Aims. 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. Methods. 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)). Results. We identified a negative correlation between PTA and anterior viable areas (rho −0.477; p = 0.001), and no correlation between PTA and necrotic (rho 0.229; p = 0.067) or posterior viable areas (rho 0.204; p = 0.132). Conclusion. Our results suggest that residual posterior tilt after FNF could affect the anteroposterior localization of necrosis. Cite this article: Bone Jt Open 2024;5(5):394–400

Objectives. 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. Methods. We retrospectively analyzed 505 hips from 310 patients (141 men, 169 women; mean age 45.5 years . (sd. 14.9; 15 to 86)) diagnosed with ONFH and classified them using the Japanese Investigation Committee (JIC) classification. The JIC system includes four visualized types based on the location and size of osteonecrotic lesions on weightbearing surfaces (types A, B, C1, and C2) and the stage of ONFH. The collapse rate due to ONFH was calculated using Kaplan–Meier survival analysis, with radiological collapse/arthroplasty as endpoints. Results. Bilateral cases accounted for 390 hips, while unilateral cases accounted for 115. According to the JIC types, 21 hips were type A, 34 were type B, 173 were type C1, and 277 were type C2. At initial diagnosis, 238/505 hips (47.0%) had already collapsed. Further, the cumulative survival rate was analyzed in 212 precollapsed hips, and the two-year and five-year collapse rates were found to be 0% and 0%, 7.9% and 7.9%, 23.2% and 36.6%, and 57.8% and 84.8% for types A, B, C1, and C2, respectively. Conclusion. Type A ONFH needs no further treatment, but precollapse type C2 ONFH warrants immediate treatment with joint-preserving surgery. Considering the high collapse rate, our study results justify the importance of early diagnosis and intervention in asymptomatic patients with type C2 ONFH. Cite this article: Y. Kuroda, T. Tanaka, T. Miyagawa, T. Kawai, K. Goto, S. Tanaka, S. Matsuda, H. Akiyama. Classification of osteonecrosis of the femoral head: Who should have surgery?. Bone Joint Res 2019;8:451–458. DOI: 10.1302/2046-3758.810.BJR-2019-0022.R1

Aims. Pain is the most frequent complaint associated with osteonecrosis of the femoral head (ONFH), but the factors contributing to such pain are poorly understood. This study explored diverse demographic, clinical, radiological, psychological, and neurophysiological factors for their potential contribution to pain in patients with ONFH. Methods. This cross-sectional study was carried out according to the “STrengthening the Reporting of OBservational studies in Epidemiology” statement. Data on 19 variables were collected at a single timepoint from 250 patients with ONFH who were treated at our medical centre between July and December 2023 using validated instruments or, in the case of hip pain, a numerical rating scale. Factors associated with pain severity were identified using hierarchical multifactor linear regression. Results. Regression identified the following characteristics as independently associated with higher pain score, after adjustment for potential confounders: Association Research Circulation Osseous classification stage IIIa or IIIb, bone marrow oedema, grade 3 joint effusion, as well as higher scores on pain catastrophizing, anxiety, and central sensitization. The final model explained 69.7% of observed variance in pain scores, of which clinical and radiological factors explained 37%, while psychological and neurophysiological factors explained 24% and demographic factors explained 8.7%. Conclusion. Multidimensional characteristics jointly contribute to the severity of pain associated with ONFH. These findings highlight the need to comprehensively identify potential contributors to pain, and to personalize management and treatment accordingly. Cite this article: Bone Joint Res 2024;13(11):673–681

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%), core decompression (1,200; 0.39%), and bone graft (3,026; 0.98%) were performed markedly less frequently. The annual percentage of patients managed using a THA (93.56% to 89.52%; p < 0.001), resurfacing (1.22% to 0.19%; p < 0.001), and osteotomy (1.31% to 1.05%; p < 0.001) also decreased during the study period. Conclusion. We found that patients with ONFH have been most commonly managed with non-joint-preserving procedures. Our findings provide valuable insight into the current management of this condition and should increase efforts being made to save the hip joint. Cite this article: Bone Joint J 2020;102-B(7 Supple B):122–128

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. Methods. A total of 67 patients (77 hips) with ONFH were enrolled in a single centre retrospective review. Success of the procedure was assessed using the Harris Hip Score (HHS) and rate of revision to total hip arthroplasty (THA). Risk factors were studied, including age, aetiology, duration of hip pain, as well as two classification systems (Association Research Circulation Osseous (ARCO) and Japanese Investigation Committee (JIC) systems). Results. After a mean follow-up period of 8.61 years (SD 1.45), 81.3% (52/64) of enrolled cases had a good or excellent HHS at latest follow-up (declining to 76.0% (38/50) for those with more than eight years of follow-up). Overall survival was 92.1% at eight years’ follow-up (95% CI 83.2% to 96.4%). A total of 12 hips (19.0%) failed (reoperation or HHS < 70 points) at final follow-up. Rate of success was adversely affected by increasing age, duration of pain, and more severe disease as measured using the ARCO and JIC classifications, but not by aetiology of the ONFH. Conclusion. We report favourable medium-term results of this procedure. Best outcomes can be expected in patients matching the following indications: younger than 40 years; less 12-month hip pain before surgery; femoral head collapse being less than 2 mm; and integrated lateral wall of femoral head. Cite this article: Bone Joint J 2020;102-B(7):838–844

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

Transtrochanteric curved varus osteotomy was designed to avoid some of the disadvantages of varus wedge osteotomy, such as post-operative leg-length discrepancy. In this retrospective study we investigated the leg-length discrepancy and clinical outcome after transtrochanteric curved varus osteotomy undertaken in patients with osteonecrosis of the femoral head. Between January 1993 and March 2004, this osteotomy was performed in 42 hips of 36 patients with osteonecrosis of the femoral head. There were 15 males and 21 females with a mean age at surgery of 34 years (15 to 68). The mean follow-up was 5.9 years (2.0 to 12.5). The mean pre-operative Harris hip score was 64.0 (43 to 85) points, which improved to a mean of 88.7 (58 to 100) points at final follow-up. The mean varus angulation post-operatively was 25° (12° to 38°) and the post-operative mean leg-length discrepancy was 13 mm (4 to 25). The post-operative leg-length discrepancy showed a strong correlation with varus angulation (Pearson’s correlation coefficient; r = 0.9530, p < 0.0001), which may be useful for predicting the leg-length discrepancy which can occur even after transtrochanteric curved varus osteotomy

In order to investigate the mechanisms of collapse in osteonecrosis of the femoral head, we examined which part of the femoral head was the key point of a collapse and whether a collapsed region was associated with the size of the necrotic lesion. Using 30 consecutive surgically removed femoral heads we retrospectively analysed whole serial cut sections, specimen photographs, specimen radiographs and histological sections. In all of the femoral heads, collapse consistently involved a fracture at the lateral boundary of the necrotic lesion. Histologically, the fractures occurred at the junction between the thickened trabeculae of the reparative zone and the necrotic bone trabeculae. When the medial boundary of the necrotic lesion was located lateral to the fovea of the femoral head, 18 of 19 femoral heads collapsed in the subchondral region. By contrast, when the medial boundary was located medial to the fovea, collapse in the subchondral region was observed in four of 11 femoral heads (p = 0.0011). We found that collapse began at the lateral boundary of the necrotic lesion and that the size of the necrotic lesion seemed to contribute to its distribution

We reviewed the outcome of curved intertrochanteric varus osteotomy in the treatment of osteonecrosis of the femoral head in 20 hips. A mean varus angulation of 31° was obtained by the osteotomy. The ratio of intact area on the weight-bearing portion increased from 19% to 61%. The mean elevation and lateral displacement of the greater trochanter were 1.2 cm and 0.5 cm, respectively. These changes in the position of the greater trochanter were very small when compared with those after conventional varus wedge osteotomy. Nonunion or delayed union was not observed. Quantitative analyses showed aggressive bone remodelling in the medial intertrochanteric region. Eighteen hips survived without collapse after a mean follow-up of 48 months. We conclude that curved varus osteotomy can be used to preserve the hip joint in patients with osteonecrosis of the femoral head

Our aim was to assess the local extent of osteocyte death in the proximal femur of 16 patients with osteonecrosis of the femoral head. We performed histological examination of the femoral heads and cancellous bone biopsies from four regions of the proximal femur in patients undergoing total hip arthroplasty. A control group consisted of 19 patients with osteoarthritis. All histological specimens were examined in a blinded fashion. Extensive osteonecrosis was shown in the proximal femur up to 4 cm below the lesser trochanter in the group with osteonecrosis. There was an overall statistically significant difference in the extent of osteocyte death distal to the femoral head between the two groups (p < 0.001). We discuss the implications of these findings as possible contributing factors in regard to the early failure of total hip arthroplasty reported in patients with osteonecrosis of the femoral head

It has been suggested that transient osteoporosis or the bone marrow oedema syndrome (BMOS) may be the initial phase of osteonecrosis of the femoral head (ONFH) and that there may be a common pathophysiology. In this study, we have assessed the MR images of 200 consecutive patients with ONFH in respect of the BMO pattern in order to test this hypothesis. This pattern was not observed in the early stage of ONFH. The initial abnormal finding detected on the MR images was an abnormal band of intensity at the junction between the necrotic area and the normal bone. Structural damage of the head seems to result in the appearance of the BMO pattern and the development of pain in ONFH. There was no finding to support the existence of a continuum between BMOS and ONFH

The rate of success of transtrochanteric rotational osteotomy for osteonecrosis of the femoral head may be improved if patients are preselected using MRI. We have used three criteria for selection for osteotomy (i) minor collapse of the infarcted area, loss of congruity or the crescent sign, without narrowing of the joint space or acetabular involvement (ii) patients younger than 55 years and with a painful hip (iii) patients with an intact area constituting an arc of more than 120° between the central vertical line of the femoral head and the posterior or anterior margin of the necrotic portion as seen on a midsagittal MRI. Seventeen patients were selected, with a follow-up of more than 42 months. A bone scan four weeks after operation showed adequate perfusion of the proximal segment in all hips. The hip score of Merle d’Aubigné et al improved from 13.5 points before operation to 17.2 points at the latest follow-up. Further collapse of the femoral head did not occur. The use of MRI instead of plain radiographs for the selection of patients has improved the success rate of transtrochanteric rotational osteotomy

The extent of necrosis is the main determining factor in the outcome of osteonecrosis of the femoral head and is best measured by MRI. Using statistical analyses, we have evaluated the accuracy and repeatability of seven different methods of measuring the extent of necrosis, of which three demonstrate good or acceptable accuracy. For the general observer their repeatability is poor; only for experienced observers were they reasonable. We conclude that within an institution or for personal use, the accuracy of some methods is acceptable, and repeatability reasonable. None is appropriate for international use

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

We have reviewed the results of 30 operations performed on 23 patients with Ficat stage-III or stage-IV osteonecrosis of the femoral head in which autogenous cortical and cancellous bone grafting had been performed through a so-called trapdoor made in the femoral head. At a mean of 56 months (30 to 60) after operation 20 of 24 stage-III hips (83%) had a good or excellent result as determined by the Harris hip-scoring system. Two of six stage-IV hips (33%) had good or excellent results. Eighteen of 21 hips (86%) with a combined necrotic angle of 200° had good or excellent clinical results compared with only four of nine hips (44%) with a combined necrotic angle of more than 200°. Six of the eight hips which had fair or poor results were in patients who had received corticosteroids; five of these six hips had lesions with a combined necrotic angle of greater than 200° or were in a late stage (stage IV). There were no perioperative complications. Our results suggest that the trapdoor procedure with autogenous cancellous and cortical bone grafting can be successful in Ficat and Arlet stage-III osteonecrosis of the hip in patients with small- to medium-sized lesions

We studied nine patients who had had a transtrochanteric anterior rotational osteotomy, as developed by Sugioka, for osteonecrosis of the femoral head. At a mean of 2.5 years after the initial operation we carried out a histological study of the previously necrotic femoral head which had not shown collapse of the new primary weight-bearing site. In seven joints, there was proliferation of fibrous tissue in the dead trabeculae with vascular ingrowth. New bone covering dead trabeculae created the characteristic appearance of ‘creeping substitution’. However, these changes were limited and did not extend over the entire necrotic area. Dead bone remained in all the cases. In the other two heads we did not observe proliferation of fibrous tissue or vascular ingrowth, only dead trabeculae and dead bone marrow

Osteonecrosis of the femoral head can be caused by a variety of disorders and affects the relatively young patient. Most studies have concentrated on the femoral changes; the sites of early lesions of the labrum and acetabular cartilage have not been recorded. We studied 17 hips with osteonecrosis and a wide congruent joint space on radiographs and by direct inspection of the femoral head, labrum and acetabular cartilage during surgery. All of the femoral heads had some anterosuperior flattening which reduced the head-neck ratio in this area. A consistent pattern of damage to the labrum and the acetabular cartilage was seen in all hips. Intraoperatively, impingement and the cam-effect with its spatial correlation with lesions of the labrum and acetabular cartilage were observed. These findings could be helpful when undertaking conservative surgery for osteonecrosis, since the recognition of early radiologically undetectable acetabular lesions may require modification of the surgical technique.

We have studied the correlation between the prevention of progressive collapse and the ratio of the intact articular surface of the femoral head, after transtrochanteric rotational osteotomy for osteonecrosis. We used probit analysis on 125 hips in order to assess the ratio necessary to prevent progressive radiological collapse over a ten-year period. The results show that a minimum postoperative intact ratio of 34% was required. This critical ratio may be useful for surgical planning and in assessing the natural history of the condition.

We investigated the factors related to the radiological outcome of a transtrochanteric curved varus osteotomy in patients with osteonecrosis of the hip. We reviewed 73 hips in 62 patients with a mean follow-up of 12.4 years (5 to 31.1). There were 28 men and 34 women, with a mean age of 33.3 years (15 to 68) at the time of surgery. The 73 hips were divided into two groups according to their radiological findings: group 1 showed progression of collapse and/or joint-space narrowing; group 2 had neither progressive collapse nor joint-space narrowing. Both of these factors and the radiological outcomes were analysed by a stepwise discriminant analysis. A total of 12 hips were categorised as group 1 and 61 as group 2. Both the post-operative intact ratio and the localisation of the necrotic lesion correlated with the radiological outcome. The cut-off point of the postoperative intact ratio to prevent the progression of collapse was 33.6%, and the cut-off point to prevent both the progression of collapse and joint-space narrowing was 41.9%.

The results of this study indicate that a post-operative intact ratio of 33.0% is necessary if a satisfactory outcome is to be achieved after this varus osteotomy.

Total hip replacement in patients with advanced osteonecrosis of the femoral head is often complicated by early loosening of the femoral component. Recent evidence has suggested that abnormal bone extending into the proximal femur may be responsible for the early failure of the femoral component. We aimed to identify which patients were at high risk of early failure by evaluating gadolinium-enhanced MR images of histologically-confirmed osteonecrotic lesions beyond the femoral head. Although the MR signal intensity has been shown to correlate well with osteonecrosis in the femoral head, it was found to be relatively insensitive at identifying lesions below the head, with a sensitivity of only 51% and a predictive value of a negative result of only 48%. However, the specificity was 90%, with the predictive value of a positive MRI finding being 86%. Only those patients with osteonecrosis of the femoral head secondary to sickle-cell disease, who are known to be at high risk of early loosening, had changes in the MR signal in the greater trochanter and the femoral shaft. This observation suggests that changes in the MR signal beyond the femoral head may represent osteonecrotic lesions in areas essential for the fixation of the femoral component. Pre-operative identification of such lesions in the neck of the femur may be important when considering hip resurfacing for osteonecrosis of the femoral head, following which early loosening of the femoral component and fracture of the neck are possible complications

Aims. Core decompression is a commonly performed procedure to treat osteonecrosis of the femoral head (ONFH) prior to femoral head collapse. The aim of the study was to identify the incidence of hip arthroplasty after core decompression and the potential risk factors for conversion through a nationwide population-based study. Methods. Patients who received core decompression for ONFH between 1 January 2009 and 31 December 2018 and were followed up until 31 December 2019 (mean 33 months (0.2 to 132)) were retrieved from Taiwan’s National Health Insurance claims database. A total of 2,918 patients were identified and included in the study. The mean age at the time of core decompression was 46 years (SD 12.5), with a male-to-female ratio of 7:3. The first total hip arthroplasty or hip hemiarthroplasty after the index core decompression was considered as the outcome of conversion to hip arthroplasty. For the analysis of conversion risk, patients’ demographic characteristics, economic status, comorbidities, and data on the type of hospital and surgeons’ experience were included. Results. Overall, 20.05% of patients received a hip arthroplasty within six months following core decompression, with the incidence rising to 60.6% by five years and 66.4% by ten years. Multivariable analysis revealed that patients aged over 40 years (HR 1.18 (95% CI 1.07 to 1.30); p = 0.002), who had a history of alcohol abuse (HR 1.57 (95% CI 1.22 to 2.02); p < 0.001), and had their procedures performed at district-level hospitals (HR 1.13 (95% CI 1.00 to 1.26; p = 0.044), were at increased risk of conversion to hip arthroplasty following core decompression. Conclusion. The five- and ten-year cumulative incidence of conversion to hip arthroplasty after core decompression was 60.6% and 66.4%, respectively. Significant risk factors for conversion to hip arthroplasty included age over 40 years, history of alcohol abuse, and procedures performed at district hospitals. Cite this article: Bone Joint J 2025;107-B(3):308–313

Aims. The effectiveness of total hip arthroplasty (THA) for patients with no or minimal radiological signs of osteoarthritis (OA) is unclear. In this study, we aimed to: 1) assess the outcome of such patients; 2) identify patient comorbidities and CT or MRI findings which predicted outcome; and 3) compare their outcome to the expected outcome of THA for hip OA. Methods. Adult patients undergoing THA for hip pain, with no or minimal radiological features of OA (Tönnis grading scale ≤ 1), were identified from a consecutive series of 1,925 THAs. Exclusion criteria were: inflammatory arthritis; osteonecrosis of the femoral head; prior trauma or infection; and patients without minimum one-year follow-up and patient-reported outcome measures (PROMs). The primary outcome measure was the Oxford Hip Score (OHS). Secondary outcome measures were EuroQol-visual analogue scale (EQ-VAS), University of California and Los Angeles (UCLA) scale, and patient satisfaction on a validated three-point ‘better’, ‘same’, or ‘worse’ scale. Results. A total of 107 patients with a median age of 41 years (IQR 18 to 73) were included, with mean follow-up of 6.0 years (SD 3.1). All patients underwent a diagnostic hip injection as a decision aid. Median postoperative OHS was 34 (IQR 28 to 42), with 36 patients (33%) achieving a patient-acceptable symptom state (OHS ≥ 42), lower than THA patients in international registries (40 to 43 points). Secondary outcomes were UCLA of 6 (4 to 8) and EQ-VAS of 73 (51 to 80); 91/102 patients (89%) felt ‘better’ and would ‘undergo surgery again'. Patients with chronic pain syndrome or hypermobility had lower OHS than patients without comorbidities (-6 points, p < 0.006). Overall, 84 patients had a CT and 34 patients an MRI. Patients with subchondral cysts (OHS 42 (37 to 45) vs 35 (26 to 36); p = 0.014) or joint space narrowing on CT (OHS 42 (IQR 37 to 44) vs 35 (26 to 36); p = 0.022) had higher function. Conclusion. Despite high satisfaction levels, patients undergoing THA with minimal or no radiological OA had lower postoperative function than typical THA patients. We recommend obtaining low-dose CT imaging and a diagnostic hip injection to aid decision-making. Cite this article: Bone Jt Open 2025;6(3):328–335

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). Methods. This retrospective comparative study included 81 patients with ONFH; 37 patients (40 hips) underwent CVO with BIG (BIG group) and 44 patients (47 hips) underwent CVO alone (CVO group). Patients in the BIG group were followed-up for a mean of 12.2 years (10.0 to 16.5). Patients in the CVO group were followed-up for a mean of 14.5 years (10.0 to 21.0). Assessment parameters included the Harris Hip Score (HHS), Oxford Hip Score (OHS), Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ), complication rates, and survival rates, with conversion to total hip arthroplasty (THA) and radiological failure as the endpoints. Results. There were no significant differences in preoperative and postoperative HHS or postoperative OHS and JHEQ between the BIG group and the CVO group. Complication rates were comparable between groups. Ten-year survival rates with conversion to THA and radiological failure as the endpoints were not significantly different between groups. Successful CVO (postoperative coverage ratio of more than one-third) exhibited better ten-year survival rates with radiological failure as the endpoint in the BIG group (91.4%) than in the CVO group (77.7%), but this difference was not significant (p = 0.079). Conclusion. Long-term outcomes of CVO with BIG were favourable when proper patient selection and accurate surgery are performed. However, this study did not show improvements in treatment results with the concomitant use of BIG. Cite this article: Bone Joint J 2021;103-B(4):665–671

Aims. 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. Methods. 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). Results. Survivorship free from femoral head collapse and THA for any reason was 84% and 67% at seven years postoperatively, respectively. Risk factors for conversion to THA included a high preoperative modified Kerboul angle (grade 3 or 4) based on preoperative MRI (hazard ratio (HR) 3.96; p = 0.047) and corticosteroid use at the time of decompression (HR 4.15; p = 0.039). The seven-year survivorship for patients with grade 1 or 2 Kerboul angles for conversion to THA for articular collapse, and THA for any reason, were 96% and 72%, respectively, versus THA for articular collapse and THA for any reason in patients with grade 3 or 4 Kerboul angles of 40% (p = 0.003) and 40% (p = 0.032). Conclusion. At seven years, hip decompression augmented with BMAC and PRP provided a 67% survivorship free from THA in patients with corticosteroid-induced ON. Ideal candidates for this procedure are patients with low preoperative Kerboul angles and can stop corticosteroid treatment prior to decompression. Cite this article: Bone Jt Open 2021;2(11):926–931

Objectives. Legg–Calvé–Perthes’ disease (LCP) is an idiopathic osteonecrosis of the femoral head that is most common in children between four and eight years old. The factors that lead to the onset of LCP are still unclear; however, it is believed that interruption of the blood supply to the developing epiphysis is an important factor in the development of the condition. Methods. Finite element analysis modelling of the blood supply to the juvenile epiphysis was investigated to understand under which circumstances the blood vessels supplying the femoral epiphysis could become obstructed. The identification of these conditions is likely to be important in understanding the biomechanics of LCP. Results. The results support the hypothesis that vascular obstruction to the epiphysis may arise when there is delayed ossification and when articular cartilage has reduced stiffness under compression. Conclusion. The findings support the theory of vascular occlusion as being important in the pathophysiology of Perthes disease. Cite this article: M. Pinheiro, C. A. Dobson, D. Perry, M. J. Fagan. New insights into the biomechanics of Legg-Calvé-Perthes’ disease: The Role of Epiphyseal Skeletal Immaturity in Vascular Obstruction. Bone Joint Res 2018;7:148–156. DOI: 10.1302/2046-3758.72.BJR-2017-0191.R1

We performed 114 consecutive primary total hip arthroplasties with a cementless expansion acetabular component in 101 patients for advanced osteonecrosis of the femoral head. The mean age of the patients at surgery was 51 years (36 to 62) and the mean length of follow-up was 110 months (84 to 129). The mean pre-operative Harris hip score of 47 points improved to 93 points at final follow-up. The polyethylene liner was exchanged in two hips during this period and one broken acetabular component was revised. The mean linear wear rate of polyethylene was 0.07 mm/year and peri-acetabular osteolysis was seen in two hips (1.9%). Kaplan-Meier analysis indicated that the survival of the acetabular component without revision was 97.8% (95% confidence interval 0.956 to 1.000) at ten years. Our study has shown that the results of THA with a cementless expansion acetabular component and an alumina-polyethylene bearing surface are good

We have previously described the mid- to long-term results of conventional simple varus intertrochanteric osteotomy for osteonecrosis of the femoral head, showing that 19 of the 26 hips had good or excellent results. We extended the follow-up to a mean of 18.1 years (10.5 to 26) including a total of 34 hips in 28 patients, with a mean age at surgery of 33 years (19 to 53). There were 18 men and ten women and 25 hips (74%) had a satisfactory result with a Harris hip score ≥ 80. In all, six hips needed total hip replacement (THR) or hemiarthroplasty. The collapse of the femoral head or narrowing of the joint space was found to have progressed in nine hips (26%). Leg shortening after osteotomy was a mean of 19 mm (8 to 36). With conversion to THR or hemiarthroplasty as the endpoint, the ten-year survival rate was 88.2% (95% confidence interval (CI) 82.7 to 93.7) and the 20-year survival rate was 79.7% (95% CI 72.1 to 87.3); four hips were converted at ten years and other two hips were converted at 20 years. Shortening of the leg after osteotomy remains a concern; however, the conventional varus half-wedge osteotomy provides favourable long-term results in hips with less than two-thirds of the medial part of the femoral head affected by necrotic bone and with normal bone superolaterally

We studied prospectively the long-term results of the Charnley Elite-Plus femoral stem in 184 consecutive young patients (194 hips). There were 130 men and 54 women with a mean age of 49.1 years (21 to 60). The predominant diagnosis was osteonecrosis of the femoral head (63.6%, 117 patients). Clinical and radiological evaluation was undertaken at each follow-up. The mean follow-up was 11.2 years (10 to 12). The mean pre-operative Harris hip score was 43.4 (12 to 49) which improved to 91 (59 to 100) at the final follow-up. The survival of the femoral stem at 12 years was 99% with revision as the end-point. The mean annual linear wear of the polyethylene liner was 0.17 mm (0.13 to 0.22). The prevalence of acetabular osteolysis was 10.8% (21 hips) and osteolysis of the calcar femorale 12.9% (25 hips). A third-generation cementing technique, accurate alignment of the stem and the use of a 22 mm zirconia head were important factors in the prevention of aseptic loosening of the Elite Plus femoral stem in these high-risk young patients

Aims

This study aimed to investigate whether the use of CT-based navigation enhances: 1) the accuracy of cup placement; and 2) the achievement rate of required range of motion (ROM). Additionally, we investigated the impact of using a large femoral head and dual-mobility liner on the achievement rates.

Aims

It is important to analyze objectively the hammering sound in cup press-fit technique in total hip arthroplasty (THA) in order to better understand the change of the sound during impaction. We hypothesized that a specific characteristic would present in a hammering sound with successful fixation. We designed the study to quantitatively investigate the acoustic characteristics during cementless cup impaction in THA.

Aims

It is important to analyze objectively the hammering sound in cup press-fit technique in total hip arthroplasty (THA) in order to better understand the change of the sound during impaction. We hypothesized that a specific characteristic would present in a hammering sound with successful fixation. We designed the study to quantitatively investigate the acoustic characteristics during cementless cup impaction in THA.

Aims

To evaluate the concurrent use of vancomycin and ε-aminocaproic acid (EACA) in primary total hip arthroplasty (THA).

Aims

The aim of this study was to evaluate the suitability of the tapered cone stem in total hip arthroplasty (THA) in patients with excessive femoral anteversion and after femoral osteotomy.

Aims

Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications.

Aims

Total hip arthroplasty (THA) is considered the preferred treatment for displaced proximal femoral neck fractures. However, in many countries this option is economically unviable. To improve outcomes in financially disadvantaged populations, we studied the technique of concomitant valgus hip osteotomy and operative fixation (VOOF). This prospective serial study compares two treatment groups: VOOF versus operative fixation alone with cannulated compression screws (CCSs).

Aims

This study aimed to develop and validate a fully automated system that quantifies proximal femoral bone mineral density (BMD) from CT images.

Aims

In this study, we aimed to visualize the spatial distribution characteristics of femoral head necrosis using a novel measurement method.

We present the long-term results of simple varus intertrochanteric osteotomy for osteonecrosis of the femoral head. We followed 26 hips in 20 patients, with a mean age at the time of surgery of 36 years, for a mean of 12.5 years. The mean varus angulation was 23°. The outcome in 19 of the hips (73%) was good or excellent; seven (27%) had a fair or poor result, with four needing some form of prosthetic arthroplasty. Simple varus intertrochanteric osteotomy is indicated, even if the extent of the capital infarct comprises more than 50% of the diameter of maximum radial distance from the circumference, provided that after operation the medial necrotic lesion measures less than two-thirds of the weight-bearing area, and the superolateral bone is normal

Six major and seven minor diagnostic criteria have been developed by the Japanese Investigation Committee for osteonecrosis of the femoral head (ONFH). We have carried out a multicentre study to clarify these. We studied prospectively 277 hips in 222 patients, from six hospitals, who had ONFH and other hip pathology and from whom histological material was available. We identified five criteria with high specificity: 1) collapse of the femoral head without narrowing of the joint space or acetabular abnormality on radiographs, including the crescent sign; 2) demarcating sclerosis in the femoral head without narrowing or acetabular abnormality; 3) a ‘cold-in-hot’ appearance on the bone scan; 4) a low-intensity band on T1-weighted images (band pattern); and 5) evidence of trabecular and marrow necrosis on histological examination. With any combination of two of these criteria, the sensitivity and specificity of the diagnosis were 91% and 99%, respectively

The treatment of osteonecrosis of the femoral head (FHN) is controversial. It mainly occurs in young patients in whom total hip replacement is best avoided because of an increased risk of revision. The objective of this long-term follow-up study was to evaluate the outcome of intertrochanteric flexion osteotomy as a hip joint preserving operation for FHN. Over a 19-year period we carried out 70 intertrochanteric flexion osteotomies for FHN in 64 patients. The mean follow-up was 10.4 years (3.0 to 20.3). The overall mean Harris hip score increased from 51 points preoperatively to 71 points postoperatively. Six patients (9%) developed early postoperative complications. A total of 19 hips (27%) underwent total hip arthroplasty at a mean of 8.7 years after osteotomy. The five-year survival rate was 90%. Survival rates of hips in Ficat stage 2 were higher than those in stages 3 or 4. Hips with a preoperative necrotic angle of < 200° had a better survival probability than those with a necrotic angle > 200°. Our findings suggest that flexion osteotomy is a safe and effective procedure in Ficat stage 2 and 3 FHN, preferably with a necrotic angle of < 200°

Aims

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).

Aims

This study aimed to use intraoperative free electromyography to examine how the placement of a retractor at different positions along the anterior acetabular wall may affect the femoral nerve during total hip arthroplasty (THA) when undertaken using the direct anterior approach (THA-DAA).

Aims

The aim of this study was to evaluate the performance of first-generation annealed highly cross-linked polyethylene (HXLPE) in cementless total hip arthroplasty (THA).

Aims

Pelvic incidence (PI) is considered an important anatomical parameter for determining the sagittal balance of the spine. The contribution of an abnormal PI to hip osteoarthritis (OA) remains controversial. In this study, we aimed to investigate the relationship between PI and hip OA, and the difference in PI between hip OA without anatomical abnormalities (primary OA) and hip OA with developmental dysplasia of the hip (DDH-OA).

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)

Aims

Bone stock restoration of acetabular bone defects using impaction bone grafting (IBG) in total hip arthroplasty may facilitate future re-revision in the event of failure of the reconstruction. We hypothesized that the acetabular bone defect during re-revision surgery after IBG was smaller than during the previous revision surgery. The clinical and radiological results of re-revisions with repeated use of IBG were also analyzed.

Aims

The purpose of this study was to examine the efficacy and safety of carbazochrome sodium sulfonate (CSS) combined with tranexamic acid (TXA) on blood loss and inflammatory responses after primary total hip arthroplasty (THA), and to investigate the influence of different administration methods of CSS on perioperative blood loss during THA.

Aims

Appropriate acetabular component placement has been proposed for prevention of postoperative dislocation in total hip arthroplasty (THA). Manual placements often cause outliers in spite of attempts to insert the component within the intended safe zone; therefore, some surgeons routinely evaluate intraoperative pelvic radiographs to exclude excessive acetabular component malposition. However, their evaluation is often ambiguous in case of the tilted or rotated pelvic position. The purpose of this study was to develop the computational analysis to digitalize the acetabular component orientation regardless of the pelvic tilt or rotation.

Aims

Although periarticular injection plays an important role in multimodal pain management following total hip arthroplasty (THA), there is no consensus on the optimal composition of the injection. In particular, it is not clear whether the addition of a corticosteroid improves the pain relief achieved nor whether it is associated with more complications than are observed without corticosteroid. The aim of this study was to quantify the safety and effectiveness of cortocosteroid use in periarticular injection during THA.

Aims

We previously reported the long-term results of the cementless Duraloc-Profile total hip arthroplasty (THA) system in a 12- to 15-year follow-up study. In this paper, we provide an update on the clinical and radiological results of a previously reported cohort of patients at 23 to 26 years´ follow-up.