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Should thorough Debridement be used in Fibular Allograft with impaction bone grafting to treat Femoral Head Necrosis: a biomechanical evaluation
- Guangquan Zhou1, 2,
- Ying Zhang2, 4,
- Linghong Zeng5,
- Wei He†1Email author,
- Zhihui Pang†2Email author,
- Xiumin Chen†3Email author,
- Yujing Xu6,
- Liao Shaoyi Stephen6 and
- LeiLei Chen1
© Zhou et al. 2015
Received: 14 November 2014
Accepted: 20 May 2015
Published: 10 June 2015
Fibular allograft with impaction bone grafting (FAIBG) is an effective hip-preservation method for avoiding total hip arthroplasty in the early stage of femoral head necrosis. However, whether thorough debridement should be used with FAIBG is controversial. This study compared the mechanical performance between FAIBG with and without thorough debridement, which provides a biomechanical basis for selecting the proper treatment in clinical settings.
Eighteen computational models were constructed and used to simulate two subtypes of femoral head collapse with seven debridement radii. The initial model was validated using the bony density distribution from X-ray images and a photograph of the cadaver bone cross-section. The stress of the anterolateral column and the debridement efficiency were computed and analyzed.
(1) The peak stress of the anterolateral column in all conditions could return to the physiological level, and in two cases, the decrement/increment of stress was almost less than 0.1 % when the debridement radius increased. (2) The load share ratio (LSR) of the cortical and cancellous bone was markedly decreased in the untreated condition and increases with an increase in the debridement radius. (3) A debridement radius greater than 1/2r yields a LSR value larger than that obtained in the normal condition.
The simulation results provide specific biomechanical evidence to support the finding that FAIBG with a debridement region of 3/8 -1/2 appears to be a better choice for resisting femoral head collapse (FHC). Furthermore, FAIBG without thorough debridement, which requires relatively simple surgical devices and reduces artificial damage, appears to be a better method for resisting FHC than FAIBG with thorough debridement.
The incidence of femoral head necrosis (FHN) is rapidly increasing worldwide because of the widespread use of steroids [1, 2] and alcohol [3–6]. FHN is associated with high morbidity and disability. Patients with FHN are often at high risk of femoral head collapse (FHC), arthritis or disarticulation, which finally results in hip replacement (HR). Statistical data show that the medium- and long-term effects of hip-implant are obviously unsatisfactory; thus, young patients with HR will require several surgical treatments . Hence, various head-preserving procedures have been developed to protect the femoral head of patients and avoid HR, particularly in the early stage of FHN.
Fibular allograft with impaction bone grafting (FAIBG) is an effective head-preservation method for avoiding HR in the early stage of FHN. The advantage of this hip-preservation method is that it provides both repaired materials and biomechanical structural support during the healing of the necrosis region [8–11]. However, the disadvantage in using the FAIBG procedure lies in the fact that wide debridement may increase the incidence of cartilage injury and the strength of impaction bone grafting is difficult master. Hence, whether thorough debridement should be used with FAIBG is controversial. “With thorough debridement” indicates that the necrotic bone should be completely cleaned, whereas “without thorough debridement” indicates that the necrotic bone should undergo partial debridement. In most cases, the choice is based on the experience and preference of the surgeon without scientific evidence. Simultaneously, relatively few studies have compared the risk of postoperative FHC with and without thorough debridement.
The clinical practice concept requires theoretical proof. This study presents two subject-specific FHN cases without FHC to compare the mechanical performance between FAIBG with and without thorough debridement, which provides a biomechanical basis for selecting the proper treatment in clinical settings.
In 2001, the Japanese Investigation Committee (JIC)  revised the diagnostic criteria used to clarify the definition of osteonecrosis of the femoral head (ONFH). According to the JIC classification criteria, FHN is classified into subtypes A, B, C1 and C2 based on the location of the lesion in the weight-bearing area. Type A lesions occupy the medial one-third or less of the weight-bearing portion, type B lesions occupy the medial two-thirds or less of the weight-bearing portion, type C1 lesions occupy more than the medial two thirds of the weight-bearing portion but do not extend laterally to the acetabular edge, and type C2 lesions occupy more than the medial two-thirds of the weight-bearing portion and extend laterally to the acetabular edge.
Generation of Intact Finite Element Models
A JIC C1 FHN-diagnosed patient (P1, last name Fu) with a weight of 70 kg and a JIC C2 FHN-diagnosed patient (P2, last name Wan) with a weight of 60 kg were selected for the biomechanical evaluation of the proximal femur (informed consent was obtained from all patients). Computed tomography datasets (0.5 mm thickness; Toshiba Aquilion 64, Japan) for each case were used to reconstruct solid models with grey-level processing with the MIMICS 15.1 software based on the “Thresholding”, “Edit Masks”, and “Calculate 3D” functions. The solid models in the STL format were inputted into the Rapidform pre-processor, and surface-fitting was then performed. Based on the “Mesh” and “Autosurfacing” functions, we found the fit hip to generate the NURBS models. The interface between the ilium and femoral head was used to identify the cartilage geometry. All NURBS models in the igs format were inputted into ABAQUS V6.13 (SIMULIA co., France) to generate nonlinear elastic finite element models. Based on the initial hip geometry, we simulated physiological and pathological models using different materials.
Stress transfer path
Stress of the anterolateral column
Peak stress of the residual necrotic bone
Efficiency of debridement
Allograft bone is currently the most commonly used materials for the hip preserving procedure of FHN. Allograft fibula is used to provide structure and biomechanical support and impaction cancellous bone was used as biological repair material to promote osteogenesis during bone healing. The FAIBG procedure, as one of allograft bone methods, represents a proven technique to maintain the shape of the femoral head and reduce the risk of FHC in its early stages. Rosenwasser  first described thorough debridement and bone grafting for the treatment of FHN in 1994. This technique is an effective method for young patients with early stage FHN, which delays the progression of osteoarthrosis and subsequent HR. Tao  reported an 80 % clinical success rate with a mean follow-up time of 24 months among fifteen patients who had surgical therapy with thorough debridement with bone grafting. However, these procedures may cause serious artificial damage and complications because of capsulotomies or the destruction of the cortical bone of the femur neck fundus and require relatively high-cost and complicated technique. In 2008, Shi  reported 67 hips subjected to internal bracket implanting with partial debridement for FHN. These researchers showed a 64.2 % (43/67) success rate with an average follow-up of 23 months. In 2013, Shi  treated 25 patients using an allograft fibula with partial debridement for FHN and reported satisfactory results in 18 of 25 (72 %) patients with a 24-month follow-up. These minimally invasive procedures could reduce the artificial damage and complications but result in a poorer clinical outcome because they cannot provide both repaired materials and biomechanical structural support during healing of the necrosis region. FAIBG with proper debridement is an effective head-preservation method, and we achieved an average clinical success rate of 90.3 % with a mean follow-up time of 37.5 months . All views are based on clinical observation experience and lack a biomechanical basis. Hence, both “thorough debridement” and “partial debridement” are not universally accepted because no compelling evidence indicates which method is better at reducing the collapse risk of the femoral head, which encourages us to apply our experiences to a computational biomechanical analysis of the extent of debridement to reduce the collapse risk of FHN.
In our study, we adopted a subject-specific computational approach to consider the changes in the stress distribution of the anterolateral cortical bone and residual necrotic bone. Fig. 4 shows that the stress transfer paths in both JIC C1 and C2 are completely broken off, which indicates that surgical intervention should be performed. The effect of the debridement size with FAIBG on the collapse risk is clearly demonstrated in Fig. 5. After FAIBG, the peak stress of the anterolateral cortical bone in all conditions could return to the physiological level, and in two cases, the decrement/increment in stress was almost less than 0.1 % when the debridement radius increased. Hence, the collapse risk of the femoral head can be effectively reduced using an allo-fibula support to bear the load. Ueo  reported that the concentrated stress around the residual necrotic bone may induce development of the disease. When the debridement size is at least 3/8 r, the peak stress of the residual necrotic bone also returns to the pathological level, which denotes that the progression of necrosis will not deteriorate after surgical intervention. Fig. 7 shows that a proper debridement region may eliminate the stress concentration, but if the debridement region is too large and the bone grafting provides an oversized support intensity, the stress shielding phenomenon may be introduced. According to Wolff’s law, the structure and function of bone are interdependent. Stress shielding may cause disused bone loss of the anterolateral cortical bone, which results in fracture and collapse. Our results provide specific biomechanical evidence to support the viewpoint that FAIBG with a debridement region of 3/8 - 1/2 appears to be a better choice for resisting the collapse of JIC C FHN.
Thorough debridement has been reported in previous studies [20, 21, 25–27]. However, this procedure is difficult and time-consuming and is associated with serious artificial damage. Simultaneously, thorough debridement and bone grafting may cause stress shielding, which results in fracture and collapse. FAIBG with partial debridement can eliminate stress concentration and stress shielding and ensure that the stress of the residual bone does not increase. This technique has a distinct biomechanical basis, saves time, requires relatively lower-cost and introduces a low risk of artificial damage. Hence, FAIBG without thorough debridement appears to be better than FAIBG with thorough debridement.
In this study, we propose using computational biomechanical technology to explore different mechanical performances of FAIBG with and without thorough debridement in order to provide a biomechanical basis for selecting the proper treatment in clinic settings. Eighteen computational models were constructed to simulate two subtypes of FHN with seven debridement radii during the FAIBG procedure. The simulation results provide specific biomechanical evidence to support the finding that FAIBG with a debridement region of 3/8 - 1/2 appears to be a better choice for resisting the collapse of JIC C FHN. Furthermore, FAIBG without thorough debridement, which requires relatively simple technique and reduces artificial damage, appears to be a better method for resisting the collapse of JIC C1 and JIC C2 FHN. This manuscript also presents a preliminary approach to investigate the FAIBG procedure with thorough debridement, and a more detailed analysis will be reported in the near future.
This study was supported by the National Science Foundation of China (81173284, 81473697) and the Natural Science Foundation of Guangdong Province (2014A030310214, S2013010011992). None of the authors of this paper have any financial and personal relationships with other people or organizations that could inappropriately influence the work.
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