JBJS | Surface Replacement Hemiarthroplasty for the Treatment of Osteonecrosis of the Femoral Head*

The Journal of Bone & Joint Surgery, Volume 80, Issue 11

Articles | November 01, 1998

Surface Replacement Hemiarthroplasty for the Treatment of Osteonecrosis of the Femoral Head*

MARC W. HUNGERFORD, M.D.†; MICHAEL A. MONT, M.D.†, BALTIMORE; RICHARD SCOTT, M.D.‡; CHRISTOPHER FIORE, M.D.‡, BOSTON, MASSACHUSETTS; DAVID S. HUNGERFORD, M.D.†; KENNETH A. KRACKOW, M.D.§, BALTIMORE, MARYLAND

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Investigation performed at the Division of Arthritis Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, and Brigham and Women's Hospital and Harvard Medical School, Boston

The Journal of Bone & Joint Surgery. 1998; 80:1656-64

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Abstract

We reviewed the results of thirty-three femoral resurfacing procedures in twenty-five patients who had stage-III or early stage-IV osteonecrosis of the femoral head according to the classification system of Ficat and Arlet. There were no perioperative complications. Thirty hip prostheses (91 percent) survived for a minimum of five years. At a mean of 10.5 years (range, four to fourteen years) postoperatively, sixteen (62 percent) of the twenty-six hips with stage-III disease had a good or excellent Harris hip score. Four of the seven hips with stage-IV disease did not have or need a total hip arthroplasty. Overall, twenty hips (61 percent) had a good or excellent result according to the scoring system of Harris, and thirteen (39 percent) had a fair or poor result and subsequently had or needed a total hip arthroplasty. The mean interval between the hemiarthroplasty and the total hip arthroplasty was sixty months (range, thirty-six to 136 months). These thirteen hips all had a successful clinical result (a Harris hip score of at least 80 points) at a mean of thirty months (range, twenty-four to seventy-two months) after the total hip arthroplasty.The results of the present study suggest that resurfacing of the femoral head can be a successful interim procedure for the management of patients who have Ficat and Arlet stage-III or early stage-IV disease with a large lesion that is not amenable to other treatment options except total hip arthroplasty.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Osteonecrosis of the femoral head remains a challenging problem in orthopaedics. Of the 209,000 total hip arthroplasties performed in the United States in 1991, 10 percent (21,000) were performed because of osteonecrosis³⁶. Furthermore, this disease typically occurs in the second through fifth decades of life. The young age of such patients magnifies the effects of the disease in terms of lost income and productivity^31,35 and especially in terms of the potentially excessive longevity required of the total hip replacement.

In addition to total hip arthroplasty, the options for the treatment of osteonecrosis of the femoral head with collapse include core decompression^{19,20,34,37,45,46}, rotational osteotomy^{13,18,26,32,37,39,47,48,51,55}, vascularized^33,53,54,56 and nonvascularized bone-grafting^37,39, and surface replacement hemiarthroplasty^{4,14,17,41,42,50}. The number and variety of procedures indicate both the lack of a clearly superior treatment and the undesirability of total hip arthroplasty for the treatment of osteonecrosis because of its high rate of failure^{7,8,10,11,15,21,22,28,38,43}. Factors that contribute to the high rate of failure include the relatively young age (mean, thirty-eight years³⁵) and long life expectancy of the patients as well as the poor quality of the femoral bone and the possible persistent defects in bone-mineral metabolism³⁸. Total hip arthroplasty for the treatment of osteonecrosis failed in ten (45 percent) of twenty-two hips in the study by Dorr et al.¹⁵ and in eleven (39 percent) of twenty-eight hips in the study by Cornell et al.¹⁰. In a study by Saito et al.³⁸, eight (17 percent) of forty-eight hips with osteonecrosis had a revision and another eight hips had impending radiographic failure at a minimum of ten years after a total hip arthroplasty. Another study²¹ showed improved results with use of modern cementing techniques or with use of stems inserted without cement, but the follow-up was short-term and the results were still inferior to those of total hip arthroplasty performed for other diagnoses.

Townley⁵² devised a total articular resurfacing arthroplasty (TARA; DePuy, Warsaw, Indiana) to replace a limited portion of the femoral head and concomitantly replace the articular surface of the acetabulum with a thin plastic shell inserted with cement. The femoral component consists of a spherical head that is available in three-millimeter increments and was designed to fit over the remaining part of the prepared femoral head. This component also has an attached curved stem that is seated into the femoral canal without cement. This device became unpopular because of high rates of failure on the acetabular side^{2,3,6,9,16,24,25,27,30}.

Resurfacing of only the femoral side of the hip joint with use of this prosthesis has had favorable results after short-term clinical and radiographic follow-up^28,41. Scott et al.⁴¹ reported a good or excellent result in twenty-two (88 percent) of twenty-five hips that had been followed for a mean of thirty-seven months (range, twenty-five to sixty months). Krackow et al.²⁸ reported a good or excellent result in sixteen of nineteen hips at a mean of three years (range, two to six years). The purpose of the present report was to combine those two series and examine the clinical and radiographic outcomes after resurfacing of only the femoral side of the hip joint for the treatment of Ficat and Arlet²⁰ stage-III or early stage-IV osteonecrosis of the femoral head. A primary aim was to determine whether the clinical results after surface replacement hemiarthroplasty are good enough to recommend the procedure to patients who have osteonecrosis in order to allow a delay of least five years before a total hip replacement is needed. Another aim was to determine whether revision of a hemiarthroplasty to a total hip arthroplasty provides a satisfactory clinical result.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Division of Arthritis Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Good Samaritan Professional Building, 5601 Loch Raven Boulevard, Baltimore, Maryland 21239. E-mail address for Dr. Mont: rhondamont@aol.com.

‡Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115.

§Department of Orthopaedic Surgery, Buffalo General Hospital, 100 High Street, Buffalo, New York 14203.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

‡Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115.

§Department of Orthopaedic Surgery, Buffalo General Hospital, 100 High Street, Buffalo, New York 14203.

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TABLE I CLASSIFICATION OF OSTEONECROSIS OF THE FEMORAL HEAD ACCORDING TO THE SYSTEM OF FICAT AND ARLET²⁰

Stage	Radiographic Appearance of Femoral Head
I	Normal
II	Cystic or osteosclerotic lesions, or both; normal contour of femoral head; no subchondral fracture
III	Crescent sign or subchondral collapse
IV	Joint-space narrowing, secondary acetabular changes (cysts, marginal osteophytes, and destruction of cartilage)

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TABLE I CLASSIFICATION OF OSTEONECROSIS OF THE FEMORAL HEAD ACCORDING TO THE SYSTEM OF FICAT AND ARLET²⁰

Stage	Radiographic Appearance of Femoral Head
I	Normal
II	Cystic or osteosclerotic lesions, or both; normal contour of femoral head; no subchondral fracture
III	Crescent sign or subchondral collapse
IV	Joint-space narrowing, secondary acetabular changes (cysts, marginal osteophytes, and destruction of cartilage)

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TABLE II RESULTS OF SURFACE REPLACEMENT HEMIARTHROPLASTY ACCORDING TO VARIOUS PARAMETERS

*The values are given as the number of hips, with the percentage in parentheses.

Parameter	No. of Hips	Outcome*
Success	Failure
Total	33	20 (61)	13
Age
>40 years	16	10	6
<40 years	17	10	7
Gender
Male	20	12 (60)	8
Female	13	8	5
Associated factors
Use of corticosteroids	18	12	6
Lupus erythematosus	9	6	3
Nonlupus erythematosus	9	6	3
Excessive intake of alcohol	6	3	3
Other	9	5	4
Previous operation
Yes	7	5	2
No	26	15 (58)	11
Involvement of hips
Bilateral procedure	16	10	6
Unilateral procedure	17	10	7
Trochanteric osteotomy
Yes	10	6	4
No	23	14 (61)	9
Stage according to system of Ficat and Arlet²⁰
III	26	16 (62)	10
IV	7	4	3

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TABLE II RESULTS OF SURFACE REPLACEMENT HEMIARTHROPLASTY ACCORDING TO VARIOUS PARAMETERS

*The values are given as the number of hips, with the percentage in parentheses.

Parameter	No. of Hips	Outcome*
Success	Failure
Total	33	20 (61)	13
Age
>40 years	16	10	6
<40 years	17	10	7
Gender
Male	20	12 (60)	8
Female	13	8	5
Associated factors
Use of corticosteroids	18	12	6
Lupus erythematosus	9	6	3
Nonlupus erythematosus	9	6	3
Excessive intake of alcohol	6	3	3
Other	9	5	4
Previous operation
Yes	7	5	2
No	26	15 (58)	11
Involvement of hips
Bilateral procedure	16	10	6
Unilateral procedure	17	10	7
Trochanteric osteotomy
Yes	10	6	4
No	23	14 (61)	9
Stage according to system of Ficat and Arlet²⁰
III	26	16 (62)	10
IV	7	4	3

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Fig. 1 Kaplan-Meier life-table analysis, with 95 percent confidence intervals (dotted lines). The five-year rate of survival of the prosthesis after hemiarthroplasty for the treatment of osteonecrosis was 91 percent (thirty hips).

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Figs. 2-A, 2-B, and 2-C: Anteroposterior radiographs of the right hip of a man who had a surface replacement hemiarthroplasty at the age of thirty-five years for the treatment of osteonecrosis of the femoral head. Fig. 2-A: Before the operation, there was evidence of stage-III osteonecrosis of the femoral head according to the system of Ficat and Arlet²⁰.

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Fig. 2-B: Three months after the hemiarthroplasty.

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Fig. 2-C: Ten years postoperatively, the hip had little joint-space narrowing and a Harris hip score of 94 points.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

The present study included twenty-five patients who had had a total of thirty-three resurfacing procedures of the femoral head for the treatment of pain in the hip or hips associated with Ficat and Arlet²⁰ stage-III or early stage-IV radiographic changes of osteonecrosis. The procedures were performed between March 1, 1981, and August 31, 1992. The subjects of the studies by Scott et al.⁴¹ and Krackow et al.²⁸ were considered for inclusion in the present study. We included all of the patients from the report by Krackow et al. and only those who were operated on by Dr. Scott in the study by Scott et al. The other patients from the study by Scott et al. were excluded from the present study. Subjects were also excluded if the results of a clinical and radiographic follow-up examination performed at least four years postoperatively were not available. One patient was lost to follow-up in the early postoperative period (at six months), and another was lost to follow-up at eighteen months. Both of these patients had been doing well clinically (a Harris hip score²³ of more than 90 points) at the latest follow-up examination, but they were excluded from the present report. No other patients were excluded. Of the remaining twenty-five patients, eight had a bilateral procedure; thus, a total of thirty-three hips were evaluated in the present study. All of the patients had had clinical and radiographic follow-up examinations at yearly intervals.

The indications for the resurfacing procedure included strict clinical as well as radiographic criteria, and evaluation of the preoperative radiographs at the time of the latest follow-up confirmed that all patients had met the criteria for the operation. All patients had had severe pain in the groin on weight-bearing, with a variable degree of pain at rest, as well as a concentrically contained femoral head with stage-III osteonecrosis (twenty-six hips) or no more than early stage-IV osteonecrosis (seven hips) according to the classification system of Ficat and Arlet²⁰ (Table I). Early stage-IV disease was defined as at least two millimeters of circumferentially intact joint space on the anteroposterior and lateral radiographs. In addition, all patients had had a lesion of the femoral head that involved an arc of more than 200 degrees as measured with the method of Kerboul et al.²⁶. With this method, outlines of the osteonecrotic lesion are made on the anteroposterior and lateral radiographs and the angle of the arc of the surface involved by the necrosis is measured with a goniometer on each radiograph. These two angles are added together to derive the combined necrotic angle.

The diagnosis of osteonecrosis was made on the basis of the clinical history and the appearance of the hip on preoperative anteroposterior, frog-leg lateral, and lateral radiographs. A biopsy of a specimen obtained from a previous core decompression provided histological proof of osteonecrosis in six hips that had stage-III disease²⁰. The time from the core decompression to the resurfacing procedure ranged from nine months to three years (mean, twenty-one months) in these six hips. One patient had had a varus flexion corrective osteotomy twelve months before the resurfacing procedure. The other twenty-six hips had not had a previous biopsy (or any other operative intervention), but they had radiographic changes pathognomonic of osteonecrosis, including an anterolateral sequestrum and a crescent sign, with a variable degree of collapse of the femoral head.

The mean duration of follow-up was 10.5 years (range, four to fourteen years), with the most recent evaluation performed between September 1, 1996, and January 31, 1997. There were sixteen men (twenty hips) and nine women (thirteen hips). The mean age at the time of the operation was forty-one years (range, twenty-five to sixty-five years).

Demographic data included associated diseases as well as use of corticosteroids and use of alcohol. Use of alcohol was quantified to determine which patients had a history of consuming more than 400 milliliters of absolute 100 percent ethanol a week. (This is the threshold reported to be associated with osteonecrosis by the Japanese Orthopaedic Association³⁵.)

The underlying factors predisposing the hip to the development of osteonecrosis included the use of corticosteroids for the treatment of other conditions in thirteen patients (52 percent; eighteen hips). Of these thirteen patients, seven (nine hips) had systemic lupus erythematosus and six had another illness (vasculitis, erythema multiforme, Ollier disease, inflammatory bowel disease [two hips], thyroiditis [two hips], and respiratory infection [two hips]). All of these patients had received the equivalent of more than twenty milligrams of prednisone a day for a minimum of three months both before and after the resurfacing procedure. An additional two patients (8 percent; two hips) had a history of trauma, and five patients (20 percent; six hips) had a history of consuming more than 400 milliliters of alcohol a week. No associated risk factors were found in the remaining five patients (20 percent; seven hips).

Operative Procedure and Postoperative Rehabilitation

The surface replacement femoral component (TARA; DePuy) consists of a spherical articular portion and a stem that curves 140 degrees and has a diameter of eight millimeters. The femoral head is available with outer diameters ranging from thirty-eight to fifty-four millimeters, in two to three-millimeter increments. Twenty-three procedures were performed through a modified anterolateral approach and a limited capsulotomy as previously described²⁸. Exposure and dissection were limited in an effort to preserve the blood supply to the remainder of the femoral head from the lateral and posterior retinacular vessels. More exposure was not necessary as only the femoral side was addressed and the acetabular cartilage was left intact. The other ten procedures were performed through a posterior approach with use of a trochanteric osteotomy. The size of the component was based on a measurement, with calipers, of the maximum diameter of the femoral head. If the head size did not match the component, the next-largest component was used. Intraoperative radiography or fluoroscopy was not performed.

Postoperatively, early range-of-motion exercises were begun on the first or second day and 50 percent weight-bearing with two crutches or a cane was allowed on the third day. Full weight-bearing without support was allowed at six weeks, depending on the patient's progress and comfort.

Clinical Evaluation

Data on clinical function were gathered by reviewing the medical records generated during the routine follow-up examinations, by a telephone interview, or by reviewing the records (made locally) of an orthopaedist who was caring for the patient at the time of the investigation. The data were entered initially by the senior ones of us (R. S., D. S. H., K. A. K., and M. A. M.), and data points for the present study were then abstracted from the medical records by two of us (M. W. H. and C. F.).

At the time of the most recent follow-up, twenty-three patients were examined by the senior ones of us. The remaining two patients were interviewed by telephone, and the results recorded by the local orthopaedic surgeon were reviewed. With use of the clinical data in the medical record, we determined the preoperative Harris hip score²³ and the score at the time of the latest follow-up. According to this system, 90 to 100 points indicates an excellent result; 80 to 89 points, a good result; 70 to 79 points, a fair result; and less than 70 points, a poor result. For the purposes of evaluating the overall result, failure was defined as a Harris hip score of less than 80 points or revision to a total hip arthroplasty. Clinical success was defined as a Harris hip score of at least 80 points.

We specifically looked for any intraoperative, perioperative, or postoperative complications related to the hemiarthroplasty.

For the hips that had had a revision procedure, we also collected data on the duration of the operation, the operative and postoperative complications, and the Harris hip score at the latest follow-up examination in order to assess the results after a revision to a total hip arthroplasty.

Radiographic Evaluation

All preoperative radiographs were evaluated to determine the stage of the osteonecrosis according to the system of Ficat and Arlet²⁰ as well as the combined necrotic angle²⁶ (Table I).

All preoperative and postoperative radiographs and those made at the time of the latest follow-up were evaluated by two of us (M. W. H. and C. F.). This evaluation included comparisons of measurements on radiographs made at the most recent follow-up examination with those on radiographs made immediately after the operation to determine if there was any evidence of subsidence of the stem, a change in the alignment (varus or valgus) of the prosthesis, or abutment of the tip of the stem on the endosteal cortex. In addition, the remaining joint space and the distance from the prosthesis to the teardrop as a measure of protrusio acetabuli were assessed.

The amount of joint-space narrowing seen on the radiographs was assessed with use of the technique of Dalldorf et al.¹². The width of the most superior aspect of the joint space was measured in millimeters with use of microcalipers. The width of the joint space at the latest follow-up examination was compared with that on the early postoperative radiographs (made within the first six weeks after the operation).

To address the problem of intraobserver and interobserver variability in the assessment of the various parameters, two of us independently evaluated the radiographs. If there was a disagreement, a third person interpreted the radiographs until a unanimous decision could be made regarding the best estimate of the stage of the osteonecrosis or evaluation of the parameters. It should be noted that the radiographic parameters have been validated only minimally in some studies^5,26,46.

Analysis of the Data

The data were compiled from The Johns Hopkins University School of Medicine and from Brigham and Women's Hospital and were tabulated with use of a database (Access, version 7.0; Microsoft, Redmond, Washington). Descriptive statistics were calculated. Parametric and nonparametric statistical analysis of the results was conducted with use of a computer program for epidemiological analysis (PEPI Software Package, version 2.03; USD, Stone Mountain, Georgia). Revision to a total hip arthroplasty was coded as a failure of the resurfacing procedure; lack of a revision to a total hip arthroplasty was coded as a satisfactory outcome. The categories that were evaluated with a chi-square test (Yates correction) for success or failure included age (more or less than forty years old), gender, use of corticosteroids, diagnostic group (for example, systemic lupus erythematosus), various risk factors (for example, excessive intake of alcohol), a previous operation, a bilateral or unilateral procedure, and Ficat and Arlet²⁰ stage-III or stage-IV disease.

A Kaplan-Meier life-table analysis, with 95 percent confidence intervals, was performed. Censored data included two patients who were lost to follow-up at eleven and twelve years.

Results

Introduction | Materials and Methods | Results | Discussion | References

Thirty hip prostheses (91 percent) survived for at least five years (Fig. 1). The result in twenty (61 percent) of the thirty-three hips was good (five hips) or excellent (fifteen hips) at the time of the latest follow-up. The mean Harris hip score for these hips had improved from 38 points (range, 29 to 61 points) preoperatively to 91 points (range, 80 to 100 points) at the time of the most recent follow-up (Figs. 2-A, 2-B, and 2-C).

Thirteen hips (39 percent) failed, and a total hip arthroplasty was performed at a mean of sixty months (range, thirty-six to 136 months) after the index procedure. Two of the hips that failed were in a patient who had had a bilateral procedure and had a Workers' Compensation claim, a history of alcohol and intravenous drug abuse, and severe back pain, which made it difficult to determine the contribution of the hips to the overall symptoms. Both hips were revised at thirty-six months. Of the other eleven hips that failed, one (in the only other patient receiving Workers' Compensation) was revised at five years; five were revised at six years; two, at eight years; and three, at thirteen to fourteen years. At the time of the revision, all of the hips showed a complete absence of cartilage in the superior aspect of the acetabular dome. All but one of the femoral components were well fixed.

All of the failed surface replacements were revised to a total hip arthroplasty without cement, and the clinical results were good (a Harris hip score of at least 80 points) at a mean of thirty months (range, twenty-four to seventy-two months) after the revision. For the ten of the revised hips for which intraoperative data were available, the duration of the procedure was a mean of 147 minutes (range, 100 to 186 minutes) and no operative or postoperative complications were noted.

On the basis of the numbers available, we detected no significant differences in outcome when we analyzed the effects of various parameters, such as age (less than or more than forty years), gender, various risk factors, and a history or no history of a previous operation (Table II).

Sixteen (62 percent) of the twenty-six stage-III hips had a successful clinical outcome (a Harris hip score of at least 80 points). Of the seven hips that had stage-IV disease (evidence of acetabular involvement), four had a successful clinical result (p = 0.80).

At the latest follow-up examination, none of the femoral components that had not been revised showed radiographic evidence of subsidence or a change in varus or valgus angulation compared with the findings on the immediate postoperative radiographs. Two patients had a slight loss of joint space (narrowing of one to two millimeters) but had no increase in symptoms (a Harris hip score of 86 and 92 points).

Only one hip that failed had notable subsidence of the stem; this was noted at fourteen months. This stem was the only loose component found at revision. All patients who had a revision had radiographic evidence of joint-space narrowing. There was no macroscopic evidence of synovitis or metal debris at the time of the revision in any patient.

Complications

There were no intraoperative complications, postoperative fractures, or medical complications. Four hips had trochanteric bursitis, which was presumed to be secondary to breakage of the wire and necessitated removal of the wire. The bursitis did not lead to any other adverse sequelae.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The plethora of options for the operative treatment of Ficat and Arlet²⁰ stage-III and early stage-IV osteonecrosis of the femoral head reflects both the importance of the problem and the lack of a clearly superior method of treatment. For small lesions in early stage-IV disease (after collapse of the femoral head but without involvement of the acetabulum), options such as corrective osteotomy as well as vascularized^53,54,57 and non-vascularized^33,35 bone-grafting have been used. However, when the lesion is large (a combined necrotic angle of more than 200 degrees or involvement of more than 30 percent of the femoral head), these treatment methods have had low rates of success³⁵ and the only viable option is salvage by total hip arthroplasty. Other methods that have been suggested include bipolar hip arthroplasty^1,7,29,49, the use of a monopolar prosthesis^16,29,49, and surface replacement hemiarthroplasty^26,41.

Bipolar hip arthroplasty for the treatment of large stage-III lesions has had poor results in several studies^1,7,29,49. Lachiewicz and Desman²⁹ reported that only fifteen (48 percent) of thirty-one hips had a good or excellent clinical outcome at a mean of 4.6 years (range, two to eleven years) after a bipolar arthroplasty. There was residual pain, despite a satisfactory clinical rating, in eight additional hips. Cabanela⁷ reported a successful clinical outcome in ten of seventeen patients at a mean of 9.2 years after implantation of a Bateman bipolar prosthesis (Howmedica, Rutherford, New Jersey) for the treatment of stage-III or stage-IV osteonecrosis. In the largest series, to our knowledge, of bipolar prosthetic replacements for the treatment of osteonecrosis of the femoral head, Takaoka et al.⁴⁹ reported that fourteen (17 percent) of eighty-three hips had a poor clinical result (that is, revision to a total hip arthroplasty) or a poor radiographic result (that is, loosening of the stem) at a mean of five and one-half years (range, three to ten years). The poor outcomes in those studies may be related in part to the necessary use of thin polyethylene in the bipolar prosthesis in these young patients.

A comparison could be made between the implants used in our study and monopolar, fixed-head prostheses such as the Austin Moore component (Howmedica). In most studies of these prostheses, there were universally poor results secondary both to failure of the stem and to destruction of the acetabulum^16,29,49,56. In the study by Takaoka et al.⁴⁹, twelve of nineteen Austin Moore prostheses had migrated proximally by the time of the five-year follow-up examination. The thin Austin Moore stem (inserted without cement in eighteen hips) loosened in nine hips within three years. The various reasons for the high rates of failure of these unipolar prostheses include inadequate press-fit fixation of a thin stem inserted without cement and use of the procedure in hips that have a more advanced stage of osteonecrosis (with acetabular involvement), which leads to rapid wear of acetabular cartilage and bone.

Use of the surface replacement hemiarthroplasty for the treatment of osteonecrosis of the femoral head has not gained widespread acceptance. A possible reason may be the poor results of the total articular resurfacing arthroplasty^2,3,9,17. However, surface replacement of only the femoral head prevents the problem of failure associated with thin polyethylene, which is used when both sides of the joint are resurfaced. Few investigators have analyzed the results of surface replacement hemiarthroplasty for the treatment of osteonecrosis. Scott et al.⁴¹ reported on twenty-five hemiarthroplasties performed for the treatment of stage-III or stage-IV osteonecrosis in twenty-one patients (some of whom were part of the present study). Twenty-two (88 percent) of the twenty-five hips had a good or excellent result at a mean of thirty-seven months (range, twenty-five to sixty months). Krackow et al.²⁸ reported a good or excellent result at a mean of three years (range, two to six years) in sixteen of nineteen hips (fifteen patients, all of whom were part of the present study) that had had insertion of a total articular resurfacing hemiarthroplasty component. Sedel et al.⁴² reported that thirty-one (82 percent) of thirty-eight hip prostheses had survived at a mean of seven years (range, one to twelve years) after a cup arthroplasty for the treatment of stage-III or stage-IV osteonecrosis. Five of the seven poor results were attributed to technical failure. Tooke et al.⁵⁰ found a satisfactory clinical outcome in ten of twelve hips at a mean of thirty-nine months (range, twenty-four to sixty-two months) after insertion of a modified Tharies femoral resurfacing component as a hemiarthroplasty for the treatment of osteonecrosis. They concluded that this procedure was an interim solution in this group of young patients who had osteonecrosis. The mean duration of follow-up in those reports was relatively short (seven years or less). In the present report, however, the mean duration of follow-up after hemiarthroplasty was 10.5 years.

We could not find any demographic factor, such as age, or any associated risk factor that predicted a better or a worse outcome. Similarly, the results in the hips that had Ficat and Arlet²⁰ stage-III osteonecrosis were no better than those in the hips that had early stage-IV disease. However, because our study was limited by the small numbers available, larger studies are needed to more clearly define the populations of patients for whom this procedure is indicated.

Although it could not be proved by the evaluative techniques or the data from the present study, we suspect that a mismatch between the size of the prosthesis and the acetabulum could have contributed to the unfavorable outcomes. This mismatch may have been responsible for the acetabular wear noted in the present study and in a recent study of twelve patients who had acetabular degeneration after bipolar arthroplasty¹². The component used in our study was available only in three-millimeter increments, which would make a two-millimeter mismatch possible. Currently, the components are available, from different manufacturers, in two-millimeter and one-millimeter increments. This newer design could favorably influence the results associated with this type of prosthesis. Another modification of a design feature that could be beneficial is removal of the stem, which might cause proximal stress-shielding or force the prosthesis into varus or valgus alignment. Amstutz et al.⁴ recently reported on ten hips that had had insertion of a titanium surface-replacement hemiarthroplasty component without a stem for the treatment of osteonecrosis. At a mean of eleven years (range, ten to twelve years), five hips functioned satisfactorily. The other five hips were revised at mean of 7.8 years (range, 3.3 to 10.3 years).

One possible concern about the use of this resurfacing procedure as an interim treatment is the potential difficulty of converting the hemiarthroplasty to a total hip arthroplasty. Revisions after bipolar replacements have been found to be a problem when the thin polyethylene had led to osteolysis^1,40,49. The resurfacing procedure avoids the problem of polyethylene particulate debris. In the present study, no osteolysis or protrusio acetabuli was found during the thirteen total hip arthroplasties, and the operative procedures were truly similar to primary hip arthroplasties. Exposure is not particularly difficult. Such a revision is not comparable in any way with a revision of a primary total hip arthroplasty or with a revision of a bipolar hemiarthroplasty. A total hip arthroplasty after a limited femoral hemiarthroplasty is much more similar to a primary total knee arthroplasty after a proximal tibial osteotomy (another temporizing procedure).

On the basis of the results in the present study, in which the patients were followed for at least four years and as long as fourteen years (mean, 10.5 years), we concluded that the use of a surface replacement hemiarthroplasty appears to be a successful interim treatment for selected patients who have osteonecrosis. We found that this procedure allowed a delay of at least five years before a total hip replacement was necessary as thirty (91 percent) of the thirty-three surface replacements survived for this length of time. At present, our criteria for the selection of patients for this procedure include stage-III osteonecrosis of the femoral head, with no narrowing of the joint space or involvement of the acetabulum, and a large lesion (more than 200 degrees of involvement of the femoral head).

References

Introduction | Materials and Methods | Results | Discussion | References

Amstutz, H. C., and Smith, R. K.: Total hip replacement following failed femoral hemiarthroplasty. J. Bone and Joint Surg.,61-A: 1161-1166, Dec. 1979.61-A1161 1979

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Dutton, R. O.; Amstutz, H. C.; Thomas, B. J.; and Hedley, A. K.: Tharies surface replacement for osteonecrosis of the femoral head. J. Bone and Joint Surg.,64-A: 1225-1237, Oct. 1982.64-A1225 1982

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Hanssen, A. D.; Cabanela, M. E.; and Michet, C. J., Jr.: Hip arthroplasty in patients with systemic lupus erythematosus. J. Bone and Joint Surg.,69-A: 807-814, July 1987.69-A807 1987

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Fig. 2-B: Three months after the hemiarthroplasty.

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Fig. 2-C: Ten years postoperatively, the hip had little joint-space narrowing and a Harris hip score of 94 points.

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TABLE I CLASSIFICATION OF OSTEONECROSIS OF THE FEMORAL HEAD ACCORDING TO THE SYSTEM OF FICAT AND ARLET²⁰

Stage	Radiographic Appearance of Femoral Head
I	Normal
II	Cystic or osteosclerotic lesions, or both; normal contour of femoral head; no subchondral fracture
III	Crescent sign or subchondral collapse
IV	Joint-space narrowing, secondary acetabular changes (cysts, marginal osteophytes, and destruction of cartilage)

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TABLE I CLASSIFICATION OF OSTEONECROSIS OF THE FEMORAL HEAD ACCORDING TO THE SYSTEM OF FICAT AND ARLET²⁰

Stage	Radiographic Appearance of Femoral Head
I	Normal
II	Cystic or osteosclerotic lesions, or both; normal contour of femoral head; no subchondral fracture
III	Crescent sign or subchondral collapse
IV	Joint-space narrowing, secondary acetabular changes (cysts, marginal osteophytes, and destruction of cartilage)

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TABLE II RESULTS OF SURFACE REPLACEMENT HEMIARTHROPLASTY ACCORDING TO VARIOUS PARAMETERS

*The values are given as the number of hips, with the percentage in parentheses.

Parameter	No. of Hips	Outcome*
Success	Failure
Total	33	20 (61)	13
Age
>40 years	16	10	6
<40 years	17	10	7
Gender
Male	20	12 (60)	8
Female	13	8	5
Associated factors
Use of corticosteroids	18	12	6
Lupus erythematosus	9	6	3
Nonlupus erythematosus	9	6	3
Excessive intake of alcohol	6	3	3
Other	9	5	4
Previous operation
Yes	7	5	2
No	26	15 (58)	11
Involvement of hips
Bilateral procedure	16	10	6
Unilateral procedure	17	10	7
Trochanteric osteotomy
Yes	10	6	4
No	23	14 (61)	9
Stage according to system of Ficat and Arlet²⁰
III	26	16 (62)	10
IV	7	4	3

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TABLE II RESULTS OF SURFACE REPLACEMENT HEMIARTHROPLASTY ACCORDING TO VARIOUS PARAMETERS

*The values are given as the number of hips, with the percentage in parentheses.

Parameter	No. of Hips	Outcome*
Success	Failure
Total	33	20 (61)	13
Age
>40 years	16	10	6
<40 years	17	10	7
Gender
Male	20	12 (60)	8
Female	13	8	5
Associated factors
Use of corticosteroids	18	12	6
Lupus erythematosus	9	6	3
Nonlupus erythematosus	9	6	3
Excessive intake of alcohol	6	3	3
Other	9	5	4
Previous operation
Yes	7	5	2
No	26	15 (58)	11
Involvement of hips
Bilateral procedure	16	10	6
Unilateral procedure	17	10	7
Trochanteric osteotomy
Yes	10	6	4
No	23	14 (61)	9
Stage according to system of Ficat and Arlet²⁰
III	26	16 (62)	10
IV	7	4	3