INCREASED ANGLE ALPHA AT THE FEMORAL HEAD-NECK JUNCTION IN 118 HIPS WITH NON-TRAUMATIC AVASCULAR NECROSIS

Abstract

Introduction: Whereas in traumatic avascular necrosis of the femoral head (ANFH) loss of the femoral head’s blood supply is due to a mechanical event, in non-traumatic AFNH it is the result of a wide variety of etiologies (e.g. alcoholism, hypercortisonism, etc.), which have in common that they lead to an intravascular complication with subsequent malperfusion of the femoral head. Additionally, for part of non-traumatic ANFH no causative factors are known, why they are called idiopathic. A mechanical cause for nontraumatic ANFH – as e.g. a repetitive trauma of the femoral head supplying deep branch of the medial femoral circumflex artery and its terminal branches by abutment of the femur against the acetabulum as in femoroacetabular impingement (FAI) – has not been discussed so far.

Methods: The anteroposterior and lateral radiographs of 118 hips in 77 patients, who were operated in our institution between January 1995 and December 2005 because of nontraumatic ANFH, were evaluated with respect to the configuration of the head-neck junction.

1. In a qualitative analysis the head-neck contour of all femora was assigned to one of the following four groups: regular waisting, mildly reduced waisting, reduced to distinctly reduced waisting or completely lacking waisting.

2. In a quantitative analysis, angle alpha according to Nötzli et al. (2002) was measured. Furthermore, the CCD angle was measured to assess the orientation of the femoral neck in the frontal plane as well as the LCE-angle according to Wiberg and the acetabular index of the weightbearing zone to rule out any acetabular anomalies.

Results: In this retrospective analysis, for 44.1% of the hip joints hypercortisonism, for 40.7% alcoholism, for 12.7% hypercholesterinemia and for 11.0% no risk factors were found documented in the patients’ files. In AP and lateral radiographs a regular waisting was found in 60.2% and 9.3%, a mildly reduced waisting in 32.2% and 37.3%, a reduced waisting or distinctly reduced waisting in 7.6% and 35.6%, and a completely lacking waisting in 0% and 16.9%, respectively, and the mean angle alpha was 63° ± 18° and 67° ± 14°, respectively. On average, the (frontally projected) CCD angle was 133° ± 6°, the LCE angle 30° ± 7° and the acetabular index of the weightbearing zone 4° ± 5°.

Conclusion: Nötzli et al. found an angle alpha of 42° ± 2° for healthy individuals. A markedly increased angle alpha in both radiographic planes of the 118 investigated hips with nontraumatic ANFH was found, demonstrating a reduced shape of their head-neck junction in the anterior and lateral aspect. Together with the fact that no gross pathological deviations for the orientation of the femoral neck and the acetabulum were found, this may hint at cam-type FAI to occur in this hips and thus potentially at a mechanical (co-) factor in developing non-traumatic ANFH.