An Analysis of Stress Transfer Behaviors within the Necrotic Cancellous Bone following Surgical Procedures or the Management of the Osteonecrosis of the Femoral Head

대퇴골두 무혈성 괴사증의 수술적 기법 적용 후 괴사 망상골 내에서의 응력 변화 해석

Operative interventions for the management of osteonecrosis of the femoral head (ONFH) include core drilling, with or without vascularized fibular bone grafting. Nevertheless, their clinical results have not been consistently satisfactory. Recently, a new surgical procedure that incorporates cementation with polymethylmethacrylate (PMMA) after core drilling has been tried clinically. In this study, a biomechanical analysis using a finite element method(FEM) was undertaken to evaluate surgical methods and their underlying surgical parameter. Our finite element models included five types. They were (1) normal model (Type I), (2) necrotic model (Type II), (3) core decompressed model (Type III). (4) fibular bone grafted model (Type IV), and (5) cemented with PMMA model (Type V). The geometric dimensions of the femur were based on digitized CT-scan data of a normal person. Various physiological loading conditions and surgical penetration depths by the core were used as mechanical variables to study their biomechanical contributions in stress transfer within the femoral head region. In addition. the peak von Mises stress(PVMS) within the necrotic cancellous bone of the femoral head was obtained. The fibular bone grafted method and cementation method provided optimal stress transfer behaviors. Here. substantial increase in the low stress level was observed when the penetration depth was extended to 0mm and 5mm from the subchondral region. Moreover, significant decrease in PVMS due to surgery was observed in the fibular bone grafted method and the cementation method when the penetration depths were extended up to 0 and 5mm from the subchondral region. The drop in PVMS was greater during toe-off than during heel-strike (57% vs. 28% in Type IV and 49% vs. 22% in Type V). Both the vascularized fibular bone grafting method (Type IV) and the new PMMA technique (Type V) appear to be very effective in providing good stress transfer and reducing the peak Von-Mises stress within the necrotic region. Overall results show that fibular bone grafting and cementation methods are quite similar. In light of above results, the new cementation method appears to be a promising surgical alternative or the treatment of ONFH. The use of PMMA for the core can be less prone to surgical complication as opposed to preparation of fibular bone graft and can achieve more immediate fixation between the core and the surrounding region.