JBJS | Scintigraphic Assessment of the Rotated Femoral Head After Transtrochanteric Rotational Osteotomy for Osteonecrosis*

The Journal of Bone & Joint Surgery, Volume 82, Issue 10

Articles | October 01, 2000

Scintigraphic Assessment of the Rotated Femoral Head After Transtrochanteric Rotational Osteotomy for Osteonecrosis*

Tsuyoshi Nakai, M.D.†; Kensaku Masuhara, M.D., Ph.D.‡; Takanobu Nakase, M.D., Ph.D.§; Nobuhiko Sugano, M.D., Ph.D.§; Kenji Ohzono, M.D., Ph.D.§; Takahiro Ochi, M.D., Ph.D.§

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Investigation performed at the Department of Orthopaedic Surgery, Osaka University Medical School, Suita, Japan
*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.
†Department of Orthopaedic Surgery, Ikeda City Hospital, 3-1-18 Johnan, Ikeda 563-8510, Japan.
‡Department of Orthopaedic Surgery, Osaka Koseinenkin Hospital, 4-2-78 Fukushima, Fukushima-ku, Osaka 553, Japan.
Â§Department of Orthopaedic Surgery, Osaka University Medical School, 2-2 Yamadaoka, Suita 565, Japan.

The Journal of Bone & Joint Surgery. 2000; 82:1421-1421

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Abstract

Background: The purpose of this study was to assess the usefulness of bone scintigraphy in predicting progressive collapse of the femoral head after transtrochanteric rotational osteotomy for the treatment of osteonecrosis of the femoral head.

Methods: We studied thirty-three hips in thirty patients with osteonecrosis of the femoral head who had undergone transtrochanteric rotational osteotomy. There were twenty male and ten female patients, with a mean age of 34.4 years at the time of the operation. The mean duration of follow-up was 10.0 years. According to the staging system of Ficat and Arlet, there were nineteen stage-2 hips and fourteen stage-3 hips at the time of the operation. Conventional anteroposterior and lateral radiographs were assessed. In addition, bone scans were performed at three weeks after the operation to predict the outcome with regard to the rotated femoral head. On the basis of the location of low scan activity within the femoral head, the scintigraphic findings were classified into one of two categories: type A if there was no low scan activity in the weight-bearing area of the femoral head or type B if low scan activity occupied the entire weight-bearing area. Six hips with collapse were studied histologically.

Results: Postoperative scintiscans revealed sixteen type-A hips and seventeen type-B hips. Of the type-A hips, only three exhibited progressive collapse of the femoral head after the osteotomy, whereas fourteen of the type-B hips exhibited progressive collapse. A significant association was found between the postoperative scintigraphic findings and the final radiographic result (p < 0.01).

Conclusions: Bone scintiscans made three weeks after transtrochanteric rotational osteotomy were useful for predicting the final clinical result.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Osteonecrosis of the femoral head is often progressive, with collapse of the head eventually leading to osteoarthritis. Since osteonecrosis of the femoral head commonly occurs in middle-aged adults, joint-preserving operations should be performed when possible. The transtrochanteric rotational osteotomy described by Sugioka is theoretically considered a reasonable joint-preserving operation for patients with osteonecrosis of the femoral head⁶. However, the rates of success of transtrochanteric rotational osteotomy reported by several authors have been inconsistent^1,2,4-6,8. The reasons for the failure of this operation include fracture of the femoral neck, variations in the postoperative regimen, and race-dependent differences in the anatomy of the hip capsule. The viability of the rotated femoral head after transtrochanteric rotational osteotomy has not been thoroughly investigated, to our knowledge. Although we performed transtrochanteric rotational osteotomy with careful intraoperative monitoring of the blood flow in the nutrient arteries by Doppler sonography, the postoperative viability of the rotated femoral head was still uncertain. Even if conventional radiographs revealed good reconstruction of the weight-bearing surface of the femoral head after transtrochanteric rotational osteotomy, some of our patients nevertheless had progressive collapse of the femoral head postoperatively. In the present study, we retrospectively reviewed bone scintiscans made at three weeks after transtrochanteric rotational osteotomy in order to determine whether this type of examination permits prediction of progressive collapse of the femoral head after the operation.

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Fig. 1-A:: Figs. 1-A and 1-B: The methods of assessment of conventional preoperative and postoperative radiographs as described by Sugioka et al.⁷.
Fig. 1-A: Diagram showing the ratio of intact articular surface of the femoral head as measured on the preoperative lateral radiograph.

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Fig. 1-B:: Diagram showing the ratio of (transposed) intact articular surface of the femoral head to the acetabular weight-bearing area as measured on the postoperative anteroposterior radiograph.

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Fig. 2:: A twenty-four-year-old woman with steroid-induced osteonecrosis of the left femoral head underwent an 80-degree anterior rotational osteotomy.
A: Preoperative anteroposterior radiograph.
B: Radiograph made immediately postoperatively.
C: Radiograph made seven years postoperatively, demonstrating no progressive collapse of the femoral head.
D: Postoperative bone scintiscan revealing high activity.

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Fig. 3:: A forty-six-year-old woman with steroid-induced osteonecrosis of the left femoral head underwent an 80-degree anterior rotational osteotomy.
A: Preoperative anteroposterior radiograph.
B: Radiograph made immediately postoperatively.
C: Radiograph made two years postoperatively, demonstrating collapse of the femoral head and osteoarthritic change.
D: Postoperative bone scintiscan revealing low activity.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

We reviewed the scintigraphic findings for thirty-three hips in thirty patients with osteonecrosis of the femoral head who had undergone transtrochanteric rotational osteotomy between 1984 and 1992. There were twenty male and ten female patients, with a mean age of 34.4 years (range, seventeen to fifty-eight years) at the time of the operation. The mean duration of follow-up was 10.0 years (range, seven years and five months to fourteen years and two months). Factors predisposing to the development of osteonecrosis of the femoral head included steroid use in twenty-four patients and alcohol consumption in four; the osteonecrosis was idiopathic in two patients. On preoperative radiographic classification with the system of Ficat and Arlet³, nineteen hips were stage 2 (a normal contour) and fourteen were stage 3 (a crescent sign or subchondral collapse) at the time of the operation. The area of necrosis was located in the anterior aspect of the femoral head and the intact non-necrotic area occupied more than one-third of the entire head in all hips. All femoral heads were rotated to displace the necrotic lesion anteriorly and to bring the intact portion of the head into the weight-bearing region. The angle of anterior rotation ranged from 60 to 100 degrees. During the operation, all procedures were performed with careful monitoring of the circulation in the posterior-column artery by Doppler sonography and palpation of pulsation. We fixed the osteotomy site with an AO hip plate in twenty-seven hips and with large screws in six hips (Mathys, Davos, Switzerland).

Postoperatively, the leg was placed in balanced suspension for three weeks, and assisted active exercises were encouraged. Partial weight-bearing with use of two crutches was advised for six months, followed by nearly full weight-bearing with use of one crutch for another six months. Full weight-bearing without an aid was then allowed.

We measured the intact area of the posterior aspect of the femoral head by calculating the percentage of intact articular surface on preoperative lateral radiographs (Fig. 1-A). The area of necrosis was measured with a digital planimeter (X-plan 360 i; Ushikata, Tokyo, Japan). We then measured the ratio of the intact area of the femoral head to the acetabular weight-bearing area on postoperative anteroposterior radiographs⁷ (Fig. 1-B). We assessed the relationship between this ratio and the final result; the result was classified as Group 1 if there was no progressive collapse of the femoral head and as Group 2 if there was progressive collapse. In addition, bone scans were performed three weeks after the operation to assess the viability of the rotated femoral head. An intravenous injection of technetium-99m-labeled methylene diphosphonate was given. The anterior projection was acquired with use of a high-resolution scintillation collimator. On the basis of the location of low scan activity within the femoral head, the scintigraphic findings were classified into two types: type A indicated no low scan activity in the weight-bearing area of the femoral head (Fig. 2), and type B indicated low scan activity that occupied the entire weight-bearing area of the femoral head (Fig. 3). In order to evaluate the scintigraphic findings, we compared them with the findings on the final postoperative radiographs.

Statistical analysis of the data was performed with the chi-square test. Probability values of less than 0.05 were considered significant.

We were able to review pathological specimens retrieved at salvage operations for five patients (six hips) who had failure due to collapse of the femoral head at two to twelve years after the transtrochanteric rotational osteotomy. The entire head specimen was cut to a thickness of five micrometers and stained with hematoxylin and eosin.

Results

Introduction | Materials and Methods | Results | Discussion | References

Monitoring of the flow in the posterior arteries at the operation revealed that twenty-nine hips had constant flow. The other four hips had absence of pulsation, and it was therefore decided to reduce the amount of anterior rotation in those hips. This restored flow in the posterior arteries in three of the hips, but it did not in the fourth. Of the hips that had progressive collapse after the osteotomy, thirteen had had constant flow, three had had decreased flow, and one had had absence of flow at the time of the operation. We found no association between the findings of the Doppler monitoring and eventual collapse of the femoral head. We also found no relationship between the final result and the fixation device that had been used.

As measured on the preoperative lateral radiographs, the percentage of intact articular surface on the femoral head ranged from 30 to 47 percent (mean, 36.9 percent). The mean percentage (and standard deviation) was 36.0 ± 4.7 percent in Group 1 (no progressive collapse) and 37.8 ± 6.0 percent in Group 2 (progressive collapse). On the postoperative anteroposterior radiographs, the ratio of the transposed intact articular surface of the femoral head to the weight-bearing surface of the acetabulum ranged from 10 to 66 percent (mean, 34.4 percent). The mean ratio was 31.8 ± 12.1 percent in Group 1 and 37.7 ± 15.0 percent in Group 2. There was no association between the findings on conventional preoperative or postoperative radiographs and the final result.

Postoperative scintiscans revealed sixteen type-A hips (Fig. 2) and seventeen type-B hips (Fig. 3). Of the type-A hips, only three exhibited progressive collapse of the femoral head following the osteotomy. In contrast, fourteen of the type-B hips exhibited progressive collapse of the femoral head. A significant association was found between the postoperative scintigraphic findings and the final radiographic result (p < 0.01). Histological analysis of the six retrieved femoral heads (from five patients) revealed that the preoperative necrotic lesion remained mostly necrotic. The marrow cells exhibited cytolysis or karyolysis. In subchondral areas just beneath the transposed articular surface at newly created weight-bearing sites, both the trabecular thickness and the number of trabeculae were decreased.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The aims of treatment of osteonecrosis of the femoral head are to prevent collapse of the subchondral bone and to slow the progress of degenerative changes. Transtrochanteric rotational osteotomy was introduced as a theoretically satisfactory joint-preserving operation. In Japan, Sugioka et al.⁷ reported that 236 (86 percent) of 274 hips had a successful result at a mean of eleven years after a transtrochanteric rotational osteotomy. However, many authors have reported rates of success that were lower than those of the originator of transtrochanteric rotational osteotomy^1,2,4-6,8. Saito et al.⁵ reported that, of fifteen patients who were followed for two to fourteen years, nine had no further collapse of the femoral head but three had a fracture of the femoral neck and two had late varus deformity of a hip treated with an AO screw. Outside of Japan, most subsequent investigators were unable to reproduce the high rate of success and low rate of complications reported by Sugioka et al. In a study of seventeen patients who were followed for a mean of thirty-nine months, Tooke et al.⁸ reported that seven had required hip replacement, three had virtual ankylosis, and three were dissatisfied with the result. Only four patients had an excellent clinical result, and one of them subsequently exhibited radiographic collapse of the femoral head.

The causes of failure of transtrochanteric rotational osteotomy have been thought to include the technical demands of the procedure, fixation of the osteotomy site, and race-dependent differences in the anatomy of the hip capsule. Whatever the reasons for failure of transtrochanteric rotational osteotomy, early and precise postoperative assessment of the result of the procedure is of prognostic value. However, we could find no report concerning the viability of the rotated femoral head early in the postoperative period. In the present study, fourteen of the seventeen hips with progressive collapse of the femoral head after the osteotomy had had low scan activity in the weight-bearing region on postoperative bone scintigraphy (Fig. 3), whereas thirteen of the sixteen hips that had a successful result had exhibited high scan activity (Fig. 2). The findings of scintigraphy performed within three weeks after the operation were associated with the final radiographic result. In contrast, the findings on conventional preoperative and postoperative radiographs were not associated with the final result. These observations suggest that bone scintigraphy can be used to predict a satisfactory outcome of rotation of the femoral head. Histological examination of specimens from six hips with failure demonstrated an area of osteoporosis associated with ischemia in the newly formed weight-bearing region, and we postulated that this region was consistent with low scan activity on bone scintigraphy. Taken together, our findings suggest the following possibility. The rotated femoral heads that collapsed (failed) were ischemic, possibly due to circumferential incision of the capsule, twisting of the ligamentum teres, and transient interruption of intraosseous nutrient arteries in addition to reduced blood flow of the stretched posterior-column artery with anterior rotation of the femoral head. If bone scintigraphy shows low scan activity at the weight-bearing site of the femoral head early after the operation, careful attention to the possibility of collapse or progression of osteoarthritis during the follow-up period is indicated.

References

Introduction | Materials and Methods | Results | Discussion | References

Dean, M. T., and Cabanela, M. E.:: Transtrochanteric anterior rotational osteotomy for avascular necrosis of the femoral head. Long-term results. J. Bone and Joint Surg.,,75-B(4): 597-601, 1993.75-B(4)597 1993

Eyb, R., and Kotz, R.: The transtrochanteric anterior rotational osteotomy of Sugioka. Early and late results in idiopathic aseptic femoral head necrosis. Arch. Orthop. and Traumatic Surg.,106: 161-167, 1987.106161 1987

Ficat, R. P., and Arlet, J.: Functional investigation of bone under normal conditions. In Ischemia and Necrosis of Bone, pp. 29-52. Edited by D. S. Hungerford. Baltimore, Williams and Wilkins, 1980

Masuda, T.; Matsuno, T.; Hasegawa, I.; Kanno, T.; Ichioka, Y.; and Kaneda, K.: Results of transtrochanteric rotational osteotomy for nontraumatic osteonecrosis of the femoral head. Clin. Orthop.,228: 69-74, 1988.22869 1988 [PubMed]

Saito, S.; Ohzono, K.; and Ono, K.: Joint-preserving operations for idiopathic avascular necrosis of the femoral head. Results of core decompression, grafting and osteotomy. J. Bone and Joint Surg.,70-B(1): 78-84, 1988.70-B(1)78 1988

Sugano, N.; Takaoka, K.; Ohzono, K.; Matsui, M.; Saito, M.; and Saito, S.: Rotational osteotomy for non-traumatic avascular necrosis of the femoral head. J. Bone and Joint Surg.,74-B(5): 734-739, 1992.74-B(5)734 1992

Sugioka, Y.; Hotokebuchi, T.; and Tsutsui, H.: Transtrochanteric anterior rotational osteotomy for idiopathic and steroid-induced necrosis of the femoral head. Indications and long-term results. Clin. Orthop.,277: 111-120, 1992.277111 1992 [PubMed]

Tooke, S. M. T.; Amstutz, H. C.; and Hedley, A. K.: Results of transtrochanteric rotational osteotomy for femoral head osteonecrosis. Clin. Orthop.,224: 150-157, 1987.224150 1987 [PubMed]

Topics

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Fig. 1-B:: Diagram showing the ratio of (transposed) intact articular surface of the femoral head to the acetabular weight-bearing area as measured on the postoperative anteroposterior radiograph.

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Ficat, R. P., and Arlet, J.: Functional investigation of bone under normal conditions. In Ischemia and Necrosis of Bone, pp. 29-52. Edited by D. S. Hungerford. Baltimore, Williams and Wilkins, 1980

Tooke, S. M. T.; Amstutz, H. C.; and Hedley, A. K.: Results of transtrochanteric rotational osteotomy for femoral head osteonecrosis. Clin. Orthop.,224: 150-157, 1987.224150 1987 [PubMed]

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Tsuyoshi Nakai, Kensaku Masuhara, Takanobu Nakase, Nobuhiko Sugano, Kenji Ohzono, Takahiro Ochi; Scintigraphic Assessment of the Rotated Femoral Head After Transtrochanteric Rotational Osteotomy for Osteonecrosis*. The Journal of Bone & Joint Surgery. 2000 Oct;82(10):1421-1421.

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