The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 88, Issue suppl 3

Femoral Head Bone-Preserving Procedures | November 01, 2006

Posterior Rotational Osteotomy for Nontraumatic Osteonecrosis with Extensive Collapsed Lesions in Young Patients

Takashi Atsumi, MD, PhD; Toshihisa Kajiwara, MD, PhD; Yasunari Hiranuma, MD; Satoshi Tamaoki, MD, PhD; Yasuhiro Asakura, MD

View Disclosures and Other Information

In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from the specific disease investigation committee under the auspices of the Japanese Ministry of Health, Labor and Welfare. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2006 Nov 01;88(suppl 3):42-47. doi: 10.2106/JBJS.F.00767

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (0)

text A A A

Abstract

Background: In young patients with nontraumatic femoral head osteonecrosis with extensive and collapsed lesions, joint preservation is a goal if total joint arthroplasty is to be avoided. We evaluated the effectiveness of a posterior rotational osteotomy in this patient population.

Methods: We reviewed thirty-five hips in twenty-eight young patients with nontraumatic femoral head osteonecrosis treated by posterior femoral neck rotational osteotomy. All femoral heads were collapsed, and seven hips showed joint-space narrowing. Lateral radiographs of the femoral head revealed that 15% of the mean posterior portion and 17% of the mean anterior portion of the femoral head consisted of radiographically apparent living bone. The mean age of the patients (ten women and eighteen men) was twenty-eight years. The mean follow-up period was eight years.

Results: Less than six months after surgery, the radiographically apparent area of living bone of the femoral head below the acetabular roof was shown to be 59% on the standard anteroposterior radiograph and 54% on the 45°-flexion radiograph. In thirty-three hips (94%), further collapse of the femoral head was prevented and an adequate amount of living bone was demonstrated on the loaded lateral portion of the femoral head on the final follow-up radiographs. Progressive joint-space narrowing was seen in four hips.

Conclusions: In young patients with osteonecrosis and extensively collapsed lesions of the femoral head, posterior femoral neck rotational osteotomy appears to be effective in delaying the progression of degeneration if an adequate area of living bone can be placed under the loaded lateral portion of the acetabulum.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.

Figures in this Article

Nontraumatic osteonecrosis of the femoral head frequently occurs in young patients. The necrotic focus is predominantly located in the loaded lateral portion of the femoral head. If lesion size is extensive in the weight-bearing area, the femoral head will usually collapse¹. Preservation of the joint is viewed as important in young patients with this disease in order to avoid joint replacement procedures. Joint-preserving procedures are usually suitable for patients who have small-to-medium-size lesions and who are in the early stages of the disease^2-6. For patients who are in an advanced stage of disease with a large collapsed lesion, an attempt to preserve the joint with a vascularized fibular graft⁶ or various osteotomies^4,5 is usually not effective. In these patients with large collapsed necrotic lesions, various types of prosthetic replacements are usually performed^7-11. However, the results of prosthetic replacement for young patients with osteonecrosis often are not optimal^7,8,11. Sugioka et al. have reported on a transtrochanteric anterior femoral rotational osteotomy to treat osteonecrosis of the femoral head and have described excellent results^12,13. According to Sugioka, the absolute indication for this operation is a necrotic focus that includes less than the posterior one-third of the entire femoral head, as seen on lateral radiographs, so that this area can be rotated and placed under the loaded portion of the acetabulum¹². Sugioka has mentioned indications for posterior rotational osteotomies to be used for femoral heads with anterior living bone¹⁴ but has not reported on this procedure in detail¹².

We have previously reported on the use of a modified approach to posterior rotational osteotomy for the treatment of femoral head osteonecrosis with extensive lesions^15,16. One possible advantage of the posterior femoral rotational osteotomy is that the posterior column artery branch from the medial femoral circumflex artery is shifted medially and is not put under tension with posterior rotation. This benefit has been confirmed by angiographic studies^17,18. Thus, a large amount of posterior rotation can be performed even when the patient has an extensive femoral head lesion that is beyond the scope of traditional anterior rotational osteotomy according to the indications suggested by Sugioka. Another advantage of the posterior osteotomy is that the necrotic femoral head lesion is transferred to the posteromedial non-weight-bearing portion of the joint and the areas of living bone of the femoral head are moved to the lateral loaded portion below the acetabular roof with hip flexion. After posterior rotation, articular surface congruency can be expected when the hip is flexed. We reviewed the effectiveness of joint preservation by means of this posterior femoral neck rotational osteotomy for extensively collapsed lesions due to osteonecrosis of the femoral head in young patients.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1: This diagram shows the necrotic lesion extending laterally to the acetabular edge (Type C2) with more than 3 mm of collapse (Stage IIIB).

Materials and Methods

Materials and Methods | Results | Discussion | References

Between January of 1988 and July of 2002, posterior rotational osteotomies were performed on forty-one hips that had been affected by nontraumatic osteonecrosis along with collapse and extensive lesions of the femoral head in young patients (less than fifty years of age) through a modified approach (the so-called high-degree) posterior rotation as developed by Atsumi et al.^15,16. Thirty-five hips in twenty-eight patients with a minimum of three years of follow-up were included in this study (the follow-up ranged from three to seventeen years, with a mean of eight years). When the hip was converted to a prosthetic replacement, the duration of follow-up ended. Six of the original forty-one hips were excluded from the study: three were lost to follow-up (all three patients visited our hospital several times after discharge, but they stopped coming back for unknown reasons); two hips were converted to a prosthetic replacement less than three years after the posterior rotational osteotomy because of early re-collapse; and one patient died due to an underlying disease.

The age of the twenty-eight patients at the time of surgery ranged from fifteen to forty-nine years (mean, twenty-eight years). Ten of the patients were women and eighteen were men. Sixteen patients had a history of corticosteroid usage. Underlying diseases included systemic lupus erythematosus in three patients, nephrosis in two, bronchial asthma in two, aplastic anemia in two, and multiple sclerosis, acute leukemia, pemphigus vulgaris, ulcerative colitis, renal transplantation, hepatitis, and brain injury in one patient each. Among the remaining twelve patients, alcohol abuse was apparent in nine and three had no apparent risk factors.

All thirty-five hips had large femoral head lesions extending from medial to lateral and from anterior to posterior. Preoperative anteroposterior radiographs revealed only dead bone in the lateral loaded portion of the femoral head facing the lateral acetabular roof (Type C2 according to the criteria of the Japanese Investigation Committee for osteonecrosis¹⁹; Fig. 1) in all thirty-five hips. All hips had >3 mm of collapse. Twenty-eight of the thirty-five hips showed no apparent joint-space narrowing (Ficat Stage III or IIIB according to the criteria of the Japanese Investigation Committee)¹⁹. The remaining seven hips had apparent joint-space narrowing. On lateral radiographs (Fig. 2)¹², the area of radiographically apparent living bone in the femoral head before surgery ranged from 6% to 29% (mean, 15%) in the posterior portion and 6% to 34% (mean, 17%) in the anterior portion. Because of the minimal amount of viable bone posteriorly, none of the hips were candidates for a traditional anterior rotational osteotomy¹³, which has traditionally required a minimum of 30% viable bone.

Bilateral osteonecrosis was seen on the radiographs or magnetic resonance images of twenty-five patients. Of these patients, eleven underwent bilateral posterior rotational osteotomy. Different procedures (or no surgical treatment at all for small, minimally symptomatic lesions) were elected for the contralateral hips in the other fourteen patients. These hips were not included in this study.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2: Diagram showing the method of measuring the extent of viable area on the anterior or posterior part of the femoral head on the lateral radiograph. The percent of viable area is calculated by dividing angle B by angle A.

View Large | Download Slide(.ppt)
Add to My JBJS

Figs. 3-A, 3-B, and 3-C: Figs. 3-A, 3-B, and 3-C A fifteen-year-old girl with osteonecrosis of the femoral head due to high-dose corticosteroid usage for the treatment of nephrosis. Fig. 3-A Preoperative anteroposterior radiograph of the right hip shows a large collapsed lesion. Fig. 3-B A 130° posterior rotational osteotomy with 25° varus position was performed. The anteroposterior radiograph made immediately after surgery revealed an adequate amount (51%) of apparently viable joint surface of the femoral head below the acetabular roof. Note that the necrotic lesion has been moved medially. The intertrochanteric osteotomy was fixed with the device developed by Atsumi et al. Four years and eight months after the operation, an anteroposterior radiograph shows that there has been no further collapse and that the joint space has been maintained.

All collapsed femoral heads were rotated in the posterior direction. The amount of rotation ranged from 70° to 160° posteriorly (mean, 131°). In addition, hips with large necrotic lesions necessitated varus positioning of the femoral head to obtain an extensive noncollapsed viable articular surface in the lateral loaded portion of the femoral head postoperatively. In all thirty-five hips, 10° to 30° (mean, 18°) of intentional varus positioning was created in addition to the rotation.

The rotational angle and intentional varus angle deemed necessary for this procedure were determined by preoperative assessment, mainly on the basis of the radiographic findings. To identify the location and extent of the necrotic femoral head lesion, lateral radiographs were taken of all hips according to the method described by Sugioka¹⁴. Radiographs of the hips were made with the patient in a supine position and with the hip in 90° of flexion, 45° of abduction, and neutral rotation. In addition, anteroposterior radiographs were made with the hip in a flexed position. The affected hip was abducted to 45° and placed in varying degrees of flexion. The location of the necrotic lesion was carefully confirmed on the radiographs made in the various flexion positions. With the aid of line drawings made from these radiographs, the varus angle and the amount of posterior rotation that would be necessary for the procedure was decided.

For the osteotomy procedure, patients were placed in the lateral position. A modified subvastus (Southern) approach¹⁵ was used in thirty-four operations, and a modified Ollier approach as reported by Sugioka¹² was used in one operation. The skin incision was performed from distal to the anterior superior iliac spine and extended distally and posteriorly, passing through the distal portion of the greater trochanter. To determine the correct osteotomy plane, two Kirschner wires were inserted with the aid of fluoroscopy into the femoral neck at the transtrochanteric level of the perpendicular axis of the femoral neck. Incision of the iliopsoas muscle near the lesser trochanter and circumferential incision of the capsule were performed to achieve adequate rotation of the femoral head without vascular impairment. For fixation of the osteotomy after femoral head rotation, we used large screws in four hips and a plate in two hips. However, these fixation devices were not strong enough to allow for early motion. Therefore, we developed and used a customized device (Figs. 3-A, 3-B, and 3-C)^15,16 in twenty-nine hips.

For postoperative management, early motion exercises and isometric exercises of the quadriceps muscle were performed immediately after the patients no longer had postoperative pain. The patients remained in bed for two weeks and then used a wheelchair. Partial weight-bearing (with the aid of two crutches) was initiated five to six weeks after the operation. Walking with the aid of one crutch was continued for six months to one year, depending on the extent of the lesion.

The radiographic outcome was assessed by taking angular measurements of the area of lateral loaded noncollapsed femoral head that corresponded to the acetabular roof on postoperative anteroposterior radiographs^13-15. The area was divided into three groups as follows: Group A, less than the medial one-third of the lateral weight-bearing area of the acetabulum involved; Group B, more than one-third but less than two-thirds involvement; and Group C, more than two-thirds involvement (Fig. 4). To evaluate the anterior portion of the femoral head, anteroposterior radiographs were also taken in 45° of hip flexion^15,16, and the area of the anterior femoral head without collapse was similarly measured. Prevention and progression of further collapse and progressive joint-space narrowing were assessed on the basis of the follow-up radiographs and then correlated with the preoperative and postoperative extent of collapse of the articular surface of the femoral head.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 4: The area of lateral, loaded noncollapsed femoral head that corresponds to the acetabular roof on the postoperative conventional anteroposterior, 45°-flexion radiograph. The area was divided into three groups: Group A, less than the medial one-third of the lateral weight-bearing area of the acetabulum involved; Group B, more than one-third but less than two-thirds involved; and Group C, more than two-thirds involved. A-P = anteroposterior.

The necrotic area of the femoral head was rotated medially, as assessed on postoperative anteroposterior radiographs, in all thirty-five hips. In twenty-nine of the thirty-five hips, collapsed areas were observed in the medial portion of the femoral head on anteroposterior radiographs less than six months after surgery. In the remaining six hips, a spherical contour of the necrotic lesion of the medial femoral head was seen immediately after surgery. The contour of the medial collapsed area was assessed on anteroposterior radiographs at the time of the final follow-up.

All hips were clinically assessed for pain, walking ability, and range of motion with use of Merle d'Aubigné hip scores²⁰, with seventeen to eighteen points representing an excellent clinical result; fifteen to sixteen points, a good result; thirteen to fourteen points, a fair result; and twelve points or less, a poor result.

Results

Materials and Methods | Results | Discussion | References

Anterior radiographically appearing living bone of the femoral head was transferred to the lateral, loaded portion below the acetabular roof in all cases. The collapsed necrotic area was moved to the posterior or posteromedial portion of the joint in all hips. On postoperative anteroposterior radiographs that were made less than six months after surgery, the area of lateral noncollapsed living femoral head joint surface facing the acetabular roof ranged from 24% to 100% (mean, 59%) in the thirty-five hips, with eleven hips categorized as being in Group A; twenty, in Group B (Fig. 3-B); and four, in Group C. On the postoperative 45°-flexion anteroposterior radiographs, the area of lateral noncollapsed living bone ranged from 19% to 91% (mean, 54%), with seven hips categorized as being in Group A; twenty-five, in Group B; and three, in Group C.

At the time of final follow-up, it was noted that further collapse had been prevented in thirty-three (94%) of thirty-five hips. None of the thirty-three hips in Groups A and B demonstrated signs of further collapse.

Progressive joint-space narrowing was found in four hips: three were classified as being in Group C and one was classified as being in Group A on the anteroposterior radiographs, and three were classified as being in Group C and one was classified as being in Group B on the 45°-flexion radiographs (Table I).

View Larger

TABLE I Further Collapse and Radiographic Signs of Joint-Space Narrowing Among the Three Subgroups

	Group A	Group B	Group C	Total
Conventional anteroposterior radiograph (n = 35 hips)
Further collapse	0	0	2	2
Joint-space narrowing	1	0	3	4
45°-flexion anteroposterior radiograph (n = 35 hips)
Further collapse	0	0	2	2
Joint-space narrowing	0	1	3	4

Add to My JBJS

TABLE I Further Collapse and Radiographic Signs of Joint-Space Narrowing Among the Three Subgroups

	Group A	Group B	Group C	Total
Conventional anteroposterior radiograph (n = 35 hips)
Further collapse	0	0	2	2
Joint-space narrowing	1	0	3	4
45°-flexion anteroposterior radiograph (n = 35 hips)
Further collapse	0	0	2	2
Joint-space narrowing	0	1	3	4

Restoration of some degree of sphericity of the medial collapsed area of the femoral head was observed in twenty-six of twenty-nine hips on the anteroposterior radiographs at the time of the final follow-up (Fig. 3-C).

Clinically, twenty-two hips were pain-free with usual activities of daily living. Mild and inconstant pain occurred in eight hips, mild walking pain occurred in three hips, and marked pain was present in the other two hips. In thirty-one hips without either further collapse or joint-space narrowing, the Merle d'Aubigné score was excellent in seventeen, good in twelve, and fair in two. All four hips with either further collapse or joint-space narrowing were associated with a poor result. One hip was revised to a total hip arthroplasty fifteen years after surgery, and three hips were awaiting a total hip arthroplasty due to poor results. Reasons for these unsuccessful results included early failure because of an apparently inadequate amount of femoral head under the weight-bearing portion of the acetabulum in three hips, a fracture of the apparently viable femoral head bone after high-level activity in two hips, and an unsuccessful surgical procedure in one hip.

Discussion

Materials and Methods | Results | Discussion | References

Core decompression² and vascularized fibular graft placement⁶ appear to be effective treatment for hips with Stage-II disease without collapse. Several kinds of femoral osteotomies^4,5 may also be effective in some hips with advanced stages of osteonecrosis. The principal concept of femoral osteotomies in the treatment of femoral head osteonecrosis is that the necrotic femoral head focus is moved away from the major weight-bearing portion underneath the acetabulum and weight-bearing forces are transmitted to living areas of the femoral head²¹. The main purpose of the anterior femoral rotational osteotomy described by Sugioka is for the remaining posterior noncollapsed living femoral head bone to be transferred to the loaded portion opposite the acetabular roof. Postoperatively, results of that procedure have been linked to the extent of the intact articular surface of the affected lateral portion of the femoral head that can be seen on the anteroposterior radiographs. According to Sugioka et al., a success rate of 93% was achieved with anterior femoral rotational osteotomy if the postoperative living lateral portion of the femoral head articular surface exceeded 36% on anteroposterior radiographs¹³. However, the rate of good results was decreased in Stage-III hips with collapse. In the present study, further collapse was prevented when an adequate amount of living femoral head bone had been placed under the acetabular roof as seen on conventional anteroposterior and 45°-flexion anteroposterior radiographs.

Sugioka et al. originally proposed an anterior rotational osteotomy if the necrotic area of the femoral head was localized anteriorly and if it involved less than two-thirds of the head^13,14. We have found that many young patients have extensive lesions with advanced collapse that would not be candidates for the procedure of Sugioka et al. For these patients, the remaining anterior area of living femoral head bone can be moved to the loaded lateral portion of the joint with use of a posterior rotational osteotomy as described in this report.

In conclusion, posterior rotational osteotomy appears to be effective for the treatment of nontraumatic osteonecrosis of the femoral head in young patients with extensive collapsed lesions. We believe that this operation may delay the progression of degeneration if adequate living bone of the femoral head can be placed under the loaded lateral portion of the acetabulum. It will be important to see if these findings continue with longer-term follow-up. ?

References

Materials and Methods | Results | Discussion | References

Merle d'Aubigné R, Postel M, Mazabraud A, Massias P, Gueguen J, France P. Idiopathic necrosis of the femoral head in adults. J Bone Joint Surg Br. 1965;47: 612-33.47612 1965 [PubMed]

Fairbank AC, Bhatia D, Jinnah RH, Hungerford DS. Long-term results of core decompression for ischaemic necrosis of the femoral head. J Bone Joint Surg Br. 1995;77: 42-9.7742 1995 [PubMed]

Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg Br. 1985;67: 3-9.673 1985

Kerboul M, Thomine J, Postel M, Merle d'Aubigné R. The conservative surgical treatment of idiopathic aseptic necrosis of the femoral head. J Bone Joint Surg Br. 1974;56: 291-6.56291 1974 [PubMed]

Mont MA, Fairbank AC, Krackow KA, Hungerford DS. Corrective osteotomy for osteonecrosis of the femoral head. J Bone Joint Surg Am. 1996;78: 1032-8.781032 1996 [PubMed]

Urbaniak JR, Coogan PG, Gunneson EB, Nunley JA. Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting. A long-term follow-up study of one hundred and three hips. J Bone Joint Surg Am. 1995;77: 681-94.77681 1995 [PubMed]

Chandler HP, Reineck FT, Wixson RL, McCarthy JC. Total hip replacement in patients younger than thirty years old. A five-year follow-up study. J Bone Joint Surg Am. 1981;63: 1426-34.631426 1981 [PubMed]

Cornell CN, Salvati EA, Pellicci PM. Long-term follow-up of total hip replacement in patients with osteonecrosis. Orthop Clin North Am. 1985;16: 757-69.16757 1985 [PubMed]

Garino JP, Steinberg ME. Total hip arthroplasty in patients with avascular necrosis of the femoral head: a 2- to 10-year follow-up. Clin Orthop Relat Res. 1997;334: 108-15.334108 1997 [PubMed]

Adili A, Trousdale RT. Femoral head resurfacing for the treatment of osteonecrosis in the young patient. Clin Orthop Relat Res. 2003;417: 93-101.41793 2003 [PubMed]

Piston RW, Engh CA. Osteonecrosis of the femoral head treated with total hip arthroplasty without cement. J Bone Joint Surg Am. 1994;76: 202-14.76202 1994

Sugioka Y. Transtrochanteric anterior rotational osteotomy of the femoral head in the treatment of osteonecrosis affecting the hip: a new osteotomy operation. Clin Orthop Relat Res. 1978;130: 191-201.130191 1978

Sugioka Y, Hotokebuchi T, Tsutsui H. Transtrochanteric anterior rotational osteotomy for idiopathic and steroid-induced necrosis of the femoral head. Indications and long-term results. Clin Orthop Relat Res. 1992;277: 111-20.277111 1992 [PubMed]

Sugioka Y. Transtrochanteric rotational osteotomy of the femoral head. In: Riley LH Jr, editor. The Hip. Proceedings of the eighth open scientific meeting of the Hip Society. St Louis: CV Mosby; 1980. p 3-23.3 1980

Atsumi T, Muraki M, Yoshihara S, Kjiwara T. Posterior rotational osteotomy for the treatment of femoral head osteonecrosis. Arch Orthop Trauma Surg. 1999;119: 388-93.119388 1999 [PubMed][CrossRef]

Atsumi T, Kuroki Y. Modified Sugioka's osteotomy: more than 130 degrees posterior rotation for osteonecrosis of the femoral head with large lesion. Clin Orthop Relat Res. 1997;334: 98-107.33498 1997 [PubMed]

Atsumi T, Kuroki Y. Role of impairment of blood supply of the femoral head in the pathogenesis of idiopathic osteonecrosis. Clin Orthop Relat Res. 1992;277: 22-30.27722 1992 [PubMed]

Atsumi T, Yamano K. Superselective angiography in osteonecrosis of the femoral head. In: Urbaniak JR, Jones JP, editors. Osteonecrosis: etiology, diagnosis, and treatment. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1997. p 247-52.247 1997

Sugano N, Atsumi T, Ohzono K, Kubo T, Hotokebuchi T, Takaoka K. The 2001 revised criteria for diagnosis, classification, and staging of idiopathic osteonecrosis of the femoral head. J Orthop Sci. 2002;7: 601-5.7601 2002 [PubMed][CrossRef]

Merle d'Aubigné R, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am. 1954;36: 451-75.36451 1954

Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. 1995;77: 459-74.77459 1995 [PubMed]

Topics

head of femur ; hip region ; necrosis ; osteotomy ; osteonecrosis

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

Accreditation Statement

These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Disclosure

Comment Title*

Comment*

Cancel

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Posterior Rotational Osteotomy for Nontraumatic Osteonecrosis with Extensive Collapsed Lesions in Young Patients'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Posterior Rotational Osteotomy for Nontraumatic Osteonecrosis with Extensive Collapsed Lesions in Young Patients'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

Takashi Atsumi, Toshihisa Kajiwara, Yasunari Hiranuma, Satoshi Tamaoki, Yasuhiro Asakura; Posterior Rotational Osteotomy for Nontraumatic Osteonecrosis with Extensive Collapsed Lesions in Young Patients. The Journal of Bone & Joint Surgery. 2006 Nov;88(suppl_3):42-47.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment