Vol. 11, No. 3, December, 1999 Abstract Core Decompression in Nontraumatic Osteonecrosis of the Femoral Head - A comparison Study of Results between Radiographic Classification and Magnetic Resonance Imaging - Myung Chul Yoo, M.D., Yoon Je Cho, M.D., Kang Il Kim, M.D., Byung Joo Park, M.D., Dae Woo Hwang, M.D., Chan Teak Lim, M.D. Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University, Seoul, Korea The purposes of this study were to compare the results of core decompression in the treatment of nontraumatic osteonecrosis of the femoral head according to radiographic classification and findings on magnetic resonance image, and to clarify the factors which influence the results of core decompression. Forty-four patients (forty-seven hips) who had been studied with preoperative magnetic resonance image were evaluated. The results of core decompression were analyzed on the basis of the extent, location and signal difference of the necrotic lesion on preoperative magnetic resonance image as well as preoperative modified Ficat and Arlet radiographic classification. The results were assessed according to the criteria of clinical progression (less than 80 points of Harris hip score), radiographic progression (more than 2mm collapse of the femoral head compared with that on preoperative radiograph) and clinical failure (conversion to THR). The survival rate of radiographic classification and findings (the extent, location and signal difference) on magnetic resonance image was plotted and analyzed by log rank test. There was no statistically significant difference among the radiological stages on the survival curve according to the results of all criteria. The extent on magnetic resonance image was significant according to all criteria (p=0.0038, 0006, 0077). The location on magnetic resonance image was significant according to one criterion of the radiographic progression results (p=0.0456). The signal difference on magnetic resonance image was insignificant according to all criteria (p>0.1). This study revealed that the extent and location of the necrotic lesion on magnetic resonance image are major predictors of the end results of core decompression in osteonecrosis of the femoral head. Key Words : Femoral head, Osteonecrosis, Magnetic resonance image, Core decompression
Fig. 1. Mid-sagittal section of femoral head on MRI. The necrotic extent was calculated on the latticed paper by ratio of necrotic area to whole femoral head. Fig. 2. Mid-coronal section of femoral head on MRI. The necrotic location was divided as 4 sites. The four sites was obtained by interval of 25 degree from the vertical line penetrating femoral head. Far-medial is medially 25-50 degree from the vertical line, medial is medially 0-25 degree from the vertical line, lateral is laterally 0-25 degree from the vertical line, far-lateral is laterally 25-50 degree from the vertical line. In this image, the location of necrotic lesion is far-lateral.
Table 1. Results according to the classification of modified Ficat and Arlet. Ficat stage Cases Clinical progression(%) Radiographic progression(%) Clinical failure(%) 0 44 1/4(25) 2/4(50) 1/4(25) 10 2/10(20) 3/10(30) 1/10(10) -a 31 12/31(39) 18/31(58) 10/31(32) -b 41 1/1(100) 1/1(100) 0/1(0) 41 1/1(100) 1/1(100) 1/1(100) Total 47 17/47(36) 25/47(53) 13/47(28)
A B C Fig. 3. A. Kaplan-Meier survival curve of core decompression for pain(clinical progression) according to the radiographic classification(stage). The survival difference among stages is statistically insignificant(logrank test: p=0.4807). B. Kaplan-Meier survival curve of core decompression for radiographic progression according to the radiographic classification(stage). The survival difference among stages is statistically insignificant(log-rank test: p=0.4410). C. Kaplan-Meier survival curve of core decompression for THR(clinical failure) according to the radiographic classification(stage). The survival difference among stages is statistically insignificant(logrank test: p=0.3925).
A B C Fig. 4. A. Kaplan-Meier survival curve of core decompression for pain(clinical progression) according to the extent of necrotic area on MRI(group A, B, C, D). The survival difference among groups is statistically significant(logrank test: p=0.0038). B. Kaplan-Meier survival curve of core decompression for radiographic progression according to the extent of necrotic area on MRI(group A, B, C, D). The survival difference among groups is statistically significant(log-rank test: p=0.0006). C. Kaplan-Meier survival curve of core decompression for THR(clinical failure) according to the extent of necrotic area on MRI(group A, B, C, D). The survival difference among groups is statistically significant(log-rank test: p=0.0077).
Table 2. Results according to the extent of necrotic lesion on MRI. Cases Clinical progression(%) Radiographic progression(%) Clinical failure(%) Group A 13 3/13(23) 4/13(31) 2/13(15) Group B 26 8/26(31) 13/26(50) 6/26(23) Group C 27 5/7(71) 7/7(100) 4/7(57) Group D 21 1/1(100) 1/1(100) 1/1(100) Total 47 17/47(36) 25/47(53) 13/47(28) Table 3. Results according to the location of necrotic lesion on MRI. Cases Clinical progression(%) Radiographic progression(%) Clinical failure(%) far-medial 24 0/4(0) 0/4(0) 0/4(0) medial 26 1/6(17) 1/6(17) 1/6(17) lateral 11 5/11(45) 8/11(73) 3/11(27) far-lateral 26 11/26(42) 16/26(62) 9/26(35) Total 47 17/47(36) 25/47(53) 13/47(28) Table 4. Results according to the signal intensity of necrotic lesion on MRI. Cases Clinical progression(%) Radiographic progression(%) Clinical failure(%) Signal H 20 8/20(40) 14/20(70) 7/20(35) Signal h 13 6/13(46) 6/13(46) 4/13(31) Signal L 27 2/7(29) 3/7(43) 1/7(14) Signal l 27 1/7(14) 2/7(29) 1/7(14) Total 47 17/47(36) 25/47(53) 13/47(28) Fig. 5. Kaplan-Meier survival curve of core decompression for radiographic progression according to the location of necrotic area on MRI(far-medial, medial, lateral, far-lateral). The survival difference among locations is statistically significant (log-rank test: p = 0. 0 4 5 6 ).
Table 5. The distribution of extent on MRI in the same stage. MRI group Ficat stage* Cases A B C D 0 4 0 2 2 0 10 6 3 1 0 -a 31 7 19 4 1 * Stage -b and are excluded. Table 6. The distribution of location on MRI in the same stage. Ficat stage* Cases MRI location far-medial medial lateral far-lateral 0 4 0 1 1 2 10 3 1 3 3 -a 31 1 3 7 20 * Stage -b and are excluded.
166:215-220, 1988 09) Beltran J, King CT, Zueler WA, et al : Core decompression for avascular necrosis of the femoral head.: Correlation between long term result and preoperative MR staging. R a d i o l o g y, 175:533-536, 1990. 10) Camp JF and Colwell CW Jr : Core decompression of the femoral head for osteonecrosis. J Bone Joint Surg, 68-A:1313-1319, 1986. 11) Chan TW, Dalinka ME, Steinberg ME and Kressel HY : MRI appearance of femoral head osteo- necrosis following core decompression and bone grafting. Skel Radiol, 20:103-107, 1991. 12) Fairbank AC, Bhatia D, Jinnah RH and Hungerford DS : Long-term results of core decompression for ischemic necrosis of the femoral head. J Bone Joint Surg, 77-B:42-49, 1995. 13) Ficat P : Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg, 67-B:3-10, 1985. 14) Ficat P : Treatment of avascular necrosis of femoral head. In Hungerford D S(ed): The Hip: Proceedings of the Eleventh Open Meeting of the Hip REFERENCES Society. St. Louis, CV Mosby Co:279-285, 1983. 15) Genez BM, Wilson MR and Houk RW : Early osteonecrosis of femoral head: Detection in highrisk patient with MRI. R a d i o l o g y, 168:521-524, 01),, :., 33:952-958, 1988. 1998. 16) Hopson CN and Siverhus SW : Ischemic necrosis 02),,,, : of the femoral head. Treatment by core decompression. J Bone Joint Surg, 70-A:1048-1051, 1988.., 32:547-553, 1997. 17) Hungerford DS : Bone marrow pressure, venography and core decompression in osteonecrosis of 03),,, :,, 24:1360-1367, 1989. femoral head. In Hungerford DS(ed): The Hip: Proceedings of the Seventh Open Meeting of the 04),,,,,, Hip :., 26:451-461, 1991. 05) Aaron RK : Treatment of osteonecrosis of the femoral head with electrical stimulation. Instuctional Course Lecture, 43:495-498, 1994. 06) Arlet J and Ficat P : Forage-biopsie de la tete femorale dans l osteonecrose primitive. Observations histo-pathologiques portant sur huit forges. R e v Rheumat, 31:257-264, 1964. 07) Bhatia D, Jinnah RH and Hungerford DS : Longterm results in core decompression of the hip, O r t h o p T r a n s, 17:1002, 1993-1994. 08) Beltran J, Herman LJ and Burk JM : Femoral head avascular necrosis : MR imaging with clinicalpathologic and radionuclide correlation, Radiology, Society. St. Louis, CV Mosby Co:218-237, 1979. 18) Kay RM, Lieberman JR, Dorey F and Seeger LL : Inter-and intraobserver variation in staging patients with proven avascular necrosis of the hip. C l i n O r t h o p, 307:124-129, 1994. 19) Kim YM, Ahn JH, Kang HS and Kim HJ : Estimation of the extent of osteonecrosis of the femoral head using MRI. J Bone Joint Surg, 80-B:954-958, 1998. 20) Kokubo TK, Takatori Y, Nonomiya S, Nakamura T and Kamogawa M : Magnetic resonance imaging and scintigraphy of avascular necrosis of the femoral head. Clin Orthop, 277:54-50, 1992. 21) Koo KH and Kim RH : Quantifying the extent of
osteonecrosis of the femoral head: a new method using MRI. J Bone Joint Surg, 77-B:875-880, 1995. 22) Kristensen KD, Pedersen NW, Kioer T and Starklint H : Core decompression in femoral head osteonecrosis. Acta Orthop Scand, 62:113-114, 1991. 23) Lafforgue P, Dahan E and Chagn C : Early stage avascular necrosis of femoral head: MR imaging for prognosis in 31 cases with at least 2 years of follow-up. Radiology, 187:199-204, 1993. 24) Lausten GS and Mathiesen B : Core decompression for femoral head necrosis. Prospective study of 28 patients. Acta Orthop Scand, 61:507-511, 1990. 25) Learmonth ID, Maloon S and Dall G : Core decompression for femoral head necrosis. J Bone Joint S u r g, 72-B:387-390, 1990. 26) Marcus ND, Enneking WF and Massam RA : The silent hip in idiopathic aseptic necrosis: Treatment by bone grafting. J Bone Joint Surg, 55- A:1351-1366, 1973. 27) Markel DC, Miskovsky C, Sculco TP, Pellicci PM and Salvati EA : Core decompression for osteonecrosis of the femoral head. Clin Orthop, 323: 226-233, 1996. 28) Matthew DM, Harold LK, Steinberg ME, Herbert YK, Alavi A and Axel A : Avascular Necrosis of the hip: comparison of MR, CT, and Scintigraphy, A J R, 147:67-71.1986. 29) Meyers MH, Telfer N and Moore TM : Detection of vascularity of the femoral head with technethium 99m-sulphur-colloid. J Bone Joint Surg, 59-A:956-664, 1997. 30) Mitchell DG, Rao VM, Dalinka MK, et al : Femoral head avascular necrosis: correlation of MR imaging, radiologic staging, radionuclide imaging, and clinical finding. Radiology, 162:709-715, 1987 31) Mont MA, Carbone JJ and Fairbank AC : Core decompression versus nonoperative management for osteonecrosis of the hip. Clin Orthop, 324:169-178, 1996. 32) Musso ES, Mitchell SN, Schind-Ascani M and Bassett CAL : Results of conservative management of osteonecrosis of the femoral head. Clin Orthop. 207:209-215, 1986 33) Ohzono K, Saito M, Sugano N, Takaoka K and Ono K : Natural history of nontraumatic avascular necrosis of the femoral head. J Bone Joint Surg, 73- B:68-72, 1991. 34) Ohzono K, Saito M, Sugano N, Takaoka K and Ono K : The fate of nontraumatic avascular necrosis of the femoral head. Clin orthop, 277:73-78, 1992. 35) Penix AR, Cook SD, Skinner HB, Weinstein AM and Haddad RJ Jr. : Femoral head stresses following cortical bone grafting for aseptic necrosis. Clin Orthop, 207:209, 1983. 36) Powell ET, Lanzer WL and Mankey MG : Core decompression for early osteonecrosis of the hip in high risk patients. Clin Orthop, 335: 181-189, 1983. 37) Robinson HJ and Springer JA : Success of core decompression in the management of early stages of avascular necrosis. Orthop Trans, 16:707, 1992-1993. 38) Saisu T, Sakamoto K, Yamada K, et al : High incidence of osteonecrosis of femoral head in patients recieving more than 2g of intravenous methylprednisolone after renal transplantation. Transplant Proc, 28:1559-1560, 1996. 39) Smith SW, Fehring TK, Griffin WL and Beaver WA : Core decompression of the osteonecrotic femoral head. J Bone Joint Surg, 77-A:674-680, 1995. 40) Smith SW, Meyer RA, Connor PM, Smith SE and Hanley EN : Interobserver reliability and intraobserver reproducibility of the modified Ficat classification system of osteonecrosis of the femoral head. J Bone Joint Surg, 78-A: 1702-1706, 1996. 41) Steinberg ME : Core decompression of the femoral head for avascular necrosis: indication and results. Canadian J of Surgery, 38 sup:s18-24, 1995. 42) Steinberg ME : Early results in the treatment of AVN of femoral head with electrical stimulation. Orthopaedic clinics of North America, 15:163-175, 1984. 43) Steinberg ME, Brighton CT, Corces A, et al : Osteonecrosis of the femoral head. Results of core decompression and grafting with and without electrical stimulation. Clin Orthop, 249: 199-208, 1989. 44) Steinberg ME, Brighton CT, Steinberg DR, Tooze SE and Hayken GD : Treatment of avascular necrosis of the femoral head by a combination of bone grafting, decompression and electrical stimulation. Clin Orthop, 186:137-153, 1984. 45) Stulberg BN, Bauer TW and Belhobek GH : Making core decompression work. Clin Orthop, 261: 186-195, 1990. 46) Stulberg BN, Davis AW, Bauer TW, Levine M and Easley K : Osteonecrosis of the femoral head. A prospective randomized treatment protocol. Clin Orthop, 268:140-151, 1991.
47) Takatori Y, Kokubo T, Ninomiya S, Nakamura S, Morimoto S and Kusaba I : Avascular necrosis of the femoral head. Natural history and magnetic resonance imaging. J Bone Joint Surg, 75-B:217-221, 1 9 9 3. 48) Tooke SMT, Nugent PJ, Bassett LW, Nottinfham P, Mirra J, and Jinnah R : Results of core decompression for femoral head osteonecrosis. Clin Orthop, 228:99-104, 1988. 49) Totty WG, Murphy WA, Ganz WI, Kumar B, Daum WJ and Siegel BA : Magnetic resonance imaging of the normal and ischemic femoral head. AJR, 143:1436-1273, 1984. 50) Warner JJP, Philip JH, Brodsky GL and Thornhill TS : Studies of nontraumatic osteonecrosis. The role of core decompression in the treatment of nontraumatic osteonecrosis of the femoral head. C l i n Orthop, 225:104-127, 1987.