Comparison of results of core decompression and intertrochanteric osteotomy for nontraumatic osteonecrosis of the femoral head using Cox regression and survivorship analysis

doi:10.1054/arth.2001.23580

The Journal of Arthroplasty

Volume 16, Issue 6, September 2001, Pages 790-794

https://doi.org/10.1054/arth.2001.23580 Get rights and content

Abstract

Different surgical procedures have been recommended for osteonecrosis of the femoral head to prevent or delay the need for arthroplasty. Core decompression is a commonly used treatment in the early stages of the disease, but the published efficacy has varied markedly. Only a few comparisons of different techniques have been reported. The aim of this study was to evaluate and compare the results of 2 commonly used procedures, core decompression and intertrochanteric osteotomy, using Cox regression and survivorship analysis. A total of 177 cases with a mean age of 41 years at surgery were treated for osteonecrosis (94 core decompressions, 83 osteotomies). Any further surgery was defined as failure and endpoint. Significant risk factors for treatment failure were age >40 years at surgery (P=.022), corticosteroid intake (P<.001), advanced stage of necrosis (Steinberg stage ≥III, P=.04), and core decompression (P=.084). To analyze the influence of the surgical procedure, patients with corticosteroid treatment were excluded, and survival analysis was performed. This analysis revealed survival rates of 74% after osteotomy and 78% after core decompression 6 years postoperatively in early, precollapse stages (P=.819). In advanced stages, the rate of survival for hips after core decompression was lower (56%) than in hips after osteotomy (76%) (P=.056). Our results indicate that core decompression may be as effective as intertrochanteric osteotomy in precollapse stages but is less traumatizing and is cost-effective. For postcollapse hips, intertrochanteric osteotomy should be considered.

Section snippets

Patients and methods

Between 1979 and 1996, 177 CDs or IOs for ONFH were performed in 141 patients (108 men). All cases were included in this study. Diagnosis was established in all patients by clinical history and radiography in 2 planes. Mean age at operation was 42 years (range, 21–60 years) in the IO group and 40 years (range, 16–77 years) in the CD group. The age limit for IO was 60 years; for the CD procedure, there was no age limit. Of patients, 49 underwent unilateral CD, and 20 underwent bilateral CD.

Results

Because there was no difference regarding failure between hips treated with IO (40 cases) and IO plus additional CD (43 cases; log-rank test, P=.66), these cases were pooled for further analysis. For Cox regression analysis, data of 167 hips (94%) were available. Alcohol intake could not be determined in 5 patients (5 hips); 3 patients (3 hips) were lost after initial hospital stay, and 1 patient (2 hips) died 3 days after bilateral CD. Significant risk factors for additional surgery are shown

Discussion

In natural history, ONFH is a progressive disease, which results in the destruction of the hip joint ^[2] and need for arthroplasty in most cases. The aim of intervention is to prevent further progression and induce healing of the necrotic area of the femoral head. For CD, the authors of the method, Ficat and Arlet ^[6], and Hungerford ^[7] report high success rates. Results published by other groups are inconsistent, however 3, 4, 12, 13, 14. The advantage of CD is that the operative procedure is

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The indications for core decompression have not been definitively established. There is significant variation in the published data regarding the efficacy of core decompression [4,5,13,17-23]. In addition, there is uncertainty regarding the optimal surgical technique for performing this procedure.
Seventy-six patients with femoral head necrosis were allocated to a program of either core decompression (control group) or core decompression and implantation of a biomaterial-loaded allograft threaded cage (treatment group). All patients were followed up prospectively clinically and radiographically. In the control group, no significant improvement in Harris hip score was found, and 13 of the 22 hips had deteriorated to stage III. In the treatment group, the mean Harris hip score was improved from 62.8 to 81.6; the clinical success rate at 36 months postoperatively was 91%. Collapse was seen in 1 hip, and another 3 hips exhibited progressive collapse. The procedure is attractive as a minimally invasive and salvage procedure, which shows encouraging success rates and early clinical results in patients with Steinberg stage I-II osteonecrosis.
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Marciniak et al [25] reported that the vascularized fibular pedicle bone graft showed a mean survival rate of 42% at 8 years of follow-up. Sugioka anterior rotational osteotomy [22] was developed, aimed at transferring the weight-bearing area to the healthy femoral head to assist revascularization in the necrotic area with some success, but again it is not easy to duplicate [26,27]. Table 3 shows a comparison of the current study with other studies of various methods of bone grafting.
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^☆: No benefits or funds were received in support of this study.

^☆☆: Reprint requests: Hans-Georg Simank, MD, Orthopädische Klinik der Universität Heidelberg, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany. E-mail: [email protected]

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Original ArticlesComparison of results of core decompression and intertrochanteric osteotomy for nontraumatic osteonecrosis of the femoral head using Cox regression and survivorship analysis☆,☆☆

Abstract

Section snippets

Patients and methods

Results

Discussion

Nontraumatic necrosis of bone (osteonecrosis)

N Engl J Med

Core decompression versus nonoperative management for osteonecrosis of the hip

Clin Orthop

Long-term results of core decompression for ischaemic necrosis of the femoral head

J Bone Joint Surg Br

Core decompression of the osteonecrotic femoral head

J Bone Joint Surg Am

Osteonecrosis of the femoral head: a prospective randomized treatment protocol

Clin Orthop

Core Dekompression bei ischämischer Femurkopfnekrose

Orthopäde

A quantitative system for staging avascular necrosis

J Bone Joint Surg Br

Core decompression in osteonecrosis of the femoral head: risk-factor-dependent outcome evaluation using survivorship analysis

Int Orthop

Winkelplatten

Nonparametric estimation from incomplete observation

Am Stat Assoc J

Original Articles
Comparison of results of core decompression and intertrochanteric osteotomy for nontraumatic osteonecrosis of the femoral head using Cox regression and survivorship analysis☆,☆☆