The localization of necrotic areas has been reported to impact the prognosis and treatment strategy for osteonecrosis of the femoral head (ONFH). Anteroposterior localization of the necrotic area after a femoral neck fracture (FNF) has not been properly investigated. We hypothesize that the change of the weight loading direction on the femoral head due to residual posterior tilt caused by malunited FNF may affect the location of ONFH. We investigate the relationship between the posterior tilt angle (PTA) and anteroposterior localization of osteonecrosis using lateral hip radiographs. Patients aged younger than 55 years diagnosed with ONFH after FNF were retrospectively reviewed. Overall, 65 hips (38 males and 27 females; mean age 32.6 years (SD 12.2)) met the inclusion criteria. Patients with stage 1 or 4 ONFH, as per the Association Research Circulation Osseous classification, were excluded. The ratios of anterior and posterior viable areas and necrotic areas of the femoral head to the articular surface were calculated by setting the femoral head centre as the reference point. The PTA was measured using Palm’s method. The association between the PTA and viable or necrotic areas of the femoral head was assessed using Spearman’s rank correlation analysis (median PTA 6.0° (interquartile range 3 to 11.5)).Aims
Methods
Successful cell therapy in hip osteonecrosis (ON) may help to avoid ON progression or total hip arthroplasty (THA), but the achieved bone regeneration is unclear. The aim of this study was to evaluate amount and location of bone regeneration obtained after surgical injection of expanded autologous mesenchymal stromal cells from the bone marrow (BM-hMSCs). A total of 20 patients with small and medium-size symptomatic stage II femoral head ON treated with 140 million BM-hMSCs through percutaneous forage in the EudraCT 2012-002010-39 clinical trial were retrospectively evaluated through preoperative and postoperative (three and 12 months) MRI. Then, 3D reconstruction of the original lesion and the observed postoperative residual damage after bone regeneration were analyzed and compared per group based on treatment efficacy.Aims
Methods
Bone marrow-derived mesenchymal stem cells obtained from bone marrow aspirate concentrate (BMAC) with platelet-rich plasma (PRP), has been used as an adjuvant to hip decompression. Early results have shown promise for hip preservation in patients with osteonecrosis (ON) of the femoral head. The purpose of the current study is to examine the mid-term outcome of this treatment in patients with precollapse corticosteroid-induced ON of the femoral head. In all, 22 patients (35 hips; 11 males and 11 females) with precollapse corticosteroid-induced ON of the femoral head underwent hip decompression combined with BMAC and PRP. Mean age and BMI were 43 years (SD 12) and 31 kg/m² (SD 6), respectively, at the time of surgery. Survivorship free from femoral head collapse and total hip arthroplasty (THA) and risk factors for progression were evaluated at minimum five-years of clinical follow-up with a mean follow-up of seven years (5 to 8).Aims
Methods
Despite advances in the treatment of paediatric hip disease, adolescent and young adult patients can develop early onset end-stage osteoarthritis. The aims of this study were to address the indications and medium-term outcomes for total hip arthroplasty (THA) with ceramic bearings for teenage patients. Surgery was performed by a single surgeon working in the paediatric orthopaedic unit of a tertiary referral hospital. Databases were interrogated from 2003 to 2017 for all teenage patients undergoing THA with a minimum 2.3 year follow-up. Data capture included patient demographics, the underlying hip pathology, number of previous surgeries, and THA prostheses used. Institutional ethical approval was granted to contact patients for prospective clinical outcomes and obtain up-to-date radiographs. In total, 60 primary hips were implanted in 51 patients (35 female, 16 male) with nine bilateral cases. The mean age was 16.7 years (12 to 19) and mean follow-up was 9.3 years (2.3 to 16.8).Aims
Methods
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. Methods. A total of 219,371 patients with ONFH were identified from a nationwide database between 1 January 2009 and 31 December 2015. The mean age was 54 years (18 to 90) and 105,298 (48%) were female. The diagnosis was made using International Classification of Disease, Ninth revision, Clinical Modification (ICD-9-CM) and Tenth Revision, Clinical Modification (ICD-10-CM) procedure codes. The percentage of patients managed using each procedure during each year was calculated and compared between years. The trends in the use of the types of procedure were also evaluated. Results. The rate of joint-preserving procedures was significantly higher in patients aged < 50 years compared with those aged > 50 years (4.93% vs 1.52%; p < 0.001). For the overall cohort, rates of arthroplasty were far greater than those for joint-preserving procedures. THA was the most commonly performed procedure (291,114; 94.03%), while osteotomy (3,598; 1.16%), partial arthroplasty (9,171; 2.96%),
Using a simple classification method, we aimed to estimate the collapse rate due to osteonecrosis of the femoral head (ONFH) in order to develop treatment guidelines for joint-preserving surgeries. We retrospectively analyzed 505 hips from 310 patients (141 men, 169 women; mean age 45.5 years Objectives
Methods
For this retrospective cohort study, patients aged ≤ 30 years
(very young) who underwent total hip arthroplasty (THA) were compared
with patients aged ≥ 60 years (elderly) to evaluate the rate of
revision arthroplasty, implant survival, the indications for revision,
the complications, and the patient-reported outcomes. We retrospectively reviewed all patients who underwent primary
THA between January 2000 and May 2015 from our institutional database.
A total of 145 very young and 1359 elderly patients were reviewed.
The mean follow-up was 5.3 years (1 to 18). Logistic generalized
estimating equations were used to compare characteristics and the revision
rate. Survival was evaluated using Kaplan–Meier curves and hazard
rates were created using Cox regression.Aims
Patients and Methods
The aim of this study was to examine the efficacy and safety
of multiple boluses of intravenous (IV) tranexamic acid (TXA) on
the hidden blood loss (HBL) and inflammatory response following
primary total hip arthroplasty (THA). A total of 150 patients were allocated randomly to receive a
single bolus of 20 mg/kg IV TXA before the incision (group A), a
single bolus followed by a second bolus of 1 g IV-TXA three hours
later (group B) or a single bolus followed by two boluses of 1 g
IV-TXA three and six hours later (group C). All patients were treated
using a standard peri-operative enhanced recovery protocol. Primary
outcomes were HBL and the level of haemoglobin (Hb) as well as the
levels of C-reactive protein (CRP) and interleukin-6 (IL-6) as markers
of inflammation. Secondary outcomes included the length of stay
in hospital and the incidence of venous thromboembolism (VTE).Aims
Patients and Methods
Transtrochanteric rotational osteotomy (TRO) is performed for
young patients with non-traumatic osteonecrosis of the femoral head
(ONFH) to preserve the hip. We aimed to investigate the long-term
outcomes and the risk factors for failure 15 years after this procedure. This study included 95 patients (111 hips) with a mean age of
40 years (21 to 64) who underwent TRO for ONFH. The mean follow-up
was 18.2 years (3 to 26). Kaplan–Meier survivorship analyses were
performed with conversion to total hip arthroplasty (THA) and radiological
failure due to secondary collapse of the femoral head or osteoarthritic changes
as the endpoint. Multivariate analyses were performed to assess
risk factors for each outcome.Aims
Patients and Methods
The primary purpose of this meta-analysis was to determine whether statin usage could reduce the risk of glucocorticoid-related osteonecrosis in animal models. A systematic literature search up to May 2015 was carried out using the PubMed, Ovid, EBM reviews, ISI Web of Science, EBSCO, CBM, CNKI databases with the term and boolean operators: statins and osteonecrosis in all fields. Risk ratio (RR), as the risk estimate of specific outcome, was calculated along with 95% confidence intervals (CI). The methodological quality of individual studies was assessed using a quantitative tool based on the updated Stroke Therapy Academic Industry Roundtable (STAIR) recommendations.Objectives
Methods
Aims. One method of femoral head preservation following avascular necrosis
(AVN) is
Hip resurfacing arthroplasty (HRA) is an alternative to conventional
total hip arthroplasty for patients with osteonecrosis (ON) of the
femoral head. Our aim was to report the long-term outcome of HRA,
which is not currently known. Long-term survivorship, clinical scores and radiographic results
for 82 patients (99 hips) treated with HRA for ON over a period
of 18 years were reviewed retrospectively. The mean age of the 67
men and 15 women at the time of surgery was 40.8 years (14 to 64).
Patients were resurfaced regardless of the size of the osteonecrotic
lesion.Aims
Patients and Methods
This preliminary study evaluates a combination
of bone morphogenetic protein (BMP)-7 and non-vascularised autologous
fibular grafting (AFG) for the treatment of osteonecrosis of the
femoral head. BMP-7/AFG combination was applied in seven pre-collapse femoral
heads (five Steinberg stage II, two stage III) in six patients.
Pre- and post-operative evaluation included clinical (Harris hip
score (HHS), visual analogue scale (VAS) for pain) and radiological
assessment (radiographs, quantitative CT) at a mean follow-up of
4 years (2 to 5.5). A marked improvement of function (mean HHS increase of 49.2)
and decrease of pain level (mean VAS decrease of 5) as well as retention
of the sphericity of the femoral head was noted in five hips at
the latest follow-up, while signs of consolidation were apparent
from the third post-operative month. One patient (two hips) required
bilateral total hip replacement at one year post-operatively. In
the series as a whole, quantitative-CT evaluation revealed similar densities
between affected and normal bone. Heterotopic ossification was observed
in four hips, without compromise of the clinical outcome. In this limited series AFG/BMP-7 combination proved a safe and
effective method for the treatment of femoral head osteonecrosis,
leading to early consolidation of the AFG and preventing collapse
in five of seven hips, while the operative time and post-operative
rehabilitation period were much shorter compared with free vascularised fibular
grafts. Cite this article:
Symptomatic hip osteonecrosis is a disabling
condition with a poorly understood aetiology and pathogenesis. Numerous
treatment options for hip osteonecrosis are described, which include
non-operative management and joint preserving procedures, as well
as total hip replacement (THR). Non-operative or joint preserving
treatment may improve outcomes when an early diagnosis is made before
the lesion has become too large or there is radiographic evidence
of femoral head collapse. The presence of a crescent sign, femoral
head flattening, and acetabular involvement indicate a more advanced-stage
disease in which joint preserving options are less effective than
THR. Since many patients present after disease progression, primary
THR is often the only reliable treatment option available. Prior
to the 1990s, outcomes of THR for osteonecrosis were poor. However,
according to recent reports and systemic reviews, it is encouraging
that with the introduction of newer ceramic and/or highly cross-linked
polyethylene bearings as well as highly-porous fixation interfaces,
THR appears to be a reliable option in the management of end-stage
arthritis following hip osteonecrosis in this historically difficult
to treat patient population. Cite this article:
The introduction of a trabecular tantalum rod
has been proposed for the management of early-stage osteonecrosis of
the femoral head but serves as a single-point of support of the
necrotic lesion. We describe a technique using two or three 4.2
mm (or later 4.7 mm) tantalum pegs for the prevention of collapse
of the necrotic lesion. We prospectively studied 21 patients (26
hips) with non-traumatic osteonecrosis of the femoral head treated
in this manner. Of these, 21 patients (24 hips) were available for
radiological and clinical evaluation at a mean follow-up of 46 months
(18 to 67). Radiological assessment showed that only eight hips
deteriorated according to the Association Research Circulation Osseous
classification, and four hips according to the Classification of
the Japanese Investigation Committee of Health and Welfare. Functional
improvement was obtained with an improvement in the mean Harris
hip score from 65.2 (33.67 to 95) to 88.1 (51.72 to 100), the mean
Merle D’Aubigné-Postel score from 13 (6 to 18) to 16 (11 to 18),
a mean visual analogue score for pain from 5.2 (0 to 9.5) to 2.6
(0 to 7), and the mean Short-Form 36 score from 80.4 (56.8 to 107.1)
to 92.4 (67.5 to 115.7). Of these 24 hips followed for a minimum
of 18 months, three were considered as failures at the final follow-up,
having required total hip replacement. One of the hips without full
follow-up was also considered to be a failure. In more than two-thirds
of the surviving hips a satisfactory clinical outcome was achieved
with promising radiological findings. The estimated mean implant
survival was 60 months (95% confidence interval 53.7 to 66.3).
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.
We have investigated the effectiveness of the transplantation of bone-marrow-derived mononuclear cells (BMMNCs) with interconnected porous calcium hydroxyapatite (IP-CHA) on early bone repair for osteonecrosis of the femoral head. We studied 22 patients (30 hips) who had osteonecrosis with a minimum follow-up of one year after implantation of BMMNCs. The mean age at surgery was 41 years (18 to 64) and the mean period of follow-up was 29 months (19 to 48). In a control group, cell-free IP-CHA was implanted into a further eight patients (9 hips) with osteonecrosis of the femoral head and the outcomes were compared. A reduction in the size of the osteonecrotic lesion was observed subsequent to hypertrophy of the bone in the transition zone in the BMMNC group. In three patients in the treatment group progression to extensive collapse was detected. In the control group subtle bone hypertrophy was observed, but severe collapse of the femoral head occurred in six of eight hips. In this limited study the implantation of BMMNCs and IP-CHA appears to confer benefit in the repair of osteonecrosis and in the prevention of collapse.
Implantation of a large-diameter femoral head prosthesis with a metal-on-metal bearing surface reduces the risk of dislocation, increases the range of movement, minimises the risk of impingement and, in theory, results in little wear. Between February 2004 and March 2007 we implanted 100 consecutive total hip replacements with a metal-on-metal bearing and a large femoral head into 92 patients. There were 51 men and 41 women with a mean age of 50 years (18 to 70) at the time of surgery. Outcome was assessed using the Western Ontario McMaster University osteoarthritis index and the Harris hip score as well as the Devane activity score. These all improved significantly (p <
0.0001). At the last follow-up there were no cases of dislocation, no impingement, a good range of movement and no osteolysis, but seven revisions, two for infection and five for aseptic loosening. The probability of groin pain increased if the other acetabular component inclination exceeded 50° (p = 0.0007). At 4.8 years of follow-up, the projected survival of the Durom acetabular component, with revision for any reason, was 92.4% ( The design of the component made it difficult both to orientate and seat, which when combined with a poor porous coating, produced unpredictable fixation and a low survival at five years.
We have reviewed 70 Harris-Galante uncemented acetabular components implanted as hybrid hip replacements with cemented stems between 1991 and 1995 in 53 patients whose mean age was 40 years (19 to 49). The mean follow-up was for 13.6 years (12 to 16) with no loss to follow-up. We assessed the patients both clinically and radiologically. The mean Oxford hip score was 20 (12 to 46) and the mean Harris hip score 81 (37 to 100) at the final review. Radiologically, 27 hips (39%) had femoral osteolysis, 13 (19%) acetabular osteolysis, and 31 (44%) radiolucent lines around the acetabular component. Kaplan-Meier survival curves were constructed for the outcomes of revision of the acetabular component, revision of the component and polyethylene liner, and impending revision for progressive osteolysis. The cumulative survival for revision of the acetabular component was 94% (95% confidence interval 88.4 to 99.7), for the component and liner 84% (95% confidence interval 74.5 to 93.5) and for impending revision 55.3% (95% confidence interval 40.6 to 70) at 16 years. Uncemented acetabular components with polyethylene liners undergo silent lysis and merit regular long-term radiological review.
Multiple drilling is reported to be an effective treatment for osteonecrosis of the head of femur, but its effect on intra-osseous pressure has not been described. We undertook multiple drilling and recorded the intra-osseous pressure in 75 osteonecrotic hips in 60 patients with a mean age of 42 years (19 to 67). At a mean follow-up of 37.1 months (24 to 60), 42 hips (56%) had a clinically successful outcome. The procedure was effective in reducing the mean intra-osseous pressure from 57 mmHg (SD 22) to 16 mmHg (SD 9). Hips with a successful outcome had a mean pressure of 26 mmHg (SD 19). It was less effective in preventing progression of osteonecrosis in hips with considerable involvement and in those with a high intra-osseous pressure in the intertrochanteric region (mean 45 mmHg (SD 25)). This study is not able to answer whether a return of the intra-osseous pressure to normal levels is required for satisfactory healing.
