Treatment of nontraumatic osteonecrosis of the femoral head using bone impaction grafting through a femoral neck window

Abstract

Nontraumatic osteonecrosis of the femoral head (non-ONFH) is a disorder that can lead to femoral head collapse and the need for total hip replacement. Various head-preserving procedures have been used for this disease to avert the need for total hip replacement. These include various vascularised and nonvascularised bone grafting procedures. We examined the effect of bone-grafting through a window at the femoral head-neck junction known as the "light bulb" approach for the treatment of osteonecrosis of the femoral head with a combination of demineralised bone matrix (DBM) and auto-iliac bone. The study included 110 patients (138 hips; 41 females, 69 males; mean age 32.36 years, range 17-54 years) with stage IIA-IIIA nontraumatic avascular necrosis of the femoral head according to the system of the ARCO (Association Research Circulation Osseous). The bone grafting procedure is called "light bulb" procedure in which the diseased bone was replaced by a bone graft substitute (combination of DBM and auto-iliac bone).The outcome was determined by the changes in the Harris hip score, by progression in radiographic stages, and by the need for hip replacement. The mean follow-up was 25.37 months (range 7-42 months). All data were processed by a statistics analysis including Cox risk model analysis and Kaplan-Meier survival analysis. Pre- and postoperative evaluations showed that the mean Harris hip score increased from 62 to 79. Clinically, 94 of 138 hips (68%) were successful at the latest follow-up, and radiological improvement was noted in 100% of patients in stage IIA, 76.67% of patients in stage IIB and 50.96% of patients in stage IIC and IIIA cases. Excellent and good results according to the Harris score were obtained in 100% of cases in stage IIA, 93.33% in stage IIB and 59.62% in stages IIIA and IIC stage, with a survivorship of 85% in stages IIA and IIB and 60% in stage IIIA and IIC cases. Cox risk model analysis showed that the clinical success rate correlated with both pre-operation stage and the necrotic area of the femoral head. The complications included ectopic ossification, lateral femoral cutaneous nerve lesion and joint infection. This procedure may be effective at avoiding or forestalling the need for total hip replacement in young patients with early to intermediate stages of osteonecrosis of the femoral head. Therefore, it may be the treatment of choice particularly in nontraumatic osteonecrosis of the femoral head of pre-collapse stage with small and middle area (<30%, or the depth of collapse <2 mm).