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ROTATIONAL AVASCULAR

OSTEOTOMY NECROSIS OF

FOR THE

NON-TRAUMATIC FEMORAL HEAD

NOBUHIKO

SUGANO,

KUNIO MASANOBU

TAKAOKA, SAITO,

KENJI SUSUMU

OHZONO, SAITO

MINORU

MATSUI,

From

Osaka

University

Medical

School

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

success
technique

depends

to a large

extent

on the amount may

and

stage

of necrosis

of the femoral of a satisfactory

careful

and the use of AO

hip plates

increase

the likelihood

avascular

necrosis with

of the

femora!

head

progressive, to osteoarthritis

collapse of the head (Merle dAubign#{233} et

1984; Sugioka, Amstutz and Ohzono and

Katsuki Hed!ey Ono

and Hotokebuchi 1982; Tooke, 1987 ; Masuda et a! 1988 ; Saito, and Lirette 1990). The are of

1988 ; Kinnard

al 1965 ; Ohzono et a! 1991). It is most common in middleaged adults and treatment by cemented total hip arthrop!asty (THA) results in a high rate of loosening in the younger patients (Chandler et a! 1981 ; Cornell, Salvati and Pellicci 1985 ; Saito et a! 1989 ; Sarmiento et a! 1990). Revision satisfactory than 1985 ; Engelbrecht not should always a good of these failures of THA is even less primary replacement (Pellicci Ct al Ct a! 1990). For these reasons, THA is option
;

main reasons for the failure of this operation postoperative fracture of the femoral neck, nonunion the osteotomy, progression to collapse, and osteoarthritic change. We considered that the success rate might improved by more efficient selection of patients better clinical rotational technique. Accordingly, we have reviewed and radiological results osteotomy, using two after methods transtrochanteric of fixation.

be and our

joint-preserving possible. rotational of replacing

operations osteotomy the region, (Sugioka necrotic but the 1978,

be considered whenever The Sugioka transtrochanteric an idea! method in the results

is theoretically segment reported

PATIENTS From performed non-traumatic able to follow 1980 to 1988 ANFH 41 hips at

AND Osaka

METHODS University rotational Hospital osteotomy we for

superior weight-bearing have been inconsistent

transtrochanteric

on 47 hips in 46 patients. in 40 patients for more 6.3). There were age of 36 years hips ANFH

We were than three 28 men and (22 to 58) at was steroidalcohol for ANFH
;

N. Sugano, MD, PhD Orth, Course Student K. Takaoka, MD, PhD, Associate Professor K. Ohzono, MD, PhD, Assistant Professor M. Matsui, MD, Assistant Professor M. Saito, MD, PhD, Assistant Professor DepartmentofOrthopaedic Surgery, Osaka University 1-1-50 Fukushima, Fukushima-ku, Osaka 553, Japan. S. Saito, MD, Department Nakanoshima, Correspondence PhD, ChiefofOrthopaedic of Orthopaedic Surgery, Kita-ku, Osaka 530, Japan. should be sent Surgery Sumitomo

years

(range

3 to 1 1 : mean with an average In 26 of these in

12 women, operation.
Medical School,

induced, consumption proposed Ministry et al 1991). type eight

1 1 it was secondary to excessive and in four it was idiopathic. fulfilled the diagnostic criteria committee et a! 1986

All 41 hips
Hospital, 5-2-2

to Dr N. Sugano. of Bone and Joint Surgery

by the Japanese investigation of Health and Welfare (Ono On their radiographic Ar!et (1980) II and 33
OF BONE

of the Ohzono all were

1992 British 0301-620X/92/5428

Editorial Society $2.00

classification,

J Bone Joint Surg [Br]

1992; 74-B :734-9.

1-C. On the Ficat and hips were in stage


THE JOURNAL

system of staging, in stage III. The


AND JOINT SURGERY

734

ROTATIONAL

OSTEOTOMY

FOR

NON-TRAUMATIC

AVASCULAR

NECROSIS

OF

THE

FEMORAL

HEAD

735

Radiographs Anteroposterior of the head the clinical

a 22-year-old woman with systemic lupus erythematosus and steroid-induced ANFH in the right hip. and lateral views show type 1-C changes at stage II. On the lateral view, 39% ofthe posterior articular surface was involved. Figure 3 - Radiograph six years after a 700 rotational osteotomy fixed with an AO blade-plate. There result was excellent.

of

Figures 1 and was intact and is no collapse,

2 28% and

operation was indicated more of the posterior lateral radiograph, and one-quarter was intact In fixing

for hip pain when one-third articular surface was intact also, in younger patients,

on when

or a

to one-third of the posterior articular in stage II or III cases (Sugioka 1984). used with Sugiokas original two or three large

surface

25 hips we the osteotomy 16 hips, making

procedure, screws.

In

the other approach,

we used a transtrochanteric considerable effort to

surgical preserve the osteotowith an

posterior vessels of the neck. In these mised and rotated proximal fragment AO greater wires some part blade-plate and reattached to trochanter with an (Figs 1 to 3). The usual in three into the hips we The femora! varus angulation.

cases the was fixed the

osteotomised and was was

SN+

SI
Fig.4

AO cancellous screw angle of the hip plates used head 1 10#{176} plates blade of through each plate the

120#{176}, but introduced

to produce inferior

Diagram showing the method of measuring lateral view and recording it as a percentage (SN, necrotic area; SI, intact area).

necrosis on the of the femoral head

of the femoral neck. The femoral head was rotated to displace the necrotic segment anteriorly and to bring the intact portion of the

pain, mobility and gait. We recorded for scores of 17 or 18, a good result result for 13 or 14, and a poor result

an excellent result for 15 or 16, a fair for 12 points or less.

head to the weight-bearing region. The angle of anterior rotation ranged from 60#{176} to 100#{176}. Five hips were placed in varus angu!ation of 15#{176} to 20#{176}. The 60#{176} to 100#{176} of rotation provided sufficient intact surface in all but the one case in which reoperation was performed. Postoperatively, the leg was placed in suspension for three weeks and assisted active were then bearing encouraged. Non-weight-bearing advised for six months, followed on one crutch for another Clinical assessments were balanced exercises

Our radiological assessment made particular note of progression to collapse and osteoarthritic change. We defined radio!ogica! success as an intact femoral neck, union of the osteotomy, no collapse of the newly created weight-bearing region, and no narrowing of the joint space. We measured the necrotic area from the accurate pre-operative lateral views as described by Sugioka et al (1982), calculating the percentage of articular involvement (Sugioka 1978). by a digital planimeter, and the necrotic whole femoral area head The area of necrosis was (X-plan 360i, Ushikata, measured Japan) of the These

on crutches was by partial weightto the

six months. made according

Merle dAubign#{233} hip scoring and Poste! 1954) which allots


VOL. 74-B, No.
5, SEPTEMBER

system (Merle dAubign#{233} up to six points each for

calculated in each

as a percentage case (Fig. 4).

1992

736

N. SUGANO,

K. TAKAOKA,

K. OHZONO,

M. MATSUI,

M. SAITO,

S. SAITO

measurements collapse.

were

related

to the likelihood

of secondary

28 hips collapse

(68%) in two

at two years. hips and

After a joint

this, space

there

was secondary without

narrowing

Statistical analysis of Fishers exact probability Probability values of less significant.

the data was performed by test and Students t-test. than 0.05 were considered

collapse in three others. This left only 23 radiologically successful hips at the latest follow-up. Risk factors for secondary collapse. The incidence secondary fixation collapse (Table II), did being not correlate with in hips the method greatest in stage

of of to

III and

RESULTS The mean pre-operative after surgery the mean good results in 26 hips an average points (Table and I). of 6.3 years, 23 hips score was 1 1 .4 points. Two years score was 14.6, with excellent or (63%). At the final follow-up, at the mean had score excellent had fallen to 13.5 results or good

in those in which the more than 80#{176}. These significant. antly higher of the 0.002). Ofthe articular 35 hips surface

femoral heads had been rotated differences were not statistically was significthan one-third (83%, p

The rate of secondary collapse in the six hips in which less articular surface was or more incidence

posterior

intact

(56%)

with one-third intact, the

ofthe posterior of secondary

Radiographs of a 51-year-old man with alcohol-associated ANFH in the left hip. Figure 5 - Six months after surgery, the osteotomy is united. Figure 6 - One year 1 1 months after surgery the femoral neck fractured. A hemiarthroplasty was then performed.

Table I. Clinical results in 41 transtrochanteric rotational osteotomies of the hip, using the Merle dAubign#{232} scoring system (see text) (number, per cent) Excellent (17-18) 1 1 27 1127 Good (15-16)
15 37

Table II. Relationship and various factors

between

the

incidence

of secondary

collapse

Secondary Follow-up Two years Fair (13-14)


7 17 Poor

collapse
Per cent

(< 12)
8 19 1537

Factor Method of fixation Largescrews AO blade-plate Stage II III Angle of rotation 80


<80

Number

Number

p-value
NS

25
16

6
4

Mean6.3years

1229

24 25 0

8 33 23
18

0 10 7
3

NS

30 30
17 NS

Complications. There were six postoperative fractures the femoral neck without major trauma and one nonunion of the osteotomy within two years (Figs 5 and 6), all the 25 hips fixed by screws. These cases were salvaged bipolar hemiarthroplasty for the neck fractures, and hip-plate fixation for the nonunion. seen in nine and narrowing Secondary collapse was three years of the osteotomy,

of in by by

Intact
<

posterior

articular

surface

35
6 view 14 21 Necrotic area on lateral 45%ofthehead <45%ofthehead
*

5
5

14
83 29 5

0.002

4 1

0.07

hips within of the joint

of difference

space was found in three hips at various surgery. Of these 12 hips, five have successfully by bipolar hemiarthroplasty (four hips) and THR for stage IV (one seven are under Radiology. The consideration radiological

intervals after been treated for stage III hip); the other in

collapse

was

higher

(29%)

in those

with than

necrosis

of 45%

or more than in those with less involved (5%), but this difference (p = 0.07) (Table II). Osteoarthritic space in three

45% of the head was not significant

for this operation. results were satisfactory

changes. There was narrowing of the joint stage III hips after several years of follow-

THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

ROTATIONAL

OSTEOTOMY

FOR

NON-TRAUMATIC

AVASCULAR

NECROSIS

OF

THE

FEMORAL

HEAD

737

up (Table successful out joint and the

III).

Some

hips

which

had

been

radiologically with7 to 10), was

developed severe osteophyte formation space narrowing, or any collapse (Figs incidence higher of such osteophyte III and formation in stage flexion hips (Table abduction

improper selection of patients and inadequate ski!! or methods of fixation. The three major

surgical complicaand and and

significantly hips retained

good

III). These movements, (Table

tions are femora! neck problems including fracture nonunion ofthe osteotomy, progressive degeneration collapse of the newly created weight-bearing region, late osteoarthritic change. Anterior rotation of the femoral neck considerable strain on the underlying trabecular

but showed severe limitation of internal IV) and had moderate disability.

rotation

may place architec-

Fig.

Fig.

Fig.

Fig.

10

Radiographs ofa 40-year-old man with alcohol-associated ANFH in the right hip. Figures 7 and 8 - Pre-operative views show type 1-C and stage III changes. Only 34% ofthe posterior articular surface is intact. Figure 9 - Radiograph one month after a 90#{176} rotation osteotomy showing the newly created weight-bearing region. Figure 10 At 1 1 years after surgery there is no progression to collapse but there is massive osteophyte formation. The hip score was 14 (pain 5, mobility 5, gait 4), with severe limitation of internal rotation.

Sugiokas treatment

osteotomy for some

DISCUSSION was introduced cases of ANFH, but

ture, as an many effective authors

which

is poorly and

adapted

to the

new

load-bearing neck. a long solid of the of the of the

conditions, Unfortunately,

may lead adequate

to fracture remodelling

of the femoral may take need for a more reinforcement plates instead of fracture

reported success rates lower than those of the originator (Sugioka 1978, 1984; Sugioka et a! 1982; Tooke et a! 1987 ; Masuda et a! 1988 ; Saito et a! 1988 ; Kinnard and Lirette
VOL. 74-B,

time, and we were aware of the method of fixation and mechanical neck. screws We therefore last used 16 cases AO hip in our

1990).

Possible

reasons
1992

for this

difference

include

; the problem

No. 5, SEPTEMBER

738

N. SUGANO,

K. TAKAOKA,

K. OHZONO,

M. MATSUI,

M. SAITO,

S. SAITO

femoral reported nonunion,

neck was thereby a very low rate but this rest may

eliminated. of femora! have been

Sugioka (1984) neck fracture and the result of a long

be determined ANFH. investigation incidence arthritis. be an fully rate, curve Al!

by comparison our cases were which committee)

with of

the type

natural 1-C

history (Japanese

of

is known

to have

a high osteocan

period of bed after-treatment. recovery can Kinnard and compression in promoting that the derotational the use positioning

(six to eight weeks) and very careful It appears that this long period of be shortened by the use of hip plates. Lirette (1990) considered the use of these may be useful yet been established

(94%) of It therefore

collapse and progression to seems that Sugiokas osteotomy

hip screws but although bony union, it has not

effective satisfied, although for this

method however, this may operation.

ofjoint preservation. We are not with our 56% clinical success partially result from the learning The skilful performance of the selection fixation of patients, surgery by AO hip plates may in all

thread of a lag screw can withstand the forces on the rotated head. Another merit of of AO when plates this is that they allow for varus is indicated.

technique, early stages, improve

the proper and solid

the results.

Table III. The operative stage

incidence of ANFH
Joint space

of osteoarthritic

change

related

to the

pre-

Table IV. Limitation to osteophyte formation success

of internal in hips

rotation related with radiological

Internal
narrowing Osteophyte formation

rotation Range
-

Osteophyte formation p-value


None or mild

Number
11

Mean*

Stage II III

Number
8

Number
0

Per cent

p-value
0.05

Number
0 13

Per cent

l0.5

30

to l0

0.03

Moderate 33 3
9

or severe

I2

20.0

5 to 60

39
*t5240p<000l

The operation necrotic

risk

factors

for

progressive by

collapse

after

the a

have been identified lesion in the weight-bearing

Sugioka (1984): region after surgery,

Conclusions. be expected osteotomy

Good clinical and radiographic from careful transtrochanteric for ANFH in stages I and II when

results can rotational more than Hips best

involvement of more than two-thirds of the articular area on the pre-operative lateral radiograph, hips in Sugioka stages III and IV, and steroid-induced ANFH. Our use of plates did not prevent secondary collapse in nine of 16 cases. The presence ofan extensive necrotic lesion in the weight-bearing region after surgery may result from inadequate rotation or varus angu!ation. We have not been able to explain secondary collapse of the newly created weight-bearing region. The mciour

one-third of the posterior articular surface which show more extensive necrosis are treated by prosthetic replacement.
The authors wish to thank editing the manuscript. No benefits from a commercial this article. in any party Professor K. Ono for help

is intact. probably

in reviewing

and

form have been related directly

received or will be received or indirectly to the subject of

dence more, third cause

was

higher

in hips

with

a necrotic

area

of 45%

or oneThe
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OF BONE

AND

JOINT

SURGERY

ROTATIONAL

OSTEOTOMY

FOR

NON-TRAUMATIC

AVASCULAR

NECROSIS

OF

THE

FEMORAL

HEAD

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1992