The conservative surgical treatment of idiopathic aseptic necrosis of the femoral head.

Most of the patients struck by idiopathic necrosis of the femoral head are men between thirty and sixty years of age in an active period of life. Although about 25 per cent improve spontaneously after one or two years and have a tolerable disability, most of them worsen; in half the cases the other hip becomes involved during the first or second year. Some degree of collapse of the head occurs in 90 per cent, leading eventually to a progressive arthrosis. Medical treatment is ineffectual. The use of crutches, and even of bed rest with or without traction, does not prevent collapse of the head. Drilling of the trochanter and neck as advised by Ficat and Arlet (1972) relieves the pain if performed at an early stage. The frequent finding of a very high intramedullary venous pressure by those authors provides a rational basis for this treatment, but it has not been used at H#{244}pital Cochin. in 1963 Merle d’Aubign#{233}, Mazabraud and Cahen and in 1965 Merle d’Aubign#{233}, Postel, Mazabraud, Massias and Gueguen reported 139 operations in this Journal, including the results of thirteen arthrodeses, thirty-four femoral head replacements, ten cup arthroplasties and sixty osteotomies. The present paper gives the results of surgical treatment in 240 hips. Replacement of the necrotic head alone by a metallic prosthesis had been used up to 1968 in eighty-four hips (Aubriot 1973). Forty-six have now been reviewed three to ten years after the operation. The functional results are classified as excellent in only three cases, good in sixteen, fair in twelve (not because of pain but because of stiffness or limited walking), and poor in fifteen. Two prostheses were removed for sepsis. Up to date five have had total replacement on account of pain. Many of those failures appeared to result from deterioration of the acetabulum. Such change was evident radiologically in all cases where thejoint space was absent before operation and in half of the others, including hips where the joint space was normal or even wider than normal. Although some hips have a reasonably good result in spite of displacement of the prosthesis into the pelvic bone, the clinical and radiological evolution strongly suggests a preference for total prosthesis. But total replacement is also an adventure, especially under the age of forty, as about half the patients are. This is why persistent attempts have been made in our department, when the patient’s disability demanded active measures, to use operations that preserve the femoral head in the hope of limiting the collapse and encouraging incorporation of the necrotic part. At the present time, apart from drilling, of which we have no experience, and curettage plus grafting, used in only five cases, two operations appear to offer that hope: intertrochanteric osteotomy and “adjusted cup” arthroplasty, an operation used in more than 100 cases since 1964. The aim of this paper is to present the results of these two operations as found in a review of two consecutive series of cases-ninety-two osteotomies followed for one to thirteen years and eighty “adjusted cup” arthroplasties followed from one to six years.