Noncemented Total Hip Arthroplasty for Osteonecrosis of the Femoral Head in Elderly Patients

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1 Noncemented Total Hip Arthroplasty for Osteonecrosis of the Femoral Head in Elderly Patients Ta-I Wang, MD; Shih-Hsin Hung, RN, MSN; Yu-Ping Su, MD; Chi-Quang Feng, MD; Fang-Yao Chiu, MD; Chien-Lin Liu, MD abstract Full article available online at Healio.com/Orthopedics. Search: The results of total hip arthroplasty (THA) for osteonecrosis of the femoral head (ONFH) in elderly patients (80 years or older) has not been well defined. The purpose of this retrospective study was to evaluate the clinical course of and the results in noncemented THA for ONFH in elderly patients. Between 1998 and 2007, one hundred seven consecutive hips with ONFH in 103 patients were evaluated. The causes of ONFH were traumatic in 46 (43%) hips and nontraumatic in 61 (57%) hips. All hips were treated with noncemented THA. Average follow-up was 72 months (range, months). The functional results improved to statistical significance after THA. However, no significant differences existed between 6 months, 1 year, and 5 years postoperatively. Nine (8.4%) postoperative complications occurred in these 107 hips, including 1 stem loosening, 1 liner wearing, 4 postoperative infections, 2 postoperative dislocations, and 1 pulmonary embolism. Fifteen (14.6%) deaths occurred during follow-up. The progression of ONFH in elderly patients was so rapid and the result of core decompression was so poor that a salvage procedure seemed to have no role in the treatment. Harris Hip Score, Short Form 36 physical function score, and Western Ontario and McMaster Universities Osteoarthritis Index scores significantly improved after noncemented THA. Ninety-two hips had a complete follow-up, and the survivorship of prosthesis was 95% (88/92) with minimal 5-year follow-up. Noncemented THA was effective in the treatment of ONFH in this group of patients. The authors are from the Department of Orthopedics and Traumatology (T-IW, Y-PS, C-QF, F-YC, C-LL), Taipei Veterans General Hospital and National Yang-Ming University; and the Department of Nursing (S-HH), National Yang-Ming University, Taipei, Taiwan, Republic of China. The authors have no relevant financial relationships to disclose. Correspondence should be addressed to: Fang-Yao Chiu, MD, Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, 201, Sec 2, Shih-Pai Rd, Taipei 112, Taiwan, Republic of China (fychiu@vghtpe.gov.tw). doi: / e271

2 Risk factors for osteonecrosis of the femoral head (ONFH) include steroid use, alcoholism, trauma, marrow-replacing diseases such as Gaucher s disease, high-dose radiation treatment, and hypercoagulable states. 1,2 The common treatment for precollapse ONFH is core decompression with or without bone graft. 1 For postcollapse ONFH, an increased failure rate of core decompression has been noted, 1,2 and arthroplasty represents a more reliable method of pain relief than other joint preservation surgery. Hemiarthroplasty with a bipolar or unipolar prosthesis has been reported to have high rates of conversion to total hip arthroplasty (THA) due to an eventual loss of acetabular cartilage and recurrent pain. 2 Total hip arthroplasty has been found to be highly successful in pain relief and function recovery, especially in extremely elderly patients. 3 Few studies focus on the treatment of ONFH in patients aged 80 years or older. Therefore, the current retrospective study was conducted to evaluate the clinical course and treatment results of noncemented THA for ONFH in elderly patients. Materials and Methods Between 1998 and 2007, one hundred thirteen consecutive patients aged 80 years or older with ONFH were managed surgically at the authors institution. All 103 patients were collected in the initial evaluation for this retrospective study. Patients with a history of hip infection (n52) or periprosthetic fracture due to postoperative trauma (n52) or lost to follow-up due to various causes (n56) were excluded from the final evaluation. The remaining 103 patients (107 hips: 58 right and 49 left) were included in the final evaluation. The patients included 69 men and 34 women with a mean age of 83.1 years (range, years). The causes of ONFH were traumatic in 46 (43%) hips and nontraumatic in 61 (57%) hips. All 46 hips with traumatic ONFH had a history of hip fracture (44 femoral neck fractures and 2 intertrochanteric fractures). Of the 61 hips with nontraumatic ONFH, 13 patients with 14 (23%) hips had no significant risk factors, 15 patients with 18 (29.5%) hips had a history of steroid usage, and 33 patients with 36 (59%) hips had a history of hypercholesterolemia under medical treatment; 4 patients with 7 (6.5%) hips had a history of both steroid intake and hypercholesterolemia. No other risk factors were found in the 103 patients. The diagnosis of ONFH was made using radiographs and a bone scan or magnetic resonance imaging, with staging according to Ficat classification. 4 The total number of hips with ONFH was 107; one hundred one hips were stage III or IV and 6 hips were stage I or II. Forty-six hips were diagnosed as Ficat stage III and 55 as Ficat stage IV at initial presentation. Bilateral nontraumatic ONFH was diagnosed in 4 patients (8 hips) at a later visit. Because of the advanced stage of the disease at diagnosis, staged bilateral THA was performed in these 4 patients. No patient was diagnosed with bilateral ONFH at initial presentation in the current series. Two hips were classified as Ficat stage I and 4 as Ficat stage II at initial presentation. All 6 hips underwent core decompression for the affected hip initially, but all failed with conversion to THA. Average time between core decompression and femoral head collapse was 9.6 months (range, 2-19 months). Average time between core decompression and THA was 9.75 months (range, 2-25 months). All patients who underwent core decompression and staged bilateral THA were men. Average time between stages in staged bilateral THA was 8.67 months (range, 4-17 months). All THAs were performed by the senior authors (Y.-P.S., C.-Q.F., F.-Y.C., C.- L.L.), and all implants were fixed without cement. Seventy-five THAs were performed via a posterior approach, and 32 via an anterolateral approach, depending on each surgeon s preference. The Versys implant (Zimmer, Warsaw, Indiana) was used in 78 hips and the Osteonics Omnifit (Stryker, Mahwah, New Jersey) was used in 29 hips. Each patient received intravenous bolus injections of 500 mg of cefazolin preoperatively and intravenous injections of 500 mg of cefazolin every 6 hours for 24 hours postoperatively. A drain was used for 36 hours and removed on postoperative day 2. No chemoprophylaxis for thromboembolic complications was used for any patient. Protected weight bearing on the operated hip was allowed from postoperative day 1 to discharge. Mean hospital stay was 6.6 days (range, 5-10 days). Data collected included preoperative ONFH staging, hospital course (ie, type of anesthesia, operative time, blood loss, postoperative transfusion, and wound condition), postoperative complications, patient and implant survival, and functional outcome. Patients were examined postoperatively at 4, 8, and 12 weeks, 6 months, and annually thereafter. Average follow-up was 72 months (range, months). Radiographic evaluation was performed at every follow-up visit, and a functional evaluation was performed starting on the third postoperative visit 12 weeks postoperatively using the Harris Hip Score (HHS), Short Form 36 (SF-36) physical function score, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and physical function and scores. Implant loosening, obvious liner wear, or revision was used as the endpoint of implant survival. All patients were measured for all response variables, which included demographic variables and important outcomes, such as functional and radiographic results. Data were recorded as mean6sd for continuous response variables and percentages for discrete variables. Differences in demographic characteristics were analyzed by Pearson s chi-square test. A P value less than.05 was considered statistically significant, and all analyses were performed with SPSS version 17.0 software (SPSS, Inc, Chicago, Illinois). e272 ORTHOPEDICS Healio.com/Orthopedics

3 Osteonecrosis of the Femoral Head Wang et al Results Preoperative and 6-month, 1-year, and 5-year postoperative HHS, SF-36 scores, and WOMAC scores are shown in Tables 1 through 3. The clinical results improved significantly after THA, but no significant difference existed between scores at 6 months, 1 year, and 5 years postoperatively. Functional results after THA were statistically insignificant between the traumatic and nontraumatic ONFH groups (Table 4). Nine (8.4%) postoperative complications occurred in the 107 hips, including 1 case of stem loosening, 1 case of liner wear, 4 infections, 2 dislocations, and 1 pulmonary embolism. The surgical approaches to the 2 hips with postoperative dislocations were posterior in 1 (1/75; 1.3%) (traumatic ONFH) and anterolateral in the other (1/32; 3.1%) (nontraumatic ONFH). The dislocations were managed with closed reduction, and no recurrence developed. Of the 4 infected hips, 2 (1 traumatic and 1 nontraumatic ONFH) were managed with 2-stage reimplantation, and 2 (1 traumatic and 1 nontraumatic ONFH) were managed with debridement and 6 weeks of parenteral antibiotics. All 4 infections were cured after management. The hips with liner wear (nontraumatic ONFH) and stem loosening (nontraumatic ONFH) were not revised until final follow-up. Fifteen (14.6%) deaths occurred during follow-up. Of Table 2 Pre- and 1-year Postoperative SF-36 Physical Function Score, WOMAC Pain and Physical Function Scores, and Harris Hip Score Score Preoperative 1-y Postoperative P SF-36 physical function WOMAC Table 1 Pre- and 6-month Postoperative SF-36 Physical Function Score, WOMAC Pain and Physical Function Scores, and Harris Hip Score Score Preoperative 6-mo Postoperative P SF-36 physical function WOMAC Pain Physical function Harris Hip Score Abbreviations: SF-36, Short Form 36; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index. Pain Physical function Harris Hip Score Abbreviations: SF-36, Short Form 36; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index. Table 3 Comparisons of Postoperative 6-month, 1-year, and 5-year SF-36 Physical Function Score, WOMAC Pain and Physical Function Score, and Harris Hip Score Score 6 mo 1 y 5 y 6 mo vs 1 y, P 6 mo vs 5 y, P 1 y vs 5 y, P SF WOMAC Pain WOMAC Physical HHS Abbreviations: HHS, Harris Hip Score; SF-36, Short Form 36; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index. e273

4 the patients who had complete minimal follow-up of 5 years, the mplant survival rate was 95% (88/92). Discussion The etiology of ONFH can be roughly divided into traumatic and nontraumatic. According to a study by Lavernia et al, 5 approximately 10% to 20% of ONFH cases without significant risk factors are classified as idiopathic ONFH. As many as 90% of cases of nontraumatic ONFH are steroid or alcohol abuse related. 6-8 Hypercholesterolemia may be responsible for microvascular obstruction leading to bone necrosis. 9 Fat metabolism disorders may also lead to immune complex deposition, causing hemorrhage and bone death. 10,11 Regarding traumatic ONFH, Chiu and Lo 12 reported 250 cases of nondisplaced femoral neck fractures in patients older than 59 years; 18 (7.2%) hips Table 4 Comparison of Postoperative SF-36 Physical Function Scores, WOMAC Pain and Physical Function Scores, and Harris Hip Scores Between Traumatic and Nontraumatic ONFH Groups Score Follow-up Traumatic ONFH Nontraumatic ONFH P SF-36 physical function 6 mo y y WOMAC pain 6 mo WOMAC physical function 1 y y mo y y Harris Hip Score 6 mo y y Abbreviations: ONFH, osteonecrosis of the femoral head; SF-36, Short Form 36; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index. developed ONFH after union. The frequency of ONFH after surgical treatment of intertrochanteric fractures has been reported to range between 0.3% and 1.16%. 13,14 In the current study, 43% (n546) of hips had traumatic ONFH and 57% (n561) had nontraumatic ONFH. Eight (13.1%) hips with nontraumatic ONFH lacked significant risk factors, which is compatible with other reports. 11,15-21 Excluding the cases with no significant risk factors, the etiology of nontraumatic ONFH in the current study differed from that reported in younger patients. 5 The relative high incidence of traumatic ONFH and low incidence of nontraumatic ONFH revealed the problem of falls among elderly patients. The general results of THA between the traumatic and nontraumatic ONFH groups were not significant in this study. All hips were diagnosed as Ficat stage III (n546) and stage VI (n555) at initial presentation, except for 4 hips diagnosed as stage II and 2 as stage I. Mont et al 15 reviewed 16 studies and reported that the mean interval of progression from asymptomatic to symptomatic osteonecrosis was 39 months and progression to collapse was 49 months following the diagnosis of asymptomatic ONFH. Other reports stated that progression to collapse occurs within 1 to 5 years after symptom onset. 4,16-19 In the current study, the interval of progression from symptomatic to advanced ONFH could not be evaluated. It is unclear why most patients in the current study were diagnosed with advanced ONFH with unrelieved hip pain at their first clinical visit, but poorer resistance of the femoral head to necrosis due to osteoporosis in elderly patients may be a reason. Besides the rapid progression of collapse, the masked effects of low back pain should be considered. According to Stupar et al, 20 low back pain predicted subsequent osteoarthritis-related pain and disability in those with hip disease. Most elderly patients have spine problems that can cause low back pain. The ONFHinduced hip pain may be masked due to low back pain, causing a delay in diagnosis and therapy for ONFH. The choice of treatment for ONFH depends on the Ficat staging. Jointpreserving procedures are used for earlystage ONFH, including nonoperative treatment, core decompression, vascularized or nonvascularized bone grafting, and osteotomy. Vascularized or nonvascularized bone grafting and osteotomy should not be considered for symptomatic patients because of the high morbidity rate. Nonoperative treatment, including protective weight bearing and analgesics, is ineffective in delaying collapse. Mont et al 15 reported that only 182 (22.7%) of 819 hips with a mean follow-up of 34 months (range, 20 months to 10 years) had satisfactory clinical results. Several studies report core decompression for early-stage ONFH, and overall success rates range from 44% to e274 ORTHOPEDICS Healio.com/Orthopedics

5 Osteonecrosis of the Femoral Head Wang et al 100% for stage I and II ONFH. 17,22,23 In all such reports with good results, average patient age seldom exceeded 60 years. Core decompression failed in all patients in the current study, so advanced age may be an important risk factor for core decompression failure for ONFH. Prosthesis survivorship was better in the current study than in a report with an agematched group. 21 This may result from the advancement of surgical techniques, better prosthesis design, and less activity among elderly patients for the current study. Comparison of clinical performance among elderly patients before and after THA has been reported, and HHS, SF-36 physical function scores, and WOMAC scores improved significantly Harris Hip Scores, SF-36 scores, and WOMAC scores were poorer in the current study than in others This may have been caused by the older age of patients in this study (older than 80 years in this study and 70 years in others). The limitations of this study included its retrospective nature and the small number of patients. However, the results of this study may be a good reference for orthopedic surgeons. Conclusion In elderly patients with ONFH, the progression of disease was so rapid and the result of early-stage core decompression so poor that salvage procedures seemed to play no role in treatment. Noncemented THA was shown to be effective in the treatment of postcollapse ONFH in elderly patients. However, further studies with more patients are warrented. References 1. Mont MA, Marulanda GA, Seyler TM, Plate JF, Delanois RE. Core decompression and nonvascularized bone grafting for the treatment of early stage osteonecrosis of the femoral head. Instr Course Lect. 2007; 56: Lee SB, Sugano N, Nakata K, Matsui M, Ohzono K. Comparison between bipolar hemiarthroplasty and THA for osteonecrosis of the femoral head. Clin Orthop Relat Res. 2004; (424): Bartonícek J, Fric V, Skála-Rosenbaum J, Dousa P. 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