Archives of Orthopaedic and Trauma Surgery

, Volume 128, Issue 9, pp 901–908 | Cite as

Treatment of osteonecrosis of the hip: comparison of extracorporeal shockwave with shockwave and alendronate

  • Ching-Jen Wang
  • Feng-Sheng Wang
  • Kuender D. Yang
  • Chung-Cheng Huang
  • Mel Shiuann-Sheng Lee
  • Yi-Sheng Chan
  • Jun-Wen Wang
  • Jih-Yang Ko
Orthopaedic Surgery

Abstract

Background and purpose

Extracorporeal shockwave therapy (ESWT) and alendronate are reported effective in early osteonecrosis of the femoral head (ONFH). We hypothesized that joint effects of ESWT and alendronate may produce superior results. This prospective study compared the results of ESWT and alendronate with that of ESWT without alendronate in early ONFH.

Patients and methods

Forty-eight patients with 60 hips were randomly divided into tow groups. There were 25 patients with 30 hips in group A and 23 patients with 30 hips in group B. Both groups showed similar demographic characteristics. All patients were treated with 6,000 impulses of ESWT at 28 KV (equivalent to 0.62 mJ/mm²) to the affected hip as a single session. Patients in group B also received alendronate 70 mg per week for 1 year, whereas patients in group A did not. The evaluations included clinical assessment, radiograph and MR image of the affected hip. Both groups were compared statistically using paired t, Mann–Whitney and Chi square tests with statistical significance at P < 0.05. The primary end point is the need for total hip arthroplasty (THA). The secondary end point is the improvement in pain and function of the hip. The third end point is the progression or regression of the lesion on image study.

Results

The overall clinical outcomes were improved in 83%, unchanged in 7% and worsened in 10% for group A; and improved in 77%, unchanged in 13% and worsened in 10% for group B. THA was performed in 10% of group A and 10% of group B (P = 1.000). Significant improvements in pain and function of the hip were noted in both groups (P < 0.001), however, the differences between the two groups were not significant (P = 0.400, 0.313). On MR images, the lesions showed progression in 10%, regression in 47% and unchanged in 43% in group A, and progression in 7%, regression in 53% and unchanged in 40% in group B (P = 0.830).

Conclusion

ESWT and alendronate produced comparable result as compared with ESWT without alendronate in early ONFH. It appears that ESWT is effective with or without the concurrent use of alendronate. The joint effects of alendronate over ESWT in early ONFH are not realized in short-term.

Keywords

Extracorporeal shockwave Alendronate Osteonecrosis Femoral head 

References

  1. 1.
    Agarwala S, Jain D, Joshi VR, Sule A (2005) Efficacy alendronate, a bisphosphate, in the treatment of AVN of the hip. A prospective open-label study. Rheumatology (Oxford) 44:352–359CrossRefGoogle Scholar
  2. 2.
    Agarwala S, Sule A, Pai BU, Joshi VR (2002) Alendronate in the treatment of avascular necrosis of the hip. Rheumatology (Oxford) 41:346–347CrossRefGoogle Scholar
  3. 3.
    Belal MA, Reichelt A (1996) Clinical results of rotational osteotomy for treatment of avascular necrosis of the femoral head. Arch Orthop Trauma Surg 115:80–84PubMedCrossRefGoogle Scholar
  4. 4.
    Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, Bauer DC, Genant HK, Haskell WL, Marcus R, Ott SM, Torner JC, Quandt SA, Reiss TF, Ensrud KE (1996) Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet 348:1535–1541PubMedCrossRefGoogle Scholar
  5. 5.
    Bone HG, Hosking D, Devogelaer JP, Tucci JR, Emkey RD, Tonino RP, Rodriquez-Portales JA, Downs RW, Gupta J, Santora AC, Liberman UA (2004) Ten years’ experience with alendronate for osteoporosis in postmenopausal women. N Engl J Med 350:1189–1199PubMedCrossRefGoogle Scholar
  6. 6.
    Bradway JK, Morrey BF (1993) The natural history of the silent hip in bilateral atraumatic osteonecrosis. J Arthroplasty 8:383–387PubMedCrossRefGoogle Scholar
  7. 7.
    Chao YC, Wang SJ, Chu HC, Chang WK, Hsieh TY (2003) Investigation of alcohol metabolizing enzyme genes in Chinese alcoholics with avascular necrosis of hip joint, pancreatitis and cirrhosis of the liver. Alcohol Alcohol 38:431–436PubMedGoogle Scholar
  8. 8.
    Chavassieux PM, Arlot ME, Reda C, Wei L, Yates AJ, Meunier PJ (1997) Histomorphometric assessment of the long-term effects of alendronate on bone quality and remodeling in patients with osteoporosis. L Clin Invest 100:1475–1480CrossRefGoogle Scholar
  9. 9.
    Chen HS, Chen LM, Huang TW (2001) Treatment of painful heel syndrome with shock waves. Clin Orthop 387:41–46PubMedCrossRefGoogle Scholar
  10. 10.
    Cummings SR, Black DM, Thompson DE, Applegate WB, Barrett-Connor E, Musliner TA, Palermo L, Prineas R, Rubin SM, Scott JC, Vogt T, Wallace R, Yates AJ, LaCroix AZ (1998) Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: result from fracture intervention trial. JAMA 280:2077–2082PubMedCrossRefGoogle Scholar
  11. 11.
    Desai MM, Sonone S, Bhasme V (2005) Efficacy of alendronate in the treatment of avascular necrosis of the hip. Rheumatology (Oxford) 44:1331–1332CrossRefGoogle Scholar
  12. 12.
    Eyb R, Kotz R (1990) Sugioka’s trans-trochanteric osteotomy: Results of interventions 1975–1983. Orthopade 19:231–235PubMedGoogle Scholar
  13. 13.
    Ficat RP (1985) Idiopathic bone necrosis of the femoral head: Early diagnosis and treatment. J Bone Joint Surg Br 67:3–9PubMedGoogle Scholar
  14. 14.
    Gardeniers JWM (1993) ARCO (Association Research Circulation Osseous) international classification of osteonecrosis. ARCO Committee on Terminology and Staging. Report on the committee meeting at Santiago de Compostella. ARCO Newslett 5:79–82Google Scholar
  15. 15.
    Harris WH (1969) Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty: an end-result study using a new method of result evaluation. J Bone Joint Surg Am 51:737–755PubMedGoogle Scholar
  16. 16.
    Hasegawa Y, Iwata H, Torii S, Iwase T, Kawamoto K, Iwasada S (1997) Vascularized pedicle bone grafting for nontraumatic avascular necrosis of the femoral head: a 5- to 11-year follow-up. Arch Orthop Trauma Surg 116:251–258PubMedCrossRefGoogle Scholar
  17. 17.
    Heaney RP, Yates AJ, Santora AC II (1997) Bisphosphonate effects and the bone remodeling transient. J Bone Miner Res 12:1143–1151PubMedCrossRefGoogle Scholar
  18. 18.
    Heller KD, Niethard FU (1998) Using extracorporeal shockwave therapy in orthopedics: a meta-analysis. Z Orthop Ihre Grenzgeb 36:390–401Google Scholar
  19. 19.
    Hungerford DS (1990) Role of core decompression as treatment method for ischemic femur head necrosis. Orthopade 19:219–223PubMedGoogle Scholar
  20. 20.
    Iorio R, Healy WL, Abramowitz AJ, Pfeifer BA (1998) Clinical outcome and survivorship analysis of core decompression for early osteonecrosis of the femoral head. J Arthroplasty 13:34–41PubMedCrossRefGoogle Scholar
  21. 21.
    Ishizaka M, Sofue M, Dohmae Y, Endo N, Takahashi HE (1997) Vascularized iliac bone graft for avascular necrosis of the femoral head. Clin Orthop 337:140–148PubMedCrossRefGoogle Scholar
  22. 22.
    Kim SY, Kim YG, Kim PT, Ihn JC, Cho BC, Koo KH (2005) Vascularized compared with nonvascularized fibular grafts for large osteonecrotic lesions of the femoral head. J Bone Joint Surg Am 87:2012–2008PubMedCrossRefGoogle Scholar
  23. 23.
    Kim YM, Oh HC, Kim HJ (2000) The pattern of bone marrow edema on MRI in osteonecrosis of the femoral head. J Bone Joint Surg Br 82:837–841PubMedCrossRefGoogle Scholar
  24. 24.
    Ko JY, Chen HS, Chen LM (2001) Treatment of lateral epicondylitis of the elbow with shock waves. Clin Orthop 387:60–67PubMedCrossRefGoogle Scholar
  25. 25.
    Koo KH, Kim R, Kim YS, Ahn IO, Cho SH, Song HR, Park YS, Kim H, Wang GJ (2002) Risk period for developing osteonecrosis of the femoral head in patients on steroid treatment. Clin Rheumatol 21:299–303PubMedCrossRefGoogle Scholar
  26. 26.
    Koo KH, Kim R, Ko GH, Song HR, Jeong ST, Cho SH (1995) Preventing collapse in early osteonecrosis of the femoral head: a randomized clinical trial of core decompression. J Bone Joint Surg Br 77:870–874PubMedGoogle Scholar
  27. 27.
    Lai KA, Shen WJ, Yang CY, Shao CJ, Hsu JT, Lin RM (2005) The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. A randomized clinical study. J Bone Joint Surg Am 87:2155–2159PubMedCrossRefGoogle Scholar
  28. 28.
    Langlais F, Fourastier J (1997) Rotation osteotomies for osteonecrosis of the femoral head. Clin Orthop 343:110–123PubMedGoogle Scholar
  29. 29.
    Learmouth ID, Maloon S, Dall G (1990) Core decompression for early atraumatic osteonecrosis of the femoral head. J Bone Joint Surg Br 72:387–390Google Scholar
  30. 30.
    Leung PC (1996) Femoral head reconstruction and revascularization: treatment for ischemic necrosis. Clin Orthop 323:139–145PubMedCrossRefGoogle Scholar
  31. 31.
    Lin JH (1996) Bisphosphonates: a review of their pharmacokinetic properties. Bone 18:75–85PubMedCrossRefGoogle Scholar
  32. 32.
    Ludwig J, Lauber S, Lauber HJ, Dreisilker U, Raedel R, Hotzinger H (2001) High-energy shock wave treatment of femoral head necrosis in adults. Clin Orthop 387:119–126PubMedCrossRefGoogle Scholar
  33. 33.
    McCormack D, Lane H, McElwain J (1996) The osteogenic potential of extracorporeal shock wave therapy: an in-vivo study. Ir J Med Sci 165:20–22PubMedGoogle Scholar
  34. 34.
    Merle D’Aubigne R, Postel M, Mazab A, Massias P, Gueguen J, France P (1965) Idiopathic necrosis of the femoral head in adults. J Bone Joint Surg Br 47:612–633PubMedGoogle Scholar
  35. 35.
    Mont MA, Carbone JJ, Fairbank AC (1996) Core decompression versus non-operative management for osteonecrosis of the hip. Clin Orthop 324:169–178PubMedCrossRefGoogle Scholar
  36. 36.
    Mont MA, Jones LC, Hungerford DS (2006) Nontraumatic osteonecrosis of the femoral head: ten years later. J Bone Joint Surg Am 88:1117–1132PubMedCrossRefGoogle Scholar
  37. 37.
    Ohzono K, Saito M, Takaoka K, Saito S, Nishina T, Kadowaki T (1991) Natural history of nontraumatic avascular necrosis of the femoral head. J Bone Joint Surg Br 73:68–72PubMedGoogle Scholar
  38. 38.
    Rodan GA (1997) Bone mass homeostasis and bisphosphonate action. Bone 20:1–4PubMedCrossRefGoogle Scholar
  39. 39.
    Rompe JD, Rosendahl T, Schollner C, Theis C (2001) High-energy extracorporeal shock wave treatment of non-unions. Clin Orthop 387:102–111PubMedCrossRefGoogle Scholar
  40. 40.
    Sahni M, Guenther HL, Fleisch H, Collin P, Martin TJ (1993) Bisphosphonates act on rat bone resorption through the mediation of osteoblasts. J Clin Invest 91:2004–2011PubMedCrossRefGoogle Scholar
  41. 41.
    Schaden W, Fischer A, Sailler A (2001) Extracorporeal shock wave therapy of nonunion or delayed osseous union. Clin Orthop 387:90–94PubMedCrossRefGoogle Scholar
  42. 42.
    Scully SP, Aaron RK, Urbaniak JR (1998) Survival analysis of hips treated with core decompression or vascularized fibular grafting because of avascular necrosis. J Bone Joint Surg Am 80:1270–1275PubMedGoogle Scholar
  43. 43.
    Steinberg ME, Hayken GD, Steinberg DR (1995) A quantitative system for staging avascular necrosis. J Bone Joint Surg Br 77:34–41PubMedGoogle Scholar
  44. 44.
    Takatori Y, Kokubo T, Ninomiya S, Nakamura S, Morimoto S, Kusaba I (1993) Avascular necrosis of the femoral head. Natural history and magnetic resonance imaging. J Bone Joint Surg Br 75:217–221PubMedGoogle Scholar
  45. 45.
    Urbaniak JR, Coogan PG, Gunneson EB, Nunley JA (1995) Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting: a long-term follow-up study of one hundred and three hips. J Bone Joint Surg Am 77:681–694PubMedGoogle Scholar
  46. 46.
    Vogel J, Hopf C, Eysel P, Rompe JD (1997) Application of extracorporeal shock waves in the treatment of pseudarthrosis of the lower extremity: preliminary results. Arch Orthop Trauma Surg 116:480–483PubMedCrossRefGoogle Scholar
  47. 47.
    Wang CJ, Chen HS, Chen CE, Yang KD (2001) Treatment of non-unions of long bone fracture with shock waves. Clin Orthop 387:95–101PubMedCrossRefGoogle Scholar
  48. 48.
    Wang CJ, Chen HS, Chen WS, Chen LM (2000) Treatment of painful heel using extracorporeal shock wave. J Formosa Med Ass 99:580–583PubMedGoogle Scholar
  49. 49.
    Wang CJ, Chen HS (2002) Shock wave therapy for patients with lateral epicondylitis of the elbow: a one- to two-year follow-up study. Am J Sports Med 30:422–425PubMedGoogle Scholar
  50. 50.
    Wang CJ, Hung HY, Pai CH (2002) Shock wave-enhanced neovascularization at the tendon-bone junction: an experiment in dogs. J Foot Ankle Surg 41:16–22PubMedGoogle Scholar
  51. 51.
    Wang CJ, Wang FS, Yang KD, Huang CS, Hsu CC (2003) Shock wave therapy induces neovascularization at the tendon-bone junction. A study in rabbits. J Orthop Res 21:984–989PubMedCrossRefGoogle Scholar
  52. 52.
    Wang CJ, Ko JY, Chen HS (2001) Treatment of calcifying tendinitis of the shoulder with shock wave therapy. Clin Orthop 387:83–89PubMedCrossRefGoogle Scholar
  53. 53.
    Wang CJ, Wang FS, Huang CC, Yang KD, Weng LH, Huang HY (2005) Treatment of osteonecrosis of the femoral head—comparison of extracorporeal shockwave and core decompression and bone grafting. J Bone Joint Surg Am 87:2380–2387PubMedCrossRefGoogle Scholar
  54. 54.
    Wang CJ, Yang KD, Chen HS, Wang FS, Wang JW (2003) Shock wave therapy for patients with calcifying tendonitis of the shoulder. A prospective clinical study with two-year follow-up. Am J Sports Med 31:425–430PubMedGoogle Scholar
  55. 55.
    Wang GJ, Cui Q, Balian G (2000) The pathogenesis and prevention of steroid-induced osteonecrosis. Clin Orthop Relat Res 370:295–310PubMedCrossRefGoogle Scholar
  56. 56.
    Zhou Q, Li Q, Yang L, Liu F (2000) Changes of blood vessels in glucocorticoid-induced avascular necrosis of the femoral head in rabbits. Chung-Hua Wai Ko Tsa Chih (Chin J Surg) 38:212–215Google Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Ching-Jen Wang
    • 1
  • Feng-Sheng Wang
    • 2
  • Kuender D. Yang
    • 2
  • Chung-Cheng Huang
    • 3
  • Mel Shiuann-Sheng Lee
    • 1
  • Yi-Sheng Chan
    • 1
  • Jun-Wen Wang
    • 1
  • Jih-Yang Ko
    • 1
  1. 1.Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Kaohsiung Medical CenterChang Gung University School of MedicineKaohsiungTaiwan
  2. 2.Department of Medical Research, Chang Gung Memorial Hospital-Kaohsiung Medical CenterChang Gung University School of MedicineKaohsiungTaiwan
  3. 3.Department of Diagnostic Radiology, Chang Gung Memorial Hospital-Kaohsiung Medical CenterChang Gung University School of MedicineKaohsiungTaiwan

Personalised recommendations