Vascularized Iliac Bone Graft with Rotational Osteotomy of the Femoral Head for Extensively Large Collapsed Lesions of Necrosis of the Femoral Head

Introduction: The treatment of osteonecrosis of the femoral head should attempt to preserve the femoral head in young patients. But it is difficult to treat the advanced and extensive lesions of the disease. We performed a combined procedure of transtrochanteric rotational osteotomy and vascularized iliac bone grafting in cases of osteonecrosis of the femoral head with an extensive and widely collapsed necrotic lesion in young patients. We postulated that this procedure would restore congruence of the joint surface with the osteotomy, and that the vascularized bone would restore sufficient viability to maintain support against weight-bearing forces. This paper reveals the long-term results of this combined procedure for this difficult condition.

Methodology and Material: The combined operation was performed in 17 hips in 17 patients (11 males and 6 females). The age at surgery ranged from 16 to 53 years old with an average of 31 years. Eleven patients had a history of administration of steroid drugs, and 2 patients had a history of alcohol abuse, while remaining 4 had no apparent history (idiopathic). Only 5 patients had affected unilateral hips, and the others had necrotic lesions on both sides. Follow-up periods ranged from one to 22 years with an average of 11 years.

Results: The average Harris hip scores at final follow-up was 77 points. Twelve of the 17 hips showed progressed degeneration or collapse, and six of them were replaced with artificial joints. The survival rate of the procedure with lost follow-up or joint replacement surgery as the end point was 76% at 15 years, and 41% at 20 years.

Four joints were replaced with artificial joints before 5 years after the combined operation. And the remaining 2 joints were replaced at 16 years and 19 years after combined operation.

Conclusions: The combined operation was useful for very young patients who had extensively large lesions with collapse in terms of “time-saving.” But if enough intact portion is available, some osteotomies are preferable. Recently, artificial joint replacement has become durable for the long-term. We now have very few opportunities for this combined operation, especially in older patients