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Table of Contents
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 32-36

Evaluation of hip arthroscopy in patients with previous history of femoral head osteonecrosis

Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA

Date of Submission15-Feb-2020
Date of Acceptance22-Sep-2020
Date of Web Publication21-May-2021

Correspondence Address:
Dr. Amy P Trammell
Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/DORJ.DORJ_7_20

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Background: Femoral head osteonecrosis (FHO) is a debilitating condition. Free vascularized fibular grafting (FVFG) has good survivorship, however patients are at risk for reoperation.
AIM and Objectives: This study compares patient characteristics, hip pathology, and surgical intervention in patients with FHO. We hypothesized that patients with FHO who underwent FVFG would demonstrate less severe degeneration of hip chondral surfaces compared to patients who did not.
Materials and Methods: A database of 1,481 hip arthroscopies performed by a single surgeon was queried. Inclusion criteria included history of FHO. Patients with a previous hip surgery were excluded. Non-FVFG patients served as a control. Demographics, presentation, physical examination, imaging, intraoperative pathology, and procedures performed were compared. Cartilage degeneration was quantified with chondromalacia severity index (CMI). The Hip Outcome Score- Activity of Daily Living (HOS-ADL), -Sports Subscale (HOS-SS), and modified Hip Harris Score (mHHS) were calculated.
Results: Sixteen patients had a history of FHO. Six (37.5%) previously underwent FVFG. Both groups had similar demographics, clinical presentation, preoperative range of motion, and radiographic findings (P>0.05). Arthroscopy identified similar chondral lesion Outerbridge grade and size for the acetabulum and femoral head (P>0.05). Compared with controls, FVFG patients had greater CMI of the acetabulum (844.7±501.3 vs. 345.8±433.3; P=0.018) and similar CMI of the femoral head (408. ±187.7 vs. 1461.0±1493.6; P=0.289). Microfracture of the acetabulum and ligamentum teres debridement were performed preferentially in patients with a history of FVFG compared with controls. Of the six previous FVFG patients, two converted to total hip arthroplasty, two completed patient reported outcomes, and two were lost to follow-up.
Conclusion: Patients with previous FVFG for FHO are at an increased risk of chondral damage to the acetabulum and demonstrated more advanced chondral degeneration compared with controls.
Level of Evidence: III; Retrospective cohort study

Keywords: Femoral head osteonecrosis, Free vascularized fibular graft, Hip arthroscopy

How to cite this article:
Luo TD, Trammell AP, Marquez-Lara A, Zuskov A, Rosas S, Stone AV, Stubbs AJ. Evaluation of hip arthroscopy in patients with previous history of femoral head osteonecrosis. Duke Orthop J 2020;10:32-6

How to cite this URL:
Luo TD, Trammell AP, Marquez-Lara A, Zuskov A, Rosas S, Stone AV, Stubbs AJ. Evaluation of hip arthroscopy in patients with previous history of femoral head osteonecrosis. Duke Orthop J [serial online] 2020 [cited 2024 Feb 27];10:32-6. Available from: https://www.dukeorthojournal.com/text.asp?2020/10/1/32/316561

  Introduction Top

Femoral head osteonecrosis (FHO) is an uncommon but debilitating condition primarily affecting white, adult males younger than 50 years of age.[1],[2] A multiplicity of FHO etiologies exist, including traumatic (e.g., femoral neck fracture, hip dislocation, unstable slipped capital femoral epiphysis) and nontraumatic (e.g., Legg-Calvé-Perthes disease, immunosuppression, radiation, alcoholism, autoimmune disease, hemoglobinopathy, malignancy) causes.[1],[2],[3] These conditions result in damage and/or dysfunction within the arterial supply of the femoral head, which can lead to ischemia, osteonecrosis, and in the majority of cases, collapse of subchondral bone if the vascular compromise is not remedied. Once collapse has occurred, the most serious complication associated with FHO is the accelerated development of end-stage osteoarthritis–one of the most common reasons for total hip replacement before age 50.[1],[4],[5],[6] Consequently, early recognition and prompt initiation of treatment in the early stages of FHO are key for minimizing the risk of progression towards collapse and the need to undergo major surgery.

Early-stage (precollapse) treatments for FHO are directed toward the preservation of the femoral head and include pharmacologic measures, core decompression, bone grafting (e. g., free-vascularized fibular grafting [FVFG]), and hip resurfacing.[5] Previous reports have demonstrated good long-term survivorship and outcomes with the use of preemptive FVFG in the setting of precollapse FHO for femoral heads with small and large early-stage lesions.[1],[7] Fibular grafts are the most commonly used free-vascularized grafts and offer a number of advantages, including desirable anatomical characteristics, reliability, versatility, restoration of blood flow, and recent evidence supporting this modality as an option for pediatric FHO patients.[4] In addition, hip preservation following FVFG for precollapse FHO may last 10–20 years, making this procedure a particularly desirable option for younger patients.[7] However, FVFG is a technically challenging procedure to perform and many patients may still be at risk for subsequent hip procedures. Previous studies have reported that patients who underwent FVFG and subsequently required conversion to total hip replacement had an average time to conversion of 8 years if they were precollapse,[7] and up to 39% of patients with femoral collapse required conversion within 5 years.[1]

A number of prearthritic hip conditions are being treated arthroscopically with increasing frequency in adult and pediatric populations.[6],[8],[9],[10] Compared with open and mini-open techniques, hip arthroscopy is less invasive, is associated with fewer complications, and demonstrates equal efficacy.[8],[10],[11],[12],[13],[14],[15] For pediatric patients, in particular, FHO is one of the most common indications for hip arthroscopy.[6] Hence, hip arthroscopy may be a viable option to treat symptomatic predegenerative FHO, potentially further delaying the need for conversion to total hip replacement. The purpose of this study was to compare patient characteristics, clinical presentation, hip pathology, and surgical intervention in patients with a history of precollapse FHO. We hypothesized that patients with a history of FHO who previously underwent an FVFG procedure would demonstrate less severe degeneration of hip chondral surfaces compared to patients who had not undergone FVFG.

  Methods Top

A prospective database of 1481 consecutive hip arthroscopies performed between 2008 and 2016 by a single, fellowship-trained orthopedic surgeon was queried. Patients were enrolled in an institutional review board-approved study before surgery. The inclusion criteria for this study were males and females with a history of precollapse FHO. Patients with a history of hip surgery (open or arthroscopic) were excluded from this study. Patients who met the inclusion criteria were then stratified into two groups based on a history of FVFG procedure. The group of patients with no history of FVFG served as the control. Groups were compared with respect to patient demographics, clinical presentation, physical examination, diagnostic imaging findings, intraoperative assessment of pathology, and arthroscopic procedures performed.

Preoperative plain film radiographs were used to identify evidence of cam and/or pincer deformities, with radiographic findings confirmed intraoperatively. Cam impingement was defined as an alpha angle > 55° on a plain film lateral view.[16] A lateral center edge angle > 40° on an AP view,[17] center of rotation of femoral head medial to posterior wall projection on an AP view, and the medial wall of the acetabulum projecting medial to the ilioischial line on an AP view were considered evidence of hip over-coverage. Profunda pincer impingement was diagnosed when a patient had two-out-of-three of these radiographic findings. Acetabular retroversion and pincer impingement were diagnosed based on the presence of a cephalad acetabular crossover sign on an AP view.

All arthroscopic procedures were performed by the senior author. Patient positioning, surgical approach, and diagnostic arthroscopic examination were performed as described previously.[15],[18] Arthroscopic assessment allowed for confirmation of impingement type and further characterization of chondral lesions, including grade, size, and location. A previously described chondromalacia severity index (CMI), defined as the product of Outerbridge chondromalacia grade (I to IV) and the affected surface area (mm2) for each chondral lesion, was used to quantify the extent of cartilage degeneration.[19] The specific arthroscopic procedures utilized for each patient were also recorded (e.g., femoroplasty, microfracture, labral repair).

Patients with FHO and FVFG were contacted postoperatively to screen for hip outcome score-activity of daily living (HOS-ADL), sports subscale (HOS-SS), Tegner Activity Level and modified Hip Harris Score (mHHS) were calculated.

Statistical analysis

IBM SPSS Statistics software (version 24.0; IBM Inc., Armonk, New York, USA) was used for all statistical analyses. Continuous variables were evaluated using a Mann–Whitney U-test for nonnormally distributed data. A Fisher's exact test was performed to evaluate categorical variables. For all statistical analyses, the threshold for significance was established at P < 0.05. Numerical values given are mean ± standard deviation unless noted otherwise.

  Results Top

A total of 16 patients met inclusion criteria for this study, including 6 patients (37.5%) who previously underwent a FVFG procedure and 10 patients (62.5%) who had no history of FVFG. Demographic factors including age, sex, and body mass index, as well as clinical presentation, were similar between controls and patients with a history of FVFG [P > 0.05 for all, [Table 1]]. Preoperative physical examination of hip range of motion (operative and nonoperative side) demonstrated similar flexion and internal rotation between the groups (P > 0.05 for all). Preoperative plain film radiographs demonstrated no significant differences in the frequency of cam or pincer deformity, lateral center edge angle, Sharp's angle, or anterior center edge angle between groups (P > 0.05 for all). Arthroscopic assessment identified similar chondral lesion outerbridge grade and size for both the acetabulum and femoral head between the groups, with the difference in acetabular outerbridge grade approaching significance [P = 0.052, [Table 2]]. Compared with controls, patients with a history of FVFG demonstrated significantly greater CMI of the acetabulum intraoperatively (P = 0.018), similar CMI of the femoral head (P = 0.289), and were preferentially treated with microfracture of the acetabulum [P = 0.035, [Figure 1]]. Ligamentum teres debridement was also performed more frequently in patients with a history of FVFG compared with controls (83.3% vs. 20.0%, P = 0.035). There were no statistically significant differences in the frequency of other arthroscopic procedures between groups.
Table 1: Summary of patient demographics, clinical presentation, and preoperative hip range of motion based on history of free vascularized fibular grafting

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Table 2: Arthroscopic assessment of chondral lesions based on a history of free vascularized fibular grafting

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Figure 1: Proportion of patients treated with microfracture of the acetabulum or femoral head based on a history of free vascularized fibular grafting. *Denotes significance compared with controls (P = 0.035)

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Of the six FVFG patients, two patients were lost to followup. Two patients required conversion to a total hip arthroplasty at an average time of 27 months from the hips arthroscopic procedure (range 19–35 months). The two remaining patients were contacted to perform patient-reported outcomes at an average of 86 months (7.1 years) postoperatively. The Tegner, HOS-ADL, HOS-SS, and mHHS scores were found to be 2.0 (2.0, 2.0), 88.3 (76.5, 100), 51.8 (28.6, 75.0), and 86.3 (80.2, 92.3), respectively.

  Discussion Top

This study found that patients with a history of FVFG for FHO demonstrated more severe acetabular chondral degeneration and similar femoral head chondral degeneration at the time of hip arthroscopy compared with patients who had not undergone FVFG. These findings suggest that a history of FVFG for precollapse FHO may not be chondroprotective, contrary to our hypothesis.

There may be a number of possible explanations for the observed differences in chondral degeneration between groups in this study. First, and despite the documented efficacy of the FVFG procedure, the natural history following FVFG is that many patients will eventually require additional surgery, due to continued degeneration of the hip. In addition, the biologic performance of the graft depends on a number of factors, including the etiology, stage, and size of FHO.[4] It is reasonable to surmise that patients in this study who previously underwent FVFG were selected for bone grafting due to more aggressive precollapse FHO. In the setting of more aggressive FHO, there would likely be other structural and degenerative changes present, such as greater acetabular damage secondary to abnormal articulation with a structurally deficient femoral head. Hence, the more severe chondral damage identified during hip arthroscopy in patients with a history of FVFG may reflect a greater original disease burden compared with controls. Further, depending on how long ago the FVFG procedure was performed, the graft may have maximized its useful life expectancy–particularly if there was the more advanced disease to begin with. Notwithstanding, previous studies have shown that hip preservation surgeries such as FVFG do not adversely affect survivorship and clinical outcomes of subsequent total hip replacement, and therefore this procedure remains a viable option for this challenging population.[5] Interestingly, despite differences in the severity of chondral degeneration between groups, differences in clinical presentation and objective preoperative examination findings were equivocal. Taken together, these results suggest that in the absence of more definitive clinical findings during examination, a history of FVFG should raise a high index of suspicion for potential chondral damage in patients with a history of FHO.

A significantly higher proportion of patients with a history of FVFG were treated with arthroscopic microfracture of the acetabulum compared with controls, consistent with the more advanced acetabular chondral degeneration observed in these patients. Further, damage to the ligamentum teres can predispose the hip to instability and cartilage injury.[20] We found that ligamentum teres debridement was performed preferentially in patients with a history of FVFG compared with controls. This finding may suggest that underlying ligamentum teres damage may be one of the factors that contributed to the greater acetabular chondral degeneration seen in these patients. Although we found that more severe injury to the articular cartilage of the acetabulum and to the ligamentum teres occurred in patients with a history of FVFG procedure, it is unclear whether these findings were sequelae of the underlying FHO, the previous FVFG procedure itself, or a combination of both.

This study has several limitations inherent to a retrospective study. Information regarding the original FHO diagnosis (e.g., presenting symptoms, etiology, severity, diagnostic imaging) and FVFG procedure (e.g., persistence of symptoms, use of conservative therapy, specific surgical indications, intraoperative details, postoperative management and rehabilitation compliance, follow-up examinations and imaging, complications) was not available with our methodology. Similarly, we could not control for the amount of time since FHO diagnosis (for controls) or FVFG procedure (for patients with a history of FVFG) until follow-up hip arthroscopy. This study reviewed a small subset of patients using a database from a single orthopedic surgeon, with all data recorded in a standardized fashion by the senior author to help ensure accuracy and reliability. The database only captured patients who underwent operative treatment and did not include patients treated nonoperatively, which possibly resulted in selection bias. The patient reported outcomes in this study were limited due, which reduces the generalizability of our findings. Finally, although every reasonable effort was made to ensure the accuracy and reliability of the database used in this study, there was the potential for errors and omissions in the data, which may have introduced confounders and influenced the results.

The findings of this study contradict our hypothesis, in that a history of FVFG for the treatment of precollapse FHO did not appear to provide protection from chondral degeneration compared with patients who did no undergo FVFG. Hip arthroscopy is a safe, minimally-invasive procedure that may be a viable option for some in this difficult-to-treat population based on the extent of disease at the time of presentation. Further studies are necessary to compare survivorship and clinical outcomes between hip arthroscopy and FVFG, as well as assess rates of conversion to total hip replacement. The results from this study may help improve patient evaluation and selection for surgery and formulate appropriate arthroscopic treatment criteria. Our findings also lend new insight for the orthopedic surgeon to counsel patients with precollapse FHO who may be considering the FVFG procedure or who may be candidates for hip arthroscopy.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1], [Table 2]


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