EVALUATION OF DIFFERENT MODALITIES OF SURGICAL TREATMENT FOR AVASCULAR NECROSIS OF THE FEMORAL HEAD IN BASRAH

This prospective study was done in Basrah General Hospital, from June 2009 to December 2011. It included 92 hips in eighty one patients affected clinically and radiologically by femoral head avascular necrosis. They were 50 males and 31 females, mean age 41 years with a range of 15-67 years with stage II-IV of femoral head AVN according to Ficat and Arlet radiological staging system. The aims of this study are; to know the pattern of avascular necrosis of the femoral head, and to evaluate the outcome of the different surgical modalities. Surgery was conducted in form of; group I includes twenty four hips (24.4%) which were treated by core decompression (12 hips =12.2% by multiple small drilling (group I-a); seven patients were satisfied with the result of surgery. Infection was reported in one patient. Twelve hips =12.2% by wide bore drilling "gutter" and bone graft(group I-b); nine patients were satisfied by the result of surgery). Group II includes fifty three hips (54.1%) which were treated by total hip arthroplasty (25=25.5% cemented THR (group II-a); seventeen patients were satisfied with the procedure; Complications were reported in three cases, and 28=28.6% cementlessTHR (group II-b); twenty one patients were satisfied; complications had been encountered in five cases); five patients had bilateral hip surgery. Group III includes twenty one hips (21.4%) which were tackled by Girdlestone (resection arthroplasty); six patients had bilateral hip surgery. Only nine patients were satisfied with this procedure. In conclusion, core decompression surgery in form of wide bore drilling with bone graft is suitable treatment for early stages of avascular necrosis. Total hip replacement is suitable option for AVN in advance stage. Resection arthroplasty still is an option for patients in certain situations (e.g. infection), although the results were less favorable. Introduction steonecrosis of the femoral head is a challenging disorder often occurring in young patients in the third through fifth decade of life 1 ; if left untreated, it leads to complete deterioration of the hip joint 2-4 . Despite advances in the understanding of the pathogenesis and etiology of this disease, non-traumatic osteonecrosis remains a challenging diagnostic and therapeutic dilemma 5,6 . The natural history of non-traumatic osteonecrosis has been well documented 4,7-10 , and a high rate of progression has been reported when non-operative treatment alone has been used for symptomatic patients 4,8,11,12 . Given the relatively young age at the time of presentation and the poor long-term results that have been reported after total hip arthroplasty in this population of patients, preservation of the joint is recommended for patients who have early-stage disease 13-16 . Patients & Methods This is a prospective study which was conducted in orthopedic department at Basrah General Hospital and Ibn-AlBaitar Private Hospital, from June 2009 to O Evaluation of treatment of avascular necrosis of femoral head Rafid Yaseen, Thamer Hamdan &, Haider Alzahid Bas J Surg, March, 18, 2012 8 December 2011. Ninety two hips in 81 patients (50 males and 31 females) their ages ranged from 15-67 years (mean age 41 years), presented with different stages of femoral head avascular necrosis were studied. Eleven patients had bilateral hip involvement and in the remaining 70 patients the involvement was unilateral. The data were recorded including the age at presentation, gender, duration of symptoms before presentation, and associated risk factors. Patients were evaluated preoperatively on the basis of the medical history, the results of physical examination, and anteroposterior radiographs. Preoperative magnetic resonance imaging studies were performed for forty seven patinets. The extent of radiographic involvement of the disease was assessed quantitatively with use of a Ficat and Arlet staging system 17 . All patients were consented. All surgeries had been done under general anesthesia; antibiotics were given at time of anesthesia induction and were continued for 3-5 days postoperatively. A.group I (core decompression): twenty four patients; procedure was done through lateral incision then the portal of entry was 2.5 cm below the greater trochanter; for multiple drilling procedures 3-4 holes by 3.2 mm pit was done, while those for wide bore core decompression single hole by 8 mm pit was done under image, and the defect was filled by cancellous bone graft from upper ipsilateral tibia. Patients kept for 2-3 days in hospital then discharged and instructed to avoid putting weight on the hip underwent surgery for 6 weeks while maintaining isometric exercise with muscle strengthening physiotherapy. High-impact loading such as jogging and jumping was not permitted for 12 months, squatting position (eastern toilet sitting position) also to be avoided. The patients were seen two weeks later for removal of stitches. Patients were encouraged to partial weight bearing after the 6th week postoperatively after clinical and radiological evaluation. Then the patients were seen periodically in three, six then twelve months. Figure (1). B.group II (total hip arthroplasty): fifty three patients; most of them approached by lateral incision apart from three patients approached by posterior incision and six patients by anterolateral approach (i.e. surgeries done in a standard way). Adductor tenotomy was done for 5 hips. After capsulotomy and hip dislocation, then excision of the femoral head, to start with acetabular reaming and fitting of acetabular cup then femoral reaming and fitting of the femoral stem, methyl methacrylate cement used for twenty five patients, the anesthesiologists were informed at time of reaming and application of bone cement. Thrombolytic drug was given 6 hours postoperatively in form of low molecular weight heparin "enoxaparin" (4000 I.U/day subcutaneously) and continued for five days, (we reported only one case of DVT which was managed successfully), then at morning the day after surgery, the patients were encouraged to sit in the bed and starting isometric exercise with muscle strengthening physiotherapy. The patients usually sent for radiography while maintaining proper transfer, then discharged and instructed to avoid weight bearing for six weeks, to be seen two weeks later for removal of stitches, After six weeks the patients encouraged for partial weight bearing using the assistive devices after clinical and radiological evaluation, while for patients with cemented THR early (within few days) weight bearing was the target, squatting position (eastern toilet sitting position) to be avoided. Then the patients were seen periodically in three, six then twelve months. We reported seven cases of hip dislocation which were managed successfully (five hips by manipulation under anesthesia using image and two hips by open reduction). Figure (2). C.group III (Girdlestone excisional arthroplasty): In twenty one patients who were treated by Girdlestone excisional Evaluation of treatment of avascular necrosis of femoral head Rafid Yaseen, Thamer Hamdan &, Haider Alzahid Bas J Surg, March, 18, 2012 01 arthroplasty; anterolateral approach was used in 15 hip operations (according to surgeon preference), lateral approach in four patients, posterior approach in one patient and anterior approach in one patient, with average time 45 mints for each hip. In six patients with bilateral AVN, surgery was done in one session. Postoperatively skin traction used in 19 hips and skeletal traction in 2 hips (obese patients), with 4-5 kg weight for 4-6 weeks. The patients were discharged after 5-7days with their traction to be continued at home. Although the patients were kept on 6 weeks traction. In all patients, physiotherapy was started 6 weeks after operation in form of walking reeducation and muscle strengthening exercise for 6 weeks. The patients were followed through 3 weeks visits. During follow up visits the patients were evaluated clinically for pain, sign of infection, shortening, unstable gait and radiologically to assess the proximal migration of femur. Figure (3). Statistical analysis of data was done to evaluate the outcome of the varieties of the surgical treatment of avascular necrosis of femoral head by the aid of Microsoft Excel program and STAT program; in which the result considered significant if P value <0.05, highly significant if P value <0.01 and nonsignificant if P value > 0.05. Figure 1: Radiograph of a patient who was managed by core decompression of the