Transtrochanteric curved varus osteotomy (TCVO) and transtrochanteric rotational osteotomy (TRO) are joint-preserving procedures for osteonecrosis of the femoral head. The purpose of this review is to provide up-to-date guidelines for the osteotomies. One retrospective comparison revealed that TCVO has shorter operation time, less bleeding, lower incidence of osteophyte formation, and lower rate of secondary collapse. To obtain successful results of the osteotomy, the patient should be younger than 40 years and should have a body mass index of less than 24 kg/m2. The osteotomy should be performed in early stages of femoral head osteonecrosis before marked collapse of the femoral head. The patient should have a medium-size lesion and an enough viable bone to restore the intact articular surface and subchondral bone in the weight-bearing area

Ha, Yong-Chan

Koo, Kyung-Hoi

Lee, Beomseok

Lee, Young-Kyun

Parvizi, Javad

English

Jefferson Digital Commons

Thomas Jefferson UniversityJefferson Digital CommonsRothman Institute Rothman Institute6-1-2019Which Osteotomy for Osteonecrosis of theFemoral Head and Which Patient for theOsteotomy?Young-Kyun Leeeoul National University Bundang HospitalBeomseok Leeeoul National University Bundang HospitalJavad ParviziRothman Institute; Thomas Jefferson University, Javad.Parvizi@jefferson.eduYong-Chan HaChung-Ang University College of MedicineKyung-Hoi Kooeoul National University Bundang HospitalLet us know how access to this document benefits youFollow this and additional works at: https://jdc.jefferson.edu/rothman_institutePart of the Orthopedics CommonsThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inRothman Institute by an authorized administrator of the Jefferson Digital Commons. For more information, please contact:JeffersonDigitalCommons@jefferson.edu.Recommended CitationLee, Young-Kyun; Lee, Beomseok; Parvizi, Javad; Ha, Yong-Chan; and Koo, Kyung-Hoi, "WhichOsteotomy for Osteonecrosis of the Femoral Head and Which Patient for the Osteotomy?" (2019).Rothman Institute. Paper 113.https://jdc.jefferson.edu/rothman_institute/113Femoral head osteonecrosis usually affects adults younger than 50 years and frequently leads to collapse and sub-sequent osteoarthritis of the hip.1,2) It is becoming more prevalent because of increasing use of steroids in the man-agement of organ transplantation and adjuvant therapy for leukemia and other myelogenous diseases.3-5) This disease frequently necessitates total hip arthroplasty (THA).6-8) As alternatives to THA, several osteotomies of the proximal femur have been introduced to preserve the hip joint.9-11) These techniques move the necrotic portion from the weight-bearing region to a non–weight-bearing region. Among them, transtrochanteric curved varus osteotomy (TCVO)11) and transtrochanteric rotational osteotomy (TRO)9) are well-known and popular in use. In 1971, Nishio and Sugioka11) introduced TCVO (Fig. 1). In this procedure, a curved osteotomy is made be-tween the greater and lesser trochanters. Then, the femoral head is rotated into a varus position. To date, five studies, four from Japan and one from Korea, have reported the results of TCVO. In these studies, the success rate ranged from 90% to 97.3%.12-15)In 1978, Sugioka9) introduced another osteotomy, TRO (Fig. 2). In this technique, the greater trochanter is osteotomized, and the femoral head fragment is rotated anteriorly. The success rates of TRO were inconsistent ranging from 17% to 100%. While studies from Japan and Korea reported successful results,16-19) further collapse of the femoral head developed in 83% in a study from the United States.20) The aim of this review is to provide up-to-date guides for the osteotomy of femoral head osteonecrosis.COMPARISON BETWEEN TCVO AND TROThere is no randomized clinical trial comparing TCVO and TRO. Thus far, only one study retrospectively com-Which Osteotomy for Osteonecrosis of the Femoral Head and Which Patient for the Osteotomy?Young-Kyun Lee, MD, Beomseok Lee, MD, Javad Parvizi, MD*, Yong-Chan Ha, MD†, Kyung-Hoi Koo, MDDepartment of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea,*Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA,†Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, KoreaTranstrochanteric curved varus osteotomy (TCVO) and transtrochanteric rotational osteotomy (TRO) are joint-preserving procedures for osteonecrosis of the femoral head. The purpose of this review is to provide up-to-date guidelines for the osteotomies. One ret-rospective comparison revealed that TCVO has shorter operation time, less bleeding, lower incidence of osteophyte formation, and lower rate of secondary collapse. To obtain successful results of the osteotomy, the patient should be younger than 40 years and should have a body mass index of less than 24 kg/m2. The osteotomy should be performed in early stages of femoral head osteo-necrosis before marked collapse of the femoral head. The patient should have a medium-size lesion and an enough viable bone to restore the intact articular surface and subchondral bone in the weight-bearing area. Keywords: Osteotomy, Femur head necrosisReview Article    Clinics in Orthopedic Surgery 2019;11:137-141   •  https://doi.org/10.4055/cios.2019.11.2.137Copyright © 2019 by The Korean Orthopaedic AssociationThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0)  which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.Clinics in Orthopedic Surgery • pISSN 2005-291X    eISSN 2005-4408Received February 19, 2019; Accepted March 20, 2019Young-Kyun Lee and Beomseok Lee contributed equally to this work as first authors.Correspondence to: Kyung-Hoi Koo, MDDepartment of Orthopedic Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, KoreaTel: +82-31-787-7194, Fax: +82-31-787-4056E-mail: khkoo@snu.ac.kr138Lee et al. Osteotomy for Osteonecrosis of the Femoral HeadClinics in Orthopedic Surgery • Vol. 11, No. 2, 2019 • www.ecios.orgpared these two osteotomies. Lee et al.15) compared 85 patients (91 hips) who were treated with TRO and 58 pa-tients (65 hips) who were treated with TCVO. The TCVO patients had shorter operation time and less blood loss. Postoperative collapse developed in 26 TRO hips (28.6%) and seven TCVO hips (10.8%). Osteophyte developed in 34 TRO hips (37.4%) and 13 TCVO hips (20%). Fifteen TRO hips (16.5%) and seven TCVO hips (10.8%) under-went conversion THA. The survival rate at 9 years with an endpoint of radiographic collapse was 68.7% in the TRO group and 84.7% in the TCVO group. With conversion to THA as the endpoint, the survival rate was 82.2% in the TRO group and 89.2% in the TCVO group. Their com-parison showed that TCVO was better than TRO in terms of operation time, the amount of blood loss, postoperative collapse, osteoarthritic change and postoperative survival.There are several differences between the two oste-otomies. In TRO, the greater trochanter should be osteoto-mized and the joint capsule should be circumferentially incised. Accordingly, TRO necessitates longer operation time and more bleeding. In TCVO, the head segment is simply rotated into varus by about 30° in the coronal plane. However, in TRO, the femoral head is rotated ante-riorly by 60° to 90° and varization is required. The femoral head is not perfectly spherical but el-liptical. The greater axis lies horizontally; that is, the radius of curvature along the meridian is greater than the radius of curvature along the equator. In the study of Hammond and Charnley,21) the mean difference of the two radiuses was 1.7 mm. Therefore, the femoral head might become less congruous to the acetabulum after TRO than after TCVO. The mechanical simplicity and avoidance of cap-sulotomy in TCVO seemed to result in less osteophyte formation compared to TRO.INDICATION OF THE OSTEOTOMYThe reported results after the osteotomies were inconsis-tent.12-14,16-18,20) Inappropriate patient selection is a reason for poor outcomes after the osteotomy;16,20) to improve the success rate, more efficient selection of patients is manda-tory. Patient’s age, body mass index, the preoperative stage of the disease, the size of the necrotic portion, and remain-ing viable portion of the femoral head are known factors affecting the result after the osteotomy.Patient’s Age and Body Mass IndexPatient’s age and body mass index are factors that affect re-sults after the osteotomy. In a previous study,22) secondary collapse was more frequent in patients who were aged > 40 years and whose body mass index was > 24 kg/m2. After the osteotomy, an intact bone is established in the weight-bearing region of the femoral head. Secondary collapse is a stress fracture of this newly-established intact portion, which is usually thin and beak-shaped. Age-related osteo-penia develops by the age of 40 years and progresses after-wards.23) In patients with high body mass index, an exces-sive load is applied on the femoral head, which leads to a stress fracture and secondary collapse of the newly formed weight-bearing portion. Stage of the DiseaseOsteotomies should be performed in the early stages of the disease before marked collapse of the femoral head: Ficat stage IIB (a crescentic subchondral fracture or slight flattening of the femoral head) or stage III (a definite head collapse without joint space narrowing).24,25)A BFig. 1. Transtrochanteric curved varus osteotomy. (A) Osteonecrosis of femoral head. (B) A curved osteotomy is made between the greater and lesser trochanter, and the femoral head is rotated into a varus position.Osteotomy lineAnteriorrotationA BFig. 2. Transtrochanteric rotational osteotomy. (A) The greater trochanter is osteotomized. (B) The femoral head fragment is rotated anteriorly.139Lee et al. Osteotomy for Osteonecrosis of the Femoral HeadClinics in Orthopedic Surgery • Vol. 11, No. 2, 2019 • www.ecios.orgSize of Necrotic PortionSmall lesions do not progress even without any medical or surgical intervention;26) whereas hips with a large lesion preoperatively have subsequent collapse of the femoral head after the osteotomy.27) Thus, the osteotomies should be performed in medium-size lesions with a combined necrotic angle between 190° and 240° (Fig. 3),28) or type B lesions involving the medial two-thirds or less of the weight-bearing portion according to Japanese Investiga-tion Committee (JIC) classification (Fig. 4).29) The extent of necrotic portion should be measured on magnetic reso-nance imaging (MRI) for the accurate measurement of the necrotic portion.< 190190 240> 240Fig. 3. The osteotomies should be performed in medium-size lesions with a combined necrotic angle between 190° and 240°.Type A Type B Type CFig. 4. The osteotomies should be performed in type B lesions involving the medial two-thirds or less of the weight-bearing portion according to Japanese Investigation Committee classification.BFig. 5. Adequate area of viable bone for transtrochanteric rotational osteotomy is an arc (B) of > 120° between the central vertical line of the femoral head and the posterior margin of the necrotic portion on a midsagittal magnetic resonance imaging scan. AFig. 6. Adequate area of viable bone for transtrochanteric curved varus osteotomy is an arc (A) of > 150° between the central vertical line of the femoral head and the lateral margin of the necrotic portion on the midcoronal magnetic resonance imaging scan.140Lee et al. Osteotomy for Osteonecrosis of the Femoral HeadClinics in Orthopedic Surgery • Vol. 11, No. 2, 2019 • www.ecios.orgViable Portion of the Femoral HeadThe femoral head should have a viable portion of such a size that restoration of an adequate weight-bearing ar-ticular surface is possible after the osteotomy.30,31) The ad-equate area of viable bone for TRO is an arc of > 120° be-tween the central vertical line of the femoral head and the posterior margin of the necrotic portion on a midsagittal MRI scan (Fig. 5), and that for TCVO is an arc of > 150° between the central vertical line of the femoral head and the lateral margin of the necrotic portion on a midcoronal MRI scan (Fig. 6).CONCLUSIONSWe recommend the use of TCVO for the treatment of femoral head osteonecrosis in patients who have (1) hip pain, (2) age less than 40 years, (3) a body mass index less than 24 kg/m2, (4) the Ficat stage IIA or III disease, (5) a medium-size lesion (combined necrotic angle between 190° and 240° or JIC type B lesion), and (6) enough viable bone (> 150° between the central vertical line and the lateral margin of the necrotic portion on the midcoronal MRI).CONFLICT OF INTERESTNo potential conflict of interest relevant to this article was reported.REFERENCES1. 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Which Osteotomy for Osteonecrosis of the Femoral Head and Which Patient for the Osteotomy?

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Which Osteotomy for Osteonecrosis of the Femoral Head and Which Patient for the Osteotomy?

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