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.

Keywords: Muscle pedicle bone graft; osteonecrosis of femoral head; vascularized pedicle graft.

Figure 1

(a, b) Line diagram (L. D.) showing anatomical landmarks and diagrammatic representation of the vascular pedicle of deep circumflex iliac artery in the vicinity of hip joint and iliac bone. (c) L. D. showing isolation of deep circumflex iliac vascular pedicle along with part of iliac bone. (d) L. D. showing implantation of vascular pedicle graft of deep circumflex iliac artery with part of iliac crest into the head and neck of femur.

Figure 2

A young male (case no. 7) age 35 years had bilateral osteonecrosis femoral head (steroid-induced osteonecrosis). (a) Preoperative anteroposterior X-ray of left hip shows stage III osteonecrosis. (b) Preoperative angiography showing the presence of deep circumflex iliac pedicle. (c) Line diagram shows proposed surgical incision for exploration of vascular pedicle graft and its implantation into the head and neck femur. (d) Clinical photograph showing operative scar. (e,f) Postoperative anteroposterior X-rays at three years showing good revascularization with preservation of joint space. (g,h) Postoperative anteroposterior X-rays at 5 and 10 years showing good revascularization, preserved joint space with no arthritic changes and no deformation.

Figure 3

Pre-operative anteroposterior (a) X-ray of the pelvis of young male patient shows osteonecrosis of the femoral head. (b) Preoperative radionuclide bone scan showing osteonecrosis of right femoral head. (c) Immediate postoperative X-rays after vascular pedicle bone grafting. (d) Postoperative X-ray at 14 months showing good revascularization of right femoral head. (e) Postoperative X-rays at 15 years showing good revascularization of right femoral head without any collapse or arthritic changes.

Figure 4

(a) Preoperative X-rays of the pelvis with both hips of a young lady shows osteonecrosis of both femoral heads. (b) Postoperative X-rays of the same patient at 2 years, where vascular pedicle graft from deep circumflex iliac artery (right side) and fibular bone graft (left side) was done. (c) Postoperative X-ray of the same patient at 5 years showing good vascularization of the right femoral head and postoperative. (d) X-ray at 10 years showing good revascularization of the femoral heads without any collapse or arthritic changes.