Idiopathic Necrosis of the Femoral Head in Adults

Abstract

1. Idiopathic necrosis of the femoral head is generally considered to be a rare disease but it appears to be rather frequent in France in view of the fact that 139 cases were recorded in the orthopaedic clinic of Hôpital Cochin between 1959 and 1963. Ninety cases treated by operation have been analysed in this paper. Men are nearly exclusively affected between the ages of eighteen and seventy, with the highest incidence between thirty and fifty years of age. Both hips are affected in 52 per cent of cases. 2. The etiology is unknown, but steroid therapy was noted in 36 per cent of the cases and some history of slight injury in 30 per cent. The sudden onset of pain in half the cases suggests the obliteration of one of the blood vessels supplying the femoral head. 3. Radiographs are often normal at the time of onset of the symptoms but later they show increased density of the head localised to the antero-superior aspect, and later still collapse of this weight-bearing region. The extent of the lesion appears to be determined from the very beginning rather than to be progressive. The superior joint space is never reduced and may in fact be widened. 4. Pathological examination of the head and neck confirms necrosis of the cancellous bone and the integrity of the overlying cartilage, but shows deep to the necrotic region a highly reactive zone characterised by hypervascularity and raised metabolism. These features have been demonstrated by injection of the blood vessels and also by the uptake of phosphorus 32 and by the succino-deshydrogenase test. 5. In six cases microscopic vascular lesions were found in the antero-lateral pedicle of the femoral head. 6. The high degree of activity of the tissue deep to the necrotic zone gives some hope for revascularisation of the necrotic segment. For this reason protection from pressure may be the way to prevent dramatic collapse of the head. Rest, medical treatment and freedom from weight bearing, however, do not achieve adequate protection. Varus or rotation osteotomy of the femoral neck not only gives relief from pain but appears to prevent collapse of the femoral head. 7. When destruction of the head has already taken place good results may be expected from the insertion of a metallic prosthesis, provided the acetabulum is sound. The results are less favourable when the acetabulum has been altered by secondary arthritic change, and arthrodesis may have to be considered if the disease is unilateral or when a prosthesis has been successfully inserted on the other side.

Vascularised greater trochanter bone graft, combined free iliac flap and impaction bone grafting for osteonecrosis of the femoral head

“…According to research concerning the biomechanics of the hip [35,36], the two key principles of hip-preserving surgery for the treatment of ONFH are promoting repair of the necrotic area and protecting the femoral head from collapsing. The main predictive risk factors of the incidence of collapse depend on the range and area of necrosis [4,11,36,37]. Our research has shown that the more normal shape the femoral head retains, the more hip function is kept.…”

“…If not treated in time, it will greatly affect the patient's life. [4,5]. The technical improvement of total hip arthroplasty (THA) seems to give hope of complete recovery from the degenerate diseases [6,7].…”

Transtrochanteric Rotational Osteotomy for Nontraumatic Osteonecrosis of the Femoral Head in Young Adults

“…The principal concept of femoral osteotomy in the treatment of ONFH, first reported by Merle D'Aubigné et al [24] in 1965, is that the necrotic femoral head focus is moved away from the major weightbearing portion underneath the acetabulum and weightbearing forces are transmitted to living areas of the femoral head. Sugioka et al [42] introduced the new concept of rotation after trochanteric osteotomy to achieve transposition of the intact articular surface of the femoral head to the weightbearing area as an effective treatment for ONFH, Masuda et al [23] reported 36 of 52 hips (69%) showed no evidence of progressive collapse of the femoral head during an average 5.1 years followup, whereas Hisatome et al [14] reported survival of 80% for 25 hips at a mean of 6.4 years after TRO.…”

“…Nontraumatic ONFH usually affects young adults during the third to fourth decades of life, and most of the radiographically larger lesions progress to collapse, resulting in osteoarthritis without treatment [24,27,28,30,43]. The risk of collapse of the femoral head depends on the extent and location of the lesion [1,24,36].…”

“…Several other studies have advocated varus osteotomy as an effective head preservation surgery in which the lateral intact area of the femoral head can be placed into the acetabular weightbearing portion, thus preventing progression of collapse [19,24,34]. Sugioka [40] suggested intentional varus positioning should be planned for patients with advanced collapse and extensive lesions, and when the ratio of the intact area of the femoral head to the acetabular weightbearing area was greater than 36% on postoperative anteroposterior (AP) radiographs, additional collapse was observed in only four of 102 hips.…”