Treatment Of Femoral Head Osteonecrosis Research Articles

Structural Augmentation with Biomaterial-Loaded Allograft Threaded Cage for the Treatment of Femoral Head Osteonecrosis

Seventy-six patients with femoral head necrosis were allocated to a program of either core decompression (control group) or core decompression and implantation of a biomaterial-loaded allograft threaded cage (treatment group). All patients were followed up prospectively clinically and radiographically. In the control group, no significant improvement in Harris hip score was found, and 13 of the 22 hips had deteriorated to stage III. In the treatment group, the mean Harris hip score was improved from 62.8 to 81.6; the clinical success rate at 36 months postoperatively was 91%. Collapse was seen in 1 hip, and another 3 hips exhibited progressive collapse. The procedure is attractive as a minimally invasive and salvage procedure, which shows encouraging success rates and early clinical results in patients with Steinberg stage I-II osteonecrosis.

Reversed flow lateral circumflex femoral vessels as recipients for free fibular grafting in treatment of femoral head osteonecrosis

Free fibular bone grafting is an effective treatment for early osteonecrosis of the femoral head in young patients. However, recipient vessels are often small rendering microvascular anastomosis difficult. We have developed a novel technique using retrograde flow through the branches of the lateral circumflex femoral artery to use the proximal end of the artery as the recipient vessel. A vessel diameter of up to 5 mm is obtained providing a good match with the peroneal vessels. We used this technique to perform vascularized bone grafting of the femoral head in 10 patients with Ficat grade 2 and 3 osteonecrosis. Pulsatile retrograde flow from the lateral circumflex femoral artery was observed in each case. Retrospective review gave a median follow up of 52 months (range 17-99). Symptoms improved in all 10 cases. There was no radiological deterioration over the period of follow-up in eight cases. One patient underwent conversion to a total hip replacement 24 months after surgery. These results compare favorably with other studies. The lateral circumflex femoral artery turnover technique is a reliable and useful technique in vascularized bone grafting of the femoral head.

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

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

Outcome after tantalum rod implantation for treatment of femoral head osteonecrosis

Background and purpose Tantalum rod implantation has recently been proposed for treatment of early stages of femoral head osteonecrosis. The purpose of our study was to report the early results of its use in pre- and post-collapse stages of the disease.Methods We studied prospectively 27 patients who underwent tantalum rod implantation for treatment of nontraumatic femoral head osteonecrosis between December 2000 and September 2005. Patients were evaluated radiologically and clinically using the Steinberg classification and the Harris hip score (HHS). Disease stage varied between stages II and IV. Mean follow-up time was 38 (15–71) months.Results 1 patient (1 hip) died 15 months after surgery for reasons unrelated to it. 13 of 26 hips remained at the same radiographic stage, and 13 deteriorated. Mean HHS improved from 49 to 85. 6 patients required conversion to total hip arthroplasty. When the procedure was used for stages III and IV, both radiological outcome and revision rates were worse than for the stage II hips. There was, however, no difference in postoperative HHS between patients at pre- and post-collapse stages at the time of initial evaluation. Survivorship, with revision to THA as the endpoint, was 70% at 6 years.Interpretation The disease process does not appear to be interrupted, but there was a significant improvement in hip function initially in most hips. Tantalum rod implantation is a safe “buy-time” technique, especially when other joint salvage procedures are not an option. Appropriate patient selection and careful rod insertion are needed for favorable results.

Local Cancellous Bone Grafting for Osteonecrosis of the Femoral Head

This study reports a novel local bone graft technique for the treatment of osteonecrosis of femoral head (ONFH). From 1998 to 2005, a procedure using local bone grafting was performed for the treatment of ONFH in 11 patients. The local bone grafts were obtained from the intertrochanteric region and then impacted into the necrotic lesion. A wire coil was inserted into the remaining space after the grafting. At a mean follow-up of 61 months (range, 30 to 103 months), all 5 ARCO stage IIC hips survived but 3 of the 6 ARCO stage IIIA hips failed. The overall clinical success rate was 73%. This study demonstrates that local cancellous bone grafting combined with a space-filling device implanted into the ONFH is a promising procedure and the wire coil showed no interference to the remodeling of the femoral head after grafting.

Biomaterial‐loaded allograft threaded cage for the treatment of femoral head osteonecrosis in a goat model

The purpose of this study was to evaluate the efficacy of core decompression with a biomaterial-loaded allograft threaded cage (ATC) for the treatment of femoral head osteonecrosis in an established goat model. First, bilateral early-stage osteonecrosis was induced. After core decompression, the remaining goats were randomly divided into three groups: Group A, the goats were left without any treatment; Group B, the goats were treated with implanting a composite of autologous bone and decalcified bone matrix (DBM); Group C, the goats were treated using insertion of ATC loaded with DBM and autogenous bone graft. Then radiographic, histological and biomechanical analysis were taken in each group at 5, 10, and 20 weeks postoperation. In Group A, the classical signs of osteonecrosis of the femoral head were identified 10 weeks after the induction. Twenty weeks later, the density, surface and biomechanical stability of the femoral head were normal in Group C, while an irregular surface and an inhomogeneous microstructure or variation of density/hardness were identified in Group B. The specimens revealed a continuous trabaecular bone structure throughout the cage and extensive bone ingrowth and remodeling in Group C, while fibrous tissue was evident in Group B. Core decompression with a biomaterial loaded ATC almost uniformly delays or arrests the progression of the disease before articular collapse, and it could help to get the balance between bone resorption and new bone formation, strengthen structural mechanics of the femoral head, provide structure support of articular cartilage.

Free Vascularized Fibular Grafting Following Failed Core Decompression for Femoral Head Osteonecrosis

The results of treatment of femoral head osteonecrosis with free vascularized fibular grafting (FVFG) following failed core decompression (core decompression–FVFG [CD-FVFG] group: 32 hips) were reviewed and compared with those of a control group that underwent FVFG only (54 hips). Outcome was considered unsuccessful if total hip arthroplasty was subsequently performed. Total hip arthroplasty was performed in 15 and 20 hips of the CD-FVFG and control groups, respectively. When considering age, sex, and presence of bilateral disease, patients with previous core decompression did not have a significantly different failure rate from patients with FVFG only. However, patients with preoperative stage V osteonecrosis or corticosteroid use had worse outcomes after vascularized fibular grafting if they had a previous core decompression of the femoral head.

Femoral head osteonecrosis: Volumetric MRI assessment and outcome

Effective treatment of femoral head osteonecrosis (FHON) requires early diagnosis and accurate assessment of the disease severity. The ability to predict in the early stages the risk of collapse is important for selecting a joint salvage procedure. The aim of the present study was to evaluate the outcome in patients treated with vascularized fibular grafts in relation to preoperative MR imaging volumetry. We studied 58 patients (87 hips) with FHON. A semi-automated octant-based lesion measurement method, previously described, was performed on the T1-w MR images. The mean time of postoperative follow-up was 7.8 years. Sixty-three hips were successful and 24 failed and converted to total hip arthroplasty within a period of 2–4 years after the initial operation. The rate of failures for hips of male patients was higher than in female patients. The mean lesion size was 28% of the sphere equivalent of the femoral head, 24 ± 12% for the successful hips and 37 ± 9% for the failed ( p < 0.001). The most affected octants were antero-supero-medial (58 ± 26%) and postero-supero-medial (54 ± 31%). All but postero-infero-medial and postero-infero-lateral octants, showed statistically significant differences in the lesion size between patients with successful and failed hips. In conclusion, the volumetric analysis of preoperative MRI provides useful information with regard to a successful outcome in patients treated with vascularized fibular grafts.

The role of MR imaging in staging femoral head osteonecrosis

Reliability, accuracy and prognostic value of any classification system are important in evaluation and treatment of femoral head osteonecrosis. The purpose of the present study was to correlate the plain radiographs with MRI in femoral head osteonecrosis. Between 2000 and 2005, 115 hips (72 patients) were evaluated and classified according to the ARCO classification criteria with the use of plain radiographs and additional application of MRI. Classification was performed by consensus between a musculoskeletal radiologist and an orthopaedic surgeon. Sensitivity (SEN), specificity (SP), positive (PPV) and negative (NPV) predictive value of X-rays were estimated. According to MRI, 17 hips were classified as stage I, 25 as stage II, 48 as stage III and 25 as stage IV. The SEN, SP, PPV and NPV of plain radiographs were for stage II 88%, 90.5%, 78.6% and 95%; for stage III 79.2% 82%, 80.8% and 87.2%; for stage IV 76%, 100%, 100% and 90.9%, respectively. The agreement between plain radiographs and MRI was 80.6% for staging the disease, 71.2% for recording the location of the osteonecrotic lesion, 67.1% for evaluating the size of the lesion, 79.2% for the presence of collapse of the articular surface and 56.3% for the degree of collapse. In conclusion, the ARCO classification could miss important information in stages II and III, where treatment aims at preservation of the hip joint integrity. The results of the present study suggest that MRI should be incorporated in the classification of osteonecrosis (stages II and III), to add accuracy and prognostic value.

Heterotopic ossification after treatment of femoral head osteonecrosis with free vascularized fibular graft

This study evaluated patients with heterotopic ossification after implantation of a free vascularized fibular graft for the treatment of femoral head osteonecrosis. We hypothesized that the osteogenic tendency of these patients might enhance the graft–host union and new bone formation in the femoral head, although the presence of heterotopic ossification might influence adversely the clinical result. Of patients with femoral head osteonecrosis, 32% developed heterotopic ossification after treatment with free vascularized fibular graft. Heterotopic bone formation did not influence the efficacy of the procedure to preserve the hip joint. The radiographic and clinical results and the rate of subsequent total hip arthroplasty were not affected by the heterotopic bone, but local trochanteric tenderness was associated with large heterotopic lesions. Copyright 2003, Elsevier Science (USA). All rights reserved.

Pathogenesis and natural history of osteonecrosis

Background and Objectives: Osteonecrosis (avascular necrosis) is a relatively common disorder seen by both rheumatologists and orthopedic surgeons. The vast majority of cases are secondary to trauma. However, for non-traumatic cases, there often remains a diagnostic challenge in defining the cause of bone death. The goal of this article is to review data extensively in the medical literature with respect to the pathogenesis of osteonecrosis, its natural history, and treatment. Methods: A review of 524 studies on osteonecrosis was performed, of which 213 were selected and cited. Results: Non-traumatic osteonecrosis has been associated with corticosteroid usage, alcoholism, infections, hyperbaric events, storage disorders, marrow infiltrating diseases, coagulation defects, and some autoimmune diseases. However, a large number of idiopathic cases of osteonecrosis have been described without an obvious etiologic factor. Although corticosteroids can produce osteonecrosis, careful history is always warranted to identify other risk factors. The pathogenesis of non-traumatic osteonecrosis appears to involve vascular compromise, bone and cell death, or defective bone repair as the primary event. Our understanding of the pathogenesis of osteonecrosis is now much better defined and skeletal scintigraphy and magnetic resonance imaging have enhanced diagnosis greatly. Early detection is important because the prognosis depends on the stage and location of the lesion, although the treatment of femoral head osteonecrosis remains primarily a surgical one. Conclusions: Osteonecrosis has been associated with a wide range of conditions. Many theories have been proposed to decipher the mechanism behind the development of osteonecrosis but none have been proven. Because osteonecrosis may affect patients with a variety of risk factors, it is important that caregivers have a heightened index of suspicion. Early detection may affect prognosis because prognosis is dependent on the stage and location of the disease. In particular, the disease should be suspected in patients with a history of steroid usage, especially in conjunction with other illnesses that predispose the patient to osteonecrosis. Relevance: A better understanding of the pathophysiology, diagnosis and treatment of osteonecrosis will help the physician determine which patients are at risk for osteonecrosis, facilitating early diagnosis and better treatment options. Semin Arthritis Rheum 32:94-124. Copyright 2002, Elsevier Science (USA). All rights reserved.

Pathogenesis and natural history of osteonecrosis

Background and Objectives: Osteonecrosis (avascular necrosis) is a relatively common disorder seen by both rheumatologists and orthopedic surgeons. The vast majority of cases are secondary to trauma. However, for non-traumatic cases, there often remains a diagnostic challenge in defining the cause of bone death. The goal of this article is to review data extensively in the medical literature with respect to the pathogenesis of osteonecrosis, its natural history, and treatment. Methods: A review of 524 studies on osteonecrosis was performed, of which 213 were selected and cited. Results: Non-traumatic osteonecrosis has been associated with corticosteroid usage, alcoholism, infections, hyperbaric events, storage disorders, marrow infiltrating diseases, coagulation defects, and some autoimmune diseases. However, a large number of idiopathic cases of osteonecrosis have been described without an obvious etiologic factor. Although corticosteroids can produce osteonecrosis, careful history is always warranted to identify other risk factors. The pathogenesis of non-traumatic osteonecrosis appears to involve vascular compromise, bone and cell death, or defective bone repair as the primary event. Our understanding of the pathogenesis of osteonecrosis is now much better defined and skeletal scintigraphy and magnetic resonance imaging have enhanced diagnosis greatly. Early detection is important because the prognosis depends on the stage and location of the lesion, although the treatment of femoral head osteonecrosis remains primarily a surgical one. Conclusions: Osteonecrosis has been associated with a wide range of conditions. Many theories have been proposed to decipher the mechanism behind the development of osteonecrosis but none have been proven. Because osteonecrosis may affect patients with a variety of risk factors, it is important that caregivers have a heightened index of suspicion. Early detection may affect prognosis because prognosis is dependent on the stage and location of the disease. In particular, the disease should be suspected in patients with a history of steroid usage, especially in conjunction with other illnesses that predispose the patient to osteonecrosis. Relevance: A better understanding of the pathophysiology, diagnosis and treatment of osteonecrosis will help the physician determine which patients are at risk for osteonecrosis, facilitating early diagnosis and better treatment options. Semin Arthritis Rheum 32:94-124. Copyright 2002, Elsevier Science (USA). All rights reserved.

Grafton demineralized bone matrix: performance consistency, utility, and value.

Tissue EngineeringVol. 6, No. 4 Portland Bone SymposiumGrafton® Demineralized Bone Matrix: Performance Consistency, Utility, and ValueJames L. RussellJames L. RussellSearch for more papers by this authorPublished Online:9 Jul 2004https://doi.org/10.1089/107632700418137AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byA triple minimally invasive surgery combination for subacute osteoporotic lower lumbar vertebral collapse with neurological compromise: a potential alternative to the vertebral corpectomy/expandable cage strategyNeurosurgical Focus, Vol. 54, No. 1Applications of xenografts in periodontal regeneration15 February 2022 | IP International Journal of Periodontology and Implantology, Vol. 6, No. 4Minor Review: An Overview of a Synthetic Nanophase Bone Substitute29 August 2018 | Materials, Vol. 11, No. 96.2 Bone Tissue Engineering: Growth Factors and Cytokines ☆Bone Tissue EngineeringCore decompression combined with implantation of a demineralised bone matrix for non-traumatic osteonecrosis of the femoral head8 May 2012 | Archives of Orthopaedic and Trauma Surgery, Vol. 132, No. 8Bone Tissue Engineering: Growth Factors and CytokinesStructural Augmentation with Biomaterial-Loaded Allograft Threaded Cage for the Treatment of Femoral Head OsteonecrosisThe Journal of Arthroplasty, Vol. 25, No. 8Biomaterial-loaded allograft threaded cage for the treatment of femoral head osteonecrosis in a goat model1 January 2008 | Biotechnology and Bioengineering, Vol. 100, No. 3Tissue engineering of osteochondral constructs in vitro using bioreactorsInjury, Vol. 39, No. 1Effects of a Putty-Form Hydroxyapatite Matrix Combined With the Synthetic Cell-Binding Peptide P-15 on Alveolar Ridge PreservationJournal of Periodontology, Vol. 79, No. 2Intervariability and Intravariability of Bone Morphogenetic Proteins in Commercially Available Demineralized Bone Matrix ProductsSpine, Vol. 31, No. 12Repair of mandible defect with tissue engineering bone in rabbitsANZ Journal of Surgery, Vol. 75, No. 11Scaffolding in Periodontal Engineering1 January 2010Tissue-Engineering von Röhrenknochen mit einer vaskularisierten Matrix in einem BioreaktorDer Orthopäde, Vol. 33, No. 12Donor age and gender effects on osteoinductivity of demineralized bone matrix1 January 2004 | Journal of Biomedical Materials Research, Vol. 70B, No. 1Tissue engineering of bone10 July 2009 | Minimally Invasive Therapy & Allied Technologies, Vol. 11, No. 3 Volume 6Issue 4Aug 2000 To cite this article:James L. Russell.Grafton® Demineralized Bone Matrix: Performance Consistency, Utility, and Value.Tissue Engineering.Aug 2000.435-440.http://doi.org/10.1089/107632700418137Published in Volume: 6 Issue 4: July 9, 2004PDF download

Posterior rotational osteotomy for the treatment of femoral head osteonecrosis.

Posterior rotational osteotomy in 46 hips of 39 patients with femoral head osteonecrosis was reviewed radiographically and clinically after 2-12 years of follow-up (mean 5 years). The age of the patients at the time of surgery ranged from 18 to 60 years, with a mean of 35 years. There were 18 women and 21 men. The cause of the osteonecrosis was steroid administration in 14, alcohol abuse in 5, trauma in 16, and no apparent risk factor in 4. According to the Ficat staging system, 2 hips were stage II, 30 hips III, and 14 hips stage IV. All hips had an extensive lesion. Forty-one hips showed less than 1/3 noncollapsed posterior living area, which was a contraindication for traditional anterior rotational osteotomy. The posterior rotational angle was 60-180 deg with an mean of 127 deg. Recollapse of the final follow-up anteroposterior radiograph was prevented in 36 hips (78%). Progressive joint space narrowing was found in 12 hips (26%). Of these hips, 9 suffered recollapse, while the remaining 3 hips did not. Clinically, 32 hips (70%) showed excellent or good results (both hips in stage II, 23 of 30 hips in stage III, 7 of 14 hips in stage IV. A fair or poor result was seen in 14 hips (30%)). These results suggest that posterior rotational osteotomy is effective in delaying the progression of degeneration for large necrotic lesions, especially in young patients. Extent of rotation is limited to 150 deg because of limitations of bone quality. The indications should be refined further, and longer term follow-up is necessary.

Posterior rotational osteotomy for the treatment of femoral head osteonecrosis

Posterior rotational osteotomy for the treatment of femoral head osteonecrosis

Magnetic Resonance Imaging of Osteonecrosis

Because the available preliminary data strongly indicate that MRI is accurate in diagnosing osteonecrosis, MRI of the hips is recommended in patients suspected of having osteonecrosis, especially if other diagnostic studies are equivocal. MRI also may be useful in following patients who have strong risk factors for osteonecrosis, such as corticosteroid therapy, femoral neck fracture, traumatic femoral head dislocation (Fig. 13), slipped capital femoral epiphysis (Fig. 14), and congenital hip dislocation. In diseases such as systemic lupus erythematosus, both hips eventually may become involved in 50 to 80 per cent of cases. Therefore, the unaffected hip of patients with systemic lupus erythematosus and unilateral nontraumatic osteonecrosis of the hip should be monitored regularly with MRI. The hope is that early diagnosis and treatment of femoral head osteonecrosis will prevent the relentless progression to subchondral collapse and disabling arthropathy. MRI also may be useful in staging patients known to have osteonecrosis. The ability of MRI to image directly in multiple planes facilitates the determination of the volume and location of infarcted segments of bone. This information is important in planning any of the surgical procedures used relatively early in the disease, such as core decompression, rotational osteotomy, or bone graft. Moreover, MRI may prove helpful in evaluating the effectiveness of any therapeutic intervention.

Fresh Autogenous Grafts and Osteochondral Allografts for the Treatment of Segmental Collapse in Osteonecrosis of the Hip

Traumatic spondylolisthesis of the axis ("hangman's fracture") occurred in an 89-year-old man who died of unrelated causes. Postmortem examination of the cervical spine revealed a correlation between the anatomic lesion and clinical treatment and prognosis. Traumatic spondylolisthesis of the axis has a high potential for union because it usually occurs through the superior facet joint, in an area of well vascularized spongy cancellous bone. Fracture through the thin cortical bone of the pars interarticularis, conversely, is predisposed to the development of a nonunion and, hence, may explain this condition. While hyperextension with compression or distraction appears to have caused the injury in some cases, axial compression with flexion was the cause in this case.

Vascularized Bone Autografts

The treatment of femoral head osteonecrosis and segmental collapse with fresh autogenous grafts and osteochondral allografts is in the experimental stages. The early results suggest that the grafts may be a satisfactory intermediate conservative alternative to radical surgery. Strict adherence to the criteria for selection of candidates for grafting and meticulous surgical technique are essential prerequisites if optimal results are to be achieved. Factors favoring the choice of autologous or allogeneic grafts in osteonecrosis of the hip are the clinically insignificant immunologic reaction and viable hyaline cartilage. Immunosuppressive agents are nonessential. Failure does not preclude artificial resurfacing, endoprosthetic replacement, or total hip arthroplasty.