|
Year |
2002 |
|---|---|
|
Question Number |
26. |
|
Category |
Hip and Knee Reconstruction |
Question
What is the most appropriate treatment for a patient with osteonecrosis of the femoral head with degenerative acetabular changes?
1- Core decompression
2- Bipolar hemiarthroplasty
3- Resurfacing hemiarthroplasty
4- Total hip arthroplasty
5- Vascularized fibular autografting
Figures
Answer (click for answer)
Preferred Response: 4
Table I. Stages of Osteonecrosis of the Hip
Stage Criteria
0 X-ray, MRI, and bone scan normal
I Normal X-ray, abnormal MRI and/or bone scan
II Abnormal X-ray showing cystic or sclerotic changes in femoral head
III Subchrondral collapse producing crescent sign
IV Flattening of femoral head
V Joint narrowing with/without acetabular involvement
VI Advanced degenerative changes
The Steinberg classification is the generally accepted system to evaluate and stage osteonecrosis (ON) of the hip. Six stages are used and each is based on the quantity of head involvement calculated by multiplying the percentage of head involvement on a coronal A-P view by the percentage of head involvement on a sagittal/lateral view.
There are several treatment options for ON including those listed in the answers above. Controversy exists regarding the appropriate timing of these operative interventions. The patient in this question a more advanced form of ON and would probably be a stage V or VI. The appropriate surgical option for this patient is total joint replacement.
Core decompression is one prophylactic measure to slow the progression of early stage ON. This procedure is typically reserved for earlier stages of ON. Good results have been demonstrated with this technique when used for stages I, II, II and for lesions that are small (<15%). A recent report of long-term results of free vascularized fibular grafting demonstrated a good outcome in 80% of patients younger than 40 years who have stage II or III disease. Partial resurfacing hemiarthroplasty is another alternative, however, higher stages of ON especially those with joint space narrowing and acetabular changes may cause impingement of the prosthesis resulting in a surgical failure.
For patients with more advanced stages of ON, the choice between total joint replacement versus hemiarthroplasty is based upon activity level, physiologic age, patient compliance, and pre-existing arthritis. Hemiarthroplasty in younger active patients may lead to rapid wear of the articular cartilage and the development of pain. As a rule, patients with radiographic evidence of degenerative changes of the acetabulum should undergo total joint replacement.
Reference: Miller MD(ed): Review of Orthopaedics, ed 3. Philadelphia, PA, W. B. Saunders Company, 2000, pp 275-276.
Judet H, Gilbert A: Long-term results of free Vascularized fibular grafts for femoral head necrosis. Clin Orthop 2001;386:114-119.
Steinberg ME, Larcom PG, Stafford B, et al: Core decompression with bone grafting for osteonecrosis of the femoral head. Clin Orthop 2001;386:71-78.
Siguier T, Siguier M, Judet T, et al: Partial resurfacing arthroplasty of the femoral head in avascular necrosis: Methods, indications, results. Clin Orthop 2001;386:85-92.