Pharmacologic therapuetic solutions for CPT recently have become available: BMP-2, BMP-7 and bisphosphonate therapy (ZA) [20, 28, 40]. Lee et al. [28] reported five cases of CPT treated with BMP-7 combined with corticocancellous allograft and IM rodding combined with external fixation. The mean patient age was 6 years, and the mean followup duration was 14 months. The authors conluded that the use of recombinant human BMP-7 is not enough to overcome the poor healing environment associated with CPT. Little and colleagues [20, 40] used bisphosphonate (ZA) for patients with CPT to control the activity of osteoclasts to promote union and prevent the bone graft from resorption.

Thabet, Paley, Kocoaglu et al [42] conducted a retrospective study of 20 patients with CPT who were treated with periosteal grafting and bone grafting combined with IM rodding of the tibia and fibula and circular external fixation by the senior authors between 1997 and 2006 at two centers. The mean age at the index operation was 4.2 years (age range, 1−11.3 years). Eleven patients (55%) had neurofibromatosis, in seven patients (35%) the condition was idiopathic, and two patients (10%) had osteofibrous dysplasia. Twelve patients (60%) had no previous surgery, and eight patients (40%) had undergone at least one unsuccessful operation (range, 0−14). All patients had established pseudarthrosis. Union was achieved in all patients (100%). The mean time spent in external fixation was 5.2 months (range, 3−12 months). Limb lengthening was achieved in 12 patients. The mean lengthening amount was 2.5 cm (range, 0−7 cm); epiphysiodesis of the opposite side was performed in one patient.

Refracture occurred in eight patients: six experienced one refracture each, and two experienced two refractures each. Six of the eight patients with refracture had fibular pseudarthrosis. The mean time between the index operation and refracture was 2.3 years (range, 1−5.8 years), and the mean time between the index operation and second refracture was 4.7 years. The mean age at the index operation of patients who experienced refracture was 4 years (range, 1−7.3 years). The mean followup duration was 4.3 years (range, 2−10.7 years). All of the refractures were treated and all healed with surgery.

Most recently Paley studied 15 cases treated by the combined pharmacologic and surgical management method described above. The age range was from 1-10 years (mean 4 years). All patients united. There were no refractures. The average followup was 2 years (range 1-4).

Based on these results there is reason to believe that combining BMP and bisphosphonate treatment in clinical practice is a useful adjunct as was shown in the animal model [40]. In a review of CPT, Johnston and Birch [22] advocated using BMP as an adjuvant treatment in all primary and recalcitrant cases. Despite optimism with the use of BMP, one must also consider theoretical risk of tumorgenesis because BMP stimulates the RAS pathway, which is also a tumor pathway. Patients with CPT have a propensity for both benign and malignant tumors. Although there has never been a report of such a complication, it should be discussed with patients since rhBMP is not FDA-approved for children or for CPT.

The Paley method of combined pharmacologic and surgical management is a shotgun approach to management of this potentially devastating problem. It optimizes the mechanical [33]and biologic environment for the CPT. It is impossible to identify which factor is more important for the healing of CPT since no control group or comparison study has been done. Since this is a rare disease and failure is devastating it is more important to have a successful method than to be certain which component of the treatment regimen is the most important to achieving successful union. As newer pharmacologic therapeutics and better understanding of the patho-etiology of this disease occur, the combined pharmacologic surgical technique will morph to include newer technologies and therapeutics. Meanwhile the combination treatment; hamartoma resection, periosteal grafting, bone grafting, internal rodding, external fixation, tibio-fibular cross union, BMP and bisphosphonate pharmacologic manipulation are the best current combination treatment for CPT.

### **5. References**

102 Bone Grafting

Toh et al. [43] reported seven cases of CPT treated with vascularized fibular graft, with a mean followup duration of 12.1 years. Casting or monolateral external fixation was used in the first cases; an Ilizarov fixator was used as a postopertative immobilization tool in one case. The author concluded that the best outcome can be acheived with combined vascularized fibular grafting and Ilizarov external fixation as a method of postopertaive

El-Gamal et al. [12] reported three cases of CPT treated with vascularized fibular grafting combined with Ilizarov fixation to distract the fibular graft to correct LLD with a single operation. They called it 'telescoping vascularized fibular graft'. The mean patient age was 9 years, and the mean followup duration was 2 years. Union was achieved in all cases. One patient experienced refracture, and another patient experienced ankle valgus of the affected

Amputation is an option in cases of CPT [18, 30]. Its incidence varies from series to series. McCarthy [30] noted that foot condition, number of operations, and severity of LLD are the

Pharmacologic therapuetic solutions for CPT recently have become available: BMP-2, BMP-7 and bisphosphonate therapy (ZA) [20, 28, 40]. Lee et al. [28] reported five cases of CPT treated with BMP-7 combined with corticocancellous allograft and IM rodding combined with external fixation. The mean patient age was 6 years, and the mean followup duration was 14 months. The authors conluded that the use of recombinant human BMP-7 is not enough to overcome the poor healing environment associated with CPT. Little and colleagues [20, 40] used bisphosphonate (ZA) for patients with CPT to control the activity of

Thabet, Paley, Kocoaglu et al [42] conducted a retrospective study of 20 patients with CPT who were treated with periosteal grafting and bone grafting combined with IM rodding of the tibia and fibula and circular external fixation by the senior authors between 1997 and 2006 at two centers. The mean age at the index operation was 4.2 years (age range, 1−11.3 years). Eleven patients (55%) had neurofibromatosis, in seven patients (35%) the condition was idiopathic, and two patients (10%) had osteofibrous dysplasia. Twelve patients (60%) had no previous surgery, and eight patients (40%) had undergone at least one unsuccessful operation (range, 0−14). All patients had established pseudarthrosis. Union was achieved in all patients (100%). The mean time spent in external fixation was 5.2 months (range, 3−12 months). Limb lengthening was achieved in 12 patients. The mean lengthening amount was 2.5 cm (range, 0−7 cm); epiphysiodesis of the opposite side was performed in one patient. Refracture occurred in eight patients: six experienced one refracture each, and two experienced two refractures each. Six of the eight patients with refracture had fibular pseudarthrosis. The mean time between the index operation and refracture was 2.3 years (range, 1−5.8 years), and the mean time between the index operation and second refracture was 4.7 years. The mean age at the index operation of patients who experienced refracture was 4 years (range, 1−7.3 years). The mean followup duration was 4.3 years (range, 2−10.7

Most recently Paley studied 15 cases treated by the combined pharmacologic and surgical management method described above. The age range was from 1-10 years (mean 4 years). All patients united. There were no refractures. The average followup was 2 years (range 1-4).

osteoclasts to promote union and prevent the bone graft from resorption.

years). All of the refractures were treated and all healed with surgery.

fixation.

site.

factors that determine the need for amputation.

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[26] Keret D, Bollini G, Dungl P, Fixsen J, Grill F, Hefti F, Ippolito E, Romanus B, Tudisco C,

[27] Kim HW, Weinstein SL. Intramedullary fixation and bone grafting for congenital

[28] Lee FY, Sinicropi SM, Lee FS, Vitale MG, Roye DP Jr, Choi IH. Treatment of congenital

[30] McCarthy RE. Amputation for congenital pseudarthrosis of the tibia: indications and

[31] McElvenny RT. Congenital pseudarthrosis of the tibia: the findings in one case and a

[32] McFarland B. Pseudarthrosis of the tibia in childhood. *J Bone Joint Surg Br.*

[33] Morrissy RT. Congenital pseudarthrosis of the tibia: factors that affect results. *Clin*

[34] Ohnishi I, Sato W, Matsuyama J, Yajima H, Haga N, Kamegaya M, Minami A, Sato M,

[35] Paley D, Catagni M, Argnani F, Prevot J, Bell D, Armstrong P. Treatment of congenital

[36] Paley D, Congenital Pseudarthrosis: Management. *PanArabOrthopaediCongress Muscat,*

[37] Paterson DC, Lewis GN, Cass CA. Treatment of congenital pseudarthrosis of the tibia with direct current stimulation. *Clin Orthop Relat Res.* 1980;148:129−135. [38] Paterson DC, Simonis RB. Electrical stimulation in the treatment of congenital

[39] Romanus B, Bollini G, Dungl P, Fixsen J, Grill F, Hefti F, Ippolito E, Tudisco C,

[40] Schindeler A, Ramachandran M, Godfrey C, Morse A, McDonald M, Mikulec K, Little

Wientroub S. Free vascular fibular transfer in congenital pseudoarthrosis of the tibia: results of the EPOS multicenter study: European Paediatric Orthopaedic

DG. Modeling bone morphogenetic protein and bisphosphonate combination therapy in wild-type and Nf1 haploinsufficient mice. *J Orthop Res.* 2008;26:65−74. [41] Sofield HA. Congenital pseudarthrosis of the tibia. *Clin Orthop Relat Res.* 1971;76:33−42. [42] Thabet AM, Paley D, Kocaoglu M, Eralp L, Herzenberg JE, Ergin ON. Periosteal

grafting for congenital pseudarthrosis of the tibia: a preliminary report. *Clin Orthop*

a multicenter study in Japan. *J Pediatr Orthop.* 2005;25:219−224.

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*Relat Res.* 2008;466:2981-94. *Epub* 2008 Oct 25.

(rhBMP-7): a report of five cases. *J Bone Joint Surg Am.* 2006;88:627−633. [29] Masserman RL, Peterson HA, Bianco AJ Jr. Congenital pseudarthrosis of the tibia: a

pseudarthrosis of the tibia. *Clin Orthop Relat Res.* 2002;405:250−257.

Wientroub S. The fibula in congenital pseudoarthrosis of the tibia: the EPOS multicenter study: European Paediatric Orthopaedic Society (EPOS). *J Pediatr*

pseudarthrosis of the tibia with recombinant human bone morphogenetic protein-7

review of the literature and 52 cases from the Mayo Clinic. *Clin Orthop Relat Res.*

suggestion as to possible etiology and treatment. *Q Bull Northwest Univ Med Sch.*

Yoshino S, Oki T, Nakamura K. Treatment of congenital pseudarthrosis of the tibia:

pseudoarthrosis of the tibia using the Ilizarov technique. *Clin Orthop Relat Res.*

[9] Dobbs MB, Rich MM, Gordon JE, Szymanski DA, Schoenecker PL. Use of an

[10] Dobbs MB, Rich MM, Gordon JE, Szymanski DA, Schoenecker PL. Use of an

[11] Dormans JP, Krajbich JI, Zuker R, Demuynk M. Congenital pseudarthrosis of the tibia: treatment with free vascularized fibular grafts. *J Pediatr Orthop.* 1990;10:623−628. [12] El-Gammal TA, El-Sayed A, Kotb MM. Telescoping vascularized fibular graft: a new

[13] El-Rosasy MA, Paley D, Herzenberg JE. Congenital pseudarthrosis of the tibia. In:

[14] El-Rosasy MA, Paley D, Herzenberg JE. Ilizarov techniques for the management of

[15] Fragnière B, Wicart P, Mascard E, Dubousset J. Prevention of ankle valgus after vascularized fibular grafts in children. *Clin Orthop Relat Res.* 2003;408:245−251. [16] Gilbert A, Brockman R. Congenital pseudarthrosis of the tibia: long-term followup of 29

[17] Grill F, Bollini G, Dungl P, Fixsen J, Hefti F, Ippolito E, Romanus B, Tudisco C,

[18] Guille JT, Kumar SJ, Shah A. Spontaneous union of a congenital pseudarthrosis of the tibia after Syme amputation. *Clin Orthop Relat Res.* 1998;351:180−185. [19] Hermanns-Sachweh B, Senderek J, Alfer J, Klosterhalfen B, Büttner R, Füzesi L, Weber

[20] Högler W, Yap F, Little D, Ambler G, McQuade M, Cowell CT. Short-term safety

[21] Ippolito E, Corsi A, Grill F, Wientroub S, Bianco P. Pathology of bone lesions associated with congenital pseudarthrosis of the leg. *J Pediatr Orthop B.* 2000;9:3−10. [22] Jacobsen ST, Crawford AH, Millar EA, Steel HH. The Syme amputation in patients with congenital pseudarthrosis of the tibia. *J Bone Joint Surg Am.* 1983;65:533−537. [23] Johnston CE II. Congenital pseudarthrosis of the tibia: results of technical variations in the Charnley-Williams procedure. *J Bone Joint Surg Am.* 2002;84:1799−1810. [24] Joseph B, Mathew G. Management of congenital pseudarthrosis of the tibia by excision

term followup study. *J Bone Joint Surg Am.* 2004;86:1186−1197.

surgical technique. *J Bone Joint Surg Am.* 2005;87(Suppl 1):33−40.

*Pediatr Orthop B.* 2004;13:48−56.

*Pediatr Orthop B.* 2000;9:75−89.

*Pathol Res Pract.* 2005;201:305−312.

the tibia. *Microsurgery.* 1996;17:459−469.

2004;145:701−704.

2000;9:16−23.

Press; 2001.

York: Informa Healthcare; 2007:485−493.

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intramedullary rod for the treatment of congenital pseudarthrosis of the tibia:

method for treatment of congenital tibial pseudarthrosis with severe shortening. *J*

Rozbruch SR, Ilizarov S, eds. *Limb Lengthening and Reconstruction Surgery.* New

congenital pseudarthrosis of the tibia (PhD Thesis). Tanta, Egypt: Tanta University

cases treated by microvascular bone transfer. *Clin Orthop Relat Res.* 1995;314:37−44.

Wientroub S. Treatment approaches for congenital pseudarthrosis of tibia: results of the EPOS multicenter study: European Paediatric Orthopaedic Society (EPOS). *J*

M. Vascular changes in the periosteum of congenital pseudarthrosis of the tibia.

assessment in the use of intravenous zoledronic acid in children. *J Pediatr.*

of the pseudarthrosis, onlay grafting, and intramedullary nailing. *J Pediatr Orthop B.*

[25] Kanaya F, Tsai TM, Harkess J. Vascularized bone grafts for congenital pseudarthrosis of

**7**

*India*

**Osteonecrosis Femoral Head Treatment by**

**Core Decompression and ILIAC CREST-TFL**

Osteonecrosis of femoral head is a painful disabling condition seen in association with many disorders like corticosteroids consumption, alcohol abuse, haemoglobinopathy (sickle cell disease, coagulopathies), certain renal, hepatic and skin disorders commonly affecting young patients ranging from 20-40 years.1-3 It is now recognized as a major musculo-skeletal problem mostly affecting the young people in their productive years of life. It is often characterized by relentless progression despite treatment, resulting in to subchondral fracture, collapse and painful arthrosis.4 Hence it is essential to diagnose and treat the patients of osteonecrosis early to prevent any further disintegration and collapse of femoral head. Advanced osteonecrosis with secondary osteoarthritis is reported in 5% to 18% of total patients undergoing total hip replacement in the US.4-7 Aim of the treatment in osteonecrosis is to reduce the intraosseous pressure and to perform the head-preserving procedure, which will cause early revascularization of ischemic head. Various types of muscle pedicle grafting after core decompression are indicated early in the disease, depending upon the stage of the disease and have shown excellent results in revascularization of femoral head and

Once diagnosed it is desirable to subject the patient to early surgical intervention. Rationale for the treatment of osteonecrosis of femoral head requires a lot of consideration. Of prime importance is the age of patients. Whether both hips are affected, etiology of the associated diseases, demands and requirement of the patients, and the stage of the disease when the patient presents for treatment are equally important. The treatment is planned according to ARCO's classification8 & Steinberg staging9. Only core decompression may relieve the pain but it does not achieve revascularization of femoral head. Hence core decompression should always be supplemented by one of the procedures of bone grafting. To achieve early vascularisation, vascular pedicle grafting using deep circumflex iliac vessel with iliac crest is a very useful, but preoperative femoral angiography is mandatory to confirm the presence of deep circumflex iliac artery pedicle10. This procedure is technically demanding, tedious and time consuming and may not be feasible bilaterally in one sitting. However Muscle pedicle graft using tensor fascia lata graft is very easy and is commonly performed

**1. Introduction**

prevention of collapse.

**Muscle Pedicle Grafting**

*Indira Gandhi Medical College, Nagpur,*

*Sushrut Hosp, Research Centre & PGI, Nagpur,*

Sudhir Babhulkar

### **Osteonecrosis Femoral Head Treatment by Core Decompression and ILIAC CREST-TFL Muscle Pedicle Grafting**

### Sudhir Babhulkar

*Indira Gandhi Medical College, Nagpur, Sushrut Hosp, Research Centre & PGI, Nagpur, India*

### **1. Introduction**

106 Bone Grafting

[43] Toh S, Harata S, Tsubo K, Inoue S, Narita S. Combining free vascularized fibula graft

[44] Weber M., Congenital pseudarthrosis of the tibia redefined: congenital crural

*Reconstruction Surgery.* New York: Informa Healthcare; 2007:495−509. [45] Weiland AJ, Weiss AP, Moore JR, Tolo VT. Vascularized fibular grafts in the treatment of congenital pseudarthrosis of the tibia. *J Bone Joint Surg Am.* 1990;72:654−662.

the tibia. *J Reconstr Microsurg.* 2001;17:497−508.

and the Ilizarov external fixator: recent approaches to congenital pseudarthrosis of

segemental dysplasia. In: Rozbruch SR, Ilizarov S, eds. *Limb Lengthening and*

Osteonecrosis of femoral head is a painful disabling condition seen in association with many disorders like corticosteroids consumption, alcohol abuse, haemoglobinopathy (sickle cell disease, coagulopathies), certain renal, hepatic and skin disorders commonly affecting young patients ranging from 20-40 years.1-3 It is now recognized as a major musculo-skeletal problem mostly affecting the young people in their productive years of life. It is often characterized by relentless progression despite treatment, resulting in to subchondral fracture, collapse and painful arthrosis.4 Hence it is essential to diagnose and treat the patients of osteonecrosis early to prevent any further disintegration and collapse of femoral head. Advanced osteonecrosis with secondary osteoarthritis is reported in 5% to 18% of total patients undergoing total hip replacement in the US.4-7 Aim of the treatment in osteonecrosis is to reduce the intraosseous pressure and to perform the head-preserving procedure, which will cause early revascularization of ischemic head. Various types of muscle pedicle grafting after core decompression are indicated early in the disease, depending upon the stage of the disease and have shown excellent results in revascularization of femoral head and prevention of collapse.

Once diagnosed it is desirable to subject the patient to early surgical intervention. Rationale for the treatment of osteonecrosis of femoral head requires a lot of consideration. Of prime importance is the age of patients. Whether both hips are affected, etiology of the associated diseases, demands and requirement of the patients, and the stage of the disease when the patient presents for treatment are equally important. The treatment is planned according to ARCO's classification8 & Steinberg staging9. Only core decompression may relieve the pain but it does not achieve revascularization of femoral head. Hence core decompression should always be supplemented by one of the procedures of bone grafting. To achieve early vascularisation, vascular pedicle grafting using deep circumflex iliac vessel with iliac crest is a very useful, but preoperative femoral angiography is mandatory to confirm the presence of deep circumflex iliac artery pedicle10. This procedure is technically demanding, tedious and time consuming and may not be feasible bilaterally in one sitting. However Muscle pedicle graft using tensor fascia lata graft is very easy and is commonly performed

Osteonecrosis Femoral Head Treatment by

vascularisation of femoral head was poor.

specialized training equipment and expertise.

decompression and TFL muscle pedicle graft of part of iliac crest.

LD – 52 years male Steroid Induced ON femoral head left side

Fig. 1. 1C, 1D – Pre op MRI showing classical changes of ON left side

Core Decompression and ILIAC CREST-TFL Muscle Pedicle Grafting 109

effectively. Core decompression only gave good clinical results initially( Ficat & Arlet)13, 14, but the long term results were poor.11 The use of nonvascularised tibial (Phemister) or fibular bone graft (Boettcher & Bonfiglio)15 is useful only in the early stages but in later stages, the results were very poor. Subarticular curettage and cancellous bone grafting failed to relieve pain and prevent progressive collapse of the femoral head.16,17 Meyers11 reported use of fresh cancellous graft combined with Quadratus femoris muscle pedicle graft which gave good results in stage I & II, but was unsatisfactory in stage III & IV. Though pain and deformity improved initially,

The vascularized fibular grafting is associated with better clinical and radiographic results than is nonvascularized fibular grafting in precollapse hips7. However, the successful use of free vascularized bone grafts requires a meticulous process of procuring the vascular fibula with microanastomosis to the recipient site. The microsurgical procedures require

The TFL muscle pedicle graft by using part of iliac crest described in this article is easy to perform and does not require any special equipment or technique, and still has the advantages of increased vascularity like vascularised bone graft (Fig 1A-1H). We analyzed and report a series of patients of osteonecrosis of femoral head treated by core

Fig. 1. 1A, 1B– Pre op X-ray 52 year's male Steroid Induced ON femoral head left side

whenever both hips need simultaneous surgery in one sitting. In the past, muscle pedicle graft using quadratus femoris (Meyer's procedure) 11 was propagated in the treatment of osteonecrosis, but it did not achieve satisfactory early revascularization and came in disrepute since the results were not encouraging. Dr DP Baksi12 reported treatment of osteonecrosis by multiple drilling and muscle pedicle grafting by use of TFL graft with relief of pain and improvement in the hip movements. Though vascularised pedicle graft by using part of iliac crest with deep circumflex iliac vessels is more advantageous since high percentage of marrow and osteogenic cells survive within a living graft, it is difficult to perform this surgery on both hips in one sitting. As per our Institutional philosophy we prefer to operate both hips in the same sitting since it reduces the hospital stay, the cost of drugs and many cases patient may not turn up for surgery on the opposite hip, especially the poor compliance group of patients. Hence use of Muscle pedicle graft of tensor fascia lata along with iliac crest after core decompression is commonly advocated when bilateral hips are involved and surgery is recommended early in single sitting.

Table 1. ARCO Classification

The natural history of osteonecrosis of femoral head, before the development of crescent sign or before the collapse of the femoral head, has never been well defined. The possibility of progression to collapse is thought to increase after the development of an abnormality that can be seen on plainradiograph and the course of collapse may be highly variable and unknown7. It is generally agreed that symptomatic radiographically abnormal hip will progress to collapse of the femoral head when treated nonoperatively7.To avoid these complications and to avoid early replacement arthroplasty in young patients many operative procedures to salvage the femoral head are in vogue. Head preserving operation of core decompression and various types of bone grafting certainly gave excellent results in early stage of osteonecrosis. Despite the many reports on the utility of various operative procedures no single method has uniformly demonstrated the arrest of the disease or prevention of collapse of the femoral head

whenever both hips need simultaneous surgery in one sitting. In the past, muscle pedicle graft using quadratus femoris (Meyer's procedure) 11 was propagated in the treatment of osteonecrosis, but it did not achieve satisfactory early revascularization and came in disrepute since the results were not encouraging. Dr DP Baksi12 reported treatment of osteonecrosis by multiple drilling and muscle pedicle grafting by use of TFL graft with relief of pain and improvement in the hip movements. Though vascularised pedicle graft by using part of iliac crest with deep circumflex iliac vessels is more advantageous since high percentage of marrow and osteogenic cells survive within a living graft, it is difficult to perform this surgery on both hips in one sitting. As per our Institutional philosophy we prefer to operate both hips in the same sitting since it reduces the hospital stay, the cost of drugs and many cases patient may not turn up for surgery on the opposite hip, especially the poor compliance group of patients. Hence use of Muscle pedicle graft of tensor fascia lata along with iliac crest after core decompression is commonly advocated when bilateral

The natural history of osteonecrosis of femoral head, before the development of crescent sign or before the collapse of the femoral head, has never been well defined. The possibility of progression to collapse is thought to increase after the development of an abnormality that can be seen on plainradiograph and the course of collapse may be highly variable and unknown7. It is generally agreed that symptomatic radiographically abnormal hip will progress to collapse of the femoral head when treated nonoperatively7.To avoid these complications and to avoid early replacement arthroplasty in young patients many operative procedures to salvage the femoral head are in vogue. Head preserving operation of core decompression and various types of bone grafting certainly gave excellent results in early stage of osteonecrosis. Despite the many reports on the utility of various operative procedures no single method has uniformly demonstrated the arrest of the disease or prevention of collapse of the femoral head

hips are involved and surgery is recommended early in single sitting.

Table 1. ARCO Classification

effectively. Core decompression only gave good clinical results initially( Ficat & Arlet)13, 14, but the long term results were poor.11 The use of nonvascularised tibial (Phemister) or fibular bone graft (Boettcher & Bonfiglio)15 is useful only in the early stages but in later stages, the results were very poor. Subarticular curettage and cancellous bone grafting failed to relieve pain and prevent progressive collapse of the femoral head.16,17 Meyers11 reported use of fresh cancellous graft combined with Quadratus femoris muscle pedicle graft which gave good results in stage I & II, but was unsatisfactory in stage III & IV. Though pain and deformity improved initially, vascularisation of femoral head was poor.

The vascularized fibular grafting is associated with better clinical and radiographic results than is nonvascularized fibular grafting in precollapse hips7. However, the successful use of free vascularized bone grafts requires a meticulous process of procuring the vascular fibula with microanastomosis to the recipient site. The microsurgical procedures require specialized training equipment and expertise.

The TFL muscle pedicle graft by using part of iliac crest described in this article is easy to perform and does not require any special equipment or technique, and still has the advantages of increased vascularity like vascularised bone graft (Fig 1A-1H). We analyzed and report a series of patients of osteonecrosis of femoral head treated by core decompression and TFL muscle pedicle graft of part of iliac crest.

LD – 52 years male Steroid Induced ON femoral head left side

Fig. 1. 1A, 1B– Pre op X-ray 52 year's male Steroid Induced ON femoral head left side

Fig. 1. 1C, 1D – Pre op MRI showing classical changes of ON left side

Osteonecrosis Femoral Head Treatment by

patients had stage III in both hips.

SCS

femoral head

Core Decompression and ILIAC CREST-TFL Muscle Pedicle Grafting 111

24 Bilateral hips, 17 patients had stage III on one side & stage II on other side. Wherein 7

Fig. 2. 2A, 2B – Pre op X-ray 50 years male Steroid Induced ON femoral head both sides

Fig. 2. 2C, 2D – Post op 1.5 years follow up X ray after CD & TFL graft on left side & free fibular graft on right side showing good revascularization and restoration of contour of

Fig. 2. 2E, 2F – 1.5 years PO showing good revascularization and restoration of contour of

femoral head on left side after CD & TFL graft

Fig. 1. 1E, 1F – Immediate Post op X ray after CD & TFL draft

Fig. 1. 1G, 1H – Post op 3 years follow up X ray after CD & TFL draft showing good revascularization and restoration of contour of femoral head left side

### **2. Material & methods**

This article reports the study of 68 patients of osteonecrosis femoral head, affecting 92 femoral heads in stage II & III, wherein 90 hips were treated with core decompression and Iliac crest-TFL muscle pedicle grafting by using part of iliac crest with Tensor Fascia lata (TFL) pedicle in a duration of 16 years, from Jan.95 to Dec.2010 with a minimum follow up for three years. All patients were young 16-52 years of age with a mean age of 30 years.

Forty four patients had unilateral affection where as twenty four patients had bilateral involvement, but on twenty two occasions bilateral TFL grafting was done in one sitting, whereas two patients in bilateral group were operated by TFL muscle pedicle graft on one side & free fibular grafting on the opposite side in single sitting (Fig 2A-2H, Fig 3A-3G). Thus TFL Grafting procedure was performed on total 90 hips in 68 patients. At our Institute many patients of Sickle cell disease with osteonecrosis are studied and treated, where the procedure of vascular pedicle grafting is not performed on any patient, because of the possibility of high prevalence of thrombosis in the vascular pedicle in this disease. Similarly in patients with bilateral involvement, surgery of TFL grafting in one sitting is preferred to vascular pedicle grafting, mainly because of the long time required for vascular pedicle procedure. Amongst 68 patients, 28 patients (42%) were following Alcohol abuse, 21 patients (30%) were following consumption of corticosteroids & 19 patients had sickle cell haemoglobinopathy (28%). The demography of patients is shown in the Chart 2. Amongst 24 Bilateral hips, 17 patients had stage III on one side & stage II on other side. Wherein 7 patients had stage III in both hips.

110 Bone Grafting

Fig. 1. 1G, 1H – Post op 3 years follow up X ray after CD & TFL draft showing good

This article reports the study of 68 patients of osteonecrosis femoral head, affecting 92 femoral heads in stage II & III, wherein 90 hips were treated with core decompression and Iliac crest-TFL muscle pedicle grafting by using part of iliac crest with Tensor Fascia lata (TFL) pedicle in a duration of 16 years, from Jan.95 to Dec.2010 with a minimum follow up for three years. All patients were young 16-52 years of age with a mean age of 30 years.

Forty four patients had unilateral affection where as twenty four patients had bilateral involvement, but on twenty two occasions bilateral TFL grafting was done in one sitting, whereas two patients in bilateral group were operated by TFL muscle pedicle graft on one side & free fibular grafting on the opposite side in single sitting (Fig 2A-2H, Fig 3A-3G). Thus TFL Grafting procedure was performed on total 90 hips in 68 patients. At our Institute many patients of Sickle cell disease with osteonecrosis are studied and treated, where the procedure of vascular pedicle grafting is not performed on any patient, because of the possibility of high prevalence of thrombosis in the vascular pedicle in this disease. Similarly in patients with bilateral involvement, surgery of TFL grafting in one sitting is preferred to vascular pedicle grafting, mainly because of the long time required for vascular pedicle procedure. Amongst 68 patients, 28 patients (42%) were following Alcohol abuse, 21 patients (30%) were following consumption of corticosteroids & 19 patients had sickle cell haemoglobinopathy (28%). The demography of patients is shown in the Chart 2. Amongst

revascularization and restoration of contour of femoral head left side

**2. Material & methods**

Fig. 1. 1E, 1F – Immediate Post op X ray after CD & TFL draft

Fig. 2. 2C, 2D – Post op 1.5 years follow up X ray after CD & TFL graft on left side & free fibular graft on right side showing good revascularization and restoration of contour of femoral head

Fig. 2. 2E, 2F – 1.5 years PO showing good revascularization and restoration of contour of femoral head on left side after CD & TFL graft

Osteonecrosis Femoral Head Treatment by

Fig. 3. 3B, 3C – MRI showing bilateral ON femoral heads

Core Decompression and ILIAC CREST-TFL Muscle Pedicle Grafting 113

Fig. 3. 3D, 3E – 12 weeks PO after CD & TFL graft left side & free fibular graft right side

Fig. 3. 3F, 3G – 1 year PO after CD & TFL graft left side & free fibular graft right side showing good consolidation of TFL graft left side with restoration of normal femoral head

contour

Fig. 2. 2G, 2H – 9 years PO showing good revascularization and restoration of contour of femoral head on left side after CD & TFL graft with good hip joint space.

Table 2. Showing demography of patients affecting 90 Hips operated by TFL grafting showing stages, age & Sex.

RC 28 year male Alcohol Induced Fig. 3. 3A – X ray showing Alcohol induced ON both sides in 31 years male

Fig. 2. 2G, 2H – 9 years PO showing good revascularization and restoration of contour of

Female Hips

Age of the patient

16-20 21-30 31-40 41 & Above

femoral head on left side after CD & TFL graft with good hip joint space.

Hips

20 13 2 11 16 4 A -

36 21 4 18 22 13 A 6

Table 2. Showing demography of patients affecting 90 Hips operated by TFL grafting

Fig. 3. 3A – X ray showing Alcohol induced ON both sides in 31 years male

Stage of

Stage II 33

B 15 C 18 Stage III 57

B 36 C 15

showing stages, age & Sex.

RC 28 year male Alcohol Induced

Disease Number of Hips Male

Fig. 3. 3B, 3C – MRI showing bilateral ON femoral heads

Fig. 3. 3D, 3E – 12 weeks PO after CD & TFL graft left side & free fibular graft right side

Fig. 3. 3F, 3G – 1 year PO after CD & TFL graft left side & free fibular graft right side showing good consolidation of TFL graft left side with restoration of normal femoral head contour

Osteonecrosis Femoral Head Treatment by

bearing after 14-16 weeks.

sample was significant (*P <0.05)*

surgery of total hip joint was advised.

**3. Discussion**

**2.3 Follow-up**

**2.4 Results**

Core Decompression and ILIAC CREST-TFL Muscle Pedicle Grafting 115

after 15 days in bed and after 4-6 weeks patient can be mobilized out of bed on non-weight bearing crutch walking if only one hip is operated. Whereas in bilateral cases, the patient is advised bed rest with mobilsation of hips after 4 weeks and weight bearing started after 10 weeks only. The patient is allowed partial weight bearing after 10 weeks and full weight

Follow-up by clinical and radiological examination was done every 3 months for one year, every six months for next five years and then yearly follow up thereafter. Harris hip score system was used for assessment of the results. The follow up period varied from three to sixteen years. Post operatively Bone scan & Digital subtraction arteriogram was done in twenty patients comprising of ten each in stage II & III, at the end of 12 weeks, which

The patients had good clinical improvement with relief from pain and improvement in the range of movements. The radiological improvement was judged by diminishen of density and attempt at revascularization as seen by healing of cystic changes, disappearance of crescent sign and restoration of normal trabecular pattern and shape of femoral head. Almost all patients had good relief from pain with good improvement in the range of movements. As per Harris Hip score results, there was improvement in the score of > 25 points in 70 % cases while in fifty % had improvement in the score of more than 28 points in both the stages. The mean +SD improvement in Harris Hip score at 3 year's follow up was 27.6 + 6.4. The difference in the preoperative and postoperative score across the whole

**Stage II:** Seventy percent of stage II hips completely improved without any deterioration

**Stage III**: About 20% patients of stage III had residual low intensity pain for about 30 weeks. About 30% patients had painless limp for 24-30 weeks with restriction of flexion beyond 100 Degrees. Eight percent patient (5 patients) progressed to further collapse, got deformed but without any progression to arthrosis. Out of this, in four percent patients (3 patients)

Need to treat ischemia of femoral head is becoming more common since many cases are detected in early stages in young patients. One must consider the possibility of osteonecrosis if individual has pain in the vicinity of hip, that had history of chronic alcoholism, corticosteroid consumption, associated disease like sickle cell disease, Gauchers, Gout etc18- 21. Early diagnosis prior to the appearance of radiological changes is crucial in the treatment of ischemic necrosis. Its diagnosis is based on clinical examination and by bone scan, CT, and MRI, as osteonecrosis is the response to the vascular impairment of the bone marrow circulation. X-ray examination is of limited value in early stage, but has importance in staging since it helps in planning the treatment and the prognosis. The X-ray become

and had complete relief from pain. No patient progressed to stage III postoperatively.

showed hundred percent of patency and viability of the TFL muscle pedicle graft.

#### **2.1 Operative technique**

Patient after spinal anesthesia, is put in supine position with the sandbag underneath the gluteal region on the operative side. A curvilinear incision is taken on lateral side of hip extending from the iliac crest about 5 cm posterior to Anterior superior iliac spine and to the greater trochanter and extending downwards about 2 cm below the base of greater trochanter in the subtrochanteric region. The iliac crest should be exposed, freed from inner lip by erasing three abdominal muscles till you just reach about 2 cm. Similarly the iliac crest with attached tensor fascia lata on external surface should be exposed. The cleavage between Sartorius and tensor fascia lata is identified. An incision is made between anterior & middle fibers of TFL and clearly 2 - 3 cm width of TFL middle fibers are separated up to the iliac crest. With pneumatic saw osteotomy of iliac crest is done superiorly, and about 2 - 3 cm distally and medially with isolation of TFL graft externally. This isolated iliac crest graft with TFL pedicle is best done by subperiosteal separation of muscles on either side of lip of the ilium without disturbing the vascular supply. The desired size of TFL with full width of iliac crest is raised & retracted downwards with attached fibers of TFL. The TFL muscle pedicle graft just prepared gets its vascular supply from the superior gluteal artery and ascending branch of lateral circumflex femoral artery. The reflected pedicle of TFL with fibers of gluteus minimus muscle is erased from the outer surface of ilium and is retracted downwards and brought down up to the anterior capsule of the involved hip joint. The hip capsule is opened with T shaped incision. The anterior capsule and thickened synovium is excised. The ischemic necrotic segment is exposed and examined for its deformation & change in the contour. A small window is made anteriorly at the junction of articular surface of the femoral head and anterior surface of the neck of the femur by pneumatic drill. Under image intensifier through this window, serial reaming is done in the ischemic segment of the femoral head right up to the subchondral region in all the directions. Care is taken not to perforate the articular surface. Subsequently the entire necrotic tissue is removed by curette which creates a big void in the head of the femur usually in the upper quadrant of the femoral head, wherein inferior quadrant is usually not disturbed. With the special instrument & punch-impactor the deformed femoral head with articular cartilage is raised superiorly to match its original shape under IITV in all the direction. The created void is partially filled and packed with little cancellous bone removed from the iliac crest after performing the osteotomy. Subsequently the retracted & raised pedicle of TFL with iliac crest is prepared nicely to repose through the window defect at the head neck junction. Two holes are made superiorly & inferiorly in the femoral neck by of 2 mm drill bits. Similarly the two holes are prepared in the pedicle of iliac bone with TFL graft. Subsequently the TFL pedicle is impacted in to the head under image control right up to the subchondral region of femoral neck and the graft tied by No.1 Vickryl to the femoral neck. Additionally, the muscle belly is also stitched to the capsule inferiorly & superiorly. The suction drain is kept at the hip & iliac crest site and wound is closed in layers. In bilateral cases, the similar procedure is performed in the same sitting on the opposite side.

#### **2.2 Post operative protocol**

Postoperatively the limb-Hip is kept in 20-degree abduction and 30 degree flexion and 10 degree of internal rotation to avoid tension on the vascular pedicle. The patient is mobilized after 15 days in bed and after 4-6 weeks patient can be mobilized out of bed on non-weight bearing crutch walking if only one hip is operated. Whereas in bilateral cases, the patient is advised bed rest with mobilsation of hips after 4 weeks and weight bearing started after 10 weeks only. The patient is allowed partial weight bearing after 10 weeks and full weight bearing after 14-16 weeks.

### **2.3 Follow-up**

114 Bone Grafting

Patient after spinal anesthesia, is put in supine position with the sandbag underneath the gluteal region on the operative side. A curvilinear incision is taken on lateral side of hip extending from the iliac crest about 5 cm posterior to Anterior superior iliac spine and to the greater trochanter and extending downwards about 2 cm below the base of greater trochanter in the subtrochanteric region. The iliac crest should be exposed, freed from inner lip by erasing three abdominal muscles till you just reach about 2 cm. Similarly the iliac crest with attached tensor fascia lata on external surface should be exposed. The cleavage between Sartorius and tensor fascia lata is identified. An incision is made between anterior & middle fibers of TFL and clearly 2 - 3 cm width of TFL middle fibers are separated up to the iliac crest. With pneumatic saw osteotomy of iliac crest is done superiorly, and about 2 - 3 cm distally and medially with isolation of TFL graft externally. This isolated iliac crest graft with TFL pedicle is best done by subperiosteal separation of muscles on either side of lip of the ilium without disturbing the vascular supply. The desired size of TFL with full width of iliac crest is raised & retracted downwards with attached fibers of TFL. The TFL muscle pedicle graft just prepared gets its vascular supply from the superior gluteal artery and ascending branch of lateral circumflex femoral artery. The reflected pedicle of TFL with fibers of gluteus minimus muscle is erased from the outer surface of ilium and is retracted downwards and brought down up to the anterior capsule of the involved hip joint. The hip capsule is opened with T shaped incision. The anterior capsule and thickened synovium is excised. The ischemic necrotic segment is exposed and examined for its deformation & change in the contour. A small window is made anteriorly at the junction of articular surface of the femoral head and anterior surface of the neck of the femur by pneumatic drill. Under image intensifier through this window, serial reaming is done in the ischemic segment of the femoral head right up to the subchondral region in all the directions. Care is taken not to perforate the articular surface. Subsequently the entire necrotic tissue is removed by curette which creates a big void in the head of the femur usually in the upper quadrant of the femoral head, wherein inferior quadrant is usually not disturbed. With the special instrument & punch-impactor the deformed femoral head with articular cartilage is raised superiorly to match its original shape under IITV in all the direction. The created void is partially filled and packed with little cancellous bone removed from the iliac crest after performing the osteotomy. Subsequently the retracted & raised pedicle of TFL with iliac crest is prepared nicely to repose through the window defect at the head neck junction. Two holes are made superiorly & inferiorly in the femoral neck by of 2 mm drill bits. Similarly the two holes are prepared in the pedicle of iliac bone with TFL graft. Subsequently the TFL pedicle is impacted in to the head under image control right up to the subchondral region of femoral neck and the graft tied by No.1 Vickryl to the femoral neck. Additionally, the muscle belly is also stitched to the capsule inferiorly & superiorly. The suction drain is kept at the hip & iliac crest site and wound is closed in layers. In bilateral cases, the similar

procedure is performed in the same sitting on the opposite side.

Postoperatively the limb-Hip is kept in 20-degree abduction and 30 degree flexion and 10 degree of internal rotation to avoid tension on the vascular pedicle. The patient is mobilized

**2.2 Post operative protocol**

**2.1 Operative technique**

Follow-up by clinical and radiological examination was done every 3 months for one year, every six months for next five years and then yearly follow up thereafter. Harris hip score system was used for assessment of the results. The follow up period varied from three to sixteen years. Post operatively Bone scan & Digital subtraction arteriogram was done in twenty patients comprising of ten each in stage II & III, at the end of 12 weeks, which showed hundred percent of patency and viability of the TFL muscle pedicle graft.

### **2.4 Results**

The patients had good clinical improvement with relief from pain and improvement in the range of movements. The radiological improvement was judged by diminishen of density and attempt at revascularization as seen by healing of cystic changes, disappearance of crescent sign and restoration of normal trabecular pattern and shape of femoral head. Almost all patients had good relief from pain with good improvement in the range of movements. As per Harris Hip score results, there was improvement in the score of > 25 points in 70 % cases while in fifty % had improvement in the score of more than 28 points in both the stages. The mean +SD improvement in Harris Hip score at 3 year's follow up was 27.6 + 6.4. The difference in the preoperative and postoperative score across the whole sample was significant (*P <0.05)*

**Stage II:** Seventy percent of stage II hips completely improved without any deterioration and had complete relief from pain. No patient progressed to stage III postoperatively.

**Stage III**: About 20% patients of stage III had residual low intensity pain for about 30 weeks. About 30% patients had painless limp for 24-30 weeks with restriction of flexion beyond 100 Degrees. Eight percent patient (5 patients) progressed to further collapse, got deformed but without any progression to arthrosis. Out of this, in four percent patients (3 patients) surgery of total hip joint was advised.

### **3. Discussion**

Need to treat ischemia of femoral head is becoming more common since many cases are detected in early stages in young patients. One must consider the possibility of osteonecrosis if individual has pain in the vicinity of hip, that had history of chronic alcoholism, corticosteroid consumption, associated disease like sickle cell disease, Gauchers, Gout etc18- 21. Early diagnosis prior to the appearance of radiological changes is crucial in the treatment of ischemic necrosis. Its diagnosis is based on clinical examination and by bone scan, CT, and MRI, as osteonecrosis is the response to the vascular impairment of the bone marrow circulation. X-ray examination is of limited value in early stage, but has importance in staging since it helps in planning the treatment and the prognosis. The X-ray become

Osteonecrosis Femoral Head Treatment by

pedicle grafting, to achieve early revascularization.39, 10, 12.

procedure is easy and is technically not demanding.

three points:

contribute to the disease

Core Decompression and ILIAC CREST-TFL Muscle Pedicle Grafting 117

more predictable pain relief and changed the indications for arthroplasty more consistently than conservative management. However, only core decompression should be avoided, and it must be coupled with bone grafting in the tract of core to avoid iatrogenic fractures.10, 37 Despite many reports on salvage procedure, no method has clearly demonstrated the arrest of disease before subchondral fracture or slow down of the progression of collapse of femoral head and arthrosis. The use of a nonvascularized bone graft, as originally described by Phemister, has had variable success in the treatment of osteonecrosis. Marcus et al28 reported satisfactory clinical results in seven out of eleven hips at the time of short-term follow up (range: 24 years). The other workers concluded that Phemister bone-grafting technique is not effective once collapse has occurred. Boettcher etal.15 reported success in 27 (71%) of 38 hips 6 years after nonvascularized tibial strut grafting. However, a longer-term evaluation (performed at a mean of 14 years postoperatively) that included the original 38 hips in the study by Boettcher et al. found that only 16 (29%) of 56 hips still had a good result.38 Once the crescent sign appears without collapse, it is desirable to couple the bone grafting procedure in addition to the core decompression, preferably vascular or muscle

Vascularized pedicle graft by using part of iliac crest with deep circumflex iliac vessels is more advantageous since high percentage of marrow and osteogenic cells survive within a living graft, which helps for early vascularization10, 40-44. However, muscle pedicle graft using tensor fascia lata graft is very easy and is commonly performed whenever both hips need simultaneous surgery. Muscle pedicle graft using quadratus femoris (Meyers procedure) 11 was also propagated in the treatment of osteonecrosis, but it did not achieve satisfactory early revascularization and went into disrepute since the results were not encouraging, though Meyers reported the success rate of 57% and Baksi12 reported 93% good results. Use of tensor fascia lata graft is commonly advocated when bilateral hips are involved and surgery is performed in the single sitting. The study by Plakseychuk et al42, 43 on free vascular fibular grafting showed better clinical results and prevention of radiographic signs of progression and collapse of the femoral head more frequently than does nonvascularized fibular grafting. A marked difference with regard to signs of radiographic progression and collapse was noted between the A and B subgroups in the precollapse groups (Stages I, and II). The potential disadvantages of vascularized fibular grafting are a longer operation time, need of microvascular technique, leaves a longer operative scar, and is associated with more donor site morbidity such as ankle instability, toe-clawing, subtrochanteric fracture, and heterotopic ossification. To achieve early vascularization TFL muscle pedicle grafting along with iliac crest is very useful. This

The TFL grafting provides a significant benefit for hips in Stages II and III. The rationale of this procedure (Fig 4A-4F, Fig 5A-5E) of TFL pedicle bone grafting is based on the following

1. Decompression of the femoral head, which acts as compartment syndrome following increased intraosseous pressure and interrupts the circulation that is thought to

3. Filling of the defect that is created after core and filled with TFL muscle pedicle with iliac crest, acts, an osteoinductive cancellous graft, which is viable and supports the

2. Excision of the necrotic tissue, which inhibits revascularization of the head

subchondral surface and enhances the revascularization process.

positive late in the condition after the process of repair has started. The ischemic death of bony and marrow tissues occur in osteonecrosis. Different imaging modalities provide different information on the mineralized and non-mineralized component of the bone. Though bone scan is also important, MRI has dramatically improved the diagnosis of osteonecrosis, and in about 30-70% cases of femoral head osteonecrosis, the other hip is affected in due course of time18, 22. Hence, it is necessary to rule out early involvement of the contralateral hip, which is asymptomatic by either bone scan or MRI. MRI is the most accurate imaging modality for the diagnosis of osteonecrosis of femoral head, especially in the early stages when there are only bone marrow changes23. Characteristic MRI signal alterations in the anterosuperior portion of the femoral head surrounded by a band of low signal intensity on T1- and T2-weighted images represent the diagnostic criteria of osteonecrosis25-27. The occurrence of a double-line sign on the T2-weighted image represents a pathognomonic sign, but its absence does not rule out the diagnosis of osteonecrosis. Marcus et al., Steinberg et al., Ficat and Arlet, and ARCOs classification28,7,8-29 are the various staging systems in vogue for diagnosis of osteonecrosis, but with inherent problems of low reliability. The Association Research Circulation Osseous (ARCO) has proposed a new international classification system including radiographs, computed tomography (CT), bone scans, and MRI8. This classification system incorporates the lesion size and the lesion location. Quantitation (% area involvement of femoral head, length of crescent sign, % surface collapse, and dome depression) and location of the lesion (medial, central or lateral) represent important prognostic factors. This ARCOs classification has been proposed as the preferred system for the future, which is used in this study.

Core decompression offers the opportunity to study histological changes of early bone ischemia. It also achieves reduction in the symptoms of pre-collapse stage of ischemic necrosis because of reduction of pressure in the compartment. Barring exceptional circumstances, there is hardly any role of conservative treatment of osteonecrosis of femoral head and surgery is rendered inevitable.

Steinberg et al. reported that progression occurred in 92% of 48 hips that had undergone nonoperative management30,31. While observing the patients with protected weight bearing, more than 85% patients had collapse of femoral head at 2 years when symptomatic hips with stage I and II were left untreated. Many studies have shown that nonoperative treatment yields poor results. The only condition for which the protected weight bearing might be effective is a type A lesion i.e. involvement of medial aspect of femoral head. No drugs have been useful and specific in the treatment of osteonecrosis, though recently the use of Alendronate has been advised. Once diagnosed, it is desirable to subject the patient to early surgical intervention. Rationale for the treatment of osteonecrosis of femoral head requires a lot of consideration. Prime consideration should be given to the age of the patient, whether both hips are affected, etiology of the associated diseases, functional demands of the patients, and the stage of the disease when the patient presents for treatment. Only core decompression may relieve the pain but is not useful for revascularization of femoral head; hence, core decompression should always be supplemented by one of the procedures of bone grafting. Core decompression is an effective treatment in the pre-radiological and precollapse stage of avascular necrosis of the femoral head, 18, 32, 33 especially if coupled with bone grafting. Jones analyzed nine studies and showed that in 218 of 369 patients (59%), where core decompression was performed in the precollapse stage, failed to prevent the progressive collapse34-36. Steinberg et al19,30,31 concluded that core decompression provided

positive late in the condition after the process of repair has started. The ischemic death of bony and marrow tissues occur in osteonecrosis. Different imaging modalities provide different information on the mineralized and non-mineralized component of the bone. Though bone scan is also important, MRI has dramatically improved the diagnosis of osteonecrosis, and in about 30-70% cases of femoral head osteonecrosis, the other hip is affected in due course of time18, 22. Hence, it is necessary to rule out early involvement of the contralateral hip, which is asymptomatic by either bone scan or MRI. MRI is the most accurate imaging modality for the diagnosis of osteonecrosis of femoral head, especially in the early stages when there are only bone marrow changes23. Characteristic MRI signal alterations in the anterosuperior portion of the femoral head surrounded by a band of low signal intensity on T1- and T2-weighted images represent the diagnostic criteria of osteonecrosis25-27. The occurrence of a double-line sign on the T2-weighted image represents a pathognomonic sign, but its absence does not rule out the diagnosis of osteonecrosis. Marcus et al., Steinberg et al., Ficat and Arlet, and ARCOs classification28,7,8-29 are the various staging systems in vogue for diagnosis of osteonecrosis, but with inherent problems of low reliability. The Association Research Circulation Osseous (ARCO) has proposed a new international classification system including radiographs, computed tomography (CT), bone scans, and MRI8. This classification system incorporates the lesion size and the lesion location. Quantitation (% area involvement of femoral head, length of crescent sign, % surface collapse, and dome depression) and location of the lesion (medial, central or lateral) represent important prognostic factors. This ARCOs classification has been proposed as the

Core decompression offers the opportunity to study histological changes of early bone ischemia. It also achieves reduction in the symptoms of pre-collapse stage of ischemic necrosis because of reduction of pressure in the compartment. Barring exceptional circumstances, there is hardly any role of conservative treatment of osteonecrosis of femoral

Steinberg et al. reported that progression occurred in 92% of 48 hips that had undergone nonoperative management30,31. While observing the patients with protected weight bearing, more than 85% patients had collapse of femoral head at 2 years when symptomatic hips with stage I and II were left untreated. Many studies have shown that nonoperative treatment yields poor results. The only condition for which the protected weight bearing might be effective is a type A lesion i.e. involvement of medial aspect of femoral head. No drugs have been useful and specific in the treatment of osteonecrosis, though recently the use of Alendronate has been advised. Once diagnosed, it is desirable to subject the patient to early surgical intervention. Rationale for the treatment of osteonecrosis of femoral head requires a lot of consideration. Prime consideration should be given to the age of the patient, whether both hips are affected, etiology of the associated diseases, functional demands of the patients, and the stage of the disease when the patient presents for treatment. Only core decompression may relieve the pain but is not useful for revascularization of femoral head; hence, core decompression should always be supplemented by one of the procedures of bone grafting. Core decompression is an effective treatment in the pre-radiological and precollapse stage of avascular necrosis of the femoral head, 18, 32, 33 especially if coupled with bone grafting. Jones analyzed nine studies and showed that in 218 of 369 patients (59%), where core decompression was performed in the precollapse stage, failed to prevent the progressive collapse34-36. Steinberg et al19,30,31 concluded that core decompression provided

preferred system for the future, which is used in this study.

head and surgery is rendered inevitable.

more predictable pain relief and changed the indications for arthroplasty more consistently than conservative management. However, only core decompression should be avoided, and it must be coupled with bone grafting in the tract of core to avoid iatrogenic fractures.10, 37 Despite many reports on salvage procedure, no method has clearly demonstrated the arrest of disease before subchondral fracture or slow down of the progression of collapse of femoral head and arthrosis. The use of a nonvascularized bone graft, as originally described by Phemister, has had variable success in the treatment of osteonecrosis. Marcus et al28 reported satisfactory clinical results in seven out of eleven hips at the time of short-term follow up (range: 24 years). The other workers concluded that Phemister bone-grafting technique is not effective once collapse has occurred. Boettcher etal.15 reported success in 27 (71%) of 38 hips 6 years after nonvascularized tibial strut grafting. However, a longer-term evaluation (performed at a mean of 14 years postoperatively) that included the original 38 hips in the study by Boettcher et al. found that only 16 (29%) of 56 hips still had a good result.38 Once the crescent sign appears without collapse, it is desirable to couple the bone grafting procedure in addition to the core decompression, preferably vascular or muscle pedicle grafting, to achieve early revascularization.39, 10, 12.

Vascularized pedicle graft by using part of iliac crest with deep circumflex iliac vessels is more advantageous since high percentage of marrow and osteogenic cells survive within a living graft, which helps for early vascularization10, 40-44. However, muscle pedicle graft using tensor fascia lata graft is very easy and is commonly performed whenever both hips need simultaneous surgery. Muscle pedicle graft using quadratus femoris (Meyers procedure) 11 was also propagated in the treatment of osteonecrosis, but it did not achieve satisfactory early revascularization and went into disrepute since the results were not encouraging, though Meyers reported the success rate of 57% and Baksi12 reported 93% good results. Use of tensor fascia lata graft is commonly advocated when bilateral hips are involved and surgery is performed in the single sitting. The study by Plakseychuk et al42, 43 on free vascular fibular grafting showed better clinical results and prevention of radiographic signs of progression and collapse of the femoral head more frequently than does nonvascularized fibular grafting. A marked difference with regard to signs of radiographic progression and collapse was noted between the A and B subgroups in the precollapse groups (Stages I, and II). The potential disadvantages of vascularized fibular grafting are a longer operation time, need of microvascular technique, leaves a longer operative scar, and is associated with more donor site morbidity such as ankle instability, toe-clawing, subtrochanteric fracture, and heterotopic ossification. To achieve early vascularization TFL muscle pedicle grafting along with iliac crest is very useful. This procedure is easy and is technically not demanding.

The TFL grafting provides a significant benefit for hips in Stages II and III. The rationale of this procedure (Fig 4A-4F, Fig 5A-5E) of TFL pedicle bone grafting is based on the following three points:

Osteonecrosis Femoral Head Treatment by

TH

Core Decompression and ILIAC CREST-TFL Muscle Pedicle Grafting 119

Fig. 5. 5A – X ray showing Alcohol induced ON both sides in 45 years male

Fig. 5. 5B, 5C – MRI showing classical changes of AVN both femoral heads

graft and showing good restoration of articular surface

Fig. 5. 5D, 5E – 12 months PO CD & TFL graft in one sitting showing good incorporation of

VS

Fig. 4. 4A, 4B – X ray showing Alcohol induced ON right side in 36 years male

Fig. 4. 4C, 4D – MRI showing ON femoral head right side

Fig. 4. 4E, 4F – X ray showing good incorporation of TFL graft maintenance of articular surface of femoral head at the end of 2 years follow up

Fig. 4. 4A, 4B – X ray showing Alcohol induced ON right side in 36 years male

Fig. 4. 4E, 4F – X ray showing good incorporation of TFL graft maintenance of articular

Fig. 4. 4C, 4D – MRI showing ON femoral head right side

surface of femoral head at the end of 2 years follow up

VS

Fig. 5. 5B, 5C – MRI showing classical changes of AVN both femoral heads

Fig. 5. 5D, 5E – 12 months PO CD & TFL graft in one sitting showing good incorporation of graft and showing good restoration of articular surface

Osteonecrosis Femoral Head Treatment by

Fig. 6. 6C, 6D – MRI showing bilateral ON in 52 years male

left side

**4. Conclusion**

Core Decompression and ILIAC CREST-TFL Muscle Pedicle Grafting 121

and TFL muscle pedicle grafting are a choice of surgery, especially in bilateral cases and patients with Sickle cell disease with stage II and III. Out of 68 patients, only five patients progressed to collapse, and surgery of joint replacement was advised in three patients.

Fig. 6. 6E, 6F – PO 1 year X ray showing collapse of femoral head with arthritic changes left side, good incorporation of graft right side with good joint space. Patient is advised THA

Basically osteonecrosis of femoral head is a multifactorial, heterogeneous group of disorder that leads to final common pathology of mechanical failure of femoral head. In this study more than seventy percent patients had osteonecrosis because of alcohol abuse (42%) & steroid consumption (30%) and in 28 percent cases belonged to Sickle cell disease. It is common in young age group where conservative surgical approach is chosen, than a radical approach of reconstructive surgery. If diagnosed early head preserving operation of core decompression and TFL Muscle pedicle bone grafting yields excellent result. Essentially the result depends on the preoperative condition of the joint and the site of necrotic focus and the associated disease, which may be the cause of osteonecrosis. From our experience, if the

It does not require advanced training of microsurgical technique nor any special equipment and can be performed by any average orthopaedic surgeon. Morbidity of the donor site is minimal and operative time required is comparable to total hip arthroplasty, and all problems and obstacles associated with vascularized fibular graft are avoided by this technique. Head-preserving operation of core decompression and TFL pedicle grafting certainly gives excellent results in stages II and III. The prognosis of stages II and III is fairly good, whereas in stage IV, it is not satisfactory since about 1/3 of the stage IV group are likely to progress further and may require total hip joint replacement or resurfacing operations. Prosthetic replacement is frequently an unappealing option for patients who have osteonecrosis because many patients are young and the etiological factors associated with the disease are also associated with complications after total hip arthroplasty, hemiarthroplasty, and surface replacement. At our institute, many patients of sickle cell disease with osteonecrosis are studied and treated, by this procedure of TFL Muscle pedicle grafting. Out of 103 patients treated by Urbanaiak et al6 by free vascular fibular grafting, total hip replacement was performed in 34% cases in stages II and III within 5 years. There was survivorship and the probability of conversion within 5 years to THR rate of 11% in stage II and 23% survival for stage III. In the study of Shin Yoon Kim, 38 the rate of conversion to total hip replacement was 13% (three of 23 hips) in the vascularized graft group and 22% (five of 23 hips) in the nonvascularized graft group in comparison only three patients out of 68 of TFL muscle pedicle grafting was advised total hip replacement in the present series at the end of 16 years (Fig 6A-6F). The hips treated with TFL muscle pedicle

Fig. 6. 6A, 6B – X ray showing Alcohol induced ON femoral heads both sides Stage II – Right side, & Stage – III left side in 52 years male

grafting seemed to have less dome depression of the femoral head and the retention of sphericity, probably because of more rapid revascularization and increased osteoinductive potential of the pedicle graft. It has been observed that there is an early failure of total hip replacement in osteonecrosis than in age-matched patients with other diagnosis because of abnormal remodeling of bones and subsidence of prosthesis because of poor quality of proximal femoral bone42. Other contributory factors for failure are ongoing systemic disease, defects in mineral metabolism, use of steroids, and high level of activity in young patients and increased body weight. Hence, we prefer to delay or eliminate the need for hip replacement by performing head-preserving surgeries10, 37, of which core decompression and TFL muscle pedicle grafting are a choice of surgery, especially in bilateral cases and patients with Sickle cell disease with stage II and III. Out of 68 patients, only five patients progressed to collapse, and surgery of joint replacement was advised in three patients.

Fig. 6. 6C, 6D – MRI showing bilateral ON in 52 years male

Fig. 6. 6E, 6F – PO 1 year X ray showing collapse of femoral head with arthritic changes left side, good incorporation of graft right side with good joint space. Patient is advised THA left side

### **4. Conclusion**

120 Bone Grafting

It does not require advanced training of microsurgical technique nor any special equipment and can be performed by any average orthopaedic surgeon. Morbidity of the donor site is minimal and operative time required is comparable to total hip arthroplasty, and all problems and obstacles associated with vascularized fibular graft are avoided by this technique. Head-preserving operation of core decompression and TFL pedicle grafting certainly gives excellent results in stages II and III. The prognosis of stages II and III is fairly good, whereas in stage IV, it is not satisfactory since about 1/3 of the stage IV group are likely to progress further and may require total hip joint replacement or resurfacing operations. Prosthetic replacement is frequently an unappealing option for patients who have osteonecrosis because many patients are young and the etiological factors associated with the disease are also associated with complications after total hip arthroplasty, hemiarthroplasty, and surface replacement. At our institute, many patients of sickle cell disease with osteonecrosis are studied and treated, by this procedure of TFL Muscle pedicle grafting. Out of 103 patients treated by Urbanaiak et al6 by free vascular fibular grafting, total hip replacement was performed in 34% cases in stages II and III within 5 years. There was survivorship and the probability of conversion within 5 years to THR rate of 11% in stage II and 23% survival for stage III. In the study of Shin Yoon Kim, 38 the rate of conversion to total hip replacement was 13% (three of 23 hips) in the vascularized graft group and 22% (five of 23 hips) in the nonvascularized graft group in comparison only three patients out of 68 of TFL muscle pedicle grafting was advised total hip replacement in the present series at the end of 16 years (Fig 6A-6F). The hips treated with TFL muscle pedicle

Fig. 6. 6A, 6B – X ray showing Alcohol induced ON femoral heads both sides Stage II – Right

grafting seemed to have less dome depression of the femoral head and the retention of sphericity, probably because of more rapid revascularization and increased osteoinductive potential of the pedicle graft. It has been observed that there is an early failure of total hip replacement in osteonecrosis than in age-matched patients with other diagnosis because of abnormal remodeling of bones and subsidence of prosthesis because of poor quality of proximal femoral bone42. Other contributory factors for failure are ongoing systemic disease, defects in mineral metabolism, use of steroids, and high level of activity in young patients and increased body weight. Hence, we prefer to delay or eliminate the need for hip replacement by performing head-preserving surgeries10, 37, of which core decompression

SR - 52 years

side, & Stage – III left side in 52 years male

Basically osteonecrosis of femoral head is a multifactorial, heterogeneous group of disorder that leads to final common pathology of mechanical failure of femoral head. In this study more than seventy percent patients had osteonecrosis because of alcohol abuse (42%) & steroid consumption (30%) and in 28 percent cases belonged to Sickle cell disease. It is common in young age group where conservative surgical approach is chosen, than a radical approach of reconstructive surgery. If diagnosed early head preserving operation of core decompression and TFL Muscle pedicle bone grafting yields excellent result. Essentially the result depends on the preoperative condition of the joint and the site of necrotic focus and the associated disease, which may be the cause of osteonecrosis. From our experience, if the

Osteonecrosis Femoral Head Treatment by

16: 747-756.

*275*

*31:257-264.*

223.

16: 747-756.

Williams & Wilkins, 1980.

*Orthop* 1989; 244:60-77

Core Decompression and ILIAC CREST-TFL Muscle Pedicle Grafting 123

[16] Steinberg ME, Brighton CT, Hayken GD et al. Electrical stimulation in the treatment of

[17] Steinberg ME, Hayken GD, Steinberg DR. The conservative management of avascular

[18] Hungerford DS, Jones LC: Diagnosis of osteonecrosis of the femoral head. In Schoutens

[19] Steinberg ME, Hayken GD, and Steinberg DR: A quantitative system for staging

[20] Arlet J, Ficat P*:* Forage-biopsie de la tete femorale dans l'osteonecrose primitive.

[21] Bradway JK, Morrey BF: The natural history of the silent hip in bilateral atraumatic

[22] Mitchell DG, Steinberg ME, Dalinka MK et al: Magnetic resonance imaging of the

[23] Shimizu K, Moriya H, Akita T et al: Prediction of collapse with magnetic resonance

[24] Beltran J, Knight CT, Zuelzer WA et al: Core decompression for avascular necrosis of

[25] Robinson HJ Jr: Success of core decompression in the management of early stages of

[26] Norman A, Bullough P: The radiolucent crescent line: An early diagnostic sign of avascular necrosis of the femoral head. *Bull Hosp Joint Dis* 1963; 24:99-104 [27] Harris WH Tarumatic arthritis of the hip, J Bone Joint Surg(Am) 1969; 51A:738-743. [28] Marcus ND, Enneking WF, Massam RA. The silent hip in idiopathic aseptic necrosis: treatment by bone grafting. *J Bone Joint Surg (Am)* 1973; 55-A: 1351-66. [29] Kerboul M, Thomine J, Postel M et al: The conservative surgical treatment of idiopathic aseptic necrosis of the femoral head. *J Bone Joint Surg* 1974; 56B: 291-296. [30] Steinberg ME, Brighton CT, Hayken GD et al. Electrical stimulation in the treatment of

Ridge, IL, *American Academy of Orthopaedic Surgeons,* 1992, p177.

Hungerford DS. Baltimore; Williams and Wilkins. 1984: 334-337.

avascular necrosis. *J Bone Joint Surg* 1995; 77B: 34-41.

osteonecrosis. *J Arthroplasty* 1993; 8:383-387.

staging. *Radiology* 1990; 175:533-536.

Osteonecrosis of the femoral head – a 1 year follow-up. *Orthop. Clin North Am* 1985;

necrosis of the femoral head. In Bone Circulation. Edited by Arlet A, Ficat RP,

A, Arlet J , Gardeniers JWM, et al (eds): Bone Circulation and Vascularisation in Normal and Pathological Conditions. New York, NY, Plenum Press*, 1993,pp 265-*

Observations histo-pathologiques portant sur huit forgaes*.* Rev Rhumat *1964;*

ischaemic hip: Alterations within the osteonecrotic , viable, and reactive zone. *Clin*

imaging of avascular necrosis of the femoral head. *J Bone Joint Surg* 1994; 76A:215-

the femoral head: Correlation between long-term results and preoperative MR

avascular necrosis: A four-year prospective study. Proceedings of the American Academy of Orthopaedic Surgeons 59th Annual Meeting, Washington DC, Park

Osteonecrosis of the femoral head – a 1 year follow-up. *Orthop. Clin North Am* 1985;

necrosis of the femoral head. In Bone Circulation. Edited by Arlet A, Ficat RP,

[31] Steinberg ME, Hayken GD, Steinberg DR. The conservative management of avascular

[32] Ficat P, Arlet J, Hungerford DS (eds): *Ischaemia and Necrosis of Bone*. Baltimore, MD,

Hungerford DS. Baltimore; Williams and Wilkins. 1984: 334-337.

ischemic necrosis of femoral head is diagnosed early in stage II, & III core decompression and TFL Muscle pedicle grafting gives very good results. In stage III, even if there is slight collapse with deformation, the depressed segment can be elevated and deformity corrected after elevation and bone grafting. Out of 68 patients with 90 hips only five patients progressed to collapse and surgery of joint replacement was advised in three patients of stage III. The long standing effect of surgery were excellent with great improvement in the Harris hip score, achieving improvement in the score between 70-80 points in majority of patients at the final follow up period.

### **5. References**

ischemic necrosis of femoral head is diagnosed early in stage II, & III core decompression and TFL Muscle pedicle grafting gives very good results. In stage III, even if there is slight collapse with deformation, the depressed segment can be elevated and deformity corrected after elevation and bone grafting. Out of 68 patients with 90 hips only five patients progressed to collapse and surgery of joint replacement was advised in three patients of stage III. The long standing effect of surgery were excellent with great improvement in the Harris hip score, achieving improvement in the score between 70-80 points in majority of

[1] Glimcher MJ, Kenzora JE: The biology of osteonecrosis of the human femoral head and

[3] Glimcher MJ, Kenzora JE: The biology of osteonecrosis of the human femoral head and

[4] Kenzora JE, Glimcher MJ: Pathogenesis of idiopathic osteonecrosis: The ubiquitous

[5] Mankin HJ: Nontraumatic necrosis of bone (osteonecrosis). *N Eng J Med* 1992; 326:1473-

[6] Mont MA, Hungerford DS: Non-traumatic avascular necrosis of the femoral head. *J Bone*

[7] Urbaniak JR, Coogan PG, Gunneson EB, et al: Treatment of osteonecrosis of the femoral

[8] Gardeniers JWM: ARCO international classification of osteonecrosis. *ARCO News 1993;*

[9] Steinberg ME, Hayken GD, and Steinberg DR: A quantitative system for staging

[10] Babhulkar SS: Osteonecrosis of femoral head: Treatment by core decompression and vascular pedicle grafting IJO – Vol 43 January Issue 1, March 2009: 27-35 [11] Meyers MH. The treatment of osteonecrosis of the hip with fresh osteochondral

[12] Baksi DP. Treatment of osteonecrosis of the femoral head by drilling and muscle-

[13] Ficat P, Arlet J, Hungerford DS (eds): *Ischaemia and Necrosis of Bone*. Baltimore, MD,

[14] Ficat RP: Idiopathic bone necrosis of the femoral head: Early diagnosis and treatment. *J*

[15] Boettcher WG, Bonfigilo M, Smith K: Non-traumatic necrosis of the femoral head: II.

pedicle bone grafting*. J Bone Joint Surg* (Br) *1991; 73-B: 241-245.*

Experiences in treatment.  *Clini Orthop* 1978; 130: 202-

of its incidence ina variety of conditions. *Clin Orthop* 1972; 86:43-62.

organ and in the hip joint. *Clin Orthop* 1979; 139:283-312.

hundred and three hips. *J Bone Joint Surg* 1995; 77A: 681-694.

avascular necrosis. *J Bone Joint Surg* 1995; 77B: 34-41.

crescent sign. *Orthop Clin North Am* 1985; 16:681-696.

its clinical implications: Part III. Discussion of the etiology and genesis of the pathological sequelae; comments on treatment*. Clin Orthop* 1979; 140:273-312. [2] Herndon JH, Aufranc OE: Avascular necrosis of the femoral heaad in the adult. A review

its clinical implications: Part II. The pathological changes in the femoral head as an

patients at the final follow up period.

**5. References**

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**8**

*China*

*Orthopaedic Department, Beijing XiYuan Hospital,*

*China Academy of Chinese Medical Science,*

**Treatment of Distal Radius Bone Defects with**

Deng Lei, Ma Zhanzhong, Yang Huaikuo, Xue Lei and Yang Gongbo

In the treatment of distal radius fractures, bone grafting for subchondral bone defects is often used in order to avoid articular surface collapse and radial shortening. At present, the bone graft materials used regularly include autogenous bone, allogeneic bone or heterogenous bone and synthetic materials. Autogenous bone graft has been the gold standard for bone grafting and is the ideal implant bone substitute, but its source is limited[1] [2].Moreover, opening reduction to expose the fracture segment and the donor site of bone will increase blood loss, surgery time and the possibility of infection. Allogeneic bone, although solving the problem of insufficient amount, has the disadvantage of the lack of sources and has the potential for immune response, infection and re-fracture [3][4]. Synthetic calcium sulphate graft has the advantage of good biocompatibility, it is biodegradable and injectable and will set in situ, which makes it an excellent choice for the clinical application of the treatment of distal radius fracture, particularly suitable to be implanted by injection. Its' relatively rapid resorption time and complete resorption will minimize the risks associated with any intra-articular migration, which could be a problem with the much slower resorbing calcium phosphate cements. The authors present a retrospective analysis of the clinical outcome on the treatment of

Over a period of four years, from January 2006 to January 2010, data from 60 patients was reviewed; 42 males and 18 females, ages from 46-68 years old (mean age 56 years old). Fractures were classified to A3 (12 cases), C2 (28 cases) and C3 (20 cases) using AO classification and all had some degree of subchondral bone defects. There were 8 cases treated with closing reduction and 52 cases treated with external fixation. In all cases fractures were implanted with calcium sulfate cement (Stimulan Kit, Biocomposites Ltd.,

distal radius fractures using calcium sulphate cement.

**2. Material and operating technique**

UK) without autogenous bone graft.

**2.1 Patient selection**

**1. Introduction**

**Injectable Calcium Sulphate Cement**

### **Treatment of Distal Radius Bone Defects with Injectable Calcium Sulphate Cement**

Deng Lei, Ma Zhanzhong, Yang Huaikuo, Xue Lei and Yang Gongbo *Orthopaedic Department, Beijing XiYuan Hospital, China Academy of Chinese Medical Science, China*

### **1. Introduction**

124 Bone Grafting

[33] Ficat RP: Idiopathic bone necrosis of the femoral head: Early diagnosis and treatment. *J*

[36] Jones JP Jr*:* Concepts of etiology and early pathogenesis of osteonecrosis. In Schafer M

[37] Babhulkar SS :Osteonecrosis of the femoral head (in young individuals) *Indian Journal of*

[38] Yoon S,Goo Y, Kim PT, Ihn JC, Cho BC, Koo KH. Vascularized compared with

[39] Dutton RO, Amstuz HC, Thomas BJ, Hedley AK Tharies surface replacement for osteonecrosis of femoral head *J Bone Joint Surgery Am* 1982; 64: 1225-1237 [40] Leung PC, Chow YY.:Reconstruction of proximal femoral defects with a vascular-

[41] Leung PC: Vascular bone grafts from iliac crest *Microsurgical technique in Orthopaedics*

[42] Plakseychuk AY, Bogov AA, Plakseychuk YA: vascularised Iliac crest Graft in the

[43] Plakseychuk AY, Kim SY, Park BC, Varitimidis SE, Rubash HE, Sotereanos DG:

[44] Iwata H, Torii S, Hasegawa Y, Itoh H et a.: Indications and results of vascularised

treatment of aseptic necrosis of femoral head; Reconstructive Microsurgery *Current Trends* Proceedings 12th Symposium International Society of Reconstructive

Vascularised compared with nonvascularised fibular bone grafting for the treatment of osteonecrosis of the femoral head. *J Bone Joint Surgery (Am)* 2003;

pedical iliac bone graft in avascular necrosis of femoral head. *Clin Orthop*, 295:281,

pedicled graft *J Bone Joint Surg Br*, Jan 1984; 66-B: 32 – 37

(ed)*:* Instructional Course Lectures 43*. Rosemont, IL, American Academy of*

nonvascularized fibular grafts for large osteonecroic lesion of the femoral head*. J*

[34] Jones JP Jr: Intravascular coagulation and osteonecrosis. *Clin Orthop* 1992; 277:41-53*.* [35] Jones JP Jr Fat embolism, intravascular coagulation, and osteonecrosis *Clin Orthop* 1993

*Bone Joint Surg* 1985; 67B:3-9.

*Orthopaedic Surgeons, 1994, pp 499-512*

*Bone Joint Surg Am 2005; 87:2012-8*

Pho Robert WH, Butterworths; 135-144

Microsurgery, Singapore 1996: 85-87

85:589-96.

1993

*Orthopaedics* Vol.37, No.2; April 2003:77-86

Jul;(292): 294-308

In the treatment of distal radius fractures, bone grafting for subchondral bone defects is often used in order to avoid articular surface collapse and radial shortening. At present, the bone graft materials used regularly include autogenous bone, allogeneic bone or heterogenous bone and synthetic materials. Autogenous bone graft has been the gold standard for bone grafting and is the ideal implant bone substitute, but its source is limited[1] [2].Moreover, opening reduction to expose the fracture segment and the donor site of bone will increase blood loss, surgery time and the possibility of infection. Allogeneic bone, although solving the problem of insufficient amount, has the disadvantage of the lack of sources and has the potential for immune response, infection and re-fracture [3][4]. Synthetic calcium sulphate graft has the advantage of good biocompatibility, it is biodegradable and injectable and will set in situ, which makes it an excellent choice for the clinical application of the treatment of distal radius fracture, particularly suitable to be implanted by injection. Its' relatively rapid resorption time and complete resorption will minimize the risks associated with any intra-articular migration, which could be a problem with the much slower resorbing calcium phosphate cements. The authors present a retrospective analysis of the clinical outcome on the treatment of distal radius fractures using calcium sulphate cement.

### **2. Material and operating technique**

### **2.1 Patient selection**

Over a period of four years, from January 2006 to January 2010, data from 60 patients was reviewed; 42 males and 18 females, ages from 46-68 years old (mean age 56 years old). Fractures were classified to A3 (12 cases), C2 (28 cases) and C3 (20 cases) using AO classification and all had some degree of subchondral bone defects. There were 8 cases treated with closing reduction and 52 cases treated with external fixation. In all cases fractures were implanted with calcium sulfate cement (Stimulan Kit, Biocomposites Ltd., UK) without autogenous bone graft.

Treatment of Distal Radius Bone Defects with Injectable Calcium Sulphate Cement 127

complications; however, only four (3.6%) were attributable to the product. Joseph[7] et al reported complications included persistent nonunion (four patients), wound drainage (five patients), wound drainage and cellulitis (one patient) and cellulitis alone (one patient).

In operation, surgery should pay attention to avoid the cement out and into the soft tissue. If the cement mass close to the major blood vessel and nerve, getting them out by surgery

Fig. 1. Female, 68 years old. Postoperative anteroposterior and lateral image shown good

Fig. 2. At 8 weeks after operation, the picture showed collapse and shortening of distal radius which may be a result of the adjustment of the external fixator too early after the

recommended.

alignment.

surgery.

### **2.2 Calcium sulphate cement filling**

After appropriate fixation, the size of the bone defect was preliminarily measured before cement injection. Puncture needles were inserted into the gaps of fracture defect under fluoroscopic control. Once the needle position was satisfactory the calcium sulphate powder and diluent were mixed. The paste was extruded into the defect cavity until full when viewed under fluoroscopy. The implantation was made in different directions to access all gaps. In all cases 3 - 5cc of paste was used and the whole implantation procedure was completed within 6 minutes.

### **3. Clinical result**

Fractures healed in all cases. All patients were followed up for 4 to 18 months (mean 8 months) and X-ray images were taken for review. The study found that callus appeared in all cases within 2 to 4 months. Most of the calcium sulphate had absorbed within 2 months and all was completely absorbed in 3 months post surgery.

X-ray images for 57 patients demonstrated that the reduction of the fracture was stable and satisfactory, with no fracture side collapse and/or displacement found. 3 cases showed slight collapse which may be a result of the adjustment of the external fixator too early after the surgery.

No foreign body reactions or infection were found in all 60 patients. No complications such as pin loosening dislocation of fixators, injury of blood vessels and radial nerves, pin track infections occurred. According to Mcbride scoring, the results were excellent in 50 cases, good in 7 cases, fair in 1 case and poor in 2 cases, the excellent and good rate being 95%. Two cases had traumatic arthritis and 1 case had wrist joint stiffness.

### **4. Complications**

Significant complications have been rare. In most cases of this group, the external fixators were applied. One case showed slight collapse since corrected the external fixator earlier after reduction, which may be a result of the adjustment of the external fixator too early after the surgery (Fig 1,2). The authors recommend that correcting the external fixator should pay attention to avoid the distal end re-displacement and collapse.

Two patients had radial shortening. Yang D.F[5] analyzed the causes of postoperative radial shortening includes: (1) patients older than 60 years; (2) severe osteoporosis; (3) preoperative displacement and comminuted fractures; (4) inappropriate fixation methods; (5) inadequate bone graft; (6) premature load. The key points to enhance the treatment outcomes include precise judgement of the fracture type and bone quality, sufficient bone graft, firmly fixed after anatomical reduction and an appropriate plan for early loadless functional exercise. Traumatic arthritis may be avoided or delayed if the above-mentioned causes can be taken into consideration or preventive measures can be taken. (Fig 3)

Sometimes the calcium sulphate cement out of the bone defect area, even outside of the medullary cavity of bone, and the cement may be overflow into soft tissue. It may be a stimulant to irritate cellulitis of soft tissue. Kelly Cynthia[6] et al reported in a prospective, nonrandomized, multicenter study, and 109 patients with bone defects were treated with a surgical grade calcium sulfate preparation as a bone graft substitute. There were 13 complications; however, only four (3.6%) were attributable to the product. Joseph[7] et al reported complications included persistent nonunion (four patients), wound drainage (five patients), wound drainage and cellulitis (one patient) and cellulitis alone (one patient).

In operation, surgery should pay attention to avoid the cement out and into the soft tissue. If the cement mass close to the major blood vessel and nerve, getting them out by surgery recommended.

126 Bone Grafting

After appropriate fixation, the size of the bone defect was preliminarily measured before cement injection. Puncture needles were inserted into the gaps of fracture defect under fluoroscopic control. Once the needle position was satisfactory the calcium sulphate powder and diluent were mixed. The paste was extruded into the defect cavity until full when viewed under fluoroscopy. The implantation was made in different directions to access all gaps. In all cases 3 - 5cc of paste was used and the whole implantation procedure was

Fractures healed in all cases. All patients were followed up for 4 to 18 months (mean 8 months) and X-ray images were taken for review. The study found that callus appeared in all cases within 2 to 4 months. Most of the calcium sulphate had absorbed within 2 months

X-ray images for 57 patients demonstrated that the reduction of the fracture was stable and satisfactory, with no fracture side collapse and/or displacement found. 3 cases showed slight collapse which may be a result of the adjustment of the external fixator too early after

No foreign body reactions or infection were found in all 60 patients. No complications such as pin loosening dislocation of fixators, injury of blood vessels and radial nerves, pin track infections occurred. According to Mcbride scoring, the results were excellent in 50 cases, good in 7 cases, fair in 1 case and poor in 2 cases, the excellent and good rate being 95%.

Significant complications have been rare. In most cases of this group, the external fixators were applied. One case showed slight collapse since corrected the external fixator earlier after reduction, which may be a result of the adjustment of the external fixator too early after the surgery (Fig 1,2). The authors recommend that correcting the external fixator should pay

Two patients had radial shortening. Yang D.F[5] analyzed the causes of postoperative radial shortening includes: (1) patients older than 60 years; (2) severe osteoporosis; (3) preoperative displacement and comminuted fractures; (4) inappropriate fixation methods; (5) inadequate bone graft; (6) premature load. The key points to enhance the treatment outcomes include precise judgement of the fracture type and bone quality, sufficient bone graft, firmly fixed after anatomical reduction and an appropriate plan for early loadless functional exercise. Traumatic arthritis may be avoided or delayed if the above-mentioned

Sometimes the calcium sulphate cement out of the bone defect area, even outside of the medullary cavity of bone, and the cement may be overflow into soft tissue. It may be a stimulant to irritate cellulitis of soft tissue. Kelly Cynthia[6] et al reported in a prospective, nonrandomized, multicenter study, and 109 patients with bone defects were treated with a surgical grade calcium sulfate preparation as a bone graft substitute. There were 13

causes can be taken into consideration or preventive measures can be taken. (Fig 3)

**2.2 Calcium sulphate cement filling**

and all was completely absorbed in 3 months post surgery.

Two cases had traumatic arthritis and 1 case had wrist joint stiffness.

attention to avoid the distal end re-displacement and collapse.

completed within 6 minutes.

**3. Clinical result**

the surgery.

**4. Complications**

Fig. 1. Female, 68 years old. Postoperative anteroposterior and lateral image shown good alignment.

Fig. 2. At 8 weeks after operation, the picture showed collapse and shortening of distal radius which may be a result of the adjustment of the external fixator too early after the surgery.

Treatment of Distal Radius Bone Defects with Injectable Calcium Sulphate Cement 129

implant material combined with BMP claiming osteoinductive activity. The characteristics of calcium sulfate can meet the criteria of an ideal bone substitute and is therefore of value in

For larger bone defects caused by trauma, the routine treatment involves bone grafting. When filling with calcium sulfate or other synthetic bone materials (pellet or granules are used commonly), the method of implantation is the same as the traditional bone grafting. However, for irregular shaped defects, pellets/granules tend to be filled by an open procedure, and also are difficult to fill into every corner. Only tightly filling can maximize the likelihood of consolidation of fracture fragments, by providing an effective scaffold for bone conduction. As calcium sulphate cement can be shaped and adapted to any irregular shapes of defect, it can overcome the disadvantages presented by granular materials. In addition, when set, it helps the defect area resists loading forces. In this study, all 60 patients with distal radial fractures combined with subchondral bone defects were treated by using injectable calcium sulphate cement to fill the defects. It was simple to inject the calcium sulphate cement and the results were satisfactory. In addition, because of the use of a minimally invasive technique, it minimized disturbing the fracture site blood supply and interference with the fracture region, and supported the biological basis of fracture healing as scheduled. Bavonratanavech[11] *et al* has also recently reported on the use of injectable cement (calcium phosphate) to treat fresh distal radius fractures, and concluded that it has the advantages of convenient use of injection, supporting metaphysis, reducing both operation time and the risk of infection with reliable healing results. The authors would not recommend any adjustment to the external fixation equipment between 1.5 and 2 months after surgery as the mean absorption time of the injectable calcium sulphate cement was 2.5 months and there is a potential risk of displacement of fracture segments prior to healing. In this study, one case presented with a slight distal radius collapse at 6 weeks after surgery when adjusting the external fixator. It was speculated it may be related with the time of adjustment in addition to the serious degree of comminuted fractures and insufficient

Lobenhoffer[12] *et al* retrospectively analyzed 26 cases sustaining unstable tibial plateau fractures. 25 cases were open reduction with plates and screws for fixation and one case was closed reduction. In all cases calcium phosphate cement (Norian SRS, Synthes) was injected into the condyle bone defects. Mean follow-up time for all cases was 19.7 months. In all cases no re-displaced fracture was evident. The authors believed that the synthetic bone cement used has the advantage of high safety, good supporting strength and avoiding the need for autogenous bone graft. The cement could be arbitrarily shaped and completely fill the defect. In addition treatment allowed passive exercises of the limbs at an average of 4.5

Calcium sulphate is not commonly expected to show bone induction ability as it is considered a simple inorganic salt. However, Walsh [13] et al used immunostaining methods and found that it increased the amount of BMP (bone morphogenic protein), IgG (immunoglobulin G), PDGF (platelet derived growth factor) and TGF-β (transforming growth factor-beta) and other important factors in new bone formation sites. Following implantion of calcium sulfate in bone defects, it may promote the fracture healing process through a variety of ways and Gitelis[14] reported that calcium sulphate was a good substitute for autogenous bone. In this study, results have indicated that although the

clinical application.

cement filling.

weeks after surgery.

Fig. 3. Male, 54 years old. Distal radius fracture and plaster splint was used after injury. No bone grafting and fixator were giving. Three months later, distal radius collapse and malunion, and traumatic arthritis occurred. Distal ulna-ectomy was given for improve the function of the wrist.

### **5. Discussion**

The routine clinical treatment of distal radius fractures is closed reduction and/or external fixation. As the fracture is commonly to the metaphyseal joint, particularly in the elderly, it is easy to cause fracture displacement, collapse, distal radioulnar joint instability and shortening of the radius following reduction because of unstable fixation. Although open reduction can help reduce the occurrence of fracture re-displacement with internal fixation, it is difficult to achieve anatomical reduction on complex and comminuted fractures. Also there is risk of infection. The ability to carry out closed reduction, effectively maintaining bone fragment stability and good alignment of the distal radioulnar joint is a key issue. In recent years, many surgeons prefer to use external fixation plus metaphyseal bone grafting to treat distal radius bone fractures[8,9,10], such as leverage reduction and bone graft. intramedullary implant with bone graft, insert pin with bone graft etc, and this technique has achieved satisfactory results. The authors retrospectively analyzed 60 patients who sustained such fractures and showed that external fixation combined with minimally invasive injection of calcium sulphate bone cement is an excellent method to treat distal radius bone defects.

### **5.1 Synthetic calcium sulfate cement**

In recent years, many biomedical scientists have carried out research to find the ideal bone substitute with mechanical strength, excellent biocompatibility, and with osteoconductive and osteoinductive properties. The bone substitute should be fully biodegradable with an absorption rate similar to the rate of new bone formation. Commonly used bone graft substitutes include heterogeneous bone, polymers and biologically active ceramics (hydroxyapatite and tricalcium phosphate) which have no osteoinductive activity and some

Fig. 3. Male, 54 years old. Distal radius fracture and plaster splint was used after injury. No bone grafting and fixator were giving. Three months later, distal radius collapse and malunion, and traumatic arthritis occurred. Distal ulna-ectomy was given for improve the

The routine clinical treatment of distal radius fractures is closed reduction and/or external fixation. As the fracture is commonly to the metaphyseal joint, particularly in the elderly, it is easy to cause fracture displacement, collapse, distal radioulnar joint instability and shortening of the radius following reduction because of unstable fixation. Although open reduction can help reduce the occurrence of fracture re-displacement with internal fixation, it is difficult to achieve anatomical reduction on complex and comminuted fractures. Also there is risk of infection. The ability to carry out closed reduction, effectively maintaining bone fragment stability and good alignment of the distal radioulnar joint is a key issue. In recent years, many surgeons prefer to use external fixation plus metaphyseal bone grafting to treat distal radius bone fractures[8,9,10], such as leverage reduction and bone graft. intramedullary implant with bone graft, insert pin with bone graft etc, and this technique has achieved satisfactory results. The authors retrospectively analyzed 60 patients who sustained such fractures and showed that external fixation combined with minimally invasive injection of calcium sulphate bone cement is an excellent method to treat distal

In recent years, many biomedical scientists have carried out research to find the ideal bone substitute with mechanical strength, excellent biocompatibility, and with osteoconductive and osteoinductive properties. The bone substitute should be fully biodegradable with an absorption rate similar to the rate of new bone formation. Commonly used bone graft substitutes include heterogeneous bone, polymers and biologically active ceramics (hydroxyapatite and tricalcium phosphate) which have no osteoinductive activity and some

function of the wrist.

radius bone defects.

**5.1 Synthetic calcium sulfate cement**

**5. Discussion**

implant material combined with BMP claiming osteoinductive activity. The characteristics of calcium sulfate can meet the criteria of an ideal bone substitute and is therefore of value in clinical application.

For larger bone defects caused by trauma, the routine treatment involves bone grafting. When filling with calcium sulfate or other synthetic bone materials (pellet or granules are used commonly), the method of implantation is the same as the traditional bone grafting. However, for irregular shaped defects, pellets/granules tend to be filled by an open procedure, and also are difficult to fill into every corner. Only tightly filling can maximize the likelihood of consolidation of fracture fragments, by providing an effective scaffold for bone conduction. As calcium sulphate cement can be shaped and adapted to any irregular shapes of defect, it can overcome the disadvantages presented by granular materials. In addition, when set, it helps the defect area resists loading forces. In this study, all 60 patients with distal radial fractures combined with subchondral bone defects were treated by using injectable calcium sulphate cement to fill the defects. It was simple to inject the calcium sulphate cement and the results were satisfactory. In addition, because of the use of a minimally invasive technique, it minimized disturbing the fracture site blood supply and interference with the fracture region, and supported the biological basis of fracture healing as scheduled. Bavonratanavech[11] *et al* has also recently reported on the use of injectable cement (calcium phosphate) to treat fresh distal radius fractures, and concluded that it has the advantages of convenient use of injection, supporting metaphysis, reducing both operation time and the risk of infection with reliable healing results. The authors would not recommend any adjustment to the external fixation equipment between 1.5 and 2 months after surgery as the mean absorption time of the injectable calcium sulphate cement was 2.5 months and there is a potential risk of displacement of fracture segments prior to healing.

In this study, one case presented with a slight distal radius collapse at 6 weeks after surgery when adjusting the external fixator. It was speculated it may be related with the time of adjustment in addition to the serious degree of comminuted fractures and insufficient cement filling.

Lobenhoffer[12] *et al* retrospectively analyzed 26 cases sustaining unstable tibial plateau fractures. 25 cases were open reduction with plates and screws for fixation and one case was closed reduction. In all cases calcium phosphate cement (Norian SRS, Synthes) was injected into the condyle bone defects. Mean follow-up time for all cases was 19.7 months. In all cases no re-displaced fracture was evident. The authors believed that the synthetic bone cement used has the advantage of high safety, good supporting strength and avoiding the need for autogenous bone graft. The cement could be arbitrarily shaped and completely fill the defect. In addition treatment allowed passive exercises of the limbs at an average of 4.5 weeks after surgery.

Calcium sulphate is not commonly expected to show bone induction ability as it is considered a simple inorganic salt. However, Walsh [13] et al used immunostaining methods and found that it increased the amount of BMP (bone morphogenic protein), IgG (immunoglobulin G), PDGF (platelet derived growth factor) and TGF-β (transforming growth factor-beta) and other important factors in new bone formation sites. Following implantion of calcium sulfate in bone defects, it may promote the fracture healing process through a variety of ways and Gitelis[14] reported that calcium sulphate was a good substitute for autogenous bone. In this study, results have indicated that although the

Treatment of Distal Radius Bone Defects with Injectable Calcium Sulphate Cement 131

Calcium sulphate, as a synthetic bone graft substitute, has demonstrated the capability to support fracture healing. All cases in this study showed callus by X-ray in 2 to 4 months. The average time of bone callus appearing was 2.9 months. Distal radioulnar joint had good

 Fig. 6. Preoperative anteroposterior and lateral X-ray image demonstrated significant dorsal

Fig. 7. Postoperative anteroposterior and lateral X-ray image shown good alignment.

Calcium sulfate filling the defect fully was evident radiographically.

**5.2 Impact on fracture healing**

alignment (Figure 6, 7, 8, 9).

fracture displacement and distal collapse.

calcium sulfate was absorbed in 2 or 3 months, strong bone healing capability was observed. Whether calcium sulphate possesses an osteoinductive function explaining why excellent bone healing is achieved in these patients is yet to be determined. Further *in-vitro* and *invivo* studies are required.

Distal radius fractures, especially classified by AO as A3, B3 and C-type of metaphyseal cancellous bone defect and articular surface collapse, were a good indication to use injectable calcium sulphate cement. In the author's experience, this injection method is suitable for patients who have collapse of the articular surface and a defect larger than 0.5cm and with the gap of cavities less than 2.5cm. An open reduction would be needed if the defect was greater than 2.5cm. The injection needle is usually introduced from the dorsal side, and great care should be taken to avoid over injection of cement to prevent neurovascular compression in the palm side (Fig 4, 5).

Fig. 4. The injection needle is usually introduced from the dorsal side, and great care should be taken to avoid over injection of cement to prevent neurovascular compression in the palm side.

Fig. 5. Postoperative image shown good alignment. Calcium sulfate filling the defect fully but the cement outside of bone defect between distal radius and ulna. Potential risk is irritating soft tissue cellulites.

### **5.2 Impact on fracture healing**

130 Bone Grafting

calcium sulfate was absorbed in 2 or 3 months, strong bone healing capability was observed. Whether calcium sulphate possesses an osteoinductive function explaining why excellent bone healing is achieved in these patients is yet to be determined. Further *in-vitro* and *in-*

Distal radius fractures, especially classified by AO as A3, B3 and C-type of metaphyseal cancellous bone defect and articular surface collapse, were a good indication to use injectable calcium sulphate cement. In the author's experience, this injection method is suitable for patients who have collapse of the articular surface and a defect larger than 0.5cm and with the gap of cavities less than 2.5cm. An open reduction would be needed if the defect was greater than 2.5cm. The injection needle is usually introduced from the dorsal side, and great care should be taken to avoid over injection of cement to prevent

Fig. 4. The injection needle is usually introduced from the dorsal side, and great care should be taken to avoid over injection of cement to prevent neurovascular compression in the

Fig. 5. Postoperative image shown good alignment. Calcium sulfate filling the defect fully but the cement outside of bone defect between distal radius and ulna. Potential risk is

*vivo* studies are required.

palm side.

irritating soft tissue cellulites.

neurovascular compression in the palm side (Fig 4, 5).

Calcium sulphate, as a synthetic bone graft substitute, has demonstrated the capability to support fracture healing. All cases in this study showed callus by X-ray in 2 to 4 months. The average time of bone callus appearing was 2.9 months. Distal radioulnar joint had good alignment (Figure 6, 7, 8, 9).

Fig. 6. Preoperative anteroposterior and lateral X-ray image demonstrated significant dorsal fracture displacement and distal collapse.

Fig. 7. Postoperative anteroposterior and lateral X-ray image shown good alignment. Calcium sulfate filling the defect fully was evident radiographically.

Treatment of Distal Radius Bone Defects with Injectable Calcium Sulphate Cement 133

calcium sulfate and bone callus formation in the implantation site is predictable and simultaneous. Therefore there should be reduced concern if the calcium sulphate is absorbed in 2 or 3 months after surgery if proper external fixation support is achieved.

It is recommended to use injection of calcium sulphate bone graft material in the treatment of comminuted distal radius fractures, especially in metaphyseal fracture defects. Minimally invasive approach causes reduced damage to the tissue, significantly decreasing the risk of infection and accelerating the bone healing. Overfilling or pressurizing the defect site should be avoided. There is the potential to cause a reaction if the bone graft material overspills into the soft tissue, in addition to potential articular cartilage damage if extravasation into the joint space occurs. Kelley and Borrelli reported that 3% to 7% of the site drainage and cellulitis are related to the product itself; such phenomenon requires further clinical investigation. In cases where sterile wound drainage occurs, changing dressings for a few days usually resolves the problem. Bacterial culture or giving prophylactic antibiotics are

Synthetic calcium sulphate bone cement is an ideal choice of bone graft substitute for stabilization and repair of comminuted distal radius fractures by minimally invasive technique and external fixation. The capability to support new bone formation is excellent and the material absorption is 100%. Calcium sulphate also has the advantage of being mouldable such that it can be shaped to fill gaps in bone, in addition to setting hard within a convenient time frame (approximately 10 minutes), combined with good mechanical strength. It can also be injected for minimally invasive surgery. Calcium sulphate is now being used as a carrier for local delivery and slow release of antibiotics, so it is a material with a huge potential clinical application. The use of calcium sulphate to treat distal radial fracture defects coupled with external fixation appears safe and efficacious, if the articular

[1] Song HP & Wang ZQ. (2005). Interference Factors in the Clinical Effects of Bone

[2] Sun SQ & Li BX. (2003). Diseases transmitted after allograft bone grafting. *Chinese Journal of Bone Tumor and Bone Disease,* Vol.2, No.6, (2003), pp. 333-335. Chinese [3] Malinin TI & Brown MD. (1981). Bone Allografts in Spinal Surgery. *Clin Orthop Rel Res,*

[4] Lane JM & Sandhu HS. (1987). Current approaches to experimental bone grafting. *Orthop*

[5] Yang DF et al. (2010). The causes and strategies for the postoperative shortening in distal

[6] Kelly CM et al. (2001). The Use of a Surgical Grade Calcium Sulfate as a Bone Graft

[7] Joseph B et al. Treatment of Nonunions and Osseous Defects with Bone Graft and

radius fractures. *Zhongguo Gu Shang.* V23N8(2010), 581-584

Substitute. *Clin Orthop,* Vol.382, (2001), pp. 42-50

Calcium Sulfate. *Clin Orthop.* 2002, 411-pp: 245-254

Allograft. *Chinese Journal of Bone Tumor and Bone Disease,* Vol.4, No.4, (2005), pp.

surface defect is larger than 0.5cm or the gap of bone cavities is less than 2.5cm.

only needed if it is suspected that an infection is present.

**6. Conclusions**

**7. References**

245-248. Chinese

Vol.154, (1981), pp. 68-73

*Clin North Am,* Vol.18, (1987), pp. 213-25

Fig. 8. Radiologic examination 4 weeks after surgery showed partial resorption of calcium sulphate.

Fig. 9. At 8 weeks after surgery the calcium sulphate was absorbed completely and callus formation and fracture stability was demonstrated. The external fixator was removed.

In the majority of cases it seems that the appearance of callus and new bone were later than the time for material absorption, which means the callus appeared after the cement was absorbed. In this study we found 86% of the patients with calcium sulphate were absorbed within 2 months with the complete absorption at 3 months.

Borrelli[15] et al assessed the calcium sulfate cement had bending and torsional strength comparable with autogenous bone in treated bone defects cases. The authors also observed that calcium sulphate had adequate mechanical strength and believe that the absorption of calcium sulfate and bone callus formation in the implantation site is predictable and simultaneous. Therefore there should be reduced concern if the calcium sulphate is absorbed in 2 or 3 months after surgery if proper external fixation support is achieved.

### **6. Conclusions**

132 Bone Grafting

 Fig. 8. Radiologic examination 4 weeks after surgery showed partial resorption of calcium

 Fig. 9. At 8 weeks after surgery the calcium sulphate was absorbed completely and callus formation and fracture stability was demonstrated. The external fixator was removed.

In the majority of cases it seems that the appearance of callus and new bone were later than the time for material absorption, which means the callus appeared after the cement was absorbed. In this study we found 86% of the patients with calcium sulphate were absorbed

Borrelli[15] et al assessed the calcium sulfate cement had bending and torsional strength comparable with autogenous bone in treated bone defects cases. The authors also observed that calcium sulphate had adequate mechanical strength and believe that the absorption of

within 2 months with the complete absorption at 3 months.

sulphate.

It is recommended to use injection of calcium sulphate bone graft material in the treatment of comminuted distal radius fractures, especially in metaphyseal fracture defects. Minimally invasive approach causes reduced damage to the tissue, significantly decreasing the risk of infection and accelerating the bone healing. Overfilling or pressurizing the defect site should be avoided. There is the potential to cause a reaction if the bone graft material overspills into the soft tissue, in addition to potential articular cartilage damage if extravasation into the joint space occurs. Kelley and Borrelli reported that 3% to 7% of the site drainage and cellulitis are related to the product itself; such phenomenon requires further clinical investigation. In cases where sterile wound drainage occurs, changing dressings for a few days usually resolves the problem. Bacterial culture or giving prophylactic antibiotics are only needed if it is suspected that an infection is present.

Synthetic calcium sulphate bone cement is an ideal choice of bone graft substitute for stabilization and repair of comminuted distal radius fractures by minimally invasive technique and external fixation. The capability to support new bone formation is excellent and the material absorption is 100%. Calcium sulphate also has the advantage of being mouldable such that it can be shaped to fill gaps in bone, in addition to setting hard within a convenient time frame (approximately 10 minutes), combined with good mechanical strength. It can also be injected for minimally invasive surgery. Calcium sulphate is now being used as a carrier for local delivery and slow release of antibiotics, so it is a material with a huge potential clinical application. The use of calcium sulphate to treat distal radial fracture defects coupled with external fixation appears safe and efficacious, if the articular surface defect is larger than 0.5cm or the gap of bone cavities is less than 2.5cm.

### **7. References**

**9**

*Iran*

**Spinal Fusion with Methylmethacrylate Cage**

*Shiraz Neurosciences Research Center, Shiraz University of Medical Sciences, Shiraz,*

A brief history of anterior cervical decompression and fusion (ACDF) surgery is useful. The first reports on ventral approaches to cervical disc pathology appeared in the 1950s. Two most common methods for ACDF were described by Robinson and Smith in 1955 (1) and Cloward in 1958 (2). Robinson and Smith described a surgical procedure for removing cervical disc material in which a rectangular bone graft, obtained from the iliac crest, was replaced to allow a cervical fusion to develop. In Cloward's method, discectomy was performed by a dowel technique. Although numerous modifications have been made to this procedure since the 1950s, a great majority of spine surgeons currently use either the Cloward or the Robinson and Smith's technique. Now, this technique is used in special circumstances. Marked motor deficit or agonizing intractable radicular pain with an appropriate disc imaging is a Principal indication for expedient intervention in root syndromes. Additionally, a myelopathic picture from soft central sequestra is an ordinarily reason for prompt surgery. Chronic persistent brachialgia with nerve root symptoms appropriate to the findings obtained from imaging warrants surgical treatment. Surgery is

In 1911, Albee (4) and Hibbs (5) used spinal fusion for stabilization. Although it was performed to prevent progressive spinal deformity in patients with Pott's disease, the procedure was later used to manage scoliosis and traumatic fractures. Hibbs' method, which was most frequently used, comprised harvesting an autologous bone graft from the laminae and overlaying the bone dorsally. Despite later improvements in this technique, the rate of pseudarthrosis especially in scoliosis remained unacceptably high (6). Robinson and Smith (1) described their technique in 1955 and Cloward (2) described his cervical fusion technique

Each year, more than 185,000 spinal arthrodeses are performed in the United States that most of them are posterolateral lumbar intertransverse process fusions (7). There should be several factors working together to obtain a successful fusion including local environment of

also indicated if there is a tumor or infection that compresses the cord (3).

fusion, systemic factors, and possible use of fusion enhancers.

**1. Introduction**

**1.1 History of spinal fusion**

**1.2 Biology of spine fusion**

in 1958.

Majid Reza Farrokhi and Golnaz Yadollahi Khales

### **Spinal Fusion with Methylmethacrylate Cage**

Majid Reza Farrokhi and Golnaz Yadollahi Khales

*Shiraz Neurosciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran*

### **1. Introduction**

134 Bone Grafting

[8] Zhang Y et al. (2008). Less invasive leverage reduction with external fixator supported

[9] Capo JT et al. (2010). Treatment of extra-articular distal radial malunions with an

[10] Bavonratanavech S et al. (2005). Distal radial fractures: Injectable calcium phosphate

[11] Lobenhoffer P et al. (2002). Use of an Injectable Calcium Phosphate Bone Cement in the

[14] Borrelli J et al. (2002). Treatment of Nonunions and Osseous Defects with Bone Graft

[15] Xu N et al. (2006). The Use of MIIG115-bone graft substitute in the Reconstruction of the

distal end of the radius Comminuted Fracture. *Orthopedic Biomechanics Materials and*

intramedullary implant. *J Hand Surg Am.* 2010V35N6:892-9

Bone Lesions. *Orthopedics,* Vol.2, (2001), pp. 162-166

*Clinical study,* Vol.3, No.2, (2006), pp. 22-24. Chinese

and Calcium Sulfate. *Clin Orthop,*Vol.411, (2002), pp. 245-254

*Chong Jian Wai Ke Za Zhi.* 2008V22N3:314-7

Vol 7. Issue 4, (2005), pp. 368-374

and bone graft for treatment of unstable fractures of distal radius. *Zhongguo Xiu Fu*

bone cement versus conventional treatment. *Chinese Journal of Orthopaedic Trauma,*

Treatment of Tibial Plateau Fractures: A Prospective Study of Twenty-Six Cases with Twenty-Month Mean Follow-Up. *J. Orthop Trauma,* Vol.16, No.3, pp. 143-149 [12] Walsh WR et al. (2003). Response of a Calcium Sulfate Bone Graft Substitute in a Confined Cancellous Defect. *Clin. Orthop.* Vol.406, (2003), pp. 228-236 [13] Gitelis S et al. (2001). Use of a Calcium Sulfate Based bone Graft Substitute for Benign

A brief history of anterior cervical decompression and fusion (ACDF) surgery is useful. The first reports on ventral approaches to cervical disc pathology appeared in the 1950s. Two most common methods for ACDF were described by Robinson and Smith in 1955 (1) and Cloward in 1958 (2). Robinson and Smith described a surgical procedure for removing cervical disc material in which a rectangular bone graft, obtained from the iliac crest, was replaced to allow a cervical fusion to develop. In Cloward's method, discectomy was performed by a dowel technique. Although numerous modifications have been made to this procedure since the 1950s, a great majority of spine surgeons currently use either the Cloward or the Robinson and Smith's technique. Now, this technique is used in special circumstances. Marked motor deficit or agonizing intractable radicular pain with an appropriate disc imaging is a Principal indication for expedient intervention in root syndromes. Additionally, a myelopathic picture from soft central sequestra is an ordinarily reason for prompt surgery. Chronic persistent brachialgia with nerve root symptoms appropriate to the findings obtained from imaging warrants surgical treatment. Surgery is also indicated if there is a tumor or infection that compresses the cord (3).

### **1.1 History of spinal fusion**

In 1911, Albee (4) and Hibbs (5) used spinal fusion for stabilization. Although it was performed to prevent progressive spinal deformity in patients with Pott's disease, the procedure was later used to manage scoliosis and traumatic fractures. Hibbs' method, which was most frequently used, comprised harvesting an autologous bone graft from the laminae and overlaying the bone dorsally. Despite later improvements in this technique, the rate of pseudarthrosis especially in scoliosis remained unacceptably high (6). Robinson and Smith (1) described their technique in 1955 and Cloward (2) described his cervical fusion technique in 1958.

### **1.2 Biology of spine fusion**

Each year, more than 185,000 spinal arthrodeses are performed in the United States that most of them are posterolateral lumbar intertransverse process fusions (7). There should be several factors working together to obtain a successful fusion including local environment of fusion, systemic factors, and possible use of fusion enhancers.

Spinal Fusion with Methylmethacrylate Cage 137

pseudarthrosis, spinal deformity, and poor fusion rate (12). The low stabilizing effect of

Taking bone graft from other species has been reported in the orthopedic literature (14). Despite processes of xenografts, they remain immunogenic and provoke a host response.