The Journal of Bone and Joint Surgery (American) 85:309-315 (2003)
© 2003 The Journal of Bone and Joint Surgery, Inc.
Quantifying the Extent of Femoral Head Involvement in Osteonecrosis
Sebastian F. Cherian, MD,
Alan Laorr, MD,
Khaled J. Saleh, MD, MSc, FRCSC,
Michael A. Kuskowski, PhD,
Robert F. Bailey, LPN and
Edward Y. Cheng, MD
Investigation performed at the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
Sebastian F. Cherian, MD
Department of Radiology, University of Minnesota, 420 Delaware Street S.E., Minneapolis, MN 55455
Alan Laorr, MD
Suburban Radiologic Consultants, 4801 West 81st Street, Suite 108, Minneapolis, MN 55437
Khaled J. Saleh, MD, MSc, FRCSC
Edward Y. Cheng, MD
Department of Orthopaedic Surgery, University of Minnesota, 420 Delaware Street S.E., MMC 492, Minneapolis, MN 55455. E-mail address for E.Y. Cheng: cheng002{at}tc.umn.edu
Michael A. Kuskowski, PhD
Veterans Affairs Medical Center, GRECC (11G), One Veterans Drive, Minneapolis, MN 55417
Robert F. Bailey, LPN
Department of Surgery, University of Minnesota, 420 Delaware Street S.E., Box 195, Minneapolis, MN 55455
In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the National Institutes of Health (Grant 2P01DK13083-300219) and the Minnesota Medical Foundation. None of the authors received 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, or educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Background: There are numerous methods for quantifying the extent of osteonecrosis of the femoral head. However, there is no consensus regarding which method is the most reliable. The purpose of this study was to determine the reliability and prognostic accuracy of three commonly used methods for quantifying the extent of osteonecrosis of the femoral head.
Methods: Thirty-nine hips in twenty-five patients who had stage-I or II osteonecrosis of the femoral head, according to the grading system of the Association Research Circulation Osseous, were independently examined on two separate occasions by three observers of different specialty backgrounds and experience. Each observer used three methods to quantify the extent of osteonecrosis of the femoral head: (1) the index of necrotic extent, (2) the modified index of necrotic extent, and (3) the percentage of femoral head involvement. The interobserver and intraobserver agreement was determined for each method, and the ability of each method to predict the time to subchondral collapse was analyzed statistically.
Results: There was significantly valid agreement among the observers for all three methods (p < 0.001 for all three). The correlation coefficients demonstrated substantial agreement among raters when they measured the index of necrotic extent and the percent involvement and nearly perfect agreement when they measured the modified index of necrotic extent. Survivorship analysis revealed that the percent involvement (p < 0.05), index of necrotic extent (p < 0.007), and modified index of necrotic extent (p < 0.04) were prognostically significant predictors of subchondral fracture.
Conclusions: Our results indicate that the index of necrotic extent, modified index of necrotic extent, and estimation of the percentage of involvement of the femoral head are reproducible and reliable methods for quantitatively evaluating the extent of osteonecrosis of the femoral head. We believe that the three methods can be utilized with confidence. Furthermore, they are clinically useful for identifying hips at greatest risk for subchondral collapse.
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