Aims. The most important complication of treatment of developmental dysplasia of the hip (DDH) is avascular necrosis (AVN) of the femoral head, which can result in proximal femoral growth disturbances leading to pain, dysfunction, and eventually to early onset osteoarthritis. In this study, we aimed to identify morphological variants in hip joint development that are predictive of a poor outcome. Methods. We retrospectively reviewed all patients who developed AVN after DDH treatment, either by closed and/or open reduction, at a single institution between 1984 and 2007 with a minimal follow-up of eight years. Standard pelvis radiographs obtained at ages one, two, three, five, and eight years, and at latest follow-up were retrieved. The Bucholz-Ogden classification was used to determine the type of AVN on all radiographs. Poor outcome was defined by Severin classification grade 3 or above on the latest follow-up radiographs and/or the need for secondary surgery. With statistical shape modelling, we identified the different shape variants of the hip at each age. Logistic regression analysis was used to associate the different modes or shape variants with poor outcome. Results. In all, 135 patients with AVN were identified, with a minimum of eight years of follow-up. Mean age at time of surgery was 7.0 months (SD 0.45), and mean follow-up was 13.3 years (SD 3.7). Overall, 46% had AVN type 1 while 54% type 2 or higher. More than half of the patients (52.6%) had a poor outcome. We found 11 shape variants that were significantly associated with a poor outcome. These shape variants were predominantly linked to AVN type 2 or higher. Conclusion. Specific morphological characteristics on pelvis radiographs of AVN hips were predictive for poor outcome, at a very young age. There was an overall stronger association to Bucholz-Ogden types 2-3-4 with the exception of two modes at age two and five years, linked to AVN type 1. Cite this article: Bone Joint J 2021;103-B(5):999–1004

Aims. The aim of this study was to compare outcomes of guided growth and varus osteotomy in treating Kalamchi type II avascular necrosis (AVN) after open reduction and Pemberton acetabuloplasty for developmental dysplasia of the hip (DDH). Methods. This retrospective study reviewed patients undergoing guided growth or varus osteotomy for Kalamchi type II AVN between September 2009 and January 2019. All children who had undergone open reduction and Pemberton acetabuloplasty for DDH with a minimum two-year follow-up were enrolled in the study. Demographic and radiological data, which included the head-shaft angle (HSA), neck-shaft angle (NSA), articulotrochanteric distance (ATD), Sharp angle (SA), and lateral centre-edge angle (LCEA) at baseline, two years, and at the extended follow-up, were compared. Revision rates were evaluated. Clinical outcomes using the Harris Hip Score were assessed two years postoperatively. Results. A total of 24 patients underwent guided growth and 19 underwent varus osteotomy, over a mean period of 3.3 years (95% confidence interval (CI) 2.8 to 3.8) and 5.2 years (95% CI 4.5 to 6.0), respectively. There were no differences in demographic and preoperative radiological data, except for a younger age at time of acetabuloplasty and larger ATD for the osteotomy group. The HSA did not differ at two years and the extended follow-up because of postoperative rebound in the osteotomy group. The NSA of the osteotomy group remained smaller postoperatively. There were no significant differences in the follow-up ATD, SA, and LCEA, except for a smaller two-year ATD of the osteotomy group. Seven patients (29.2%) in the guided growth group underwent revision surgery and none in the osteotomy group. The Harris Hip Score was similar between groups. Conclusion. Guided growth and varus osteotomy had comparable results in improving caput valgum deformity, given the rebound of lateral tilting of the physis after osteotomy correction. There were no differences in clinical outcomes at two years postoperatively. Cite this article: Bone Joint J 2022;104-B(7):902–908

The cause of fracture of the femoral neck after hip resurfacing is poorly understood. In order to evaluate the role of avascular necrosis we compared 19 femoral heads retrieved at revision for fracture of the femoral neck and 13 retrieved for other reasons. We developed a new technique of assessing avascular necrosis in the femoral head by determining the percentage of empty osteocyte lacunae present. Femoral heads retrieved as controls at total hip replacement for osteoarthritis and avascular necrosis had 9% (. sd. 4; n = 13) and 85% (. sd. 5; n = 10, p < 0.001) empty lacunae, respectively. In the fracture group the percentage of empty lacunae was 71% (. sd. 22); in the other group it was 21% (. sd. 13). The differences between the groups were highly significant (p < 0.001). We conclude that fracture after resurfacing of the hip is associated with a significantly greater percentage of empty osteocyte lacunae within the trabecular bone. This indicates established avascular necrosis and suggests that damage to the blood supply at the time of surgery is a potent risk factor for fracture of the femoral neck after hip resurfacing

Avascular necrosis of the scaphoid following a fracture in children is rare and there is no established treatment protocol in the literature. We present two boys with nonunion and avascular necrosis of the scaphoid treated by simple immobilisation. Both cases healed with painless wrists and full movements. Our cases confirm that an ununited scaphoid fracture in children may heal with conservative treatment, even when an MRI scan suggests avascular necrosis. Unlike in adults, operative treatment need only be considered in children when conservative treatment fails

Aims. The aim of this study was to clarify the factors that predict the development of avascular necrosis (AVN) of the femoral head in children with a fracture of the femoral neck. Patients and Methods. We retrospectively reviewed 239 children with a mean age of 10.0 years (. sd. 3.9) who underwent surgical treatment for a femoral neck fracture. Risk factors were recorded, including age, sex, laterality, mechanism of injury, initial displacement, the type of fracture, the time to reduction, and the method and quality of reduction. AVN of the femoral head was assessed on radiographs. Logistic regression analysis was used to evaluate the independent risk factors for AVN. Chi-squared tests and Student’s t-tests were used for subgroup analyses to determine the risk factors for AVN. Results. We found that age (p = 0.006) and initial displacement (p = 0.001) were significant independent risk factors. Receiver operating characteristic (ROC) curve analysis indicated that 12 years of age was the cut-off for increasing the rate of AVN. Severe initial displacement (p = 0.021) and poor quality of reduction (p = 0.022) significantly increased the rate of AVN in patients aged 12 years or greater, while in those aged less than 12 years, the rate of AVN significantly increased only with initial displacement (p = 0.048). A poor reduction significantly increased the rate of AVN in patients treated by closed reduction (p = 0.026); screw and plate fixation was preferable to cannulated screw or Kirschner wire (K-wire) fixation for decreasing the rate of AVN in patients treated by open reduction (p = 0.034). Conclusion. The rate of AVN increases with age, especially in patients aged 12 years or greater, and with the severity of displacement. In patients treated by closed reduction, anatomical reduction helps to decrease the rate of AVN, while in those treated by open reduction, screw and plate fixation was preferable to fixation using cannulated screws or K-wires. Cite this article: Bone Joint J 2019;101-B:1160–1167

The use of bisphosphonates in the treatment of avascular necrosis of the femoral head is an encouraging but relatively new option with most published data being derived from small trials with limited follow-up. We present a clinicoradiological analysis of 395 hips with avascular necrosis which were treated with oral alendronate for three years with a mean follow-up of four years (1 to 8). Our results show an improvement in the clinical function, a reduction in the rate of collapse and a decrease in the requirement for total hip replacement, compared with the findings of other studies in which no treatment was given. This improvement is particularly marked if the treatment is begun in the pre-collapse stages of the disease. Even in Ficat stage-III hips some benefit was obtained from treatment with alendronate by at least a delay in the need for total hip replacement

Whereas avascular necrosis of the scaphoid after a fracture is well-documented, idiopathic avascular necrosis of the scaphoid (Preiser’s disease) is rare. Little is known of the aetiology of the condition and even less about the best course of management. We describe a rare case of bilateral Preiser’s disease. Possible aetiological factors and a summary of the current concepts of management are discussed

We performed 96 Birmingham resurfacing arthroplasties of the hip in 71 consecutive patients with avascular necrosis of the femoral head. A modified neck-capsule-preserving approach was used which is described in detail. The University of California, Los Angeles outcome score, the radiological parameters and survival rates were assessed. The mean follow-up was for 5.4 years (4.0 to 8.1). All the patients remained active with a mean University of California, Los Angeles activity score of 6.86 (6 to 9). Three hips failed, giving a cumulative survival rate of 95.4%. With failure of the femoral component as the endpoint, the cumulative survival rate was 98.0%. We also describe the combined abduction-valgus angle of the bearing couple, which is the sum of the inclination angle of the acetabular component and the stem-shaft angle, as an index of the optimum positioning of the components in the coronal plane. Using a modified surgical technique, it is possible to preserve the femoral head in avascular necrosis by performing hip resurfacing in patients with good results

Avascular necrosis is a serious complication of slipped capital femoral epiphysis and is difficult to treat. The reported incidence varies from 3% to 47% of patients. The aims of treatment are to maintain the range of movement of the hip and to prevent collapse of the femoral head. At present there are no clear guidelines for the management of this condition and treatment can be difficult and unrewarding. We have used examination under anaesthesia and dynamic arthrography to investigate avascular necrosis and to determine the appropriate method of treatment. We present 20 consecutive cases of avascular necrosis in patients presenting with slipped capital femoral epiphysis and describe the results of treatment with a mean follow-up of over eight years (71 to 121 months). In patients who were suitable for joint preservation (14), we report a ten-year survivorship of the hip joint of 75% and a mean Harris hip score of 82 (44 to 98)

Aims. Osteonecrosis (ON) can cause considerable morbidity in young people who undergo treatment for acute lymphoblastic leukaemia (ALL). The aims of this study were to determine the operations undertaken for ON in this population in the UK, along with the timing of these operations and any sequential procedures that are used in different joints. We also explored the outcomes of those patients treated by core decompression (CD), and compared this with conservative management, in both the pre- or post-collapse stages of ON. Methods. UK treatment centres were contacted to obtain details regarding surgical interventions and long-term outcomes for patients who were treated for ALL and who developed ON in UKALL 2003 (the national leukaemia study which recruited patients aged 1 to 24 years at diagnosis of ALL between 2003 and 2011). Imaging of patients with ON affecting the femoral head was requested and was used to score all lesions, with subsequent imaging used to determine the final grade. Kaplan-Meier failure time plots were used to compare the use of CD with non surgical management. Results. Detailed information was received for 85 patients who had developed ON during the course of their ALL treatment. A total of 206 joints were affected by ON. Of all joints affected by ON, 21% required arthroplasty, and 43% of all hips affected went on to be replaced. CD was performed in 30% of hips affected by ON. The majority of the hips were grade 4 or 5 at initial diagnosis of ON. There was no significant difference in time to joint collapse between those joints in which CD was performed, compared with no joint-preserving surgical intervention. Conclusion. There is a high incidence of surgery in young people who have received treatment for ALL and who have developed ON. Our results suggest that CD of the femoral head in this group of patients does not delay or improve the rates of femoral head survival. Cite this article: Bone Joint J 2021;103-B(3):589–596

Avascular necrosis is an iatrogenic complication of the treatment of congenital dislocation of the hip. In order to assess the incidence of this and other complications, we have reviewed a consecutive series of 211 children treated at some stage with the modified Denis Browne splint used in Adelaide. In 173 children treated with this splint alone for 238 subluxed or dislocated hips which were stable when reduced, six hips (2.5%) developed radiographic avascular necrosis, though there was progressive growth deformity in only one. There was a much higher incidence among cases treated for unstable reduction by tenotomy, plaster spica and then the splint, 20 of 33 hips (60.6%) showing radiographic signs, though only one led to progressive abnormality. Of seven patients treated by adductor tenotomy and the splint no case of avascular necrosis was encountered. In the whole series the incidence of significant long-term growth disturbance in children treated in this splint was 0.7%. The great majority of our cases of avascular necrosis were attributable to manipulation and plaster, not to the subsequent use of a splint

We investigated the incidence and risk factors for the development of avascular necrosis (AVN) of the femoral head in the course of treatment of children with cerebral palsy (CP) and dislocation of the hip. All underwent open reduction, proximal femoral and Dega pelvic osteotomy. The inclusion criteria were: a predominantly spastic form of CP, dislocation of the hip (migration percentage, MP > 80%), Gross Motor Function Classification System, (GMFCS) grade IV to V, a primary surgical procedure and follow-up of > one year. There were 81 consecutive children (40 girls and 41 boys) in the study. Their mean age was nine years (3.5 to 13.8) and mean follow-up was 5.5 years (1.6 to 15.1). Radiological evaluation included measurement of the MP, the acetabular index (AI), the epiphyseal shaft angle (ESA) and the pelvic femoral angle (PFA). The presence and grade of AVN were assessed radiologically according to the Kruczynski classification. Signs of AVN (grades I to V) were seen in 79 hips (68.7%). A total of 23 hips (18%) were classified between grades III and V. Although open reduction of the hip combined with femoral and Dega osteotomy is an effective form of treatment for children with CP and dislocation of the hip, there were signs of avascular necrosis in about two-thirds of the children. There was a strong correlation between post-operative pain and the severity of the grade of AVN. Cite this article: Bone Joint J 2015;97-B:270–6

Much of the current confusion and contradiction on the treatment of avascular necrosis of the femoral head is caused by the lack of an agreed efficient, quantitative system for evaluation and staging. We have used a new system to evaluate over 1000 hips with avascular necrosis during a period of 12 years; it has proved to be very valuable. The system is based on the sequence of pathological events known to take place. It allows accurate quantification in both early and later stages, does not use older, invasive diagnostic procedures, and incorporates the newer techniques of bone scanning and MRI. Clinical records of pain and reduced function are not a specific part of the system, although they help to determine treatment and outcome. Hips are first placed into one of seven stages from 0 to VI, based upon the type of radiological change. The extent of involvement is then measured. This allows more accurate evaluation of progression or resolution and better comparison of different methods of management. The system also helps to provide a prognosis and to decide on the best available method of treatment

We used MRI to examine the hips of 32 asymptomatic patients at 9 to 21 months after renal transplantation covered by high-dose corticosteroids. Five hips in three patients showed changes which indicate avascular necrosis, although radiographs, CT scans and isotope scans were normal. These patients had repeat MRI scans after another two years and three years. One patient with bilateral MRI changes developed symptoms and abnormal radiographs and CT and isotope scans in one hip nine months after the abnormal MRI. Intraosseous pressure was found to be raised in both hips, and core biopsies revealed necrotic bone on both sides. The other three hips have remained asymptomatic with unchanged MRI appearances three years after the initial MRI. It seems that idiopathic avascular necrosis does not always progress to bone collapse in the medium term

We reviewed 41 hips in 40 patients at three to 11 years (average 6.3 years) after Sugioka transtrochanteric rotational osteotomy for non-traumatic avascular necrosis of the femoral head. The clinical results were excellent or good in 23 hips (56%) and the radiological success rate was 56%. Failure was due to fracture of the femoral neck, nonunion of the osteotomy, secondary collapse, or osteoarthritis. Nonunion and femoral neck fracture were more common after the use of the large screws described by Sugioka than with AO blade plates. Secondary collapse was significantly more common when less than one-third of the posterior articular surface was intact (p = 0.002). Postoperative degenerative changes were seen in cases with stage III avascular necrosis. We conclude that success depends to a large extent on the amount and stage of necrosis of the femoral head, but that careful technique and the use of AO hip plates may increase the likelihood of a satisfactory result

Avascular necrosis (AVN) is a serious complication of high-dose chemotherapy for haematological malignancy in childhood. In order to describe its incidence and main risk factors and to evaluate the current treatment options, we reviewed 105 children with a mean age of 8.25 years (1 to 17.8) who had acute lymphoblastic or acute myeloid leukaemia, or a non-Hodgkin’s lymphoma. Overall, eight children (7.6%) developed AVN after a mean of 16.8 months (8 to 49). There were four boys and four girls with a mean age of 14.4 years (9.8 to 16.8) and a total of 18 involved sites, 12 of which were in the femoral head. All these children were aged > nine years (p < 0.001). All had received steroid treatment with a mean cumulative dose of prednisone of 5967 mg (4425 to 9599) compared with a mean of 3943 mg (0 to 18 585) for patients without AVN (p = 0.005). No difference existed between genders and no thrombophilic disorders were identified. Their initial treatment included 11 core decompressions and two bipolar hip replacements. Later, two salvage osteotomies were done and three patients (four hips) eventually needed a total joint replacement. We conclude that AVN mostly affects the weight-bearing epiphyses. Its risk increases with age and higher steroid doses. These high-risk patients may benefit from early screening for AVN. Cite this article: Bone Joint J 2013;95-B:1708–13

This retrospective study describes the long-term results of core decompression and placement of a non-vascularised bone graft in the management of avascular necrosis of the femoral head. We treated 80 hips in 65 patients, 18 by a cortical tibial autograft and 62 by a fibular allograft. The mean age of the patients was 36 years (. sd. 13.2). A total of 78 hips were available for evaluation of which pre-operatively six were Ficat-Arlet stage 0, three stage I, 31 stage IIA, 16 stage IIB, 13 stage III and nine stage IV. A total of 34 hips (44%) were revised at a mean of four years (. sd. 3.8). Survivorship analysis using a clinical end-point showed a survival rate of 59% five years after surgery. We found a significant difference (p = 0.002) in survivorship, when using a clinical and radiological end-point, between the two grafts, in favour of the tibial autograft. We considered this difference to be the result of the better quality and increased volume of tibial bone compared with that from the trochanteric region used with the fibular allograft. This is a relatively simple, extra-articular and reproducible procedure. In our view core decompression, removal of the necrotic tissue and packing of the cancellous grafts into the core track are vital parts of the procedure

We have studied the histological appearances of forty femoral heads with idiopathic avascular necrosis. The characteristic histopathological changes of recurrent necrosis were present in 83 per cent. Recurrent necrosis occurred widely after revascularisation had progressed as far as the subchondral zone. The aetiology of idiopathic avascular necrosis of the femoral head may be a chronic condition which produces repeated infarction. The deformation and incomplete revascularisation of the femoral head may be due to repeated episodes of infarction as well as to mechanical factors related to weight-bearing

In order to determine the incidence of avascular necrosis after osteotomy of the talar neck, we re-evaluated 11 patients (16 feet) with idiopathic club foot who had undergone this procedure at a mean age of eight years (5 to 13) to correct a residual adduction deformity. All had been initially treated conservatively and operatively. The mean follow-up was 39 years (36 to 41). Surgery consisted of a closing-wedge osteotomy of the talar neck combined, in 14 feet, with lengthening of the first cuneiform and a Steindler procedure. At follow-up eight feet were free from pain, three had occasional mild pain and five were regularly painful after routine activities. Two patients were unlimited in their activity, six occasionally limited after strenuous and three regularly limited after strenuous activity. Using the Ponseti score, the feet were rated as good in four, fair in three and poor in nine. In seven feet avascular necrosis with collapse and flattening of the talar dome had occurred. In all of these feet the children were younger than ten years of age at the time of surgery. In three feet, avascular necrosis of the talar head was also observed. We conclude that osteotomy of the talar neck in children under the age of ten years can cause avascular necrosis and should be abandoned

We studied the pathogenesis, incidence and consequences of avascular necrosis in 184 children treated for congenital dislocation of the hip. Of 210 hips, 99 (47%) had some evidence of avascular necrosis (total 81, partial 18). The incidence was not influenced by the age at reduction, the duration of traction or the use of adductor tenotomy. Patients treated by closed reduction without preliminary traction did not have a higher incidence of avascular necrosis. At long-term clinical and radiological review of 81 hips, early avascular necrosis significantly increased the chance of a poor outcome but did not predispose to acetabular dysplasia. If review includes minor forms of avascular necrosis, then this condition is common after closed reduction. Its presence is an important determinant of long-term radiological and clinical outcome

We describe the results of 76 total arthroplasties of the hip for stage-III or stage-IV avascular necrosis of the femoral head. Harris Galante Porous cups were used in 63 patients between 1986 and 1994 and followed prospectively. We reviewed 70 hips with a follow-up of more than five years (mean 7.6). At the latest review the mean Harris Hip Score had improved from a preoperative value of 29 ± 14.7 to 94 ± 6.8. Radiologically, there was no evidence of acetabular migration. The rate of revision for the femoral component was 8.6%, three being undertaken for loosening and three to allow downsizing of the femoral head. The rate of revision for the acetabular component was 7.1% (five cups). At the time of revision none of the cups was clinically loose, and only required the liner to be changed. The rate of complications was low with no case of deep infection or dislocation, but nine of the 76 hips (11.8%) showed grade-III heterotopic ossification. Previous studies of patients undergoing cemented total hip arthroplasty for the treatment of advanced avascular necrosis have indicated a high incidence of loosening of the acetabular component. Our findings show good medium-term results using the Harris Galante Porous cup for acetabular reconstruction, together with a variety of cemented femoral components, for the treatment of this difficult problem

The clinical and pathological findings in a case of early avascular necrosis of the femoral head following renal transplantation are described. Regions of subchondral bone distant from the principal lesions showed increased numbers of empty osteocytic lacunae. This has been quantified and it is suggested that a loss of osteocytes is perhaps one of the earliest lesions leading to established avascular necrosis

Avascular necrosis of bone is a well-recognised phenomenon in patients on long-term steroid therapy, especially after renal transplantation. There are only four cases reported in the literature of multifocal avascular necrosis after short-term high-dose steroid therapy, and three additional cases are reported in this paper. All the hips have needed reconstructive surgery within two and a half years of the onset of symptoms; in one patient, however, this has been prevented by other medical problems. In two of the three patients reported in this paper the shoulders also were affected; eventually they became pain-free but movement was restricted. Short-term high-dose steroid therapy has only recently been recognised as a cause of avascular necrosis and attempts should be made to prevent the incidence increasing

The purpose of this study was to evaluate the clinical results of a newly designed prosthesis to replace the body of the talus in patients with aseptic necrosis. Between 1999 and 2006, 22 tali in 22 patients were replaced with a ceramic prosthesis. A total of eight patients were treated with the first-generation prosthesis, incorporating a peg to fix into the retained neck and head of the talus, and the remaining 14 were treated with the second-generation prosthesis, which does not have the peg. The clinical results were assessed by the American Orthopaedic Foot and Ankle Society ankle/hindfoot scale. The mean follow-up was 98 months (18 to 174). The clinical results of the first-generation prostheses were excellent in three patients, good in one, fair in three and poor in one. There were, however, radiological signs of loosening, prompting a change in design. The clinical results of the second-generation prostheses were excellent in three patients, good in five, fair in four and poor in two, with more favourable radiological appearances. Revision was required using a total talar implant in four patients, two in each group. Although the second-generation prosthesis produced better results, we cannot recommend the use of a talar body prosthesis. We now recommend the use of a total talar implant in these patients

Aims. The modified Dunn procedure has the potential to restore the anatomy in hips with severe slipped capital femoral epiphyses (SCFE). However, there is a risk of developing avascular necrosis of the femoral head (AVN). In this paper, we report on clinical outcome, radiological outcome, AVN rate and complications, and the cumulative survivorship at long-term follow-up in patients undergoing the modified Dunn procedure for severe SCFE. Patients and Methods. We performed a retrospective analysis involving 46 hips in 46 patients treated with a modified Dunn procedure for severe SCFE (slip angle > 60°) between 1999 and 2016. At nine-year-follow-up, 40 hips were available for clinical and radiological examination. Mean preoperative age was 13 years, and 14 hips (30%) presented with unstable slips. Mean preoperative slip angle was 64°. Kaplan–Meier survivorship was calculated. Results. At the latest follow-up, the mean Merle d’Aubigné and Postel score was 17 points (14 to 18), mean modified Harris Hip Score was 94 points (66 to 100), and mean Hip Disability and Osteoarthritis Outcome Score was 91 points (67 to 100). Postoperative slip angle was 7° (1° to 16°). One hip (2%) had progression of osteoarthritis (OA). Two hips (5%) developed AVN of the femoral head and required further surgery. Three other hips (7%) underwent implant revision due to screw breakage or change of wires. Cumulative survivorship was 86% at ten-year follow-up. Conclusion. The modified Dunn procedure for severe SCFE resulted in a low rate of AVN, low risk of progression to OA, and high functional scores at long-term follow-up. The slip deformities were mainly corrected but secondary impingement deformities can develop in some hips and may require further surgical treatment. Cite this article: Bone Joint J 2019;101-B:403–414

A new method of vascularised tibial grafting has been developed for the treatment of avascular necrosis (AVN) of the talus and secondary osteoarthritis (OA) of the ankle. We used 40 cadavers to identify the vascular anatomy of the distal tibia in order to establish how to elevate a vascularised tibial graft safely. Between 2008 and 2012, eight patients (three male, five female, mean age 50 years; 26 to 68) with isolated AVN of the talus and 12 patients (four male, eight female, mean age 58 years; 23 to 76) with secondary OA underwent vascularised bone grafting from the distal tibia either to revascularise the talus or for arthrodesis. The radiological and clinical outcomes were evaluated at a mean follow-up of 31 months (24 to 62). The peri-malleolar arterial arch was confirmed in the cadaveric study. A vascularised bone graft could be elevated safely using the peri-malleolar pedicle. The clinical outcomes for the group with AVN of the talus assessed with the mean Mazur ankle grading scores, improved significantly from 39 points (21 to 48) pre-operatively to 81 points (73 to 90) at the final follow-up (p = 0.01). In all eight revascularisations, bone healing was obtained without progression to talar collapse, and union was established in 11 of 12 vascularised arthrodeses at a mean follow-up of 34 months (24 to 58). MRI showed revascularisation of the talus in all patients. . We conclude that a vascularised tibial graft can be used both for revascularisation of the talus and for the arthrodesis of the ankle in patients with OA secondary to AVN of the talus. Cite this article: Bone Joint J 2015; 97-B:802–8

In ten patients with sickle-cell disease, we used a new technique of cement injection for the treatment of 16 painful hips with a radiographic crescent line or flattening of the articular surface due to avascular necrosis. The necrotic bone and overlying cartilage are elevated by the injection to restore the sphericity of the femoral head. Five days after the operation, full weight-bearing was allowed with the help of crutches for three weeks. The time in hospital averaged eight days; the average blood loss was 100 ml. There was early pain relief and postoperative radiographs showed improvement in the shape of the femoral head. At a mean follow-up of 5 years (3 to 7), 14 of the 16 hips were still improved although some gave slight pain. Only two hips had required revision to total hip arthroplasty, at one year and two years respectively. The increasing longevity of patients with sickle-cell disease means that avascular necrosis will be an increasing problem. Total hip replacement has a poor prognosis because of the risks of infection, high blood loss, and early loosening. Cement injection does not have these problems and allows for earlier, more conservative surgery

We reviewed the prevalence of avascular necrosis (AVN) in a series of patients with sickle cell disease, using radiography and magnetic resonance imaging. We found AVN of at least one hip in 11 of 27 patients (41%). This is a significantly greater prevalence than reported. MRI was not as helpful in patients with sickle cell disease as it is in patients with AVN from other causes; it detected no more cases than radiography

Of 24 intertrochanteric osteotomies for avascular necrosis of the femoral head, 22 were followed up for an average of 63 months. Sixteen of the 22 cases had good or excellent results, including 5 of the 6 cases with Stage II disease and 11 of the 16 with Stage III changes. Success seemed to be inversely related to the size of the lesion. There were six major orthopaedic complications, but despite these we feel that the operation has a definite role in the treatment of the young active patient

Haemophilia is a rare cause of avascular necrosis of the femoral head. We report three cases from one centre, an incidence of 2.8%. All three cases presented "silently", and this makes the early diagnosis difficult. Awareness of the condition should lead to examination of the hips of haemophiliac patients at every outpatient visit and admission in the hope that hip disease can be diagnosed at an early stage. This may allow earlier treatment, less femoral head deformity, and an improvement in the long-term prognosis

Between 1994 and 1999, we treated six patients with avascular necrosis of the talus by excision of the necrotic body of the talus and tibiocalcaneal fusion using an Ilizarov frame. This was combined with corticotomy and a lengthening procedure. Shortening was corrected in all patients except two, who were over 60 years of age. All patients had previous operations which had failed. All achieved solid bony fusion, with five out of six having either a good or an excellent result. We conclude that this is an effective reconstructive technique which gives a good functional result

Aims

The aim of this study was to evaluate the epidemiology and treatment of Perthes’ disease of the hip.

Between January 1987 and December 1988 there were 7575 births in the Swansea maternity unit. Of these 823 (10.9%) were considered to be at ‘high risk’ for developmental dysplasia of the hip (DDH). Static ultrasound examination was performed in each case and the results classified on the basis of the method of Graf. A total of 117 type III–IV hips in 83 infants was splinted using the Aberdeen splint. Radiographs of these hips were taken at six and 12 months. Hilgenreiner’s measurements of the acetabular angle were made in all cases and the development of the femoral capital epiphysis was assessed by measuring the epiphyseal area. The effect of splintage on the acetabular angle and the epiphyseal area between the normal and abnormal splinted hips was compared. Radiographs of 16 normal infants (32 normal unsplinted hips) were used as a control group. This cohort has now been followed up for a minimum of nine years. There have been no complications as a result of splintage. The failure rate was 1.7% or 0.25 per 1000 live births. No statistical difference was found when comparing the effect of splintage on the acetabular angle and epiphyseal area between normal and abnormal splinted hips and normal unsplinted hips. Our study has shown that while the Aberdeen splint had a definite but small failure rate, it was safe in that it did not produce avascular necrosis. The current conventional view that a low rate of splintage is always best is therefore brought into question if the Aberdeen splint is chosen for the management of neonatal DDH

We studied the natural history of nontraumatic avascular necrosis of the femoral head (ANFH) in 115 hips in 87 patients, 69 steroid-induced, 21 related to misuse of alcohol and 25 idiopathic. The average length of follow-up was over five years. Collapse occurred most often when the focus of bone necrosis occupied the weight-bearing surface of the femoral head. Flatness of the head due to subchondral fracture was an early manifestation of collapse. Classification into six types based upon the radiographic findings provided an accurate prognosis for individual cases of ANFH which is useful in planning treatment and in assessing its outcome

This paper reports a detailed examination of three lesions of aseptic necrosis of bone occurring in a man who had worked in compressed air eleven years previously. Although two of the lesions were juxta-articular, in neither had the bone collapsed. Histology of only one similar lesion is reported in the literature (McCallum et al. 1966). Necropsy material is considered, together with radiographs and bone scans of the same lesions taken four years earlier. Similar changes have been shown to occur in commercial divers. On the evidence of this case it becomes clear that radiography is limited in its use and that bone scans as an indicator of repair may be open to misinterpretation. There may be a place for operation before the onset of symptoms in these cases of aseptic bone necrosis

Total hip replacement was performed in 27 hips of patients who had sickle cell anaemia with avascular necrosis of the femoral head. The disease was bilateral in 11 patients. Considerable medical problems were encountered although most of the patients had exchange transfusion before surgery (86%), which prevented postoperative sickle cell crises in all but two cases. At the primary operation hard sclerotic bone was seen in nine femora with complete obliteration of the femoral canal. There were four femoral fractures, three following perforation of the shaft due to this hard bone. There was a very high morbidity due to loosening in both cemented and uncemented prostheses. With a rate of 59% over a cumulative 5.5 year period, revision was being performed at an average of only 43 months. Surgeons should be aware of these problems

We have studied core biopsy specimens from 16 femoral heads affected by idiopathic avascular necrosis at the silent stage, when there were no clinical or radiographic manifestations but scintigraphy was positive. All the specimens showed necrosis of trabeculae and of bone marrow, but the most common and characteristic feature was evidence of old and new haemorrhage in the marrow. In the areas of intramedullary haemorrhages, trabeculae and bone marrow were completely necrotic, with a transitional area of incomplete necrosis between these areas and those without haemorrhagic lesions, where the trabeculae and bone marrow were normal. There was good correlation between necrosis and haemorrhagic episodes, and it was concluded that repeated intramedullary haemorrhage at the silent stage is probably related to the pathogenesis of idiopathic avascular necrosis of the femoral head

Two cases of idiopathic avascular necrosis of the scaphoid are reported and it is suggested that the aetiology could be the same as that recently described for Keinboeck's disease by Beckenbaugh et al. (1980). The condition described in this paper is a different entity from that described by Preiser (1910), which was probably not an osteochondritis but an undiagnosed fracture

From 1974 to 1981, we performed 28 core decompressions of the distal femur for pathologically confirmed avascular necrosis. At a mean follow-up of 54 months (range 20 to 140 months) and using the Ficat stages, all seven cases in stage I and stage II had good results. Of 21 cases in stage III, 11 cases had good results, four had poor results, and six needed total knee replacement. There were no significant orthopaedic complications. The procedure is worthwhile and will be more accurate with new methods of imaging

We have compared different types of intertrochanteric osteotomy for avascular of necrosis of the hip and evaluated their performance in the light of improving outcome after total hip arthroplasty (THA). During a period of 14 years we performed 63 flexion osteotomies (partly combined with varus or valgus displacement), 29 rotational osteotomies, 13 varus osteotomies, eight medialising osteotomies and two extension osteotomies. The mean period of follow-up for all 115 operations was 7.3 years (maximum 24.6). At follow-up, 27 of 29 patients with a rotational osteotomy had already undergone a THA, compared with 36 of 63 after flexion osteotomy. A high incidence of complications (55.2%) was seen early after rotational osteotomy, compared with 17.5% after flexion osteotomy. For all osteotomies there was a high correlation between the size of the necrotic area and the incidence of failure, which also correlated with the preoperative Ficat and Steinberg stages. Using Kaplan-Meier survivorship analysis, Sugioka’s rotational osteotomy showed a survival probability after five years of 0.26 (95% confidence interval 0.49 to 0.14), and after ten years of 0.15 (CI 0.36 to 0.06). The survival probability for flexion osteotomy was 0.70 (CI 0.83 to 0.59) after five years and 0.50 (CI 0.65 to 0.38) after ten years. The subgroup of flexion osteotomy with a necrotic sector of less than 180° achieved the best survival probability of 0.90 (CI 1.00 to 0.80) after five years and 0.61 (CI 0.84 to 0.45) after ten years. The indications for intertrochanteric osteotomy for avascular necrosis of the hip have to be addressed critically. Even flexion osteotomy in cases with small areas of necrosis provides only temporary benefit. Rotational osteotomy was associated with a high incidence of complications

Ninety-five patients with steroid-induced avascular necrosis of bone have been personally treated by the author. Of these, eighteen had a lesion of the head of the humerus, on one or both sides. The conditions for which the steroids were given included post-transplantation, lupus erythematosus, glomerulonephritis and asthma. The characteristic lesion began as a subchondral osteolytic area which frequently progressed to collapse. The articular cartilage divided from the subchondral bone, either becoming detached as a free cap or at a later stage reattaching. In some cases the lesion was minimal and the symptoms were slight. Conservative treatment has consisted of pendulum exercises and avoidance of abduction, particularly against resistance. In fourteen patients this led to satisfactory function with only intermittent symptoms. Four patients required replacement of five humeral heads with Neer's prostheses. After one to seven years the results of all five were classified as excellent in terms of absence of symptoms and a free range of movement

We report the results of conservative treatment of stage III and stage IV avascular necrosis of bone (AVN) affecting the hip or knee in renal transplant patients. Twenty-nine patients were followed for a mean period of five years. Conservative management was successful in controlling symptoms in 40% of those with AVN of the hip and in 70% of those with AVN of the knee. Knowledge of the natural history of AVN is important because of the long survival times after renal transplantation

We reviewed 18 hips in 17 patients at a mean of five years after performing Sugioka's transtrochanteric anterior rotational osteotomy for avascular necrosis. The results were satisfactory in only three hips (17%). Twelve hips had been revised by hip replacement, revision was pending in one and two others were unsatisfactory. Hip replacement was not compromised by the previous Sugioka osteotomy. Fifteen hips (83%) had shown further collapse of the femoral head, and we conclude from this and from isotope scans that the osteotomy may have impaired the residual blood supply of the femoral head. It seems that ethnic origin may be a factor in the outcome of this procedure; we have abandoned its use

Aims

We compared the clinical outcomes of curved intertrochanteric varus osteotomy (CVO) with bone impaction grafting (BIG) with CVO alone for the treatment of osteonecrosis of the femoral head (ONFH).

We have carried out a prospective study of 17 patients (14 women, 3 men) of mean age 48 years (21 to 76) with transcervical fractures of the femur using MRI to detect early evidence of avascular necrosis of the head. Two fractures were Garden stage I, 12 stage II, and three stage III. We performed internal fixation under radiological control at a mean of five days (2 to 15) after injury using a titanium cannulated cancellous screw or a titanium compression hip screw. MRI was performed at one, six and 12 months and then yearly after operation. T1- and T2-weighted images were obtained by a spin-echo technique. The duration of follow-up of patients who did not subsequently require replacement of the head of the femur was from 2 to 5 years (mean 3.2). One month after operation eight of the 17 hips showed a band of low signal intensity on T1-weighted images and high signal intensity on T2-weighted images indicating lesions in the femoral head away from the fracture line. These were of three types: type I was a small infarct at the superolateral region of the femoral head and was seen in three hips; type II was a shallow lesion from the superolateral region to the fovea of the femoral head (three hips); and type III was a large lesion occupying most of the femoral head (two hips). No further changes were seen in the MRI after six months from operation. Collapse of the femoral head did not occur in the three hips with type-I lesions, but two of the three type-II hips and both type-III hips subsequently collapsed. At the final follow-up the three hips with a type-I lesion and one with a type-II were still asymptomatic but radiography showed sclerosis in the femoral head corresponding to the MRI lesions. The nine hips which showed no changes on MRI at one month had no abnormal findings on physical examination, radiography or MRI at final follow-up

Aims

The aim of this study was to report the medium-term outcomes of impaction bone allograft and fibular grafting for osteonecrosis of the femoral head (ONFH) and to define the optimal indications.

Of 899 patients with sickle-cell disease, aged between 6 and 28 years, who attended clinics in the Guinea Savannah of Nigeria in 1982 and 1983, 29 had symptoms of avascular necrosis of the femoral head. This group was studied in detail. Twenty-eight patients had haemoglobin-SS electrophoretic patterns and one had haemoglobin-SC. The male to female ratio was 1 to 1.6, and most of the patients were aged between 6 and 15 years at the onset of hip symptoms. These symptoms correlated with the radiographic lesions, but were not related to the age or sex of the patient. The radiographic lesions varied widely and were related to the age at onset of hip symptoms. A new radiological classification is proposed

We have reviewed 54 hips in 46 patients from 2 to 14 years after a joint-preserving operation for idiopathic avascular necrosis of the femoral head. The choice between core decompression (17 hips), bone grafting (18), rotation osteotomy (15) or varus osteotomy (4) was determined by the stage and location of the area of necrosis. The overall success rate was unexpectedly low at 60%. Core decompression and bone grafting by our techniques gave poor long-term results, but those of rotation or varus osteotomies, performed with care for the correct indications, were better. The indications for each procedure are discussed: osteotomy is best when the area of necrosis is shallow and localised in the medial or anterior portion of the femoral head

Twenty-nine patients with avascular necrosis of the femoral head after injury have been treated by operation. Multiple drilling of the femoral head was performed, necrotic bone removed and a muscle-pedicle bone graft implanted into the head and neck of the femur. In 17 of the patients the necrosis was associated with an un-united femoral neck fracture, in 11 it occurred after the fracture had united, and one case followed reduction of a dislocated hip. The hips became painless soon after operation. The patients were young (average age 35 years), and full weight-bearing was not allowed for several months. The follow-up period ranged from 22 to 64 months. The results were excellent in 20 patients, good in five, fair in three and poor in one

Aims

Earlier studies dealing with trends in the management of osteonecrosis of the femoral head (ONFH) identified an increasing rate of total hip arthroplasties (THAs) and a decreasing rate of joint-preserving procedures between 1992 and 2008. In an effort to assess new trends in the management of this condition, this study evaluated the annual trends of joint-preserving versus arthroplasties for patients aged < or > 50 years old, and the incidence of specific operative management techniques.