Bilateral - Treatment Of Osteoarthritic Change In The Hip - Joint Preservation Or Joint Replacement

0 25 50 75 100125150175200225 Time Fig. 7. Survival rates when endpoint was set at progress of collapse of the femoral head apparently were not affected by the factors thought to affect clinical results of VIBG such as sex , side of ION , and side of VIBG A1 P<0.05 B1 P<0.05 Current Old .8 .6 .4 .2 Age<30y.o. Age>30y.o. .8 .6 .4 .2 0 25 50 75 100125150175200225 Time 0 25 50 75 100125150175200225 Time C1 .8 .6 .4 .2 D1 Unknown .8 P<0.05 P<0.05 No .6 Steroid Alcohol 0 25 50 75 100125150175200225 Time Yes 0 25 50 75 100125150175200225 Time Fig. 8. When the endpoint was set at progress of femoral head collapse, age over 30 years , the old method of bone graft , preoperative collapse of the femoral head , and abuse of alcohol significantly reduced the survival rate Cumulative Surv. Curve Cumulative Surv. Rate Cumulative Surv. Rate Cumulative Surv. Rate Cumulative Surv. Rate Cumulative Surv. Rate Cumulative Surv. Rate 132 K. Tokunaga et al. concluded that VIBG could not always prevent femoral head collapse. We confirmed vascularization in the grafted iliac bone for a couple of years after surgery using dynamic MRI . However, we did not show histologically whether the grafted iliac bone could be incorporated in the host necrotic bone around the necrotic lesion. During the repair process following osteonecrosis, new bones are formed by additional bone formation in which the new bone is directly added on the dead bone surface without osteoclastic resorption [11]. Dead bones remain for a long time, and it takes more than a couple of years to completely replace the dead bone in human osteonecrotic lesions. Therefore, it will take a long time for the vascularized grafted bone to be incorporated into the host osteonecrotic bone. Patients were restricted to partial weight-bearing for about 612 months after VIBG in our series; however, this time period might be too short to allow incorporation of the grafted bone into the host bones. These data indicate that it is difficult to prevent collapse of the femoral head because of the remnants of necrotic tissue in the weight-bearing area. Noguchi et al. reported that stage progression was observed in three of four joints in a group who underwent VIBG alone, whereas stage progression was noted in two of ten joints in a group who underwent combined VIBG with transtrochanteric anterior rotational osteotomy [12]. To prevent complete collapse, displacement of the necrotic lesion out of the weight-bearing area such as is done in transtrochanteric anterior rotational osteotomy of the femoral head is needed [13,14]. The mechanical property of an iliac bone block is inferior to other harder struts such as that from a fibula. Our bone block consisted of a solid rectangle, and only three of its six faces were covered with cortical bone. In addition, the cross-sectional area of our bone block was usually 1.5cm ×2.5cm. This area was not sufficient to support the weight of a human body. These data indicated that VIBG cannot always meet the original goal of regenerating bones and supporting body weight. The position of the grafted bone is also important. Nakamura et al. reported that the bony strut should be placed at 5°10° of the valgus position relative to the neckshaft angle [9,15]. They also emphasized that the distance between the subchondral bone and the tip of the grafted bone should be less than 5mm [15]. Because the femoral head is spherical, it is quite difficult to place the graft in that position. Indeed, the average distance between the grafted bones and the subchondral bones was more than 5 mm in our series . We recently developed a metal cast of grafted bone that is used to confirm the direction and depth of the bony gutter in the femoral head by fluoroscopy during VIBG to secure graft position. Little is known about factors affecting the clinical results of VIBG except for the position of the grafted bone [9]. Our previous study concluded that risk factors for VIBG were female sex, systemic lupus erythematosis , steroid administration, and bilateral cases by investigating unsuccessful cases after VIBG [16]. However, the present study demonstrated that female sex and steroids did not always affect JOA score and survival rate after VIBG. The other risk factor that we should further consider is preoperative collapse, which affects JOA score and survival rate. Once collapse occurs, the vascularized iliac bone cannot support the destroyed bone structure in the femoral head. Male sex and abuse of alcohol were also found to be risk factors for survival rate after VIBG. This finding might be explained by the fact that most osteonecrosis-affected patients with abuse of alcohol are men. Vascularized Iliac Bone Graft for Femoral Head Necrosis 133 Taken together, VIBG should be indicated in limited cases with early-stage ION. Hip joints without collapse should be treated with VIBG. However, we found that patients with pain in the affected hip always showed a certain degree of collapse of the femoral head. Therefore, actual indications of VIBG should be restricted. In addition, VIBG cannot always prevent progress of femoral head collapse or advancement of osteoarthritic changes, even though the femoral head shows no collapse. We conclude that VIBG for ION should be indicated for joints without or with little collapse of the femoral head and joints with a wide lesion for which transtrochanteric rotational osteotomies are never indicated. VIBG is a time-saving surgery for young patients to postpone total hip arthroplasty or hemiarthroplasty. Conclusions 1. VIBG cannot always prevent stage progression of the femoral head after ION. 2. Preoperative collapse, sex, total curettage of the necrotic lesion for bone grafts, and bilateral ION reduce JOA score after VIBG. 3. Total curettage of the necrotic lesion, operative age over 30 years, precollapse, and abuse of alcohol reduce survival rate of ION when the endpoint is set at progress of femoral head collapse. 4. VIBG is a time-saving surgery for young patients with ION to postpone perfor mance of total hip arthroplasty or hemiarthroplasty. Acknowledgments. This work was not supported by any grant. References 1. Solonen KA, Rindell K, Paavilainen T Vascularized pedicled bone graft into the femoral head: treatment of aseptic necrosis of the femoral head. Arch Orthop Trauma Surg 109 :160163 2. Cheung HS, Stewart IE, Ho KC, Leung PC, Metreweli C Vascularized iliac crest grafts: evaluation of viability status with marrow scintigraphy. Radiology 186 : 241245 3. Sugano N, Atsumi T, Ohzono K, Kubo T, Hotokebuchi T, Takaoka K The 2001 revised criteria for diagnosis, classification, and staging of idiopathic osteonecrosis of the femoral head. J Orthop Sci 7 :601605 4. Hasegawa Y, Iwata H, Mizuno M, Genda E, Sato S, Miura T The natural course of osteoarthritis of the hip due to subluxation or acetabular dysplasia. Arch Orthop Trauma Surg 111 :187191 5. Leung PC Femoral head reconstruction and revascularization. Treatment for ischemic necrosis. Clin Orthop Relat Res 323:139145 6. Pavlovcic V, Dolinar D, Arnez Z Femoral head necrosis treated with vascularized iliac crest graft. Int Orthop 23 :150153 7. Eisenschenk A, Lautenbach M, Schwetlick G, Weber U Treatment of femoral head necrosis with vascularized iliac crest transplants. Clin Orthop Relat Res 386: 100105 8. Feng CK, Yu JK, Chang MC, Chen TH, Lo WH Vascularized iliac bone graft for treating avascular necrosis of the femoral head. Zhonghua Yi Xue Za Zhi 61 :463469 134 K. Tokunaga et al. 9. Nagoya S, Nagao M, Takada J, Kuwabara H, Wada T, Kukita Y, Yamashita T Predictive factors for vascularized iliac bone graft for nontraumatic osteonecrosis of the femoral head. J Orthop Sci 9 :566570 10. Hasegawa Y, Iwata H, Torii S, Iwase T, Kawamoto K, Iwasada S Vascularized pedicle bone-grafting for nontraumatic avascular necrosis of the femoral head. A 5to 11-year follow-up. Arch Orthop Trauma Surg 116 :251258 11. Norman D, Reis D, Zinman C, Misselevich I, Boss JH Vascular deprivationinduced necrosis of the femoral head of the rat. An experimental model of avascular osteonecrosis in the skeletally immature individual or LeggPerthes disease. Int J Exp Pathol 79 :173181 12. Noguchi M, Kawakami T, Yamamoto H Use of vascularized pedicle iliac bone graft in the treatment of avascular necrosis of the femoral head. Arch Orthop Trauma Surg 121 :437442 13. Sugioka Y Transtrochanteric anterior rotational osteotomy of the femoral head in the treatment of osteonecrosis affecting the hip: a new osteotomy operation. Clin Orthop Relat Res 130:191201 14. Sugioka Y, Hotokebuchi T, Tsutsui H Transtrochanteric anterior rotational osteotomy for idiopathic and steroid-induced necrosis of the femoral head. Indications and long-term results. Clin Orthop Relat Res 277:111120 15. Nakamura H, Watanabe Y, Hasegawa K, Tanabe H, Yoshino K, Fukuda T, Katsuro T Analysis of vascularized iliac bone graft using superficial circumflex iliac artery and vein. Relationship between bone strut and collapse of the femoral head . J Musculoskel Syst 15 :355361 16. Endo N, Kitahara H, Ohkawa Y, Ogawa T, Matsuba A, Tokunaga K, Dohmae Y, Sofue M, Minato I Analysis of patients underwent vascularized iliac bone graft with poor clinical results and required additional surgeries . Hip Joint 26: 373375 Part III Osteoarthritis of the Hip: Joint Preservation or
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