Segmental collapse occurs in the early stage of avascular necrosis (AVN) of the femoral head, and is associated with a poor prognosis. Since it develops at a relatively young age, the long-term outcome after total hip replacement is a major concern. We have compared the long-term results of pedicle bone grafting (PBG) with those of transtrochanteric rotational osteotomy (TRO). In the PBG group there were 23 men (27 hips) and three women (4 hips) with a mean age at the time of surgery of 38 years and a mean follow-up of 13 years. In the TRO group there were 44 men (55 hips) and 19 women (22 hips) with a mean age at the time of surgery of 39 years and a mean follow-up of seven years. Failure was defined as a need for total hip replacement or a Harris hip score below 70. The long-term results were similar for the two groups. The survival rates at five and ten years were 85% and 67%, respectively, in the PBG group, and 71% and 61%, respectively, in the TRO group, according to Kaplan-Meier survivorship analysis. In the TRO group patients in stage II had significantly better results that those in stage III.

We investigated the results of 31 hips in 26 patients with nontraumatic (n = 20) and steroid-induced (n = 6) avascular necrosis of the femoral head (ANFH) treated with vascularized iliac pedicle bone graft (PBG). The average age at operation was 38.3 years. Three were women and 23 men. The average follow-up was 8.0 years. The Harris hip score prior to operation and at latest follow-up improved from 62 to 83; one hip collapsed and was revised with a bipolar endoprosthesis. At the final follow-up, 19 hips (63%) were clinically rated as good to excellent, 4 fair, and 7 poor. At the final follow-up, 15 of 27 hips (56%) of stage II before operation showed progressive collapse after bone grafting. In steroid-induced ANFH, in three women, 2 of 4 hips showed poor results. These results are only slightly better than those of core decompression and no better than those obtained after decompression and simple nonvascularized grafts to provide support for the subchondral bone. We concluded that vascularized PBG is sometimes indicated for ANFH in an early stage before collapse of the femoral head.

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We reviewed 48 hips in 43 patients 3-7.1 years (average 4.6 years) after Sugioka transtrochanteric rotational osteotomy for osteonecrosis of the femoral head. The average age at operation was 41 years. Thirty-four patients were men and 9 women. Overall results at the final follow-up were satisfactory in 30 hips (62%). Kaplan-Meier's survivorship was 62% at 3 years and 60% at 5 years postoperatively. Six hips for which the ratio of the intact area of the articular surface on the preoperative lateral radiograph was less than 30% showed further collapse. Five hips were converted to bipolar hemiarthroplasties or total hip arthroplasties. Complications, such as varus deformity, subtrochanteric fracture, and ectopic bone formation, occurred in eight hips. Five of them were operated on in the first 2 years of this series. Three of these five operations had unsatisfactory results. We conclude that satisfactory results can be achieved using this osteotomy by maintaining exact surgical technique and by limiting the surgical indications to hips with an intact area of more than one-third of the entire articular surface on the lateral radiograph of the femoral head.

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