One-stage Total Hip Arthroplasty and “Light-bulb” Procedure for Bilateral Non-traumatic Osteonecrosis of Femoral Head in Different Stages
Non-traumatic osteonecrosis of the femoral head (NONFH) is a debilitating condition that often affects both hips, leading to significant pain and functional impairment. In clinical practice, it is not uncommon for patients with bilateral NONFH to present with one hip requiring total hip arthroplasty (THA) and the contralateral hip being asymptomatic or less symptomatic, potentially necessitating hip preservation surgery. The management of such cases poses a unique challenge, as the timing and approach to treatment must balance the immediate need for THA with the long-term goal of preserving the contralateral hip. This study explores the outcomes of a one-stage surgical approach combining THA for the severely affected hip and the “light-bulb” procedure for the contralateral hip, compared to a staged surgical approach.
Background and Rationale
The management of bilateral NONFH often involves addressing the more symptomatic hip with THA while considering hip preservation techniques for the contralateral hip. Theoretically, the hip requiring preservation should be treated prior to or simultaneously with the THA side to optimize outcomes. However, patients may be reluctant to undergo surgery on the asymptomatic or less symptomatic side due to concerns about the necessity or safety of the procedure. This study hypothesizes that a one-stage approach, combining THA and the “light-bulb” procedure, can provide significant benefits for these patients.
Patient Selection and Methodology
The study involved a consecutive series of 26 patients with bilateral NONFH who underwent one-stage THA and contralateral “light-bulb” procedure between January 2013 and January 2018. The control group consisted of 26 age-, gender-, etiology-, stage-, extent-, and follow-up-matched patients who underwent staged surgery during the same period. The etiologies of NONFH in the study group were steroid-induced in 17 patients (65.4%) and alcohol-induced in 9 patients (34.6%). The follow-up period averaged 30.8 months.
Patients were diagnosed with NONFH based on symptoms, physical signs, past medical history, related risk factors, and imaging data. Inclusion criteria for hip preservation surgery included hips in Association Research Circulation Osseous (ARCO) stage II or IIIa, while THA was indicated for hips in ARCO stage IV or ARCO stage IIIb and IIIc with severe pain. Exclusion criteria for hip preservation surgery included patients over 50 years of age, those unable to stop corticosteroid administration due to corticosteroid-dependent diseases, and those who failed to quit alcohol abuse. Patients under 18 years of age were excluded from THA.
Surgical Techniques
Under general anesthesia, THA was performed first, with patients in a lateral decubitus position and a posterolateral approach. Cementless DePuy prostheses were utilized. The “light-bulb” procedure was then carried out through a direct anterior approach (DAA). Autogenous fresh cancellous bone for grafting was harvested from the resected femoral head, femur neck, and proximal femur. Insufficient grafting bone was supplemented with PRODENSETM to prevent donor site morbidity. In the staged surgery group, the same procedures were performed, but the necrotic area after debridement was filled with a combination of PRODENSETM and cancellous bone harvested from the bone window during the “light-bulb” procedure. The interval between surgeries in the two-stage group ranged from 6 to 24 months, with a median of 11 months.
Postoperative Follow-up
Clinical and radiological follow-ups were conducted at 3-month intervals in the first year and 6-month intervals in subsequent years. Clinical outcomes were assessed using the Harris Hip Score (HHS), with clinical failure defined as an HHS of 70 points or less or conversion to THA for any reason. Radiographic failure was defined as collapse greater than 2 mm or premature osteoarthritis.
Outcomes and Comparisons
The one-stage surgery group demonstrated safety comparable to the two-stage surgery group, with no significant difference in total blood loss (373.08 ± 106.20 mL vs. 387.50 ± 78.25 mL, P = 0.497). However, the one-stage group had a longer operative time (157.69 ± 28.51 min vs. 124.38 ± 14.94 min, P < 0.001). Despite the increased operative time, there was no significant difference in complication rates between the two groups (3.8% vs. 7.7%, P = 1.000).
For the THA side, both groups showed significant improvements in HHS, with no statistical difference between the one-stage and two-stage groups (93.58 ± 2.99 points vs. 94.04 ± 2.01 points, P = 0.518). Radiological outcomes for the THA side were also comparable, with no reports of loosening or revision of the hip prosthesis in either group.
For the hip preservation side, the one-stage group demonstrated superior clinical and radiographic outcomes. At the final follow-up, excellent or good results were observed in 73.1% of patients in the one-stage group compared to 46.2% in the two-stage group (P = 0.048). Radiological examination revealed no progression of necrosis in 65.4% of the one-stage group compared to 34.6% in the two-stage group (P = 0.027). Progression in stage and/or extent with minimal or mild symptoms was observed in 19.2% of the one-stage group and 23.1% of the two-stage group (P = 0.734). Conversion to THA was required in 15.4% of the one-stage group and 42.3% of the two-stage group (P = 0.032).
Cost and Hospital Stay
The one-stage approach was associated with significant reductions in medical expenses and hospital stay. The cost per case was reduced by 11,000 RMB Yuan (79,769.23 ± 13,087.10 RMB Yuan vs. 91,034.62 ± 4496.35 RMB Yuan, P < 0.001), constituting a 13% reduction in overall expenses. The hospital stay was also shorter in the one-stage group (11.77 ± 2.58 days vs. 14.84 ± 2.13 days, P < 0.001).
Discussion
For young, active patients with NONFH, hip preservation procedures are prioritized, with the understanding that THA may eventually be required. The “light-bulb” procedure, initially reported by Rosenwasser et al., has shown promising clinical outcomes. Mont et al. reported an 86% success rate with a mean follow-up of 48 months, which is higher than the success rate observed in this study (71.15%; excellent and good rates: 59.62%). The “light-bulb” procedure via DAA is less invasive, with an average operative time of less than one hour and moderate blood loss. In cases of surgical failure, it does not increase the operative difficulty of subsequent THA.
The success of the one-stage treatment approach can be attributed to several factors. Early intervention is crucial, and the one-stage approach avoids unnecessary delays in hip preservation surgery. Autologous bone grafting stimulates bone formation, supports the subchondral bone and articular cartilage, and allows for early non-weight-bearing exercises on the preserved hip, as the weight is distributed to the THA side.
Limitations
The study has several limitations. The retrospective nature and limited sample size may weaken the objective evaluation of outcomes. The procedures discussed are applicable only to a specific subset of patients, and the use of two different bone grafting materials (autologous bone and synthetic bone substitute) may introduce heterogeneity. Long-term follow-up is necessary to further validate the findings.
Conclusion
The one-stage approach combining THA and the “light-bulb” procedure offers significant benefits for patients with bilateral NONFH. It provides superior clinical and radiographic outcomes for the salvaged hip, reduces the rate of conversion to THA, and is cost-effective. While these findings may not necessitate immediate changes in clinical practice, they provide a foundation for future research and potential improvements in the management of bilateral NONFH.
doi.org/10.1097/CM9.0000000000000545
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