Arch. orthop. Unfall-Chir. 83, 115--122 (1975) © by J. F. Bergmann Verlag M/inchen 1975

The Pediculate Bone Graft as Treatment for the Aseptic Necrosis of the Femoral Head Carlos P a l a z z i a n d J o a q u i n X i c o y Orthopaedic Surgery Department of the Hospital Sagrado Corazdn, Barcelona (Chief of the Department: Dr. A. S. Palazzi) Received March 27, 1975

Das gestielte K n o c h e n t r a n s p l a n t a t als B e h a n d l u n g s m e t h o d e bei den a s e p t i s c h e n K n o c h e n n e k r o s e n des Htiftkopfes

Zusammen/assung. Wit sind davon tiberzeugt, dab durch frfihe Diagnose und daran ansehliel3ende Behandlung der Endausgang der H/iftkopfnekrosen gebessert werden kann. Sobald wit eine Coxarthrose auf der Grundlage einer aseptisehen Hiiftkopfnekrose vorfinden, halten wir eine Untersuehung der Hgmodynamik sowie eine K_nochenbiopsie des Htiftkopfes ffir erforderlich, selbst wenn radiologiseh keine Anzeiehen f/it eine Hiiftkopfnekrose vorliegen. Die Einfachheit der operativen Teehnik plus der Tatsache, dal3 die tItiftmeehanik im ttinblick auf zusS~tzliche Operationen unvergndert bleibt, haben uns dazu veranlai3t, das gestielte Knoehentransplantat als Methodik der Wahl in den oben besehriebenen Fgllen anzuwenden. Summary. We believe that if an early diagnosis is stated and therefore its treatment, the final prognosis is considerably better. When faced with a eoxarthropathy, presumably an aseptic necrosis of the hip, we believe that the hemodynamies of the femoral head plus a biopsy should be carried out, even in the eases where the radiology is negative. The simplicity of the technique in addition to the fact that the mechanics of the hip remain unaltered in view of any future operations, leads us to the point where the pediculate bone graft is the technique of choice in those eases with similar conditions to the above described.

The aseptic necrosis of t h e hip j o i n t is a r e s u l t of a v a s c u l a r (partial or total) d i s t u r b a n c e of t h e femoral h e a d which can be f o u n d a n d b y m e a n s of t h e a n a t o m o p a t h o l o g i c a l s t u d y of t h e bone. B y i n v e s t i g a t i n g t h e h e m o d y n a m i c s of t h e femoral h e a d it is possible to determine t h e v a s c u l a r d i s t u r b a n c e s before t h e a p p e a r a n c e of large areas of necrotic bone. As a rule, t h e v a s c u l a r d i s t u r b a n c e goes along w i t h a slowing of t h e m e t a p h y s e a l venous d r a i n a g e which can be shown b y m e a n s of a p h l e b o g r a p h y (Ruffle et al.; Serre a n d S i m o n ; A r l e t a n d F i c a t ) , a n d b y an increased intra-osseous pressure which a t t i m e s duplicates. The d e s c r i p t i o n of necrosis checked b y m e a n s of femoral h e a d a n d neck b i o p s y in p a t i e n t s p r e s e n t i n g n o r m a l r a d i o l o g y a n d even in p a t i e n t s whose r a d i o l o g y ( F i c a t et al.) i n d u c e d an a r t h r i t i c or o s t e o a r t h r i t i s diagnosis, r e c o m m e n d s t h a t all p a t i e n t s p r e s e n t i n g p a i n in t h e hip j o i n t a r e a with or w i t h o u t decreased m o b i l i t y r a n g e should u n d e r g o a biopsy. (l~utishauser has described a v a s c u l a r necrosis in p a t i e n t s whose r a d i o l o g y showed a n a r r o w e d j o i n t space plus a local

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decalcification.) I n our experience t h e r e is a case of aseptic necrosis checked b y m e a n s of a b i o p s y a n d showing a r a d i o g r a p h i c o s t e o a r t h r i t i c i m a g e s e c o n d a r y to a t u b e r c u l o u s a r t h r i t i s occurred 4 y e a r s earlier. T h e t r e a t m e n t we r e c o m m e n d is t h e s u b s t i t u t i o n of necrotic bone b y cancellous bone w i t h a m u s c u l a r insertion in it, t h u s ensuring its survival. As a result, t h e femoral h e a d is revivified a n d p a i n is relieved w h e n t h e venous d r a i n a g e is eased bringing m e t a p h y s e a l decompression a n d fresh blood s u p p l y is b r o u g h t b y t h e muscle. B y this we do n o t aim to change t h e shape of t h e femoral h e a d which r e m a i n s t h e s a m e previous to t h e operation. B y this t e c h n i q u e we a t t e m p t to relieve p a i n a n d to stop t h e progressive d a m a g e of t h e j o i n t ; we do n o t a t t e m p t to increase t h e m o b i l i t y range a l t h o u g h in some eases, w i t h t h e d i s s a p p e a r a n e e of t h e m u s c u l a r c o n t r a c t i o n a n increase of t h e m o b i l i t y range was observed. Obviously, t h e sooner t h e diagnosis is reached, t h e b e t t e r t h e m o b i l i t y a n d therefore t h e results o b t a i n e d . W e a t t a c h g r e a t i m p o r t a n c e to t h e flexion a n d we use this t e c h n i q u e only in t h o s e cases w i t h a m i n i m u m flexion of 7 0 - - 7 5 ° enabling t h u s t h e p a t i e n t to climb a n d descend stairs. Some cases r e q u i r e d in a d d i t i o n a t e n o t o m y of t h e a d d u c t o r muscles which resolved a f a u l t y position a n d t h e lack o f a b d u c t i o n .

Technique By means of a Watson-Jones incision extended proximally along the iliac crest (Fig. 1) we expose the spina iliaca anterior superior and the coxofemoral joint. With an osteotome we cut a piece of bone from the iliac crest in the shape of a quadrangle with an approximate size of 3 × 2 era, and with the tensor fasciae latae inserted in it. The muscle together with the bone fragment is turned down exposing widely the joint capsule. We proceed then to a capsulotomy and we explore the joint in search of any free joint mice. The necrotic bone of the head is then removed through an opening in the anterior superior area of the neck close to the head; with an osteotome and a marrow spoon we perform a wide curettage removing

Inclslbn ileofernorat lateral.

Fig. 1

Pediculate Bone Graft as Treatment for the Aseptic Necrosis of the Femoral Head

117

Fig. 2

Fig. 3 1 Tensor fasciae latae, 2 Rectus feuioris, 3 Sartorius

thus from the head all the necrotic tissue. In addition to this we also pierce the cancellous bone. I n some cases the necrotic bone came out as a whole (Fig. 2). The iliac pediculate fragment is then placed with a slight percussion so as to fit it closely to the subehondral area. In tile ease of any free spaces left, these should be filled with cancellous bone chips. I f the fitting does not appear very solid it is then fixed with a screw or a Palmer nail (Fig. 3). The patient is then subject to a period of complete rest in bed of 3 weeks; then, he is allowed to walk with no weight bearing. The average period of time required for a total weight bearing ranges within 4 and 41/2 months after the operation, depending on the radiology.

118

C. Palazzi and J. Xieoy (3asuisties

Since J a n u a r y 1967 until November 1973, 16 patients presenting aseptic necrosis of the femoral head were treated with the pediculate bone graft, at the Department of Orthopaedic Surgery, Hospital Sagrado Coraz6n, Chief of the Department Dr. A. S. Palazzi.

16 patients

Sex

Side

Age

9 males 7 females

9 right side 7 left side

11--62 years average: 41 years

Prior to the operation the record of these patients was : Fracture of the femoral neck (operated) Osteotomy of the femoral neck Cortisone therapy Poliomyelitic hip Childhood arthritis Tuberculous arthritis in adult age With no previous record

4 1 3 1 1 1 5 Total

16

Results The results were established according to the dissappearance of pain. The different kinds of pain were classified as follows : Continuous pain Nightly pain Arthrosic pain Weariness pain Initial walking pain Change of weather pain

C N A W I CH

The results were divided as follows: Bad Useful Good Very good

no improvement weariness pain and change of weather pain weariness pain o r change of weather pain without pain or occasionally change of weather pain

The results obtained were: (B) (U) (G) (VG)

Exitus Bad Useful Good Very good Total

1 1 4 4 6

(6.25%) (6.25%) (25%) (25%) (37.5%)

16 (100%)

Pediculate Bone Graft as Treatment for the Aseptic Necrosis of the Femoral I-Iead 119 Graphic Age Case and sex

Side

Pain before Pain after operation operation

Subjective Results Clinical notes improvemerit

I m

11

L

A

oeeas. CH

90O/o

VG

2f 3m 4f 5m

58 60 31 62

R, L L L

oceas. Ctt light W W and CH CH

90% 85~o 70% 80~o

VG G U G

6m

47

L

A A A N, W and CH C and N

7f

62

R

8 m

4~7

R

9f

62

L

10 f 11 m 12 m

40 5~ 53

R L R

13 f

40

R

14 f 15 m 16 m

19 47 17

R R t{

W and CtI 70~o

walks 3 hrs without interruption with no stick no stick Fig. 4 no stick Fig. 5 no stick no stick

U

walks 1.5 hrs without interruption with no stick CH 85% G walks 5 km without stick C Fig. 6 CH 80~o G no stick A I 90°/o VG walks 5 hrs without C and N interruption no stick Fig.7 W and CtI 75~o U use of stick C and N exitus 10 days after operation by pulmonary embolism W none 90~o VG walks 4 km without interr. A and N no stick, increased mobility range A none 70~o U loss of flexion, no stick Fig. 8 A and Ctt A 0~o B loss of flexion, use of stick A none 90% VG no stick A none 95% VG no stick

We o b s e r v e d t h a t all p a t i e n t s increased t h ei r walking range, t h a t is t h e y were able to walk larger distances a n d during a longer t i m e t h a n before t h e operation. All p a t i e n t s were asked to give t h e i r personal opinion a b o u t t h e results, c o m p a r i n g it w i t h t h e ir condition prior to th e o p e r a t i o n ; these were expressed in percentages. A 100% i m p r o v e m e n t i m p l ie d t o t a l r e c o v e r y a n d a 0 % i m p r o v e m e n t no change o f condition. I n t h e g r a p h i c this is expressed as " s u b j e c t i v e i m p r o v e Inent~. Complications I n 2 cases we e n c o u n t e r e d t h e loss of a c t i v e flexion of t h e hip. This we assu m ed it was due to f a u l t y t e c h n i q u e because in b o t h eases t h e tensor fasciae l at ae was dissected i m p e r f e c t l y a n d th e spina iliaca anterior superior was t h e n g r a f t e d w i t h all its m u s c u l a r insertions. I n order to a v o i d this we h a v e used in some eases t h e a n t e r i o r fibers of t h e gluteus medius as m u s c u l a r pedicle. T h e eases in which this m o d i f i c a t i o n was i n t r o d u c e d are n o t included in this work, t h ei r follow-up being u n d e r 1 year.

Fig. 4

Fig. 5

Fig. 6

Fig.

7

122

C. Palazzi and J. Xicoy

Fig. 8

References Bonflglio, M., Bardenstein, M. B. : Treatment by bone-grafting of aseptic necrosis of the femoral head and non-union of the femoral neck. J. Bone Jt Surg. 40-A, 1329 (1958) Ficat, P.: RSsultats du forage-biopsie duns l'ost@on~crose de la hanche. Aeta orthop, belg. 38, 566 (1972) Float, P., Arlet, J., Sebbag, D.: Int~rSt de la mesure de la pression intram~dullaire duns le massif trocant~ricn chez l'homme, en particulier pour le diagnostic de l'ost~onScrose f~moro-capitale. Rev. t~hum. 35, 516 (1966) Lequesne, M. : La n~erose de la tSte f~morale uvec chrondolyse rapide. Acta orthop, belg. 38, 516 (1972) Ruffle, R., Fournie, A., Ayrolles, Ch., Cuq, P. : R~sultats de la phl~bographie pertrochant@rienne duns les osteon~croses primitives de la t~te fdmorale ehez l'adulte. Rev. Rhum. ~.9, 551 (1962) Rutishauser, E., Taillard, W. : L'iseh~mie articulaire an p athologie humaine et exp@rimentale. La notion vaseulaire. Rev. Chit. orthop. ~2, 197 (1966) Seze, S. de: Ost@on~crose aseptique primitive de la t~te f@morale. Aeta orthop, belg. 38, 507 (1972) Sherman, S., Coleman: Aseptic necrosis of bone due to trauma. Orthop. Clin. N. Amer. ~, No. 4 (1974) Dr. Carlos Palazzi Londres, 65 Bureelona-15, Espafia