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Hip resurfacing may not be indicated for patients with osteonecrosis
Case series reveals a 10.6% failure rate with hip resurfacing in patients with osteonecrosis.
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A single-surgeon case series of patients with osteonecrosis undergoing resurfacing showed poor implant survival, and surgeons at the institution now consider osteonecrosis a contraindication to hip resurfacing.
“The predominant mode of resurfacing failure in this diagnosis is further collapse of the femoral head,” Joseph Daniel, FRCS, of the McMinn Centre in Birmingham, United Kingdom, told Orthopedics Today. “It is recognized that etiologies such as steroid- or ethanol-induced osteonecrosis tend to recur in the years after a resurfacing, leading to continuing collapse of the femoral head and a failure of the resurfacing.”
Daniel presented the 5- to 15-year results of 104 hips (95 patients) with severe femoral head osteonecrosis treated with hip resurfacing at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons in New Orleans. Patients were a mean age of 43 years (range, 18-68 years) — a decade younger than the mean age of patients in other resurfacing series, according to Daniel. Derrick McMinn, FRCS, performed the resurfacing procedure on all patients using two types of devices and a posterior approach.
Worse failure rate
Three patients died before follow-up due to unrelated causes, and two were lost to follow-up, Daniel said. Thirteen patients did not attend the follow-up review. Patients with implant survival had a mean Oxford hip score of 17; the best score among these patients was 12. Daniel and his colleagues found 11 failures, including one femoral neck fracture, seven further collapsed femoral heads, two deep infections and one aseptic cup loosening. According to Daniel, the majority of patients who failed had steroid-induced avascular necrosis.
A Kaplan-Meier analysis revealed an 88% survivorship at 15 years. “When we compare it with other diagnoses, osteonecrosis is significantly worse,” Daniel said. “When we compare it to osteoarthritis treated with hip resurfacing, it is even worse.”
Daniel said that resurfacing has worked for patients with osteoarthritis, because osteoarthritis is a surface problem. However, the same techniques may not work for osteonecrosis, because it affects the substance of the bone.
Osteonecrosis
“The problems with osteonecrosis are that … it can jeopardize the life of any device, the etiology can be recurring, there can be technical challenges, [and there is] nearly a five times higher infection rate and nearly a 10-times higher femoral head collapse rate.”
Daniel said he and his colleagues at the McMinn Centre no longer perform hip resurfacing in patients with osteonecrosis.
“Careful patient selection and precise operative technique are vital to success with hip resurfacing,” he told Orthopedics Today. “In patients with poor-quality femoral head bone or those with femoral head osteonecrosis, a device that is less reliant on the integrity of the femoral head bone is needed. In young patients with such femoral head lesions, a neck-preserving proximal load-bearing short-stem device that does not invade the medullary canal of the femur is the ideal option. [In the case of failure,] conversion to a total hip replacement is required.” — by Tina DiMarcantonio
Reference:
- Daniel J, Pradhan C, Ziaee H, et al. Osteonecrosis: A substance problem rather than a surface disease. Is resurfacing a viable solution? Paper 481. Presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons. March 9-13, 2010. New Orleans.
- Joseph Daniel, FRCS, can be reached at The McMinn Centre, 25 Highfield Road, Egbaston, Birmingham B15 3DP, United Kingdom; 44-121-455-0411; e-mail: mr.jdaniel@yahoo.co.uk.
- The McMinn Centre receives institutional research support from Smith and Nephew Orthopedics UK Ltd and one of the authors, Derek McMinn, is a consultant to Smith & Nephew Orthopaedics UK, Ltd.
