Contents: November , Volume 87, Issue 11 Scientific Articles:

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1 Contents: November , Volume 87, Issue 11 Scientific Articles: gfedc gfedc Mininder S. Kocher, Sumeet Garg, and Lyle J. Micheli Physeal Sparing Reconstruction of the Anterior Cruciate Ligament in Skeletally Immature Prepubescent Children and Adolescents J Bone Joint Surg Am. 2005;87: Ching-Jen Wang, Feng-Sheng Wang, Chung-Cheng Huang, Kuender D. Yang, Lin-Hsiu Weng, and Hsuan-Ying Huang Treatment for Osteonecrosis of the Femoral Head: Comparison of Extracorporeal Shock Waves with Core Decompression and Bone- Grafting J Bone Joint Surg Am. 2005;87: gfedc Patrick T. McCulloch, John France, Dina L. Jones, William Krantz, Thuan- Phuong Nguyen, Craig Chambers, Joe Dorchak, and Peter Mucha Helical Computed Tomography Alone Compared with Plain Radiographs with Adjunct Computed Tomography to Evaluate the Cervical Spine After High-Energy Trauma J Bone Joint Surg Am. 2005;87: gfedc gfedc Timothy Bhattacharyya, Howard Yeon, and Mitchel B. Harris The Medical-Legal Aspects of Informed Consent in Orthopaedic Surgery J Bone Joint Surg Am. 2005;87: Burak Demirag, Bartu Sarisozen, Ozgur Ozer, Tolga Kaplan, and Cagatay Ozturk Enhancement of Tendon-Bone Healing of Anterior Cruciate Ligament Grafts by Blockage of Matrix Metalloproteinases J Bone Joint Surg Am. 2005;87: gfedc Merrill A. Ritter, Alan E. Thong, E. Michael Keating, Philip M. Faris, John B. Meding, Michael E. Berend, Jeffery L. Pierson, and Kenneth E. Davis The Effect of Femoral Notching During Total Knee Arthroplasty on the Prevalence of Postoperative Femoral Fractures and on Clinical Outcome J Bone Joint Surg Am. 2005;87: gfedc Antony R. Boody and Montri D. Wongworawat Accuracy in the Measurement of Compartment Pressures: A Comparison of Three Commonly Used Devices J Bone Joint Surg Am. 2005;87:

2 gfedc Wade Smith, Paul Shurnas, Steve Morgan, Juan Agudelo, Gianna Luszko, Eric C. Knox, and Gaia Georgopoulos Clinical Outcomes of Unstable Pelvic Fractures in Skeletally Immature Patients J Bone Joint Surg Am. 2005;87: gfedc gfedc B. Sonny Bal, Doug Haltom, Thomas Aleto, and Matthew Barrett Early Complications of Primary Total Hip Replacement Performed with a Two-Incision Minimally Invasive Technique J Bone Joint Surg Am. 2005;87: Christopher P. Little, Alastair J. Graham, Georgios Karatzas, David A. Woods, and Andrew J. Carr Outcomes of Total Elbow Arthroplasty for Rheumatoid Arthritis: Comparative Study of Three Implants J Bone Joint Surg Am. 2005;87: gfedc D. Luis Muscolo, Miguel A. Ayerza, Luis A. Aponte-Tinao, and Maximiliano Ranalletta Use of Distal Femoral Osteoarticular Allografts in Limb Salvage Surgery J Bone Joint Surg Am. 2005;87: gfedc gfedc Daniel J. Berry, Marius von Knoch, Cathy D. Schleck, and William S. Harmsen Effect of Femoral Head Diameter and Operative Approach on Risk of Dislocation After Primary Total Hip Arthroplasty J Bone Joint Surg Am. 2005;87: M.F. Termaat, P.G.H.M. Raijmakers, H.J. Scholten, F.C. Bakker, P. Patka, and H.J.T.M. Haarman The Accuracy of Diagnostic Imaging for the Assessment of Chronic Osteomyelitis: A Systematic Review and Meta-Analysis J Bone Joint Surg Am. 2005;87: gfedc Alastair Gray, Diana Elbourne, Carol Dezateux, Andrew King, Anne Quinn, Frances Gardner on Behalf of the United Kingdom Collaborative Hip Trial Group Economic Evaluation of Ultrasonography in the Diagnosis and Management of Developmental Hip Dysplasia in the United Kingdom and Ireland J Bone Joint Surg Am. 2005;87: gfedc Harish S. Hosalkar, Eric L. Cain, David Horn, Kingsley R. Chin, John P. Dormans, and Denis S. Drummond Traumatic Atlanto-Occipital Dislocation in Children J Bone Joint Surg Am. 2005;87: gfedc Steven A. Lietman, Changlin Ding, and Michael A. Levine A Highly Sensitive Polymerase Chain Reaction Method Detects Activating Mutations of the GNAS Gene in Peripheral Blood Cells in McCune- Albright Syndrome or Isolated Fibrous Dysplasia J Bone Joint Surg Am. 2005;87:

3 gfedc Jason P. Young, Paul H. Young, Michael J. Ackermann, Paul A. Anderson, and K. Daniel Riew The Ponticulus Posticus: Implications for Screw Insertion into the First Cervical Lateral Mass J Bone Joint Surg Am. 2005;87: gfedc B. Willem Schreurs, J.J. Chris Arts, Nico Verdonschot, Pieter Buma, Tom J.J.H. Slooff, and Jean W.M. Gardeniers Femoral Component Revision with Use of Impaction Bone-Grafting and a Cemented Polished Stem J Bone Joint Surg Am. 2005;87: gfedc Mitsuhiro Aoki, Hiroshi Takasaki, Takayuki Muraki, Eiichi Uchiyama, Gen Murakami, and Toshihiko Yamashita Strain on the Ulnar Nerve at the Elbow and Wrist During Throwing Motion J Bone Joint Surg Am. 2005;87: gfedc Hans-Christoph Pape, Boris A. Zelle, Frank Hildebrand, Peter V. Giannoudis, Christian Krettek, and Martijn van Griensven Reamed Femoral Nailing in Sheep: Does Irrigation and Aspiration of Intramedullary Contents Alter the Systemic Response? J Bone Joint Surg Am. 2005;87: gfedc Athanasios I. Tsirikos and Michael J. McMaster Congenital Anomalies of the Ribs and Chest Wall Associated with Congenital Deformities of the Spine J Bone Joint Surg Am. 2005;87: Case Reports: Nikolaos G. Papadimitriou, John Christophoridis, Agkeliki Papadimitriou, and Theodoros A. Beslikas Acute Torticollis After Isolated Stress Fracture of the First Rib in a Child. A Case Report J Bone Joint Surg Am. 2005;87: Vikram David, J. Thambiah, Fareed H.Y. Kagda, and V. Prem Kumar Bilateral Gluteal Compartment Syndrome. A Case Report J Bone Joint Surg Am. 2005;87: Samir Shaheen and Eltayeb Alasha Hemophilic Pseudotumor of the Distal Parts of the Radius and Ulna. A Case Report J Bone Joint Surg Am. 2005;87: Current Concepts Review: gfedc Christopher H. Evans and Randy N. Rosier Molecular Biology in Orthopaedics: The Advent of Molecular Orthopaedics J Bone Joint Surg Am. 2005;87:

4 Selected Instructional Course Lecture: Patrick J. Duffy, Bassam A. Masri, Donald S. Garbuz, and Clive P. Duncan Evaluation of Patients with Pain Following Total Hip Replacement J Bone Joint Surg Am. 2005;87: The Orthopaedic Forum: Vincent D. Pellegrini, Jr., Terrance Peabody, David F. Dinges, Jennifer Moody, and Peter J. Fabri Symposium Resident Work-Hour Guidelines. A Sentence or An Opportunity for Orthopaedic Education? J Bone Joint Surg Am. 2005;87: Letters to the Editor: Justin S. Cummins, James N. Weinstein, E. Louis Peak, Javad Parvizi, and Richard H. Rothman The Role of Patient Restrictions in Reducing the Prevalence of Early Dislocation Following Total Hip Arthroplasty E.L. Peak, J. Parvizi, and R.H. Rothman reply: J Bone Joint Surg Am. 2005;87: Amir Ali Narvani, Elefterios Tsiridis, and Riley J. Williams, III Anterior Cruciate Ligament Reconstruction with a Four-Strand Hamstring Tendon Autograft R.J. Williams III replies: J Bone Joint Surg Am. 2005;87:2588. Senthil Nathan Sambandam, Arif Gul, and Jeffrey O. Anglen Comparison of Soap and Antibiotic Solutions for Irrigation of Lower- Limb Open Fracture Wounds J. O. Anglen replies: J Bone Joint Surg Am. 2005;87: Krishna Reddi Boddu Siva Rama, Sunil Apsingi, and Joseph P. Iannotti Effect of Humeral Component Anteversion on Shoulder Stability with Glenoid Component Retroversion J.P. Iannotti replies: J Bone Joint Surg Am. 2005;87:2589. Nitin R. Shetty, A.J. Hamer, I. Stockley, R. Eastell, J.M. Wilkinson, Mohit Bhandari, Sohail Bajammal, and Thomas A. Einhorn Effect of Bisphosphonates on Periprosthetic Bone Mineral Density After Total Joint Arthroplasty M. Bhandari, S. Bajammal, and T.A. Einhorn reply: J Bone Joint Surg Am. 2005;87: Roy A. Meals, Brian W. Su, and Melvin P. Rosenwasser Device for Zone-II Flexor Tendon Repair B.W. Su and M.P. Rosenwasser reply: J Bone Joint Surg Am. 2005;87:

5 Evidence-Based Orthopaedics: Glossary of Terms for Evidence-Based Orthopaedics J Bone Joint Surg Am. 2005;87:2592. Freddie H. Fu Rate of Improvement Was Not Different After Osteochondral Repair with Matrix-Induced Autologous Chondrocyte Implantation or Autologous Chondrocyte Implantation with a Cover Made from Porcine- Derived Type I/Type III Collagen J Bone Joint Surg Am. 2005;87:2593. Robert B. Bourne Continuous Passive Motion Improves Active Knee Flexion and Shortens Hospital Stay but Does Not Affect Other Functional Outcomes After Knee Arthroplasty J Bone Joint Surg Am. 2005;87:2594. Jonathan Braman and Evan Flatow Arthroscopic Decompression and Physiotherapy Have Similar Effectiveness for Subacromial Impingement J Bone Joint Surg Am. 2005;87:2595. Book Reviews: Charles R. Clark Revision Total Knee Arthroplasty J Bone Joint Surg Am. 2005;87:2600

6 2371 COPYRIGHT 2005 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Physeal Sparing Reconstruction of the Anterior Cruciate Ligament in Skeletally Immature Prepubescent Children and Adolescents BY MININDER S. KOCHER, MD, MPH, SUMEET GARG, MD, AND LYLE J. MICHELI, MD Investigation performed at the Division of Sports Medicine, Department of Orthopaedic Surgery, Children s Hospital, Harvard Medical School, Boston, Massachusetts Background: The management of anterior cruciate ligament injuries in skeletally immature patients is controversial. Conventional adult reconstruction techniques risk potential iatrogenic growth disturbance due to physeal damage. The purpose of this study was to evaluate the results of a physeal sparing, combined intra-articular and extra-articular reconstruction technique in prepubescent skeletally immature children. Methods: Between 1980 and 2002, forty-four skeletally immature prepubescent children and adolescents who were in Tanner stage 1 or 2 (with a mean chronological age of 10.3 years) underwent physeal sparing, combined intraarticular and extra-articular reconstruction of the anterior cruciate ligament with use of an autogenous iliotibial band graft. Twenty-seven patients had additional meniscal surgery. Functional outcome, graft survival, radiographic outcome, and growth disturbance were evaluated at a mean of 5.3 years after surgery. Results: Two patients underwent a revision reconstruction for graft failure at 4.7 and 8.3 years postoperatively. In the remaining forty-two patients, the mean International Knee Documentation subjective knee score (and standard deviation) was 96.7 ± 6.0 points, and the mean Lysholm knee score was 95.7 ± 6.7 points. The results of the Lachman examination for anterior cruciate ligament integrity was normal for twenty-three patients, nearly normal for eighteen patients, and abnormal for one patient. The results of the pivot-shift examination were normal for thirty-one patients and nearly normal for eleven patients. Four of the twenty-three patients who underwent concurrent meniscal repair had a repeat arthroscopic meniscal repair or partial meniscectomy. The mean growth in total height from the time of surgery to the final follow-up evaluation was 21.5 cm. No patient had an angular deformity measured radiographically or a discrepancy in the length of the lower extremities measured clinically. Conclusions: Physeal sparing, combined intra-articular and extra-articular reconstruction of the anterior cruciate ligament with use of an autogenous iliotibial band graft in skeletally immature prepubescent children and adolescents provides excellent functional outcome with a low revision rate and a minimal risk of growth disturbance. Levels of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. Intrasubstance injuries of the anterior cruciate ligament in children and adolescents were once thought to be rare, with avulsion fractures of the tibial eminence considered to be the pediatric equivalent of an anterior cruciate ligament A video supplement to this article will be available from the Video Journal of Orthopaedics. A video clip will be available at the JBJS web site, The Video Journal of Orthopaedics can be contacted at (805) , web site: A commentary is available with the electronic versions of this article, on our web site ( and on our quarterly CD-ROM (call our subscription department, at , to order the CD-ROM). injury 1-4. However, intrasubstance injuries of the anterior cruciate ligament in children and adolescents are being seen with greater frequency and have received increased attention. In clinical series of pediatric patients with acute traumatic hemarthrosis of the knee, anterior cruciate ligament injury has been reported to occur in 10% to 65% of such patients Controversy exists with regard to the management of anterior cruciate ligament injuries in patients with open physes. Nonoperative management of complete tears generally has a poor prognosis, with instability leading to further meniscal and chondral injury Conventional surgical reconstruction tech-

7 2372 PHYSEAL SPARING RECONSTRUCTION OF THE ACL IN SKELETALLY IMMATURE PREPUBESCENT CHILDREN AND ADOLESCENTS niques risk iatrogenic growth disturbance because of physeal damage to the distal femoral physis or the proximal tibial physis, or both Surgical techniques to address anterior cruciate ligament insufficiency in skeletally immature patients include primary repair, extra-articular tenodesis, transphyseal reconstruction, partial transphyseal reconstruction, and physeal sparing reconstruction 10-12,14, The management of these injuries in prepubescent children and adolescents is particularly vexing, given the poor prognosis with nonoperative management, the substantial amount of growth remaining, and the consequences of potential growth disturbance. The purpose of this study was to evaluate the results of a physeal sparing, combined intra-articular and extra-articular reconstruction technique in skeletally immature prepubescent children and adolescents. Our hypothesis was that this technique would yield a good functional outcome with minimal risk of growth disturbance. Materials and Methods nstitutional review board approval and informed patient Iconsent were obtained for this study. The study design is a retrospective case series. Patients returned for follow-up outcome analysis. Between 1980 and 2002, fifty skeletally immature prepubescent patients underwent physeal sparing, combined intra-articular and extra-articular reconstruction of the anterior cruciate ligament with use of an autogenous iliotibial band graft performed by two surgeons (M.S.K. and L.J.M.). Six patients were unable to be located for follow-up, but forty-four (88%) had complete follow-up. Thus, the study population included forty-four patients (forty-four knees) who had reconstruction of the anterior cruciate ligament. The six patients lost to follow-up were similar to the study population in terms of age, gender, mechanism of injury, and associated injuries. The study population included twenty-eight boys (64%) and sixteen girls (36%). The mean chronological age at the time of surgery was 10.3 years (range, 3.6 to 14.0 years). According to age-group, three patients were three to six years old, twenty-four were seven to ten years old, and seventeen were eleven to fourteen years old. A 3.6-year-old boy underwent anterior cruciate ligament reconstruction because of symptomatic knee instability due to congenital absence of the anterior cruciate ligament associated with proximal femoral focal deficiency. Skeletal age was determined by pediatric radiologists on an anteroposterior radiograph of the left hand and wrist with use of the atlas of Greulich and Pyle 47. Despite the potential increased variance in the determination of skeletal age in young children, we believed that it was necessary to assess skeletal age to allow for comparisons with other studies. The mean skeletal age at the time of surgery was 10.1 years (range, 3.5 to 14.0 years). Biological age was determined according to the method of Tanner and Whitehouse (see Appendix) 48. The Tanner stage was assessed by the patients and families on a questionnaire completed preoperatively and was confirmed by the surgeon at the time of surgery after the patient was placed under general anesthesia. Thirty-one patients were in Tanner stage 1, and thirteen patients were in Tanner stage 2. No patient in this study was in Tanner stage 3 or 4. The mechanisms of injury included accidents that occurred during soccer (eight patients), football (seven), basketball (five), gymnastics (four), bicycling (four), free play (three), jumping on a trampoline (three), and during a dance, wrestling, lacrosse, field hockey, baseball, martial arts, and a fall from stairs (one patient each). The mean time-interval from the injury to surgery was 11.1 months (range, three to forty months). Five patients had undergone arthroscopic surgery prior to anterior cruciate ligament reconstruction for a partial lateral meniscectomy (two patients), lateral meniscal repair (one patient), and diagnostic arthroscopy (two patients). Three patients did not have a specific injury, but they had congenital absence of the anterior cruciate ligament associated with proximal femoral focal deficiency (two patients) or with fibular hemimelia (one patient). Two of those patients underwent anterior cruciate ligament reconstruction after limb-lengthening procedures, and one patient underwent reconstruction prior to limb-lengthening. Patients were managed surgically if they had an associated meniscal injury requiring repair or if they had had failure of prior nonreconstructive management consisting of rehabilitation and functional bracing with recurrent episodes of instability and limited function. The duration of nonoperative management prior to reconstruction and the compliance with nonoperative management were not reliably recorded. Twentyseven patients had an associated meniscal injury at the time of anterior cruciate ligament reconstruction involving the lateral meniscus (twenty-three patients) or the medial meniscus (four patients). Meniscal injury was treated with meniscal repair in twenty-three patients and with partial meniscectomy in four patients. Functional outcome was assessed with use of questionnaires completed by the patients to determine the International Knee Documentation Committee (IKDC) subjective knee score 49 and the Lysholm knee score 50. The IKDC subjective knee form is a validated region-specific outcome measure that consists of eighteen questions in the domains of symptoms, function during activities of daily living and sports, current function of the knee, and participation in work and/ or sports 49. An overall score of 0 to 100 points is calculated. The Lysholm knee scale is a condition-specific outcome measure that contains eight domains: limp, locking, pain, stairclimbing, support, instability, swelling, and squatting 50. An overall score of 0 to 100 points is calculated, with 95 to 100 points indicating an excellent result; 84 to 94 points, a good result; 65 to 83 points, a fair result; and <65 points, a poor result. The objective examination included a comprehensive physical evaluation of the knee, with stability assessed with use of the Lachman and pivot-shift examinations as graded according to the IKDC criteria by two of the authors (M.S.K. and L.J.M.). Radiographic examination of the knee included weight-bearing anteroposterior, notch, lateral, and Merchant radiographs. Radiographic evidence of a growth disturbance

8 2373 PHYSEAL SPARING RECONSTRUCTION OF THE ACL IN SKELETALLY IMMATURE PREPUBESCENT CHILDREN AND ADOLESCENTS Fig. 1-A Figs. 1-A through 1-H The technique of physeal sparing, combined intra-articular and extraarticular reconstruction of the anterior cruciate ligament with use of an autogenous iliotibial band graft. Fig. 1-A The iliotibial band is harvested through an oblique lateral knee incision. was evaluated by a single observer and was assessed according to the integrity of the physes and the symmetry of the Harris lines. A radiographically important angular growth disturbance was considered to be any anatomic varus and/or valgus change of >5 from the findings on the preoperative radiographs. Clinically, growth disturbance was assessed with use of blocks to level the top of the iliac crests with the patient standing with the knees extended and with measurement of the true lower-extremity length from the anterior superior iliac spine to the medial malleolus. A clinically important Fig. 1-B The iliotibial band graft is detached proximally, left attached distally, and dissected free from the lateral patellar retinaculum.

9 2374 PHYSEAL SPARING RECONSTRUCTION OF THE ACL IN SKELETALLY IMMATURE PREPUBESCENT CHILDREN AND ADOLESCENTS Fig. 1-C The iliotibial band graft is brought through the knee with use of a full-length clamp placed from the anteromedial portal through the over-the-top position into the lateral incision. limb-length discrepancy was considered to be >2 cm, as measured with either method. Surgical Technique The surgical technique consists of arthroscopically assisted, physeal sparing, combined intra-articular and extra-articular reconstruction of the anterior cruciate ligament with use of an autogenous iliotibial band graft. This procedure is a modification of the combined intra-articular and extra-articular reconstruction described by MacIntosh and Darby 51. Modifications include application in skeletally immature patients, arthroscopic assistance, graft fixation, and accelerated rehabilitation. Fig. 1-D Fig. 1-E Fig. 1-D The graft is then brought through the over-the-top position. Fig. 1-E A clamp is placed from the proximal medial incision in the leg under the intermeniscal ligament, and a groove is made in the anteromedial tibial epiphysis with use of a rasp.

10 2375 PHYSEAL SPARING RECONSTRUCTION OF THE ACL IN SKELETALLY IMMATURE PREPUBESCENT CHILDREN AND ADOLESCENTS Fig. 1-F The graft is brought through the knee in the over-the-top position and under the intermeniscal ligament. The procedure is performed with the patient under general anesthesia as an overnight observation procedure. The child is positioned supine on the operating table with a pneumatic tourniquet about the proximal aspect of the thigh, which is used routinely. With the patient under anesthesia, he or she is examined to confirm anterior cruciate ligament insufficiency. An incision of approximately 6 cm is made obliquely from the lateral joint line to the superior border of the iliotibial band (Fig. 1-A). Proximally, the iliotibial band is separated from the subcutaneous tissue with use of a periosteal elevator under the skin of the lateral part of the thigh. The anterior and posterior borders of the iliotibial band are incised, and the incisions are carried proximally under the skin with use of a curved meniscotome. The iliotibial band is detached proximally under the skin with use of a curved meniscotome or an open tendon stripper. The iliotibial band is left attached distally at Gerdy s tubercle. Dissection is performed distally to separate the iliotibial band from the joint capsule and from the lateral patellar retinaculum (Fig. 1-B). The free proximal end of the iliotibial band is then tubularized with use of a whipstitch with a number-5 Ethibond suture (Ethicon, Johnson and Johnson, Somerville, New Jersey). Arthroscopy of the knee is then performed through standard anterolateral and anteromedial portals. Management of meniscal injury or chondral injury is performed, if present. The anterior cruciate ligament remnant is excised. The over-the-top position on the femur and the over-the-front position under the intermeniscal ligament are identified. A minimal notchplasty is performed to avoid iatrogenic injury to the perichondrial ring of the distal femoral physis, which is in close proximity to the over-the-top position 52. The free end of the iliotibial band graft is brought through the over-the-top position with use of a full-length clamp (Figs. 1-C and 1-D) or a two-incision rear-entry guide and out the anteromedial portal. A second incision of approximately 4.5 cm is made over the proximal medial aspect of the Fig. 1-G The graft is brought out of the proximal medial incision in the leg. It is sutured to the intermuscular septum and periosteum of the lateral femoral condyle through the lateral knee incision and it is sutured in a trough to the periosteum of the proximal medial tibial metaphysis.

11 2376 PHYSEAL SPARING RECONSTRUCTION OF THE ACL IN SKELETALLY IMMATURE PREPUBESCENT CHILDREN AND ADOLESCENTS Fig. 1-H Schematic appearance of a combined intra-articular and extra-articular reconstruction. tibia in the region of the pes anserinus. Dissection is carried through the subcutaneous tissue to the periosteum. A curved clamp is placed from this incision into the joint under the intermeniscal ligament (Fig. 1-E). A small groove is made in the anteromedial aspect of the proximal tibial epiphysis under the intermeniscal ligament with use of a curved rat-tail rasp to bring the tibial graft placement more posterior. The free end of the graft is then brought through the joint (Fig. 1-F), under the intermeniscal ligament in the anteromedial epiphyseal groove, and out the medial tibial incision (Fig. 1-G). The graft is fixed on the femoral side through the lateral incision with the knee at 90 of flexion and 15 of external rotation with use of mattress sutures to the lateral femoral condyle at the insertion of the lateral intermuscular septum to effect an extraarticular reconstruction. The tibial side is then fixed through the medial incision with the knee flexed 20 and tension applied to the graft. A periosteal incision is made distal to the proximal tibial physis as checked with fluoroscopic imaging. A trough is made in the proximal medial tibial metaphyseal cortex, and the graft is sutured to the periosteum at the rough margins with mattress sutures (Fig. 1-H). Postoperatively, the patient is maintained with touchdown weight-bearing for six weeks. Immediate mobilization is performed, from 0 to 90 for the first two weeks, followed by progression to a full range of motion. Continuous passive motion from 0 to 90 is used for the first two weeks postoperatively to initiate motion and overcome the anxiety associated with postoperative movement in these young children. A protective hinged knee brace is used for six weeks postoperatively with motion limits of 0 to 90 for the first two weeks. Progressive rehabilitation consists of range-of motion exercises, patellar mobilization, electrical stimulation, pool therapy (if available), proprioception exercises, and closed-chain strengthening exercises during the first three months postoperatively followed by straight-line jogging, plyometric exercises, sport cord exercises, and sport-specific exercises. Return to full activity, including sports that involve cutting, is usually allowed at six months postoperatively. A custom-made functional knee brace is used routinely during cutting and pivoting activities for the first two years after the return to sports. Compliance with bracing was not formally assessed. Results he mean postoperative duration of follow-up was 5.3 years T (range, 2.0 to 15.1 years). The mean duration of the operation was 101 minutes (range, sixty to 140 minutes), and the mean tourniquet time was seventy-two minutes (range, fortythree to 109 minutes). There were no surgical complications, such as infection, failure of graft harvest, or arthrofibrosis. Two patients (4.5%) underwent a revision anterior cruciate ligament reconstruction for graft failure at 4.7 and 8.3 years postoperatively. Both patients had a reinjury and were participating in cutting and pivoting sports. Both had midsubstance rupture of the iliotibial band graft. The grafts appeared well incorporated at the femoral and tibial insertions. Four patients who underwent concurrent meniscal repair during anterior cruciate ligament reconstruction had repeat arthroscopic meniscal repair or partial meniscectomy. For the remaining forty-two patients without revision anterior cruciate ligament repair, the mean IKDC subjective knee score (and standard deviation) was 96.7 ± 6.0 points (range, 88.5 to 100 points) and the mean Lysholm knee score was 95.7 ± 6.7 points (range, 74 to 100 points). All patients, other than the three patients with congenital limb deficiencies, had returned to cutting or pivoting sports. According to the IKDC criteria, the findings of the Lachman examination were normal for twenty-three patients, nearly normal for eighteen patients, and abnormal for one patient. The results of the pivot-shift examination were normal for thirty-one patients and nearly normal for eleven patients. The mean growth in total height from the time of surgery to the final follow-up examination was 21.5 cm (range, 9.5 to cm). It should be noted that total height is a combination of trunk and lower extremity lengths. No patient had a substantial angular deformity measured radiographically. No patient had a substantial limb-length discrepancy measured clinically. Discussion here is controversy regarding the management of anterior T cruciate ligament injuries in patients with open physes. Nonoperative management, consisting of rehabilitation, brac-

12 2377 PHYSEAL SPARING RECONSTRUCTION OF THE ACL IN SKELETALLY IMMATURE PREPUBESCENT CHILDREN AND ADOLESCENTS ing, and activity restriction, is often recommended in order to temporize for later conventional reconstruction near skeletal maturity. Nonoperative management of partial tears may be successful in patients with a lower-grade partial tear, in younger children, and in patients with a tear that predominantly involves the anteromedial bundle 53. However, nonoperative management of complete tears generally has a poor prognosis, with recurrent instability leading to further meniscal and chondral injury Graf et al. 12, Janarv et al. 13, and Mizuta et al. 16 reported instability symptoms, subsequent meniscal tears, a decreased activity level, and a need for anterior cruciate ligament reconstruction in skeletally immature patients treated nonoperatively. Similarly, when comparing the results of operative and nonoperative management of complete anterior cruciate ligament injuries in adolescents, Mc- Carroll et al. 14 and Pressman et al. 17 found that those managed with anterior cruciate ligament reconstruction had less instability, higher levels of activity and return to sports, and lower rates of subsequent reinjury and meniscal tears. These subsequent meniscal and chondral injuries have important implications in terms of the long-term prognosis for the knee and the risk of degenerative joint disease. In addition, compliance with activity restriction is often problematic in the pediatric athlete and is unappealing to the patient s family. Conventional surgical reconstruction techniques risk potential iatrogenic growth disturbance due to physeal damage. Cases of growth disturbance have been reported in animal models Animal models have demonstrated mixed results regarding growth disturbances from soft-tissue grafts across the physes. In a canine model with iliotibial band grafts through 0.16-in (4-mm) tunnels, Stadelmaier et al. found no evidence of growth arrest in four animals with a soft-tissue graft across the physis, whereas four animals with drill-holes and no graft demonstrated physeal arrest 54. In a rabbit model with use of a semitendinosus graft through 2-mm tunnels, Guzzanti et al. noted cases of growth disturbance; however, they were not common 18. Examining the effect of a tensioned soft-tissue graft across the physis, Edwards et al. found a substantial rate of deformity 19. In a canine model with an iliotibial band graft tensioned to 80 N, those investigators found increases, compared with the nonoperatively treated control limb, in distal femoral valgus deformity and proximal tibial varus deformity despite no evidence of an osseous bar. Similarly, Houle et al. reported growth disturbance after use of a tensioned tendon graft in a bone tunnel across the rabbit physis 20. However, the tension applied to the graft in the studies by Edwards et al. and Houle et al. may have been correspondingly excessive for their animal models, thus resulting in growth disturbance. Clinical reports of growth deformity after anterior cruciate ligament reconstruction are unusual. In a series of twenty-four skeletally immature patients who had reconstruction with transphyseal semitendinosis and gracilis grafts, Lipscomb and Anderson described one patient who had 20 mm of shortening 21. This was associated with staple fixation of a graft across the physis. Koman and Sanders reported the case of a patient who had a distal femoral valgus deformity requiring an osteotomy and contralateral epiphyseodesis after transphyseal reconstruction with a doubled semitendinosus graft 22. This deformity was also associated with fixation across the distal femoral physis. In a study based on a survey of experts in the management of anterior cruciate ligament injuries in pediatric patients, Kocher et al. reported the cases of an additional fifteen patients who had growth disturbances, including eight patients who had a distal femoral valgus deformity with an arrest of the lateral distal femoral physis; three patients who had tibial recurvatum with an arrest of the tibial tubercle apophysis; two patients who had genu valgum, without arrest, due to a lateral extra-articular tether; and two patients who had a leg-length discrepancy (one who had shortening and one who had overgrowth) 23. Associated factors included fixation hardware across the lateral distal femoral physis in three patients, bone plugs of a patellar tendon graft across the distal femoral physis in three patients, large (12-mm) tunnels in two patients, lateral extra-articular tenodesis in two patients, fixation hardware across the tibial tubercle apophysis in two patients, and suturing near the tibial tubercle apophysis in one patient. Surgical techniques to address anterior cruciate ligament insufficiency in skeletally immature patients include primary repair, extra-articular tenodesis, transphyseal reconstruction, partial transphyseal reconstruction, and physeal sparing reconstruction. Primary ligament repair 24,25 and extraarticular tenodesis alone 12,14 in children and adolescents have had poor results, similar to the outcomes seen in adults. Transphyseal reconstructions with tunnels that violate both the distal femoral and proximal tibial physes have been performed with hamstrings autograft, patellar tendon autograft, and allograft tissue 11,14, Partial transphyseal reconstructions damage only one physis with a tunnel through the proximal tibial physis and over-the-top positioning on the femur or with a tunnel through the distal femoral physis with an epiphyseal tunnel in the tibia 36,37,39,40. A variety of physeal sparing reconstructions to avoid tunnels across either the distal femoral physis or the proximal tibial physis have been described 10,38, The management of anterior cruciate ligament injuries in prepubescent children and adolescents is particularly vexing, given the large amount of growth remaining. Most clinical series of skeletally immature patients with anterior cruciate ligament injuries have involved adolescent patients, not prepubescent patients. The consequences of growth disturbance in the prepubescent age-group are substantial, requiring major limb reconstruction with osteotomy and/or limb-lengthening. However, anterior cruciate ligament insufficiency must be adequately corrected with reconstructive techniques in order to avoid subsequent meniscal and chondral injuries, which also have substantial consequences. Case reports or small clinical series of patients in this age-group managed with physeal sparing techniques to provide a stable knee while avoiding violation of the physes have been described. DeLee and Curtis 43 used a portion of the patellar tendon without drill-holes. Brief 42 and Parker et al. 46 used hamstrings tendons, left at-

13 2378 PHYSEAL SPARING RECONSTRUCTION OF THE ACL IN SKELETALLY IMMATURE PREPUBESCENT CHILDREN AND ADOLESCENTS longitudinal deficiency of the lower extremities. Our indications for reconstruction of the anterior cruciate ligament in a child with congenital deficiency of a limb are symptomatic instability that substantially limits function and is uncontrolled by bracing. In older, skeletally immature adolescents (Tanner stage 3 and 4) with an anterior cruciate ligament injury, we perform transphyseal reconstruction with a quadrupled hamstrings tendon graft with fixation away from the physes. However, in our opinion, the consequences of potential iatrogenic growth disturbance caused by transphyseal reconstruction in prepubescent children are prohibitive and, therefore, we perform the physeal sparing reconstruction. This procedure is nonanatomic as the graft is in the over-thetop position on the femur and under the intermeniscal ligament on the tibia. Although nonanatomic, it provided for a stable knee with excellent function in children who returned to sports that involved cutting and pivoting. We counsel parents that this may be a temporizing procedure for later conventional reconstruction near skeletal maturity; however, this technique has functioned as the definitive reconstruction for most of our patients. Fig. 2 A STIR (short-tau-inversion-recovery) sagittal magnetic resonance imaging scan of an iliotibial band graft at 3.4 years after reconstruction. tached distally, that were brought through the knee under the intermeniscal ligament on the tibial side and the over-the-top position on the femoral side. More recently, physeal sparing reconstruction techniques with use of hamstrings tendon in prepubescent patients were described by Guzzanti et al. 38, who used an epiphyseal tibial tunnel with distal femoral epiphyseal fixation, and by Anderson 41, who used epiphyseal tibial and femoral tunnels. In the present study, we report the results of a physeal sparing, combined intra-articular and extra-articular reconstruction technique with use of an autogenous iliotibial band graft in prepubescent, skeletally immature children (Fig. 2). In forty-four children who were followed for a mean of 5.3 years, this technique provided excellent functional outcome with a low revision rate and no growth disturbance. Our rationale for the utilization of this technique is to provide knee stability and improve function while avoiding the risk of iatrogenic growth disturbance in prepubescent, skeletally immature patients with complete intrasubstance injuries of the anterior cruciate ligament who have repairable meniscal tears or who have had failure of nonoperative treatment. This series included three prepubescent patients with congenital insufficiency of the anterior cruciate ligament associated with Appendix A table showing the Tanner staging system is available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation and click on Supplementary Material ) and on our quarterly CD-ROM (call our subscription department, at , to order the CD-ROM). Mininder S. Kocher, MD, MPH Lyle J. Micheli, MD Division of Sports Medicine, Department of Orthopaedic Surgery, Children s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA address for M.S. Kocher: mininder.kocher@childrens.harvard.edu Sumeet Garg, MD Department of Orthopaedic Surgery, Washington University Orthopaedic Residency Program, One Barnes Hospital Plaza, St. Louis, MO The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated. doi: /jbjs.d References 1. Kocher MS, Micheli LJ, Gerbino P, Hresko MT. Tibial eminence fractures in children: prevalence of meniscal entrapment. Am J Sports Med. 2003;31: Rang M. Children s fractures. 2nd ed. Philadelphia: Lippincott; Kocher MS, Foreman ES, Micheli LJ. Laxity and functional outcome after arthroscopic reduction and internal fixation of displaced tibial spine fractures in children. Arthroscopy. 2003;19: Kocher MS, Mandiga R, Klingele K, Bley L, Micheli LJ. Anterior cruciate ligament injury versus tibial spine fracture in the skeletally immature knee: a comparison of skeletal maturation and notch width index. J Pediatr Orthop. 2004;24:185-8.

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15 2380 COPYRIGHT 2005 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Treatment for Osteonecrosis of the Femoral Head: Comparison of Extracorporeal Shock Waves with Core Decompression and Bone-Grafting BY CHING-JEN WANG, MD, FENG-SHENG WANG, PHD, CHUNG-CHENG HUANG, MD, KUENDER D. YANG, MD, PHD, LIN-HSIU WENG, MD, AND HSUAN-YING HUANG, MD Investigation performed at the Departments of Orthopaedic Surgery, Medical Research, Diagnostic Radiology, and Pathology, Chang Gung Memorial Hospital Medical Center, Kaohsiung, Taiwan Background: There is continuing controversy regarding the optimal treatment for patients with symptomatic earlystage osteonecrosis of the femoral head. We compared the results of noninvasive treatment with extracorporeal shock waves with those of core decompression and bone-grafting in similar groups of patients. Methods: Patients with stage-i, II, or III osteonecrosis were randomly assigned to be treated either with shock waves or with core decompression and nonvascularized fibular grafting. The shock-wave group consisted of twenty-three patients (twenty-nine hips), and the surgical group consisted of twenty-five patients (twenty-eight hips). The patients in the two groups had similar demographic characteristics, duration and stage of disease, and duration of follow-up. The patients in the shock-wave group received a single treatment with 6000 impulses of shock waves at 28 kv to the affected hip. The evaluation parameters included clinical assessment of pain with a visual analog pain scale, Harris hip scores, and an assessment of activities of daily living and work capacity. Radiographic assessment was performed with serial plain radiographs and magnetic resonance imaging. Results: Before treatment, the two groups had similar pain and Harris hip scores. At an average of twenty-five months after treatment, the pain and Harris hip scores in the shock-wave group were significantly improved compared with the pretreatment scores (p < 0.001). In this group, 79% of the hips were improved, 10% were unchanged, and 10% were worse. Of the hips treated with a nonvascularized fibular graft, 29% were improved, 36% were unchanged, and 36% were worse. In the shock-wave group, imaging studies showed regression of five of the thirteen lesions that had been designated as stage I or II before treatment and no regression of a stage-iii lesion. Two stage-ii and two stage-iii lesions progressed. In the surgical group, four lesions regressed and fifteen (of the nineteen graded as stage I or II) progressed. The remaining nine lesions were unchanged. Conclusions: Extracorporeal shock-wave treatment appeared to be more effective than core decompression and nonvascularized fibular grafting in patients with early-stage osteonecrosis of the femoral head. Long-term results are needed to determine whether the effect of this novel method of treatment for osteonecrosis of the femoral head endures. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence. Untreated symptomatic osteonecrosis of the femoral head usually results in collapse of the femoral head and degenerative changes of the hip joint 1-3. Therefore, A commentary is available with the electronic versions of this article, on our web site ( and on our quarterly CD-ROM (call our subscription department, at , to order the CD-ROM). surgical intervention is usually indicated, with the type of procedure varying according to the severity and the radiographic stage of the disease 4-6. For patients with early-stage osteonecrosis of the femoral head, current joint-preserving treatment options include core decompression, vascularized or nonvascularized bone-grafting, muscle pedicle grafting, and rotational osteotomy 3,7-9. The results of these procedures are generally

16 2381 TREATMENT OF FEMORAL HEAD OSTEONECROSIS WITH SHOCK WAVES OR CORE DECOMPRESSION AND BONE-GRAFTING TABLE I Patient Demographics Shock-Wave Group Surgical Group Patients/hips (no.) 23/29 25/28 Age* (yr) 39.8 ± 12.1 (19-63) 39.9 ± 9.3 (19-53) Male/female (no. of patients) 20/3 23/2 Right/left (no. of hips) 18/11 14/14 Bilateral disease (no. of patients) 6 3 Duration of symptoms* (mo) 5.9 ± ± 7.4 ARCO stage (no. of patients/hips) I 3/3 2/2 II 9/10 14/17 III 11/16 9/9 Medical history (no. of patients) Alcoholism Corticosteroids 2 2 Negative 5 7 Duration of follow-up* (mo) 25.2 ± 3.7 (24-38) 25.8 ± 4.6 (24-39) *The values are given as the mean and standard deviation with the range in parentheses. better in patients with the earliest stages of osteonecrosis of the femoral head, and none is uniformly successful Accordingly, the development of an effective and noninvasive treatment would be extremely valuable. Extracorporeal shock waves have been shown to be effective in promoting bone-healing and relieving pain due to insertional tendinopathy The positive effects of shockwave therapy on fracture-healing also have been demonstrated in animal experiments 14, The purpose of this study was to evaluate the effects of extracorporeal shock-wave treatment for early stages of osteonecrosis of the femoral head and to compare the results with those of core decompression and nonvascularized fibular grafting. Materials and Methods he institutional review board of our hospital and the TRegulatory Board of the Department of Health approved this study. The inclusion criterion was stage-i, II, or III osteonecrosis of the femoral head according to the ARCO (Association Research Circulation Osseous) classification (see Appendix) 5. The exclusion criteria included skeletal immaturity, a stage-iv lesion, immunosuppressive drug therapy, and a current or previous infection. Between March 2001 and December 2002, forty-eight patients (fifty-seven hips) were recruited for this study. All patients signed an informed-consent form before participating in the study. The patients were randomly assigned to either the shock-wave group or the surgical group according to the day of the week of treatment. Patients who were seen on odd days of the week were assigned to the shock-wave group, and patients who were seen on even days were assigned to be treated with surgery. Twenty-three patients (twenty-nine hips) were assigned to the shock-wave group, and twenty-five patients (twenty-eight hips), to the surgical group. The patient demographics are summarized in Table I. Pretreatment assessments consisted of a complete history and physical examination; laboratory tests, including a complete blood-cell count, a platelet count, measurement of the prothrombin time and partial thromboplastin time, chemistry profiles, and measurement of the blood urea nitrogen and creatinine levels; an electrocardiogram; a chest radiograph; and magnetic resonance imaging and radiographs of the affected hip. The diagnosis of osteonecrosis of the femoral head was confirmed with plain radiographs and/or magnetic resonance imaging. Application of Shock Waves Shock waves were administered with an electrohydraulic OssaTron orthotriptor (High Medical Technology, Kreuzlingen, Switzerland) in one treatment, performed with the patient under general anesthesia and in the supine position. The affected hip was positioned in adduction and internal rotation with the limb secured to the table. The femoral artery was identified by digital palpation, and its location was confirmed with an ultrasound Doppler scan to avoid any direct shock-wave contact with it during the course of treatment. In patients with a stage-ii or III lesion, the junctional zone between avascular and vascular bone of the femoral head was delineated under c-arm control. Four focal points, approximately 1.0 cm apart, within the junctional zone were selected, and the corresponding locations on the skin in the groin area were marked with a marker (Figs. 1-A and 1-B). In patients with a stage-i lesion, the junctional zone was selected on the basis of findings on magnetic resonance imaging. The intended depth of treatment, the center of the femoral head, was determined by raising the height of the hip on the table

17 2382 TREATMENT OF FEMORAL HEAD OSTEONECROSIS WITH SHOCK WAVES OR CORE DECOMPRESSION AND BONE-GRAFTING until two ring markers on the machine were seen to be at that level under lateral c-arm control. Surgical lubricant was placed on each of the four skin sites prior to placement of the shock-wave tube on the skin. Each of the four points was treated with 1500 impulses of shock waves at 28 kv (equivalent to 0.62 mj/mm 2 energy flux density), for a total of 6000 impulses of shock waves applied to the affected femoral head. Immediately after application of the shock waves, the groin area was inspected for ecchymosis, swelling, and hematoma. The integrity of the femoral artery was checked with the Doppler ultrasound before and after the procedure. After treatment, patients were instructed to walk on crutches with partial weight-bearing on the affected limb for four to six weeks. Non-narcotic analgesics such as acetaminophen were prescribed for pain. Core Decompression and Nonvascularized Fibular Grafting Surgery was performed through a lateral approach with the patient on a fracture table and under either general or spinal anesthesia. The location of the osteonecrosis of the femoral head was verified with c-arm imaging. A guide pin was inserted from the proximal lateral femoral cortex into the femoral head. A 10-mm bone channel was made with a core reamer over the guide pin. The necrotic bone and its margins were removed with a curet, and complete removal of the necrotic lesion was verified with arthroscopic examination through the bone channel. Through a separate incision made over the anterior iliac crest on the same side, cancellous bone grafts were harvested from the anterior iliac crest, and cancellous bone chips were gently packed into the defect of the femoral head with a bone tamp. Then, a cortical fibular strut allograft was fashioned and sized. The graft was inserted into the bone channel to maintain the cancellous bone grafts in place. Postoperatively, the patients walked with crutches and non-weight-bearing on the affected limb for three months, then with partial weight-bearing for three months, and finally with full weight-bearing when there was radiographic evidence of graft healing. Methods of Evaluation Follow-up examinations were scheduled at one, three, six, and twelve months and then once a year. Clinical assessments included calculation of pain scores and Harris hip scores as well as evaluation of the ability to carry out activities of daily living and work capacity. The intensity of pain was recorded on a visual analog scale ranging from 0 to 10, with 0 indicating no pain and 10 indicating severe pain. The Harris hip score measures pain, function, activity, and motion of the hip 10. The evaluation of activities of daily living included determination of the level of activity; walking capacity with or without support; the length of time that the patient could walk; and the ability to ascend and descend stairs, change from a sitting to a standing position, and put on shoes and socks. The work capacity in the previous three months included the number of days absent from work or school. The clinical outcome was defined as improved if the patient had a 50% reduction in hip pain and a 50% improvement in hip function in activities of daily living, unchanged if the patient had a <50% reduction in hip pain and a <50% improvement in hip function in activities of daily living, and worse if the patient had more hip pain and less hip function compared with the pretreatment status. Anteroposterior and lateral radiographs were made be- Fig. 1-A Fig. 1-B Sketches of anteroposterior (Fig. 1-A) and lateral (Fig. 1-B) views of the hip, showing the junctional zone between the avascular and vascular bones of the femoral head and the four overlying skin markers (X s) for shock-wave application.

18 2383 TREATMENT OF FEMORAL HEAD OSTEONECROSIS WITH SHOCK WAVES OR CORE DECOMPRESSION AND BONE-GRAFTING TABLE II Pain Scores in Shock-Wave and Surgical Groups Before and After Treatment Before Treatment 6 Mo 12 Mo 24 Mo Shock-wave group No. of patients No. of hips Pain score* (points) 4.3 ± 2.8 (2-9) 1.4 ± 1.6 (0-5) 0.8 ± 1.2 (0-5) 0.4 ± 0.6 (0-2) Difference compared with pretreatment score (p value) <0.001 <0.001 <0.001 Surgical group No. of patients No. of hips Pain score* (points) 5.1 ± 1.0 (4-9) 5.0 ± 1.4 (3-7) 4.9 ± 1.4 (3-7) 4.7 ± 1.6 (3-7) Difference compared with pretreatment score (p value) Difference compared with shock-wave group (p value) <0.001 <0.001 <0.001 *The values are given as the mean and standard deviation with the range in parentheses. The pain score was measured on a visual analog scale ranging from 0 to 10, with 0 indicating no pain and 10 indicating severe pain. fore treatment; at three, six, and twelve months after treatment; and then once a year. Plain radiographs of the hip were used to evaluate the size of the lesion, the extent of collapse of subchondral bone, and degenerative changes of the hip joint. Magnetic resonance imaging (Horizon, 1.5-T; GE Medical Systems, Milwaukee, Wisconsin) was performed before treatment, at six and twelve months after treatment, and then once a year with axial, coronal, and sagittal T1-weighted images; coronal proton-weighted and T2-weighted images; and sagittal fast-spin-echo T2-weighted fat-suppression images. These images were utilized to examine the size of the lesion, the congruency of the femoral head, the presence of a crescent sign, bone marrow edema, and degenerative changes of the hip joint. A radiologist who was blinded to the nature of the treatment evaluated the findings on the radiographs and magnetic resonance images. Statistical Analysis The Student t test was used to compare the pretreatment and posttreatment values in each group, and the Mann-Whitney U test was used to compare the shock-wave group and the surgical group. Significance was set at p < The primary outcome end point was conversion to a total hip arthroplasty. The secondary end point was a decrease in hip pain and an improvement in hip function. Results pain scores for both groups are summarized in Table II. TThe pretreatment pain scores of the two groups did not differ significantly from each other. In the shock-wave group, the mean pain score significantly improved at each time interval (p < 0.001), whereas, with the numbers available, it did not significantly improve at the consecutive time intervals in the TABLE III Harris Hip Scores in Shock-Wave and Surgical Groups Before and After Treatment Before Treatment 6 Mo 12 Mo 24 Mo Shock-wave group No. of patients No. of hips Harris hip score* 78.7 ± 13.5 (57-98) 92.1 ± 8.4 (67-100) 93.5 ± 8.5 (57-100) 97.5 ± 2.9 (93-100) Difference compared with <0.001 <0.001 <0.001 pretreatment score (p value) Surgical group No. of patients No. of hips Harris hip score* 74.6 ± 4.7 (62-88) 74.9 ± 5.3 (65-89) 75.0 ± 5.4 (68-89) 76.8 ± 5.6 (68-89) Difference compared with pretreatment score (p value) Difference compared with shock-wave group (p value) <0.001 <0.001 <0.001 *The values are given as the mean and standard deviation with the range in parentheses.

19 2384 TREATMENT OF FEMORAL HEAD OSTEONECROSIS WITH SHOCK WAVES OR CORE DECOMPRESSION AND BONE-GRAFTING TABLE IV Overall Clinical Outcomes in Shock-Wave and Surgical Groups Shock-Wave Group Total Series Stage-I Lesions Stage-II Lesions Stage-III Lesions Surgical Group Shock-Wave Group Surgical Group Shock-Wave Group Surgical Group Shock-Wave Group Total no. of hips Improved Unchanged Worse Total hip arthroplasty* Difference between <0.001 treatment groups (p value) Surgical Group *Of the three total hip arthroplasties (performed in three patients) in the shock-wave group, two were done because of disease progression at four and thirteen months after the shock-wave treatment and one was done because of hip infection. Of the nine total hip arthroplasties (performed in seven patients) in the surgical group, six were done at one year and three were done at two to three years after the index surgery. surgical group. At each time interval, the mean pain score was significantly better in the shock-wave group than in the surgical group (p < 0.001). The Harris hip scores of the shock-wave and surgical groups are summarized in Table III. Before treatment, the groups had comparable hip scores (p = 0.066). After treatment, significant improvement in the mean Harris hip score was noted at each time interval in the shock-wave group (p < 0.001), but the serial changes in the surgical group were not significant. The shock-wave group was found to have a significantly better mean hip score than the surgical group at each time interval (p < 0.001). The clinical outcomes in the shock-wave and surgical groups are summarized in Table IV. In the shock-wave group, the overall result was improved in 79% (twenty-three) of the twenty-nine hips, it was unchanged in 10% (three), and it was worse in 10%. In the surgical group, the result was improved in 29% (eight) of the twenty-eight hips, it was unchanged in 36% (ten), and it was worse in 36%. The majority of the patients in the shock-wave group reported substantial relief of night pain and less restricted hip motion after treatment. Total hip arthroplasty was performed in three patients (three hips; 10%) in the shock-wave group and in seven patients (nine hips; 32%) in the surgical group. In the shock-wave group, total hip arthroplasty was performed because of progression of the lesion in two hips, at four and thirteen months after treat- Fig. 2 Serial T1-weighted magnetic resonance images (MRI) and radiographs (X-ray) of the right hip of a forty-year-old man, made before shock-wave treatment for stage-ii osteonecrosis of the femoral head and at six, twelve, twenty-four, and thirty-six months after treatment. The lesion regressed, and the patient had no pain in the right hip, which was fully functional, thirty-six months after the shock-wave treatment.

20 2385 TREATMENT OF FEMORAL HEAD OSTEONECROSIS WITH SHOCK WAVES OR CORE DECOMPRESSION AND BONE-GRAFTING TABLE V Sizes of the Lesions on Radiographs and Magnetic Resonance Images Before and After Treatment Before Treatment 6 Mo 12 Mo 24 Mo Shock-wave group No. of patients No. of hips Size of lesion* (%) 61 ± 41 (1-73) 29 ± 19 (1-65) 30 ± 20 (1-67) 30 ± 20 (1-65) Difference compared with pretreatment score (p value) Surgical group No. of patients No. of hips Size of lesion* (%) 40 ± 23 (11-87) 46 ± 4 (40-52) 42 ± 15 (42-52) 41 ± 27 (45-64) Difference compared with pretreatment score (p value) Difference compared with shock-wave group (p value) < *The values, given as the mean and standard deviation with the range in parentheses, represent the percentage of the involved area of the femoral head. ment, and because of infection of the hip secondary to pneumonia and septicemia in another hip. In the surgical group, total hip arthroplasty was performed because of progression of the lesion, at one year after the index surgery in four patients (six hips) and at two to three years in three patients (three hips). In the shock-wave group, thirteen patients had had a prior total hip arthroplasty on the contralateral hip. Of those patients, six stated that they had less thigh pain and better hip function on the side that had been treated with the shockwave therapy than on the side treated with the arthroplasty, three patients preferred the side treated with the total hip arthroplasty, and four patients reported comparable function of the two hips. The changes in the sizes of the lesions as seen on the radiographs and the magnetic resonance images made after treatment are summarized in Table V. In the shock-wave group, there was a trend toward a decrease in the size of the lesion, compared with the pretreatment size, at each time interval, but the magnitudes of the changes were not significant. In the surgical group, there was no significant serial regression of the lesions. When compared with the surgical group, the shock-wave group had a significantly greater mean decrease in the size of the lesion at each time interval (p < 0.001, 0.003, and 0.040). The radiographic stages of the lesions before and after treatment are summarized in Table VI. In the shock-wave group, there was regression of five of the thirteen lesions that had been graded as stage I or II (Fig. 2), whereas none of the stage-iii lesions regressed. Four lesions, two of which were stage II and two of which were stage III, progressed. The remaining lesions were seen to be unchanged on the radiographs and magnetic resonance images. In the surgical group, four lesions regressed and fifteen of the nineteen lesions that had been stage I or II progressed. The remaining nine lesions in that group were unchanged. There were minimal changes in the stage-iii lesions, as seen on plain radiographs and magnetic resonance imaging, in both groups despite the clinical improvement in the patients who had undergone shock-wave treatment. With the number of hips available, we did not find TABLE VI Changes in the Stages of the Lesions as Seen on Radiographs and Magnetic Resonance Images Before and After Treatment* Shock-Wave Group Total Series Stage-I Lesions Stage-II Lesions Stage-III Lesions Surgical Group Shock-Wave Group Surgical Group Shock-Wave Group Surgical Group Shock-Wave Group Before treatment After treatment Surgical Group *In the shock-wave group, five lesions (three stage I and two stage II) regressed and four (two stage II and two stage III) progressed. In the surgical group, four lesions regressed, fifteen (fourteen stage II and one stage I) progressed, and nine were unchanged. The values are given as the number of lesions.