Osteonecrosis of the hip: is there a difference in the survivorship of total hip arthroplasty with or without previous vascular iliac bone grafting?
08 Apr 2021-Journal of Orthopaedic Surgery and Research (BioMed Central)-Vol. 16, Iss: 1, pp 244-244
TL;DR: In this paper, the authors compared 27 patients who had undergone prior vascularized iliac bone graft (VIBG) surgery to improve blood supply to the avascular portion of the femoral head which may delay secondary osteoarthritis and total hip arthroplasty (THA).
Abstract: 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. 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. 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. 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.
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TL;DR: In this article, an end-result analysis is presented of thirty-nine mold arthroplasties performed at the Massachusetts General Hospital between 1945 and 1965 in thirty-eight consecutive private patients for arthritis of the hip following fractures of the acetabulum or dislocations.
Abstract: An end-result analysis is presented of thirty-nine mold arthroplasties performed at the Massachusetts General Hospital between 1945 and 1965 in thirty-eight consecutive private patients for arthritis of the hip following fractures of the acetabulum or dislocations of the hip.
Of the nineteen unilateral cases in the second half of the series, sixteen were rated good or excellent. Results in the second half of the series were significantly better statistically than those in the first half of the series. Possible reasons for this improvement are discussed.
No significant deterioration occurred with the passage of time. Among the thirty-nine hips, three revisions were required. One patient had postoperative sepsis after arthroplasty. Four patients who had had intra-articular sepsis prior to arthroplasty showed no evidence of sepsis postoperatively.
Factors influencing the choice between hip fusion and hip arthroplasty in these cases are presented.
A new system for rating hip function is proposed and is compared with the systems of Larson and Shepherd.
5,665 citations
TL;DR: These methods of diagnosis, together with a classification developed in association with Professor J. Arlet, are presented, termed by us the functional exploration of bone (FEB).
Abstract: Our understanding of idiopathic necrosis of the femoral head depends upon two fundamental concepts. The first is that a standard radiograph shows only the shadow of the mineralised portion of a bone. The radiographic appearance of living bone is the same as that of dead bone ofEgyptian mummies or prehistoric skeletons. Consequently, bone necrosis has no specific radiographic appearance and a normal radiograph does not necessarily mean a normal hip. A standard radiograph cannot help with early diagnosis, and every case of bone necrosis must pass through a preradiographic stage. When radiographic changes do appear, they are due to the reaction of living tissue to the ischaemia. The second fundamental concept is that bone necrosis is the end result of severe and prolonged ischaemia. This again presupposes an initial stage in which vascular and medullary abnormality passes undetected by routine radiography. These concepts point the need for other methods of investigation, especially in early cases. These methods include scintimetry and the study of the haemodynamics of the medullary circulation, termed by us the functional exploration of bone (FEB). These methods of diagnosis, together with a classification developed in association with Professor J. Arlet, are now presented (Ficat and Arlet 1977, 1980).
1,130 citations
TL;DR: Implantation of autologous bone-marrow mononuclear cells appears to be a safe and effective treatment for early stages of osteonecrosis of the femoral head.
Abstract: Background: Aseptic nontraumatic osteonecrosis of the femoral head is a disorder that can lead to femoral head collapse and the need for total hip replacement. Since osteonecrosis may be a disease of mesenchymal cells or bone cells, the possibility has been raised that bone marrow containing osteogenic precursors implanted into a necrotic lesion of the femoral head may be of benefit in the treatment of this condition. For this reason, we studied the implantation of autologous bone-marrow mononuclear cells in a necrotic lesion of the femoral head to determine the effect on the clinical symptoms and the stage and volume of osteonecrosis. Methods: We studied thirteen patients (eighteen hips) with stage-I or II osteonecrosis of the femoral head, according to the system of the Association Research Circulation Osseous. The hips were allocated to a program of either core decompression (the control group) or core decompression and implantation of autologous bone-marrow mononuclear cells (the bone-marrow-graft group). Both patients and assessors were blind with respect to treatment-group assignment. The primary outcomes studied were safety, clinical symptoms, and disease progression. Results: After twenty-four months, there was a significant reduction in pain (p = 0.021) and in joint symptoms measured with the Lequesne index (p = 0.001) and the WOMAC index (p = 0.013) within the bone-marrow-graft group. At twenty-four months, five of the eight hips in the control group had deteriorated to stage III, whereas only one of the ten hips in the bone-marrow-graft group had progressed to this stage. Survival analysis showed a significant difference in the time to collapse between the two groups (p = 0.016). Implantation of bone-marrow mononuclear cells was associated with only minor side effects. Conclusions: Implantation of autologous bone-marrow mononuclear cells appears to be a safe and effective treatment for early stages of osteonecrosis of the femoral head. Although the findings of this study are promising, their interpretation is limited because of the small number of patients and the short duration of follow-up. Further study is needed to confirm the results. Level of Evidence: Therapeutic study, Level II-I (prospective cohort study). See Instructions to Authors for a complete description of levels of evidence.
385 citations
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23 Jul 2018TL;DR: The lack of level 1 evidence in the literature makes it difficult to identify optimal treatment protocols to manage patients with pre-collapse avascular necrosis of the femoral head, and early intervention prior to collapse is critical to successful outcomes in joint preserving procedures.
Abstract: It is estimated that 20000 to 30000 new patients are diagnosed with osteonecrosis annually accounting for approximately 10% of the 250000 total hip arthroplasties done annually in the United States. The lack of level 1 evidence in the literature makes it difficult to identify optimal treatment protocols to manage patients with pre-collapse avascular necrosis of the femoral head, and early intervention prior to collapse is critical to successful outcomes in joint preserving procedures. There have been a variety of traumatic and atraumatic factors that have been identified as risk factors for osteonecrosis, but the etiology and pathogenesis still remains unclear. Current osteonecrosis diagnosis is dependent upon plain anteroposterior and frog-leg lateral radiographs of the hip, followed by magnetic resonance imaging (MRI). Generally, the first radiographic changes seen by radiograph will be cystic and sclerotic changes in the femoral head. Although the diagnosis may be made by radiograph, plain radiographs are generally insufficient for early diagnosis, therefore MRI is considered the most accurate benchmark. Treatment options include pharmacologic agents such as bisphosphonates and statins, biophysical treatments, as well as joint-preserving and joint-replacing surgeries. the surgical treatment of osteonecrosis of the femoral head can be divided into two major branches: femoral head sparing procedures (FHSP) and femoral head replacement procedures (FHRP). In general, FHSP are indicated at pre-collapse stages with minimal symptoms whereas FHRP are preferred at post-collapse symptomatic stages. It is difficult to know whether any treatment modality changes the natural history of core decompression since the true natural history of core decompression has not been delineated.
302 citations
TL;DR: Statin drugs may offer some protection against having osteonecrosis develop when steroid treatment is necessary, and this 1% incidence is much less than the 3% to 20% incidence usually reported for patients receiving high-dose steroids.
Abstract: Osteonecrosis is a devastating complication of systemic steroid use. Prolonged steroid use produces a hyperlipidemic state in most patients and puts them at risk for osteoporosis and osteonecrosis. The fat content within the femoral head increases, resulting in increased intracortical pressure that may lead to sinusoidal collapse and osteonecrosis. Statins are lipid-clearing agents that dramatically reduce lipid levels in blood and tissues. Statins are widely used to prevent cardiovascular disease and have been shown to reduce the adverse effects of steroids on lipid metabolism. The purpose of this study was to determine whether the use of statin drugs affects later development of osteonecrosis in patients receiving steroids. The records of 284 patients who were taking statin drugs at the time they were started on high dose steroids were examined to determine whether osteonecrosis had developed. The patients remained on statin drugs during the entire time of steroid exposure. Magnetic resonance imaging scans were used to verify the osteonecrosis unless it was visible by radiograph. After an average of 7.5 years (minimum followup, 5 years), only three patients (1%) from the group had osteonecrosis develop. This 1% incidence is much less than the 3% to 20% incidence usually reported for patients receiving high-dose steroids. Statins may offer some protection against having osteonecrosis develop when steroid treatment is necessary.
233 citations