AVN2

This is an enhanced PDF from The Journal of Bone and Joint Surgery
The PDF of the article you requested follows this cover page.
Osteonecrosis of the Hip: Management in the Twenty-first Century

Jay R. Lieberman, Daniel J. Berry, Michael A. Montv, Roy K. Aaron, John J. Callaghan, Amar Rayadhyaksha and
James R. Urbaniak
J. Bone Joint Surg. Am. 84:834-853, 2002.
This information is current as of November 11, 2006
Subject Collections Articles on similar topics can be found in the following collections
Adult Disease (1317 articles)

Hip (535 articles)
Osteonecrosis (63 articles)
Reprints and Permissions Click here to order reprints or request permission to use material from this
article, or locate the article citation on jbjs.org and click on the [Reprints and
Permissions] link.
Publisher Information The Journal of Bone and Joint Surgery
20 Pickering Street, Needham, MA 02492-3157
www.jbjs.org
Downloaded from www.ejbjs.org on November 11, 2006


Selected
The American Academy of Orthopaedic Surgeons

Printed with permission of the D ONALD C. FERLIC
American Academy of EDITOR, VOL. 52
Orthopaedic Surgeons. This article,
as well as other lectures presented C OMMITTEE
at the Academy’s Annual Meeting,
D AVID L. H ELFET
will be available in March 2003 in CHAIRMAN
Instructional Course Lectures,
Volume 52. The complete J AMES H. B EATY
volume can be ordered online D ONALD C. FERLIC
at www.aaos.org, or by TERR Y R. L IGHT
calling 800-626-6726 VINCENT D. PELLEGRINI J R.
(8 A.M.-5 P.M., Central time).
E X -O FFICIO
D EMPSEY S. S PRINGFIELD
DEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY
FOR INSTRUCTIONAL COURSE LECTURES
J AMES D. HECKMAN
EDITOR-IN-CHIEF,
THE JOURNAL OF BONE AND JOINT SURGERY


THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG O S T E O N E C RO S I S O F T H E H I P : M A N A G E M E N T
VO L U M E 84-A · N U M B E R 5 · M AY 2002 IN THE TW E N T Y - F I R S T C E N T U R Y
Osteonecrosis of the Hip:

Management in the
Twenty-first Century
BY JAY R. LIEBERMAN, MD, DANIEL J. BERRY, MD, MICHAEL A. MONT, MD, ROY K. AARON, MD,
JOHN J. CALLAGHAN, MD, AMAR RAYADHYAKSHA, MD, AND JAMES R. URBANIAK, MD
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
Osteonecrosis, also known as avascular cause, for the most part, reported etio- lence of osteonecrosis associated with
necrosis or aseptic necrosis, is a disease logic associations are based not on dislocations of more than twelve hours
of impaired osseous blood flow. The prospective studies but rather on cross- in duration being double that associ-
term aseptic necrosis had been com- sectional and case-control studies. ated with dislocations that are reduced
monly used in the past to distinguish Osteonecrosis can be associated with more promptly 5. Displaced fractures of
osteonecrosis related to nonseptic traumatic or nontraumatic conditions. the femoral neck have been associated
causes from that related to septic Since osteonecrosis eventually develops with a 15% to 50% prevalence of os-
causes. It commonly affects patients in only a relatively small percentage of teonecrosis, depending on fracture
in the third, fourth, or fifth decade of patients with any of these conditions2, type, time until reduction, and accuracy
life. Three hundred thousand to six recent attention has been focused on of reduction6-8. It is presumed that both
hundred thousand people have os- understanding underlying predisposi- hip dislocations and femoral neck frac-
teonecrosis of the femoral head in the tions to the development of osteonecro- tures are associated with mechanical in-
United States. The development of os- sis when challenged by environmental terruption of the circulation to the
teonecrosis can have a major impact on factors. Current interest is centering on femoral head.
an individual’s lifestyle. Since so many genetic mutations leading to hyperco-
of the patients are young when they are agulability, which results in micro- Nontraumatic Osteonecrosis
diagnosed, they often need to alter their thrombosis and osteonecrosis when A variety of etiologic associations with
work and leisure activities. The ultimate challenged by environmental (epige- osteonecrosis have been proposed and
goal of treating osteonecrosis of the hip netic) events. Patients with so-called id- have been more or less convincingly
is preservation of the femoral head. iopathic osteonecrosis most likely have demonstrated. They include cortico-
However, this is difficult since the con- some type of coagulation abnormality steroid intake, excessive alcohol use,
dition is associated with a number of that has not been identified. hemoglobinopathies, and dysbarisms.
different diseases and neither the etiol- Osteonecrosis has been associated with
ogy nor the natural history has been de- Traumatic Osteonecrosis a variety of other medical conditions,
finitively determined. The diagnosis of Osteonecrosis of the femoral head due including Gaucher disease, intraos-
osteonecrosis accounts for 5% to 12% to trauma almost always involves a dis- seous lipid deposition, hypersensitivity
of total hip replacements performed1. placed fracture of the femoral neck or a reactions, Shwartzman reaction, and
hip dislocation. The prevalence of os- conditions associated with thrombo-
Etiology and Risk Factors teonecrosis after hip dislocation has plastin release including pregnancy,
It is difficult to obtain an understanding been reported to be 10% to 25% in vari- malignant tumors, and inflammatory
of the etiologic factors in osteonecrosis ous series2-4. The duration of dislocation bowel disease.
because the clinical composition of may be related to the eventual develop- In cross-sectional studies, 10% to
medical centers varies widely and be- ment of osteonecrosis, with the preva- 30% of the cases of osteonecrosis have


been associated with corticosteroid sis, the mean daily or peak dose, rather <4000 drink-years (with drink-years
administration. However, the few pro- than the cumulative dose or duration of defined as weekly alcohol consumption
spective longitudinal studies that can be therapy, appeared to be associated with multiplied by the number of years of
found in the literature have indicated osteonecrosis11,12. Higher doses, even for drinking) to 9.0 for 10,000 drink-years13,14.
that osteonecrosis may occur in only shorter duration, present greater risks. Osteonecrosis has been associated
8% to 10% of patients exposed to corti- Doses of corticosteroids of >20 mg/day with several hemoglobinopathies includ-
costeroid therapy9. With some diseases, appear to be associated with a higher ing hemoglobin SS (sickle cell disease),
it is difficult to separate the effects on risk of osteonecrosis. The risk of osteo- hemoglobin SC, and sickle thalassemia.
bone of corticosteroids from those of necrosis associated with corticosteroids The reported prevalence of osteone-
the underlying diseases, including min- may be particularly high in patients crosis in these populations has been 4%
eralization defects and osteoporosis as- undergoing renal transplantation, to 20%15,16.
sociated with renal and liver failure, and possibly because of an association of Dysbaric osteonecrosis is largely
vasculitis associated with systemic lu- underlying mineralization defects and of historic interest and now occurs
pus erythematosus. Evidence linking structural weakening of the cancellous quite rarely. It has been associated with
corticosteroids and osteonecrosis is bone. A meta-analysis of twenty-two working environments using com-
largely circumstantial and is based on studies of steroid-associated osteone- pressed air (caisson disease) and with
the association of osteonecrosis with crosis revealed a 4.6-fold increase in the deep sea diving with poorly controlled
corticosteroid therapy in a number of rate of osteonecrosis for every 10 mg/ decompression. Occupational Safety
respiratory and rheumatic conditions day increase in mean daily dose9. and Health Administration standards
and in patients who have undergone Excessive alcohol intake has been mandating atmospheric pressures of
organ transplantation as well as on the identified as an etiologic factor in os- <17 psi and safe decompression sched-
fact that patients with Cushing disease teonecrosis, but difficulties have been ules for divers have made dysbaric os-
have a somewhat higher prevalence of encountered in defining the term exces- teonecrosis relatively uncommon9.
osteonecrosis10. sive. The true prevalence of alcohol-
Finally, the dose of corticosteroids associated osteonecrosis has been dif- Pathophysiology
necessary to induce osteonecrosis is ficult to determine since most reports Contemporary studies of the pathophys-
not known. Dose has been expressed as are cross-sectional. One prospective iology of osteonecrosis have focused on
mean daily dose, peak dose, cumulative study13 suggested that an intake of >400 the vulnerable microcirculation of the
dose, and duration of exposure. In the mL of alcohol per week increased the femoral head and the ischemic conse-
few studies examining the relationship relative risk of osteonecrosis 9.8-fold. quences of microvascular occlusion. The
of corticosteroid dose with osteonecro- The relative risk increased from 2.7 for microcirculation of the femoral head is
Alcohol Corticosteroids
Fig. 1
A concept of pathogenesis of osteonecro- Intravascular

Etiology Trauma coagulation Fat
sis that unifies several hypotheses. Many
emboli
etiologies may contribute to the patho-
genic mechanisms of mechanical inter- Pathogenesis Vascular Thrombotic Extravascular
ruption, thrombotic occlusion, or interruption occlusion compression
extravascular compression. These mech-
anisms all may decrease blood flow, lead-
ing to ischemia and subsequently Decreased
blood flow
to osteocyte necrosis. The presence of
necrotic bone induces a repair process in Pathophysiology
which bone resorption exceeds produc- Ischemia
tion, leading to a loss of structural
integrity of the subchondral trabeculae
Osteocyte necrosis
and eventually to subchondral collapse.
(Reprinted, with permission, from: Aaron
RK. Osteonecrosis: etiology, pathophysi- Repair
ology and diagnosis. In: Callaghan JJ, Histopathology
Rosenberg AG, Rubash HE, editors. The
adult hip. Philadelphia: Lippincott-Raven; Loss of structural integrity
1998. p 457.)
Collapse


high-dose radiation or chemotherapy.

TABLE I Prevalence of Thrombophilic Mutations
The most likely common patho-
General Patients with physiologic event in nontraumatic
Mutation Population Thrombosis osteonecrosis is intravascular coagu-
Factor VLeiden 3%-5% 20% lation and microcirculatory thrombo-
Prothrombin G20210A 1%-3% 5%-10%
sis. Indeed, thrombotic and fat emboli
have been found in both arterioles and
Hyperhomocysteinemia 5%-10% 25% venules in specimens of osteonecrotic
tissue and have been associated with
vulnerable to occlusion both from intra- pathophysiology of osteonecrosis has osteocyte necrosis in some animal
vascular thrombi and from extravascu- recently been presented (Fig. 1)18. This models, if not with full-blown human
lar compression. A 1.6-fold reduction in concept emphasizes the central role of osteonecrosis.
femoral head blood flow reduces local vascular occlusion and ischemia leading Thrombotic occlusion of the mi-
PO2 by one-third17. Osteocyte necrosis to both marrow-cell and osteocyte ne- crocirculation in the femoral head has
occurs after two to three hours of isch- crosis. Vascular occlusion may occur been associated with hypercoagulabil-
emia, although histologic signs of os- through mechanical interruption from ity due to hereditary thrombophilia,
teocyte death are apparent only after fractures or dislocations, intravascular impaired fibrinolysis, antiphospho-
twenty-four to seventy-two hours. Adi- occlusion from thrombi or lipid emboli, lipid antibodies, or hyperlipidemia.
pocyte necrosis and necrosis of hemato- or extravascular compression associated Three thrombophilic mutations occur
poietic marrow occur before osteocyte with intraosseous hypertension. Unusual with some frequency (Table I).
necrosis. A unifying concept of the causes of direct osteocyte death may be Factor V Leiden results from an
TABLE II Radiographic Classifications of Osteonecrosis of the Femoral Head
Classification System Criteria

Ficat and Arlet classification system30,39
Stage I Normal
Stage II Sclerotic or cystic lesions
Stage III Subchondral collapse
Stage IV Osteoarthritis with decreased joint space with articular collapse
University of Pennsylvania system of
classification and staging41
Stage 0 Normal or nondiagnostic radiograph, bone scan, and magnetic resonance imaging
Stage I Normal radiograph; abnormal bone scan and/or magnetic resonance imaging
A Mild (<15% of head affected)
B Moderate (15% to 30% of head affected)
C Severe (>30% of head affected)
Stage II Lucent and sclerotic changes in femoral head
A Mild (<15% of head affected)
B Moderate (15% to 30% of head affected)
C Severe (>30% of head affected)
Stage III Subchondral collapse (crescent sign) without flattening
A Mild (<15% of articular surface)
B Moderate (15% to 30% of articular surface)
C Severe (>30% of articular surface)
Stage IV Flattening of femoral head
A Mild (<15% of surface and <2-mm depression)
B Moderate (15% to 30% of surface or 2 to 4-mm depression)
C Severe (>30% of surface or >4-mm depression)
Stage V Joint narrowing and/or acetabular changes
A Mild
B Moderate
C Severe
Stage VI Advanced degenerative changes


Fig. 2 rosis, suggesting that, of a variety of

A lateral radiograph of etiologic associations, intravascular
the hip, demonstrating coagulation with microcirculatory oc-
the crescent sign. clusion is, indeed, the most likely final
common pathophysiologic pathway for
nontraumatic osteonecrosis.
Clearly defining the pathophysi-
ology of osteonecrosis would enhance
our ability to treat this problem. The
development of osteonecrosis is not due
to one single precipitating event; it is a
multifactorial process. In a study of the
vascular anatomy of ninety-nine hips
undergoing vascularized fibular graft-
ing for osteonecrosis of the femoral
head, ninety-three (94%) had abnormal
vascular patterns. In contrast, in a con-
trol group only 31% had abnormal vas-
cular patterns. Absence or hypoplasia
of the superior capsular artery was the
most common abnormality21. These
findings suggest that there is also a pop-
ulation of patients at risk for osteone-
crosis as a result of anomalies of the
macrovascular circulation of the femo-
ral head.
Diagnosis
A prompt diagnosis of osteonecrosis al-
lows early treatment, which may result
in a better outcome. As with any diag-
arginine-to-glutamine substitution in cell membranes and promote the activa- nosis, the history is critical. A high in-
the factor-V peptide chain because of a tion of soluble clotting factors. dex of suspicion is essential, especially
CGA→CAA mutation. This substitu- Hypercoagulability associated if the patient has one of the atraumatic
tion occurs at the point of cleavage of with any one of these conditions may conditions that are associated with os-
factor V, by its regulatory protein (pro- represent an underlying predisposition teonecrosis. An associated risk factor
tein C), making factor V more resistant for microvascular thrombosis and should be sought out during the initial
to inactivation19. This is measured clini- osteonecrosis20. However, thrombosis evaluation. The most common present-
cally as resistance to activated protein C is a complex event, and more than one ing symptom is a deep pain in the groin.
(RAP-C). Elevations in plasminogen ac- risk factor may be needed to produce The findings on physical examination
tivator inhibitor (PAI-1) and decreases in clinical manifestations. Genetic predis- can be unremarkable or can include
tissue plasminogen activator (tPA) re- position may require one or several pain on internal rotation of the hip, a
sult in impaired fibrinolysis and poorly epigenetic factors to result in clinical decreased range of motion, an antalgic
regulated clotting, leading to hypercoag- disease syndromes. Certain environ- gait, and clicking in the hip when the
ulability. The presence of lipoprotein- mental or acquired risk factors have necrotic fragment has collapsed. Pain
associated antigen Lp(a) has also been been specifically associated with os- with internal rotation of the hip and a
associated with impaired fibrinolysis. teonecrosis, including hyperlipidemia limited range of hip motion are often
Lp(a) has sequence homology with plas- and fat embolism, hypersensitivity and signs that the femoral head has already
minogen and competes for tPA but does endotoxin reactions, and conditions as- collapsed.
not result in a fibrinolytic product. Fi- sociated with thromboplastin release. Radiographic studies are essen-
nally, the presence of circulating an- Local hyperlipidemia and intravascular tial for a definitive diagnosis of the dis-
tiphospholipid antibodies is associated lipid deposits have been noted in pa- ease22-25. Plain radiography should still be
with hypercoagulability. These antibod- tients with corticosteroid or alcohol in- the first step in the diagnostic evaluation.
ies include anticardiolipin antibodies take. Heritable and acquired risk factors Adequate anteroposterior and frog-leg
and lupus anticoagulants. They react for hypercoagulability have been iden- lateral radiographs are essential. Radio-
against a β-2 glycoprotein in endothelial tified in many patients with osteonec- graphic changes in the femoral head


usually occur many months after the early osteonecrosis on magnetic reso- cation systems have been developed,
onset of the disease and include cysts, nance imaging. In one study, >95% of including that of Marcus et al.40, the
sclerosis, or a crescent sign. The cres- such cases did not progress38. University of Pennsylvania system of
cent sign results from subchondral col- classification and staging41, that of the
lapse of the necrotic segment (Fig. 2). Classification and Staging Association Research Circulation Os-
Technetium-99 bone scans were previ- The goal of any classification system is seous42, and that of the Japanese Investi-
ously used for high-risk patients who to provide guidelines for treatment and gation Committee on Osteonecrosis43.
had a negative radiographic examina- prognosis. A number of different classi- The development of the University of
tion. However, recent studies have fication systems have been developed to Pennsylvania system is a major advance-
shown that bone scans have limited evaluate patients with osteonecrosis, ment because it includes findings of
value and are often misleading because but there is no standard unified classifi- magnetic resonance imaging (Table II).
they are false-negative in 25% to 45% of cation system for determining the ex- In addition, in this system the extent of
cases that have been confirmed by mag- tent and location of the necrotic area in the involvement of the femoral head is
netic resonance imaging or histologic the femoral head and the involvement classified as A (<15%), B (15% to 30%),
evaluation25-28. Magnetic resonance imag- of the acetabulum. These are the critical or C (>30%).
ing has become the standard for diag- elements in developing an appropriate
nosing osteonecrosis. It is 99% sensitive treatment plan. Treatment
and specific. A single-density line on Ficat and Arlet originally devel- Core Decompression
the T1-weighted image demarcates the oped a four-stage classification system Core decompression of the hip currently
normal ischemic bone interface, and a based on radiographic changes and the is the most common procedure used to
double-density line on the T2-weighted functional exploration of bone, which treat the early stages of osteonecrosis of
image represents the hypervascular included intraosseous venography and the femoral head. However, despite the
granulation tissue (Figs. 3-A and 3-B). measurement of bone marrow pres- fact that this procedure has been em-
Computed tomography scans and plain sure30,39. A number of different classifi- ployed for approximately three decades
tomograms can identify collapse of the
femoral head. However, they are seldom
Fig. 3
used because of their high cost and the
Fig. 3-A T1-weighted mag-
amount of radiation exposure28,29. Func-
netic resonance image
tional evaluation of bone, which involves
direct measurements of marrow pres- demonstrating a small os-
sure, venography, and biopsy30, it is not teonecrotic lesion on the
widely used at present because of its in- right, a large lesion on the
vasive nature and because of the high ac- left, and loss of signal in-
curacy of magnetic resonance imaging. tensity beyond the lesion
The most important differential on the left. Fig. 3,-B T2-
diagnosis to consider for patients with weighted magnetic reso-
suspected osteonecrosis is transient os- nance image of the right
teoporosis of the hip (Fig. 4)31-37. Tran-
hip, demonstrating the
sient osteoporosis of the hip is a self-
double-line sign, with the
limiting condition that is usually seen in
outer dark line representing
women in the third trimester of preg-
nancy and in men in the fifth and sixth the sclerotic rim and the in-
decades of life. Magnetic resonance im- ner high-intensity, signal line
aging of these patients shows edema into representing hypervascular-
the femoral neck and metaphysis, which ity of the repair zone. (Re-
is not common with osteonecrosis. Os- printed, with permission,
teonecrosis has been reported in 2% to from: Hoffman S, Kramer J,
5% of patients who initially had tran- Plenk H, Kneeland JB. Imag-
sient osteoporosis of the hip. Such pa- ing of osteonecrosis. In: Ur-
tients often have severe pain in the groin
baniak JR, Jones JP, editors.
and an antalgic gait. They are instructed
Osteonecrosis: etiology, di-
to use crutches while the condition re-
solves, which often takes six months. In agnosis and treatment.
addition, one should be cautious about Rosemont, IL: American
instituting aggressive treatment of pa- Academy of Orthopaedic
tients who have changes consistent with Surgeons; 1997. p 218.)


Fig. 4 number of medical conditions, and since

T1-weighted magnetic earlier investigators did not have mag-
resonance image with netic resonance imaging available to
low-intensity signal rep- analyze the extent and location of the os-
resenting bone mar- teonecrotic lesion, it is often difficult to
row edema in the compare the results of different series.
femoral head, neck, This is one explanation for the substan-
and metaphysis consis- tial differences in success rates reported
tent with transient os- in various studies. In addition, core de-
teopenia of bone. compression is a generic term and it is
often accompanied by supplemental
procedures. For example core decom-
pression can be performed alone or
combined with nonvascularized grafts
(allograft bone or demineralized bone
matrix)45,46, vascularized bone grafts (fib-
ula or iliac crest)47-50, electrical stimu-
lation51, or electromagnetic fields52.
We are aware of only a few ran-
domized trials in which the efficacy of
core decompression was assessed. Stul-
berg et al. compared core decompres-
sion alone with conservative treatment
in a prospective, randomized study of
fifty-five hips53. On the basis of Harris
hip scores, operative treatment was suc-
cessful in approximately 70% of hips
and there are numerous reports analyz- the hip? This question is difficult to an- with Ficat Stage-I, II, or III osteonecro-
ing its efficacy, there is no general con- swer because the true natural history of sis. In contrast, nonoperative treatment
sensus regarding either the indications osteonecrosis remains unknown. Fur- was successful for 20% of hips with Fi-
for this procedure or the techniques that thermore, despite numerous studies, cat Stage-I disease, 0% with Stage-II,
optimize results. the true success rate of core decompres- and 10% with Stage-III. The authors
Originally, core decompression sion is difficult to determine because of concluded that core decompression was
was employed by Ficat and Arlet to differences among studies with regard more effective than nonoperative man-
obtain histologic specimens to confirm to selection of patients (i.e., differences agement of early osteonecrosis.
that patients actually had osteonecrosis in patient diagnoses), classification sys- Koo et al. performed a random-
of the femoral head30. Intraosseous tems, operative procedures, postopera- ized trial comparing core decompres-
venography was performed to confirm tive management, and evaluation of sion with nonoperative management in
an abnormal pattern of blood flow clinical outcome44. thirty-seven hips54. Those authors noted
within the femoral head, and bone mar- Osteonecrosis is associated with a radiographic signs of progression in 72%
row pressure was also found to be ele-
vated in these patients30. Ficat and Arlet
then started to use core decompression
as a therapeutic, rather than just as a
diagnostic, procedure30. Since decom-
pression of the femoral head allowed
the intraosseous pressure to return to
normal, it was referred to as a core de-
compression. The goal of a core decom-
pression was to decompress the femoral
head and thereby reduce the intraos-
seous pressure in the femoral head,
restore normal vascular flow, and sub-
sequently alleviate the pain in the hip. Fig. 5
Does core decompression change The fibular graft with the peroneal vessels is harvested from the ipsilateral calf for insertion into
the natural history of osteonecrosis of the core in the femoral neck and head.


throplasty. In contrast to the study by

Stulberg et al. 53, Koo et al. concluded that
there was no important improvement of
outcome when osteonecrosis was treated
with core decompression.
Recently, there have been a num-
ber of extensive literature reviews as-
sessing the clinical results of core
decompression. Smith et al. reviewed
twelve articles, published between 1979
and 1991, that included a total of 702
hips with an average duration of follow-
up of thirty-eight months55. Using the
University of Pennsylvania staging sys-
tem, they reported a successful result in
78% of the Ficat Stage-I hips, 62% of
the Stage-II hips, and 41% of the Stage-
III hips. In another comprehensive lit-
Fig. 6
erature review, Mont et al. assessed
Cancellous bone harvested from the greater tro-
forty-two studies in which a total of
chanteric area is inserted into the cavity formed
1206 hips had been treated with core
by removal of the necrotic bone. The fibular
decompression and 819, with various
graft is inserted into the core tract and stabi-
nonoperative means56. Of the hips
lized with a 0.62-mm Kirschner wire (K). The treated prior to collapse, 71% had a
peroneal veins and artery are anastomosed to good result after core decompression
the ascending branches of the lateral femoral and 35% had a good result after nonop-
circumflex artery (LFCA) and vein. erative management. Overall, a satisfac-
tory clinical result was reported in 64%
of the hips treated with core decompres- patients treated nonoperatively, 79% had of the hips in the twenty-four studies of
sion, and 72% of those hips eventually radiographic signs of progression and core decompression and in only 23% of
required a total hip arthroplasty. Of the 68% eventually required a total hip ar- those in the twenty-one studies of non-
Fig. 7-A Fig. 7-B Fig. 7-C

Figs. 7-A, 7-B, and 7-C Anteroposterior radiographs of the right hip of a thirty-year-old woman who had Ficat Stage-III osteonecrosis of the femoral
head. (Reprinted from: Mont MA, Fairbank AC, Krackow KA, Hungerford DS. Corrective osteotomy for osteonecrosis of the femoral head. The results
of a long-term follow-up study. J Bone Joint Surg Am. 1996;78:1035.) Fig. 7-A Before the osteotomy, there was minimal evidence of collapse of the
femoral head. Fig. 7-B Two months after the corrective osteotomy with insertion of a blade-plate. Fig. 7-C Eleven years postoperatively, despite
some evidence of additional collapse, the patient had done well, with a Harris hip score of 92 points.


operative management. hips with a small area of involvement through the proximal part of the femur.
There have been several fairly large (Stage IA and IIA). In contrast, 39% of Grafting of the femoral head with dem-
retrospective reviews assessing the results the Stage-I hips and 40% of the Stage-II ineralized bone matrix is an attractive
of core decompression performed with hips with involvement of ≥15% of the option because it may enhance the heal-
various techniques55-58. In all of these head (Stages IB, IIB, and IIC) eventually ing potential of the femoral head but it
studies, the authors found that the re- required a total hip arthroplasty. does not change the anatomy of the fem-
sults of core decompression were sub- oral neck if a total hip arthroplasty is
stantially worse when there had been Surgical Technique necessary. However, we are not aware of
collapse of the femoral head preopera- There are a number of different surgical any randomized trials comparing core
tively. Smith et al. retrospectively evalu- techniques for core decompression. decompression alone with core decom-
ated 114 hips and noted a substantial Some surgeons prefer a single core tract, pression combined with use of deminer-
decrease in the rate of satisfactory results whereas others make multiple core holes. alized bone matrix. There is also interest
when a crescent sign had been present55. There is general agreement that these in using growth factors that can enhance
The success rate for Ficat Stage-I hips procedures should be done with fluoro- either the patient’s osteogenic potential
was 81%, but the rates for hips with a scopic guidance in two planes. The pa- (bone morphogenetic protein) or the
crescent sign or definitive collapse were tients are usually placed on a fracture patient’s angiogenic potential (fibroblast
20% and 0%, respectively. In a retro- table. A guide wire should be placed into growth factor or vascular endothelial
spective review of 128 hips, Fairbank et the area of osteonecrosis. It is critical that growth factor). Hopefully, the efficacy of
al. also reported a poor rate of success the starting hole for the core decompres- these growth factors will be evaluated in
(27%; fourteen of fifty-two hips) for pa- sion be made just proximal to the level of future randomized, controlled trials.
tients with collapse of the femoral head57. the lesser trochanter to avoid the devel- Core decompression seems to be
Using the University of Pennsylvania sys- opment of stress fractures in the femur. more effective than symptomatic treat-
tem of classification and staging, Stein- A biopsy specimen should be obtained ment. In order to optimize the results of
berg retrospectively assessed 297 hips in whenever possible to provide definitive core decompression, the osteonecrosis
205 patients who had undergone core confirmation of the diagnosis. Protec- must be diagnosed and treated early.
decompression combined with place- tive weight-bearing with crutches is rec- The prognosis is better when the hip is
ment of a loose cancellous graft in the ommended for a minimum of six weeks treated before collapse, when the lesion
core tract and had been followed for a after the surgical procedure. is smaller, and when there is a sclerotic
minimum of two years58. The author Some surgeons have recom- rim59. In addition, patients who continue
concluded that the stage and site of the mended combining core decompression to take steroids seem to have a worse
lesion clearly influence the results of core with nonvascularized or vascularized prognosis58.
decompression. Total hip arthroplasty grafts to enhance bone formation in the
was required in 22% of the Stage-I and II femoral head and to prevent fracture Free Vascularized Fibular Grafts
The use of vascularized bone grafts to
Fig. 8 treat osteonecrosis of the femoral head
Schematic diagram demonstrating the was developed to prevent collapse of the
cortical window at the femoral head- femoral head and to enhance vascular-
neck junction. The defect within the ization of the bone in this region47-50,60.
femoral head can be filled with autoge- The rationale for management of os-
nous bone graft or various bone-graft
teonecrosis of the femoral head with a
substitutes. Reprinted, with permis-
free vascularized fibular graft is based
on five principles: (1) decompression of
sion, Rosenwasser MP, Garino JP, Kier-
the femoral head, (2) removal of the ne-
nan HA. Michelsen CB. Long term
crotic bone, (3) replacement with fresh
followup of thorough debridement and
autogenous cancellous bone, (4) sup-
cancellous bone grafting of the femo-
port of the subchondral bone with a
ral head for avascular necrosis. Clin
viable strong bone strut, and (5) revas-
Orthop. 1994;306:21. cularization and osteogenesis of the
femoral head.
Full details of the operative pro-
cedure have been provided previously50,
so we will discuss only the highlights of
the technique. With the patient in a lat-
eral decubitus position, two teams op-
erate simultaneously; one performs the
hip exposure, and the other harvests the


ipsilateral fibula (Fig. 5). The proximal Fig. 9-A

part of the femur is exposed through an Preoperative anteropos-
interval between the gluteus medius terior radiograph of the
and the tensor fasciae latae muscles. left hip joint, showing
With use of fluoroscopy, a core (16 to collapse of the femoral
19 mm) is made just distal to the vastus head with an intact joint
ridge and precisely into the necrotic space.
area of the femoral head. Most of the
necrotic bone is removed and is re-
placed with autogenous fresh cancel-
lous bone from the greater trochanteric
area. The sufficiency of the packing of
the cavity with the cancellous bone is
assessed with water-soluble contrast
medium and fluoroscopy. The fibula
with its peroneal artery and two veins is
inserted into the core to within 3 to 5
mm of the subchondral area and is sta-
bilized with a 0.62-mm Kirschner wire
(Fig. 6). With use of microvascular
surgical techniques, the ascending
branches of the lateral femoral cir-
cumflex artery and vein are anasto-
mosed to the peroneal vessels of the
fibula. At the conclusion of the repair,
retrograde flow must be visible from
the exposed endosteum of the fibula.
The average hospital stay is less
than four days. Patients use crutches tained in the patients who had had no (80%) of twenty hips. Scully et al. re-
with non-weight-bearing on the treated collapse of the subchondral bone or ar- ported a retrospective matched-group
side for six weeks and graduate to particular cartilage preoperatively. Unfortu- comparison of patients treated with a
tial weight-bearing in three to six nately, 1021 (67%) of the hips had joint free vascularized fibular graft or core
months, depending on the stage and space narrowing or advanced degenera- decompression63. When evaluating pa-
size of the lesion. tive changes. Of the hips that had not tients with Ficat Stage-III osteonecrosis
Successful results with this tech- had preoperative subchondral or articu- (articular collapse), they found an 81%
nique have been reported at a number lar collapse, 91% had a successful result fifty-month rate of survival of the fem-
of centers48,50,60. In 1995, Urbaniak et al. (no subsequent surgery) after six months oral head (405 of 500 hips) in the group
reported on 103 patients with osteone- to twenty-two years of follow-up. How- treated with the free vascularized fibu-
crosis of the femoral head treated with ever, if collapse had been present, the lar graft compared with a 21% rate (ten
a free vascularized fibular graft50. After success rate was 85%, and if there had of forty-seven hips) in that treated with
a median duration of follow-up of also been joint-space narrowing, it was core decompression. Unfortunately,
seven years (range, 4.5 to 12.2 years), 73%. Of course, it was projected that there have been no large randomized,
thirty-one of the 103 hips had required failure rates would increase with the controlled trials comparing the efficacy
conversion to a total hip arthroplasty. passage of time. of these treatment modalities, to our
Patients with preoperative collapse of The results of core decompression knowledge.
the femoral head had a worse progno- have been compared with those of free Although free vascularized fibular
sis. In an update of their experience, vascularized fibular grafts in two stud- grafts have proven to be successful,
Urbaniak and Harvey analyzed 646 ies. Kane et al. reported a prospective there are some potential disadvantages
consecutive grafts in patients followed study of thirty-nine hips treated with to such an extensive surgical procedure.
for one to seventeen years61. The ex- core decompression or a free vascular- First, complications associated with the
pected ten-year survivorship was 82%. ized fibular graft and followed for two harvesting of the fibula have been
Urbaniak reviewed the results in to five years62. The core decompression noted. In a review of the cases of 198
1523 hips treated with a free vascularized was successful (no subsequent surgery) patients (247 free vascularized fibular
fibular graft for osteonecrosis between in eight (42%) of nineteen hips, whereas grafts), Vail and Urbaniak reported a
1979 and October 1, 2000 (unpublished treatment with the free vascularized 19% rate of complications, including
data). Again, the best results were ob- fibular graft was successful in sixteen motor weakness, subjective discomfort


in the ankle and other sites in the leg, tients. It is a reasonable option for pa- joint. This area is replaced with a seg-
and sensory abnormalities in the lower tients under the age of fifty without ment of articular cartilage of the femo-
limb64. The prevalence of pain in the an- collapse of the femoral head. The proce- ral head that is supported by healthy,
kle and the lower limb increased with dure is more controversial in patients viable bone. Some authors have attrib-
time and was 11.5% at five years after with collapse of the femoral head, and uted the efficacy of osteotomies to the
the operation. In addition, the rate of whether or not it is used should be de- reduction of venous hypertension and
fracture of the proximal part of the fe- termined by the diagnosis, the age of the subsequent decrease in intrame-
mur after use of a free vascularized fib- the patient, and the extent of progres- dullary pressure that occur after such
ular graft in the hip was noted to be sion of the disease. Other treatment procedures82.
2.5% (eighteen of 707) in one large options should be considered for pa- Osteotomies are not widely ac-
series65. The investigators recommended tients over the age of forty with exten- cepted as a standard method of treat-
that the patient remain non-weight- sive involvement of the femoral head ment of osteonecrosis of the femoral
bearing with crutches during the early and evidence of femoral head collapse. head because the outcomes have been
postoperative period. Second, the However, some advocates of the pro- variable and it is difficult to convert
placement of vascularized graft alters cedure consider a vascularized fibular failed cases to a total hip replace-
the bone stock in the femoral neck and graft a treatment option to avoid per- ment66-68,70,77,78,81. It is difficult to com-
calcar region and may make a total hip forming an arthroplasty in patients pare the results of different reports
arthroplasty more difficult to perform. under twenty years of age with even 2 because the series have varied with
It has not been established whether this or 3 mm of collapse and acetabular regard to the patients’ associated risk
procedure has a negative effect on the involvement50. factors, the methods of radiographic
longevity of a total hip prosthesis. staging, the indications for the proce-
If the use of free vascularized fib- Osteotomies dure, and the methods of osteotomy.
ular grafts provides a long-term solu- Various types of osteotomies have been Two main types of osteotomies
tion with respect to preserving the reported for the treatment of osteone- have been utilized: transtrochanteric
femoral head, then the benefits of the crosis of the femoral head66-81. One ra- rotational osteotomies and intertro-
procedure clearly outweigh the risks. tionale for performing an osteotomy is chanteric varus or valgus osteotomies
The relative indications for the proce- based on the biomechanical effect of (usually combined with flexion or ex-
dure in patients with osteonecrosis removing the necrotic or collapsing tension). Transtrochanteric rotational
continue to evolve. At this time, it is segment of the femoral head from the osteotomies were first reported by
generally reserved for symptomatic pa- principal weight-bearing area of the hip Wagner and Zeiler81 in the 1960s, to
our knowledge. They performed a dou-
Fig. 9-B ble osteotomy with a maximum of 180°
Anteroposterior radio- of rotation of the necrotic segment. In
graph of the same hip a cohort of seventy-one patients who
joint three years after lim- had a total of eighty-three rotational
ited femoral resurfacing. osteotomies and were followed for ten
years, the best results were obtained in
patients who had had minimal osteoar-
thritic changes and a small radiographic
combined necrotic angle preoperatively.
(Kerboul et al.68 described the combined
necrotic angle as an estimation of lesion
size. It is calculated by combining the
arc of surface involvement by the os-
teonecrotic lesion on anteroposterior
radiographs with that on lateral radio-
graphs. Small combined necrotic an-
gles are ≤150°, medium angles are
between 151° and 200°, and large angles
are >200°.)
To our knowledge, the best results
with transtrochanteric rotational osteot-
omies were achieved by Sugioka et al. in
Japan, who reported that 229 (78%) of
295 hips had a successful outcome at a
mean of eleven years (range, three to six-


teen years) postoperatively72,80. Other other type of osteotomy should be con- tients were not affected by previous
Japanese surgeons have also reported fa- sidered. Patients with a combined ne- osteotomies86. However, the rate of in-
vorable results with this technically diffi- crotic angle of <200° and under the traoperative complications was 17%
cult procedure79,80. Masuda et al. reported age of forty-five years have a better (eighteen of 105). The problems en-
a good result in thirty-six (69%) of fifty- prognosis68. countered included difficulty in remov-
two hips that were followed for a mean In a study by Scher and Jakim, ing the screws or plate and in reaming
of five years (range, one to ten years)79. valgus osteotomy combined with bone- or broaching the femur. Broken screws
Sugano et al. had a similar success rate grafting was successful in thirty-six were encountered, and some patients
at six years, with a satisfactory result in (80%) of forty-five young patients who had a fracture of the shaft, calcar, or
twenty-three (56%) of forty-one hips71. were not taking corticosteroids70. This greater trochanter. These technical diffi-
However, these success rates in Japan finding is in concordance with the re- culties appear to be manageable as long
have not been reproduced in the United sults in the report by Mont et al., in as the surgeon has prepared for them
States73,75,76. In one representative report, which patients receiving corticoste- preoperatively and intraoperatively.
the procedure failed in fifteen of eighteen roids had a lower rate of clinical suc- On the basis of the results of these
hips that had been followed for a mean cess69. The osteotomy was clinically different studies, the criteria for the se-
of five years75. successful (a Harris hip score of >80 lection of patients for osteotomy include:
The less technically demanding points) in only eleven (65%) of seven- (1) an age of less than forty-five years
varus and valgus osteotomies have been teen hips in the corticosteroid group, and a painful hip; (2) an early post-
utilized commonly in Europe, with whereas it was successful in seventeen collapse or late pre-collapse status of the
variable success rates. In 1965, Merle (85%) of twenty hips in patients who hip, with no narrowing of the joint space
d’Aubigné et al.83 reported good-to- had not received corticosteroids (Figs. or acetabular involvement; (3) a small-
excellent pain reduction in fifty-nine 7-A, 7-B, and 7-C). to-medium lesion (a combined necrotic
(79%) of seventy-five hips with Ficat A major concern about using an angle of ≤200°); and (4) no chronic use
stage-II or III disease that had been fol- osteotomy as an interim procedure is of high doses of corticosteroids.
lowed for one to six years. In a follow- that it may be difficult to convert the
up report from the same institution, osteotomized hip to a total hip arthro- Nonvascularized Bone-Grafting
twenty-eight (60%) of forty-seven hips plasty if necessary. Benke et al. reported Nonvascularized bone-grafting has
were pain-free at a mean of five years68. that the long-term results of 105 total numerous theoretical advantages for
In a report by Maistrelli et al., seventy- hip arthroplasties in ninety-three pa- the treatment of pre-collapse and early
five (71%) of 106 hips in ninety-eight
patients had a successful clinical result Fig. 10-A
at two years postoperatively78. At a mean Anteroposterior radio-
of eight years (range, four to fifteen graph of a failed vascu-
years), sixty-one (58%) of the 106 hips larized fibular graft
had a good or excellent result and only used for treatment of
twenty-four (23%) needed a total hip osteonecrosis of the
replacement or an arthrodesis. Mont et femoral head.
al.69 reported a good or excellent Harris
hip score84 in twenty-eight (76%) of
thirty-seven hips at a mean of 11.5 years
after treatment with varus osteotomy
combined with flexion or extension.
In a number of different series,
the size of the osteonecrotic lesion was
determined to be a critical factor in the
rate of success of the osteotomy70,77,81,85.
Kerboul et al. stressed the importance
of preoperative radiographic evalua-
tion of hips to determine if it is possible
to move the necrotic area away from the
point of maximum pressure with the
acetabulum, which is easier if the lesion
is small68. For example, a varus osteot-
omy is appropriate only if a 20° arc of
the lateral aspect of the femoral head
is free of necrosis. Otherwise, some


post-collapse osteonecrosis of the femo- tilage in the femoral head. techniques. Boettcher et al. reported
ral head when the articular cartilage is Cortical strut-grafting, a proce- clinical and radiographic success in
relatively undamaged87-98. The procedure popularized by Phemister99, Boett- twenty-seven (71%) of thirty-eight
dure provides decompression of the cher et al.90, and Bonfiglio et al.91,92, is hips six years after the use of tibial strut
osteonecrotic lesion, removal of the ne- not commonly used today. This tech- grafts90. However, in a long-term evalua-
crotic bone, and structural support nique involves the removal of an 8 to tion by Smith et al.97 that included the
and scaffolding for repair and remod- 10-mm-diameter cylindrical core of original thirty-eight patients evaluated
eling of subchondral bone. Currently, bone from the femoral head and neck. by Boettcher et al., forty (71%) of fifty-
three distinct approaches can be used to This core tract is then filled with corti- six hips had a poor clinical result after a
introduce bone graft into the femoral cal strut grafts harvested from the il- mean duration of follow-up of fourteen
head; the cortical strut graft can be in- ium, fibula, or tibia. Postoperatively, years (range, four to twenty-seven years).
troduced through (1) a core tract, (2) a protected weight-bearing is used for In a short-term follow-up study (range,
window in the femoral neck (a “light- three to six months. two to four years), Marcus et al. found a
bulb” procedure), or (3) a “trapdoor” A wide range of success rates has satisfactory clinical result in seven of
that is made through the articular car- been reported with cortical strut-grafting eleven hips treated with the Phemister
technique of bone-grafting100. However,
Dunn and Grow reported only four
Fig. 10-B
good results in twenty-three patients so
Anteroposterior radio-
treated93. Buckley et al. reported their re-
graph made after con- sults with a similar procedure involving
version to a core decompression combined with tib-
cementless total hip ial autogenous grafts (three hips), fibu-
arthroplasty. A power lar autogenous grafts (seven hips), or
burr and broaches fibular allografts (ten hips)88. They re-
were used to facilitate ported an excellent clinical result, after a
shaping of the proxi- mean duration of follow-up of eight
mal part of the femur. years (range, two to nineteen years), in
eighteen (90%) of twenty hips that had
Ficat Stage-I or II disease.
Another method of introducing
bone graft is through a window in the
femoral neck. An anterior hip arthrot-
omy is performed through a lateral or
anterolateral approach. A cortical win-
dow is removed from the inferior aspect
of the femoral neck, and the necrotic
bone is excavated from within the fem-
oral head. To our knowledge, Ganz and
Buchler were the first to use this pro-
cedure combined with an osteotomy,
filling the defect of the femoral head
with cancellous bone graft101. This pro-
cedure was modified by Japanese inves-
tigators, who used autogenous cortical
iliac strut grafts94,102. Itoman and Yama-
moto reported a good or excellent clini-
cal result in twenty-three (61%) of
thirty-eight Ficat Stage-II or III hips at
an average of nine years (range, two to
fifteen years) postoperatively94. Scher
and Jakim further modified this proce-
dure by combining a valgus osteotomy
with the autogenous cortical iliac strut
graft70. They reported a good or excel-
lent result in thirty-six (80%) of forty-
five hips at a mean of five years (range,


three to eleven years). a collapsed femoral head, but only DePuy, Warsaw, Indiana) to resurface
The term lightbulb procedure was small numbers of patients have been the articulating surface of the femoral
introduced by Rosenwasser et al.89. In studied89,95,103-105. The procedures that head with a metal component while re-
this procedure, the cortical window is utilize either a window in the femoral surfacing the articulating surface of the
lifted from the femoral head-neck junc- neck or elevation of a flap of cartilage acetabulum with a thin plastic shell in-
tion (Fig. 8). Cancellous bone graft from require extensive surgical dissection, serted with cement. Because of the high
the iliac crest is used to fill the defect in and these techniques need to be as- failure rates on the acetabular side, this
the femoral head after complete evacua- sessed in randomized trials with larger prosthesis is no longer used111-116. How-
tion of the necrotic bone. In their series, numbers of patients in order to deter- ever, use of the femoral cap without
thirteen of fifteen hips were asymptom- mine their true efficacy. However, in the the acetabular resurfacing eliminates
atic at a mean of twelve years (range, ten future, the indications for and efficacy failure secondary to polyethylene wear
to fifteen years). of nonvascularized bone-grafting may or loosening of the acetabular compo-
Another approach to bone- increase with the addition of growth nent. Krackow et al. reported a good-
grafting of the femoral head is through factors and cytokines and the use of to-excellent result of limited femoral
a “trapdoor” that is made through the various bone-graft substitutes. resurfacing in sixteen (84%) of nineteen
articular cartilage of the femoral head. Ficat Stage-III hips at a mean of three
Intraoperatively, the femoral head is Limited Femoral years (range, two to six years)117. Scott et
dislocated and the collapsed segment is Resurfacing Arthroplasty al. reported a good-to-excellent result
exposed. An approximately 2-cm2 flap is Limited femoral resurfacing or hemi- in twenty-two (88%) of twenty-five
elevated from the chondral surface with resurfacing arthroplasty is a viable op- hips that had been followed for a mean
use of scalpels and osteotomes. The ne- tion in young patients with either an of thirty-seven months (range, twenty-
crotic bone is then removed from the extensive pre-collapse lesion or a post- five to sixty months)118. Hungerford et
femoral head with curets and burrs un- collapse lesion without acetabular in- al. followed thirty-three hips from the
til viable bone is reached. This void can volvement (Figs. 9-A and 9-B). This prior two studies and reported a good-
then be filled with various types of au- procedure offers several advantages: (1) to-excellent result in 91% and 61% at
togenous grafts or bone-graft extenders. the damaged cartilage on the femoral five years and 10.5 years, respectively119.
This procedure was first delineated in head is removed, (2) femoral head and In a report by Nelson et al., a cemented
detail by Meyers et al.103,104. The void in neck bone stock is preserved, and (3) titanium-alloy shell was used in twenty-
the femoral head was packed with can- revision to a subsequent total hip ar- one hips, and 86% (eighteen) had a
cellous bone graft. At a mean of three throplasty is not complicated106. When good-to-excellent result at a mean of
years (range, one to nine years), a good- there is moderate-to-severe involve- 6.2 years120. Finally, Beaule et al. re-
to-excellent clinical result was reported ment of the femoral head, a total hip ar- ported on a series of thirty-seven hips
in eight of nine Ficat Stage-III hips. Ko throplasty may be the only alternative. followed for a mean of 6.5 years (range,
et al. modified this technique by adding Since osteonecrosis is a disease that two to eighteen years); a good-to-
a containment osteotomy and reported commonly affects patients in the third, excellent result was found in 79% and
a good-to-excellent result in eight of ten fourth, or fifth decade of life (average 62% at five and ten years, respectively121.
hips at a mean of 4.5 years105. Mont et al. age, thirty-six years), if femoral head Beaule et al. concluded that a longer
subsequently described filling the void resurfacing can consistently delay the duration of preoperative symptoms
in the femoral head with a combina- necessity for a total hip arthroplasty, it was associated with more degenerative
tion of cortical struts and cancellous is a viable treatment option. changes of the acetabulum and that
bone95. At a mean of fifty-six months The principle of limited femoral these patients required revision to a to-
(range, thirty to sixty months), twenty resurfacing originated from the Smith- tal hip arthroplasty sooner.
(83%) of twenty-four Ficat Stage-III Petersen mold arthroplasty107 and other One concern about the use of
hips had a good or excellent clinical re- designs reported by Aufranc, Luck, and limited femoral resurfacing as an in-
sult, whereas only two of six Ficat Stage- Thomine108. Langlais et al. reviewed the terim treatment is the possible difficulty
IV hips were considered to have a suc- results of eighty-six adjusted cup arthro- of conversion to a total hip arthroplasty.
cessful result. plasties of different designs and re- Revision of the TARA device to a total
There is no consensus regarding ported 85% good-to-excellent results at hip arthroplasty was difficult because of
the indications for nonvascularized a mean of 6.5 years109. These particular the osteolysis caused by the particulate
bone-grafting. Proponents of these cup prostheses were press-fit to the debris generated by wear of the polyeth-
procedures recommend them for hips reamed femoral head. However, this ylene acetabular component. However,
with <2 mm of femoral head depression procedure fell out of favor as a result of with the use of a femoral head com-
or those in which a core decompression the advances in total hip arthroplasty ponent as a hemiresurfacing device,
has failed and there is no acetabular that increased longevity and durability. osteolysis is no longer an issue. The
involvement. Some investigators have Townley110 designed a total arti- operative procedure of converting a
reported good results in patients with cular resurfacing arthroplasty (TARA; hemiresurfacing arthroplasty to a total


hip arthroplasty is similar in difficulty than do other treatment procedures. plasty performed for osteonecrosis of
to a primary total hip arthroplasty119,122. There is a wide range of opinions the femoral head and reported groin
In one study, thirteen (39%) of thirty- concerning the indications for total hip pain in 42% of patients124. Cabanela re-
three limited femoral resurfacing de- arthroplasty in the treatment of os- ported that the results of bipolar ar-
vices were converted to a total hip ar- teonecrosis of the femoral head. Never- throplasty were poorer than those of
throplasty at a mean of sixty months theless, a consensus has emerged about total hip arthroplasty in patients with
(range, thirty-six to 136 months)119. some circumstances in which total hip osteonecrosis of the femoral head125.
These thirteen total hip arthroplasties arthroplasty is clearly indicated and The less predictable results of hemiar-
were all successful clinically (a Harris some in which it is not. The main indi- throplasty in comparison with those of
hip score of at least 80 points) at a mean cations for total hip arthroplasty are (1) total hip arthroplasty may be related to
of thirty months (range, twenty-four to osteonecrosis of the femoral head and pain that occurs when only one side of
seventy-two months). Ash et al. re- associated advanced secondary degen- the joint is resurfaced (particularly in
ported on fifty-eight hips in which a erative arthritis with severe damage of young active patients) and may also be
cup arthroplasty was converted to a to- the femoral head articular cartilage and explained by the finding that the ace-
tal hip arthroplasty with cement122. A loss of acetabular cartilage123, and (2) an tabular articular cartilage of many pa-
satisfactory clinical result was found in older or low-demand patient with ex- tients with osteonecrosis of the femoral
92% and 74% of the hips at ten and tensive involvement or collapse of the head is histologically abnormal even
twenty years, respectively, and there femoral head as well as sufficient symp- before radiographs demonstrate loss
were no cases of femoral loosening. toms to justify total hip arthroplasty. of joint space126. Thus, the acetabular
Further study is required to deter- For both of these patient groups, total cartilage is predisposed to degenerative
mine the specific indications for femo- hip arthroplasty is the most reliable change when only the femoral head is
ral head resurfacing. There is general method for providing pain relief and replaced or resurfaced. The amount
agreement that patients do better if this prompt functional return with a single of acetabular cartilage abnormality
procedure is performed prior to the de- operation. The main groups in whom correlates with the degree of femoral
velopment of substantial degeneration total hip arthroplasty is contraindi- head collapse127.
of the acetabular cartilage. Potential cated are (1) young patients with early- The most controversial issue with
candidates for limited resurfacing of the stage osteonecrosis of the femoral head regard to the results of total hip arthro-
femoral head include (1) young patients for whom treatment options that save plasty for the treatment of osteonecrosis
with no or minimal degeneration of the the femoral head are available, and (2) is the durability of the prosthesis rela-
acetabular cartilage presenting with ei- patients at excessively high risk for tive to that in patients with osteoarthri-
ther a crescent sign or collapse of the complications of total hip arthroplasty tis. One body of literature suggests that
femoral head and (2) young patients (for example, those with severe ongoing total hip prostheses in patients with os-
without femoral head collapse but with ethanol abuse who might be at excessive teonecrosis of the femoral head are less
extensive osteonecrotic involvement of risk for dislocation of a total hip pros- durable than those in the general pa-
the femoral head (a combined necrotic thesis). A relatively large number of tient population128, while another body
angle of >200° or femoral head involve- patients, particularly those in middle of literature suggests that osteonecrosis
ment of >50%). However, patients need age with variable amounts of femoral of the femoral head itself is not a risk
to be cautioned that the degree of pain head involvement and femoral head factor for failure of total hip arthro-
relief following a femoral head resurfac- collapse, fall into a gray zone in which plasty129,130. Ritter and Meding found no
ing procedure (Fig. 9-B) is not as con- total hip arthroplasty is one of several significant difference between the long-
sistent as that following a total hip reasonable treatment options, including term complication rate after sixty-four
arthroplasty and that patients fifty years resurfacing hemiarthroplasty. total hip arthroplasties performed for
of age or older may be better off with a Total hip arthroplasty has pre- osteonecrosis and that after sixty-five
total hip arthroplasty. dictably provided excellent pain relief total hip arthroplasties performed for
and functional improvement for pa- osteoarthritis129. Xenakis et al. com-
Total Hip Arthroplasty tients with osteonecrosis of the femoral pared twenty-nine total hip arthroplas-
Of the many different operations that head, just as it has for patients with ties performed for osteonecrosis with
are available to treat osteonecrosis of the other diagnoses, such as osteoarthritis twenty-nine performed for osteoar-
femoral head, total hip arthroplasty is or inflammatory arthritis. Several au- thritis130. At a mean of between seven
the single treatment with the highest thors have demonstrated that total hip and eight years, there was no signifi-
likelihood of providing excellent early arthroplasty provides more complete cant difference in the failure rate be-
pain relief and a good functional out- and reliable pain relief than does hemi- tween the two groups, which were also
come. These advantages of total hip ar- arthroplasty for patients with osteone- equivalent with regard to postoperative
throplasty must be balanced against the crosis of the femoral head124,125. Ito et al. pain, function, and improvement in hip
fact that it sacrifices more host bone and evaluated forty-eight hips at a mean of scores. In contrast, in an evaluation of
narrows future operative options more 11.4 years after bipolar hemiarthro- the variables associated with implant


durability in a large group of total hip tal hip prostheses remains unresolved and the ten-year survivorship was
arthroplasties with cement, Sarmiento because it has proven difficult to disen- 85.7%. The authors concluded that sec-
et al. concluded that the diagnosis of tangle the variables involved. Most pa- ond-generation cementing techniques
osteonecrosis had a negative impact131. tient cohorts with osteonecrosis may improved results but the failure rate was
Saito et al. compared twenty-nine total have a high percentage of individuals still high.
hip arthroplasties performed for os- with demographic factors and under- A number of reports on unce-
teonecrosis with sixty-three performed lying diagnoses that also put them at mented femoral components have dem-
for osteoarthritis and found a higher higher risk for mechanical failure of the onstrated good implant fixation and
failure rate in the patients with osteo- arthroplasty. In addition, many of these durability. Fye et al. reported a 94% rate
necrosis132 . However, the group with patients are young and active or may of good or excellent clinical results and
osteonecrosis had a different gender have poor bone quality secondary to a 98% eleven-year rate of survival of
distribution and mean weight than chronic corticosteroid use, ethanol selected uncemented femoral stems in
the patients with osteoarthritis. Finally, abuse, or sickle cell disease136-138. Whether a large series of total hip arthroplasties
Ortiguera et al. compared 178 patients something about osteonecrosis of the performed in young patients with
with osteonecrosis with a group with femoral head itself leads to changes in the osteonecrosis145. In a study of twenty-
osteoarthritis matched by age, sex, bone around the hip joint and poorer nine patients with osteonecrosis treated
surgeon, and implant (all cemented implant durability remains uncertain. with an uncemented stem, Xenakis et al.
Charnley total hip prostheses)133. At a However, it is likely that at least some of found only one femoral failure at a
mean of 17.8 years, there was no signifi- the reported problems with the durabil- mean of 7.1 years postoperatively130.
cant difference between groups with re- ity of total hip prostheses in patients Piston et al. reported on thirty-five
gard to the durability of the total hip with osteonecrosis can be explained by total hip arthroplasties performed with
prosthesis in patients over fifty. How- patient demographics and the underly- a porous-coated uncemented stem in
ever, in the group of thirty-five patients ing diagnoses leading to osteonecrosis patients with osteonecrosis; at a mean
who were less than fifty years old, those rather than by the osteonecrosis itself. of 7.5 years (range, five to ten years),
with osteonecrosis had a significantly The reported results of total hip 94% of the stems demonstrated bone
greater risk of mechanical failure than arthroplasty, with and without cement, ingrowth and only one had been
did the matched osteoarthritis cohort for patients with osteonecrosis of the revised140. D’Antonio et al. found no
(p < 0.05)133. femoral head vary with the success of the stem failures, after a minimum of five
The underlying diagnosis associ- specific implants used in each series and years, in fifty-three hips treated with a
ated with osteonecrosis of the femoral with the demographic features of the hydroxyapatite-coated uncemented
head appears to have an impact on im- patients in each cohort. Despite the dif- femoral stem for osteonecrosis146. Good
plant durability. Chiu et al. compared ficulty of comparing different series, results with the use of uncemented
thirty-six cementless total hip arthro- several generalizations can be made. On stems in patients with osteonecrosis of
plasties performed for osteonecrosis the acetabular side, the greatest problem the femoral head mostly have been
with thirty-six performed for osteo- with cemented sockets has been loosen- achieved with implant designs that also
arthritis134. Of the patients with osteo- ing and the greatest problems with unce- have had a high success rate in the gen-
necrosis, those who used corticosteroids mented sockets have been polyethylene eral hip arthroplasty population.
or abused ethanol had worse prosthetic wear and periprosthetic osteolysis139-141. Patients with osteonecrosis of the
durability than did the group with os- On the femoral side, components ce- femoral head, in general and in certain
teoarthritis, but there was no difference mented with early techniques have had subgroups, may be at increased risk for
in prosthetic durability between the pa- a high failure rate in patients with os- specific complications of total hip ar-
tients with posttraumatic or idiopathic teonecrosis in most reports. However, a throplasty. Patients being managed
osteonecrosis and those with osteoar- number of studies have demonstrated with immunusuppression (such as
thritis. Brinker et al. reported on ninety improved results with modern cementa- long-term corticosteroid therapy or
young patients (mean age, 39.9 years) tion methods142-144. Garino and Steinberg post-transplant regimens) may be at
treated with total hip arthroplasty for reported on 123 cemented and hybrid increased risk for infection. There is
osteonecrosis135. Patients who were under total hip arthroplasties performed with some evidence that patients with os-
thirty-five years of age at the time of the second-generation cement techniques teonecrosis of the femoral head may be
total hip arthroplasty had a high failure in patients with osteonecrosis142 . At two at higher risk for postoperative dislo-
rate, and the results varied by underly- to ten years, the overall revision rate was cation134. This risk may be higher be-
ing diagnosis. Patients with systemic only 4%. Kantor et al. reviewed the re- cause specific subgroups (such as
lupus erythematosus or an organ trans- sults of twenty-four total hip arthroplas- ethanol abusers) are at risk for disloca-
plant had worse results than did those ties performed for osteonecrosis with tion or because patients with osteone-
with idiopathic osteonecrosis of the fem- second-generation femoral cementing crosis of the femoral head frequently
oral head. The effect of osteonecrosis of techniques143; at a mean of 7.7 years, have less capsular hypertrophy than pa-
the femoral head on the longevity of to- three had been revised for loosening, tients with osteoarthritis and therefore


TABLE III Treatment Algorithm According to the University of Pennsylvania System of Classification and Staging41
Radiographic Stage Symptoms Procedure

I and II Asymptomatic Observation, pharmacological treatment,
possible core decompression ± bone-grafting
IA, IB, IC, IIA, IIB, and IIC Symptomatic Core decompression ± bone-grafting, vascularized graft
IC, IIC, IIIA, IIIB, IIIC, and IVA Symptomatic Bone-grafting (vascularized or nonvascularized), osteotomy,
limited femoral head resurfacing, total hip arthroplasty
IVB and IVC Symptomatic Limited femoral head resurfacing, total hip arthroplasty
V and VI Symptomatic Total hip arthroplasty
may have less optimal soft-tissue re- cortical grafts led to suboptimal im- throplasty for as long as possible. When
straints against dislocation. plant position in the coronal plane in this disease is diagnosed in a younger
Specific technical issues are im- ten of thirteen hips147. Milling tech- patient, it may be advisable to perform
portant to consider when total hip ar- niques and high-speed burrs can help to the most conservative surgical proce-
throplasty is performed for patients remove the sclerotic bone safely, and dure possible with the knowledge that a
with osteonecrosis of the femoral head. intraoperative radiographs are re- future intervention may be necessary.
Patients with risk factors for dislocation commended for checking of broach There are a number of findings
such as ethanol abuse may be consid- alignment. on plain radiographs and magnetic res-
ered candidates for specific measures to There is a good likelihood that to- onance images that clearly should influ-
reduce the risk of dislocation, such as an tal hip arthroplasty will provide excel- ence the choice of treatment. First, it
anterolateral operative approach or lent pain relief and function for patients is essential to determine whether the
methods of enhanced posterior soft- with osteonecrosis of the femoral head. femoral head has collapsed. A good in-
tissue repair with the posterior ap- The durability of total hip prostheses in dication of collapse is the crescent sign,
proach. Implant choice is based on the cohorts with osteonecrosis of the femo- which can be seen on radiographic
preference and experience of the sur- ral head may be poorer than the dura- examination, especially the frog-leg lat-
geon, but the individual patient’s cir- bility in the general population, in part eral view. The crescent sign represents
cumstances also should be kept in mind. because of patient demographics and subchondral collapse or fracture. In
For example, a young, active, healthy reduced bone quality in some patient general, once the femoral head has col-
patient with good bone might be con- subgroups. Good surgical technique lapsed, the success of procedures such
sidered a good candidate for an un- and implant choice may minimize the as core decompression or vascularized
cemented implant and an alternative negative impact of osteonecrosis of the fibular grafting decreases substantially.
bearing surface, whereas an older, sicker femoral head on implant durability. The second factor is the size and lo-
patient with poor bone stock might be Osteonecrosis of the femoral head is cation (extent of involvement of the
better treated with hybrid or cement fix- associated with a disparate group of weight-bearing surface) of the lesion.
ation. When total hip arthroplasty is diagnoses and affects patients with very Studies have shown that both the size
performed in patients with osteonecro- different levels of activity and bone and the location of the lesion are cru-
sis of the femoral head but without quality. Individualizing operative tech- cial in determining both clinical and
advanced secondary arthritis, the ace- nique and implant choice accordingly radiographic outcomes148,149. Size and
tabular bone may not be as hard or may help to optimize results and to location can be determined on plain
sclerotic as the bone in most osteoar- minimize complications of total hip radiographs or magnetic resonance
thritic hips. When implanting a socket arthroplasty in these patients. images148. Clearly, if there is extensive
without cement, the surgeon should be involvement of the femoral head (>30%)
aware that this weaker acetabular bone Potential Treatment Algorithim and almost complete involvement of
may be at greater risk for fracture. The Since osteonecrosis presents with a wide the weight-bearing surface, then the
femoral anatomy may have been altered spectrum of disease, a number of differ- success rate of procedures that save the
by a previous osteotomy, core decom- ent treatment modalities are appropri- femoral head will be decreased, and this
pression, or bone graft. Previous bone ate depending on the age and diagnosis must be discussed with the patient. The
grafts in the femoral neck and head can of the patient, the extent and location of third factor is the amount of depres-
leave behind hard sclerotic bone that is the osteonecrosis, and whether the fem- sion of the femoral head. Treatment of
difficult to shape with rasps or broaches oral head has collapsed. The primary patients who have femoral head depres-
and can force instruments and implants goals of treatment should be to relieve sion is somewhat controversial. Some
into malposition (Figs. 10-A and 10-B). pain, to maintain a congruent hip joint, surgeons attempt bone-grafting proce-
Fehrle et al. found that previous tibial and to delay the need for a total hip ar- dures if the collapse is <2 mm, whereas


others believe that some type of arthro- should be performed. Some authors Daniel J. Berry, MD
plasty should be performed because have recommended hip arthroscopy to Mayo Clinic, 200 First Street S.W., Rochester,
of the inconsistent results and limited assess the cartilage prior to performing MN 55905
data available on the efficacy of bone- a vascularized fibular graft procedure, Roy K. Aaron, MD
grafting in these patients. There is gen- but further study of the efficacy of this 100 Butler Drive, Providence, RI 02906
eral agreement that patients with >2 diagnostic step is necessary150.
mm of femoral head depression should On the basis of the aforemen- Michael A. Mont, MD
have an arthroplasty. The final factor in tioned treatment criteria, we developed 2401 West Belvedere Avenue, Baltimore, MD
the choice of treatment of osteonecro- an algorithm that uses the University 21215
sis of the femoral head is acetabular in- of Pennsylvania radiographic classifi- John J. Callaghan, MD
volvement. If the acetabular cartilage is cation of the disease. These are just gen- University of Iowa Health Care, 200 Hawkins
markedly involved, total hip arthro- eral guidelines. A treatment program Drive, Iowa City, IA 52242
plasty is the only appropriate surgical must be individualized for each patient
treatment. (Table III). Amar Rayadhyaksha, MD
An intraoperative assessment of Osteonecrosis remains a difficult 2401 West Belvedere Avenue, Baltimore, MD
21215
the femoral head and/or acetabular car- condition to treat because of our lack
tilage is necessary if one is considering of understanding of the etiology of the James R. Urbaniak, MD
performing a bone-grafting procedure disease and because it often affects Division of Orthopaedic Surgery, Department
that involves elevation of the cartilage, a young patients during the prime of of Surgery, Duke University Medical Center,
window in the femoral neck, or a lim- their lives. The multitude of treatment Box 2912, Durham, NC 27710
ited femoral head resurfacing. The in- modalities being employed confirms
Printed with the permission of the American
traoperative examination is essential to both a lack of consensus and the diffi-
Academy of Orthopaedic Surgeons. This arti-
confirm findings seen on radiographs culty in successfully treating these pa- cle, as well as other lectures presented at the
or magnetic resonance images. For ex- tients. The availability of growth factors Academy’s Annual Meeting, will be available in
ample, preoperatively, one might plan that will promote bone formation and March 2003 in Instructional Course Lectures,
a bone-grafting procedure of the femo- angiogenesis may revolutionize treat- Volume 52. The complete volume can be
ral head, but if the femoral head carti- ment of this condition. Hopefully, ordered online at www.aaos.org, or by calling
lage is noted to be damaged and the research efforts to enhance our under- 800-626-6726 (8 A.M.-5 P.M., Central time).
acetabular cartilage is seen to be pris- standing of the pathophysiology of this The authors did not receive grants or outside
tine at the time of the operation, a disease will enable us to improve our funding in support of their research or prepa-
limited femoral resurfacing would be ability to treat patients with osteone- ration of this manuscript. They did not receive
appropriate. However, if the femoral crosis of the hip in the future. payments or other benefits from a commercial
head and acetabular cartilage appear entity. A commercial entity (DePuy, a Johnson
healthy and undamaged, the bone- and Johnson company) paid or directed, or
Jay R. Lieberman, MD agreed to pay or diret, benefits to a research
grafting procedure is a reasonable op- Department of Orthopaedic Surgery, Univer- fund, foundation, educational institution, or
tion. If degeneration of the acetabular sity of California at Los Angeles Medical Cen- other charitable or nonprofit organization
cartilage is noted on intraoperative ex- ter, 10833 LeConte Avenue, 76-134 CHS, Los with which one of the authors (D.J.B.) is affili-
amination, then a total hip arthroplasty Angeles, CA 90095 ated or associated.
References
1. Mont MA, Hungerford DS. Non-traumatic avas- 7. Garden RS. Malreduction and avascular necrosis in systemic lupus erythematosus. Am J Med.
cular necrosis of the femoral headJ Bone Joint in subcapital fractures of the femur. J Bone Joint 1985;79:596-604.
Surg Am. 1995;77:459-74. Surg Br. 1971;53:183-97.
13. Matsuo K, Hirohata T, Sugioka Y, Ikeda M,
2. Cruess RL. Steroid-induced osteonecrosis. J R 8. Jacobs B. Epidemiology of traumatic and non- Fukuda A. Influence of alcohol intake, cigarette
Coll Surg Edinb. 1981;26:69-77. traumatic osteonecrosis. Clin Orthop. 1978; smoking, and occupational status on idiopathic
130:51-67. osteonecrosis of the femoral head. Clin Orthop.
3. Roeder LF Jr, DeLee JC. Femoral head fractures
1988;234:115-23.
associated with posterior hip dislocation. Clin 9. Felson DT, Anderson JJ. Across-study evalua-
Orthop. 1980;147:121-30. tion of association between steroid dose and 14. Ono K, Sugioka Y. Epidemiology and risk fac-
bolus steroids and avascular necrosis of bone. tors in avascular osteonecrosis of the femoral
4. Upadhyay SS, Moulton A, Srikrishnamurthy K. head. In: Schoutens A, Arlet J, Gardeniers JWM,
Lancet. 1987;1:902-6.
An analysis of the late effects of traumatic pos- Hughs SPF, editors. Bone circulation and vascu-
terior dislocation of the hip without fractures. J 10. Jones JP Jr. Etiology and pathogenesis of os- larization in normal and pathologic conditions.
Bone Joint Surg Br. 1983;65:150-2. teonecrosis. Semin Arthroplasty. 1991;2:160-8. New York: Plenum; 1993. p 243-8.
5. Brav EA. Traumatic dislocation of the hip. Army 11. Vakil N, Sparberg M. Steroid-related osteonecro- 15. Tanaka KD, Clifford GO, Axelrod AR. Sickle cell
experience and results over a twelve-year pe- sis in inflammatory bowel disease. Gastroenter- anemia (Homozygous S) with aseptic necrosis
riod. J Bone Joint Surg Am. 1962;44:1115-34. ology. 1989;96:62-7. of the femoral head. Blood. 1956;11:998-1008.
6. Barnes R, Brown JT, Garden RS, Nicoll EA. Sub- 12. Zizic TM, Marcoux C, Hungerford DS, 16. Barton CJ, Cockshott WP. Bone changes in
capital fractures of the femur. A prospective re- Dansereau JV, Stevens MB. Corticosteroid ther- hemoglobin SC disease. Am J Roentgenol.
view. J Bone Joint Surg Br. 1976;58:2-24. apy associated with ischemic necrosis of bone 1962;88:523-32.


17. Kiaer T, Pedersen NW, Kristensen KD, Star- 33. Potter H, Moran M, Schneider R, Bansal M, sults of vascularized pedicle iliac bone graft in
klint H. Intra-osseous pressure and oxygen Sherman C, Markisz J. Magnetic resonance avascular necrosis of the femoral head. Clin
tension in avascular necrosis and osteoarthri- imaging in diagnosis of transient osteoporosis Orthop. 1993;295:281-8.
tis of the hip. J Bone Joint Surg Br. 1990;72: of the hip. Clin Orthop. 1992;280:223-9.
50. Urbaniak JR, Coogan PG, Gunneson EB, Hunley
1023-30.
34. Takatori Y, Kokubo T, Ninomiya S, Nakamura T, JA. Treatment of osteonecrosis of the femo-
18. Aaron RK. Osteonecrosis: etiology, patho- Okutsu I, Kamogawa M. Transient osteoporo- ral head with free vascularized fibular graft-
physiology, and diagnosis. In: Callaghan JJ, sis of the hip. Magnetic resonance imagining. ing. A long-term follow-up study of one
Rosenberg AG, Rubash HE, editors. The Clin Orthop. 1991;271:190-4. hundred and three hips. J Bone Joint Surg
adult hip. Philadelphia: Lippincott-Raven; Am. 1995;77:681-94.
35. Turner DA, Templeton AC, Selzer PM, Rosen-
1998. p 451-66.
berg AG, Petasnick JP. Femoral capital os- 51. Steinberg ME, Larcom PG, Stafford BB, Hosick
19. Rosendaal FR, Koster T, Vandenbroucke JP, teonecrosis: MR findings of diffuse marrow WB, Corces A, Bands RE, Hartmann KM. Treat-
Reitsma PH. High risk of thrombosis in pa- abnormalities without focal lesions. Radiology. ment of osteonecrosis of the femoral head by
tients homozygous for factor V Leiden (acti- 1989;171:135-40. core decompression, bone grafting, and electri-
vated protein C resistance). Blood. 1995;85: cal stimulation. In: Urbaniak JR, Jones JP, edi-
36. Unger E, Moldofsky P, Gatenby R, Hartz W,
1504-8. tors. Osteonecrosis: etiology, diagnosis, and
Broder G. Diagnosis of osteomyelitis by MR
20. Aaron RK, Ciombor DM. Coagulopathies and treatment. Rosemont; IL: American Academy of
imaging. AJR Am J Roentgenol. 1988;150:
osteonecrosis. Curr Opin Orthop. 2001;12: 605-10. Orthopaedic Surgeons; 1997. p 293-9.
370-83. 52. Aaron RK, Lennox D, Bunce GE, Ebert T. The
37. Guerra JJ, Steinberg ME. Distinguishing
21. Wheeless CR, Lins RE, Knelson MH, Urbaniak transient osteoporosis from avascular necro- conservative treatment of osteonecrosis of fem-
JR. Digital subtraction angiography in patients sis of the hip. J Bone Joint Surg Am. 1995; oral head. A comparison of core decompression
with osteonecrosis of the femoral head. In: Ur- 77:616-24. and pulsing electromagnetic fields. Clin Orthop.
baniak JR, Jones JP, editors. Osteonecrosis: etiol- 1989;249:209-18.
38. Kopecky KK, Braunstein EM, Brandt KD, Filo
ogy, diagnosis, and treatment. Rosemont, IL: 53. Stulberg BN, Davis AW, Bayer TW, Levine M,
RS, Leapman SB, Capello WN. Apparent avas-
American Academy of Orthopaedic Surgeons; Easley K. Osteonecrosis of the femoral head.
cular necrosis of the hip: appearance and
1997. p 241-5. A prospective randomized treatment protocol.
spontaneous resolution of MR findings in
22. Norman A, Bullough P. The radiolucent crescent renal allograft recipients. Radiology. 1991; Clin Orthop. 1991;268:140-51.
line—an early diagnostic sign of avascular ne- 179:523-7. 54. Koo KH, Kim R, Ko GH, Song HR, Jeong ST,
crosis of the femoral head. Bull Hosp Joint Dis. Cho SH. Preventing collapse in early osteone-
39. Ficat RP. Idiopathic bone necrosis of the femo-
1963;24:99-104. crosis of the femoral head. A randomised clini-
ral head. Early diagnosis and treatment. J Bone
23. Steinberg ME, Steinberg DR. Avascular necro- Joint Surg Br. 1985;67:3-9. cal trial of core decompression. J Bone Joint
sis of the femoral head. In: Steinberg ME, edi- Surg Br. 1995;77:870-4.
40. Marcus ND, Enneking WF, Massam RF. The si-
tor. The hip and its disorders. Philadelphia: WB 55. Smith SW, Fehring TK, Griffin WL, Beaver WB.
lent hip in ideopathic aseptic necrosis. Treat-
Saunders; 1991. p 623-47. Core decompression of the osteonecrotic femo-
ment by bone grafting. J Bone Joint Surg Am.
24. Totty WG, Murphy WA, Ganz WI, Kumar B, 1973;55:1351-66. ral head. J Bone Joint Surg Am. 1995;77:674-80.
Daum WJ, Siegel BA. Magnetic resonance imag- 56. Mont MA, Carbone JJ, Fairbank AC. Core de-
41. Steinberg ME, Hayken GD, Steinberg DR. A
ing of the normal and ischemic femoral head. compression versus nonoperative management
quantitative system for staging avascular necro-
AJR Am J Roentgenol. 1984;143:1273-80. for osteonecrosis of the hip. Clin Orthop. 1996;
sis. J Bone Joint Surg Br. 1995;77:34-41.
25. Beltran J, Herman LJ, Burk JM, Zuelzer WA, 324:169-78.
42. ARCO (Association Research Circulation
Clark RN, Lucas JG, Weiss LD, Yang A. Femo- 57. Fairbank AC, Bhatia D, Jinnah RH, Hungerford
Osseous). Committee on Terminology and
ral head avascular necrosis: MR imaging with DS. Long-term results of core decompression
Classification. ARCO News. 1992;4:41-6.
clinical-pathologic and radionuclide correlation. for ischaemic necrosis of the femoral head.
Radiology. 1988;166:215-20. 43. Ohzono K, Salto M, Sugano N, Takaoka K, Ono J Bone Joint Surg Br. 1995;77:42-9.
K. The fate of nontraumatic avascular necro-
26. Jiang CC, Shih TT. Epiphyseal scar of the femo- 58. Steinberg ME. Core decompression. Semin
sis of the femoral head. A radiologic classifica-
ral head: risk factor for osteonecrosis. Radiol- Arthroplasty. 1998;9:213-20.
tion to formulate prognosis. Clin Orthop. 1992;
ogy. 1994;191:409-12.
277:73-8. 59. Bozic KJ, Zurakowski D, Thornhill TS. Survivor-
27. Markisz JA, Knowles RJ, Altchek DW, Schneider ship analysis of hips treated with core decom-
44. Mont MA, Jones LC, Sotereanos DG, Amstutz
R, Whalen JP, Cahill PT. Segmental patterns pression for nontraumatic osteonecrosis of
HC, Hungerford DS. Understanding and treat-
of osteonecrosis of the femoral head: early de- the femoral head. J Bone Joint Surg Am. 1999;
ing osteonecrosis of the femoral head. Instr
tection with MR imaging. Radiology. 1987;162: 81:200-9.
Course Lect. 2000;49:169-85.
717-20.
45. Smith KR, Bonfiglio M, Montgomery WJ. 60. Sotereanos DG, Plakseychuk AY, Rubash HE.
28. Mitchell DG, Rao VM, Dalinka MK, Spritzer CE, Free vascularized fibula grafting for the treat-
Non-traumatic necrosis of the femoral
Alavi A, Steinberg ME, Fallon M, Kressel HY. ment of osteonecrosis of the femoral head. Clin
head treated with tibial bone-grafting. A
Femoral head avascular necrosis: correlation of Orthop. 1997;344:243-56.
follow-up note. J Bone Joint Surg Am. 1980;
MR imaging, radiographic staging, radionuclide
62:845-7. 61. Urbaniak JR, Harvey EJ. Revascularization of the
imaging, and clinical findings. Radiology. 1987;
46. Aaron RK, Ciombor DM, Lord CF. Core femoral head in osteonecrosis. J Am Acad
162:709-15.
decompression augmented with human Orthop Surg. 1998;6:44-54.
29. Mitchell MD, Kundel HL, Steinberg ME,
decalcified bone matrix graft for osteo- 62. Kane SM, Ward WA, Jordan LC, Guilford WB,
Kressel HY, Alavi A, Axel L. Avascular
necrosis of the femoral head. In: Urbaniak Hanley EN Jr. Vascularized fibular grafting com-
necrosis of the hip: comparison of MR,
JR, Jones JP, editors. Osteonecrosis: etiology, pared with core decompression in the treatment
CT, and scintigraphy. AJR Am J Roentgenol.
diagnosis, and treatment. Rosemont, IL: of femoral head osteonecrosis. Orthopedics.
1986;147:67-71.
American Academy of Orthopaedic Surgeons; 1996;19:869-72.
30. Ficat RP, Arlet J. Functional investigation 1997. p 301-7.
63. Scully SP, Aaron RK, Urbaniak JR. Survival
of bone under normal conditions. In: Hunger-
47. Meyers MH. The treatment of osteonecrosis analysis of hips treated with core decompres-
ford DS, editor. Ischemia and necrosis of
of the hip with fresh osteochondral grafts and sion or vascularized fibular grafting because
bone. Baltimore: Williams and Wilkins; 1980.
with the muscle pedicle graft technique. Clin of avascular necrosis. J Bone Joint Surg Am.
p 29-52.
Orthop. 1978;130:202-9. 1998;80:1270-5.
31. Bramlett KW, Killian JT, Nasca RJ, Daniel WW.
48. Yoo MC, Chung DW, Hahn CS. Free vascular- 64. Vail TP, Urbaniak JR. Donor-site morbidity with
Transient osteoporosis. Clin Orthop. 1987;222:
ized fibular grafting for the treatment of os- use of vascularized autogenous fibular grafts.
197-202.
teonecrosis of the femoral head. Clin Orthop. J Bone Joint Surg Am. 1996;78:204-11.
32. Kaplan SS, Stegman CJ. Transient osteoporo- 1992;277:128-38.
65. Aluisio FV, Urbaniak JR. Proximal femur frac-
sis of the hip. A case report and review of
49. Iwata H, Torii S, Hasegawa Y, Itoh H, Mizuno tures after free vascularized fibular grafting to
the literature. J Bone Joint Surg Am. 1985;
M, Genda E, Kataoka Y. Indications and re- the hip. Clin Orthop. 1998;356:192-201.
67:490-3.


66. Mont MA, Hungerford DS. Non-traumatic avas- Orthop Scand. 1971;42:454-5. 100. Marcus ND, Enneking WF, Massam RA. The
cular necrosis of the femoral head. J Bone Joint silent hip in idiopathic aseptic necrosis. Treat-
83. Merle d’Aubigné R, Postel M, Mazabraud A,
Surg Am. 1995;77:459-74. ment by bone-grafting. J Bone Joint Surg Am.
Massias P, Gueguen J, France P. Idiopathic ne-
67. Gottschalk F. Indications and results of intertro- crosis of the femoral head in adults. J Bone 1973;55:1351-66.
chanteric osteotomy in osteonecrosis of the Joint Surg Br. 1965;47:612-33. 101. Ganz R, Buchler U. Overview of attempts to re-
femoral head. Clin Orthop. 1989;249:219-22. vitalize the dead head in aseptic necrosis of
84. Harris WH. Traumatic arthritis of the hip after
68. Kerboul M, Thomine J, Postel M, Merle the femoral head—osteotomy and revascular-
dislocation and acetabular fractures: treatment
d’Aubigné R. The conservative surgical treat- by mold arthroplasty. An end-result study using ization. Hip. 1983:296-305.
ment of idiopathic aseptic necrosis of the femo- a new method of result evaluation. J Bone Joint 102. Yamamoto M, Itoman M, Sagamoto N, Morita
ral head. J Bone Joint Surg Br. 1974;56:291-6. Surg Am. 1969;51:737-55. M. [Strut bone graft for aseptic necrosis of the
69. Mont MA, Fairbank AC, Krackow KA, Hunger- 85. Saito S, Ohzono K, Ono K. Joint-preserving oper- femoral head: theory and surgical technique].
ford DS. Corrective osteotomy for osteonecrosis ations for idiopathic avascular necrosis of the Orthop Surg. 1983;34:902-8. Japanese.
of the femoral head. J Bone Joint Surg Am. femoral head. Results of core decompression, 103. Meyers MH, Jones RE, Bucholz RW, Wenger
1996;78:1032-8. grafting and osteotomy. J Bone Joint Surg Br. DR. Fresh autogenous grafts and osteochon-
70. Scher MA, Jakim I. Intertrochanteric osteotomy 1988;70:78-84. dral allografts for the treatment of segmental
and autogenous bone-grafting for avascular ne- 86. Benke GJ, Baker AS, Dounis E. Total hip re- collapse in osteonecrosis of the hip. Clin
crosis of the femoral head. J Bone Joint Surg placement after upper femoral osteotomy. A Orthop. 1983;174:107-12.
Am. 1993;75:1119-33. clinical review. J Bone Joint Surg Br. 1982;64: 104. Meyers MH, Convery FR. Grafting procedures
71. Sugano N, Takaoka K, Ohzono K, Matsui M, 570-1. in osteonecrosis of the hip. Semin Arthro-
Saito M, Saito S. Rotational osteotomy for non- 87. Wang GJ, Sweet DE, Reger SI, Thompson RC. plasty. 1991;2:189-97.
traumatic avascular necrosis of the femoral Fat-cell changes as a mechanism of avascular 105. Ko JY, Meyers MH, Wenger DR. “Trapdoor”
head. J Bone Joint Surg Br. 1992;74:734-9. necrosis of the femoral head in cortisone- procedure for osteonecrosis with segmental
72. Sugioka Y, Hotokebuchi T, Tsutsui H. Transtro- treated rabbits. J Bone Joint Surg Am. 1977; collapse of the femoral head in teenagers. J
chanteric anterior rotational osteotomy for idio- 59:729-35. Pediatr Orthop. 1995;15:7-15.
pathic and steroid-induced necrosis of the 88. Buckley PD, Gearen PF, Petty RW. Structural 106. Rubash HE, Sinha RK, Shanbhag AS, Kim SY.
femoral head. Indications and long-term re- bone-grafting for early atraumatic avascular ne- Pathogenesis of bone loss after total hip ar-
sults. Clin Orthop. 1992;277:111-20. crosis of the femoral head. J Bone Joint Surg throplasty. Orthop Clin North Am. 1998;29:
73. Tooke SM, Amstutz HC, Hedley AK. Results Am. 1991;73:1357-64. 173-86.
of transtrochanteric rotational osteotomy for 89. Rosenwasser MP, Garino JP, Kiernan HA, Mich- 107. Smith-Petersen MN. The classic. Evolution of
femoral head osteonecrosis. Clin Orthop. 1987; elsen CB. Long term followup of thorough de- mould arthroplasty of the hip joint. Clin
224:150-7. bridement and cancellous bone grafting of Orthop. 1978;134:5-11.
74. Willert HG, Buchhorn G, Zichner L. Results of the femoral head for avascular necrosis. Clin
108. Amstutz HC, Grigoris P, Dorey FJ. Evolution
flexion osteotomy on segmental femoral head Orthop. 1994;306:17-27.
and future of surface replacement of the hip. J
necrosis in adults. In: Weil UH, editor. Progress 90. Boettcher WG, Bonfiglio M, Smith K. Non- Orthop Sci. 1998;3:169-86.
in orthopaedic surgery. Volume 5, Segmental id- traumatic necrosis of the femoral head. II. Ex-
109. Langlais F, Barthas J, Postel M. [Adjusted
iopathic necrosis of the femoral head. New periences in treatment. J Bone Joint Surg Am.
cups for idiopathic necrosis. Radiological re-
York: Springer; 1981. p 63-80. 1970;52:322-9.
sults]. Rev Chir Orthop Reparatrice Appar Mot.
75. Dean MT, Cabanela ME. Transtrochanteric ante- 91. Bonfiglio M, Bardenstein MB. Treatment by 1979;65:151-5. French.
rior rotational osteotomy for avascular necrosis bone-grafting of aseptic necrosis of the femoral
110. Townley CO. Hemi and total articular replace-
of the femoral head. Long-term results. J Bone head and non-union of the femoral neck (Phe-
ment arthroplasty of the hip with the fixed
Joint Surg Br. 1993;75:597-601. mister technique). J Bone Joint Surg Am. 1958;
femoral cup. Orthop Clin North Am. 1982;13:
76. Eyb R, Kotz R. The transtrochanteric anterior rota- 40:1329-46.
869-94.
tional osteotomy of Sugioka. Early and late results 92. Bonfiglio M, Voke EM. Aseptic necrosis of the
111. Amstutz HC, Dorey F, O’Carroll PE. THARIES
in idiopathic aseptic femoral head necrosis. Arch femoral head and non-union of the femoral
resurfacing arthroplasty. Evolution and long-
Orthop Trauma Surg. 1987;106:161-7. neck. Effect of treatment by drilling and bone-
term results. Clin Orthop. 1986;213:92-114.
77. Jacobs MA, Hungerford DS, Krackow KA. Inter- grafting (Phemister technique). J Bone Joint
Surg Am. 1968;50:48-66. 112. Bierbaum BE, Sweet R. Complications of re-
trochanteric osteotomy for avascular necrosis of
surfacing arthroplasty. Orthop Clin North Am.
the femoral head. J Bone Joint Surg Br. 1989; 93. Dunn AW, Grow T. Aseptic necrosis of the femo-
1982;13:761-75.
71:200-4. ral head. Treatment with bone grafts of doubtful
value. Clin Orthop. 1977;122:249-54. 113. Drinker H, Murray WR. The universal proximal
78. Maistrelli G, Fusco U, Avai A, Bombelli R. Os-
femoral endoprosthesis. A short-term com-
teonecrosis of the hip treated by intertrochan- 94. Itoman M, Yamamoto M. [Pathogenesis and
parison with conventional hemiarthroplasty.
teric osteotomy. A four- to 15-year follow-up. J treatment of idiopathic aseptic necrosis of the
J Bone Joint Surg Am. 1979;61:1167-74.
Bone Joint Surg Br. 1988;70:761-6. femoral head]. Clin Immunol. 1989;21:713-25.
Japanese. 114. Head WC. Total articular resurfacing arthro-
79. Masuda T, Matsuno T, Hasegawa I, Kanno T,
plasty. Analysis of component failure in sixty-
Ichioka Y, Kaneda K. Results of transtrochan- 95. Mont MA, Einhorn TA, Sponseller PD, Hunger-
seven hips. J Bone Joint Surg Am. 1984;66:
teric rotational osteotomy for nontraumatic os- ford DS. The trapdoor procedure using autoge-
28-34.
teonecrosis of the femoral head. Clin Orthop. nous cortical and cancellous bone grafts for
1988;228:69-74. osteonecrosis of the femoral head. J Bone 115. Jolley MN, Salvati EA, Brown GC. Early re-
Joint Surg Br. 1998;80:56-62. sults and complications of surface replace-
80. Sugioka Y, Katsuki I, Hotokebuchi T. Transtro-
ment of the hip. J Bone Joint Surg Am. 1982;
chanteric rotational osteotomy of the femoral 96. Phemister DB. Treatment of the necrotic head
64:366-77.
head for the treatment of osteonecrosis. Follow- of the femur in adults. J Bone Joint Surg Am.
up statistics. Clin Orthop. 1982;169:115-26. 1949;31:55-66. 116. Kim WC, Grogan T, Amstutz HC, Dorey F.
Survivorship comparison of THARIES and
81. Wagner H, Zeiler G. Idiopathic necrosis of 97. Smith KR, Bonfiglio M, Montgomery WJ. Non-
conventional hip arthroplasty in patients
the femoral head. Results of intertrochan- traumatic necrosis of the femoral head treated
younger than 40 years old. Clin Orthop.
teric osteotomy and joint resurfacing. In: Weil with tibial bone-grafting. A follow-up note. J
1987;214:269-77.
UH, editor. Progress in orthopedic surgery. Bone Joint Surg Am. 1980;62:845-7.
Volume 5, Segmental idiopathic necrosis of 117. Krackow KA, Mont MA, Maar DC. Limited
98. Springfield DS, Enneking WJ. Surgery for asep-
the femoral head. New York: Springer; 1981. femoral endoprosthesis for avascular necro-
tic necrosis of the femoral head. Clin Orthop.
p 87-116. sis of the femoral head. Orthop Rev. 1993;
1978;130:175-85.
22:457-63.
82. Arnoldi CC, Lemperg R, Linderholm H. Immedi-
99. Phemister DB. Treatment of the necrotic head
ate effect of osteotomy on the intramedullary 118. Scott RD, Urse JS, Schmidt R, Bierbaum BE.
of the femur in adults. J Bone Joint Surg Am.
pressure in the femoral head and neck in pa- Use of TARA hemiarthroplasty in advanced os-
1949;31:55-66.
tients with degenerative osteoarthritis. Acta teonecrosis. J Arthroplasty. 1987;2:225-32.


119. Hungerford MW, Mont MA, Scott R, Fiore C, tive osteoarthritis of the hip. Clin Orthop. crosis: a 2- to 10-year evaluation. Clin Orthop.
Hungerford DS, Krackow KA. Surface replace- 1997;341:62-8. 1997;334:116-23.
ment hemiarthroplasty for the treatment of os-
131. Sarmiento A, Ebramzadeh E, Gogan WJ, McK- 142. Garino JP, Steinberg ME. Total hip arthroplasty
teonecrosis of the femoral head. J Bone Joint
ellop HA. Total hip arthroplasty with cement. A in patients with avascular necrosis of the
Surg Am. 1998;80:1656-64.
long-term radiographic analysis in patients femoral head: a 2- to 10-year follow-up. Clin
120. Nelson CL, Walz BH, Gruenwald JM. Re- who are older than fifty and younger than fifty Orthop. 1997;334:108-15.
surfacing of only the femoral head for os- years. J Bone Joint Surg Am. 1990;72:1470-6.
143. Kantor SG, Huo MH, Huk OL, Salvati EA.
teonecrosis. Long-term follow-up study. J
132. Saito S, Saito M, Nishina T, Ohzono K, Ono Cemented total hip arthroplasty in patients
Arthroplasty. 1997;12:736-40.
K. Long-term results of total hip arthroplasty with osteonecrosis. A 6-year minimum
121. Beaule PE, Schmalzried TP, Campbell PA, Do- for osteonecrosis of the femoral head. A com- follow-up study of second-generation ce-
rey F, Amstutz HC. Duration of symptoms and parison with osteoarthritis. Clin Orthop. 1989; ment techniques. J Arthroplasty. 1996
outcome of hemiresurfacing for hip osteone- 244:198-207. 11:267-71.
crosis. Clin Orthop. 2001;385:104-17.
133. Ortiguera CJ, Pulliam IT, Cabanela ME. Total 144. Ritter MA, Helphinstine J, Keating EM,
122. Ash SA, Callaghan JJ, Johnston RC. Revision hip arthroplasty for osteonecrosis: matched- Faris PM, Meding JB. Total hip arthroplasty
total hip arthroplasty with cement after cup ar- pair analysis of 188 hips with long-term follow- in patients with osteonecrosis. The effect
throplasty. Long-term follow-up. J Bone Joint up. J Arthroplasty. 1999;14:21-8. of cement techniques. Clin Orthop. 1997;
Surg Am. 1996;78:87-93. 338:94-9.
134. Chiu KH, Shen WY, Ko CK, Chan KM. Os-
123. Lavernia CJ, Sierra RJ, Grieco FR. Osteone- teonecrosis of the femoral head treated with 145. Fye MA, Huo MH, Zatorski LE, Keggi KJ. To-
crosis of the femoral head. J Am Acad Orthop cementless total hip arthroplasty. A compari- tal hip arthroplasty performed without cement
Surg. 1999;7:250-61. son with other diagnoses. J Arthroplasty. in patients with femoral head osteonecrosis
1997;12:683-8. who are less than 50 years old. J Arthro-
124. Ito H, Matsuna T, Kaneda K. Bipolar hemiar-
throplasty for osteonecrosis of the femoral plasty. 1998;13:876-81.
135. Brinker MR, Rosenberg AG, Kull L, Galante
head. A 7- to 18- year followup. Clin Orthop. JO. Primary total hip arthroplasty using nonce- 146. D’Antonio JA, Capello WN, Manley MT, Fein-
2000;374:201-11. mented porous-coated femoral components in berg J. Hydroxyapatite coated implants. Total
patients with osteonecrosis of the femoral hip arthroplasty in the young patient and pa-
125. Cabanela ME. Bipolar versus total hip arthro-
head. J Arthroplasty. 1994;9:457-68. tients with avascular necrosis. Clin Orthop.
plasty for avascular necrosis of the femoral
head. A comparison. Clin Orthop. 1990;261: 1997;344:124-38.
136. Clarke HJ, Jinnah RH, Brooker AF, Michaelson
59-62. JD. Total replacement of the hip for avascular 147. Fehrle MJ, Callaghan JJ, Clark CR, Peterson
necrosis in sickle cell disease. J Bone Joint KK. Uncemented total hip arthroplasty in pa-
126. Steinberg ME, Corces A, Fallon M. Acetabu-
Surg Br. 1989;71:465-70. tients with aseptic necrosis of the femoral
lar involvement in osteonecrosis of the femo-
ral head. J Bone Joint Surg Am. 1999;81:60-5. head and previous bone grafting. J Arthro-
137. Hanker GJ, Amstutz HC. Osteonecrosis of the
plasty. 1993;8:1-6.
hip in the sickle-cell diseases. Treatment and
127. Im GI, Kim DY, Shin JH, Cho WH, Lee CJ.
complications. J Bone Joint Surg Am. 1988; 148. Steinberg ME, Bands RE, Parry S, Hoffman E,
Degeneration of the acetabular cartilage in
70:499-506. Chan T, Hartman KM. Does lesion size affect
osteonecrosis of the femoral head: histo-
pathologic examination of 15 hips. Acta the outcome in avascular necrosis? Clin
138. Moran MC. Osteonecrosis of the hip in sickle cell
Orthop Scand. 2000;71:28-30. Orthop. 1999;367:262-71.
hemoglobinopathy. Am J Orthop. 1995;24:18-24.
128. Salvati EA, Cornell CN. Long-term follow-up 149. Mont MA, Jones LC, Pacheco I, Hungerford
139. Phillips FM, Pottenger LA, Finn HA, Vander-
of total hip replacement in patients with DS. Radiographic predictors of outcome
molen J. Cementless total hip arthroplasty in
avascular necrosis. Instr Course Lect. 1988; of core decompression for hips with os-
patients with steroid-induced avascular necro-
37:67-73. teonecrosis stage III. Clin Orthop. 1998;
sis of the hip. A 62-month follow-up study. Clin
354:159-68.
Orthop. 1994;303:147-54.
129. Ritter MA, Meding JB. A comparison of os-
teonecrosis and osteoarthritis patients follow- 150. Sekiya JK, Ruch DS, Hunter DM, Pope JR TL,
140. Piston RW, Engh CA, De Carvalho PI, Suthers
ing total hip arthroplasty. A long-term follow-up Koman LA, Russell GB. The role of arthros-
K. Osteonecrosis of the femoral head treated
study. Clin Orthop. 1986;206:139-46. copy in the diagnosis and staging of osteone-
with total hip arthroplasty without cement. J
crosis. In: Urbaniak JR, Jones JP, editors.
Bone Joint Surg Am. 1994;76:202-14.
130. Xenakis TA, Beris AE, Malizos KK, Koukoubis Osteonecrosis: etiology, diagnosis, and treat-
T, Gelalis J, Soucacos PN. Total hip arthro- 141. Stulberg BN, Singer R, Goldner J, Stulberg J. ment. Rosemont IL: American Academy of Or-
plasty for avascular necrosis and degenera- Uncemented total hip arthroplasty in osteone- thopaedic Surgeons; 1997. p 253-61.

AVN2

Enviado por

Dados do documento

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

AVN2

Enviado por

Direitos autorais:

Formatos disponíveis

This is an enhanced PDF from The Journal of Bone and Joint Surgery

Osteonecrosis of the Hip: Management in the Twenty-first Century

This information is current as of November 11, 2006

Adult Disease (1317 articles)

Downloaded from www.ejbjs.org on November 11, 2006

The American Academy of Orthopaedic Surgeons

Downloaded from www.ejbjs.org on November 11, 2006

Osteonecrosis of the Hip:

Downloaded from www.ejbjs.org on November 11, 2006

A concept of pathogenesis of osteonecro- Intravascular

Downloaded from www.ejbjs.org on November 11, 2006

high-dose radiation or chemotherapy.

TABLE II Radiographic Classifications of Osteonecrosis of the Femoral Head

Classification System Criteria

Downloaded from www.ejbjs.org on November 11, 2006

Fig. 2 rosis, suggesting that, of a variety of

Downloaded from www.ejbjs.org on November 11, 2006

Downloaded from www.ejbjs.org on November 11, 2006

Fig. 4 number of medical conditions, and since

Downloaded from www.ejbjs.org on November 11, 2006

throplasty. In contrast to the study by

Fig. 7-A Fig. 7-B Fig. 7-C

Downloaded from www.ejbjs.org on November 11, 2006

Downloaded from www.ejbjs.org on November 11, 2006

ipsilateral fibula (Fig. 5). The proximal Fig. 9-A

Downloaded from www.ejbjs.org on November 11, 2006

Downloaded from www.ejbjs.org on November 11, 2006

Downloaded from www.ejbjs.org on November 11, 2006

Downloaded from www.ejbjs.org on November 11, 2006

Downloaded from www.ejbjs.org on November 11, 2006

Downloaded from www.ejbjs.org on November 11, 2006

Downloaded from www.ejbjs.org on November 11, 2006

Radiographic Stage Symptoms Procedure

V and VI Symptomatic Total hip arthroplasty

Downloaded from www.ejbjs.org on November 11, 2006

Downloaded from www.ejbjs.org on November 11, 2006

Downloaded from www.ejbjs.org on November 11, 2006

Downloaded from www.ejbjs.org on November 11, 2006

Downloaded from www.ejbjs.org on November 11, 2006

Você também pode gostar