes of femoral osteotomy and total hip arthroplasty (THA) for osteonecrosis of the femoral head (ONFH).

Methods

Forty-two symptomatic ONFH patients with asymptomatic contralateral hip underwent either transtrochanteric anterior rotational osteotomy (ARO) or THA as a primary operation. Of these, 20 patients whose contralateral hips remained asymptomatic at the final follow-up (more than 1 year postoperatively) were recruited to participate in this study. Nine patients were treated with ARO (ARO group) and 11 patients were treated with THA (THA group). Both the Oxford hip score (OHS) and the short form 36 (SF-36) were evaluated preoperatively and at the final follow-up.

Results

The preoperative OHS was 29.1 ± 10.9 and 21.9 ± 9.6 points in the ARO and THA groups, which significantly improved to 38.4 ± 9.4 and 40.3 ± 5.1 points at the final follow-up, respectively. The preoperative physical component summary score was 30.8 ± 12.8 and 17.8 ± 14.5 points in the ARO group and THA groups, which significantly improved to 44.5 ± 10.6 and 43.3 ± 10.4 points at the final follow-up, respectively. The preoperative mental component summary score was 48.0 ± 8.5 and 48.6 ± 11.3 points in the ARO and THA groups, both of which remained unchanged at the final follow-up.

Conclusions

The short-term patient-reported outcomes of this study suggested that both ARO and THA for ONFH resulted in significantly improved postoperative hip joint function.

Results of the Sugioka transtrochanteric rotational osteotomy for osteonecrosis: Frequency and role of a defect of the quadratus femoris muscle in osteonecrosis progression

BACKGROUND

During transtrochanteric rotational osteotomy (RO), it is important to preserve the posterior column artery (PCA), which is generally located in the adipose tissue underneath the quadratus femoris muscle (QF). If there is a defect in the QF, the risk of injuring the PCA, subsequently resulting in total necrosis of the femoral head, may increase. Therefore, we investigated: (1) the frequency of defects of the QF at the time of RO, and (2) clinical outcome of RO based upon a defect of the QF.

HYPOTHESIS

The presence of defects of the QF at the time of RO could be detected pre-operatively by magnetic resonance imaging.

METHODS

RO was performed in 124 hips between 2001 and 2010. In all, 95 of the hips were in male patients and 29 in female patients. The mean age was 45.4 years (range: 11-61 years) at the time of surgery and MRI was performed before RO in all cases. We retrospectively evaluated the progression of a collapse through 3 years after RO.

RESULTS

MRI showed a defect in the QF in four hips (3.2%) (2 males, 2 females), all of which were confirmed intra-operatively. Among the four patients, one (25%) underwent total hip arthroplasty because of varus deformity of the osteotomy site due to total necrosis of the femoral head 1 year after RO. The 120 hips with a normal QF showed no evidence of total necrosis or progression of necrosis of the femoral head, indicating that the presence of defects of the QF may increase the risk of poor survivorship of this procedure.

CONCLUSIONS

Defects of the QF have been reported to occur in 1-2% of all patients, whereas in our study the incidence in ON was approximately 3%. In ON patients with QF defects, pre-operative MRI evaluation of the QF appears to be important when planning RO, followed by a carefully performed surgical procedure.

LEVEL OF EVIDENCE

IV; retrospective case series without control group.

Core decompression or quadratus femoris muscle pedicle bone grafting for nontraumatic osteonecrosis of the femoral head: A randomized control study

BACKGROUND

The traditional management for osteonecrosis of the femoral head (ONFH) includes core decompression (CD) and quadratus femoris muscle pedicle bone graft (QF-MPBG). The aim of this study was to investigate the effects of CD and QF-MPBG on the patients with nontraumatic ONFH in an early stage.

MATERIALS AND METHODS

39 patients (47 hips) with ONFH in an early stage (Ficat Stage I or II) were randomly divided into two groups according to random number table method. One group was treated with CD and cancellous bone grafting. Another group was treated QF-MPBG with cancellous bone grafting. The hip function was evaluated using Harris hip score (HHS). The repair of the femoral head was estimated through X-ray, computed tomography (CT), or magnetic resonance imaging (MRI). The surgical time and intraoperative blood loss was calculated.

RESULTS

All patients were followed for an average 2.5 years (range from 1.5 to 4 years). Two hips in CD group progressed into stage 3 and three hips in QF-MPBG group processed into stage 3. No patient accepted the THA at the last followup. The HHSs significantly increased in both groups after surgery (P < 0.05). No statistical differences were found between CD and QF-MPBG groups in postoperative HHSs at last followup (P > 0.05). X-ray and CT showed that the femoral head did not progress to collapse after operation in both groups. In addition, MRI showed that the edema signals decreased. However, the surgical time was longer in QF-MPBG group than that in CD group (P < 0.05). The intraoperative blood loss was more in QF-MPBG than that in CD group (P < 0.05).

CONCLUSION

The CD with bone graft could relieve hip pain, improve hip function with much lesser surgical trauma compared to QF-MPBG. Hence, the CD with bone graft should be generally used for the treatment of patients with an early stage (Ficat Stage I or II) ONFH.

Review of various treatment options and potential therapies for osteonecrosis of the femoral head

Size and location of the lesion, subchondral collapse occurrence, and articular cartilage involvement are general disease progression criteria for direct osteonecrosis of the femoral head (ONFH) classifications. Treatment options for ONFH are usually based on individual factors and lesion characteristics. Although spontaneous repair of ONFH occurs in some cases, untreated ONFH is unlikely to escape the fate of subchondral collapse and usually ends up with total hip arthroplasty. Operations to preserve the femoral head, e.g., core decompression and bone grafting, are usually recommended in younger patients. They are helpful to relieve pain and improve function in the affected femoral head without subchondral collapse, however, poor prognosis after surgical procedures remains the major problem for ONFH. Pharmacological and physical therapies only work in the early stage of ONFH and have also been recommended as a supplement or prevention treatment for osteonecrosis. Following advances in basic science, many new insights focus on bone tissue engineering to optimize therapies and facilitate prognosis of ONFH. In this review, disease classifications, current treatment options, potential therapies, and the relevant translational barriers are reviewed in the context of clinical application and preclinical exploration, which would provide guidance for preferable treatment options and translation into novel therapies.

Managing AVN following internal fixation: treatment options and clinical results

Avascular necrosis (AVN) after internal fixation of intracapsular hip fractures is a progressive multifactorial disease that ultimately results in local ischemia with ensuing osteocyte necrosis and structural compromise. This disease can cause significant clinical morbidity and affects patients of any age, including young and active patients. Effective treatment of this condition among young adults is challenging due to their high functional demands. The aim of managing AVN is to relieve pain, preserve range of movement and improve function. Treatment methods vary depending on the stage of the disease and can be broadly categorised into two options, hip preserving surgery and hip arthroplasty. Although, hip preserving techniques are attractive in the young adult, they may alter the morphology of the proximal femur and make subsequent arthroplasty more challenging. Conversely, arthroplasty in the young adult may require repeat revision procedures throughout the patient's life. Current evidence suggests that modifications of prevailing treatments, in addition to new technologies, have led to the development of management strategies that may be able to alter the course of femoral head osteonecrosis. This review aims to summarise the options available for treatment of AVN in the young adult and review the clinical results.

Summary of the various treatments for osteonecrosis of the femoral head by mechanism: A review

Osteonecrosis of the femoral head (ONFH), also known as femoral head avascular necrosis, is a pathological state with a number of possible etiologies including steroid administration, alcohol abuse, traumatic events, vascular injury and idiopathic origins. ONFH causes a reduction in the vascular supply to the subchondral bone of the femoral head, which results in osteocyte death and the collapse of the articular surface. Treatments for ONFH include non-weight-bearing therapy, physical support, the promotion of osteoclast apoptosis, and the reduction of osteoblast and osteocyte apoptosis. The aim of the present review was to summarize the treatments for ONFH by mechanism from a new perspective and to describe the condition with an emphasis on treatment options.

Conversion total hip arthroplasty after previous transtrochanteric rotational osteotomy for osteonecrosis of the femoral head

The results of conversion total hip arthroplasty (THA) after failed transtrochanteric rotational osteotomy (TRO) are still controversial. We retrospectively reviewed 18 patients with ONFHs who had been treated previously by TRO and were later converted to THAs (conversion group). We made a matched control group of 18 primary THAs for ONFH done by same hip surgeon (PTHA group). There was an improvement in the Harris hip score and WOMAC score at the final follow-up but the improvement was not statistically significant between the two groups. Only internal rotation was significantly better in the PTHA group than in the conversion group. THA after TRO provides satisfactory clinical and radiological outcomes with no significant increase in perioperative morbidity in comparison with that in the primary THA.

Hip osteonecrosis: does prior hip surgery alter outcomes compared to an initial primary total hip arthroplasty?

The purpose of this study was to assess the clinical and radiographic outcomes of total hip arthroplasty (THA) in patients who had osteonecrosis to see if prior hip preserving surgery affected outcomes. Implant survivorship, Harris hip scores, and radiographic outcomes were compared between 87 patients (92 hips) who had undergone prior hip preserving procedures and 105 patients (121 hips) who had only undergone THA. Patients were also sub-stratified into low- and high-risk groups for osteonecrosis. At a mean follow-up of 75 months, there were no significant differences in survivorship, clinical, and radiographic outcomes among the cohorts. Higher revision rates were associated with patients who were in the high-risk group. The authors believe that hip joint preserving procedures may not adversely affect the outcomes of later THA in patients with osteonecrosis.

Radiological outcome analyses of transtrochanteric posterior rotational osteotomy for osteonecrosis of the femoral head at a mean follow-up of 11 years

BACKGROUND

This study investigated the radiological factors that correlated with progression of collapse and joint space narrowing after transtrochanteric posterior rotational osteotomy (PRO) for osteonecrosis of the femoral head.

METHODS

This study reviewed 51 hips in 47 patients with a mean follow-up of 11 years (5-20). The subjects included 29 males and 18 females with a mean age of 34 years (12-54) at the time of surgery. The 51 hips were divided into two groups based on the radiological outcome (group I: evidence of progression of collapse and/or joint space narrowing, group II: no evidence of either progression of collapse or joint space narrowing). Both clinical and radiological factors were analyzed by both univariate and multivariable analyses.

RESULTS

Six hips were categorized as group I and 45 hips were categorized as group II. The postoperative intact ratio and preoperative stage were significantly correlated with the radiological outcome in both univariate (P < 0.0001, P = 0.006) and multivariate (P = 0.0014, P = 0.0039) analysis. The cutoff point for the postoperative intact ratio (the minimum ratio required to prevent both progression of collapse and joint space narrowing) was 36.8 %.

CONCLUSIONS

The results of this study indicate that the postoperative intact ratio is one of the main influences on progression of collapse and/or joint space narrowing after PRO, and should be at least 36.8 %. An increased awareness of this critical ratio would be useful for planning the optimal use of this procedure.

Clinico-radiological factors affecting the joint space narrowing after transtrochanteric anterior rotational osteotomy for osteonecrosis of the femoral head

PURPOSE

The purpose of this study was to investigate the factors that affect the joint space narrowing after transtrochanteric anterior rotational osteotomy (ARO) for osteonecrosis of the femoral head (ONFH).

METHODS

We reviewed 39 cases (43 hips) of ONFH in patients who underwent ARO between 2000 and 2004. Their mean age was 42 years (23-61) at the time of surgery. The mean follow-up period was 7.3 years (3-10). The following clinical and radiological factors were investigated: the preoperative stage, localization and extent of the necrotic lesion, and the postoperative intact ratio (transposed intact articular surface of the femoral head to the weight-bearing surface of the acetabulum). The 43 hips were divided into two groups: a joint space narrowing (JSN) group and a non-joint space narrowing (non-JSN) group.

RESULTS

Thirty-seven hips (86 %) were categorized as non-JSN and six (14 %) as having JSN. The preoperative Japanese Orthopaedic Association score was significantly higher in the non-JSN group than in the JSN group (P = 0.01). In the non-JSN group, the rate of early stage disease was significantly higher than in the JSN group (P = 0.03). The postoperative intact ratio was significantly higher in the non-JSN group than in the JSN group (P = 0.002). A multivariate analysis revealed that the postoperative intact ratio was an independent predictor of the progression of joint space narrowing after ARO, and the cutoff point was 39.2 %.

CONCLUSION

The results of this study suggest that the postoperative intact ratio is one of factors determining the progression of joint space narrowing after ARO and that an approximately 40 % or higher postoperative intact ratio is recommended to prevent joint space narrowing.

Ilizarov hip reconstruction for the management of advanced osteonecrosis in an adolescent with leukemia

With advances in chemotherapy, long-term survival for childhood leukemia is improving. However, chemotherapy-induced osteonecrosis of the proximal femur remains a challenging problem. We present a case of an adolescent female with advanced osteonecrosis of the proximal femur after chemotherapy for acute lymphoblastic leukemia. She underwent an Ilizarov hip reconstruction with a subtrochanteric valgus extension osteotomy and distal femoral lengthening with varus angulation using an external fixator. At a 3-year follow-up, her symptoms and gait had markedly improved. On the basis of this preliminary report, Ilizarov hip reconstruction is a viable alternative for advanced osteonecrosis of the proximal femur in an adolescent.

Long-term results of conventional varus half-wedge proximal femoral osteotomy for the treatment of osteonecrosis of the femoral head

We have previously described the mid- to long-term results of conventional simple varus intertrochanteric osteotomy for osteonecrosis of the femoral head, showing that 19 of the 26 hips had good or excellent results. We extended the follow-up to a mean of 18.1 years (10.5 to 26) including a total of 34 hips in 28 patients, with a mean age at surgery of 33 years (19 to 53). There were 18 men and ten women and 25 hips (74%) had a satisfactory result with a Harris hip score ≥ 80. In all, six hips needed total hip replacement (THR) or hemiarthroplasty. The collapse of the femoral head or narrowing of the joint space was found to have progressed in nine hips (26%). Leg shortening after osteotomy was a mean of 19 mm (8 to 36). With conversion to THR or hemiarthroplasty as the endpoint, the ten-year survival rate was 88.2% (95% confidence interval (CI) 82.7 to 93.7) and the 20-year survival rate was 79.7% (95% CI 72.1 to 87.3); four hips were converted at ten years and other two hips were converted at 20 years.

Shortening of the leg after osteotomy remains a concern; however, the conventional varus half-wedge osteotomy provides favourable long-term results in hips with less than two-thirds of the medial part of the femoral head affected by necrotic bone and with normal bone superolaterally.

Femoral head osteonecrosis: why choose free vascularized fibula grafting

Osteonecrosis of the femoral head is a disease in which bone death occurs and usually progresses to articular incongruity and subsequent osteoarthritis. To delay the process of the disease and the conversion to total hip arthroplasty, many surgical techniques have been described. Core decompression, nonvascularized autologous bone grafts, porous tantalum implant procedure, and various osteotomies have been used for the management of early precollapse stage osteonecrosis of the femoral head. However, none of these procedures is neither entirely effective nor can obtain predictable results. With the progress of microsurgery, the implantation of a free vascularized fibula graft to the necrotic femoral head has provided the most consistently successful results. Although the procedure is technically demanding, there is growing recognition that the use of free vascularized fibula graft may improve patient quality of life by functional improvement and pain alleviation. The success of the procedure is related to decompression of the femoral head, excision of the necrotic bone, and addition of cancellous bone graft with osteoinductive and osteoconductive properties, which augments revascularization and neoosteogenesis of the femoral head. Free vascularized fibula graft, especially in younger patients, is a salvaging procedure of the necrotic femoral head in early precollapse stages. In postcollapse osteonecrosis, the procedure appears to delay the need for total hip arthroplasty in the majority of patients. The purpose of this review article is to update knowledge about treatment strategies in femoral head osteonecrosis and to compare free vascularized fibula grafting to traditional and new treatment modalities.

Effects of age and body mass index on the results of transtrochanteric rotational osteotomy for femoral head osteonecrosis

BACKGROUND

Advanced-stage osteonecrosis and a large area of necrotic bone are known risk factors for failure of transtrochanteric rotational osteotomy of the hip in patients with osteonecrosis. The purpose of this study was to determine whether there are other risk factors for failure of this osteotomy.

METHODS

One hundred and five patients (113 hips) underwent an anterior transtrochanteric rotational osteotomy for the treatment of femoral head osteonecrosis and were followed for a mean of 51.3 months postoperatively. Radiographic failure was defined as secondary collapse or osteoarthritic change. Multivariate analysis was performed to assess factors associated with secondary collapse and osteophyte formation. The Kaplan-Meier product-limit method was used to estimate survival.

RESULTS

Secondary collapse occurred in twenty-seven hips (24%), and fourteen hips (12%) were converted to a total hip arthroplasty. At the time of the most recent follow-up, the hip scores according to the system of Merle d'Aubigné et al. ranged from 6 to 18 points (mean, 15.8 points). Multivariate analysis showed that the stage of the necrosis (III or greater) (hazard ratio = 3.28; 95% confidence interval = 1.49 to 7.24), age of the patient (forty years or older) (hazard ratio = 1.08; 95% confidence interval = 1.02 to 1.14), body mass index (> or = 24 kg/m(2)) (hazard ratio = 1.19; 95% confidence interval = 1.03 to 1.38), and extent of the necrosis (a combined necrotic angle of > or = 230 degrees ) (hazard ratio = 1.08; 95% confidence interval = 1.04 to 1.11) were associated with secondary collapse. Seven of the eighty-six hips without collapse showed progression to osteoarthritis. The survival rate at 110 months was 63.4% (95% confidence interval = 51.1% to 75.7%) with total hip arthroplasty or radiographic failure as the end point and 56.0% (95% confidence interval = 44.6% to 67.4%) with total hip arthroplasty, radiographic failure, or loss to follow-up as the end point.

CONCLUSIONS

Our study showed that age, body mass index, and the stage and extent of the osteonecrosis were determining factors for secondary collapse, unsatisfactory clinical results, and conversion to total hip arthroplasty. These factors should be considered when selecting patients for a transtrochanteric rotational osteotomy.

Total hip arthroplasty after previous transtrochanteric anterior rotational osteotomy for femoral head osteonecrosis

We compared the perioperative morbidity, position of the implants, implant stability, and clinical results of 14 conversion total hip arthroplasties after previous transtrochanteric anterior rotational osteotomy with those of a matched control group of 28 primary total hip arthroplasties. The operation time was prolonged, perioperative blood loss increased, and the risk of stem or cup malposition was increased in the conversion group. However, there were no significant differences in the postoperative complications, clinical results, and implant stability between the 2 groups. None of the implants were loose in both groups. Transtrochanteric anterior rotational osteotomy should be advised, planned, and executed bearing in mind the operative morbidity and technically demanding nature of the conversion total hip arthroplasty.

Evaluation of instability after transtrochanteric anterior rotational osteotomy for nontraumatic osteonecrosis of the femoral head

BACKGROUND

Transtrochanteric anterior rotational osteotomy results in improvement of joint congruity and prevention of progressive collapse and osteoarthritic changes in patients with femoral head osteonecrosis. However, this procedure remains controversial for patients with extensive collapse due to potential osteoarthritis caused by postoperative instability. The purpose of this study was to evaluate hip instability after osteotomy and determine the relation between instability and radiological and clinical outcomes.

METHODS

In all, 27 hips of 24 patients that were followed up for a mean period of 3.8 years were included. Instability was defined as more than 1 mm translation of the femoral head in transverse computed tomography scans obtained at 0 degrees and 45 degrees flexion of the hip joint. Hips were divided into instability and stability groups.

RESULTS

Eleven hips (40%) developed instability after surgery. Osteophytes on the femoral head in 10 hips of the instability group and 2 hips of the stability group had increased in size at follow-up. There was a significant relation between postoperative instability and osteophyte formation. Joint space narrowing was not seen in any of the cases. There was no significant difference between the groups in either the postoperative intact ratio of the femoral head or the Japanese Orthopaedic Association hip score.

CONCLUSIONS

Neither instability nor osteophyte formation on the femoral head after transtrochanteric anterior rotational osteotomy correlated with progressive osteoarthritic changes or clinical outcome in the presence of an adequate femoral head intact ratio facing the weight-bearing area.

SAS weekly rounds: avascular necrosis

Osteonecrosis of the femoral head is a condition that affects upwards of 10,000 individuals in the USA each year. The peak incidence is in the fourth decade of life, and overall, there is a male preponderance. The condition accounts for up to 12% of total hip arthroplasties performed in developed countries. The etiology can be traumatic or non-traumatic, with 90% of atraumatic cases attributed to corticosteroid therapy or excess alcohol consumption. Osteonecrosis of the femoral head reflects the final common pathway of a range of insults to the blood supply and ultimately results in femoral head collapse, acetabular involvement, and secondary osteoarthritis. Currently, conservative treatment options, which aim to correct pathophysiologic features allowing revascularization and new bone formation, appear to be able to delay but not halt the progression of this condition. As a consequence of femoral head osteonecrosis, many individuals undergo surgical treatments including: core decompression, osteotomy, non-vascularized bone matrix grafting, free vascularized fibular grafts, limited femoral resurfacing, total hip resurfacing, and total hip arthroplasty.

Transtrochanteric anterior rotational osteotomy for osteonecrosis of the femoral head in patients 20 years or younger

BACKGROUND

For young patients with osteonecrosis of the femoral head, especially those younger than 20 years, a joint-preserving operation may be one of the surgical treatment options to be considered. We investigated the clinical and radiological results of transtrochanteric anterior rotational osteotomy for the treatment of osteonecrosis of the femoral head in patients 20 years or younger.

METHODS

Between 1976 and 2001, a transtrochanteric anterior rotational osteotomy was performed in 28 hips of 23 patients aged 20 years or younger with osteonecrosis of the femoral head. Among them, 27 hips of 22 patients with a minimum follow-up duration of 2 years were investigated (follow-up rate, 96.4%). They included 7 males and 15 females with a mean age of 16 years at the time of surgery. The mean follow-up period was 14.7 years (range, 2.0-31.7 years). The clinical assessment was made based on the Merle d'Aubigné-Postel score. The postoperative intact ratio, joint-space narrowing, and progression of collapse were all investigated radiographically.

RESULTS

Two (7.4%) of the 27 hips required total hip arthroplasty because of restrictions in the range of motion, whereas the original hip joints in 25 (92.6%) of the 27 hips were preserved at the time of final follow-up. The mean preoperative Merle d'Aubigné-Postel score was 10.4 points, which improved to 15.9 points at the final follow-up (P < 0.0001). The mean postoperative intact ratio was 49.8% (range, 30-100). Five (18.5%) of the 27 hips had a progressive joint-space narrowing, but progression of the collapse was not observed in anyhips.

CONCLUSIONS

Transtrochanteric anterior rotational osteotomy appears to be a useful joint-preserving operation for patients younger than 20 years.

LEVEL OF EVIDENCE

Level 4 (Therapeutic Study).

Transtrochanteric rotational osteotomy for nontraumatic osteonecrosis of the femoral head in young adults

Transtrochanteric rotational osteotomy (TRO) is a controversial procedure with reported inconsistent results. We reviewed 50 patients (60 hips) who underwent this procedure for extensive osteonecrosis of the femoral head, focusing on varization to determine its effectiveness as a head-preserving procedure in young adults. The mean age of the patients was 28 years (range, 18-46 years). Using the Ficat-Arlet classification, 40 hips had Stage II and 20 hips had Stage III involvement. According to the classification system of Shimizu et al., the extent of the lesions were Grade C in 54 hips and Grade B in six hips; the location of the lesions were Grade c in 56 hips and Grade b in four hips. Minimum followup was 18 months (mean, 84 months; range, 18-156 months). The mean preoperative Harris hip score was 44.7 points (range, 32-62 points) which improved to an average postoperative score of 80.1 points (range, 44-100 points) at the latest followup. Forty-four hips showed no radiographic evidence of progression of collapse. Ten hips showed progressive collapse, seven hips showed progressive varus deformity, three hips had stress fractures of the femoral neck, and one hip had infection. We believe TRO with varization is worth attempting for extensive osteonecrosis of the femoral head in young adults, although failures and complications are not uncommon.

LEVEL OF EVIDENCE

Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.

Current status of hemi-resurfacing arthroplasty for osteonecrosis of the hip: a 27-year experience

The purpose of the study discussed in this article is to review the authors' long-term experience with this procedure, compare their clinical results to those of other centers, particularly regarding the difficulty of predicting pain relief, and determine the role of hemi-resurfacing in the future.

Total hip arthroplasty after failed treatment for osteonecrosis of the femoral head

This article presents results for total hip arthroplasty after failed transtrochanteric rotational osteotomy according to Sugioka and after failed bone impaction grafting, both initially performed for osteonecrosis of the femoral head. After a minimal follow-up of 2 years, 33 hips were studied. In total hip arthroplasty after failed osteotomy, when compared with total hip arthroplasty after failed bone impaction grafting, clinical and radiologic outcome was less favorable, more complications were observed, and there was a higher revision rate for a technically more demanding procedure.

Transtrochanteric posterior rotational osteotomy for osteonecrosis

When osteonecrosis is located in the mid- to posterior region, we generally perform a transtrochanteric posterior rotational osteotomy. We retrospectively reviewed the clinical and radiographic results in 47 consecutive patients (51 hips) in whom we performed posterior rotational osteotomies. The average age was 37 years at the time of surgery. There were 30 male and 17 female patients. Thirty-six hips were ARCO Stage III, and 15 were Stage IV. Conversion to THA was defined as the failure end point. Three patients died and one was lost to followup. We were therefore able to follow 43 patients (46 of the 51 hips, or 90%) a minimum of 1.2 years (average, 12 years; range, 1.2-21 years). We used the Harris hip score for preoperative and most recent followup. The average preoperative Harris hip score of 52 points improved to an average of 84 at the latest followup. Radiographically, the osteonecrosis in 30 hips (65%) had no progressive collapse, and 13 (28%) showed osteoarthritic changes, but no patients underwent THA. A posterior rotational osteotomy appears useful for patients with extensive necrosis and advanced collapse.

Modified transtrochanteric rotational osteotomy for femoral head osteonecrosis

Osteonecrosis of the femoral head is a disabling condition affecting young patients and treatment of the disease in these patients is variable. We retrospectively reviewed 39 patients (43 hips) in whom a modified transtrochanteric rotational osteotomy was performed for osteonecrosis. The minimum followup was 24 months (mean, 36.6 months; range, 24-52 months). The mean patient age was 34.3 years (range, 20-51 years). Based on the ARCO classification, 17 hips were classified as Stage II and 26 as Stage III. We performed rotational osteotomy alone in 15 cases, in combination with simple bone grafting in three, and in combination with muscle-pedicle-bone grafting in 25. Sixteen of 17 ARCO Stage II cases and 24 of 26 ARCO Stage III cases had no progression of collapse or lesion size; three hips progressively collapsed. Of the 40 hips without progression the Harris hip score improved from a mean 70 to 92 points at final followup, as did the range of motion of the hip. Modified transtrochanteric rotational osteotomy is an effective method for delaying the progression of collapse in the treatment of selected cases of osteonecrosis of the femoral head.

Long-term results of decompression and muscle-pedicle bone grafting for osteonecrosis of the femoral head

In this paper, 152 patients with 187 osteonecrotic femoral heads (83 idiopathic, 56 corticosteroid induced, 40 post-traumatic, seven alcohol abuse and one associated with gout) were classified according to the staging by Ficat and Arlet (Ischemia and necroses of bone, Williams and Wilkins, Baltimore, Maryland, pp 171-182, 1980); four were in Stage I, 82 in Stage II and 101 in Stage III. The majority of the patients were young (average age 35.5 years). Multiple drilling, curettage of the necrotic bone and muscle-pedicle bone grafting using tensor fascia lata was carried out in all patients except in six adolescents, where sartorius grafting was performed. Cheilectomy of the femoral head and subcutaneous adductor tenotomy were also performed in the advanced stages. During the follow up of 10 to 21.5 years (average 16.5 years), radiological improvement was noted in 81.3% of patients in Stage II and 70.1% of patients in Stage III cases. Excellent and good results according to the Hospital for Special Surgery (HSS) score were obtained in 100% of cases in Stage I, 92% in Stage II and 80.4% in stage III, with a survivorship of 91% in Stage II and 82% in Stage III cases. The patients having an HSS score below 20 (non-survival) were recommended for total hip replacement (THR) therapy.