25 January 2015: Clinical Research
Hip Resurfacing Arthroplasty in Treatment of Avascular Necrosis of the Femoral Head
Michał Pyda ABCDEF , Bogdan Koczy AD , Wojciech Widuchowski E , Małgorzata Widuchowska E , Tomasz Stołtny F , Michał Mielnik A , Jacek Hermanson A
DOI: 10.12659/MSM.891031
Med Sci Monit 2015; 21:304-309
Abstract
BACKGROUND: Hip resurfacing is a conservative type of total hip arthroplasty but its use is controversial, especially in patients with osteonecrosis. The aim of this study was analysis of the clinical and radiographic outcomes of hip resurfacing in patients with osteonecrosis.
MATERIAL AND METHODS: Between 2007 and 2008, 30 hip resurfacing arthroplasties were performed due to osteoarthritis secondary to avascular necrosis of femoral head staged as Ficat III and IV. Patients were qualified to resurfacing arthroplasty when the extent of avascular necrosis using Kerboul’s method was <200° and the angle between avascular necrosis and head-neck junction was >20°. All patients were evaluated clinically and radiologically before and 60 months after the operation.
RESULTS: The mean Harris Hip Score (HHS) score increased from 47.8 to 94.25 (p<0.05). Physical activity level (University of California, Los Angeles activity score – UCLA activity score) improved from 3.7 to 7.55 (p<0.05). No implant migration was observed.
CONCLUSIONS: Management of osteonecrosis of the hip with resurfacing arthroplasty seems to be effective in strictly-selected patients.
Keywords: Arthroplasty, Replacement, Hip - methods, Body Mass Index, Femur Head - surgery, Femur Head Necrosis - surgery, Hip Prosthesis, Osteonecrosis - surgery
Background
Osteonecrosis of the femoral head is caused by impaired vascular supply. Avascular necrosis is a progressive condition leading to complete destruction of the hip joint. Usually young, active people between 20 and 50 years of age are affected by the disease and their occupational and physical activity is substantially limited [1–3].
Surgical treatment of the advanced stage (Ficat III° and IV°) of this entity is a challenging issue. Total hip replacement (THR) is the criterion standard in the management of end-stage avascular necrosis of the femoral head [4]. Because of relatively young age and high activity of the patients, the results of THR in this group of patients are not encouraging. Especially, the use of cemented hip endoprostheses results in high rate of revision surgeries [5,6]. Introduction of uncemented total hip arthroplasty significantly improved clinical results [7,8]. Kim et al. did not observe any aseptic loosening incident after almost 10 years of follow-up in 118 total hip replacements [9].
Despite good results of uncemented total hip replacement, the lifespan of patients with osteonecrosis of the femoral head exceeds the longevity of the implant and further revision surgeries are usually required. Thus, conditions leading to increased osteolysis around the implants (e.g., stress-shielding and wear of polyethylene) may substantially deteriorate the situation during revision surgery [10,11]. Also, the higher dislocation rate among patients undergoing hip replacement with use of standard 28-mm heads has been unsatisfactory [12,13].
New technologies like total hip resurfacing are a new approach to surgical management of end-stage avascular necrosis of the femoral head.
This study aims to present clinical and radiological outcomes of metal-on-metal hip resurfacing in a series of strictly selected patients with osteonecrosis of the femoral head.
Material and Methods
SURGICAL TECHNIQUE:
All operations were performed with the patient in the lateral position and through a lateral approach (Hardinge approach) and all patients received antibiotic prophylaxis at the time of induction of anesthesia as well as 2 postoperative doses of antibiotics. Enoxaparin was used as prophylaxis for thromboembolic disease.
CLINICAL ANALYSIS:
Pain, function, deformity, and range of motion were evaluated with the use of the Harris hip score [14].
Level of physical activity was assessed with UCLA activity score prior to surgery and at each postoperative visit up to 3 years after surgery [15].
RADIOGRAPHIC ANALYSIS:
The femoral head necrosis was calculated by adding the area of necrosis in the anteroposterior and frog-lateral radiographs as in Kerboul’s method [16]. The angle between the necrotic fragment and head-neck junction was also evaluated in anteroposterior preoperative x-rays (Figure 1C). Migration of prosthesis components was assessed in immediate anteroposterior postoperative radiographs and 5 years after the operation. The abduction angle was measured on the acetabular side. On the femoral side, varus-valgus shift was determined by measurement of stem-shaft angle. Additionally, detection of axial collapse of femoral component was assessed with the use of the component-lateral cortex ratio (the ratio of the prosthesis length to the length of prosthesis and the bone segment extending to the lateral femoral cortex, (Figure 2A, 2B).
STATISTICAL METHODS:
Statistical analysis was performed using Statistica 7.1 PL. The Shapiro-Wilks test was used to evaluate whether individual datasets were consistent with a normal distribution: groups were then compared using an unpaired t-test or Mann-Whitney U test, as appropriate. Paired data were assessed using the paired t-test or Wilcoxon’s matched-pairs signed ranks test. A p-value <0.05 was considered to be statistically significant.
Results
The mean preoperative Harris hip score of 47.8 (range 6.9–80.9) improved significantly (p value <0.001), to 94.25 (range 87.8–100) at the latest follow-up. Physical activity level (UCLA activity score) improved from 3.7 (range 2–7) to 7.55 (range 4–10) (p<0.05) (Table 2).
The mean Kerboul’s angle and the angle between the necrotic fragment and head-neck junction in the study group were 161.4° (range 90–200) and 26.4 (range 20–38), respectively.
There was no significant change (p=0.1) in acetabular inclination from the baseline, where the mean acetabular abduction angle was 51.1 (range 33–64) to the latest follow-up, where it was 52.6 (range 33–65). The mean postoperative stem-shaft angle (139.9; range 126–159) and component-lateral cortex ratio (0.6; range 0.3–0.7) remained unchanged at 140.2 (range 126–158, p=0.64) and 0.6 (range 0.3–0.7, p=0.91), respectively (Table 3).
Discussion
LIMITATIONS:
The limitations of our study are that it was a retrospective analysis performed over a short period of observation, and had a small cohort. The small number of patients is related to the strict inclusion criteria.
Conclusions
Based on the results, we can state that hip resurfacing leads to significant reduction in pain and improves daily functioning of patients. In addition, the qualification criteria used in our study seem to be appropriate, but the limitations mentioned above are drawbacks of this work.
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