Osteonecrosis of femoral head: Treatment by core decompression and vascular pedicle grafting

Abstract

Background:Femoral head-preserving core decompression and bone grafting have shown excellent result in preventing collapse. The use of vascularized grafts have shown better clinical results. The vascular pedicle bone graft is an easy to perform operation and does not require special equipment. We analyzed and report a series of patients of osteonecrosis of femoral head treated by core decompression and vascular pedicle grafting of part of iliac crest based on deep circumflex iliac vessels.Materials and Methods:The article comprises of the retrospective study of 31 patients of osteonecrosis of femoral head in stage II and III treated with core decompression and vascular pedicle grafting by using part of iliac crest with deep circumflex iliac vessels from January 1990 to December 2005. The young patients with a mean age 32 years (18–52 years) with a minimum follow-up of five years were included for analysis. Sixteen patients had osteonecrosis following alcohol abuse, 12 patients following corticosteroid consumption, 3 patients had idiopathic osteonecrosis. Nine patients were stage IIB, and 22 patients were stage IIIC according to ARCO's system. The core decompression and vascular pedicle grafting was performed by anterior approach by using part of iliac crest with deep circumflex iliac vessels.Results:Digital subtraction arteriography performed in 9 patients at the end of 12 weeks showed the patency of deep circumflex artery in all cases, and bone scan performed in 6 other patients showed high uptake in the grafted area of the femoral head proving the efficacy of the operative procedure. Out of 31 patients, only one patient progressed to collapse and total joint replacement was advised. At the final follow up period of 5–8 years, Harris Hip Score improved mean ± SD of 28.2 ± 6.4 (p < 0.05). Forty-eight percent of patients had an improvement in Harris Hip Score of more that 28 points.Conclusion:The core decompression and vascular pedicle grafting reduces the intraosseous tension to achieve early revascularization of ischemic femoral head. The high percentage of marrow and osteogenic cells survive within a vascularized pedicle graft, which helps in early vascularization and we have been able to achieve good outcome.

Osteonecrosis Femoral Head Treatment by Core Decompression and ILIAC CREST-TFL Muscle Pedicle Grafting

“…However, only core decompression should be avoided, and it must be coupled with bone grafting in the tract of core to avoid iatrogenic fractures. 10,37 Despite many reports on salvage procedure, no method has clearly demonstrated the arrest of disease before subchondral fracture or slow down of the progression of collapse of femoral head and arthrosis. The use of a nonvascularized bone graft, as originally described by Phemister, has had variable success in the treatment of osteonecrosis.…”

“…Other contributory factors for failure are ongoing systemic disease, defects in mineral metabolism, use of steroids, and high level of activity in young patients and increased body weight. Hence, we prefer to delay or eliminate the need for hip replacement by performing head-preserving surgeries 10,37 , of which core decompression and TFL muscle pedicle grafting are a choice of surgery, especially in bilateral cases and patients with Sickle cell disease with stage II and III. Out of 68 patients, only five patients progressed to collapse, and surgery of joint replacement was advised in three patients.…”

“…38 Once the crescent sign appears without collapse, it is desirable to couple the bone grafting procedure in addition to the core decompression, preferably vascular or muscle pedicle grafting, to achieve early revascularization. 39, 10, 12. Vascularized pedicle graft by using part of iliac crest with deep circumflex iliac vessels is more advantageous since high percentage of marrow and osteogenic cells survive within a living graft, which helps for early vascularization 10,[40][41][42][43][44] . However, muscle pedicle graft using tensor fascia lata graft is very easy and is commonly performed whenever both hips need simultaneous surgery.…”

“…Hence core decompression should always be supplemented by one of the procedures of bone grafting. To achieve early vascularisation, vascular pedicle grafting using deep circumflex iliac vessel with iliac crest is a very useful, but preoperative femoral angiography is mandatory to confirm the presence of deep circumflex iliac artery pedicle 10 . This procedure is technically demanding, tedious and time consuming and may not be feasible bilaterally in one sitting.…”

Vascular pedicled iliac bone grafting is effective in patients with an early stage of femoral head avascular necrosis

“…Several head preserving procedures such as core decompresion, osteotomies and non-vascularized or vascularized bone grafting have been used to avert the need for total hip replacement. [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] The vascularized fibular grafting is associated with better clinical and radiographic results than non-vascularized fibular grafting in precollapse hips. [9][10][11][12] The rationale of vascular pedicled fibula grafting procedure is based on the following points: decompression of the femoral head diminishes intraosseous pressure like compartment syndrome and improves the interrupted circulation which contributes the disease progression.…”