Abstract
Background: Osteonecrosis of the distal portion of the femur
produces a segment of dead bone in the weight-bearing portion of the femoral
condyle, frequently associated with subchondral fracture and collapse and
eventually resulting in secondary osteoarthritis. Treatment of these late
stages of osteonecrosis in the knee can be problematic. The purpose of the
present study was to evaluate a new surgical technique in which the
subchondral osteonecrotic lesion is removed. The bone defect is then
reconstructed with impacted bone grafts to prevent collapse and/or to regain
distal femoral sphericity.
Methods: In this prospective, one-surgeon study, nine consecutive
knees in six patients were studied, all of which had extensive
corticosteroid-associated osteonecrotic lesions of the femoral condyles. Six
knees had collapsed lesions when they were initially treated. The mean age of
the patients was thirty-one years. Both the clinical and radiographic outcomes
were assessed at a minimal follow-up time of two years.
Results: At a mean follow-up time of fifty-one months, none of the
reconstructed knees had been converted to a total knee prosthesis. The
objective Knee Society score improved from a mean of 63 to 89 points. The
functional Knee Society score improved from a mean of 19 to 81 points. During
the follow-up period, there was no progression of collapse observed; however,
three knees showed early signs of osteoarthritis. Clinical success was
achieved in six of eight knees, and radiographic success was achieved in seven
of nine knees.
Conclusions: At the time of writing (at the time of midterm
follow-up), this method appears attractive as a joint-preserving procedure. It
is a relatively simple procedure that is not likely to interfere with future
knee procedures. It appears that this technique can be effective in knees with
collapse of the femoral condyle, and it may delay the need for a total knee
arthroplasty.
Level of Evidence: Therapeutic Level IV. See Instructions
to Authors on
jbjs.org for a
complete description of levels of evidence.
Osteonecrosis of the distal aspect of the femur produces a segment of dead
bone in the weight-bearing portion of the femoral condyle. It frequently is
associated with femoral subchondral fracture and
collapse1,2,
and it eventually results in secondary osteoarthritis. After the femoral head,
the femoral condyles are the second most commonly affected anatomic location
for
osteonecrosis3.
Secondary osteonecrosis of the knee is observed in younger patients, is
usually bilateral, and has multiple condylar involvement. Often, these
patients have osteonecrosis of other large joints. The onset of the disease is
more gradual and the necrotic area is larger and more diffuse than the
segmental necrosis observed in idiopathic osteonecrosis of the medial femoral
condyle4,5.
Approximately 90% of all occurrences of secondary osteonecrosis of the knee
are associated with alcohol abuse and the use of
corticosteroids2,6-8.
Treatment options for secondary osteonecrosis of the knee include
nonoperative therapy, such as restricted weight-bearing, and administration of
analgesics. Various surgical treatment alternatives include core
decompression6,9,
bone-grafting10,
and resurfacing with osteoarticular
allografts8,11,12.
When these measures fail to relieve disability,
unicondylar13 or
total knee
arthroplasty14-18
is the only treatment alternative. However, knee prostheses are less desirable
in this young and active patient population.
The bone impaction grafting technique was developed primarily for the
repair of bone deficiencies during revision total hip arthroplasty. The
initial and secondary stability of these reconstructions has been sufficient,
and the long-term clinical and radiographic results have been reported as
being
satisfactory19,20.
Histologic analysis has shown that graft incorporation is nearly always
complete21. In the
present study, we adapted for the knee a previously described technique that
has been used for the treatment of femoral head
osteonecrosis22.
The purpose of this study was to evaluate if bone impaction grafting can be
used for the treatment of osteonecrosis of the femoral condyles. We also
sought to answer the questions of whether the technique is simple,
reproducible, and safe; whether the technique leads to improvements in
clinical and radiographic outcomes; and whether the technique impedes the
progression of collapse.
From July 1994 to May 2002, ten consecutive knees in seven patients with
extensive osteonecrotic lesions of the femoral condyles were treated with the
bone impaction grafting technique. No patient was lost to follow-up, but one
patient who died nine months postoperatively due to a cause unrelated to
surgery was excluded from the series. Therefore, nine knees in six patients
were available for follow-up.
The mean age of the six patients (three men and three women) at the time of
surgery was thirty-one years (range, sixteen to forty-seven years). The mean
body mass index was twenty-five (range, twenty-one to thirty-four). The
diagnosis of osteonecrosis was partially based on the clinical history and
anteroposterior and lateral radiographs. In all patients, the final diagnosis
and the quantification and location of the lesion were confirmed by magnetic
resonance imaging scans.
The mean duration of symptoms before surgery was twenty-five months (range,
two to eighty-one months). All patients had a history of systemic
corticosteroid administration. All knees had bone impaction grafting as the
primary treatment for osteonecrosis. Two of the patients (patients 1 and 2)
had symptomatic osteonecrosis of joints other than the knee
(Table I).
Surgical Technique
All procedures were done by one surgeon (J.W.M.G.). Patients were placed in
the supine position with the knee in 30° of flexion. The incision was made
on the affected side, just proximal to the epicondyle. The margin of either
the vastus medialis or the vastus lateralis muscle was exposed and retracted
anteri-orly to expose bone, with care taken to avoid the collateral ligament.
The joint space was not entered, thus leaving the joint capsule intact. The
periosteum was removed, and a 1 × 2 cm cortical window was made. Under
fluoroscopy from two directions, all of the necrotic bone was removed with the
use of osteotomes, sharp curettes, and an Anspach 65K bur (Anspach, Palm Beach
Gardens, Florida). The exact extent and position of this necrotic area were
determined preoperatively with use of magnetic resonance imaging scans.
Next, the area over the subchondral plate was filled with bone chips and
impacted, layer by layer, in such a way that the subchondral plate was first
covered and impacted completely by autogenous trabecular bone chips. In the
first three knees, extra autogenous trabecular bone was obtained from the
iliaccrest. In the final six knees, only healthy autogenous bone from the
metaphyseal area was used. The bone was nibbled into bone chips with a size of
approximately 8 mm. The bone chips were impacted with use of specially
designed, bayonet-shaped impactors of different sizes to achieve solid
impaction and initial stability.
Next, the remaining volume of the created extensive cavity was filled with
solidly impacted trabecular bone chips made from fresh-frozen allograft
femoral heads obtained from a local bone bank. One complete femoral head was
needed for each reconstruction. Finally, the cortical window was replaced in
its original position and impacted in place. The periosteum was sutured back
into place.
After surgery, all patients followed a strict rehabilitation and training
program. During the first six weeks, toe-touch weight-bearing with the use of
two crutches was allowed. In the second six weeks, patients were instructed to
practice bearing weight with a maximum of 50% body weight. During the third
six weeks, full weight-bearing was permitted, often with the use of one crutch
to slow down activity.
All patients were prospectively followed clinically and radiographically by
one of the authors (J.W.M.G.) four times during the first year and annually
thereafter. The visual analog score and Knee Society rating system,
differentiated by objective and functional scores, were used for clinical
evaluation preoperatively and at the time of the final follow-up. A score of
90 or more points was considered an excellent outcome; between 80 and 89
points, a good outcome; 70 to 79 points, a fair outcome; and 69 or less, a
poor outcome. A clinically successful result was defined as a minimal
objective score of 80 points and no conversion to total knee arthroplasty. Two
visual analog scales were used to grade either the satisfaction of the patient
concerning function of the knee or pain (range, 0 to 100, with 100 as the
highest score).
For radiographic follow-up, serial anteroposterior and lateral radiographs
were used. According to the classification system of Ficat and
Arlet23, three
knees were in stage II and six knees were in stage III. Locations of lesions
were tabulated as previously
described24. All
knees had a lesion involving the femoral epiphysis. Five knees presented with
only distal femoral involvement and four presented with both femoral and
tibial involvement. One patient had unilateral involvement, and five patients
had bilateral osteonecrosis. Four knees had only lateral condylar involvement,
one knee only medial, and in another four knees both condyles were affected.
In two knees the lesion was situated in the distal quadrant; in three knees,
the posterior quadrant; and in four knees, both the distal and posterior
quadrants24. The
size of the lesion was expressed, as previously described, as a percentage of
the width of the involved femoral condyle on the anteroposterior
radiograph25. The
presence of osteoarthritic signs, classified with use of the Kellgren
score26 was
determined. Radiographic failure was defined as the onset or the progression
of collapse or progressive osteoarthritis.
Surgical Evaluation
The mean surgical time was eighty-nine minutes (range, sixty to 135
minutes), and the mean blood loss through drains was 180 mL (range, 5 to 560
mL). During the operation, two perforations of the cortex of the condyle were
observed. These occurred once on the lateral side of the lateral condyle and
once on the posterior facet of the lateral condyle. Neither was situated in
the major weight-bearing part of the femoral condyles.
Clinical Evaluation
The mean duration of hospital stay was eleven days (range, three to
twenty-eight days). The mean time until the final follow-up after the index
operation was fifty-one months (range, twenty-nine to ninety-three months).
The technique improved the clinical outcome for all patients. The objective
Knee Society score increased from a mean of 63 points (range, 43 to 90 points)
to a mean of 89 points (range, 70 to 100 points). The functional Knee Society
score improved from a mean of 19 points (range, 0 to 70 points) to a mean of
81 points (range, 50 to 100 points) postoperatively. No conversion to a total
knee arthroplasty was performed.
The visual analog scale functional score averaged 27 points (range, 10 to
50 points) before the operation. The mean score at the time of follow-up was
85 points (range, 50 to 100 points). The visual analog scale pain score was,
on the average, 78 points (range, 50 to 90 points) before the operation and 25
points (range, 10 to 70 points) at the time of the final follow-up. One
patient was moderately satisfied with a relatively high visual analog scale
pain score of 70 at the time of final follow-up. However, all patients had
some relief of pain. The clinical success rate, defined as a minimal objective
score of 80 points and no conversion to a total knee arthroplasty, was 75%
(six of eight knees).
Radiographic Evaluation
At the time of final follow-up, none of the six knees with pre-operative
collapse of the femoral condyles had progression of collapse
(Figs. 1-A through 1-F).
Incorporation of the impacted bone grafts was seen radiographically in all
knees. At the time of follow-up, minimal osteoarthritis was observed in three
knees, all of which had a Kellgren score of 1. In one knee, the osteoarthritis
had been present preoperatively.
The size of the lesion, expressed as a percentage of the width of the
involved femoral condyle on the anteroposterior radiograph, averaged 65%
(range, 52% to 86%). The radiographic success rate, defined as absence of
progression of osteoarthritis or collapse, was 78% (seven of nine knees).
This new treatment technique shows promising results at the time of midterm
follow-up in a small series of younger patients with extensive osteonecrotic
lesions of the knee. The clinical success rate in all patients was promising
at a mean duration of follow-up of fifty-one months. This is important
considering that, preoperatively, two-thirds of the knees had collapse of the
femoral condyle. Visual analog scale and functional Knee Society scores showed
promising subjective results with a major decrease in perception of pain and
an increase in function. The two perforations that were made in the cortex of
the condyle did not appear to affect clinical outcome.
The radiographic results also were favorable. The osteonecrotic lesions
were extensive in all instances, affecting at least 50% of the condyles in the
weight-bearing area. Success was radiographically demonstrated in seven of the
nine knees. In only two knees was minimal progression of osteoarthritis
observed. No collapse of the affected condyle occurred after surgery and no
progression of a preoperative collapse was seen. The impacted bone grafts
showed adequate incorporation in all knees.
This study involved a series of patients who were being managed for
corticosteroid-associated osteonecrosis of the knee. This technique of
impaction bone-grafting of the femoral condyle was used because there is still
a need for a relatively simple, minimally invasive, surgical method to
reconstruct advanced osteonecrotic knees in younger patients. The aim of a
suitable technique in this group of young patients should be to improve
clinical results, prevent further collapse and the development of
osteoarthritis of the femoral condyles, and at least postpone the need for a
total knee arthroplasty. In addition, the technique is not likely to make
future implantation of a total knee prosthesis more difficult.
In the literature, several surgical and nonsurgical treatments for
corticosteroid-associated osteonecrosis are reported. However, nonsurgical
treatments have met with limited success in this group of patients, with only
18% survival found in one study at six
years9.
Various surgical treatment modalities for osteonecrosis of the distal
portion of the femur have been described. Mont et
al.9 described 73%
good or excellent results after eleven years in forty-seven knees with
corticosteroid-associated osteo-necrosis treated by core decompression;
however, 85% of all knees were in an early stage of the disease, without
collapse. Fukui et
al.10 used
autologous osteoperiosteal iliac bone grafts, which were placed into the
osteochondral lesion and, in some cases, combined with a high tibial
osteotomy. After seventy-nine months, nine of ten knees showed a good result.
The use of unicompartmental arthroplasty has been reported in patients with
spontaneous osteonecrosis of the medial femoral
condyle13. Total
knee arthroplasty after spontaneous osteonecrosis of the knee has been
reported to result in midterm survival rates of 80 to
95%1,17.
However, the treatment of corticosteroid-associated osteonecrosis has been
associated with less favorable results. Mont et
al.15 reported a
45% failure rate after eight years, and Seldes et
al.18 showed an
implant survival rate of 84% in thirty-one knees after five years. Better
cementation techniques and prostheses improved survival rates to 97% after
nine years16.
We report the first clinical experience with this new technique, with the
learning curve included, from the experience of a single surgeon. The
technique has proven to be relatively straightforward, and the surgical time
is not extensive. Future implantation of a total knee prosthesis should not be
hampered because the joint space is left intact and the bone stock is
reconstructed. The clinical and radiographic outcomes of this study are
promising; yet, because osteonecrosis of the knee is a disease with a low
incidence, the number of patients that we studied was limited, and our results
are presented after only a midterm follow-up period, we await the longer-term
evaluation of this technique with more patients. ?
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