Discussion

The etiology of osteonecrosis of the femoral head has been unclear, although young patients under 40 years of age are frequently affected, with progression to femoral head collapse and degenerative arthritis. Options for treatment range from simple observation to surgical procedures. Surgical treatment can be largely categorized into joint salvage procedure and THA. THA has been known to be the one and only definitive treatment for osteonecrosis of the femoral head that directly removed the lesion and renewed the articular surface. Nevertheless, THA is not a permanent treatment. It should not be a final choice in young patients because new problems such as prosthetic wear, osteolysis, and loosening have developed in THA, requiring later revision surgery. Therefore, it is reasonable to perform a salvage procedure for those patients who are young and are diagnosed early.

Core decompression, nonvascularized or vascularized bone graft, and transtro-chanteric rotational osteotomy were developed and performed as head preservation procedures. Core decompression has its theoretical basis in the following principles: first, pain relief from decreasing intraosseous pressure; second, decompression of interstitial edema; and third, neovascularization that eventually alleviates femoral head necrosis [15]. Many investigators believe that temporary symptom relief can be expected from core decompression, but it is hard to prevent femoral head collapse if the necrotic lesion is large [16,17]. Vascularized bone grafting was introduced by Judet and associates [18] and popularized by Urbaniak and associates [19]. However, Urbaniak reported that vascularized bone grafting requires a surgeon experienced in microsurgical technique, and because fibular bone is sacrificed, weight-bearing is restricted for 6 months, eventually leading to weakness of ankle dorsiflexion, sensory deficit, and progressive foot pain.

In 1980, Wagner and Zeiler proposed transtrochanteric rotational osteotomy, but compared to classical procedures it was difficult and the results were quite similar or unsatisfactory [20]. Sugioka [12] introduced a new method of transtrochanteric rotational osteotomy, and it has been performed as one of the procedures for osteone-

crosis of femoral head. Sugioka transtrochanteric rotational osteotomy is applied to young patients with an intact posterior femoral area so that the necrotic zone is shifted to a lesser weight-bearing portion of the posteroinferior aspect. The weight-bearing surface is replaced by healthy bone or cartilage, aiming at elimination of shearing forces in the femoral head and progressive collapse and realignment of the articular surface of the subluxated femoral head [13,17].

Sugioka reported a 86% success rate in 11 years of follow-up study; not only the early necrotic stage but also Ficat stage III and IV with advanced collapse and arthritic change had 73% and 68% success rates, respectively [13]. Maistrelli and associates [21] reported transtrochanteric rotational osteotomy is not permanent, but those young patients who have neither metabolic bone disease nor articular destruction can gain enough time to delay THA. Although successful results were seen on short-term follow-up, long-term follow-up results were variable and not quite satisfactory [21,22]. Some authors reported a 50% success rate after transtrochanteric osteotomy [23], and Ohzono and associates [4] proposed that lack of skilled surgical technique or inappropriate patient selection or fixation causes a high failure rate. Our modified trans-trochanteric osteotomy for rotational osteotomy in which the greater trochanter is not detached has several advantages: no greater trochanteric fixation is needed, operation time is shortened, additional procedures such as muscle pedicle vascularized or nonvascularized bone graft can be combined, early rehabilitation is possible because shear force is reduced, and subsequent THA is not affected because the greater tro-chanter anatomy is not altered. However, our modification is also technically demanding. It may be reasonable that it is performed by only experienced surgeons if a good outcome is to be expected.

In our study, overall early survival rate was 90%. Although this study had a short-term follow-up, we had 62% success rate even in stage IV patients, in whom joint preservation is usually known to be impossible, thus effectively delaying performing THA.

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