Summary

Arthroscopic Treatment of Osteonecrosis of Femoral Head shown to have acceptable conversion rate to THA over long-term follow-up while simultaneously addressing concomitant intraarticular pathologies.

Abstract

Introduction

Osteonecrosis of femoral head (ONFH) has a progressive course leading to femoral head collapse and severe arthritis. The preferred method of femoral head preservation remains controversial. Almost all surgical methods, even when attempted during the early stages of ONFH, have unfavorable results.

There is growing evidence that the pathophysiologic process of osteonecrosis impacts not only the area of necrosis of the femoral head but the entire total joint environment. Therefore, a surgical approach that cares for the holistic joint environment could provide advantageous management of ONFH. We present that an arthroscopic approach for the management of ONFH provides minimally invasive decompression while addressing concomitant intraarticular pathologies resulted in long-term reliable results.

Methods

This was a prospectively collected, retrospective analyzed clinical trial to evaluate long-term results of arthroscopic treatment of ONFH. Between 2007 and 2017, all patients with ONFH who underwent hip arthroscopy by a senior surgeon in a hip-preserving service at a single center were identified. All patients received standard hip radiographs and Hip MRI. Inclusion criteria were: patients with radiographic findings of Stage 0, I, IIa, and IIB (pre-collapse), based on Ficat-Alret classification for OFNH. Exclusion criteria were: less than 5-year follow-up, post-traumatic ONFH, dysplastic hips and any ONFH of severity of Ficat-Alret Stage III or greater. Statistical analysis was performed using STATA 14.2 (STATA SE 2015) and Microsoft Excel 2015 (Microsoft Corp). Categorical statistics are represented as a number and percentage, while continuous statistics are represented as a mean average and standard deviation.

Results

The sample included 11 patients. The mean patient age was 37.8 year (range 17 to 48). The mean patient follow-up was 7 years (range 64-115 months). The group consisted of 1 (9.1%) female and 10 (90.9%) male patients. The mean patient BMI was 26.7 (SD, 3). Two patients (18.2%) had inhaled corticosteroid exposure, four patients (36.4%) had a history of substance abuse, and four patients (36.4%) had a history of smoking. Laterality of the arthroscopy, was 4 (36.4%) of the right hip, and 7 (63.6%) of the left hip.

The Ficat-Alret classification found on preoperative imaging was Stage I, IIa, IIb in 3 (27.2%), 4 (36.4%), and 4 (36.4%) patients, respectively. Concomitant pathology addressed at the time of arthroscopy includes: labral repair/debridement, microfracture, femoral osteochondroplasty, and synovectomy which was performed in 8 (73%), 7 (64%), 1 (9%), and 1 (9%) patients. The mean traction time was 56.7 minutes (SD, 11.4 min).

At final follow-up, 6 (55%) of the patients had not converted to total hip arthroplasty (THA). Upon further stratification, 6 out of 7 (87%) patients categorized as Stage I or IIa had not converted to THA, in contrast, 4 out of 4 (100%) patients categorized as Stage IIb had converted to THA.

Conclusion

We believe that arthroscopic treatment allows for treatment of ONFH as a total joint disease. Arthroscopic management is a promising surgical approach to address osteonecrosis with an acceptable conversion rate to THA over long-term follow-up, while simultaneously addressing concomitant intraarticular pathologies.