Materials and Methods Materials

We reviewed 82 hips in 75 patients with osteonecrosis of the femoral head in whom follow-up was possible for more than 1 year. The surgery was performed by one surgeon (T.R.Y.). The average age was 33 years (range, 19-51 years). The study population included 64 men and 11 women. Fourteen were classified as Ficat stage 2, 55 as stage 3, and 13 as Ficat stage 4 (Table 1). The causes of osteonecrosis were excessive alcohol consumption in 30 hips, steroid use in 26, idiopathic in 17, and posttraumatic in 9. The direction of rotation was anterior in 77 cases and posterior in 5 cases. We performed a simple modified rotational osteotomy in 16 cases, a combination of osteotomy and simple bone grafting in 7 (Fig. 1), and a combination of osteotomy and muscle-pedicle-bone grafting in 59 (Fig. 2). The average follow-up was 1.8 years (range, 1-3.3 years).

Surgical Technique

The lateral approach was used with dissection of the joint capsule to expose the femoral head. The short external rotator muscles were completely transected, preserving the quadratus femoris, and being wary of injury to the medial circumflex artery above the lesser trochanter, and then the joint capsule was exposed. A line on the osteotomy site was drawn. A Kirschner wire was driven into the femur perpendicular to its neck. Using the Kirschner wire as a guide, the osteotomy was performed.

Table 1.

Classification of cases on

the basis of the Ficat stage and operation procedure

Stage

Only

Transtrochanteric

Transtrochanteric rotational

Total

transtrochanteric

rotational

osteotomy with MPBG

rotational osteotomy

osteotomy with bone graft

II

4

3

7

14

III

12

4

39

55

IV

0

0

13

13

Total

16

7

59

82

MPBG, muscle-pedicle-bone graft

MPBG, muscle-pedicle-bone graft

Fig. 1. Radiographs of a 42-year-old man who had transtrochanteric rotational osteotomy with bone graft for osteonecrosis of the femoral head (Ficat stage II) (A, B). Radiographs 14 months postoperatively show good union of the osteotomy site and good incorporation of grafted bone at the necrotic area (C)

Fig. 1. Radiographs of a 42-year-old man who had transtrochanteric rotational osteotomy with bone graft for osteonecrosis of the femoral head (Ficat stage II) (A, B). Radiographs 14 months postoperatively show good union of the osteotomy site and good incorporation of grafted bone at the necrotic area (C)

Fig. 2. Radiographs of a 19-year-old woman who had transtrochanteric rotational osteotomy with muscle-pedicle-bone graft for osteonecrosis of the femoral head (Ficat stage IV) (A, B). Radiographs 18 months postoperatively show no progression to degenerative osteoarthritis (C)

Fig. 4. The femoral head (arrow) was rotated anteriorly depending on the necrotic area in this case

In contrast to Sugioka's traditional technique, the greater trochanter is not detached (Fig. 3); only the femoral neck is osteotomized. The femoral head was then rotated anteriorly or posteriorly, depending on the location of necrotic area, and stabilized using two or three cannulated screws (Figs. 4, 5).

Methods

Clinical evaluation was performed with use of the Harris hip score (HHS). A clinical score was considered to be excellent if it was above 90 points, good if between 89 and 80 points, fair if between 79 and 70 points, and poor if 69 points or less. If there was progression of osteonecrosis or THA was performed in the follow-up period, the results were considered as a "failure."

Fig. 5. Fixation for the rotational osteotomy was accomplished by two cannulated screws m-

Radiologic evaluation was performed with bone scan 3 weeks after the operation to assess revascularization or vascular injury. Also, periodic anteroposterior and lateral roentgenograms were taken to monitor for femoral head collapse or degenerative change. If there was no progression of necrosis on the newly formed weight-bearing surface, evidence of union could be found on the osteotomized site, and no collapse of femoral head greater than 2 mm and no degenerative change of joint space narrowing occurred, we defined the operation as a radiologic success; otherwise, it was considered a failure.

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