TREATMENT

TREATMENT OF OSTEONECROSIS WITH IMPACTION GRAFTING

J Gardeniers*, W Rijnen, P Buma*, B Schreurs*, K Yamano+, TJ Slooff
*University of Nijmegen, +Showa University Yokohama

The clinical results of treatment of Osteonecrosis with moderate or severe collapse are often poor. Using MRI preradiologic lesions can be detected and prediction of collapse is possible by measuring the extent of the necrotic lesion(1,2). Furthermore the location of the lesion is an important factor. Procedures to prevent collapse were and still are fibular grafting or structural bone grafting. These do not prevent failure and clinical results are not satisfactory. In the past 20 years the Orthopaedic Department of the University of Nijmegen has developed the technique of impacted morsellized chip grafting to repair bone deficiencies in revision arthroplasties. Long term clinical results have shown that the initial and secondary stability is sufficient to allow load bearing and graft incorporation.

In ONFH therapy is core biopsy, several types of osteotomy and total hip replacement. The goal of the treatment must be the containment of the sphericity and mechanical properties of the femoral dome.

Because of the good results of impacted grafting in revision arthroplasties (4,5) this technique is used: total excision of the lesion and replacement by an impacted chip graft.

Materials and Method: Through the major trochanter a core biopsy of 1 cm diameter is drilled into the lesion. With the Anspach 65K the cyst and all the necrotic bone it are completely removed. The extensive cavity that is created is then filled with solidly impacted bone chips from the bone bank.

Results: From 1992 onwards 22 young patients, average age 32.7 years, 17 males and 5 females with severe complaints due to a osteonecrotic lesions in stage 2, early and late 3 and even stage 4 have been operated. 11 right hips and 12 left hips were operated. The average follow-up is 29.7 months. The results of all patients with a minimum FU of at least 10 months will be shown.

At the time of follow-up 11 patients of the whole group were completely free of complaints with a perfect radiographical result, full consolidation and no osteolysis. One patient developed a policystic total head involvement.

The preoperative HHS is 53.3, postoperative HHS is 90 for all stages. The overall success rate Stage 2 and 3 is 85%. The success rate for Stage 2 is 90 %, for Stage 3 is 82 % and Stage 4 100% despite collapse preoperatively.

Discussion: The results show that the impacted grafting technique is a good treatment for early osteonecrosis and very promising for the treatment of late Stages of osteonecrosis of the femoral head. Experimental results, an animal study in Dutch Milk Goats, give the histological proof that the technique is indeed very promising and is an addition to the treatment modalities for Stage 1, 2 and early 3 Osteonecrosis. Some results will be shown.

Literature:

1. Kokubo T et al : MRI and scintigraphy of avascular necrosis of the femoral head. Clin Orthop Rel Res 277:54-55.
2. Ohzono K et al: The fate of nontraumatic avascular necrosis of the femoral head. A radiological classification to formulate prognosis. Clin Orthop Rel Res 227:73-89.
3. Buma P et al: Histological evaluation of allograft incorporation after cemented and non-cemented hip arthroplasty in the goat. Bone Implanting Grafting. Springer Verlag, Berlin.
4. Schimmel et al: Acetabular reconstruction with cancellous grafting in revision hip arthroplasty. In: Bone Implanting Grafting. Springer Verlag, Berlin.
5. Slooff TJ el al: Bone Grafting for total hip replacement in acetabular protrusion. Acta Orth Scand 1984, 55:593-597.
6. Buma et al: Impacted graft incorporation after cemented acetabular revision: Histological evaluation in 8 patients. Acta Orth Scand 1996, 76: 536-540.
7. Slooff TJ et al: Impaction morcellized allografting and cement. Instructional Course Lectures 1998,47:265-274 and 1999,48:79-89.