SILVER JUBILEE COMMEMORATION LECTURE
|Year : 2006 | Volume
| Issue : 3 | Page : 138-146
|Osteonecrosis : Early diagnosis, various treatment options and outcome in young adults
Sushrut Hospital Research centre & Post-Graduate Institute of Orthopedics, Nagpur, India
Click here for correspondence address and email
|How to cite this article:|
Babhulkar S. Osteonecrosis : Early diagnosis, various treatment options and outcome in young adults. Indian J Orthop 2006;40:138-46
| Introduction|| |
Both the Diagnosis and appropriate treatment of osteonecrosis of femoral head poses difficulty in the minds of all orthopaedic surgeons. The dilemma is always about instituting the exact treatment so as to avoid further progression collapse and thus early requirement for total hip replacement. Osteonecrosis has a natural history of relentless progress once the disease has advanced but some efforts may certainly be taken to delay the so called speed of progression of collapse
Since osteonecrosis is now increasingly seen in young adults in their 20's, 30's, and 40's with considerable morbidity arthroplasty is best deferred as much as possible  . Non surgical treatment modalities for the preservation of necrotic femoral head have been very time consuming and uniformly unsuccessful.
Early diagnosis seems to be the key to potentially reverse the lesion. All authors agree the earlier instituted treatment is successful in maintaining the femoral head integrity and possibly salvage the femoral head for a longer duration of time.
Etiology & pathogenesis: Various theories of pathogenesis in avascular necrosis of femoral head are given to explain the circulatory disturbance caused by various etiological factors as a cause of osteonecrosis ,,,,, .
i) 'Acute infarction theory' postulates that there is a disruption in the blood supply to the femoral head either from major trauma or from embolic disease.
ii) Second theory contends that ischemic necrosis of the femoral head represents a 'Compartment syndrome' of the proximal femur.
iii 'Accumulative cell stress theory', as developed by Kenzora and Glimcher 8 , proposes that the cause of ischemic necrosis of femoral head is multifactorial. Various factors including anatomic location, systemic illness and insults put more and more stress upon the marrow and osteogenic cells until bony necrosis finally occurs  .
Radiological changes: According to the Meyers there are three factors which causes radiodensity of the bone , .
1)Increased vascularity in response to attempt to revascularise the necrotic area causes demineralisation of viable bone surrounding necrotic area giving relative sclerosis.
2) Increase in mass of new bone which is laid down around the necrotic trabeculii.
3) Impact of bone where the trabeculii gets compacted and increases the area of mineralised tissue.
Classification: ARCO'S international classification (Association Research Circulation Osseous) was accepted by the "General Assembly of ARCO in Basel, Switzerland in December 1991 as a proposal for an international classification  . This is as follows
STAGE 0: All present diagnostic techniques are normal or nondiagnostic except histology.
Stage I: Plain X ray and CT scan are normal. At least one of the following techniques is positive. Scintigraphy and MRI, open biopsy is confirmatory. The classic MRI changes are pathognomic according to the extension of the area of femoral head involvement. A < 15% B< 15 30%; C > 30%
Stage II: Radiography shows mottled area, Sclerosis cysts and process. No Signs of collapse and femoral head is intact. Scintigraphy and MRI are positive sub classification in A, B and C is important, as described in stage-I
Stage III: Crescent sign, no flattening, sub classification must be included.
Stage IV: Articular surface flattened, joint line narrowing, acetabular involvement
Sub classification recommended
A = <15% Involvement or depression < 2mm
B = 15 30% Involvement or depression 2 4 mm
C > 30% involvement or depression > 4 mm
Stage V: Articular surface flattened, joint surface narrowing, signs of beginning osteonecrosis sub classification has to be done.
Stage VI: Radiographic examination shows advanced degenerative changes and finally as complete joint destruction.
Treatment: Treatment options  those have been widely used and popularised for treatment starting from managing conservatively are:
- Core decompression ,,
- Core decompression with phemister type bone grafting 
- Use of vascularized graft ( free fibula or iliac crest vascular pedicle graft )
- Muscle pedicle grafting ,,,
- Transtrochanteric rotational osteotomy ,,
- Intertrochanteric osteotomies 
- Hip arthrodesis
- Girdlestone resection
- Total hip replacement
- Hip resurfacing arthroplasty
| Material and methods|| |
The study of was carried out at Indira Gandhi Medical College and Mayo General Hospital, Nagpur and Sushrut Hospital, Research Centre & Post-graduate Institute of Orthopaedics, Nagpur during the period from January 1995 to December 2003. Three hundred and fourty Five patients of avascular necrosis of the femoral head were selected for the study. The patients excluded Stage IV patients who definitely required only joint arthroplasty.
In all these 345 cases, detail history was obtained and complete clinical examination was carried out. These patients were then subjected to investigations. All patients selected for this study underwent following investigations or tests Hb %, ESR, RA factor, Sickling test, A.D. test, Hb electrophoresis, Serum uric acid, Serum lipids, LFT and Bone biopsy.
Clinical examination, radiographic study and functional bone marrow investigations like BMP measurement and bone biopsy were carried out to aid the diagnosis of condition.
Various Operative procedures employed were:
i) Core decompression
ii) Core decompression with bone grafting.
- Phemister type fibular bone grafting
- Cancellous iliac bone grafting.
- Meyer's quadratus femoris muscle pedicle grafting
- Sartorius muscle pedicle grafting.
- Tensor fascia lata pedicle grafting.
- Vascularised muscle pedicle bone grafting.
iii) Osteotomies: flexion osteotomy, varus osteotomy, Sugioka's ventral rotation osteotomy.
In 25 patients core decompression procedure was done after measurement of functional bone marrow pressure in the same sitting. These patients were Stage 0 (15) and stage I (10). These were asymptomatic contra lateral hip without any X-ray changes, but MRI positive and the diagnosis was confirmed by functional bone marrow investigation and histopathology.
Core decompression with bone grafting
This procedure was carried out in 305 hips with proved diagnosis of avascular necrosis of the femoral head having stage I - III involvement. Out of these 305 hips, 160 hips were treated with Phemister type of fibular bone grafting, 12 with cancellous iliac bone grafting, 16 with Meyers muscle pedicle grafting, 10 with sartorius muscle pedicle grating, 45 hips with tensor fascia lata pedicle bone grafting and 62 hips with vascularised iliac crest bone grafting.
Tensor fascia lata pedicle bone grafting
In supine position under image intensifier control by a straight lateral incision curved anteriorly in its proximal part TFL was exposed. TFL alongwith a piece of iliac crest was harvested. Base of head was approached from superior aspect and a window was created under image intensifier control. This window was utilized for scooping out the necrosed bone out. TFL along with piece of iliac crest was stuffed into the created area thus elevating the collapsed zone and supporting the subchondral area. No additional fixation was usually necessary. If additional chillus (lateral impinging bone on the femoral head side) was present, it was trimmed using a small osteotome and adequate removal was confirmed on table by smooth abduction without any "lift-up" of the hip.
Vascularised iliac crest bone grafting
Cadaveric Studies: This was conducted at Indira Gandhi Medical College and Mayo General Hospital in the Department of Forensic Medicine. Ten Fresh cadavers were obtained with an average height of 5 feet 3 inches, weight of 65 kgs and age range between 30 to 55 years. From 10 cadavers 16 hips were dissected and an attempt towards development of approach and demonstration of deep circumflex iliac artery was made.
Observation: A detailed description of approach was made. Course and finding of various landmarks like location of inferior epigastric artery, its relationship with deep circumflex iliac artery was demonstrable and was consistent in all the cadavers. Consistently a 6 to 10 cm of vascular pedicle was harvested each time and further increase was possible upto 3 cm by mobilizing the iliac muscles and surrounding soft tissue anteriorly.
Surgical Procedure: Two teams worked simultaneously so that by the time the free iliac crest graft was isolated with its intact vasculature, the recipient site was also ready to receive the graft for reconstruction. The skin incision was made along the inguinal ligament towards the iliac crest. It extended from just medial to the femoral pulsation to the uppermost convexity of the iliac crest. Inguinal ligament was exposed and separated from the deep fascia of the groin region. The lateral cutaneous nerve was identified in the gap between the tensor fascia lata and sartorius just lateral to the anterior superior iliac spine and needs to be protected. Femoral artery was identified and was traced upwards where it became external iliac artery. The origin of inferior epigastric artery was then identified and traced. This is a branch constantly found and it always helps the surgeon to identify the deep circumflex iliac artery which lies just opposite it on the lateral side of external iliac artery. This further was traced down to its bony entrance in the iliac crest. Isolation of the bone graft with its supplying vessels was continued by subperiosteal separation of the tensor fascia lata and gluteal muscles from the external surface of the iliac crest. Desired size of iliac crest graft was obtained from outer surface. Profound pulsatile bleeding was always seen from the raw surface. The vascular pedicle measures 6-10 cm and further length can be obtained by striping the bone graft off its inner periosteal attachment for a distance upto 2 cm. The bone graft itself measures up to 12-13 cm in length and a varying width of 2-5 cm may be taken. This then was swung around to the hip region. A window was created at the base of neck which also works as a portal to decompress the subchondral area of the head and scooping out portion of already necrosed and dead tissue. In order to make a more direct route and to avoid kinking of the vascular pedicle, the graft was tunneled through the intermuscular plane between the rectus femoris and pectineus muscles, dividing their neighbouring fibres if necessary. The graft was then placed in the window. No need of additional fixation is usually necessary.
III) Osteotomies : Various osteotomies were performed:
Flexion oseotomy - 4 hips
Varus osteotomy - 4 hips and
Transtrochanteric anterior rotational osteotomy (Sugioka's) - 15 hips.
All these patients were followed minimum for 2 years and maximum for period of 8 years. They were called after every three months for clinical and radiological evaluation for one year and then followed up annually.
| Observations|| |
We selected 345 hips (195 patients; 150 patients with bilateral involvement) for head salvaging procedures at our institute. We excluded patients who reported with advanced collapse and had already reached stage IV and who were a clearcut candidates for some kind of joint arthroplasty (which kind of joint arthroplasty suit which kind of bone morphology is part of another study conducted concomitantly). The detailed observation on clinical study, investigation and treatment, with follow-up are discussed in following paragraphs and tables
Age Incidence: Maximum number of patients which were operated were in the age group of 30-40 years. Male to Female ratio was 2.5:1. The age and sex wise distribution of patients and percentage are given in the following [Table - 1].
Family history of avascular necrosis of femoral head was present in none of these cases. No patient gave any history of such complaint in past. None gave any history of radiotherapy and jaundice. History of trauma was present in 30 patients. In our study 42 patients were chronic alcoholic and were consuming 100-300 ml of alcohol daily since last 10 years. History of taking corticosteroid was given by 20 patients. In our study maximum number of patients were having sickle cell disease i.e. 95 patients. In 8 patients no cause was detected.
Out of these selected cases all the patients reported with significant complaint of pain which was disturbing their ADL's and in 180 patients the pain was also disturbing their sleep. Squatting and sitting cross legged was not possible in 182 patients. One hundred eighty two patients could walk less than 5 kms at one stretch and 160 patients could walk less than a kilometer.
There was no side predilection. There were 105 left hips and 90 right hips. Fixed flexion deformity of 5-15 degrees was noted in 178 patients. Thigh muscle wasting was a significant finding, 190 patients were having painful hip joint movements. Abduction and internal rotation were restricted in all these cases, while most of the patients ere having good range of flexion and adduction. All the patients had sectoral deviation test positive even in stage 0. Detailed clinical findings in all the cases are given in [Table - 3].
Investigations like ESR, clotting time, bleeding time, serum uric acid, Rh factor, Liver function test were conducted in all patients sickling test was positive in all the sickler patients. All of them were subjected to detailed skeletal survey, further evaluation and assessment of their electrophoretic pattern.
A histopathological investigation of core biopsy was done in all the patients who showed evidence of necrosis of bone tissue. Roentgenographic study was carried out in all cases, in which anteroposterior and Frog leg lateral views of affected hip joint were taken.
A study of preoperative roentgenographs was based on findings like mottled densities, sclerosis, subchondral cyst formation, crescent sign, extent of the lesion and amount of collapse. Bilateralinvolvement of the hip joint was found very commonly and was present in various stages in 150 patients.
We classified femoral head involvement by a staging system given by Arlet and Ficat  . [Table - 2] shows number of cases and their stage of involvement and percentage of cases in each stage.
All the operated patient were hospitalized for approximately 12 days. Patients were operated after complete medical assessment and preparation for surgery. In follow up the parameters on which patient was examined were pain and function
Scale of Merle d'Aubigne  and Postel as modified by Charnley were used for the clinical evaluation of the patients preoperatively and postoperatively. In this study we obtained overall excellent results in 95(27.53%) patients (hips), Good results in 171 (49.56%), fair results in 65 (18.84%) and poor in 14 patients(4.05%); The produced results were absolutely stage and extent specific and treatment modality specific. Earlier treated stages showed an inclination towards better results.
Radiographic assessment was made with particular reference to progressive collapse or osteoarthritic change in the hip as used by Saito et al  . Results of radiological assessment are showing in [Table - 3]. Radiologically overall good results were obtained in 304 (88.11%) Patients with an attempt of bone towards preservation of integrity and contour of the femoral head and a tendency towards reformation.
The average duration of non weight bearing was 3 months after care decompression and bone grafting, and 9 weeks after core decompression alone and 6 weeks after osteotomy. Patients were ambulated as soon as possible with three point crutch gait. Partial weight bearing with crutches was allowed after twelve weeks of osteotomy.
In our study, we noted a few postoperative complications which were basically related to various surgical procedures and not to the disease process per se:
1) Superficial skin infection - was noted in 12 patients, which was treated with daily dressing and proper antibiotics.
2) Iatrogenic fracture - This was seen in two patients. One Patient developed subtrochanteric fracture 17 days after the core decompression with associated history of fall and the fracture was treated with open reduction and internal fixation by DHS. Second patient had transcervical fracture 53 days after the core decompression, when he started gradual weight bearing, which was treated with three cancellous screws. Both the patient had full recovery in follow up.
| Discussion|| |
Three hundred and forty five patients were selected for the study of head salvaging procedures in osteonecrosis of the femoral head. In our study, it was observed that the incidence of avascular necrosis of femoral head is more in 3rd decade. According to Merle D'Aubigne  , men are exclusively affected between the age of 18-70 years, with highest incidence between 30 and 50 years. A peak incidence between 40-60 years (52%) by Arlet and Ficat  was given in the analysis of their personal series. The sex wise distribution in our series was in favor of males (61.5 %) and was similar to one given by Arlet and Ficat  with a male predominance having a 2:1 male is to female ratio.
The commonest variety of avascular necrosis was found to be in association with sickle cell disease 95 patients (48.71%) and alcohol induced 42 patients (21.53 %). Where as steroid induced was in only 20 cases (10.25 %), Trauma 30 patietns (15.38%) and no definitive cause could be determined in 8 cases (4.10%). In the study of Arlet and Ficat  majority of avascular necrosis cases was attributed to minor trauma (25.1%) while patients also had hyper uricaemia (16%), hyperlipemia (15.5%) and hyper triglyceridemia (18.4%).
A considerable amount of thoughts and literature has been devoted in the past to the problem of treatment of avascular necrosis of the femoral head. Many joint preserving operations have been devised for the treatment of idiopathic avascular necrosis of the femoral head ,,,,,, . Each of these authors has recorded satisfactory results for their own procedure in their own hands. However, such satisfactory results have not been generally reproducible.
Early diagnosis prior to the appearance of radiological changes is essential in the treatment of ischemic necrosis for good results. X-ray examination is of limited value in early diagnosis but has importance in staging since it helps in planning the treatment and the prognosis. The X-ray becomes positive late in the condition after the process of repair has started. Elevated bone marrow pressure is a useful investigation where the X-ray is of little or no value ,, .However, MRI is going to substitute all investigations for early pre-radiological diagnosis and FBI will be an obsolete investigation for diagnosis in future.
Out of these 345 patients we performed core decompression in 25 patients, core decompression with bone grafting in 297 patients and various osteotomies in 22 patients. We have selected 15 silent hips for core decompression. They had one hip frankly involved and the other though had no symptoms had MRI positive. They were convinced to undergo surgery to salvage the hip and hat further progression of disease process.
All the Patients were evaluated for progression to collapse more than 3mm which is considered significant at the end of 18 months. Radiologically we saw progression of the disease to collapse in 9 hips (36%) after core decompression as against in 92 hips (30.97%) after core decompression been supplemented by some kind of Bone Grafting. This difference was statistically significant. Various osteotomies also showed collapse in 33- 50% cases. Remarkably TFL muscle pedicle bone grafting procedure and vascularised iliac crest bone grafting showed collapse in 28.88% and only 16.12% cases respectively. In both these groups a dramatic radiological attempt towards revascularization and remolding was observed.
All these patients with good results have shown arrest of progression of ischemic necrosis, early vascularization and complete symptomatic relief. Ficat showed good clinical results in 93.9% of stage I hips and in 82.3% of stage 11 hips and good radiographic results in 86.6% of stage I and 66.7% of stage II  .
Our findings suggest that more biologically done procedure like TFL grafting and vascularised iliac crest grafting add on to the only mechanical effect created by Bone Graft. Vascularised iliac crest seems to be also triggering the process of attempt towards revascularization rapidly thus yielding in rebuilding the bone in subchondral zone and encouraging rapid remolding.
In our study, whenever the crescent sign had appeared without any collapse it was taken as the indication for vascular muscle pedicle grafting in addition to core decompression as it requires quick revascularization. On 16 occasions Meyers quadratus femoris muscle pedicle grafting procedure was performed showed 62.5% good and 37.5% poor results clinically and radiologically. On 10 occasions sartorius muscle pedicle grafting in addition to forage was done and 60 % good results were obtained. Meyer's in 1985 reported 100% good results with quadratus femoris muscle pedicle graft for the treatment of avascular necrosis of the femoral head in stage I and II but stage III and IV were not satisfied. Once major sectoral collapse of ischemic segment with deformed head occurs all the procedures of core decompression and bone grafting are not expected to do any more good and at this stage osteotomy amongst head preserving operations plays important role ,, . Sugioka's transtrachanteric ventral rotational osteotomy showed 60% good results in which there was subjective relief of complaints and X ray did not show any further progression of necrosis while (40%) had fair results in which there was definite reduction in intensity of pain but had residual limitations of movements and required a stick in the hand.
Sugioka reported 78% excellent surgical results with long follow up of 3 to I0 years  . Masuda et al  showed satisfactory results in 69% with this osteotomy. Sugioka stated that this osteotomy with anterior torsion of the neck of the femur upon it's longitudinal axis is deviced to reduce the weight bearing forces on the necrotic area and transfer shear forces to the healthy posterior cartilage of the femoral head.
We obtained clinically overall very good results in 95 hips (53.33%), good in 135 hips (39.13 %); medium in 36 cases (10.43%) ; fair in 65 cases (18.84%) and poor in 14 cases(4.05%) of patients.
In an untreated series of cases of idiopathic avascular necrosis of the femoral head  84% progressed to collapse. In the study by Saito, the incidence of collapse was reduced to 40% after joint preserving operation  .
The two iatrogenic fractures, one in the trochanteric region and other through the neck of femur are observed by us after core decompression procedure. These fractures can be attributed to early undesirable weight bearing. It also indicates that the diameter of the reamer is large enough to weaken the neck and trochanter and that strict non weight bearing should be followed for at least 6 8 weeks after operation. Complication of fracture through the tract of core decompression is not unknown. Camp and Colwell  reported 5% to 10% incidence of fracture of the proximal femur related to the core procedure.
In patients with Stage IV disease promising early results have been obtained from hip resurfacing surgery. Instead of total hip replacement we chose to do hip resurfacing in certain situations because of following reasons:
- Metal on metal combination as against metal on plastic that has been conventionally used in total hip replacements.
- Because of larger size femoral head that is used in
Resurfacing chances of dislocation are meager.
- Less bone is removed as part of surgery.
- No intra-medullary penetration of the Implant hence if at all subsequent revision surgery is required most of the bone of the proximal femur may be still used.
- Better LLD correction can be achieved.
- Near normal sense of proprioception and much quicker recovery is experienced by the patients following resurfacing surgery.
There are some technical aspects such as combating huge size cysts occupying crucial area in femoral had, filling up of collapsed defects by employing BMP's and Bone grafting etc. Early short term results following hip resurfacing look promising in hips especially in active younger population where in we are anticipating a probable revision in their lifetime.
| Conclusion|| |
From this study we could conclude that:
- Early detection of avascular necrosis of femoral head is essential to start early and prompt treatment for prevention of the femoral head from being getting collapsed.
- MRI seems to be the best noninvasive modality of investigation to pick up the impending osteonecrotic changes.
- Core decompression with bone grafting is preferred aid in diagnosis of osteonecrosis of the femoral head in silent hip i.e. Ficat stage 0. It also adds therapeutic advantage to prevent collapse of femoral head.
- Only Core decompression without grafting is of very limited value in treatment.
- Cancellous bone grafting procedure, and other muscle pedicle procedures like meyer's, sartorius when used with core decompression shows progressive collapse of femoral head in most of the cases though an attempt towards revascularization is early and therefore more dynamic procedures like TFL bone grafting and more so vascularised iliac crest bone grafting should be preferred over others.
- All oteotomies show successful results only when performed for localized lesion in segmental necrosis of femoral head and in lesions with minimal collapse of the femoral head. But if in near future total hip arthroplasty is contemplated, it is best avoided.
- Thus, for all pre-collapse hips and also in some select case of early post-collapse vascularised iliac crest bone grafting seems to be the surgery of choice as on today followed by tensor fascia lata bone grafting procedure.
- Hip resurfacing is a better option to be strongly considered as against a conventional total hip replacement in this select group of active enthusiast younger arthritic patients who want to return back to high level of activity and range of motion.
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Division of Joint Reconstruction Surgery, Sushrut Hospital Research Centre & Post-graduate Institute of Orthopedics, Nagpur
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]
[Table - 1], [Table - 2], [Table - 3]
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