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MINISTRY OF EDUCATION MINITRY OF HEALTH AND TRAINING HANOI MEDICAL UNIVERSITY PHAN BA HAI EVALUATION OF THE RESULTS OF TOTAL HIP REPLACEMENT IN PATIENTS WITH AVASCULAR NECROSIS OF THE FEMORAL HEAD AT VIETDUC UNIVERSITY HOSPITAL Specialism : Orthopedic and Plastic surgery Code : 9720104 ABSTRACT OF THESIS HA NOI – 2022 The thesis has been completed at HANOI MEDICAL UNIVERSITY Supervisors: Assoc Prof Ngo Van Toan Reviewer 1: Assoc Prof Luu Hong Hai Reviewer 2: Assoc Prof Dang Hoang Anh Reviewer 3: Assoc Prof Tran Cong Hoan The thesis will be present in front of the board of university examiners and reviewer lever at Hanoi Medical University on … 20… This thesis can be found at: National Medical Informatics Library Library of Hanoi Medical University THE LIST OF PUBLISHED PAPERS RELATED TO THE THESIS Phan Bá Hải, Ngô Văn Toàn (12/2020), Xray and MRI imaging of avascular necrossis of femoral head at Vietduc University Hospital Journal of medicine and pharmacy, No 11, pages 187-192 Phan Bá Hải, Ngô Văn Toàn (1/2021), Avascular necrosis of femoral head: clinical feature, Xray and MRI imaging, and risk factors Journal of community medicine, Vol 62, No 1, pages 12-18 Phan Bá Hải, Ngơ Văn Tồn (12/2021), Clinical outcomes of total hip arthroplasty in patients with avascular necrossis of the femoral head, Vol 62, No 7, pages 68-75 INTRODUCTION Urgency of the study Aseptic necrosis of the femoral head is a disease with necrotic damage to osteocyte and bone marrow cells cause by the interruption of blood supply to the femoral head, which lead to loss of hip joint’s function Conserving surgical methods such as hip core decompression bone grafting are only effective in the early stages, however, the disease tends to progress and become indications for artificial joint replacement Diagnostic imaging methods for AVN such as X-ray and especially magnetic resonance imaging allow early and accurate assessment of lesions On the other hand, hip replacement surgery has become routine with accuracy and efficiency for the patient’s quality of life However, there are no studies in-depth about follow-up after hip replacement surgery to treat ASN and to evaluate the relationship and progression of the disease between the two hip joints on imaging Therefore, we performed the study "Evaluation of the results of total hip replacement in patients with avascular necrosis (AVN) of the femoral head at Viet Duc-University hospital", with two objectives: Analysis of some pathological features of aseptic necrosis of the femoral head on X-ray and Magnetic Resonance Imaging Evaluation of the results of total hip replacement therapy in patients with aseptic necrosis of the femoral head New contributions of the thesis Analysis of some pathological characteristics of AVN on X-ray and MRI This result can be used as a reference for orthopedic surgeons as well as other specialists to further study the pathology, lesion progression on images and give appropriate surgical indications for each stage of the disease Therefore, MRI is an important diagnosis imaging method in early diagnosis of the disease Total hip arthroplasty is one of the most effective and consistently successful surgeries performed in the late stages (III, IV), with an average 25.5 months postoperative follow-up results of 97.5% good and very good The mean Harris score before surgery and after surgery were 54.6 ± 6.7 and 96.7 ± 6.2, respectively Surgery also considered safety with no intra- and postoperative complications This thesis also described some risk factors of the disease, relationships between clinical symptoms, preoperative imaging and postoperative results, which are data to give prognosis and follow-up patients after surgery Moreover, surgeons can learn from these results which help to prevent progression of the disease and increase lifespan of the prosthetic hip Therefore, these results make important contributions to Orthopedic Trauma in diagnosis, operative treatment and postoperative follow-up of AVN In this study, there are appropriate patient data that prove the reliability and effectiveness of the method and can be used as a scientific reference for colleagues Structure of the thesis The thesis consists of 137 pages, of which the introduction is pages, review of related literature and studies is 41 pages, the methodology is 23 pages, presentation, analysis data is 29 pages, discussion 41 pages, results Page The thesis has 44 tables, charts; 194 references, consists of 12 Vietnamese and 182 English documents CHAPTER LITERATURE OVERVIEW 1.1 Aseptic necrosis of the femoral head In 1738 Alexander Munro was the first to describe AVN In 1842 Jean Cruveilhier concluded that necrosis of the femoral head was because of the vascular supply Studies at this stage show that the majority of patients with femoral head necrosis are post-traumatic However, at the same time, the authors also found that the number of patients with primary AVN also increased gradually In diagnosis of AVN, in addition to typical clinical symptoms, a definitive diagnosis of AVN is when patients are having ≥ out of of the criteria, according to the research conference on Special Pathologies in Japan in June 2001 - Femoral head collapse or crescent sign on X-ray - There is partial bone thickening in the femoral head on radiographs (with non-narrow joint space and normal acetabulum) - MRI with hypointense band/line on T1W - Bone scintigraphy shows images of an increased radioactivity among areas of decreased radioactivity (cold in hot) - There are necrotic lesions of bone marrow and trabecular bone on histopathology 1.2 Diagnostic imaging of AVN Diagnostic imaging plays an important role in AVN Value of imaging methods: Methods X-ray CT Bone scintigtaphy Lesion signs osteosclerosis, osteoporosis, subchondral fracture, collapse of femoral head osteosclerosis, osteoporosis, subchondral fracture, collapse of femoral head Early stage: Decrease radioactivity Late stage: Increase readioactivity Diagnosis time Effective Detect disease ability month Bad sensitivity Poor specificity 41% month Bad sensitivity Average specificity 55% week Good sensitivity Bad specificity 76% SPECT Hypoperfusion lesion Day-week MRI Hyper/hypointense lesion Day-week Good sensitivity Average specificity Very good sensitivity Good specificity 85% 94% 1.3 Hip Athroplasty Surgery in treatment of AVN Total Hip Athroplasty is still the last and most efective treatment of late stages AVN, when there is head deformity, dysfunction and degểnation of hip joint Indications: Late stage AVN (III, IV according to ARCO), when the femoral head cannot be treated by conservative treatment 1.3.1 Surgical approach in hip replacement surgery Currently in the world as well as in Vietnam, the posterior lateral incision is the most popular approach because the technique is easier to perform than other incisions, although it also has some disadvantages On the other hand, the anterior, anterolateral, and lateral incisions and less invasive techniques are gradually used 1.3.2 Hip replacement Hemiarthroplasty: is rarely indicated in AVN In hemiarthroplasty, the acetabulum is gradually damaged by abrasion with the metal cup Total hip replacement surgery is often used today because AVN is common in young and middle-aged people, required active movement Besides, with the development of joint replacement techniques, joint generation: materials used, artificial joint structure, uncemented total prothetic hip provide better outcome for patients 1.4 Status of research on AVN pathology and hip replacement surgery 1.4.1 Worldwide clinical studies 1.4.1.2 Researchs on imaging diagnostic methods for AVN - In 1987, Mitchell decribed a classification based on MRI and the relationship between clinical symptoms, MRI, and radiographs in patients with AVN - In 1990, Lee compared the effectiveness of diagnosing AVN methods and recommended MRI for early diagnosis - In 2008, Calder showed that MRI has the ability to detect early AVN with sensitivity of 86%, specificity of 91% - In 2018, Zhang et al published 43 literatures on the diagnostic effectiveness of MRI: most effective in early stage diagnosis with 95% sensitivity and specificity 1.6.1.3 Research on hip replacement surgery - Hamadouche (2005) performed a study with 118 prothetic hips and an average of 20 years of follow-up, the lifespan of the acetabulum is 85.6%; uncemented stem is 84.9% - Ha (2008) treated 46 cases of AVN with Hydroxyapatite coated stem, the survival rate after 13 years was 93.3% - According to Simon in 2011, the 10-year survival rate is 100% After 10 - 15 years of follow-up, acetabular cup loosening rate is increased by - 15% - Kim (2011) performed a long-term follow-up study, with a group of patients under 50 years of age, of which 66% are AVN, the survival rate of the prothesis after 18 years is 96%, - According to Johnson (2014) analyzing the new trend of AVN treatment in the US after 16 years, total hip replacement surgery is the preferred choice, increasing from 75% to 88% of the total methods 1.4.2 In Viet Nam - Nguyen Lan Anh (2006), evaluating the characteristics of AVN lesions according to Arlet - Ficat stages on X-ray, MRI - Luu Thi Binh (2011), has studied clinical symptoms and diagnostic imaging of AVN: MRI has diagnostic efficiency with very high sensitivity and specificity - In 2012, Dao Xuan Thanh followed 83 uncemented prosthetic hips wtih 24 months post-surgery follow-up time Patients with AVN accounted for 44.6% Very good and good result is 95.2% and 1.2%, respectively - In 2015, Ngo Hanh published a research with 96 patients received uncemented prostheis, followed up over 12 months Patients with AVN accounted for 62.5% Very good and good result is 94.12%, quite good 5.88% - In 2017, Mai Dac Viet studied clinical characteristics, histopathology and evaluated the results of AVN in patients with stage IV, V, VI (Steinberg) Very good and good results is 96.7%, 3.3%, respectively CHAPTER 2: MATERIALS AND METHODS 2.1 Research subjects There were 120 patients with AVN were examined, diagnosed and had total uncemented hip arthroplasty from January 2017 to January 2019 at Viet Duc University Hospital 2.1.1 Criteria for patient selection: The patient was diagnosed with primary AVN in stage III, IV according to ARCO's classification and had uncemented total hip arthroplasty for the first time using posterior lateral approach without any contraindications to surgery 2.1.2 Exclusion criteria: Patients who refused to participate in the study or was not alert, mentally ill Patients who having previous hip surgery or having secondary necrosis of the head, hip degeneration that not due to AVN 2.2 Methods: Study Design: A cross-sectional descriptive study with longitudinal follow-up Sample size and sample selection: Convenience sampling 2.3 Content and process: - Patients are clinically examined, taken medical records and laboratory tests - Metal on Polyethylene uncemented total hip arthroplasty(Highly Cross-Linked Polyethylene), neutral stem position - Assess hip joint function by Harris score Lesions staging: ARCO and Mitchell - Patients were taken X-ray of the pelvis and femur with a digital scale on film The CT scanner is a 1.5 Tesla machine X-ray and CT films are stored on PACS film reader software (MicroDicom) 2.4 Surgical method The surgery was performed under spinal anesthesia or endotracheal anesthesia with the patients were positioned in lateral decubitus, lying 90-degree side on the operating table Make an incison along posteriorlateral approach with moderate size Surgeon dissect through the gluteal muscle and the external rotator cuff muscle Incise posterior hip joint capsule with an L or T shaped incision to expose the hip joint Cut the femoral neck about 1cm from the superior border of the lesser trochanter Expose and ream the acetabulum, so that the plane passing through the acetabulum border make an angle with the horizontal plane (oblique angle) about 35-45 degrees At the same time, the axis of the acetabulum is also anteversion about 10-20 degrees Assembling the femoral canal: anteversion prostheitc stem about 15 degrees Change and test stem size to find the exact prothetic stem size Adjust and re-exam the stability, motion range of the prosthesis, and post-implanted lower limb length 2.5 Information collected in the study General patient information, risk factors, clinical symptoms and preoperative diagnostic imaging Intraoperative and postoperative characteristics were recorded until the end of the study period: shortterm outcomes long-term outcomes, complications, assessment of postoperative prosthetic hip radiographic scales 2.6 Data processing The collected data were saved and processed according to medical statistical methods by using SPSS, Stata 10, Excel software 2.7 Ethics in medical research AVN surgical therapy is a common treatment method nowadays and is on the list of surgery of the Ministry of Health The topic has been approved by the Research Ethics Committee of Hanoi Medical University CHAPTER RESULTS 120 patients were diagnosed avascular necrosis and performed total hip cementless arthroplasty at Vietduc University Hospital from 1/2017 to 1/2019 3.1 General characteristics Mean age: 47,7 ± 10 Group age from 31 to 60: 86,67% Ratio Male/female = 11:1 Bilateral AVN: 83,33% 3.2 Clinical characteristics and risk factors associated with AVN of the hip Mean time of disease until operation is 11,19 ± 5,5 months, after months is 93,4% Mean time of disease between two hips of 100 bilateral patients is 5,82 ± 2,14 months Table 3.1 Pain and stage distribution of bilateral of the AVN hip (n=220) Operation side Opposite side Stage Total Pain Painless Pain Painless I 0 13 13 II 0 42 20 62 III 111 25 136 IV 0 Total 120 67 33 220 % 54,5 30,5 15 100 Comment: There are 187/220 hips have pain symptom, ratio is 85% Mechanical pain increasing at night 10 Table 3.6 The lesion area of femoral head on MRI (n = 122) Lesion area Stage I Stage II Stage III Stage IV P n % n % n % 7.1 2.5 15 – 30% 11 85.7 28 67.5 30% 7.1 12 30 59 88.1 100 Total 13 100 41 100 67 100 122 100 100 P12=0.0001 P= 0.0001 * Comment: At early stage, lesion area more common in 15 – 30% group, ratio is 85,7% and 67,5% At lately stage, lesion area in >30% group ratio is 88,1% Table 3.7 Lesion distribution on MRI according to Mitchell classification (n = 122) Early stage Lately stage Signal P I II Total III IV Total Head 21 30 7 A (FatP < 0,05 like) % 55,5 10,3 11 13 4 B (Blood- Head P > 0,05 like) % 24,1 5,8 10 17 17 C (Fluid- Head P > 0,05 like) % 18,5 25,0 Head 1 39 40 D (FibrousP < 0,05 % 1,9 58,9 like) Head 13 41 54 67 68 Total * Comment: Early stage, fatlike (class A) have ratio 55,5% Lately stage, fibrouslike (class D) have ratio 58,9% (P80%, ratio is 79,8% - Acetabular cup inclination angle is 42,2° ± 4,8°, group with angle 40° - 45° has high ratio: 74,2% Table 3.8 The relationship between femoral fit and femoral type (n=120) Femoral fit < 80% ≥ 80% Total P n % n % n % Femoral type A 14.5 53 85.5 62 100 PAB=0.05 B 11 22.4 38 77.6 49 100 PAC=0.028 C 57.1 42.9 100 PBC=0.006 Total 24 20.3 96 79.7 120 100 P= 0.03 * Comment: Femoral fit >80% of femoral type A and B have high ratio: 85,5% and 77,6% There is different from type C (P