and necrotic bone. Fig. 3c. The pin is then removed and low-viscosity cement is injected, using a cement gun. .... a pregnancy. Before operation seven patients.
AVASCULAR
NECROSIS
SICKLE-CELL
DISEASE
TREATMENT
OF
P. HERNIGOU, From
D.
the Henri
In ten
COLLAPSE
BACHIR,
Mondor
patients
BY
hips with articular
a radiographic surface due
FEMORAL
INJECTION
OF
injection
disease,
used
we
for the treatment
crescent to avascular
a new
line or flattening necrosis. The
of the necrotic
and overlying cartilage are elevated by the injection to restore the sphericity of the femoral head. Five days after the operation, full weight-bearing was allowed with for three
The time in hospital blood loss was 100 ml. postoperative
shape
weeks.
showed
improvement
in
the
At a mean follow-up were still improved
Only
two hips had required
of 5 years (3 to 7), 14 of the 16 although some gave slight pain. revision
years
at one year and two The increasing
to totalhip
arthroplasty,
of patients
with
of the risks of infection, high blood loss, Cement injection does not have these
loosening. and allows JBoneJoint
for earlier, Surg[BrJ
2 February
Received
more
1993;
1993
conservative
75-B
sickle-cell
total that
hip
head.
1993
new We
hips) When collapse has occurred femoral head, it is generally will lead to osteoarthritic (SCD) is the most common
in black a rapidly expectancy
in avascular necrosis of the agreed that the deformation changes. Sickle-cell disease cause offemoral head necrosis
people (Hernigou et al 1989, 1991) and presents growing problem in a disease in which life is increasing. Opinions on the treatment of
men
bone
in 16 hips
Paris
MD,
Professor
of
Orthopaedic
Surgery,
University
D. Bachir, MD, Consultant, Centre for Sickle-cell Disease F. Galacteros, MD, Professor of Medicine, University of Paris Centre for Sickle-cell Disease H#{244}pitalHenri Mondor, 94010 Cr#{233}teil,France.
SI Avenue
Correspondence
be sent
should
©l993 British Editorial Society 0301 -620X/93/666l $2.00
VOL.
of
XII
75-B,
No. 6, NOVEMBER
du Mar#{233}chal de Lattre
to Professor of Bone
1993
P. Hernigou. and
Joint
Surgery
XII,
de Tassigny,
two
treatof most such as
confirmed
the
articular
the injection of of the femoral
in ten patients
caused
who
by SCD.
METHODS suitable for this operation were of 160 adult SCD patients who had
and
investigated
Of these, 52 had developed as children and have been et al 1991). Twenty-one necrosis injection.
and
of the hip All gave
for bone avascular previously patients
as adults and their informed
compli-
necrosis of reported developed were treated consent for
procedure. now eight
report
the
results
up for at least women
and
three their
in the years. average
ten
patients
There age
was
were
(16 two
33 years
(23 to 34) at the time of surgery. Six patients had HB 55 disease, 3 had SC disease and one had an 5-thal variant; the average follow-up is 5 years (3 to 7). Preparation for operation. Before operation, each patient had an exchange transfusion to bring the concentration of haemoglobin S or HbS + C to less than 30%, and to raise the haematocrit to about 40%. Most were anaemic and none could have been autotransfusion. During the operation
P. Hernigou,
between
been
elevated by the sphericity
to collapse
The patients from a group
followed
however,
: necrotic
due
AND
followed and
vary
of all surgical
has a poor prognosis in SCD. surgical treatment for hips at the
the results
pain
closely
in SCD
It has,
collapse
We report severe
PATIENTS
the
29 April
arthroplasty.
overlying it are cement to restore
avascular by cement
surgery.
hip
avoidance
of the generally poor condition others advise radical early surgery
of early
cartilage acrylic
been
and early problems
of the
suggest
total hip replacement We describe a new
cations. the hip (Hernigou
:875-80.
; Accepted
necrosis
Patients. selected
respectively.
longevity
disease means that avascular necrosis will be an increasing problem. Total hip replacement has a poor prognosis
because
IN
CEMENT
: some
ment because patients, but
had
head.
hips
avascular
stage
averaged eight days; the average There was early pain relief and
radiographs
of the femoral
ACRYLIC
extremes
of 16 painful
bone
the help of crutches
HEAD
Cr#{233}teil,France
sickle-cell
ofcement
THE
THE
F. GALACTEROS
Hospital,
with
technique
OF
following maintained Blood-gas by pulse prophylaxis Operative position the hip
of the patients a candidate for and for the
48
to 72 hours, intravenous hydration was and oxygen was given by the nasal route. levels were monitored by laboratory tests and oximetry. The patients were given antibiotic for ten days. technique. The patient is placed in a supine on a fracture table and the is exposed by a Smith-Petersen
anterior capsule of approach, using a
875
876
P. HERNIGOU,
Fig. The operation is performed T-shaped capsular incision
D. BACHIR,
F. GALACTEROS
la
Fig.
on a fracture (b) with care
table. The hip is exposed by a Smith-Petersen to preserve the blood supply to the femoral
Fig. The
area
ofcollapse
is surrounded
by folded
articular
neck
lb
approach and head.
(a) and
a
2b
cartilage.
fascia lata (Fig. 1 a). In exposing and opening the capsule, care is taken to preserve the anterior circumferential artery. A T-shaped incision in the capsule exposes the
A pin is then driven in from the anterior neck to reach the junction of the living bone and the necrotic segment. Leverage on this pin elevates the necrotic bone and visibly reduces the collapse (Fig. 3). The pin is removed and replaced by a cannula through which lowviscosity cement (Cerafix ; Ceraver Osteal, Roissy Ch. de
anterior
Gaulle,
skin incision from about superior iliac spine, along and down over the groove
head
femoral (Fig.
The
neck
surface
for alteration and
obvious
: the articular
but the pressure
area on
for
of the
the
femoral
in its colour
softening.
femoral
The
cartilage
head
and
necrotic
overlying
is then
contour,
zone
for
is usually
it looks
normal
by a furrow or a fold. Gentle which retains its elasticity,
but this recovers like a piano key This mobility is due to the presence
a subchondral and subchondral from
of
is surrounded this cartilage,
causes depression ping-pong ball.
separation
part ofthe
France)
injection
articular
examined
bone
and the anterior
I b).
erosion
either tilage
7 cm behind the anterior the outer lip of the iliac crest between sartorius and tensor
fracture bone
a larger living
separating from necrotic
segment bone
beneath
of
articular bone,
necrotic it (Fig.
caror the
cancellous 2).
or a of
the
articular
whole and
periphery surface sites.
the
capsule
a suction After
mobilise days.
is repaired drain. operation,
the The
has
of the of the It may
hip and
use ofcrutches
THE
with
a cement
or repeated been
area
be necessary
into the subchondral is complete and the
over
injected
cartilage
it may
of the several
is
is continued
until corrected
head also
hip
and to repeat be necessary
of
4). The
cannot
the
The
collapse (Fig.
of collapse
to rotate
gun.
the
be seen,
to expose
more
the injection at to inject cement
fracture (Fig. 5). When the injection shape of the head has been restored
and
the
the
patient
wound is
weight-bearing continues
JOURNAL
closed
in layers
encouraged
is allowed for three
OF BONE
AND
after
to five
weeks.
JOINT
SURGERY
AVASCULAR
The depressed thejunction
NECROSIS
segment can be lifted by leverage ofliving and necrotic bone.
OF
on a pin
THE
driven
FEMORAL
HEAD
IN
SICKLE-CELL
in at
Fig.
The pin is then removed and low-viscosity is injected, using a cement gun. The segment is now restored to position and
Assessment.
For
the
also be needed into head with avascular
preoperative
performed included raphy
VOL.
the Trendelenburg plain radiography or CT
75-B,
(or
both)
No. 6, NOVEMBER
assessment
fracture
we
1969). We also measured and the limb lengths and
test. Imaging of all patients and
of six patients;
1993
the subchondral necrosis.
clinical
used the Harris hip score (Harris the range of motion of the hip
3c
cement collapsed is stable.
Fig.
Injection of cement may demonstrated in a femoral
877
DISEASE
the
last
studies tomogmethods
superficial
were
used
collapse. We avascular hips had were all
to the
when use the necrosis collapse at stage
main
there
fragment
was
4b
of necrotic
difficulty
bone.
This
in demonstrating
is
the
Ficat and Arlet (1980) staging of of the femoral head, but since all 16 but no secondary osteoarthritis, they III. The sphericity of the femoral
P. HERNIGOU,
878
head
was
measured
on
the
anteroposterior
radiographs, using Mose (1980) loss of sphericity in millimetres. Postoperatively,
we
D. BACHIR,
and
templates
and
lateral
recording
the
appearance
of subchondral
sclerosis,
graded
improvement
through
cysts,
or narrowing
according
and Ponseti follow-up. was taken
was
not
lost
more
latest
recorded
osteophytes,
of the joint
to the classification
by the
abduction
and
operation some
and
flexion
eight
hips
by the
time
had of the
follow-up.
Shape
of the head.
showed
a crescent
was 3 mm radiographs
Preoperatively,
all the
line and the average
femoral
heads
loss of sphericity
(1 to 5 ; Fig. 6a). Postoperatively, showed an improvement in shape
the early (Fig. 6b),
sub-
space
ofBoyer,
improved
Radiology
in the
shape of the femoral head by the disappearance of the crescent line and the general improvement in shape. The postoperative radiographs were also studied for evidence of progression of the infarct, recurrence of collapse, and any degenerative changes. Degenerative changes such as chondral
F. GALACTEROS
were
Mickelson
(1981), on the radiographs made at the latest The measurement of the superior joint space as the distance between the cortices on a line
the
mid-point
of
the
femoral
head
drawn
perpendicular to the line joining the lowest points of the two tear drops (Armbuster et al 1978). A superior joint space of less than 3 mm was recorded as evidence of osteoarthritis.
RESULTS No patient had haematological complications : there were no painful sickle-cell crises, and no problems of thrombosis or anaemia. The average duration of the operation, one hour. No patient
were
from induction of extradural anaesthesia was The average blood loss was 100 ml (50 to 250). required postoperative transfusion and there
no wound The
time
was
eight
days,
scored
more
it was than
85 (73
to 95).
Of the
16 hips,
recurrent required
and were regarded two worst patients had both required total hip
The year;
Size
there
arthroplasty. The ing pain. the pain has been since
the
operation
was
particularly
successful
clear improvement decrease in hip
mobility.
Some
assessment
but
they
all still
over their preoperative score was mainly due
patients
have
some have pain when they position and some complain
slight
stand up of aching
operation seven patients pain ; no patient needed four patients walked with Before and
abduction
surgery,
there
with a
on walking,
from a sitting in the groin or
thigh after prolonged exercise. In no case does the pain limit activity or necessitate medication. One patient had a transient increase in pain during a pregnancy. Before walked
with
a cane
a cane
after
surgery
to relieve and
only
was
usually
but not offlexion.
The
loss of hip range
rotation
of movement
the
crescent
1 mm
in
infarct.
relief
6b
head. years
line
all
and
16 hips.
no change from smallest infarcts flattening of the still
In the
Figure 6b after cement
loss At
-
of
latest
postoperative in the series. femoral head,
had a better geometrical The other two hips had
sphericity
14 hips
of did
which
5 mm) not
in the size of the infarct. changes. At the latest follow-up,
and
collapse,
was no change slight space
recurrent
the time Failures. of
eight
degenerative to less than
changes, with reduction 3 mm in four. The two
collapse
had definite
both
of total hip arthroplasty. The two hips in which
arthroplasty, operations and there operation. improved.
pain
after at
cement
one
were
and
there
performed
years
by the
of hips
osteoarthritis was
injection two
hips
at
no immediate both
required
respectively.
posterior
The
approach
were no difficulties related to the previous In both cases pain relief and mobility were The removed femoral heads were examined histologically and showed typical changes of avascular necrosis with sickling of red blood cells. Both showed the histopathological changes of recurrent necrosis (Inoue and
a limp.
ofthe
showed the joint
state. This loss of hip
to
pain
show
than
collapse (loss of total hip arthroplasty.
Degenerative
in reliev-
All 16 hips caused severe pain before operation; was relieved immediately after surgery. There some deterioration in the scores in eight hips one-year
of
less
of the femoral femoral head five
but no crescent line, and shape than preoperatively.
two
at 5 years
91 points
as having excellent results. scores of 73 and 75 at one
of
follow-up, six hips showed sphericity; they had the Eight hips showed some
which
included the time spent in haematological preparation. Clinical assessment. Before operation, the mean Harris hip score was 60 points (50 to 75). At the latest follow-up at 3 to 7 years,
Fig.
disappearance
sphericity in hospital
6a
Figure 6a - Preoperative collapse Improved sphericity of the same injection.
with
infections.
average
Fig.
Ono
the marrow was
found
1979)
and
(Saito, both
also
Inoue
beneath
THE
signs
of old
and Ono the
JOURNAL
haemorrhage
1987).
articular
OF BONE
cartilage
AND
into
Acrylic
JOINT
cement and
under
SURGERY
AVASCULAR
NECROSIS
OF
THE
FEMORAL
to
determine
whether
they
or
due
were to
related
of
to the presence
extension
of
the
with
SCD,
osteonecrosis
of the
hip
hip replacement; head (Chung
reported, have
operations and Ralston
partly a poor
because life
which preserve 1969) have
these
patients
expectancy.
however, has a bad prognosis increased risks of infection and Recent advances in the
of their been total
the femoral rarely been
were
Total
hip
thought
to
because
of the
of
SCD
will
improve survival, and there will therefore be a greater place for conservative surgery when the condition of the joint still allows it. When collapse has
trochanteric
osteotomy
results
because
union.
Some
head
decompression osteotomy
have
(Ficat are not (Sugioka
of difficulties
methods been
and Arlet effective, 1978)
with These
1980) and and trans-
has
fixation
of reconstruction
reported.
given
poor
and
delayed
of the
femoral
include
the
use
of
autologous iliac bone grafts combined with a musclepedicle bone graft (Meyers 1978), a vascularised fibular graft with multiple drilling (Judet, Judet and Gilbert 198 1 ), and
these
muscle
techniques
pedicle
require
bone
grafts
a period
and for patients with multiple many previous hospital admissions, which allows early weight-bearing
(Baksi
1 99 1 ). All
of non-weight-bearing, medical problems and a simpler treatment seems more appro-
priate. When
collapse
first
occurs
hip
in avascular
necrosis,
the
a fold
bone.
The injection of low-viscosity restores sphericity and
these spaces provides immediate
immobilisation
necrotic
crescent and living
VOL.
75-B,
No. 6, NOVEMBER
1993
cement cartilage
in
cement
has
for example (Eckardt and
further
collapse
failure
ofthe
of
cement
for our patients and our results those reported for
SCD.
a complication
(1978)
Clarke
et
al
(1989)
followed
rates
for
are
rate
3.3
27%
arthroplasty revised. Epps of
years.
for and
63%
Other
(Gunderson,
at an average follow-up of five years treated by cement injection, had hip those achieved by total hip arthroplasty
in
45
reported
D’Ambrosia
had
needed
Cement
injection
treatments
in time
and
used
delay
that
without the
loss
for osteonecrosis
of
does
technique
One
and
stages
the
of
authors
from
(PH)
other
and Goutallier 1992). availability of CT and
to identify avascular
separated
cement and
hip
should
with
injection
congruity
for
immediate symptomatic relief later revision to total hip
for osteonecrosis
Hernigou The recent
of the cartilage
of
total
; they
of SCD
change,
concentricity
It provides not jeopardise
and
methods, of necrosis.
stages
arthritic
years.
arthroplasty. 1990;
for different
conclude but
several and
revision.
14 of the 16 hips scores as good as in SCD and only
arthroplasty are not competititve rather be viewed as complementary
two
it possible
will have deleterious near ajoint surface
resection had been
and Shoji 1977), 100% (Hanker and Amstutz 1988), and 49% (Acurio and Friedman 1992). Our own experience of total hip arthroplasty for SCD (Hernigou et al 1989) includes 1 1 patients followed for between 1 .5 and 10 years. Four have needed further operations, three for mechanical loosening and one for late sepsis. By contrast,
into and for the may be
had
arthroplasties complication
cement congruity,
bone. This is the probable explanation immediate symptomatic improvement, but there an element of decompression as well. It may be thought that effects on bone and articular
the
when the hip is in the retains some elasticity This mobility is due to
the collapse of bone about the subchondral fracture, and between the deeper necrotic bone ‘repair’
arthroplasty
Castro
can
or
from
or mechanical
needed others
opposite
a furrow
but resulted bone
years, three had infection, and four
being
by
but
reporting 17 total hip arthroplasties for SCD followed for than two years (mean 5.5) had a revision rate of 59% (10 hips); revision was required after an average period of only 43 months. Bishop et al (1988) reported 13 total hip arthroplasties ; at an average follow-up of seven
We collapse
edge of the acetabulum position. The cartilage be sprung by pressure.
1987),
by loosening or fracture. The only alternative treatment would have been joint replacement, should therefore be compared with
normal and The necrotic commonly
surrounded
Jessee
articular cartilage before, of giant-cell tumours
cartilage,
the subchondral
articular cartilage is usually macroscopically the acetabulum is not affected (Cruess 1977). zone of the femoral head is easily located, anterior extended and can
and
more
considerably
occurred, core intertrochanteric
used under the curettage
total
replacement,
in SCD loosening. treatment
been after
879
DISEASE
Cardea
articular
is a cause
of chronic severe pain and further deterioration quality of life. The commonest treatment has
SICKLE-CELL
Grogan 1986), and it has in some cases been left in place for several years without adverse effects. The articular cartilage is nourished from the synovial fluid and may therefore remain histologically and biochemically normal. We think that the joint-space narrowing in our patients was not due to the presence of cement under the
original
DISCUSSION In patients
IN
(Rutherford,
the area ofnecrosis ; the cement masses were encapsulated within a thin connective tissue membrane. Some areas recent marrow necrosis were seen, but it was impossible of the cement pathology.
HEAD
subchondral necrosis
has
causes MRI
fractures ; early
used
the
(Hernigou now
makes
in the
treatment
may
early be
advisable.
No benefits commercial article.
in any party
form have been related directly
received or will be received or indirectly to the subject
from a of this
880
P. HERNIGOU,
D. BACHIR,
F. GALACTEROS
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THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
