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The Results of Total Hip Arthroplasty After Sugioka Transtrochanteric Anterior Rotational Osteotomy for Osteonecrosis
The Journal of Arthroplasty xxx (2017) 1e6
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The Results of Total Hip Arthroplasty After Sugioka Transtrochanteric Anterior Rotational Osteotomy for Osteonecrosis Takeshi Utsunomiya, MD, Goro Motomura, MD, PhD *, Satoshi Ikemura, MD, PhD, Satoshi Hamai, MD, PhD, Jun-ichi Fukushi, MD, PhD, Yasuharu Nakashima, MD, PhD Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 January 2017 Received in revised form 10 April 2017 Accepted 18 April 2017 Available online xxx
Background: Since Sugioka transtrochanteric anterior rotational osteotomy (ARO) for osteonecrosis of the femoral head (ONFH) changes the morphology of the proximal femur, total hip arthroplasty (THA) after previous ARO is considered a technically demanding procedure. The purpose of this study was to compare the clinicoradiologic outcomes of THA after ARO with those of THA without any antecedent surgery for ONFH. Methods: Twenty-four hips in 20 patients who underwent cementless THA after ARO (postosteotomy group) were retrospectively reviewed and compared with patients who underwent cementless THA without any antecedent surgery for ONFH during the same period (primary group). In the postosteotomy group, the mean duration from ARO to THA was 19.7 years. All patients were followed for at least 5 years (mean, 8.3 years; follow-up rate, 78.5%). A clinical assessment was performed preoperatively and at the latest follow-up using the Harris Hip Score. A radiographic examination was performed at 3 months after THA and at the latest follow-up. Results: The Harris Hip Score at the latest follow-up in the postosteotomy group was equivalent to that in the primary group, but longer operation time and greater intraoperative blood loss were observed in the postosteotomy group. There were no significant differences in postoperative complications, including dislocation (2 hips in each group). The leg lengthening in the postosteotomy group tended to be longer. No hips showed implant malpositioning, loosening, or required any revision surgery. Conclusion: The clinicoradiologic outcomes of THA after ARO are considered to be comparable with those of THA without any antecedent surgery for ONFH. © 2017 Elsevier Inc. All rights reserved.
Keywords: osteonecrosis of the femoral head osteotomy conversion total hip arthroplasty surgical technique
Osteonecrosis of the femoral head (ONFH) has been reported to occur in young adults [1e3]. Once a necrotic lesion within the weight-bearing area of the femoral head progresses to the point of
This work was partially supported by the Practical Research Project for Rare/ Intractable Diseases from Japan Agency for Medical Research and Development, and a grant-in-aid in Scientific Research (grant 16K10906 and grant 16H07057) from the Japan Society for the Promotion of Science. One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.04.034. This work was performed at Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. * Reprint requests: Goro Motomura, MD, PhD, Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan. http://dx.doi.org/10.1016/j.arth.2017.04.034 0883-5403/© 2017 Elsevier Inc. All rights reserved.
collapse, patients suffer from hip pain and a loss of the hip function, resulting in secondary osteoarthritis. Therefore, cases with a collapsed femoral head generally require surgical treatments, including total hip arthroplasty (THA) [4e11] and joint-preserving procedures [12e17]. THA has been used to treat ONFH, especially in the advanced stages [7,18], since this procedure can achieve pain relief and provide prompt functional improvement [5e11]. However, the durability of THA for ONFH has been questioned because of the relatively young age and high activity level of ONFH patients [18e20]. In addition, the revision rates in patients with ONFH have been reported to be significantly higher than those in patients with osteoarthritis, even in the same age groups (<50 years old) [4,5]. Therefore, joint-preserving procedures are usually considered in young patients with ONFH. Sugioka transtrochanteric anterior rotational osteotomy (ARO) was developed as a joint-preserving procedure for ONFH [12]. Briefly, ARO includes transtrochanteric osteotomies as well as
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detachment of the major trochanter and anterior rotation of the femoral head with varus realignment to transpose the intact healthy area to a weight-bearing area, resulting in transfer of the necrotic area to a noneweight-bearing area [12] (Fig. 1A and B). The findings for ARO remain controversial. Some previous studies have reported good clinicoradiologic outcomes with ARO [12e17]. Hosokawa et al [16] showed that 85% of hips with ONFH and <2 mm of collapse achieved satisfactory results at >10 years follow-up after ARO. Motomura et al [17] also reported that the hip survival rate at 25 years after ARO was 73.7% (95% confidence interval, ±19.8%) in patients with systemic lupus erythematosus. On the other hand, other patients who underwent ARO suffered secondary osteoarthritis or failure of osteotomy. These cases required conversion to THA as a salvage operation, which is considered a technically demanding procedure because of the anatomic changes of the proximal femur after the osteotomy [21e24] (Fig. 1B). To our knowledge, there have been few reports describing the outcomes of THA after ARO in detail [21e24]. The authors hypothesized that the proper treatments for the anatomic changes of the proximal femur after ARO could provide the equivalent outcomes of conversion THA after ARO. The purpose of this study was to assess whether previous ARO affects the clinicoradiologic outcomes of conversion THA. Materials and Methods
Fig. 1. Schematic illustration of Sugioka transtrochanteric anterior rotational osteotomy (ARO) in the left femur. (A) Posterior view of the left femur during ARO. ARO includes 3 osteotomies: (1) osteotomy of the greater trochanter, (2) intertrochanteric osteotomy (parallelogram), which is perpendicular to the neck axis (black dotted line) and passes through superolateral to inferomedial, and (3) an osteotomy which passes from the proximal flare of the lesser trochanter inferolaterally toward the inferomedial extent of the intertrochanteric osteotomy. After these osteotomies, the proximal fragment of the femur is rotated anteriorly (arrow) around the neck axis (black dotted line) to transpose the intact healthy area to a weight-bearing area, resulting in transfer of the necrotic area (arrow heads) to a noneweight-bearing area. (B) Lateral view of the left femur after ARO. Anterior overhang of the trochanteric region is seen (black allows).
Patients This retrospective review was approved by the local institutional review board. Between January 1998 and December 2010, 67 hips in 56 patients with ONFH underwent cementless THA at our institution. The diagnosis of ONFH was based on the findings of radiographs and magnetic resonance imaging. All the patients were classified as Stage IV with the modified Ficat system [25,26]. Of these patients, 53 hips in 44 patients who could be followed for at least 5 years were the subjects of this study (mean follow-up duration: 8.3 years; follow-up rate: 78.5%). These patients were divided into 2 groups depending on the presence/absence of previous ARO for ONFH. Since 24 hips in 20 patients (12 males and 8 females) who had been treated with ARO for ONFH subsequently underwent cementless THA after ARO, we defined these patients as the postosteotomy group. The remaining 29 hips in 24 patients (10 males and 14 females) did not have any antecedent surgery for ONFH and were therefore defined as the primary group. The details of the patients are listed in Table 1. The mean patient age at the time of THA was 58.4 and 57.3 years in the postosteotomy group and the primary group, respectively. In the postosteotomy group, the mean duration from ARO to THA was 19.7 years (range, 6.3-29.8 years) after ARO. The mean body mass index was 23.5 and 23.7 kg/m2 in the postosteotomy and the primary groups, respectively. The etiology of ONFH in the postosteotomy group was steroid associated in 8 patients, alcohol associated in 8 patients, and idiopathic in 4 patients. The etiology of ONFH in the primary group was steroid associated in 16 patients, alcohol associated in 6 patients, and idiopathic in 2 patients. Both the Harris Hip Score (HHS) [27] and the range of motion were compared between the postosteotomy and primary groups preoperatively and at the latest follow-up, respectively. Regarding the short-term disability (within 12 months after THA), the length of stay as well as the duration using assistive devices and the narcotic usage were compared between the 2 groups. In addition, both the operation time and the intraoperative blood loss were assessed from the medical records. Complications were also assessed in terms of dislocation, intraoperative fracture, infection, deep vein thrombosis, sciatic nerve palsy, and heterotopic ossification [28].
Radiologic Assessments Anteroposterior radiographs of the hips were assessed preoperatively, at 3 months after THA, and at the latest follow-up. The cup abduction angle was measured using the methods described by Nomura et al [29]. The cup anteversion angle was calculated using the method by Widmer [30]. The cup migration was defined as a change in position of S2 mm or more at the latest follow-up compared with that at 3 months after THA [21]. The femoral stem alignment was determined by measuring the angle between the longitudinal axis of femoral stem and that of the femoral canal. The stem alignment was defined as valgus with >5 of lateral deviation, and as varus with >5 of medial deviation [21]. Subsidence of the femoral stem was defined when the femoral stem progressively sank >3 mm between 3 months after THA and the latest follow-up
Table 1 Demographic Data of Patients and Implants.
Age at THA (y)a Gender (n) Male/female Body mass indexa (kg/m2) Etiology of ONFH (n) Steroid/alcoholism/idiopathic Follow-up duration after THA (y)a Implants of cementless THA (number of hips) AMS cup with PerFix910 stem Trabecular metal cup with VerSys cementless stem Trilogy with APS Natural-Hip system Ball size 22 mm/26 mm/32 mm
Postosteotomy Group: 24 Hips (20 Patients)
Primary Group: 29 Hips (24 Patients)
P Value
58.4 ± 9.2
57.3 ± 9.9
.92
12/8 23.5 ± 2.5
10/14 23.7 ± 3.6
.36 .78
8/8/4 9.5 ± 3.3
16/6/2 7.3 ± 2.1
.21 .022b
23 1
25 1
.306
0
3
7/15/2
0/25/4
ONFH, osteonecrosis of the femoral head; THA, total hip arthroplasty. a Data were expressed as the mean ± standard deviation. b Statistical significance was established at P < .05 for all tests.
.0042b
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Fig. 2. Intraoperative picture of the proximal femur in total hip arthroplasty (THA) after Sugioka transtrochanteric anterior rotational osteotomy. (A) At the time of insertion of the femoral trial component. The anterior overhang of the trochanteric region is prominent anteriorly (white arrows). The scale on the ruler indicates millimeters. (B) The straight chisel is used to cut the anterior overhang of the trochanteric region along the line that seems to be parallel to the original anterior cortex of the proximal femur with sufficient thickness. (C) After resection of the anterior overhang of the trochanteric region. There is no bony prominence that can cause impingement at the motion of flexioneinternal rotation. In addition, a markedly thickened anterior joint capsule is detected (arrow heads) and carefully resected.
[31]. Stability of the femoral stem was classified as ingrowth fixation, stable fibrous fixation, and unstable fixation [32]. To evaluate the leg lengthening, we measured the distance between the interischial tuberosity line and the lower margin of the lesser trochanter preoperatively and 3 months after THA [33,34].
Operation All THA procedures were performed via the posterolateral approach [35]. In the postosteotomy group in particular, THA procedures were performed with careful attention to the characteristic deformities of the proximal femur after ARO, including anterior overhang of the trochanteric region (Fig. 2A), a markedly thickened anterior joint capsule, the bony partition within the marrow cavity (Fig. 3A), and leg shortening because of varus deformity (Fig. 3A). The anterior overhang of the trochanteric region and markedly thickened anterior joint capsule were carefully resected (Fig. 2B). For canal preparation of the femur in the postosteotomy group, reaming of the medullary canal followed perforations of bony partition within the marrow cavity using a burr. In both groups, an intraoperative radiograph of the anteroposterior view was taken after the trial component reduction, and then, the alignment of the implants and the leg length were adjusted if necessary (Fig. 3B). The posterior capsule or pseudocapsule was sutured as possible. In both groups, full weight-bearing was allowed from the day after surgery.
Implants Three designs of cementless implants were used (Table 1): an AMS cup with a PerFix910 stem (Kyocera, Osaka, Japan) in 48 hips, a Trabecular Metal cup with a VerSys cementless stem (Zimmer, Warsaw, IN) in 2 hips, and a Trilogy with an APS Natural-Hip system (Zimmer, Warsaw, IN) in 3 hips. The head size depended on both the periods of THA and cup size. A 22-mm zirconia ball was used in 7 hips in the postosteotomy group. Forty hips were treated with a 26-mm zirconia or alumina ball, and 6 hips were treated with a 32mm alumina ball. Statistical Analyses The preoperative and postoperative HHSs were compared using a paired t test, and the Wilcoxon test was used for other numerical variables. The gender and etiology of ONFH were compared between 2 groups using the Fisher exact test. The difference was considered significant when the P value was <.05. These statistical analyses were performed using the JMP statistical analysis software program (version 11; SAS Institute, Cary, NC). Results The preoperative HHS in the postosteotomy group (32.0 ± 12.4 points) improved significantly at the latest follow-up over the
Fig. 3. An illustrative case of the postosteotomy group. A 67-year-old female who had undergone Sugioka transtrochanteric ARO for osteonecrosis of the femoral head at the age of 45 years underwent conversion THA because of a complaint of secondary osteoarthritis with a Harris Hip Score of 33. (A) An anteroposterior radiograph obtained 22 years after ARO pre-THA shows joint space narrowing in the left hip as well as femoral deformities, including a bony partition within the femoral canal (white arrow) and the leg shortening because of varus deformity. (B) An anteroposterior radiograph obtained 8 years after conversion THA after ARO shows that the leg shortening is almost corrected and the femoral stem is positioned in a neutral alignment.
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Table 2 The Results of Harris Hip Score, Range of Motion and Perioperative Assessment. Postosteotomy Group: 24 Hips Harris Hip score (points) At pre-THA At the latest follow-up Range of motion ( ) At pre-THA Flexion Abduction At the latest follow-up Flexion Abduction Perioperative assessment Operation time (min) Intraoperative blood loss (mL)
Primary Group: 29 Hips
P Value
32.0 ± 12.4 88.0 ± 9.3
31.2 ± 11.7 86.2 ± 10.2
.96 .54
63.9 ± 25.6 15.4 ± 10.5
87.2 ± 21.9 18.6 ± 8.4
.0009a .15
97.5 ± 16.6 20.9 ± 8.9 132.5 ± 48.8 391.4 ± 202.5
.47 .61
85.8 ± 23.9 248.9 ± 162.8
.0001a .0034a
preoperative value (88.0 ± 9.3 points; P < .0001), similar to findings in the primary group (Table 2). The preoperative flexion range in the postosteotomy group (63.9 ± 25.6 ) was significantly smaller than that in the primary group (87.2 ± 21.9 ; P ¼ .0009). At the latest follow-up, the flexion range in the postosteotomy group improved to 97.5 ± 16.6 , which was similar to that in the primary group (102.8 ± 7.8 ). The length of stay in the postosteotomy group (4.2 ± 1.0 weeks) was similar to that in the primary group (4.0 ± 0.8 weeks; P ¼ .62). The duration using assistive devices within 12 months after THA in the postosteotomy group (6.5 ± 2.8 months) was also similar to that in the primary group (7.0 ± 3.0 months; P ¼ .62). In addition, 3 patients used narcotics within 12 months after THA in each group (P ¼ 1.00). The operation time in the postosteotomy group (132.5 ± 48.8 minutes) was significantly longer than that in the primary group (85.8 ± 23.9 minutes; P ¼ .0001). The intraoperative blood loss in the postosteotomy group (391.4 ± 202.5 mL) was significantly greater than that in the primary group (248.9 ± 162.8 mL; P ¼ .0034). The radiologic results are shown in Table 3. The cup abduction angle in the postosteotomy group (40.3 ± 6.2 ) was similar to that in the primary group (40.1 ± 6.7 ; P ¼ .84). The cup anteversion angle tended to be lower in the postosteotomy group (12.9 ± 7.6 ) than in the primary group (15.6 ± 6.5 ; P ¼ .17). No hips showed cup migration, malalignment of the femoral stem, or subsidence of the femoral stem in either group. Fifty-two of 53 stems showed evidence of fixation by bone ingrowth, and 1 stem of the postosteotomy group had stable fibrous ingrowth (P ¼ .45). The leg lengthening in the postosteotomy group (14.1 ± 8.9 mm) Table 3 Radiologic Results of Implant Position, Fixation of Femoral Stem and Leg Lengthening.
Cup position at the latest follow-up Cup abduction angle ( ) 40.3 ± 6.2 Cup anteversion angle ( ) 12.9 ± 7.6 Cup migration (number of hips) 0 Femoral stem (number of hips) Malalignment 0 Subsidence 0 Fixation Ingrowth/stable 23/1/0 fibrous/unstable Leg lengthening (mm) 14.1 ± 8.9
Primary Group: 29 Hips
P Value
40.1 ± 6.7 15.6 ± 6.5 0
.84 .17 1.00
0 0
1.00 1.00
29/0/0
Data were expressed as the mean ± standard deviation. Statistical significance was established at P < .05.
9.3 ± 6.1
Number of hips Dislocation (%) Intraoperative fracture Infection Deep vein thrombosis Sciatic nerve palsy Ectopic ossification Revision surgery a
102.8 ± 7.8 21.6 ± 7.9
Data were expressed as the mean ± standard deviation. THA, total hip arthroplasty. a Statistical significance was established at P < .05.
Postosteotomy Group: 24 Hips
Table 4 Complications After Total Hip Arthroplasty.
.45 .068
Postosteotomy Group
Primary Group
P Value
24 2 (8.3) 0 1 (Superficial) 0 0 0 0
29 2 (6.8) 1a 0 0 0 0 0
.84 .26 .89 1.00 1.00 1.00 1.00
Calcar fracture.
tended to be longer than that in the primary group (9.3 ± 6.1 mm; P ¼ .068). Complications in the postosteotomy group were comparable with those in the primary group (Table 4). Two hips dislocated in each group (P ¼ .84), and all of them were treated with closed reduction. In 1 hip of the primary group, calcar fracture occurred intraoperatively, and it was treated with cerclage wires. In 1 hip of the postosteotomy group, superficial infection occurred and was treated conservatively. There were no patients with sciatic nerve palsy, symptomatic venous thromboembolism, or heterotopic ossification in either group. No hips required any revision surgery during the follow-up period.
Discussion To our knowledge, there have been 4 published studies on the results of THA after ARO (Table 5). Of these, 3 studies demonstrated that previous ARO did not influence the clinical results as well as the stability of implants and survival rates in conversion THA [21e24]. On the other hand, Rijnen et al [24] reported the less favorable outcome of THA after ARO including more complications and higher revision rate. In the present study, with more patients and longer follow-up, we found that the midterm clinicoradiologic outcomes of THA after ARO were comparable with those of THA without any antecedent surgery for ONFH. Similar to previous studies, we found both a longer operation time and greater blood loss in THA after ARO, possibly because of the requirement for treatments for severe deformities of the proximal femur. Resection of the anterior overhang of the trochanteric region and a markedly thickened anterior joint capsule are necessary to avoid impingement at the motion of flexion-internal rotation that could cause dislocation [36]. Bony partition within the marrow cavity must be removed carefully to avoid malposition of the femoral stem [21,22]. Since the neck-shaft angle is intentionally distorted into varus alignment, careful correction of the leg shortening is also needed. Although both a longer operation time and greater blood loss are considered to be down-sides of THA after ARO, we found an improved hip joint function comparable with that in patients with THA without any antecedent surgery for ONFH. Bearing both the longer operation time and greater intraoperative blood loss in mind, THA after ARO should be performed carefully. In the present study, dislocation was the most common complication of THA after ARO as well as THA without any antecedent surgery for ONFH. Previous studies on THA after ARO also reported the occurrence of dislocation (at rates of 7.1%-13.3%; Table 5). However, the reason for dislocation following THA after ARO was still unclear. In this study, 2 hips with THA after ARO (8.3%) dislocated. Of these, 1 hip used a 22-mm ball, which might have been an associated risk factor of dislocation. Since previous studies have reported higher rates of dislocation after THA for ONFH than after THA for osteoarthritis [37,38], we should recognize the
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Table 5 THA After Transtrochanteric Rotational Osteotomy: A Survey of the Literature. Interval From Osteotomy to THA (y)
Follow-Up Duration After THA (y)
Mean Operation Time (min)
Mean Operative Blood Loss
Dislocation (Hips), n (%)
Stem Malalignment (Stems)
Revision THA (Hips)
43 40
4 (0.5-7) 1.7 (0.3-3.1)
5 (3.4-8.7) 4.8 (2.0-9.6)
146 190
508 (g) 1050 (mL)
2 (13.3) 1 (7.1)
1 0
38 35 58
2.6 (0-6.0) 4.7 (1.4-10.1) 19.7 (6.3-37.0)
4.5 (2.2-9.1) 6.4 (2.2-12.7) 9.5 (5.0-16.3)
96 161 132.5
550 (mL) 1350 (cc) 391.4 (mL)
0 2 (12.5) 2 (8.3)
NA 4 in varus, 1 in valgus 0 5 in varus 0
Authors (Ref.)
Number of THAs After Osteotomy (Hips)
Age at THA (y)
Kawasaki et al [21] Lee et al [22]
15 14
Park et al [23] Rijnen et al [24] Our study
18 16 24
0 3 0
The values in parentheses indicate the range. NA, not applicable; Ref., reference; THA, total hip arthroplasty.
potentially high risk of dislocation with both THA after ARO and THA without any antecedent surgery for ONFH. In our study, the cup anteversion angle tended to decrease in THA after ARO compared with THA without any antecedent surgery for ONFH. Lee et al [22] reported that both the cup abduction angle and cup anteversion angle were significantly smaller in THA after ARO. The acetabular deformity due to massive osteophyte formation in THA after ARO seems to influence the position of the acetabular component. It is important to recognize the presence of an anatomic deformity exists in both the acetabulum as well as the femur for THA after ARO. Several limitations associated with the present study warrant mention. First, our study had a relatively small sample size undergoing THA for ONFH. However, to our knowledge, this study enrolled the largest number of patients undergoing THA after ARO to date. Since the interval from ARO to THA in our study was longer than that in previous studies (Table 5), we feel that our findings are meaningful and have not yet been described. Second, we were unable to assess the patient-reported outcomes in this retrospective study. Further prospective studies should be performed to clarify the timeline to a full recovery after conversion THA following ARO using the patient-reported outcome measures. Third, we were unable to evaluate the stem anteversion angle, since not all the patients were routinely evaluated using postoperative computed tomography after THA. Further prospective studies are needed to compare the femoral deformities with the stem position after conversion THA using computed tomography. In conclusion, THA after ARO provides comparable clinicoradiologic outcomes with those of THA without any antecedent surgery for ONFH. The proper treatments for the anatomic changes of the proximal femur after ARO are essential to succeed in conversion THA. References [1] Kang JS, Moon KH, Kwon DG, Shin BK, Woo MS. The natural history of asymptomatic osteonecrosis of the femoral head. Int Orthop 2013;37:379e84. [2] Fukushima W, Fujioka M, Kubo T, Tamakoshi A, Nagai M, Hirota Y. Nationwide epidemiologic survey of idiopathic osteonecrosis of the femoral head. Clin Orthop Relat Res 2010;468:2715e24. [3] Yamaguchi R, Yamamoto T, Motomura G, Ikemura S, Iwamoto Y. Incidence of nontraumatic osteonecrosis of the femoral head in the Japanese population. Arthritis Rheum 2011;63:3169e73. [4] Ortiguera CJ, Pulliam IT, Cabanela ME. Total hip arthroplasty for osteonecrosis. Matched-pair analysis of 188 hips with long-term follow-up. J Arthroplasty 1999;14:21e8. [5] Radl R, Hungerford M, Materna W, Rehak P, Windhager R. Higher failure rate and stem migration of an uncemented femoral component in patients with femoral head osteonecrosis than in patients with osteoarthrosis. Acta Orthop 2005;76:49e55. [6] Dorr LD, Kane 3rd TJ, Conaty JP. Long-term results of cemented total hip arthroplasty in patients 45 years old or younger. J Arthroplasty 1994;9:453e6. [7] Johannson HR, Zywiel MG, Marker DR, Jones LC, McGrath MS, Mont MA. Osteonecrosis is not a predictor of poor outcomes in primary total hip arthroplasty: a systematic literature review. Int Orthop 2011;35:465e73.
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[28] Brooker AF, Bowerman JW, Robinson RA, Riley Jr LH. Ectopic ossification following total hip arthroplasty. Incidence and a method of classification. J Bone Joint Surg Am 1973;55:1629e32. [29] Nomura T, Naito M, Nakamura Y, Ida T, Kuroda D, Kobayashi T. An analysis of the best method for evaluating anteversion of the acetabular component after total hip replacement on plain radiographs. Bone Joint J 2014;96-B:597e603. [30] Widmer KH. A simplified method to determine acetabular cup anteversion from plain radiographs. J Arthroplasty 2004;19:387e90. [31] Kim TH, Kim JS, Oh SH, Kim JM. Comparison or porous coated titanium femoral stems with and without hydroxyapatite coating. J Bone Joint Surg Am 2003;85:1682e8. [32] Engh CA, Massin P, Suthers KE. Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components. Clin Orthop Relat Res 1990:107e28. [33] Williamson JA, Reckling FW. Limb length discrepancy and related problems following total hip joint replacement. Clin Orthop Relat Res 1978:135e8.
[34] Woolson ST, Hartford JM, Sawyer A. Results of method of leg-length equalization for patients undergoing primary total hip replacement. J Arthroplasty 1999;14:159e64. [35] Nakashima Y, Hirata M, Akiyama M, Itokawa T, Yamamoto T, Motomura G, et al. Combined anteversion technique reduced the dislocation in cementless total hip arthroplasty. Int Orthop 2014;38:27e32. [36] Bartz RL, Nobel PC, Kadakia NR, Tullos HS. The effect of femoral component head size on posterior dislocation of the artificial hip joint. J Bone Joint Surg Am 2000;82:1300e7. [37] Berry DJ, von Knoch M, Schleck CD, Harmsen WS. The cumulative long-term risk of dislocation after primary Charnley total hip arthroplasty. J Bone Joint Surg Am 2004;86:9e14. [38] Itokawa T, Nakashima Y, Yamamoto T, Motomura G, Ohishi M, Hamai S, et al. Late dislocation is associated with recurrence after total hip arthroplasty. Int Orthop 2013;37:1457e63.
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The Results of Total Hip Arthroplasty After Sugioka Transtrochanteric Anterior Rotational Osteotomy for Osteonecrosis Takeshi Utsunomiya, MD, Goro Motomura, MD, PhD *, Satoshi Ikemura, MD, PhD, Satoshi Hamai, MD, PhD, Jun-ichi Fukushi, MD, PhD, Yasuharu Nakashima, MD, PhD Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 January 2017 Received in revised form 10 April 2017 Accepted 18 April 2017 Available online xxx
Background: Since Sugioka transtrochanteric anterior rotational osteotomy (ARO) for osteonecrosis of the femoral head (ONFH) changes the morphology of the proximal femur, total hip arthroplasty (THA) after previous ARO is considered a technically demanding procedure. The purpose of this study was to compare the clinicoradiologic outcomes of THA after ARO with those of THA without any antecedent surgery for ONFH. Methods: Twenty-four hips in 20 patients who underwent cementless THA after ARO (postosteotomy group) were retrospectively reviewed and compared with patients who underwent cementless THA without any antecedent surgery for ONFH during the same period (primary group). In the postosteotomy group, the mean duration from ARO to THA was 19.7 years. All patients were followed for at least 5 years (mean, 8.3 years; follow-up rate, 78.5%). A clinical assessment was performed preoperatively and at the latest follow-up using the Harris Hip Score. A radiographic examination was performed at 3 months after THA and at the latest follow-up. Results: The Harris Hip Score at the latest follow-up in the postosteotomy group was equivalent to that in the primary group, but longer operation time and greater intraoperative blood loss were observed in the postosteotomy group. There were no significant differences in postoperative complications, including dislocation (2 hips in each group). The leg lengthening in the postosteotomy group tended to be longer. No hips showed implant malpositioning, loosening, or required any revision surgery. Conclusion: The clinicoradiologic outcomes of THA after ARO are considered to be comparable with those of THA without any antecedent surgery for ONFH. © 2017 Elsevier Inc. All rights reserved.
Keywords: osteonecrosis of the femoral head osteotomy conversion total hip arthroplasty surgical technique
Osteonecrosis of the femoral head (ONFH) has been reported to occur in young adults [1e3]. Once a necrotic lesion within the weight-bearing area of the femoral head progresses to the point of
This work was partially supported by the Practical Research Project for Rare/ Intractable Diseases from Japan Agency for Medical Research and Development, and a grant-in-aid in Scientific Research (grant 16K10906 and grant 16H07057) from the Japan Society for the Promotion of Science. One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.04.034. This work was performed at Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. * Reprint requests: Goro Motomura, MD, PhD, Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan. http://dx.doi.org/10.1016/j.arth.2017.04.034 0883-5403/© 2017 Elsevier Inc. All rights reserved.
collapse, patients suffer from hip pain and a loss of the hip function, resulting in secondary osteoarthritis. Therefore, cases with a collapsed femoral head generally require surgical treatments, including total hip arthroplasty (THA) [4e11] and joint-preserving procedures [12e17]. THA has been used to treat ONFH, especially in the advanced stages [7,18], since this procedure can achieve pain relief and provide prompt functional improvement [5e11]. However, the durability of THA for ONFH has been questioned because of the relatively young age and high activity level of ONFH patients [18e20]. In addition, the revision rates in patients with ONFH have been reported to be significantly higher than those in patients with osteoarthritis, even in the same age groups (<50 years old) [4,5]. Therefore, joint-preserving procedures are usually considered in young patients with ONFH. Sugioka transtrochanteric anterior rotational osteotomy (ARO) was developed as a joint-preserving procedure for ONFH [12]. Briefly, ARO includes transtrochanteric osteotomies as well as
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detachment of the major trochanter and anterior rotation of the femoral head with varus realignment to transpose the intact healthy area to a weight-bearing area, resulting in transfer of the necrotic area to a noneweight-bearing area [12] (Fig. 1A and B). The findings for ARO remain controversial. Some previous studies have reported good clinicoradiologic outcomes with ARO [12e17]. Hosokawa et al [16] showed that 85% of hips with ONFH and <2 mm of collapse achieved satisfactory results at >10 years follow-up after ARO. Motomura et al [17] also reported that the hip survival rate at 25 years after ARO was 73.7% (95% confidence interval, ±19.8%) in patients with systemic lupus erythematosus. On the other hand, other patients who underwent ARO suffered secondary osteoarthritis or failure of osteotomy. These cases required conversion to THA as a salvage operation, which is considered a technically demanding procedure because of the anatomic changes of the proximal femur after the osteotomy [21e24] (Fig. 1B). To our knowledge, there have been few reports describing the outcomes of THA after ARO in detail [21e24]. The authors hypothesized that the proper treatments for the anatomic changes of the proximal femur after ARO could provide the equivalent outcomes of conversion THA after ARO. The purpose of this study was to assess whether previous ARO affects the clinicoradiologic outcomes of conversion THA. Materials and Methods
Fig. 1. Schematic illustration of Sugioka transtrochanteric anterior rotational osteotomy (ARO) in the left femur. (A) Posterior view of the left femur during ARO. ARO includes 3 osteotomies: (1) osteotomy of the greater trochanter, (2) intertrochanteric osteotomy (parallelogram), which is perpendicular to the neck axis (black dotted line) and passes through superolateral to inferomedial, and (3) an osteotomy which passes from the proximal flare of the lesser trochanter inferolaterally toward the inferomedial extent of the intertrochanteric osteotomy. After these osteotomies, the proximal fragment of the femur is rotated anteriorly (arrow) around the neck axis (black dotted line) to transpose the intact healthy area to a weight-bearing area, resulting in transfer of the necrotic area (arrow heads) to a noneweight-bearing area. (B) Lateral view of the left femur after ARO. Anterior overhang of the trochanteric region is seen (black allows).
Patients This retrospective review was approved by the local institutional review board. Between January 1998 and December 2010, 67 hips in 56 patients with ONFH underwent cementless THA at our institution. The diagnosis of ONFH was based on the findings of radiographs and magnetic resonance imaging. All the patients were classified as Stage IV with the modified Ficat system [25,26]. Of these patients, 53 hips in 44 patients who could be followed for at least 5 years were the subjects of this study (mean follow-up duration: 8.3 years; follow-up rate: 78.5%). These patients were divided into 2 groups depending on the presence/absence of previous ARO for ONFH. Since 24 hips in 20 patients (12 males and 8 females) who had been treated with ARO for ONFH subsequently underwent cementless THA after ARO, we defined these patients as the postosteotomy group. The remaining 29 hips in 24 patients (10 males and 14 females) did not have any antecedent surgery for ONFH and were therefore defined as the primary group. The details of the patients are listed in Table 1. The mean patient age at the time of THA was 58.4 and 57.3 years in the postosteotomy group and the primary group, respectively. In the postosteotomy group, the mean duration from ARO to THA was 19.7 years (range, 6.3-29.8 years) after ARO. The mean body mass index was 23.5 and 23.7 kg/m2 in the postosteotomy and the primary groups, respectively. The etiology of ONFH in the postosteotomy group was steroid associated in 8 patients, alcohol associated in 8 patients, and idiopathic in 4 patients. The etiology of ONFH in the primary group was steroid associated in 16 patients, alcohol associated in 6 patients, and idiopathic in 2 patients. Both the Harris Hip Score (HHS) [27] and the range of motion were compared between the postosteotomy and primary groups preoperatively and at the latest follow-up, respectively. Regarding the short-term disability (within 12 months after THA), the length of stay as well as the duration using assistive devices and the narcotic usage were compared between the 2 groups. In addition, both the operation time and the intraoperative blood loss were assessed from the medical records. Complications were also assessed in terms of dislocation, intraoperative fracture, infection, deep vein thrombosis, sciatic nerve palsy, and heterotopic ossification [28].
Radiologic Assessments Anteroposterior radiographs of the hips were assessed preoperatively, at 3 months after THA, and at the latest follow-up. The cup abduction angle was measured using the methods described by Nomura et al [29]. The cup anteversion angle was calculated using the method by Widmer [30]. The cup migration was defined as a change in position of S2 mm or more at the latest follow-up compared with that at 3 months after THA [21]. The femoral stem alignment was determined by measuring the angle between the longitudinal axis of femoral stem and that of the femoral canal. The stem alignment was defined as valgus with >5 of lateral deviation, and as varus with >5 of medial deviation [21]. Subsidence of the femoral stem was defined when the femoral stem progressively sank >3 mm between 3 months after THA and the latest follow-up
Table 1 Demographic Data of Patients and Implants.
Age at THA (y)a Gender (n) Male/female Body mass indexa (kg/m2) Etiology of ONFH (n) Steroid/alcoholism/idiopathic Follow-up duration after THA (y)a Implants of cementless THA (number of hips) AMS cup with PerFix910 stem Trabecular metal cup with VerSys cementless stem Trilogy with APS Natural-Hip system Ball size 22 mm/26 mm/32 mm
Postosteotomy Group: 24 Hips (20 Patients)
Primary Group: 29 Hips (24 Patients)
P Value
58.4 ± 9.2
57.3 ± 9.9
.92
12/8 23.5 ± 2.5
10/14 23.7 ± 3.6
.36 .78
8/8/4 9.5 ± 3.3
16/6/2 7.3 ± 2.1
.21 .022b
23 1
25 1
.306
0
3
7/15/2
0/25/4
ONFH, osteonecrosis of the femoral head; THA, total hip arthroplasty. a Data were expressed as the mean ± standard deviation. b Statistical significance was established at P < .05 for all tests.
.0042b
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3
Fig. 2. Intraoperative picture of the proximal femur in total hip arthroplasty (THA) after Sugioka transtrochanteric anterior rotational osteotomy. (A) At the time of insertion of the femoral trial component. The anterior overhang of the trochanteric region is prominent anteriorly (white arrows). The scale on the ruler indicates millimeters. (B) The straight chisel is used to cut the anterior overhang of the trochanteric region along the line that seems to be parallel to the original anterior cortex of the proximal femur with sufficient thickness. (C) After resection of the anterior overhang of the trochanteric region. There is no bony prominence that can cause impingement at the motion of flexioneinternal rotation. In addition, a markedly thickened anterior joint capsule is detected (arrow heads) and carefully resected.
[31]. Stability of the femoral stem was classified as ingrowth fixation, stable fibrous fixation, and unstable fixation [32]. To evaluate the leg lengthening, we measured the distance between the interischial tuberosity line and the lower margin of the lesser trochanter preoperatively and 3 months after THA [33,34].
Operation All THA procedures were performed via the posterolateral approach [35]. In the postosteotomy group in particular, THA procedures were performed with careful attention to the characteristic deformities of the proximal femur after ARO, including anterior overhang of the trochanteric region (Fig. 2A), a markedly thickened anterior joint capsule, the bony partition within the marrow cavity (Fig. 3A), and leg shortening because of varus deformity (Fig. 3A). The anterior overhang of the trochanteric region and markedly thickened anterior joint capsule were carefully resected (Fig. 2B). For canal preparation of the femur in the postosteotomy group, reaming of the medullary canal followed perforations of bony partition within the marrow cavity using a burr. In both groups, an intraoperative radiograph of the anteroposterior view was taken after the trial component reduction, and then, the alignment of the implants and the leg length were adjusted if necessary (Fig. 3B). The posterior capsule or pseudocapsule was sutured as possible. In both groups, full weight-bearing was allowed from the day after surgery.
Implants Three designs of cementless implants were used (Table 1): an AMS cup with a PerFix910 stem (Kyocera, Osaka, Japan) in 48 hips, a Trabecular Metal cup with a VerSys cementless stem (Zimmer, Warsaw, IN) in 2 hips, and a Trilogy with an APS Natural-Hip system (Zimmer, Warsaw, IN) in 3 hips. The head size depended on both the periods of THA and cup size. A 22-mm zirconia ball was used in 7 hips in the postosteotomy group. Forty hips were treated with a 26-mm zirconia or alumina ball, and 6 hips were treated with a 32mm alumina ball. Statistical Analyses The preoperative and postoperative HHSs were compared using a paired t test, and the Wilcoxon test was used for other numerical variables. The gender and etiology of ONFH were compared between 2 groups using the Fisher exact test. The difference was considered significant when the P value was <.05. These statistical analyses were performed using the JMP statistical analysis software program (version 11; SAS Institute, Cary, NC). Results The preoperative HHS in the postosteotomy group (32.0 ± 12.4 points) improved significantly at the latest follow-up over the
Fig. 3. An illustrative case of the postosteotomy group. A 67-year-old female who had undergone Sugioka transtrochanteric ARO for osteonecrosis of the femoral head at the age of 45 years underwent conversion THA because of a complaint of secondary osteoarthritis with a Harris Hip Score of 33. (A) An anteroposterior radiograph obtained 22 years after ARO pre-THA shows joint space narrowing in the left hip as well as femoral deformities, including a bony partition within the femoral canal (white arrow) and the leg shortening because of varus deformity. (B) An anteroposterior radiograph obtained 8 years after conversion THA after ARO shows that the leg shortening is almost corrected and the femoral stem is positioned in a neutral alignment.
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Table 2 The Results of Harris Hip Score, Range of Motion and Perioperative Assessment. Postosteotomy Group: 24 Hips Harris Hip score (points) At pre-THA At the latest follow-up Range of motion ( ) At pre-THA Flexion Abduction At the latest follow-up Flexion Abduction Perioperative assessment Operation time (min) Intraoperative blood loss (mL)
Primary Group: 29 Hips
P Value
32.0 ± 12.4 88.0 ± 9.3
31.2 ± 11.7 86.2 ± 10.2
.96 .54
63.9 ± 25.6 15.4 ± 10.5
87.2 ± 21.9 18.6 ± 8.4
.0009a .15
97.5 ± 16.6 20.9 ± 8.9 132.5 ± 48.8 391.4 ± 202.5
.47 .61
85.8 ± 23.9 248.9 ± 162.8
.0001a .0034a
preoperative value (88.0 ± 9.3 points; P < .0001), similar to findings in the primary group (Table 2). The preoperative flexion range in the postosteotomy group (63.9 ± 25.6 ) was significantly smaller than that in the primary group (87.2 ± 21.9 ; P ¼ .0009). At the latest follow-up, the flexion range in the postosteotomy group improved to 97.5 ± 16.6 , which was similar to that in the primary group (102.8 ± 7.8 ). The length of stay in the postosteotomy group (4.2 ± 1.0 weeks) was similar to that in the primary group (4.0 ± 0.8 weeks; P ¼ .62). The duration using assistive devices within 12 months after THA in the postosteotomy group (6.5 ± 2.8 months) was also similar to that in the primary group (7.0 ± 3.0 months; P ¼ .62). In addition, 3 patients used narcotics within 12 months after THA in each group (P ¼ 1.00). The operation time in the postosteotomy group (132.5 ± 48.8 minutes) was significantly longer than that in the primary group (85.8 ± 23.9 minutes; P ¼ .0001). The intraoperative blood loss in the postosteotomy group (391.4 ± 202.5 mL) was significantly greater than that in the primary group (248.9 ± 162.8 mL; P ¼ .0034). The radiologic results are shown in Table 3. The cup abduction angle in the postosteotomy group (40.3 ± 6.2 ) was similar to that in the primary group (40.1 ± 6.7 ; P ¼ .84). The cup anteversion angle tended to be lower in the postosteotomy group (12.9 ± 7.6 ) than in the primary group (15.6 ± 6.5 ; P ¼ .17). No hips showed cup migration, malalignment of the femoral stem, or subsidence of the femoral stem in either group. Fifty-two of 53 stems showed evidence of fixation by bone ingrowth, and 1 stem of the postosteotomy group had stable fibrous ingrowth (P ¼ .45). The leg lengthening in the postosteotomy group (14.1 ± 8.9 mm) Table 3 Radiologic Results of Implant Position, Fixation of Femoral Stem and Leg Lengthening.
Cup position at the latest follow-up Cup abduction angle ( ) 40.3 ± 6.2 Cup anteversion angle ( ) 12.9 ± 7.6 Cup migration (number of hips) 0 Femoral stem (number of hips) Malalignment 0 Subsidence 0 Fixation Ingrowth/stable 23/1/0 fibrous/unstable Leg lengthening (mm) 14.1 ± 8.9
Primary Group: 29 Hips
P Value
40.1 ± 6.7 15.6 ± 6.5 0
.84 .17 1.00
0 0
1.00 1.00
29/0/0
Data were expressed as the mean ± standard deviation. Statistical significance was established at P < .05.
9.3 ± 6.1
Number of hips Dislocation (%) Intraoperative fracture Infection Deep vein thrombosis Sciatic nerve palsy Ectopic ossification Revision surgery a
102.8 ± 7.8 21.6 ± 7.9
Data were expressed as the mean ± standard deviation. THA, total hip arthroplasty. a Statistical significance was established at P < .05.
Postosteotomy Group: 24 Hips
Table 4 Complications After Total Hip Arthroplasty.
.45 .068
Postosteotomy Group
Primary Group
P Value
24 2 (8.3) 0 1 (Superficial) 0 0 0 0
29 2 (6.8) 1a 0 0 0 0 0
.84 .26 .89 1.00 1.00 1.00 1.00
Calcar fracture.
tended to be longer than that in the primary group (9.3 ± 6.1 mm; P ¼ .068). Complications in the postosteotomy group were comparable with those in the primary group (Table 4). Two hips dislocated in each group (P ¼ .84), and all of them were treated with closed reduction. In 1 hip of the primary group, calcar fracture occurred intraoperatively, and it was treated with cerclage wires. In 1 hip of the postosteotomy group, superficial infection occurred and was treated conservatively. There were no patients with sciatic nerve palsy, symptomatic venous thromboembolism, or heterotopic ossification in either group. No hips required any revision surgery during the follow-up period.
Discussion To our knowledge, there have been 4 published studies on the results of THA after ARO (Table 5). Of these, 3 studies demonstrated that previous ARO did not influence the clinical results as well as the stability of implants and survival rates in conversion THA [21e24]. On the other hand, Rijnen et al [24] reported the less favorable outcome of THA after ARO including more complications and higher revision rate. In the present study, with more patients and longer follow-up, we found that the midterm clinicoradiologic outcomes of THA after ARO were comparable with those of THA without any antecedent surgery for ONFH. Similar to previous studies, we found both a longer operation time and greater blood loss in THA after ARO, possibly because of the requirement for treatments for severe deformities of the proximal femur. Resection of the anterior overhang of the trochanteric region and a markedly thickened anterior joint capsule are necessary to avoid impingement at the motion of flexion-internal rotation that could cause dislocation [36]. Bony partition within the marrow cavity must be removed carefully to avoid malposition of the femoral stem [21,22]. Since the neck-shaft angle is intentionally distorted into varus alignment, careful correction of the leg shortening is also needed. Although both a longer operation time and greater blood loss are considered to be down-sides of THA after ARO, we found an improved hip joint function comparable with that in patients with THA without any antecedent surgery for ONFH. Bearing both the longer operation time and greater intraoperative blood loss in mind, THA after ARO should be performed carefully. In the present study, dislocation was the most common complication of THA after ARO as well as THA without any antecedent surgery for ONFH. Previous studies on THA after ARO also reported the occurrence of dislocation (at rates of 7.1%-13.3%; Table 5). However, the reason for dislocation following THA after ARO was still unclear. In this study, 2 hips with THA after ARO (8.3%) dislocated. Of these, 1 hip used a 22-mm ball, which might have been an associated risk factor of dislocation. Since previous studies have reported higher rates of dislocation after THA for ONFH than after THA for osteoarthritis [37,38], we should recognize the
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Table 5 THA After Transtrochanteric Rotational Osteotomy: A Survey of the Literature. Interval From Osteotomy to THA (y)
Follow-Up Duration After THA (y)
Mean Operation Time (min)
Mean Operative Blood Loss
Dislocation (Hips), n (%)
Stem Malalignment (Stems)
Revision THA (Hips)
43 40
4 (0.5-7) 1.7 (0.3-3.1)
5 (3.4-8.7) 4.8 (2.0-9.6)
146 190
508 (g) 1050 (mL)
2 (13.3) 1 (7.1)
1 0
38 35 58
2.6 (0-6.0) 4.7 (1.4-10.1) 19.7 (6.3-37.0)
4.5 (2.2-9.1) 6.4 (2.2-12.7) 9.5 (5.0-16.3)
96 161 132.5
550 (mL) 1350 (cc) 391.4 (mL)
0 2 (12.5) 2 (8.3)
NA 4 in varus, 1 in valgus 0 5 in varus 0
Authors (Ref.)
Number of THAs After Osteotomy (Hips)
Age at THA (y)
Kawasaki et al [21] Lee et al [22]
15 14
Park et al [23] Rijnen et al [24] Our study
18 16 24
0 3 0
The values in parentheses indicate the range. NA, not applicable; Ref., reference; THA, total hip arthroplasty.
potentially high risk of dislocation with both THA after ARO and THA without any antecedent surgery for ONFH. In our study, the cup anteversion angle tended to decrease in THA after ARO compared with THA without any antecedent surgery for ONFH. Lee et al [22] reported that both the cup abduction angle and cup anteversion angle were significantly smaller in THA after ARO. The acetabular deformity due to massive osteophyte formation in THA after ARO seems to influence the position of the acetabular component. It is important to recognize the presence of an anatomic deformity exists in both the acetabulum as well as the femur for THA after ARO. Several limitations associated with the present study warrant mention. First, our study had a relatively small sample size undergoing THA for ONFH. However, to our knowledge, this study enrolled the largest number of patients undergoing THA after ARO to date. Since the interval from ARO to THA in our study was longer than that in previous studies (Table 5), we feel that our findings are meaningful and have not yet been described. Second, we were unable to assess the patient-reported outcomes in this retrospective study. Further prospective studies should be performed to clarify the timeline to a full recovery after conversion THA following ARO using the patient-reported outcome measures. Third, we were unable to evaluate the stem anteversion angle, since not all the patients were routinely evaluated using postoperative computed tomography after THA. Further prospective studies are needed to compare the femoral deformities with the stem position after conversion THA using computed tomography. In conclusion, THA after ARO provides comparable clinicoradiologic outcomes with those of THA without any antecedent surgery for ONFH. The proper treatments for the anatomic changes of the proximal femur after ARO are essential to succeed in conversion THA. References [1] Kang JS, Moon KH, Kwon DG, Shin BK, Woo MS. The natural history of asymptomatic osteonecrosis of the femoral head. Int Orthop 2013;37:379e84. [2] Fukushima W, Fujioka M, Kubo T, Tamakoshi A, Nagai M, Hirota Y. Nationwide epidemiologic survey of idiopathic osteonecrosis of the femoral head. Clin Orthop Relat Res 2010;468:2715e24. [3] Yamaguchi R, Yamamoto T, Motomura G, Ikemura S, Iwamoto Y. Incidence of nontraumatic osteonecrosis of the femoral head in the Japanese population. Arthritis Rheum 2011;63:3169e73. [4] Ortiguera CJ, Pulliam IT, Cabanela ME. Total hip arthroplasty for osteonecrosis. Matched-pair analysis of 188 hips with long-term follow-up. J Arthroplasty 1999;14:21e8. [5] Radl R, Hungerford M, Materna W, Rehak P, Windhager R. Higher failure rate and stem migration of an uncemented femoral component in patients with femoral head osteonecrosis than in patients with osteoarthrosis. Acta Orthop 2005;76:49e55. [6] Dorr LD, Kane 3rd TJ, Conaty JP. Long-term results of cemented total hip arthroplasty in patients 45 years old or younger. J Arthroplasty 1994;9:453e6. [7] Johannson HR, Zywiel MG, Marker DR, Jones LC, McGrath MS, Mont MA. Osteonecrosis is not a predictor of poor outcomes in primary total hip arthroplasty: a systematic literature review. Int Orthop 2011;35:465e73.
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