- Email: [email protected]
Is There a Role for Resurfacing Hemiarthroplasty?
Is There a Role for Resurfacing Hemiarthroplasty? Vineet Sharma, MD,* and Edward Y. Cheng, MD† The treatment of Ficat stage III osteonecrosis is a challenge in young patients. Various treatment methods to preserve the native femoral head have been used with varying success. Limited femoral head resurfacing has been used traditionally with mixed results. It is an extremely conservative arthroplasty for the young patient with osteonecrosis. The unpredictable and incomplete pain relief afforded by this procedure however, may negate the benefit of bone conservation. The present paper discusses the history, current indications, results, and future of this procedure. Semin Arthro 18:211-215. © 2007 Published by Elsevier Inc. KEYWORDS osteonecrosis, resurfacing, hemiarthroplasty
T
reatment of Ficat stage 3 osteonecrosis continues to be a subject of debate. Proposed treatment options include bone grafting procedures, core decompression with or without vascularized bone grafting, and various proximal femoral osteotomies. All of these treatment options have met with varying success.1-7 Another head preserving procedure used infrequently is femoral head resurfacing hemiarthroplasty. The earliest of these procedures were done in the form of mold arthroplasty using various materials.8 There was no means of fixation of the prosthesis to the underlying bone. With the advent and success of Charnley’s low friction arthroplasty, this procedure was abandoned. Resurgence of interest in this procedure again occurred in the 1980s. This procedure was thought to be good for patients with early stage osteonecrosis (up to Ficat stage III) as it replaced only the diseased part, ie, the femoral head, and left the acetabulum undisturbed. Aseptic loosening remained a problem, however, as fixation and optimal positioning during implantation were unsolved issues. Resurfacing hemiarthroplasty is attractive as it is less invasive than bipolar hemiarthroplasty. Only the cartilage and subchondral bone of the diseased femoral head are replaced with a prosthesis (Figs. 1-5). Improvements in implant design, surgical technique, and instrumentation have enabled more reliable implantation and positioning of the device. Nonetheless, hemiarthroplasty is associated with residual groin pain. Resurfacing total hip arthroplasty (THA) likely would be associated with a lower incidence of groin pain but *Ranawat Orthopaedic Center, New York, NY. †Department of Orthopaedics, University of Minnesota, Minneapolis, MN. Address reprint requests to Edward Y. Cheng, MD, 2450 Riverside Avenue S., R 200, Department of Orthopaedics, University of Minnesota, Minneapolis, MN 55404. E-mail: [email protected]
1045-4527/07/$-see front matter © 2007 Published by Elsevier Inc. doi:10.1053/j.sart.2007.06.007
at the cost of resurfacing an otherwise healthy acetabulum. In addition, resurfacing THA using the improved devices was not approved by the United States Food and Drug Administration (FDA) until 2007. This review focuses on the expected outcome and indications for resurfacing hemiarthroplasty given the improvements in implant design and implantation as well as recent introduction of resurfacing THA in the United States.
Indications Patients who have osteonecrosis of the femoral head (ONFH) with a subchondral fracture, without development of acetabular arthrosis, are ideal candidates for femoral head resurfacing. However, the procedure is likely to fail rapidly if done in patients with visible evidence of acetabular cartilage wear either on preoperative imaging or at the time of surgery. Therefore, the use of magnetic resonance and computed tomographic imaging is important to identify the presence of early degenerative acetabular changes not otherwise visible.
Contraindications Any sign of acetabular degeneration, either on preoperative imaging or at surgery, should be considered a contraindication for hemiarthroplasty and an indication for THA using conventional or resurfacing implants. Patients with an expected remaining lifespan of 20 years or less are better served with conventional femoral stemmed implants instead of resurfacing implants as conventional THA has a high likelihood of being successful for the remainder of their lifetime. Another contraindication to femoral head resurfacing is lack of sufficient structural support for the device on the femoral 211
212
V. Sharma and E.Y. Cheng
Figure 1 Preoperative AP radiograph of 57 year old male with bilateral steroid induced osteonecrosis.
neck. Osteonecrosis or cysts involving more than 25 to 30% of the area of femoral head after reaming should be considered a contraindication. Finally, a varus position of the device is associated with a higher risk of loosening and, therefore, patients with varus neck shaft angle (⬍110°) are poor candidates.
Clinical Results Various authors have reported mixed clinical results with resurfacing hemiarthroplasty.9-16 Adili and Trousdale10 reported on clinical and radiographic results in 29 femoral head resurfacing procedures in 28 patients with osteonecrosis. The average age of the cohort was 31.6 years (range, 12-48 years). The Harris Hip Score improved from 48.1 before surgery to 79.3 at the last follow up. The survivorship was 75.9% at 3 years. Eight hips were converted to THA at an average 18 months (range, 8-43 months) after resurfacing.
Figure 2 Preoperative lateral radiograph of the same patient.
Figure 3 Preoperative MRI showing the extent of the lesion on left side.
The authors concluded that this procedure helps provide pain relief in these young patients. But the results were not as predictable as only 62.5% of patients were satisfied with the pain relief. All but one revision in the series were done for groin pain due to acetabular arthrosis. There was one revision due to fracture of the stem and one case of dislocation. The authors could not find any factor that was associated with a
Figure 4 Preoperative axial MRI image showing the extent of the lesion.
Is there a role for resurfacing hemiarthroplasty?
213 with hemiresurfacing. The overall survivorship was 79, 59, and 45% at 5, 10, and 15 years. Ten hips were revised for acetabular cartilage wear and 1 for femoral component loosening. The average time to conversion was 7.5 years. The authors concluded that a longer duration of symptoms before surgery is associated with a higher risk for failure even though the difference was not statistically different. In our own unpublished series of 37 resurfacing procedures in 29 patients, the mean survivorship was 72.6% at 4 years (Fig. 6). The Harris Hip Score improved from 53.8 preoperatively to 68.2 at 1 year and 64.2 at 4 years after surgery. There were 8 revisions to THA at a mean follow up of 16.6 months (range, 12-44 months); all of these were done for acetabular wear. We could not find any factor that could be associated with a higher risk of failure, such as age, gender, body mass index, etiology of osteonecrosis, prior surgery, preoperative necrotic arc angle, implant shaft angle, or continued steroid intake (Fig. 7). There were no cases of femoral neck fracture or dislocation. All revisions to THA were straightforward.
Fracture of the Femoral Neck
Figure 5 Radiograph 30 months after undergoing resurfacing on left side, patient had no pain and remained employed as a construction worker.
higher risk of failure. The authors also reported that they continue to offer this procedure to young patients with large necrotic lesions with the understanding that this procedure provides somewhat unpredictable pain relief. In a similar paper, Cuckler and coworkers9 reported on results of hemiresurfacing in 59 patients with ARCO stage 3 osteonecrosis. At a mean follow up of 4.5 years, 16 patients were considered failures due to conversion to THA or persistent groin pain. The only factor that correlated with revision was a low preoperative Harris Hip Score. The authors also reported that revision to THA was straightforward in most cases. Pain relief and recovery was less reliable than after THA. They concluded that this procedure was valuable to patients less than 30 years of age and advised that patients receive preoperative education about the expectations from the procedure in terms of pain relief. Hungerford and coworkers12 reported on 33 resurfacing procedures in 25 patients with ARCO stage 3 and 4 osteonecrosis. The survivorship was 91% at 5 years. Overall, 61% of patients had a good or excellent result according to the Harris Hip Score. Twelve revisions were done for groin pain and 1 for femoral component loosening. The mean duration between resurfacing and THA was 60 months. The authors could not detect any factor, such as age, gender, risk factor for osteonecrosis, or history of prior surgery, associated with a higher risk for revision. Beaule and coworkers14 reported on 37 hips with ARCO stage 2, 3, or early 4 osteonecrosis treated
Fracture of the femoral neck after resurfacing is a well-known complication. The reported incidence with hemiresurfacing is between 0 and 3%.9,17 The possible causes are notching of the femoral neck at surgery and varus placement of the implant. Female gender and osteoporosis are other known risk factors.17 Most fractures occur within the first few months after surgery. Careful attention to the surgical technique and proper patient selection are keys to avoid this complication. The selection criteria laid down for total resurfacing may be a useful guide to prevent this complication.18,19 The treatment of this complication is revision to a THA.
Present Status Since the introduction of resurfacing THA, resurfacing hemiarthroplasty is being performed less frequently. The primary reason for this is the incomplete pain relief afforded by this
Figure 6 Kaplan–Meier survivorship of the revision-free survival of resurfaced hips.
V. Sharma and E.Y. Cheng
214
procedure. The prime mode of failure is groin pain related to acetabular cartilage wear. History reveals that the results of a metal on articular cartilage articulation has been disappointing.20,21 Previous reports on the use of bipolar hemiarthroplasty for ARCO stage 3 osteonecrosis have shown poor midand long-term results.21,22 A central issue is the inability to detect microscopic changes in the articular cartilage of the acetabulum with various imaging studies and/or the naked eye at surgery.23 Even in the absence of early degenerative cartilage changes at the time of surgery, the metal on cartilage articulation may be associated with accelerated wear of the native cartilage. The durability of conventional THA is likely to improve due to recent advancements in the bearing surface technology. Ceramic bearings, highly crosslinked polyethylene, and metal on metal bearing surfaces are considered “alternative” bearing surfaces at this time but are rapidly coming into widespread use. Contrary to previous reports, the results of THA in patients with osteonecrosis are favorable and comparable to those in patients with osteoarthritis.24-28 Unfortunately, little advancement has been made at the basic science level to assess the health and condition of acetabaular articular cartilage either pre- or intraoperatively. This would facilitate patient selection and allow prediction of which patient is more appropriate for total hip replacement as opposed to femoral head resurfacing hemiarthroplasty. In our opinion, this procedure does have a select role in the management of young patients (adolescence to middle age) with noncollapsed osteonecrosis, acting as a bridge and delaying an eventual THA instead of allowing progression to end stage degenerative disease (Fig. 7). It preserves the native femoral head and neck, does not distort proximal femoral anatomy, provides reasonable pain relief with improved function, and side effects related to bearing surfaces such as osteolysis or metal ion exposure are avoided. This is especially important during childbearing years. Unfortunately, osteonecrosis at a young age continues to occur too frequently in patients. Etiologies are usually related to solid organ or bone marrow transplantation immunosuppression, lupus erythematosis, steroid treatment for asthma, ethanol usage, and trauma. This procedure can postpone the need for THA by many years in these young patients. Also revision to THA in the event of failure is uncomplicated and the results are comparable to primary THA.
References
Figure 7 Anterior-posterior pelvis radiographs of 26-year-old female with bilateral ONFH (A), after left hip surface replacement hemiarthroplasty (B), and 2 years later (C). Left hip is asymptomatic; right hip is painful with end stage degenerative disease.
1. Ito H, Kaneda K, Matsuno T: Osteonecrosis of the femoral head. Simple varus intertrochanteric osteotomy. J Bone Joint Surg Br 81:969-974, 1999 2. Jacobs MA, Hungerford DS, Krackow KA: Intertrochanteric osteotomy for avascular necrosis of the femoral head. J Bone Joint Surg Br 71:200204, 1989 3. Mont MA, Fairbank AC, Krackow KA, et al: Corrective osteotomy for osteonecrosis of the femoral head. J Bone Joint Surg Am 78:1032-1038, 1996 4. Scher MA, Jakim I: Late follow-up of femoral head avascular necrosis managed by intertrochanteric osteotomy and bone grafting. Acta Orthop Belg 65:73-77, 1999 (suppl 1) 5. Scher MA, Jakim I: Intertrochanteric osteotomy and autogenous bonegrafting for avascular necrosis of the femoral head. J Bone Joint Surg Am 75:1119-1133, 1993
Is there a role for resurfacing hemiarthroplasty? 6. Scully SP, Aaron RK, Urbaniak JR: Survival analysis of hips treated with core decompression or vascularized fibular grafting because of avascular necrosis. J Bone Joint Surg Am 80:1270-1275, 1998 7. Sugioka Y, Hotokebuchi T, Tsutsui H: Transtrochanteric anterior rotational osteotomy for idiopathic and steroid-induced necrosis of the femoral head: Indications and long-term results. Clin Orthop Relat Res 277:111-120, 1992 8. Smith-Petersen MN: The classic: Evolution of mould arthroplasty of the hip joint. by M. N. Smith-Petersen J. Bone Joint Surg 30B:L:59, 1948. Clin Orthop Relat Res 134:5-11, 1978 9. Cuckler JM, Moore KD, Estrada L: Outcome of hemiresurfacing in osteonecrosis of the femoral head. Clin Orthop Relat Res 429:146-150, 2004 10. Adili A, Trousdale RT: Femoral head resurfacing for the treatment of osteonecrosis in the young patient. Clin Orthop Relat Res 417:93-101, 2003 11. Mont MA, Rajadhyaksha AD, Hungerford DS: Outcomes of limited femoral resurfacing arthroplasty compared with total hip arthroplasty for osteonecrosis of the femoral head. J Arthroplasty 16:134-139, 2001 (suppl 1) 12. Hungerford MW, Mont MA, Scott R, et al: Surface replacement hemiarthroplasty for the treatment of osteonecrosis of the femoral head. J Bone Joint Surg Am 80:1656-1664, 1998 13. Grecula MJ, Thomas JA, Kreuzer SW: Impact of implant design on femoral head hemiresurfacing arthroplasty. Clin Orthop Relat Res 418: 41-47, 2004 14. Beaule PE, Schmalzried TP, Campbell P, et al: Duration of symptoms and outcome of hemiresurfacing for hip osteonecrosis. Clin Orthop Relat Res 385:104-117, 2001 15. Nelson CL, Walz BH, Gruenwald JM: Resurfacing of only the femoral head for osteonecrosis: Long-term follow-up study. J Arthroplasty 12: 736-740, 1997 16. Amstutz HC, Grigoris P, Safran MR, et al: Precision-fit surface hemiarthroplasty for femoral head osteonecrosis: Long-term results. J Bone Joint Surg Br 76:423-427, 1994
215 17. Shimmin AJ, Back D: Femoral neck fractures following Birmingham hip resurfacing: A national review of 50 cases. J Bone Joint Surg Br 87:463464, 2005 18. Schmalzried TP, Silva M, de la Rosa MA, et al: Optimizing patient selection and outcomes with total hip resurfacing. Clin Orthop Relat Res 441:200-204, 2005 19. Beaule PE, Dorey FJ, LeDuff M, et al: Risk factors affecting outcome of metal-on-metal surface arthroplasty of the hip. Clin Orthop Relat Res 418:87-93, 2004 20. Dalldorf PG, Banas MP, Hicks DG, et al: Rate of degeneration of human acetabular cartilage after hemiarthroplasty. J Bone Joint Surg Am 77: 877-882, 1995 21. Ito H, Matsuno T, Kaneda K: Bipolar hemiarthroplasty for osteonecrosis of the femoral head: A 7- to 18-year followup. Clin Orthop Relat Res 374:201-211, 2000 22. Cabanela ME: Bipolar versus total hip arthroplasty for avascular necrosis of the femoral head: A comparison. Clin Orthop Relat Res 261:5962, 1990 23. Steinberg ME, Corces A, Fallon M: Acetabular involvement in osteonecrosis of the femoral head. J Bone Joint Surg Am 81:60-65, 1999 24. Kim YH, Oh SH, Kim JS, et al: Contemporary total hip arthroplasty with and without cement in patients with osteonecrosis of the femoral head. J Bone Joint Surg Am 85A:675-681, 2003 25. Delank KS, Drees P, Eckardt A, et al: Results of the uncemented total hip arthroplasty in avascular necrosis of the femoral head. Z Orthop Ihre Grenzgeb 139:525-530, 2001 26. Schneider W, Knahr K: Total hip replacement in younger patients: Survival rate after avascular necrosis of the femoral head. Acta Orthop Scand 75:142-146, 2004 27. Phillips FM, Pottenger LA, Finn HA, et al: Cementless total hip arthroplasty in patients with steroid-induced avascular necrosis of the hip: A 62-month follow-up study. Clin Orthop Relat Res 303:147-154, 1994 28. Cheng EY, Klibanoff JE, Robinson HJ, et al: Total hip arthroplasty with cement after renal transplantation: Long-term results. J Bone Joint Surg Am 77A:1535-1542, 1995
T
reatment of Ficat stage 3 osteonecrosis continues to be a subject of debate. Proposed treatment options include bone grafting procedures, core decompression with or without vascularized bone grafting, and various proximal femoral osteotomies. All of these treatment options have met with varying success.1-7 Another head preserving procedure used infrequently is femoral head resurfacing hemiarthroplasty. The earliest of these procedures were done in the form of mold arthroplasty using various materials.8 There was no means of fixation of the prosthesis to the underlying bone. With the advent and success of Charnley’s low friction arthroplasty, this procedure was abandoned. Resurgence of interest in this procedure again occurred in the 1980s. This procedure was thought to be good for patients with early stage osteonecrosis (up to Ficat stage III) as it replaced only the diseased part, ie, the femoral head, and left the acetabulum undisturbed. Aseptic loosening remained a problem, however, as fixation and optimal positioning during implantation were unsolved issues. Resurfacing hemiarthroplasty is attractive as it is less invasive than bipolar hemiarthroplasty. Only the cartilage and subchondral bone of the diseased femoral head are replaced with a prosthesis (Figs. 1-5). Improvements in implant design, surgical technique, and instrumentation have enabled more reliable implantation and positioning of the device. Nonetheless, hemiarthroplasty is associated with residual groin pain. Resurfacing total hip arthroplasty (THA) likely would be associated with a lower incidence of groin pain but *Ranawat Orthopaedic Center, New York, NY. †Department of Orthopaedics, University of Minnesota, Minneapolis, MN. Address reprint requests to Edward Y. Cheng, MD, 2450 Riverside Avenue S., R 200, Department of Orthopaedics, University of Minnesota, Minneapolis, MN 55404. E-mail: [email protected]
1045-4527/07/$-see front matter © 2007 Published by Elsevier Inc. doi:10.1053/j.sart.2007.06.007
at the cost of resurfacing an otherwise healthy acetabulum. In addition, resurfacing THA using the improved devices was not approved by the United States Food and Drug Administration (FDA) until 2007. This review focuses on the expected outcome and indications for resurfacing hemiarthroplasty given the improvements in implant design and implantation as well as recent introduction of resurfacing THA in the United States.
Indications Patients who have osteonecrosis of the femoral head (ONFH) with a subchondral fracture, without development of acetabular arthrosis, are ideal candidates for femoral head resurfacing. However, the procedure is likely to fail rapidly if done in patients with visible evidence of acetabular cartilage wear either on preoperative imaging or at the time of surgery. Therefore, the use of magnetic resonance and computed tomographic imaging is important to identify the presence of early degenerative acetabular changes not otherwise visible.
Contraindications Any sign of acetabular degeneration, either on preoperative imaging or at surgery, should be considered a contraindication for hemiarthroplasty and an indication for THA using conventional or resurfacing implants. Patients with an expected remaining lifespan of 20 years or less are better served with conventional femoral stemmed implants instead of resurfacing implants as conventional THA has a high likelihood of being successful for the remainder of their lifetime. Another contraindication to femoral head resurfacing is lack of sufficient structural support for the device on the femoral 211
212
V. Sharma and E.Y. Cheng
Figure 1 Preoperative AP radiograph of 57 year old male with bilateral steroid induced osteonecrosis.
neck. Osteonecrosis or cysts involving more than 25 to 30% of the area of femoral head after reaming should be considered a contraindication. Finally, a varus position of the device is associated with a higher risk of loosening and, therefore, patients with varus neck shaft angle (⬍110°) are poor candidates.
Clinical Results Various authors have reported mixed clinical results with resurfacing hemiarthroplasty.9-16 Adili and Trousdale10 reported on clinical and radiographic results in 29 femoral head resurfacing procedures in 28 patients with osteonecrosis. The average age of the cohort was 31.6 years (range, 12-48 years). The Harris Hip Score improved from 48.1 before surgery to 79.3 at the last follow up. The survivorship was 75.9% at 3 years. Eight hips were converted to THA at an average 18 months (range, 8-43 months) after resurfacing.
Figure 2 Preoperative lateral radiograph of the same patient.
Figure 3 Preoperative MRI showing the extent of the lesion on left side.
The authors concluded that this procedure helps provide pain relief in these young patients. But the results were not as predictable as only 62.5% of patients were satisfied with the pain relief. All but one revision in the series were done for groin pain due to acetabular arthrosis. There was one revision due to fracture of the stem and one case of dislocation. The authors could not find any factor that was associated with a
Figure 4 Preoperative axial MRI image showing the extent of the lesion.
Is there a role for resurfacing hemiarthroplasty?
213 with hemiresurfacing. The overall survivorship was 79, 59, and 45% at 5, 10, and 15 years. Ten hips were revised for acetabular cartilage wear and 1 for femoral component loosening. The average time to conversion was 7.5 years. The authors concluded that a longer duration of symptoms before surgery is associated with a higher risk for failure even though the difference was not statistically different. In our own unpublished series of 37 resurfacing procedures in 29 patients, the mean survivorship was 72.6% at 4 years (Fig. 6). The Harris Hip Score improved from 53.8 preoperatively to 68.2 at 1 year and 64.2 at 4 years after surgery. There were 8 revisions to THA at a mean follow up of 16.6 months (range, 12-44 months); all of these were done for acetabular wear. We could not find any factor that could be associated with a higher risk of failure, such as age, gender, body mass index, etiology of osteonecrosis, prior surgery, preoperative necrotic arc angle, implant shaft angle, or continued steroid intake (Fig. 7). There were no cases of femoral neck fracture or dislocation. All revisions to THA were straightforward.
Fracture of the Femoral Neck
Figure 5 Radiograph 30 months after undergoing resurfacing on left side, patient had no pain and remained employed as a construction worker.
higher risk of failure. The authors also reported that they continue to offer this procedure to young patients with large necrotic lesions with the understanding that this procedure provides somewhat unpredictable pain relief. In a similar paper, Cuckler and coworkers9 reported on results of hemiresurfacing in 59 patients with ARCO stage 3 osteonecrosis. At a mean follow up of 4.5 years, 16 patients were considered failures due to conversion to THA or persistent groin pain. The only factor that correlated with revision was a low preoperative Harris Hip Score. The authors also reported that revision to THA was straightforward in most cases. Pain relief and recovery was less reliable than after THA. They concluded that this procedure was valuable to patients less than 30 years of age and advised that patients receive preoperative education about the expectations from the procedure in terms of pain relief. Hungerford and coworkers12 reported on 33 resurfacing procedures in 25 patients with ARCO stage 3 and 4 osteonecrosis. The survivorship was 91% at 5 years. Overall, 61% of patients had a good or excellent result according to the Harris Hip Score. Twelve revisions were done for groin pain and 1 for femoral component loosening. The mean duration between resurfacing and THA was 60 months. The authors could not detect any factor, such as age, gender, risk factor for osteonecrosis, or history of prior surgery, associated with a higher risk for revision. Beaule and coworkers14 reported on 37 hips with ARCO stage 2, 3, or early 4 osteonecrosis treated
Fracture of the femoral neck after resurfacing is a well-known complication. The reported incidence with hemiresurfacing is between 0 and 3%.9,17 The possible causes are notching of the femoral neck at surgery and varus placement of the implant. Female gender and osteoporosis are other known risk factors.17 Most fractures occur within the first few months after surgery. Careful attention to the surgical technique and proper patient selection are keys to avoid this complication. The selection criteria laid down for total resurfacing may be a useful guide to prevent this complication.18,19 The treatment of this complication is revision to a THA.
Present Status Since the introduction of resurfacing THA, resurfacing hemiarthroplasty is being performed less frequently. The primary reason for this is the incomplete pain relief afforded by this
Figure 6 Kaplan–Meier survivorship of the revision-free survival of resurfaced hips.
V. Sharma and E.Y. Cheng
214
procedure. The prime mode of failure is groin pain related to acetabular cartilage wear. History reveals that the results of a metal on articular cartilage articulation has been disappointing.20,21 Previous reports on the use of bipolar hemiarthroplasty for ARCO stage 3 osteonecrosis have shown poor midand long-term results.21,22 A central issue is the inability to detect microscopic changes in the articular cartilage of the acetabulum with various imaging studies and/or the naked eye at surgery.23 Even in the absence of early degenerative cartilage changes at the time of surgery, the metal on cartilage articulation may be associated with accelerated wear of the native cartilage. The durability of conventional THA is likely to improve due to recent advancements in the bearing surface technology. Ceramic bearings, highly crosslinked polyethylene, and metal on metal bearing surfaces are considered “alternative” bearing surfaces at this time but are rapidly coming into widespread use. Contrary to previous reports, the results of THA in patients with osteonecrosis are favorable and comparable to those in patients with osteoarthritis.24-28 Unfortunately, little advancement has been made at the basic science level to assess the health and condition of acetabaular articular cartilage either pre- or intraoperatively. This would facilitate patient selection and allow prediction of which patient is more appropriate for total hip replacement as opposed to femoral head resurfacing hemiarthroplasty. In our opinion, this procedure does have a select role in the management of young patients (adolescence to middle age) with noncollapsed osteonecrosis, acting as a bridge and delaying an eventual THA instead of allowing progression to end stage degenerative disease (Fig. 7). It preserves the native femoral head and neck, does not distort proximal femoral anatomy, provides reasonable pain relief with improved function, and side effects related to bearing surfaces such as osteolysis or metal ion exposure are avoided. This is especially important during childbearing years. Unfortunately, osteonecrosis at a young age continues to occur too frequently in patients. Etiologies are usually related to solid organ or bone marrow transplantation immunosuppression, lupus erythematosis, steroid treatment for asthma, ethanol usage, and trauma. This procedure can postpone the need for THA by many years in these young patients. Also revision to THA in the event of failure is uncomplicated and the results are comparable to primary THA.
References
Figure 7 Anterior-posterior pelvis radiographs of 26-year-old female with bilateral ONFH (A), after left hip surface replacement hemiarthroplasty (B), and 2 years later (C). Left hip is asymptomatic; right hip is painful with end stage degenerative disease.
1. Ito H, Kaneda K, Matsuno T: Osteonecrosis of the femoral head. Simple varus intertrochanteric osteotomy. J Bone Joint Surg Br 81:969-974, 1999 2. Jacobs MA, Hungerford DS, Krackow KA: Intertrochanteric osteotomy for avascular necrosis of the femoral head. J Bone Joint Surg Br 71:200204, 1989 3. Mont MA, Fairbank AC, Krackow KA, et al: Corrective osteotomy for osteonecrosis of the femoral head. J Bone Joint Surg Am 78:1032-1038, 1996 4. Scher MA, Jakim I: Late follow-up of femoral head avascular necrosis managed by intertrochanteric osteotomy and bone grafting. Acta Orthop Belg 65:73-77, 1999 (suppl 1) 5. Scher MA, Jakim I: Intertrochanteric osteotomy and autogenous bonegrafting for avascular necrosis of the femoral head. J Bone Joint Surg Am 75:1119-1133, 1993
Is there a role for resurfacing hemiarthroplasty? 6. Scully SP, Aaron RK, Urbaniak JR: Survival analysis of hips treated with core decompression or vascularized fibular grafting because of avascular necrosis. J Bone Joint Surg Am 80:1270-1275, 1998 7. Sugioka Y, Hotokebuchi T, Tsutsui H: Transtrochanteric anterior rotational osteotomy for idiopathic and steroid-induced necrosis of the femoral head: Indications and long-term results. Clin Orthop Relat Res 277:111-120, 1992 8. Smith-Petersen MN: The classic: Evolution of mould arthroplasty of the hip joint. by M. N. Smith-Petersen J. Bone Joint Surg 30B:L:59, 1948. Clin Orthop Relat Res 134:5-11, 1978 9. Cuckler JM, Moore KD, Estrada L: Outcome of hemiresurfacing in osteonecrosis of the femoral head. Clin Orthop Relat Res 429:146-150, 2004 10. Adili A, Trousdale RT: Femoral head resurfacing for the treatment of osteonecrosis in the young patient. Clin Orthop Relat Res 417:93-101, 2003 11. Mont MA, Rajadhyaksha AD, Hungerford DS: Outcomes of limited femoral resurfacing arthroplasty compared with total hip arthroplasty for osteonecrosis of the femoral head. J Arthroplasty 16:134-139, 2001 (suppl 1) 12. Hungerford MW, Mont MA, Scott R, et al: Surface replacement hemiarthroplasty for the treatment of osteonecrosis of the femoral head. J Bone Joint Surg Am 80:1656-1664, 1998 13. Grecula MJ, Thomas JA, Kreuzer SW: Impact of implant design on femoral head hemiresurfacing arthroplasty. Clin Orthop Relat Res 418: 41-47, 2004 14. Beaule PE, Schmalzried TP, Campbell P, et al: Duration of symptoms and outcome of hemiresurfacing for hip osteonecrosis. Clin Orthop Relat Res 385:104-117, 2001 15. Nelson CL, Walz BH, Gruenwald JM: Resurfacing of only the femoral head for osteonecrosis: Long-term follow-up study. J Arthroplasty 12: 736-740, 1997 16. Amstutz HC, Grigoris P, Safran MR, et al: Precision-fit surface hemiarthroplasty for femoral head osteonecrosis: Long-term results. J Bone Joint Surg Br 76:423-427, 1994
215 17. Shimmin AJ, Back D: Femoral neck fractures following Birmingham hip resurfacing: A national review of 50 cases. J Bone Joint Surg Br 87:463464, 2005 18. Schmalzried TP, Silva M, de la Rosa MA, et al: Optimizing patient selection and outcomes with total hip resurfacing. Clin Orthop Relat Res 441:200-204, 2005 19. Beaule PE, Dorey FJ, LeDuff M, et al: Risk factors affecting outcome of metal-on-metal surface arthroplasty of the hip. Clin Orthop Relat Res 418:87-93, 2004 20. Dalldorf PG, Banas MP, Hicks DG, et al: Rate of degeneration of human acetabular cartilage after hemiarthroplasty. J Bone Joint Surg Am 77: 877-882, 1995 21. Ito H, Matsuno T, Kaneda K: Bipolar hemiarthroplasty for osteonecrosis of the femoral head: A 7- to 18-year followup. Clin Orthop Relat Res 374:201-211, 2000 22. Cabanela ME: Bipolar versus total hip arthroplasty for avascular necrosis of the femoral head: A comparison. Clin Orthop Relat Res 261:5962, 1990 23. Steinberg ME, Corces A, Fallon M: Acetabular involvement in osteonecrosis of the femoral head. J Bone Joint Surg Am 81:60-65, 1999 24. Kim YH, Oh SH, Kim JS, et al: Contemporary total hip arthroplasty with and without cement in patients with osteonecrosis of the femoral head. J Bone Joint Surg Am 85A:675-681, 2003 25. Delank KS, Drees P, Eckardt A, et al: Results of the uncemented total hip arthroplasty in avascular necrosis of the femoral head. Z Orthop Ihre Grenzgeb 139:525-530, 2001 26. Schneider W, Knahr K: Total hip replacement in younger patients: Survival rate after avascular necrosis of the femoral head. Acta Orthop Scand 75:142-146, 2004 27. Phillips FM, Pottenger LA, Finn HA, et al: Cementless total hip arthroplasty in patients with steroid-induced avascular necrosis of the hip: A 62-month follow-up study. Clin Orthop Relat Res 303:147-154, 1994 28. Cheng EY, Klibanoff JE, Robinson HJ, et al: Total hip arthroplasty with cement after renal transplantation: Long-term results. J Bone Joint Surg Am 77A:1535-1542, 1995