Association Research Circulation Osseous Classification Research Articles

Residual deformity after femoral neck fracture affects the location of osteonecrosis of the femoral head.

The localization of necrotic areas has been reported to impact the prognosis and treatment strategy for osteonecrosis of the femoral head (ONFH). Anteroposterior localization of the necrotic area after a femoral neck fracture (FNF) has not been properly investigated. We hypothesize that the change of the weight loading direction on the femoral head due to residual posterior tilt caused by malunited FNF may affect the location of ONFH. We investigate the relationship between the posterior tilt angle (PTA) and anteroposterior localization of osteonecrosis using lateral hip radiographs. Patients aged younger than 55 years diagnosed with ONFH after FNF were retrospectively reviewed. Overall, 65 hips (38 males and 27 females; mean age 32.6 years (SD 12.2)) met the inclusion criteria. Patients with stage 1 or 4 ONFH, as per the Association Research Circulation Osseous classification, were excluded. The ratios of anterior and posterior viable areas and necrotic areas of the femoral head to the articular surface were calculated by setting the femoral head centre as the reference point. The PTA was measured using Palm's method. The association between the PTA and viable or necrotic areas of the femoral head was assessed using Spearman's rank correlation analysis (median PTA 6.0° (interquartile range 3 to 11.5)). We identified a negative correlation between PTA and anterior viable areas (rho -0.477; p = 0.001), and no correlation between PTA and necrotic (rho 0.229; p = 0.067) or posterior viable areas (rho 0.204; p = 0.132). Our results suggest that residual posterior tilt after FNF could affect the anteroposterior localization of necrosis.

Serum glutathione peroxidase 4 as a novel biomarker for nontraumatic osteonecrosis of the femoral head: A retrospective case-control study.

There are no serum biomarkers available in nontraumatic osteonecrosis of the femoral head in clinical practice. This study aimed to evaluate the clinical value of serum glutathione peroxidase 4 in nontraumatic osteonecrosis of the femoral head. This retrospective study analyzed serum glutathione peroxidase 4 levels and clinical data of 80 patients with nontraumatic osteonecrosis of the femoral head and 80 healthy controls between August 2021 and May 2022. Serum glutathione peroxidase 4 levels were analyzed using an enzyme-linked immunosorbent assay. The Association Research Circulation Osseous classification system determined disease progression. Clinical severity was assessed by Harris hip score and visual analogue scale. Correlations between serum glutathione peroxidase 4 and disease progression as well as clinical severity were evaluated statistically. The diagnostic accuracy of serum glutathione peroxidase 4 in nontraumatic osteonecrosis of the femoral head was determined using receiver operating characteristic analysis. The baseline characteristics of participants between 2 groups were comparable. Patients with nontraumatic osteonecrosis of the femoral head displayed a decreased glutathione peroxidase 4 level compared with healthy controls (11.87 ± 2.76 μU/mL vs 16.54 ± 4.89 μU/mL, P < .01). The levels of glutathione peroxidase 4 were inversely correlated with Association Research Circulation Osseous stage (P < .01) and visual analogue scale scores (P < .01), and positively correlated with Harris score (P < .01). Receiver operating characteristic analyses showed that area under curves of glutathione peroxidase 4 was 0.808 (95% CI 0.721-0.858) and 0.847 (95% CI 0.743-0.951) with regard to diagnosis and collapse prediction in nontraumatic osteonecrosis of the femoral head, respectively. Serum glutathione peroxidase 4 could serve as a novel biomarker for diagnosing nontraumatic osteonecrosis of the femoral head and predicting collapse of the femoral head.

Updating Osteonecrosis of the Femoral Head.

Osteonecrosis of the femoral head (ONFH), a condition characterized by the presence of a necrotic bone lesion in the femoral head, is caused by a disruption in the blood supply. Its occurrence is more common in young and middle-aged adults and it is the main reason for performance of total hip arthroplasty in this age group. Its incidence is increasing along with increased use of glucocorticoids for management of adjuvant therapy for treatment of leukemia as well as organ transplantation and other myelogenous diseases. Current information on etiology and pathogenesis, as well as natural history, stage system, and treatments is provided in this review. A description of the Association Research Circulation Osseous (ARCO) criteria for classification of glucocorticoids- and alcohol-associated ONFH, 2019 ARCO staging system, and 2021 ARCO classification using computed tomography for the early stages of ONFH is also provided.

Arthroscopic classification in comprehensive diagnosis of avascular necrosis of femoral head

The paper proposes and substantiates an arthroscopic classification of pathological processes in the hip joint associated with avascular necrosis of the femoral head (ANFH). In 2018–2022, the authors developed and advanced to the clinic “Method of minimally invasive two-stage decompression with bone alloplasty” (RF patent No. 2691543), which involved diagnostic and therapeutic arthroscopy of the hip joint as its first stage. The international ARCO classification (Association Research Circulation Osseous classification) was chosen as the prototype for the invention. The endoscopic view was recorded and compared with the data of radiological research methods (radiography, spiral CT and MRI). The revealed changes are characterized by the absence of pronounced pathological signs at stages 0, I according to ARCO, which testifies to the possibility of arthroscopic intervention only for the purpose of joint cavity drainage. Further development of necrosis is accompanied by the formation of cartilage flaps, cartilage defects, acetabular labrum tears, lysis of the ligament of the femoral head with the subsequent development of arthrosis, and, therefore, requires a combined approach.

Reliability and repeatability of 2021 ARCO classification and its guiding significance in treatment of nontraumatic osteonecrosis of the femoral head

BackgroundThe study was designed to evaluate the interobserver reliability and intraobserver repeatability of the 2021 Association Research Circulation Osseous (ARCO) classification and explore its guiding significance in the treatment of nontraumatic osteonecrosis of the femoral head (ONFH).MethodsIn this retrospective study, we randomly selected and investigated 50 sets of preoperative computed tomography or magnetic resonance imaging scans from 96 patients (139 hips) to validate the reliability and repeatability of the 2021 ARCO classification. Patients with a nano-hydroxyapatite/polyamide-66 support rod were included in the clinical efficacy study. The Harris hip score (HHS) was used to assess hip function. Femoral head collapse of > 2 mm was considered radiological failure. Total hip arthroplasty (THA) was performed for clinical failure, and follow-up was discontinued.ResultsThe average kappa value of interobserver consistency was 0.652. The average rate of consistency was 90.25%, and the average kappa value of intraobserver consistency was 0.836. Eighty-two patients (122 hips) were enrolled and followed up for a mean of 43.57 ± 9.64 months. There was no significant difference in the HHS among the three groups before surgery, but the difference was statistically significant at the last follow-up. Among them, types 1 and 2 had significantly higher scores at the last follow-up than preoperatively (P < 0.05), whereas type 3 had a lower score at the last follow-up than preoperatively, although the difference was not statistically significant (P > 0.05).According to the imaging evaluation, the failure rate of type 1, 2, and 3 at the last follow-up was 0%, 19%, and 87%, respectively. Univariate analysis showed that the femoral head survival rate of radiography was significantly affected by the new classification system (P = 0.00). At the last follow-up, the incidence rate of THA in type 1, 2, and 3 was 5%, 7%, and 31%, respectively. Univariate analysis showed that the femoral head survival rate was significantly affected by the new classification system (P = 0.001).ConclusionsThe 2021 ARCO classification for early-stage ONFH shows substantial consistency and repeatability. We do not recommend femoral head-preserving surgery for patients with type 3 ONFH.

The 2021 Association Research Circulation Osseous Classification for Early-Stage Osteonecrosis of the Femoral Head to Computed Tomography-Based Study.

The Association Research Circulation Osseous developed a novel classification for early-stage (precollapse) osteonecrosis of the femoral head (ONFH). We hypothesized that the novel classification is more reliable and valid when compared to previous 3 classifications: Steinberg, modified Kerboul, and Japanese Investigation Committee classifications. In the novel classification, necrotic lesions were classified into 3 types: type 1 is a small lesion, where the lateral necrotic margin is medial to the femoral head apex; type 2 is a medium-sized lesion, with the lateral necrotic margin being between the femoral head apex and the lateral acetabular edge; and type 3 is a large lesion, which extends outside the lateral acetabular edge. In a derivation cohort of 40 early-stage osteonecrotic hips based on computed tomography imaging, reliabilities were evaluated using kappa coefficients, and validities to predict future femoral head collapse by chi-squared tests and receiver operating characteristic curve analyses. The predictability for future collapse was also evaluated in a validation cohort of 104 early-stage ONFH. In the derivation cohort, interobserver reliability (k= 0.545) and intraobserver agreement (63%-100%) of the novel method were higher than the other 3 classifications. The novel classification system was best able to predict future collapse (P < .05) and had the best discrimination between non-progressors and progressors in both the derivation cohort (area under the curve= 0.692 [0.522-0.863], P < .05) and the validation cohort (area under the curve= 0.742 [0.644-0.841], P= 2.46×10-5). This novel classification is a highly reliable and valid method of those examined. Association Research Circulation Osseous recommends using this method as a unified classification for early-stage ONFH. Level III, diagnostic study.

Magnetic resonance imaging of avascular necrosis of the femoral head: predictive findings of total hip arthroplasty.

BackgroundAvascular osteonecrosis of the femoral head (AVNFH) is an ischemic condition which despite different treatments often leads to collapse of the femoral head and to total hip arthroplasty. However, the magnetic resonance imaging findings predisposing to disease progression and total hip arthroplasty are somewhat elusive.PurposeTo evaluate the magnetic resonance imaging findings of AVNFH and to assess the patterns of findings which may predict total hip arthroplasty.Materials and methodsA retrospective study was conducted with a total of 18 diagnosed AVNFH treated with core decompression combined with intraosseous stem cell treatment. After treatment, magnetic resonance imaging follow-ups were done at three-month and one-year follow-up or until total hip arthroplasty. Association Research Circulation Osseous classification and magnetic resonance imaging findings such as the size and the location of the AVNFH, bone marrow edema in femoral neck, effusion and subchondral fracture were evaluated.ResultsHips advancing to total hip arthroplasty have more often bone marrow edema in femoral neck (90% vs. 0%), adjacent to necrotic lesion (100% vs. 43%) and in acetabulum (90% vs. 14%), but also subchondral fractures (70% vs. 0%), effusion (80% vs. 29%), and synovitis (80% vs. 14,3%). The greater size and the lateral weight-bearing location of the necrotic lesion also predicted future total hip arthroplasty.ConclusionHips advancing to total hip arthroplasty have often a combination of pathognomonic AVNFH imaging findings compared to hips not advancing to total hip arthroplasty.

Plasma and local expressions of CircRNA CDR1as are linked with disease severity in patients with non-traumatic osteonecrosis of femoral head

ObjectiveTo investigate the correlation of plasma and local expressions of Circ CDR1as with disease severity in patients with non-traumatic osteonecrosis of femoral head (ONFH).MethodsNinety-nine non-traumatic ONFH patients receiving surgery and 99 healthy individuals were enrolled in our study. Plasma and local Circ CDR1as were detected using real-time quantitative PCR (RT-qPCR). Radiographic progression was determined using Association Research Circulation Osseous (ARCO) classification system. Harris hip score (HHS) and visual analogue scale (VAS) were used to assess the clinical severity. Receiver operating characteristic (ROC) curve was carried out to evaluate the diagnostic value of plasma Circ CDR1as with regard to the radiographic severity.ResultsPlasma Circ CDR1as expressions were significantly higher in non-traumatic ONFH patients compared with healthy controls. In non-traumatic ONFH patients, there were no significant differences of CircCDR1as expressions between patients with alcohol-induced ONFH and steroid-induced ONFH. CircCDR1as in local necrotic tissue were significantly higher than adjacent non-affected tissue. Plasma and local Circ CDR1as expressions in patients with ARCO phase 4 were markedly upregulated compared with ARCO phase 3; plasma and local Circ CDR1as expressions in patients with ARCO phase 3 were markedly upregulated compared with ARCO phase 1/2. Plasma and local CircCDR1as expressions were positively associated with ARCO classification. In addition, plasma and local Circ CDR1as expressions were positively correlated with VAS and HHS scores. ROC curve analysis indicated that plasma Circ CDR1as may act as a decent marker for radiographic progression in non-traumatic ONFH patients.ConclusionsBoth plasma and local expressions of CircRNA CDR1as are linked with disease severity in patients with non-traumatic ONFH.

Decreased Serum Pituitary Adenylate Cyclase Activating Polypeptide (PACAP) Levels May Reflect Disease Severity in Patients with Non-traumatic Osteonecrosis of Femoral Head

To investigate serum pituitary adenylate cyclase activating polypeptide (PACAP) levels in relation to disease progression in patients diagnosed with non-traumatic osteonecrosis of femoral head (ONFH). A total of 102 non-traumatic ONFH patients and 95 healthy controls were enrolled in this study. Serum PACAP levels were examined using enzyme-linked immunosorbent assay (ELISA). Radiographic progression of ONFH was detected using the Association Research Circulation Osseous (ARCO) classification system. Harris hip score (HSS) and visual analogue scale (VAS) were analyzed to understand clinical severity. Serum levels of the ONFH marker IL-33 and β‐CTX were also detected. ROC curve analysis was performed to investigate the potential diagnostic value of serum PACAP in the radiographic progression of ONFH. Serum PACAP levels were significantly decreased in non-traumatic ONFH patients when compared to healthy controls. ARCO stage 4 showed markedly lower serum PACAP levels than stage 3. ARCO stage 3 had significantly decreased serum PACAP levels compared to stage 1/2. Serum PACAP levels were negatively correlated with the ARCO classification. In addition, serum PACAP levels were positively associated with HSS score and negatively related to VAS score. Last, PACAP levels were negatively correlated with serum IL-33 and positively associated with β-CTX. ROC curve analysis indicated that PACAP may serve as an early indicator for the radiographic progression of ONFH. Reduced serum PACAP levels may reflect disease severity in non-traumatic ONFH patients.

Single approach to double-channel core decompression and bone grafting with structural bone support for treating osteonecrosis of the femoral head in different stages

BackgroundWe created a novel method—single approach to double-channel core decompression and bone grafting with structural bone support (SDBS)—to treat early-stage osteonecrosis of the femoral head (ONFH) by improving the Phemister technique. This study aimed to evaluate the results of SDBS for early-stage ONFH.MethodsAltogether, 53 patients (73 hips) were treated using SDBS during 2016–2018. Bilateral (20 patients) and unilateral (33 patients = 18 left hips, 15 right hips) ONFH was diagnosed. According to the Association Research Circulation Osseous classification stages, the femoral heads were staged as IIB (n = 15), IIC (n = 19), IIIA (n = 34), IIIB (n = 4), and IIIC (n = 1). The Harris hip score was used to evaluate the hips’ clinical function, computed tomography to evaluate subchondral fractures, and plain radiography to assess the extent of femoral head collapse.ResultsThe average follow-up was 20.71 ± 6.65 months (6–36 months). At the patients’ last follow-up, 4 hips were found to require arthroplasty. Thus, the overall femoral head survival rate was 94.52% (69/73). Also, the overall Harris score (84.44 ± 14.57) was significantly higher than that preoperatively (77.67 ± 14.37) (P = 0.000). The combined excellent and good rate (76.71%) was significantly higher than that preoperatively (38.36%) (P = 0.000). Imaging showed that 16 femoral heads had some ONFH progression. The average length of stay was 6.15 ± 0.86 days. The average incision measured 2.69 ± 0.30 cm. Intraoperative blood loss was 61.20 ± 4.81 ml. There were no complications during or after the operation.ConclusionSDBS is an effective method for treating early-stage ONFH. It is a hip-preserving surgical approach to slow/prevent ONFH progression.

The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head

BackgroundThe Association Research Circulation Osseous (ARCO) presents the 2019 revised staging system of osteonecrosis of the femoral head (ONFH) based on the 1994 ARCO classification. MethodsIn October 2018, ARCO established a task force to revise the staging system of ONFH. The task force involved 29 experts who used a web-based survey for international collaboration. Content validity ratios for each answer were calculated to identify the levels of agreement. For the rating queries, a consensus was defined when more than 70% of the panel members scored a 4 or 5 rating on a 5-point scale. ResultsResponse rates were 93.1%-100%, and through the 4-round Delphi study, the 1994 ARCO classification for ONFH was successfully revised. The final consensus resulted in the following 4-staged system: stage I—X-ray is normal, but either magnetic resonance imaging or bone scan is positive; stage II—X-ray is abnormal (subtle signs of osteosclerosis, focal osteoporosis, or cystic change in the femoral head) but without any evidence of subchondral fracture, fracture in the necrotic portion, or flattening of the femoral head; stage III—fracture in the subchondral or necrotic zone as seen on X-ray or computed tomography scans. This stage is further divided into stage IIIA (early, femoral head depression ≤2 mm) and stage IIIB (late, femoral head depression >2 mm); and stage IV—X-ray evidence of osteoarthritis with accompanying joint space narrowing, acetabular changes, and/or joint destruction. This revised staging system does not incorporate the previous subclassification or quantitation parameters, but the panels agreed on the future development of a separate grading system for predicting disease progression. ConclusionA staging system has been developed to revise the 1994 ARCO classification for ONFH by an expert panel-based Delphi survey. ARCO approved and recommends this revised system as a universal staging of ONFH.

A comparative study of cortico-cancellous iliac bone graft with or without the combination of vascularized greater trochanter flap for the management of femoral head osteonecrosis: a minimum 6\u2009years follow-up

BackgroundTo compare the mid-long-term clinical and radiological outcomes between a combination of cortico-cancellous iliac bone graft with vascularized greater trochanter flap (Group A) and isolate iliac bone graft (Group B) in the treatment of Osteonecrosis of the Femoral Head (ONFH).MethodsFrom January 2006 to December 2012, 123 patients (135 hips) who underwent abovementioned hip-preserving surgeries were included for analysis. Clinical outcomes were assessed based on Harris Hip Score (HHS) System and The Western Ontario and McMaster University Index (WOMAC) scores between the preoperative and the last follow-up. A series of postoperative X-rays were compared to preoperative images for radiological evaluation.ResultsThe HHS in Group A and B were enhanced from 50.57 ± 3.39 to 87.60 ± 4.15 and from 50.24 ± 3.30 to 85.18 ± 6.45, respectively, which both showed significance between preoperative and postoperative latest follow-up (p < 0.001). Group A revealed better improvement in terms of HHS (p = 0.017). The WOMAC total, postoperative stiffness, difficulty subscale scores in Group A showed better outcomes when compared to Group B (p < 0.01), while pain improvement between these two groups revealed no significance (p = 0.402). Besides, Group A suggested better necrotic region repair (p = 0.020), but no femoral head collapse difference in terms of Association Research Circulation Osseous classification change was found (p > 0.05).ConclusionsA combination of cortico-cancellous iliac bone graft and concurrent vascularized greater trochanter flap with the lateral femoral circumflex transverse branch has been proved can obtain better functional and radiological results than isolate iliac bone grafting, which is attributed to blood reconstruction of the femoral head.

Clinical characteristics and role of whole-body bone scan in multifocal osteonecrosis

BackgroundMultifocal osteonecrosis (ON) is defined as ON involving three or more distinct anatomical sites. We investigated the clinical characteristics and utility of whole-body bone scans (WBBS) in patients with multifocal ON.MethodsA total of 254 patients with ON confirmed by magnetic resonance imaging (MRI) or X-rays of the hips or other anatomic regions were evaluated using WBBS and divided into those with multifocal disease and those with oligofocal disease; their clinical characteristics were then compared. All data were analyzed retrospectively both visually and quantitatively (via uptake grading and defect scoring). Associations between the MRI Association Research Circulation Osseous (ARCO) classification and bone scan photon defects and uptake grade were assessed. Factors associated with multifocal ON were identified using logistic regression.ResultsOf the 254 ON patients, 26 (10.2%) had multifocal ON. Their mean age (42.8 ± 14.3 years) was less than that of patients with oligofocal ON (50.9 ± 15.4 years; p = 0.011). Comorbidities, corticosteroid use, and treatment with immunosuppressive agents were more frequent in patients with multifocal ON. Age (odds ratio [OR] = 0.964, p = 0.013), the presence of a comorbidity (OR = 3.387, p = 0.006), present corticosteroid use (OR = 5.696, p < 0.001), and treatment with immunosuppressive agents (OR = 3.447, p = 0.004) were significantly associated with multifocal ON. The MRI ARCO classification was not associated with photon defects in the bone scans of those with femoral ON. However, the ARCO classification was significantly associated with uptake grade.ConclusionsWBBS may be an additional tool for evaluating ON patients with risk factors for multiple ON, such as younger age, corticosteroid use, and comorbidities.

Femoral osteochondroplasty can be performed effectively without the risk of avascular necrosis or femoral neck fractures in an experimental ovine FAI model.

The experimental induction of cam-type femoroacetabular impingement (FAI) in sheep is established. To tap the full potential of this ovine model, one should be able to perform a femoral osteochondroplasty safely. This study was based on previous cadaver experiments on the blood supply to the ovine femoral head and on the biomechanical strength of the proximal femur following offset creation. We hypothesized that offset creation in this ovine FAI model does not lead to (1) avascular necrosis (AVN) of the ovine femoral head or (2) iatrogenic femoral neck fractures and (3) can be performed effectively. In this experimental, controlled, prospective study nine sheep underwent unilateral FAI induction through an intertrochanteric, varus osteotomy. Seventy days following FAI induction, femoral osteochondroplasty was performed. Sheep were sacrificed after another 140 days. Radiographs, computed tomography (CT) scans and MRI were acquired. Histologic samples were stained with hematoxylin-eosin. (1) The multimodal Association Research Circulation Osseous (ARCO) classification was used for assessment of AVN. (2) Femoral neck fractures were assessed with the multimodal imaging approach. (3) Pre- and postoperative (=after sacrifice) alpha angles and femoral neck diameters were compared. (1) No signs for AVN according to the ARCO classification or (2) for femoral neck fractures were detected. (3) Mean alpha angles and femoral neck diameters decreased significantly (p < 0.001) superiorly by at least 30° respectively 4mm after the offset creation. Femoral osteochondroplasty can be performed effectively and without the risk of AVN or femoral neck fractures in this ovine FAI model.

Free Vascularized Fibular Grafting Improves Vascularity Compared With Core Decompression in Femoral Head Osteonecrosis: A Randomized Clinical Trial.

Management of osteonecrosis of the femoral head remains challenging. Core decompression and free vascularized fibular grafting are commonly used surgical procedures for treatment of osteonecrosis of the femoral head. Few studies, however, have compared these two procedures in a randomized controlled study, in terms of improved vascularity of the femoral head, progression of disease, or hip scores. QUESTION/PURPOSES: (1) What is the effect of core decompression and fibular grafting on vascularity of the femoral head as measured by single-photon emission CT (SPECT)/CT? (2) Does one of these two methods lead to greater progression of Association Research Circulation Osseous (ARCO) stage as determined by serial MRI? (3) What is the relationship between the change in vascularity of the femoral head and hip function as measured by the Harris hip score (HHS) and progression to THA as an endpoint? Arandomized controlled trial was performed between June 2010 and October 2012 at Zhongshan Hospital, Fudan University. During the study period, 51 patients who presented with ARCO Stages I to IIIB bilateral osteonecrosis were potentially eligible for inclusion, and 33 patients were identified as meeting the inclusion criteria and offered enrollment and randomization. Six patients declined to participate at the time of randomization, leaving a final sample of 27 participants (54 hips). Bilateral hips of each patient were randomly assigned to surgical options: one side was treated with core decompression and the contralateral side was concurrently treated with fibular grafting. SPECT/CT examinations were performed to quantify radionuclide uptake to evaluate vascularity of the femoral head before treatment and at 6 and 36 months after surgery. With the numbers available, we found no differences between the groups regarding vascularity at baseline (64% ± 8% core decompression-treated hips versus 64% ± 7% in the fibular-grafted hips; 95% CI, -5% to 5%; p = 0.90). MR images of the hips were obtained before surgery and at 6, 12, 24, and 36 months postoperatively and staged based on the ARCO classification. All patients were assessed clinically before treatment and followed up at 6, 12, 18, 24, 30, and 36 months after treatment using the HHS. We considered a difference in the HHS of 10 as the minimal clinically important difference (MCID). Patient progression to THA was defined as the endpoint for followup. Six patients (22%) were lost to followup. By SPECT/CT analysis, decompression-treated hips had lower vascularity than fibular-grafted hips at 6 months (68 % ± 6% versus 95% ± 5%; mean difference, -27%; 95% CI, -32% to -23%; p < 0.001) and 36 months (57% ± 4% versus 91% ± 3%; mean difference, -34%; 95% CI, -37% to -32%; p < 0.001). MRI analysis showed no differences between decompression-treated hips and fibular-grafted hips regarding ARCO stage at 12 months (p = 0.306) and 24 months (p = 0.06). Progression of ARCO staging was more severe in the decompression group than the fibular grafting group at 36 months (p = 0.027). The mean HHS was lower in the decompression group than in the fibular grafting group throughout the followup period, although these differences were at or below the MCID of 10 points early on. However, by 18 months, the scores favored fibular grafting (72 ± 4 versus 84 ± 4; mean difference, -13; 95% CI, -15 to -7; p < 0.001), a finding that was maintained at 24, 30, and 36 months. We found no differences between decompression-treated hips and fibular-grafted hips regarding progression to THA at 36 months (two of 21; p = 0.893). Hips that underwent a vascularized fibular grafting procedure fared better than hips receiving core decompression as measured by improved vascularity and less progression of osteonecrosis as measured by ARCO staging. The mean HHS of the fibular-grafted hips was better than that of the decompression-treated hips during the entire postoperative period, but the differences were modest early on, and for the early postoperative period the differences were unlikely to have been clinically important; by 18 months after surgery, the differences probably were clinically important. The mid-term outcomes associated with vascularized fibular grafting seen in our patients are associated with improvements in femoral head vascularity and the potential for bone revitalization. Level I, therapeutic study.

Effect of local application of tranexamic acid on the hidden blood loss after total hip arthroplasty

Objective To assess the impact of local application of tranexamic acid on the hidden blood loss after unilateral total hip arthroplasty (THA). Methods Between September 2014 and December 2015, 82 patients underwent primary unilateral THA because of avascular necrosis of the femoral head. They were divided into an experimental group and a control group. In the experimental group, there were 42 patients, 24 males and 18 females; according to the Association Research Circulation Osseous (ARCO) classification, necrosis of the femoral head was type Ⅲ in 8 cases of and type Ⅳ in 34. In the control group, there were 40 patients, 22 males and 18 females; according to ARCO classification, necrosis of the femoral head was type Ⅲ in 7 cases and type Ⅳ in 33. In the experimental group, tranexamic acid was injected around the hip joint and into the hip articular cavity. In the control group, a same amount of physiological saline was injected around the hip joint and into the hip articular cavity. The 2 groups were compared postoperatively in terms of total blood loss, hidden blood loss, difference in diameter of the affected thigh, prothrombin time, partial thromboplastin time, D-dimer concentration, and incidence of deep vein thrombosis (DVT). Results The postoperative total blood loss and hidden blood loss in the experimental group (875.2±79.6 mL and 476.3±54.8 mL) were significantly less than those in the control group (1,262.7±105.2 mL and 683.5±75.9 mL) (P 0.05). DVT happened 2 weeks after surgery in 3 cases in the experimental group and in 4 cases in the control group. Conclusion Intraoperative local use of tranexamic acid can significantly reduce postoperative total and hidden blood loss, and effectively decrease swelling of the thigh, but does not increase the risk of DVT. Key words: Arthroplasty, replacement, hip; Tranexamic acid; Postoperative hemorrhage; Embolism and thrombosis

COMPARISON OF DIFFERENT CORE DECOMPRESSION TECHNIQUES FOR TREATMENT OF EARLY STAGES OF OSTEONECROSIS OF THE FEMORAL HEAD

Today one of the most interesting organ surgical interventions for patients with osteonecrosis of the femoral head are still different core decompression procedure. However, in the literature, we could not find any indication on what stage of the disease is different proposed techniques is the most effective.Purpose of the study compare the results of different methods of core decompression in the early stages of the disease, before the development of hip osteoarthritis.Materials and methods. From 2006 to 2015 we treated 84 patients (96 hips) with a diagnosis of osteonecrosis of the femoral head. The mean age of patients was 37,4±9,1 (from 18 to 71) years. Classification Association Research Circulation Osseous (ARCO) was used to determine the stage of the disease. 20 patients core decompression performed on stage II, 71 stage III and 5 in stage IV of disease. Core decompression by one tunnel 9 mm diameter was performed in 55 cases, and in 33 cases, the destruction of the core to the healthy bone has been made. Grafting of the residual cavity has been made by allogeneic bone, calcium sulfate, a combination of calcium sulfate and p3-calcium phosphate and p3-calcium phosphate. Eight joints operated by core decompression multiple tunnels of small diameter without subsequent plastic tunnels. We assessed the results on the basis of X-ray and CT scan data of the operated hip, and according to Oxford Hip Score at 3, 6 and 12 months, and then once in 1 year after surgery. In case of subsequent hip replacement was performed pathological examination area of core osteonecrosis of the femoral head.Results. The average period of follow-up was 31,6 months (from 12 to 110 months). Preventing hip arthroplasty during this time managed in 43 cases (44.8%), 53 joints (55.2%), total hip replacement has been made in the period from 4 to 72 months (average 21.6 months) from the date of implementation of core decompression. The greater the number of good and satisfactory results have shown methods aimed at complete destruction of nonviable bone on the border of core osteonecrosis healthy bone.Frequency of hip replacement is directly dependent on the stage of the disease.In the second stage of the disease hip replacement made in 4 cases (20%) at the third stage satisfactory performance were observed mainly in the case of small and medium sized core osteonecrosis of the femoral head (4, 18 and 16 of the joints 27, respectively). In the fourth stage of the disease arthroplasty was performed in all five cases.Conclusions. Different techniques of core decompression are most effective before the formation of the Impressions of the loaded part of the femoral head, which corresponds to stage III ARCO classification inclusive. Efficacy techniques depends not only on the stage but also on the size and location core of osteonecrosis.

Tantalum Rod Implantation and Vascularized Iliac Grafting for Osteonecrosis of the Femoral Head

Osteonecrosis of the femoral head is a progressive disease. Without operative intervention, it most often results in collapse and deterioration of the joint. Many joint-preserving surgeries have been implemented, but no uniform treatment exists. The authors report a modified technique of tantalum rod implantation combined with vascularized iliac grafting for the treatment of osteonecrosis of the femoral head. Fifty-two patients (56 hips) with osteonecrosis of the femoral head (Association Research Circulation Osseous classification stage II-IV) treated with this technique were retrospectively reviewed. The major steps of this technique included vascularized iliac graft harvested, necrotic lesion excised, and combined interventions implantation. All patients were followed for a mean of 60 months. Seven hips had to be converted to a total hip arthroplasty. The 5-year joint-preserving success rate of entire group was 87.5%, with 95% for Association Research Circulation Osseous stage II hips, 92% for Association Research Circulation Osseous stage III hips, and 63.6% for Association Research Circulation Osseous stage IV hips. The success rate was lower for stage IV hips compared with stage II and III hips. Mean Harris Hip score of the 49 hips improved significantly from 50 to 91 points. Forty-three (76.8%) of 56 hips remained stable on radiographs. The technique of tantalum rod implantation combined with vascularized iliac grafting may be an effective joint-preserving method for the treatment of intermediate-stage osteonecrosis of the femoral head. A larger group of patients that is compared with a control group is necessary to further research.

Treatment of osteonecrosis of the femoral head with thorough debridement, bone grafting and bone-marrow mononuclear cells implantation

Osteonecrosis of the femoral head (ONFH) is a disease with a wide-ranging etiology and poorly understood pathogenesis seen commonly in young patients. Various head-preserving procedures have been used to avert the need for total hip replacement. These include vascularized and non-vascularized bone grafting procedures, bone marrow containing osteogenic precursors implanted into the necrotic lesion. We use drills, curettes, broaches under image intensifier to perform a thorough debridement of all necrotic lesion, pack autogenous cortical and cancellous bone which were harvested from the ipsilateral iliac crest tightly into the femoral head, implant bone-marrow mononuclear cells containing mesenchymal stem cells into the necrotic lesion. The study included 15 patients (20 hips, 10 males, 5 females, mean age 35 years, range 23-58 years) with stage II-III ONFH according to the association research circulation osseous classification. The outcome was determined by changes in the Harris hip score (HHS), by progression in radiographic stages, and by the need for hip arthroplasty. The mean follow-up was 24 months (range 9-36 months). The mean HHS increased from 64 to 85 points. The overall clinical success rate is 80 %. There were no infection, femoral neck fracture or other complications. Thorough debridement, autogenous bone grafting and bone-marrow mononuclear cells implantation is an effective procedure in patient with small lesion, early-stage ONFH.

Early results of a novel technique using multiple small tantalum pegs for the treatment of osteonecrosis of the femoral head

The introduction of a trabecular tantalum rod has been proposed for the management of early-stage osteonecrosis of the femoral head but serves as a single-point of support of the necrotic lesion. We describe a technique using two or three 4.2 mm (or later 4.7 mm) tantalum pegs for the prevention of collapse of the necrotic lesion. We prospectively studied 21 patients (26 hips) with non-traumatic osteonecrosis of the femoral head treated in this manner. Of these, 21 patients (24 hips) were available for radiological and clinical evaluation at a mean follow-up of 46 months (18 to 67). Radiological assessment showed that only eight hips deteriorated according to the Association Research Circulation Osseous classification, and four hips according to the Classification of the Japanese Investigation Committee of Health and Welfare. Functional improvement was obtained with an improvement in the mean Harris hip score from 65.2 (33.67 to 95) to 88.1 (51.72 to 100), the mean Merle D'Aubigné-Postel score from 13 (6 to 18) to 16 (11 to 18), a mean visual analogue score for pain from 5.2 (0 to 9.5) to 2.6 (0 to 7), and the mean Short-Form 36 score from 80.4 (56.8 to 107.1) to 92.4 (67.5 to 115.7). Of these 24 hips followed for a minimum of 18months, three were considered as failures at the final follow-up, having required total hip replacement. One of the hips without full follow-up was also considered to be a failure. In more than two-thirds of the surviving hips a satisfactory clinical outcome was achieved with promising radiological findings. The estimated mean implant survival was 60 months (95% confidence interval 53.7 to 66.3).