Home Member Services Library Clinical Topics Total Hip Arthroplasty for Patients with Avascular Necrosis of the Femoral Head
Total Hip Arthroplasty for Patients with Avascular Necrosis of the Femoral Head PDF Print E-mail

Colin Burnell, M,D., FRCSC
Winnipeg, MB

David R. Hedden, M.D., FRCSC
Winnipeg, MB

Other authors in this issue have discussed the treatment of avascular necrosis of the femoral head (AVN) in its early stages, prior to collapse of the articular surface. Efforts to salvage the femoral head in the presence of large lesions or significant collapse have not been met with clinical success25,26. Certainly, the development of secondary degenerative changes within the joint virtually eliminates all treatment options short of arthroplasty. Fusion, given the propensity for bilaterality, is usually not a viable consideration. There remains controversy over arthroplasty treatment options of Ficat stage III lesions (University of Pennsylvania III + IV) with some authors recommending hemiarthroplasty or resurfacing procedures. However, persistent groin pain and wear of acetabular cartilage are problematic with these procedures2,10,12,17. Results with bipolar hemiarthroplasty have also been disappointing in this patient population with high failure rates reported2,3,22.  

Figure 1
30-year-old male with AVN and early head collapse


Once degenerative changes develop in the acetabulum, replacement of both sides of the joint becomes necessary. Attempts at total resurfacing arthroplasty have been mainly unsuccessful due to significant polyethylene wear and osteolysis1. Total hip arthroplasty, although highly successful for other degenerative conditions, has not proven as reliable in AVN20. The mode of failure in the majority of these patients is polyethylene wear, associated osteolysis and component loosening18,20. Interpretation of these results is difficult, as most series employ techniques or implants now shown in all patient populations to be prone to failure with long-term follow-up. Combining these underlying problems with the relatively young age and higher activity level of the affected patient population, increased failures are to be expected.

Given the poor published results of THA in patients with AVN, it is prudent to look at past problems and what strategies have been employed to address them. There has been significant technological evolution in THA in the past decade in both surgical technique and implant design and the results of THA reported in more recent studies show more favorable outcomes6,7,8. Recognizing wear as the prime issue affecting longevity of THA in these patients, efforts should focus on wear reduction to maximize long-term results.

Bearing surface options now available hold considerable promise in reducing wear debris. Standard polyethylene cobalt chrome couples have been shown to generate up to 500 000 particles per step and average linear wear rates of 0.05 to 0.26 per year15. The correlation with osteolysis and loosening has been clearly established24. Improved polyethylene sterilization and storage, and more recently, cross-linking, have the potential to significantly improve wear and failure with this couple. Hip simulator studies have been very encouraging19; however clinical confirmation is pending and will require randomized clinical trials.

Figure 2
1-year x-ray shows a press fit titanium cup and stem, with ceramic- ceramic bearing and retoration of leg length and femoral offset
Ceramic on ceramic bearings are continuing to evolve. Improved sintering and reduction in grain size has increased burst strength and reduced fracture rates to 0.04%. The linear wear rates are extremely low; 5 to 9 µm/year (4000 times less than metal and polyethylene)4,5. Ability to use larger head sizes also has the advantage of improved range of motion, less risk of impingement and lower dislocation rates. Preoperative planning and attention to detail are especially important using these hips because of the limited number of available neck lengths. Component orientation is important to avoid ceramic metal impingement. Metal on metal articulations have also demonstrated extremely low wear rates and avoid the fracture risk associated with the ceramics. Concern has however been raised about the biological effects of this coupled with a recent study showing elevated erythrocyte and urine cobalt, chromium and titanium levels14. The clinical significance is however un-certain and needs further evaluation.

Figure 3
1-year x-ray shows proximally coated press fit stem
Implant selection in patients with AVN should be individualized. Although studies support the use of either cemented or uncemented femoral components6,7,23, the femoral geometry will often determine the appropriate choice. These patients are usually young and often have small diaphyseal diameters (champagne-fluted configuration). This would require the use of a smaller size stem, if cementing, to accommodate an adequate cement mantle. Restoration of normal hip biomechanics (offset and leg length) is made more difficult with smaller stems (which generally have shorter neck lengths). Generally an uncemented stem with a tapered shape will suit this type of femur best. The selection of a proximally fixed stem may also minimize the proximal stress- shielding that occurs with a distally fixed uncemented stem. Clearly, uncemented acetabular components have superior longevity over cemented in these patients. Limiting effective joint space by isolation of the ingrowth surface from the bearing surface should be considered (cups without holes, filling all screw holes or man-hole covers).

It has been recognized that surgical expertise and experience affect outcome in THA11. Preoperative planning to match patients and implants, restoration of hip center and hip biomechanics are important components of this. Intraoperative attention to offset, leg length, component orientation, stability, and motion without impingement are critical.

Walking activity after THA has been shown to vary widely with age and gender and can have a dramatic influence on wear21. There is poor agreement among surgeons regarding specific activity recommendation9. Further studies are necessary to delineate what are safe and appropriate activities in this young and often active population.

Currently, THA is usually the procedure of choice in the patient with AVN with femoral head collapse. With continued technical advances the longevity of implants in these young patients should continue to improve.

References

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