Thorough debridement under endoscopic visualization with bone grafting and stabilization for femoral head osteonecrosis in children.
BACKGROUND
Osteonecrosis of the femoral head has become increasingly common after steroid therapy and as a consequence of improved survival in children with sickle cell anemia and leukemia. Multiple operative and nonoperative treatments have been explored in the pediatric patient population, and core decompression is a relatively safe and possibly effective option. To optimize core decompression further, we have tested a new technique involving thorough decompression of the osteonecrotic zone under endoscopic visualization (TDEV) combined with cancellous bone grafting and stabilization with a nail plate device.


METHODS
We retrospectively reviewed 16 hips in 13 patients (< or =20 years old) with femoral head osteonecrosis related to steroid treatment, sickle cell anemia, or leukemia. The Steinberg classification system was used to classify all cases. Each patient underwent TDEV, bone grafting, and stabilization of the grafting site. Patients were followed up postoperatively for changes in pain level, functional ability, and Steinberg radiologic stage.


RESULTS
The mean follow-up was 28 months (range, 18-49 months). All patients in whom the procedure was successful had improvement in pain symptoms at latest follow-up, except for 1. Radiologically, all Steinberg stage II cases (B and C), except for 1, demonstrated good incorporation of graft without further progression of disease. Seven of the 8 patients that showed radiologic progression and deterioration of function or progressive symptoms had grade IIIB disease or higher at the time of procedure.


CONCLUSIONS
Our initial results demonstrate that TDEV combined with cancellous bone grafting and stabilization produces encouraging early results for pediatric patients with lesions graded lower than Steinberg stage IIIB. Our findings were less optimistic for patients with higher-grade lesions. Our recommendation, therefore, is to use TDEV by trained surgeons for treatment of early-stage lesions, preferably less than Steinberg stage IIIB.


METHODS
Level IV, Therapeutic Study.
Wells
Lawrence
L
Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA 19104-4399, USA. WellsL@email.chop.edu
Hosalkar
Harish S
HS
Crawford
Eileen A
EA
Agrawal
Nina
N
Goebel
Jennifer
J
Dormans
John P
JP
D000293:Adolescent; D000755:Anemia, Sickle Cell / Q000150:complications; D001858:Bone Nails; D001860:Bone Plates; D016025:Bone Transplantation / Q000379:methods*; D002648:Child; D003646:Debridement / Q000379:methods*; D018450:Disease Progression; D004724:Endoscopy / Q000379:methods; D005260:Female; D005271:Femur Head Necrosis / Q000209:etiology / Q000601:surgery*; D005500:Follow-Up Studies; D006801:Humans; D007938:Leukemia / Q000150:complications; D008297:Male; D010146:Pain / Q000209:etiology / Q000601:surgery; D012189:Retrospective Studies; D013256:Steroids / Q000009:adverse effects; D055815:Young Adult
D013256:Steroids