The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 91, Issue 10

Scientific Articles | October 01, 2009

Vascularized Iliac Bone-Grafting for Osteonecrosis with Segmental Collapse of the Femoral Head

Chun-Chieh Chen, MD¹; Chun-Li Lin, PhD²; Wei-Chih Chen, MD¹; Hsin-Nung Shih, MD¹; Steve W.N. Ueng, MD¹; Mel S. Lee, MD, PhD¹

¹ Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsin Street, Kweishan, Taoyuan, Taiwan 333, Republic of China. E-mail address for M.S. Lee: bone@doctor.com
² Department of Mechanical Engineering, Chang Gung University, 259, Wen-Hwa First Road, Kweishan, Taoyuan, Taiwan 333, Republic of China

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan, Republic of China

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2009 Oct 01;91(10):2390-2394. doi: 10.2106/JBJS.H.01814

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Abstract

Background: Vascularized iliac bone-grafting has been reported to be successful for patients with osteonecrosis of the femoral head. However, its benefit in patients with segmental collapse of the femoral head has not been determined. The purpose of this study was to analyze the results of vascularized iliac grafting in osteonecrotic femoral heads with segmental collapse.

Methods: We retrospectively analyzed thirty-three hips in thirty-two patients in whom an osteonecrotic femoral head with segmental collapse (Association Research Circulation Osseous [ARCO] stage IIIA [<2-mm collapse] or stage IIIB [2 to 4-mm collapse]) had been treated with vascularized iliac bone-grafting between 1994 and 1999. The average age of the patients at the time of surgery was thirty-seven years. Twenty-six patients (twenty-seven hips) overused alcohol, five patients (five hips) had no known risk factor, and one patient (one hip) used corticosteroids for refractory bronchial asthma. Clinical outcomes were evaluated with the Harris hip score. We defined clinical failure as conversion to total hip replacement for any reason and radiographic failure as progressive femoral head collapse or secondary osteoarthritis of the involved hip.

Results: At the conclusion of the study, only eight (24%) of the thirty-three hips were preserved. The mean survival time for the series as a whole was seventy-four months (95% confidence interval, fifty-four to ninety-five months) after the surgery. Eighteen of the twenty-six ARCO stage-IIIA hips were converted to a total hip replacement, and the mean survival time for the stage-IIIA hips was eighty-five months (95% confidence interval, sixty-one to 108 months). All of the seven ARCO stage-IIIB hips were converted to a total hip replacement, and the mean survival time for the stage-IIIB hips was thirty-five months (95% confidence interval, eleven to fifty-eight months). The mean Harris hip score for the eight hips that still survived at the time of follow-up had improved from 62 points to 80 points. However, all of them had progressive collapse of the femoral head—i.e., radiographic failure—at the time of final follow-up.

Conclusions: Vascularized iliac bone-grafting with use of the technique described in this study is not indicated for the treatment of osteonecrotic femoral heads with segmental collapse.

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

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Osteonecrosis of the femoral head often affects young active adults and leads to destruction of the hip joint and disabling arthritis. The prognosis is influenced by the stage, size, and location of the lesion^1,2. Steinberg et al. reported that 92% of forty-eight hips managed with nonoperative treatment progressed to collapse³.

Joint preservation remains the goal of treatment of precollapse osteonecrosis of the femoral head, whereas it is generally agreed that prosthetic replacement is indicated for cases in which preservation procedures have failed or in which there is segmental collapse. Whether joint preservation surgery can be justified for cases of segmental collapse is controversial^4,5. Some have reported successful results with transtrochanteric rotational osteotomy in such cases^6,7, but the results could not be reproduced by most others^4,5,8,9. In a series of 188 patients (224 hips) with segmental collapse and prearthritic lesions, 64.5% had a satisfactory result at a minimum of five years after use of a vascularized fibular graft¹⁰. Comparable results, with success rates ranging from 50% to 59%, have also been reported in other studies of vascularized fibular grafting^1,11. In contrast, the use of vascularized iliac grafting has seldom been reported for the treatment of osteonecrotic femoral heads with segmental collapse. The purpose of this study was to analyze the clinical and radiographic results of vascularized iliac grafting in patients with osteonecrosis and segmental collapse of the femoral head.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Patient Demographics

Between December 1994 and August 1999, eighty-six patients (100 hips) with osteonecrosis of the femoral head were treated with vascularized iliac grafting at the Chang Gung Memorial Hospital, Linkou Medical Center. Sixty-two hips with a precollapse lesion (Association Research Circulation Osseous [ARCO]¹² stage II) were excluded, leaving thirty-eight osteonecrotic femoral heads with segmental collapse (ARCO stage IIIA [<2-mm collapse] or stage IIIB [2 to 4-mm collapse]) in the study group. During that period of time, 937 osteonecrotic femoral heads with segmental collapse were treated with total hip replacement; 312, with bipolar hemiarthroplasty; seventeen, with osteotomy; and forty-one, with core decompression with or without bone-grafting. The indication for vascularized iliac grafting was osteonecrosis of the femoral head without collapse or with early segmental collapse in a patient who was less than sixty-five years of age. Contraindications included a femoral head with advanced segmental collapse (a stage of IIIC or higher), a questionable vascular supply to the iliac graft due to factors such as surgery or trauma, preexisting thromboembolic disease, a risk of bleeding or thrombocytopenia, untreated inguinal or femoral hernia, and an age of sixty-five years or more.

Following institutional review board approval (number 97-1410B), the patients were analyzed for functional and radiographic outcomes. Three patients (three hips) were lost to follow-up, and two patients (two hips) had died of unrelated diseases, leaving thirty-three hips in thirty-two patients followed for a mean of sixty-nine months (range, eight to 165 months). There were thirty-one male patients and one female patient with a mean age of thirty-seven years (range, twenty-three to sixty-four years) at the time of the grafting. Twenty-six patients (twenty-seven hips) overused alcohol, consuming >400 mL per week (expressed as milliliters of 100% alcohol after conversion according to the percentage of alcohol in commonly consumed alcoholic beverages); five patients (five hips) had no known risk factor (i.e., had idiopathic osteonecrosis of the femoral head); and one patient (one hip) used corticosteroids to treat refractory bronchial asthma.

Surgical Technique

The patient was placed in the supine position with a sandbag placed under the buttock to elevate the ilium. A curvilinear skin incision was made along the iliac crest downward to the level of the lesser trochanter. The deep circumflex iliac artery was identified and was dissected along the inguinal ligament. The first few tributaries were ligated with use of hemoclips for 2.5 cm behind the anterior superior iliac spine. A tricortical vascularized bone block of approximately 1.5 cm in depth and 5 cm in length, perfused by the deep circumflex iliac artery, was then harvested from the iliac crest. Cancellous bone chips were also harvested for later use. The hip joint was approached in the interval between the sartorius and the tensor fasciae latae superficially and between the gluteus medius and the rectus femoris underneath. The anterior aspect of the joint capsule was excised to expose the femoral neck from the head-neck junction to the base of the neck. The osteonecrotic lesion was excised through a bone trough made on the anterior aspect of the head-neck junction. A high-speed burr was used to remove the lesion as completely as possible under direct vision. A Penrose drain was used as a channel to transfer the pedicle bone graft to the anterior aspect of the femoral neck. It was passed beneath the inguinal ligament, through the iliacus muscle, and above the reflected head of the rectus femoris. After cancellous bone chips were impacted into the femoral head, the vascularized iliac bone was transferred to the femoral head with the distal tip (based on the vascular pedicle) abutting the subchondral bone. Postoperatively, toe-touch weight-bearing was prescribed for the first six weeks, then progressive weight-bearing was permitted; full weight-bearing was achieved after six months.

Viability of the Grafts

Magnetic resonance imaging studies were used to evaluate the extent of the osteonecrosis and the viability of the graft in seventeen hips at an average of six months (range, one to eighteen months) postoperatively. Graft viability was determined by the signal intensity and gadolinium enhancement according to the criteria suggested by Wassenaar et al.¹³. The graft viability was also evaluated with Tc-99m single-photon-emission computed tomography in nine hips at an average of seven months (range, one to eighteen months) postoperatively. In total, twenty-four patients had either a magnetic resonance imaging scan or single-photon-emission computed tomography and one patient had both to evaluate graft viability.

Evaluation and End Points

Hip function was evaluated with use of the Harris hip score¹⁴. Survivorship, with 95% confidence intervals, was estimated with use of the Kaplan-Meier method. Failure was defined as conversion to a total hip replacement for any reason. The time to failure was calculated as the time between the date of the vascularized iliac grafting and the date of the conversion. Hips without conversion were censored at the date of the last follow-up evaluation. The difference in survivorship between ARCO stage-IIIA and stage-IIIB hips was analyzed with use of the log-rank test. A p value of less than 0.05 was considered to be significant. Radiographic failure was defined as progressive collapse of the femoral head or secondary osteoarthritis of the involved hip.

Source of Funding

There was no external source of funding in support of the research for or the preparation of this study.

Results

Introduction | Materials and Methods | Results | Discussion | References

In all seventeen hips evaluated with a postoperative magnetic resonance imaging scan, the graft was viable, with an isointense signal relative to the normal marrow and gadolinium enhancement (Fig. 1). The graft was viable in eight of the nine hips evaluated with postoperative single-photon-emission computed tomography; the viability of the graft was questionable in the remaining hip.

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Fig. 1: A thirty-one-year-old man with the risk factors of alcohol overuse and bilateral osteonecrosis. A: Vascularized iliac grafting was done in the left hip, which was ARCO stage IIC, two months before it was performed in the right hip, which was ARCO stage IIIA. B: Eighteen months postoperatively, the osteonecrotic lesions and the iliac grafts (arrows) were assessed with T2-weighted magnetic resonance imaging. C: The viability of the iliac graft (asterisk) was demonstrated by a T1-weighted magnetic resonance imaging study. D: Progressive collapse of the heads necessitated bilateral total hip arthroplasty 112 months postoperatively in spite of the viable iliac grafts.

At the conclusion of the study, only eight (24%) of the thirty-three hips were preserved. The mean survival time for the series as a whole was seventy-four months (95% confidence interval, fifty-four to ninety-five months). The twenty-six ARCO stage-IIIA hips had a mean survival time of eighty-five months (95% confidence interval, sixty-one to 108 months). Eighteen of these hips were converted to a total hip replacement, at an average of fifty months (range, ten to 124 months). All of the seven ARCO stage-IIIB hips were converted to a total hip replacement, and the mean survival time was thirty-five months (95% confidence interval, eleven to fifty-eight months). The survivorship differed significantly between the ARCO stage-IIIA and the ARCO stage-IIIB hips (p = 0.016) (Fig. 2).

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Fig. 2: Kaplan-Meier survivorship curves for hips in which osteonecrosis of the femoral head with segmental collapse had been treated with vascularized iliac grafting.

The mean Harris hip score for the twenty-five hips that were converted to a total hip replacement had changed from 54 points (range, 47 to 65 points) preoperatively to 60 points (range, 45 to 75 points) at the time of conversion. The score for the eight hips that were preserved by the surgery improved from 62 points to 80 points. However, all eight hips had radiographic evidence of failure, with progressive collapse of the femoral head or secondary osteoarthritis (Fig. 3).

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Fig. 3: A twenty-seven-year-old man with bilateral steroid-induced osteonecrosis of the femoral head. A: ARCO stage-IIIC disease is seen in the right hip, and ARCO stage-IIIA disease is seen in the left hip. B and C: Vascularized iliac grafting (arrow) was performed on the left hip. D: Advanced collapse of the left hip was noted 121 months postoperatively. The graft was well incorporated into the femoral head.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The mainstay of treatment of osteonecrosis of the femoral head is joint preservation before collapse through early diagnosis and intervention. The most frequent intervention for segmental collapse has been reported to be total hip replacement¹⁵; only a few surgeons offer vascularized bone-grafting or osteotomy (intertrochanteric or rotational), and the decision would depend on patient age, the extent of the necrosis, the degree of involvement of the weight-bearing surface, and symptoms¹⁵. Joint preservation procedures are rarely used for treatment of osteonecrosis of the femoral head with segmental collapse because they are usually temporizing and unpredictable in these cases.

Osteotomy (intertrochanteric or rotational) theoretically is a rational treatment for segmental collapse because it can reposition the collapsed part to a non-weight-bearing area and transfer the intact part of the head for weight-bearing. However, it is technically difficult, and the long-term results are not convincing^4-9. Vascularized fibular grafting may be more promising for hips with segmental collapse, with rates of successful results of 50% to 64.5% at the time of mid-term to long-term follow-up^1,10,11.

Vascularized iliac grafting, when performed by us and by others^16-19, has been reported to be successful in >80% of precollapse cases at two to 12.5 years postoperatively. However, its role in the treatment of patients with segmental collapse has seldom been reported in the literature. In the present study, in which the mean duration of follow-up was sixty-nine months, only 24% of the hips were preserved and 76% were converted to a total hip replacement. Although the mean Harris hip score was 80 points (range, 76 to 85 points) for the hips that were preserved by the surgery, all of those hips had progressive collapse and arthritic changes—i.e., a 100% rate of radiographic failure. We speculate that the unsatisfactory results in this study might be related not to the technique but to the patient selection. After reviewing the indications for and results of vascularized iliac grafting in patients with osteonecrosis of the femoral head, Hasegawa et al. recommended not using the procedure to treat segmental collapse because of unpredictable results and high failure rates^20,21.

The differences between the results of vascularized fibular grafting and those of iliac grafting for the treatment of segmental collapse could be related to the biomechanical properties and the reparative potential of the grafts. In this study, the viability of the vascularized iliac grafts was confirmed by magnetic resonance imaging or single-photon-emission computed tomography in twenty-four of the twenty-five hips. However, even a viable iliac graft did not prevent disease progression as well as has been reported in studies of fibular grafts^1,10,11. It may be that the deep circumflex iliac artery supplying the iliac graft is smaller than the peroneal artery supplying the fibular graft. During surgery, the deep circumflex iliac artery must be rerouted to the recipient site, and kinking, compression, or overstretching of the vascular pedicle is possible. In addition, during the iliac grafting procedure, the anterior aspect of the joint capsule is excised, perhaps further compromising the blood supply to the already ischemic femoral head.

Biomechanically, iliac graft is not as strong as fibular graft and thus cannot provide as much structural support abutting against the subchondral bone. Furthermore, the fibular graft can be placed in the ideal position, within 3 to 5 mm of the subchondral bone, under fluoroscopic guidance by creating a tract on the inferior-lateral aspect of the greater trochanter without disturbing the joint capsule²². The iliac graft, on the other hand, is transplanted from the anterior aspect of the neck to the femoral head, and it is more difficult to place it in the ideal position for mechanical support^20,21.

In this study, twenty-seven of the thirty-two patients had a risk factor consisting of alcohol overuse or corticosteroid therapy. It has been reported that the activity of stem cells in both the hematopoietic and the stromal compartment of the iliac bone marrow is decreased in patients who are receiving corticosteroids or who overuse alcohol²³. A decreased reparative potential of the iliac graft associated with the abnormal bone marrow activity could be another cause for the inferior results in the current study.

This study was limited by the retrospective methodology, by the small number of patients and the strong male predominance, and by the high proportion of patients who overused alcohol or used corticosteroid therapy. Therefore, our results may not be generalizable to other groups of patients. Furthermore, in this study, the débridement and grafting were done under direct vision, and we cannot know whether the results would have been better if fluoroscopy had been used routinely. Nevertheless, this study has a number of strengths, including restriction of patient selection to those with segmental collapse and the use of scintigraphy or magnetic resonance imaging to evaluate the graft viability postoperatively.

In conclusion, on the basis of the poor results in this retrospective case series, we believe that vascularized iliac grafting is not indicated for the treatment of patients with an osteonecrotic femoral head with segmental collapse. Image Not Available

References

Introduction | Materials and Methods | Results | Discussion | References

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Topics

ethanol ; alcohols ; bone transplantation ; head of femur ; femur head necrosis ; hip region ; hip joint ; ilium ; hip replacement arthroplasty ; osteonecrosis

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Chun-Chieh Chen, Chun-Li Lin, Wei-Chih Chen, Hsin-Nung Shih, Steve W.N. Ueng, Mel S. Lee; Vascularized Iliac Bone-Grafting for Osteonecrosis with Segmental Collapse of the Femoral Head. The Journal of Bone & Joint Surgery. 2009 Oct;91(10):2390-2394.

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