Modified trapdoor procedures using autogenous tricortical iliac graft without preserving the broken cartilage for treatment of osteonecrosis of the femoral head: a prospective cohort study with historical controls

Hip joint-preserving strategies for treating osteonecrosis of the femoral head: From nonoperative to operative procedures

Osteonecrosis of the femoral head (ONFH) has an exceedingly high prevalence and disability rate, causing a tremendous socioeconomic burden. The prevalence of ONFH is increasing, while the population of the patients with ONFH is becoming younger. Once the femoral head collapses, treatment becomes difficult and often requires a hip joint replacement, which is not favorable for young patients. Therefore, hip joint-preserving treatments at an early stage of ONFH are particularly important. This study provides a comprehensive review on hip-preserving strategies for treating ONFH, including nonoperative treatments (e.g., protective weight bearing, hyperbaric oxygen, pulsed electromagnetic, extracorporeal shockwave, bisphosphonate, anticoagulants, hypolipidemics, vasodilators, and traditional Chinese medicine) and operative treatments (e.g., core decompression, osteotomy, bone grafting, mesenchymal stem cell transplantation, tantalum rods, and tissue engineering). Nonoperative treatments aim to slow down the progression of the disease and delay the need for joint replacement; however, they usually cannot effectively prevent the progression of the disease, except in cases of small necrosis areas (<10 %). Additionally, nonoperative treatments have unclear mechanisms that require further investigation. In contrast, operative treatments may stop the negative outcomes of necrosis and therefore appear to be more promising. Currently, an emerging area in operative treatments is regenerative medicine, which could promote the generation of bone tissues and blood vessels and restore hip joint function to pre-necrotic levels as much as possible. This review seeks to not only provide an important reference for clinicians when choosing appropriate strategies for treating ONFH but also offer certain guidance for future basic research in developing ONFH treatments.

The translational potential of this article

The incidence of ONFH is increasing, and patients are becoming younger on average. Therefore, the development of hip joint-preserving strategies to treat ONFH at earlier stages is urgently needed, particularly for young patients. However, a comprehensive review is lacking regarding the currently-available hip joint-preserving strategies and their effectiveness. This study is motivated to fill this gap and serve as an important reference for clinicians in choosing appropriate strategies to treat ONFH.

Jack Surgery: Reconstructing Collapsed Femoral Head in Association Research Circulation Osseous Stage III Osteonecrosis: A Series of 13 Cases

OBJECTIVE

According to Association Research Circulation Osseous (ARCO) staging, patients with ARCO III osteonecrosis of femoral head (ONFH) have joint pain and dysfunction due to the collapse of femoral head. Current hip preservation surgeries are not satisfying in the treatment of ARCO III ONFH according to the long-term follow-up. In our practice, we focused on reconstructing femoral head by restoring the round shape of femoral head and subsequently preventing the development of hip arthritis. To lift the collapsed femoral head and postpone the potential total hip arthroplasty, we practiced Jack surgery, combining surgical hip dislocation, removal of necrotic bone, impaction bone grafting, and lifting the cartilage of femoral head.

METHODS

From February 2019 to July 2022, 13 patients (15 hips) who received Jack surgery in the research center were included in this retrospective study. Follow-up was conducted every 3 months after surgery for imaging and clinical evaluation. The differences between visual analogue scale (VAS) and Harris hip score (HSS) before and after surgery were compared to observe whether the femoral head collapsed and whether osteotomy healed after surgery. Severe collapse of the femoral head ( > 2 mm) or receiving total hip arthroplasty (THA) was defined as failure of hip preservation therapy. An Independent sample t-test was used to compare the data, and the chi-square test was used for categorical data.

RESULTS

All the 13 patients successfully completed the surgery and were followed up. The average time of follow-up was 36.46 ± 16.87 months (ranging from 14 to 66 months). HSS was assessed 12 months after surgery: excellent in 1 patient with 1 hip; good in 9 patients with 11 hips; modest in 3 patients with 3 hips. To the last follow-up, the VAS scores decreased from 6.17 ± 1.02 to 2.08 ± 0.90 (p < 0.001), HSS increased from 46.69 ± 4.15 to 89.77 ± 2.86 (p < 0.001). No deep infection, fracture, osteotomy nonunion, nerve injury, deep vein thrombosis, pulmonary embolism, or other complications occurred.

CONCLUSION

For young patients with ONFH of ACRO III, this surgical technique can effectively restore the original shape of the femoral head and achieve satisfactory hip function in the short term. The mechanism is similar to jacking the roof of a house; thus, we named it "Jack surgery".

Aneurysmal Bone Cyst of Femoral Head : A Rare Case Report

Introduction

Aneurysmal Bone Cyst (ABC) is a benign, non neoplastic, expansile lesion of bone characterized by channels of blood and spaces separated by fibrous septae. ABC of femoral head is an extremely rare condition and is difficult to treat as the surgical approach is a dilemma .

Case Report

We hereby report a case of aneurysmal bone cyst in femoral head of a 19 year old female patient. To preserve the vascularity of the femoral head, we approached the lesion by ganz safe surgical dislocation of the affected femoral head, trapdoor procedure of femoral head followed by curettage and bone grafting . The patient was followed up for 6 months & at latest follow up, lesion has healed completely & patient is walking pain free .

Conclusion

In rare cases like ABC of femoral head, a trapdoor osteotomy of femoral head with bone grafting followed by stabilization of the bone graft and osteotomy gives excellent functional and radiological outcomes.

Application of Biomaterials in Treating Early Osteonecrosis of the Femoral Head: Research Progress and Future Perspectives

Osteonecrosis of the femoral head (ONFH), a progressive pathological process of femoral head ischemia and osteocyte necrosis, is a refractory orthopedic disease caused by multiple etiologies and there is no complete cure at present. With the extension of ONFH duration, osteocyte apoptosis and trabecular bone loss can decrease the load-bearing capacity of the femoral head, which leads to the collapse of the articular cartilage and subchondral bone. Therefore, an urgent clinical need exists to develop effective treatment strategies of early-stage ONFH for maintaining the hip joint function and preventing femoral head collapse. In recent years, extensive attention has been paid to the application of diverse biomaterials in treating early ONFH for sustaining the normal morphology and function of the autologous femoral head, and slowing disease progression. Herein, we review the research progress of bone grafts, metallic materials, bioceramics, bioglasses and polymer materials for early ONFH treatment, and discuss the biological mechanisms of bone repair and regeneration in the femoral-head necrotic area. We propose suggestions for future research directions, from a special perspective of improving the local microenvironment in femoral head by facilitating vessel-associated osteoclasts (VAOs) generation and coupling of bone-specific angiogenesis and osteogenesis, as well as inhibiting bone-associated osteoclasts (BAOs) and BAO-mediated bone resorption. This review can provide ideas for the research, development, and clinical application of biomaterials for treating early ONFH. STATEMENT OF SIGNIFICANCE: We believe that at least three aspects of this manuscript make it interesting to readers of the Acta Biomaterialia. First, we briefly summarize the incidence, pathogenesis, risk factors, classification criteria and treatment of early osteonecrosis of the femoral head (ONFH). Second, we review the research progress in biomaterials for early ONFH treatment and the biological mechanisms of bone repair and regeneration in femoral-head necrotic area. Third, we propose future research progress on improving the local microenvironment in femoral head by facilitating vessel-associated osteoclasts generation and coupling of bone-specific angiogenesis and osteogenesis, as well as inhibiting bone-associated osteoclasts and bone resorption. We hope this review can provide ideas for the research, development, and clinical application of biomaterials for treating early ONFH.

One in five patients require conversion to arthroplasty after non-vascularized bone grafts in patients with osteonecrosis of the femoral head: a systematic review

BACKGROUND

Non-vascularized bone grafting (NVBG) has demonstrated to treat osteonecrosis of the femoral head (ONFH). There are a number of articles updating the use of NVBG to treat the ONFH, but the percentage of patients subsequently undergoing a total hip arthroplasty (THA) is controversial.

METHODS

Several electronic databases, including PubMed, Embase, Web of Science, and Cochrane databases, were searched to find studies using NVBG to treat ONFH. The pooled rate and 95% confidence interval (CI) were used to assess the conversion rate to THA after NVBG. In addition, we performed subgroup, sensitivity, and publication bias analysis.

RESULTS

A total of 37 studies describing 2599 hips were included. The mean weighted follow-up time was 50.5 months and the mean age at surgery was 36.3 years. The conversion rate to THA after NVBG was 21% (95%CI: 17% to 25%), and subgroup analyzes indicated lightbulb, trapdoor and Phemister techniques incidences with THA of 15%, 19%, and 24%, respectively.

CONCLUSIONS

This study preliminarily obtained the general trend of the survival rate of NVBG patients, but these results should be interpreted cautiously. Pooled results from 2599 hips and of these nearly 80% with early stage of osteonecrosis, showed that approximately 21% of patients underwent a THA following NVBG. NVBG treatment for patient with ONFH appears to defer or at least delay the need for THA.

Biomechanical research of medial femoral circumflex vascularized bone-grafting in the treatment of early-to-mid osteonecrosis of the femoral head: a finite element analysis

PURPOSE

Hip preservation therapy of early ONFH (Osteonecrosis of the femoral head) has emerged as one of the hot areas of research. We have optimized the procedure of traditional MFCVBG (medial femoral circumflex vascularized bone grafting) by using specialized surgical tools and used the finite element analysis to guide the implantation position of the bone flap during surgery and validate the biological mechanical stability of the modified MFCVBG.

METHODS

This study was based on the data of a male patient with left hip (ARCO stage IIB, JIC type C) hormonal ONFH. Harris score (HHS), anteroposterior and lateral hip radiographs, frog position hip radiographs and SPECT/CT of femoral head flow imaging were performed postoperatively to evaluate clinical efficacy. The patient's CT data were used to establish upper femur finite element model of the normal group, osteonecrosis group and postoperative group, respectively. The force on the femoral structure of each group was analyzed under four different loads in the gait cycle of 0.5 times the body weight (0.5 G, standing on two feet), 2.75 G (standing on one foot), 4 G (walking with the middle foot on the ground) and 7 G (walking with the toe off the ground) to validate the biological mechanical stability of the modified MFCVBG, predict femoral head collapse risk, simulate of the different healing conditions of postoperative bone flap, and analyze the postoperative effect of non-ideal surgical model.

RESULTS

According to the follow-up results, the bone flap and the inner wall of decompression channel healed well, no osteonecrosis progression, no local collapse or micro-fracture occurred in the femoral head, and the articular surface was intact and the necrosis was well repaired. According to the result of the finite element analysis, compared with the osteonecrosis group, the overall stress and displacement peak of the upper femur and the cortical bone stress peak of the femoral head in the postoperative group and normal group were significantly reducing; modified MFCVBG can significantly improve the biomechanical stability of necrotic femoral head and reduce the risk of femoral head collapse; there was no obvious abnormal stress distribution in the greater trochanter and intertrochanter region after the flap was removed; the bone flap of the complete removal of necrotic focus + long bone flap group was directly placed at the bottom of the decompression passage, and the bone flap cortical bone can provide substantial mechanical support; in theory, patients can try to reduce the load with crutches or walking aids and carry out appropriate flat activities to effectively promote the early postoperative recovery.

CONCLUSIONS

The modified MFCVBG resulted in good efficacy, safety and feasibility. The necrotic focus should be completely removed during the operation, and the long bone flap should be placed directly under the subchondral bone. For patients with better bone healing ability, a more positive attitude can be taken to promote early postoperative weight-bearing.

[The importance of removing osteonecrosis during treatment of femoral head osteonecrosis]

Atraumatic femoral head necrosis (aFHN) in adults is estimated to be the leading cause of approximately 10% of all hip prosthesis implantations. Due to the relatively frequent occurrence of aFHN at a young age, the possibility of a joint-preserving intervention should be examined. This includes the classic "core decompression" and modifications based on it. There are different data on the success rates of this method. Reasons for treatment failure could include a lack of clearance of the necrosis zone. The clearance of the necrosis zone is taken into account by alternative surgical procedures for the treatment of aFHN. These are the "trap-door procedure", the "light-bulb procedure" and "advanced core decompression". The current state of knowledge on these procedures is reviewed in this keynote article. It is shown that the extensive excision of femoral head necrosis is of particular importance. None of the procedures mentioned can currently be recommended in preference over the others.

Clinical Outcome of Surgical Hip Dislocation Combined with Impacting Bone Grafts and Implanting Iliac Bone Flaps in the Treatment of Osteonecrosis of the Femoral Head: A Mid-term Retrospective Study

Objective

To report the medium‐term outcomes of surgical hip dislocation (SHD) combined with impacting bone grafts and implanting iliac bone flaps in the treatment of osteonecrosis of the femoral head (ONFH) and to define the indications for this treatment.

Methods

This was a single‐center retrospective study. In total, 64 patients (70 hips) with ONFH treated from January 2014 to December 2017 were included in this study. There were 51 males and 13 females aged 18–55 years with an average age of 32 years. All patients underwent surgery for SHD combined with impacting bone grafts and implanting iliac bone flaps. Preoperative and postoperative clinical outcomes were assessed. The clinical outcome was assessed using the Harris hip score (HHS) and the conversion rate of total hip arthroplasty (THA). Univariate and multivariate logistic regression analyses were performed to identify risk factors affecting the clinical outcome. Kaplan–Meier (K‐M) analysis was applied to calculate the survival rate of the femoral head.

Results

At the last follow‐up (60 ± 15.08 months), the HHS was excellent for 41 hips, good for 17 hips, fair for three hips, and poor for nine hips. All nine hips with poor HHS underwent THA, including five in the first 2 years following the index surgery and four between three and 5 years. The conversion rate of total hip arthroplasty was 12.86%. Univariate and multivariate logistic regression analyses showed that the duration of hip pain and JIC classification type were significantly associated with clinical outcomes. Elderly age and advanced ONFH stage tended to lead to worse surgical outcomes. The overall survival rate of JIC classification type C1 and duration of pain ≤6 months was 98.1% and 97.8% at 72 months, respectively, as estimated by the Kaplan–Meier method.

Conclusion

Surgical hip dislocation combined with impacting bone grafts and implanting iliac bone flaps in the treatment of ONFH had a good mid‐term clinical outcome, especially for patients with retention of the lateral column of the femoral head and hip pain less than 1 year.

Hip preserving procedures for osteonecrosis of the femoral head after collapse

Osteonecrosis of the femoral head (ONFH) affects mainly young patients and causes secondary hip osteoarthritis if remains untreated. Several operative treatments have been introduced with successful outcomes in the early stages. However, in late stages of ONFH treatment may be challenging due to the progressive nature of disease and many surgeons prefer arthroplasty option after collapse. Considering the size, age and etiology an effort should be made to preserve hip joint selected patients with early collapse or minimal arthritic changes. The purpose of the current review is to discuss the results of joint preserving procedures for late stages of ONFH.

Femoral cartilage damage occurs at the zone of femoral head necrosis and can be accurately detected on traction MR arthrography of the hip in patients undergoing joint preserving hip surgery

The primary purpose was to answer the following question: What is the location and pattern of necrosis and associated chondrolabral lesions and can they be accurately detected on traction MR arthrography compared with intra-operative findings in patients undergoing hip preservation surgery for femoral head necrosis (FHN)? Retrospective, diagnostic case series on 23 patients (23 hips; mean age 29 ± 6 years) with diagnosis of FHN undergoing open/arthroscopic joint preserving surgery for FHN and pre-operative traction MR arthrography of the hip. A MR-compatible device for weight-adapted application of leg traction (15-23 kg) was used and coronal, sagittal and radial images were acquired. Location and pattern of necrosis and chondrolabral lesions was assessed by two readers and compared with intra-operative findings to calculate diagnostic accuracy of traction MR arthrography. On MRI all 23 (100%) hips showed central FHN, most frequently antero-superiorly (22/23, 96%) where a high prevalence of femoral cartilage damage was detected (18/23, 78%), with delamination being the most common (16/23, 70%) damage pattern. Intra-operative inspection showed central femoral head cartilage damage most frequently located antero-superiorly (18/23, 78%) with femoral cartilage delamination being most common (14/23, 61%). Traction MR arthrography enabled detection of femoral cartilage damage with a sensitivity/specificity of 95%/75% for reader 1 and 89%/75% for reader 2. To conclude, femoral cartilage damage occurs at the zone of necrosis and can be accurately detected using traction MR arthrography of the hip which may be helpful for surgical decision making in young patients with FHN.

Failure and progression to total hip arthroplasty among the treatments for femoral head osteonecrosis: a Bayesian network meta-analysis

INTRODUCTION

Osteonecrosis of the femoral head (ONFH) often leads to secondary osteoarthritis and total hip arthroplasty.

SOURCE OF DATA

Recent published literatures.

AREAS OF AGREEMENT

There has been increasing focus on the early intervention in ONFH patients to preserve the native hip articulation, reduce pain and improve function.

AREAS OF CONTROVERSY

Efficacy of surgical strategies for ONFH is debated. Several clinical studies showed controversial results, and the best treatment has not yet been clarified.

GROWING POINTS

To provide an overview over current treatment options for ONFH compares their failure rates and conversion to total hip arthroplasty (THA) rates.

AREAS TIMELY FOR DEVELOPING RESEARCH

Core decompression (CD) augmented with autologous bone grafting plus the implantation of bone marrow concentrate can decrease the rate of failure and progression to THA rates compared to CD alone.