Color Doppler Imaging Assessment of Blood Flow in Vascularized Pedicle Grafts for Avascular Necrosis of the Femoral Head:

Angiographic Correlation
Jochen Duchow, MD, Rainer Kubale, MD, Thomas Hopf, MD
The aim of this study was to examine whether color Doppler imaging can be used to assess vascular patency after use of pedicle pelvic bone grafts in the operative treatment of avascular necrosis of the femoral head. We performed color Doppler imaging and selective angiography in 10 consecutive patients (12 hip joints) treated for avascular necrosis of the femoral head. In comparison to angiographic results, nine patent and two occluded grafts were demonstrated correctly by color Doppler imaging. In one case, a graft confirmed as patent by angiography was not demonstrable by color Doppler imaging. Accuracy, sensitivity, and specificity of color Doppler imaging were high when compared to angiography as a standard. Color Doppler imaging is suited to evaluate vascular patency after use of vascularized pedicle bone grafts in the treatment of avascular necrosis of the femoral head. KEY WORDS: Color Doppler imaging; Angiography; Bone grafts, vascularized pedicle; Transplants, perfusion.

he implantation of vascularized bone grafts, either pedicled or free, is a currently used joint-preserving treatment for AVN of the femoral head.13 In the evaluation of such operations the demonstration of graft patency is crucial, as alter-

native treatments involve the transplantation of cancellous bone alone.4,5 Usually selective angiographic examinations are performed postoperatively to show transplant patency.1,6,7 This study was performed to examine if transplant perfusion (DCIA) could be assessed noninvasively by CDI. SUBJECTS AND METHODS From 1993 to 1995, 10 consecutive patients (12 hip joints) treated for AVN of the femoral head by pedicled bone grafts originating from the anterior iliac crest were assessed postoperatively. CDI was carried out 3 to 6 months after the operation using an Ultramark 9 HDI (Advanced Technology Laboratories, Bothell, WA) with a 5 MHz linear transducer. Examinations were performed nonblinded by two physicians routinely involved in CDI. With the

ABBREVIATIONS CDI, Color Doppler imaging; AVN, Avascular necrosis; DCIA, Deep circumflex iliac artery

Received January 28, 1998, from the Departments of Orthopedics (J.D.) and Radiology (R.K.), University of the Saarland, Homburg Saar, Germany; and the Department of Orthopedics (T.H.), Krankenhaus der Barmherzigen Brder, Trier, Germany. Revised manuscript accepted for publication May 16, 1998.

1998 by the American Institute of Ultrasound in Medicine J Ultrasound Med 17:509512, 1998 0278-4297/98/$3.50

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patient in supine position the femoral artery was visualized just distal to the inguinal ligament. If possible, the DCIA was then demonstrated at its origin and followed to the femoral neck. If this was not feasible, the vessel was sought close to the transplanted bone graft ventral to the femoral neck. Visualization of flow at the ventral femoral neck was set as the criterion for vessel perfusion. Selective angiographic studies were performed during routine follow-up examination 2 to 5 months after the operation. Time range between angiographic studies and CDI was 1 to 4 months. RESULTS Nine of the 10 patent grafts as confirmed by angiography were correctly demonstrated by CDI. In seven cases the vessel could be followed from its origin to the graft implantation site at the femoral neck (Fig. 1).

Figure 2 shows the corresponding Doppler sonographic tracing. In two patients the DCIA could be identified only near the graft close to the ventral femoral neck. Owing to the small diameter of most of the transplants a reproducible quantification of flow (Doppler tracing) was not possible. An example of a typical postoperative angiogram is shown in Figure 3 (same patient as depicted in Fig. 1); note the absence of major vessels in the region of the ventral femoral neck, which could possibly hinder the sonographic examination or identification of the transplanted DCIA. In one case, a graft confirmed as being patent by angiography was not demonstrable by means of CDI. In this patient, sonographic examination was hindered by periarticular calcifications, which made proper demonstration of the ventral femoral neck anatomy difficult. Neither occluded graft as confirmed with angiography could be demonstrated correctly with CDI (Table 1).

Figure 1 CDI sequence from the left hip joint in one representative patient shows the femoral artery just distal to the inguinal ligament (a) with the DCIA leaving the femoral artery laterally, first ascending (b), then descending to the ventral femoral neck (c).

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Author: Clarify meaning of will help to judge the operative procedure as such.

Figure 2 Pulsed Doppler tracing of the DCIA close to the femoral head with rapid systolic increase and slow diastolic decrease (same patient as in Fig. 1).

DISCUSSION Bone grafting using pedicled bone grafts is a currently used joint-preserving operative procedure in the treatment of AVN of the femoral head. We used a corticocancellous graft derived from the anterior iliac crest with its blood supply coming from the DCIA.8,9 This graft is implanted into the ventral femoral neck after curettage of the necrotic area in the femoral head and filling of the defect with cancellous bone. The postoperative assessment of transplant perfusion is crucial to the further clinical evaluation of the method; other treatments consist of core decompression or curettage and filling of the defect with cancellous bone alone.4,5,10 We have used selective angiography routinely to evaluate graft perfusion after surgery. The results of this nonblinded study suggest that CDI is a useful means in the assessment of postoper-

ative transplant perfusion after pedicled bone grafting of the hip joint. Other investigators, too, have used CDI successfully to evaluate transplant perfusion after different operative procedures, such as those involving the latissimus dorsi and transverse abdominal myocutaneous flaps.11,12 In comparison to routinely performed angiography as a standard, CDI achieved high levels for sensitivity, specificity, accuracy, and positive predictive value. In the single false-negative ultrasonographic result, the sonographer was unable to visualize the area of interest successfully well owing to massive periarticular calcifications. This case clearly demonstrates the limitations of CDI. In such a setting, thorough assessment of routine radiographs should indicate the need to perform angiography and thereby prevent futile attempts to localize the transplant by means of CDI.

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REFERENCES
1. Iwata H, Torii S, Hasegawa Y, et al: Indications and results of vascularized pedicle iliac bone graft in avascular necrosis of the femoral head. Clin Orthop 295:281, 1993 Malizos KN, Soucacos PN, Beris AE: Osteonecrosis of the femoral head: Hip salvaging with implantation of a vascularized fibular graft. Clin Orthop 314:67, 1995 Urbaniak JR, Coogan PG, Gunneson EB, et al: 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] 77:681, 1995 Rosenwasser MP, Garino JP, Kiernan HA, et al: Longterm follow-up of thorough debridement and cancellous bone grafting of the femoral head for avascular necrosis. Clin Orthop 306:17, 1994 Fairbank AC, Bhatia D, Jinnah RH, et al: Long-term results of core decompression for ischaemic necrosis of the femoral head. J Bone Joint Surg Br [Am] 77:42, 1995 Langer R, Scholz A, Langer A, et al: Vascular pedicled pelvic bone span: Value of digital subtraction angiography in pre- and postoperative diagnosis. Digitale Bilddiagn 10:25, 1990 Schwetlick G, Klingmuller V: Superselective angiography as a therapy control of femur head necrosis treated with a vascular pedicled pelvic bone graft. Z Orthop 125:382, 1987 Ganz R, Buechler V: Overview of attempts to revitalize the dead head in aseptic necrosis of the femoral head: Osteotomie and revascularisation. In The Hip. Proceedings of the 11th Open Scientific Meeting of the Hip Society. St. Louis, CV Mosby, 1983 Schwetlick G, Rettig H, Klingmuller V: Vascular pedicled iliac bone graft in therapy of femur head necrosis in the adult: Clinical and angiographic results. Z Orthop 126:500, 1988

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7. Figure 3 Angiogram of the left DCIA in cross-over shows the postoperative anatomy; the vessel can be followed from the femoral artery in a curved manner to the femoral neck. No other arteries with a similar diameter can be seen close by.

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As a noninvasive method, CDI is a feasible alternative to conventional angiography in the specific setting of perfusion assessment after pedicled pelvic bone grafts. The ease of repeating examinations during postoperative follow-up study is an argument for its use. Whether the data concerning transplant perfusion correlate with the long-term clinical outcome will help to judge the operative procedure as such. Table 1: Comparison of CDI and Angiography*
Selective Angiography Positive Negative CDI Positive Negative 9 1 0 2

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10. Ficat P: Idiopathic bone necrosis of the femoral head: Early diagnosis and treatment. J Bone Joint Surg [Br] 67:3, 1985 11. Evans GR, David CL, Loyer EM, et al: The long-term effects of internal mammary chain irradiation and its role in the vascular supply of the pedicled transverse rectus abdominis musculocutaneous flap breast reconstruction. Ann Plast Surg 35:342, 1995 12. Dominici C, Pacifici A, Tinti A, et al: Preoperative and postoperative evaluation of latissimus dorsi myocutaneous flap vascularization by color flow duplex scanning. Plast Reconstr Surg 96:1358, 1995

*Results of postoperative perfusion assessment of the transplanted DCIA by CDI and selective angiography (n = 12 hip joints in 10 patients; table displays data of matched cases). For detection of flow CDI has a sensitivity of 90%, a specificity of 100%, an accuracy of 92%, a positive predictive value of 100%, and a negative predictive value of 66%.