Impact of hip synovitis on the long-term outcomes of free vascularized fibular grafting for osteonecrosis of femoral head

doi:10.3969/j.issn.1674-8115.2025.03.013

Abstract

Abstract:

Objective ·To observe the impact of hip synovitis on the long-term outcomes of free vascularized fibular grafting (FVFG) for osteonecrosis of femoral head (ONFH). Methods ·Between October 2001 and December 2013, 370 patients diagnosed with ONFH (556 hips) underwent FVFG. Preoperative synovitis was assessed using magnetic resonance imaging (MRI) and quantified with the Hip Inflammation MRI Scoring System (HIMRISS). Patients were divided into no synovitis group, moderate synovitis group, and severe synovitis group. Harris hip scores and the incidence of total hip arthroplasty were collected with an average follow-up duration of 90.5 months (range: 5‒215 months). Hip survival failure (defined as a Harris hip score lower than 80 at the final follow-up or the occurrence of total hip arthroplasty) was calculated. Multivariable Cox regression analysis was adopted to compare the influence of different degrees of synovial inflammation on long-term prognosis. Results ·The proportion of hip survival failure was 28.0% in patients without synovitis and 28.5% in those with moderate synovitis, whereas it was significantly higher (60.4%) in patients with severe synovitis. The results of multivariable Cox regression analysis showed that severe synovitis was an independent risk factor for poor prognosis ( HR 2.06, 95% CI 1.21‒3.53) after adjusting for age, gender, education level, marital status, ONFH type, affected side of ONFH, smoking history, baseline Harris hip score and other hip MRI-based covariates (collapse, bone marrow edema, and degeneration). Conclusion ·Severe synovitis in patients with ONFH significantly increases the failure rate of hip preservation after FVFG, and the severity of synovitis should be considered in surgical decision-making.

Key words: osteonecrosis of femoral head, free vascularized fibular grafting, synovitis

CLC Number:

R684.3

ZHU Daoyu, FU Kai, HE Haiyan, CAI Qianying, PENG Hao, CHEN Shengbao, YIN Jimin, LUO Pengbo, JIN Dongxu, ZHANG Changqing, GAO Youshui. Impact of hip synovitis on the long-term outcomes of free vascularized fibular grafting for osteonecrosis of femoral head[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2025, 45(3): 357-364.

Figures/Tables 4

TrendMD

References 23

1	MONT M A, ZYWIEL M G, MARKER D R, et al. The natural history of untreated asymptomatic osteonecrosis of the femoral head[J]. J Bone Joint Surg Am, 2010, 92(12): 2165-2170.
2	MONT M A, SALEM H S, PIUZZI N S, et al. Nontraumatic osteonecrosis of the femoral head: where do we stand today? A 5-year update[J]. J Bone Joint Surg Am, 2020, 102(12): 1084-1099.
3	YOON B H, MONT M A, KOO K H, et al. The 2019 revised version of association research circulation osseous staging system of osteonecrosis of the femoral head[J]. J Arthroplasty, 2020, 35(4): 933-940.
4	张长青, 冯勇. 加强科普宣传与教育以提升股骨头坏死早期诊治水平[J]. 骨科临床与研究杂志, 2024, 9(2): 65-67.
	ZHANG C Q, FENG Y. Strengthening science popularization and education to improve the early diagnosis and treatment level of femoral head necrosis[J]. Journal of Clinical Orthopedics and Research, 2024, 9(2): 65-67.
5	EWARD W C, RINEER C A, URBANIAK J R, et al. The vascularized fibular graft in precollapse osteonecrosis: is long-term hip preservation possible?[J]. Clin Orthop Relat Res, 2012, 470(10): 2819-2826.
6	DING H, GAO Y S, CHEN S B, et al. Free vascularized fibular grafting benefits severely collapsed femoral head in concomitant with osteoarthritis in very young adults: a prospective study[J]. J Reconstr Microsurg, 2013, 29(6): 387-392.
7	CHEN S, FU K, CAI Q, et al. Development of a risk-predicting score for hip preservation with bone grafting therapy for osteonecrosis[J]. iScience, 2024, 27(4): 109332.
8	中华老年骨科与康复电子杂志编辑委员会. 股骨头坏死保髋治疗指南(2016版)[J]. 中华老年骨科与康复电子杂志, 2016, 2(2): 65-70.
	Editorial Committee of Chinese Journal of Geriatric Orthopedics and Rehabilitation. Guidelines for hip preservation treatment of necrosis of femoral head (2016 edition)[J]. Chinese Journal of Geriatric Orthopaedics and Rehabilitation (Electronic Edition), 2016, 2(2): 65-70.
9	SANCHEZ-LOPEZ E, CORAS R, TORRES A, et al. Synovial inflammation in osteoarthritis progression[J]. Nat Rev Rheumatol, 2022, 18: 258-275.
10	刘斌, 鲜艳思, 郭保生, 等. 骨关节炎中滑膜炎症致病因素的研究进展[J]. 国际骨科学杂志, 2023, 44(5): 274-278.
	LIU B, XIAN Y S, GUO B S, et al. Research progress on the pathogenic factors of synovitis in osteoarthritis[J]. International Journal of Orthopaedics, 2023, 44(5): 274-278.
11	RABQUER B J, TAN G J, SHAHEEN P J, et al. Synovial inflammation in patients with osteonecrosis of the femoral head[J]. Clin Transl Sci, 2009, 2(4): 273-278.
12	SHIRAI C, OHTORI S, KISHIDA S, et al. The pattern of distribution of PGP 9.5 and TNF-alpha immunoreactive sensory nerve fibers in the labrum and synovium of the human hip joint[J]. Neurosci Lett, 2009, 450(1): 18-22.
13	WANG C J, YANG Y J, HUANG C C. The effects of shockwave on systemic concentrations of nitric oxide level, angiogenesis and osteogenesis factors in hip necrosis[J]. Rheumatol Int, 2011, 31(7): 871-877.
14	SAIDI S, MAGNE D. Interleukin-33: a novel player in osteonecrosis of the femoral head?[J]. Joint Bone Spine, 2011, 78(6): 550-554.
15	LIM J C, MITCHELL C H. Inflammation, pain, and pressure: purinergic signaling in oral tissues[J]. J Dent Res, 2012, 91(12): 1103-1109.
16	HATANAKA H, MOTOMURA G, IKEMURA S, et al. Volume of hip synovitis detected on contrast-enhanced magnetic resonance imaging is associated with disease severity after collapse in osteonecrosis of the femoral head[J]. Skeletal Radiol, 2019, 48(8): 1193-1200.
17	GAO Y S, CHEN S B, JIN D X, et al. Modified surgical techniques of free vascularized fibular grafting for treatment of the osteonecrosis of femoral head: results from a series of 407 cases[J]. Microsurgery, 2013, 33(8): 646-651.
18	AHEDI H, AITKEN D, BLIZZARD L, et al. Quantification of hip effusion-synovitis and its cross-sectional and longitudinal associations with hip pain, MRI findings and early radiographic hip OA[J]. BMC Musculoskelet Disord, 2020, 21(1): 533.
19	ZALAVRAS C G, LIEBERMAN J R. Osteonecrosis of the femoral head: evaluation and treatment[J]. J Am Acad Orthop Surg, 2014, 22(7): 455-464.
20	BAYLISS L E, CULLIFORD D, MONK A P, et al. The effect of patient age at intervention on risk of implant revision after total replacement of the hip or knee: a population-based cohort study[J]. Lancet, 2017, 389(10077): 1424-1430.
21	RICHARD M J, DIPRINZIO E V, LORENZANA D J, et al. Outcomes of free vascularized fibular graft for post-traumatic osteonecrosis of the femoral head[J]. Injury, 2021, 52(12): 3653-3659.
22	FONTECHA C G, ROCA I, BARBER I, et al. Femoral head bone viability after free vascularized fibular grafting for osteonecrosis: spect/CT study[J]. Microsurgery, 2016, 36(7): 573-577.
23	SELLAM J, BERENBAUM F. The role of synovitis in pathophysiology and clinical symptoms of osteoarthritis[J]. Nat Rev Rheumatol, 2010, 6: 625-635.

Item	Overall ( n=556)	No synovitis group ( n=254)	Moderate synovitis group ( n=249)	Severe synovitis group ( n=53)	P value
ONFH type/ n (%)					0.003
Trauma	53 (9.5)	21 (8.3)	27 (10.8)	5 (9.4)
Steroid	243 (43.7)	107 (42.1)	119 (47.8)	17 (32.1)
Alcohol	130 (23.4)	52 (20.5)	58 (23.3)	20 (37.8)
Idiopathic	99 (17.8)	61 (24.0)	32 (12.9)	6 (11.3)
N/A	31 (5.6)	13 (5.1)	13 (5.2)	5 (9.4)
Baseline HHS/point	75.80±16.28	77.99±14.99	76.22±15.96	63.26±18.36	<0.001
Baseline HHS level/ n (%)					<0.001
HHS≥90 points	138 (24.8)	70 (27.5)	62 (24.9)	6 (11.3)
HHS 80‒89 points	112 (20.2)	55 (21.7)	54 (21.7)	3 (5.7)
HHS 70‒79 points	132 (23.7)	69 (27.2)	54 (21.7)	9 (17.0)
HHS≤69 points	174 (31.3)	60 (23.6)	79 (31.7)	35 (66.0)
MRI range/ n (%)					<0.001
<30%	194 (34.9)	101 (39.8)	91 (36.5)	2 (3.8)
30%‒66%	278 (50.0)	120 (47.2)	124 (49.8)	34 (64.1)
>66%	84 (15.1)	33 (13.0)	34 (13.7)	17 (32.1)
MRI crescent sign/ n (%)					<0.001
No	199 (35.8)	115 (45.3)	82 (32.9)	2 (3.8)
<30%	272 (48.9)	107 (42.1)	135 (54.2)	30 (56.6)
≥30%	85 (15.3)	32 (12.6)	32 (12.9)	21 (39.6)
MRI collapse/ n (%)					<0.001
No	292 (52.5)	143 (56.3)	141 (56.6)	8 (15.1)
<2 mm	194 (34.9)	91 (35.8)	84 (33.7)	19 (35.9)
2‒4 mm	57 (10.3)	17 (6.7)	19 (7.6)	21 (39.6)
>4 mm	13 (2.3)	3 (1.2)	5 (2.1)	5 (9.4)
MRI bone marrow edema/ n (%)	206 (37.1)	92 (36.2)	80 (32.1)	34 (64.2)	<0.001
No	350 (63.0)	162 (63.8)	169 (67.9)	19 (35.8)	<0.001
Mild	162 (29.1)	80 (31.5)	58 (23.3)	24 (45.3)
Severe	44 (7.9)	12 (4.7)	22 (8.8)	10 (18.9)
MRI class/ n (%)					<0.001
Grade 1	508 (91.5)	208 (82.2)	247 (99.2)	53 (100.0)
Grade 2	286 (51.4)	143 (56.3)	137 (55.0)	6 (11.3)
Grade 3	252 (45.3)	106 (41.7)	105 (42.2)	41 (77.4)
Grade 4	18 (3.2)	5 (2.0)	7 (2.8)	6 (11.3)
MRI degeneration/ n (%)	138 (24.8)	62 (24.4)	52 (20.9)	24 (45.3)	0.001
Follow-up duration/month	81.81±51.85	84.15±52.41	81.37±51.15	72.68±52.39	0.337
Last HHS/point	84.70±11.82	85.73±11.61	85.23±11.51	77.58±11.89	<0.001
Last HHS level/ n (%)					<0.001
HHS ≥90 points	241 (43.3)	120 (47.3)	115 (46.2)	6 (11.3)
HHS 80‒89 points	149 (26.8)	65 (25.6)	66 (26.5)	18 (34.0)
HHS 70‒79 points	105 (18.9)	44 (17.3)	45 (18.1)	16 (30.2)
HHS ≤69 points	61 (11.0)	25 (9.8)	23 (9.2)	13 (24.5)
HHS change from baseline/score	9.23±17.02	8.01±16.22	9.30±17.47	14.58±17.86	0.041
THA/ n (%)	33 (5.9)	10 (3.9)	13 (5.2)	10 (18.9)	<0.001

Item	Overall ( n=556)	No synovitis group ( n=254)	Moderate synovitis group ( n=249)	Severe synovitis group ( n=53)	P value
ONFH type/ n (%)					0.003
Trauma	53 (9.5)	21 (8.3)	27 (10.8)	5 (9.4)
Steroid	243 (43.7)	107 (42.1)	119 (47.8)	17 (32.1)
Alcohol	130 (23.4)	52 (20.5)	58 (23.3)	20 (37.8)
Idiopathic	99 (17.8)	61 (24.0)	32 (12.9)	6 (11.3)
N/A	31 (5.6)	13 (5.1)	13 (5.2)	5 (9.4)
Baseline HHS/point	75.80±16.28	77.99±14.99	76.22±15.96	63.26±18.36	<0.001
Baseline HHS level/ n (%)					<0.001
HHS≥90 points	138 (24.8)	70 (27.5)	62 (24.9)	6 (11.3)
HHS 80‒89 points	112 (20.2)	55 (21.7)	54 (21.7)	3 (5.7)
HHS 70‒79 points	132 (23.7)	69 (27.2)	54 (21.7)	9 (17.0)
HHS≤69 points	174 (31.3)	60 (23.6)	79 (31.7)	35 (66.0)
MRI range/ n (%)					<0.001
<30%	194 (34.9)	101 (39.8)	91 (36.5)	2 (3.8)
30%‒66%	278 (50.0)	120 (47.2)	124 (49.8)	34 (64.1)
>66%	84 (15.1)	33 (13.0)	34 (13.7)	17 (32.1)
MRI crescent sign/ n (%)					<0.001
No	199 (35.8)	115 (45.3)	82 (32.9)	2 (3.8)
<30%	272 (48.9)	107 (42.1)	135 (54.2)	30 (56.6)
≥30%	85 (15.3)	32 (12.6)	32 (12.9)	21 (39.6)
MRI collapse/ n (%)					<0.001
No	292 (52.5)	143 (56.3)	141 (56.6)	8 (15.1)
<2 mm	194 (34.9)	91 (35.8)	84 (33.7)	19 (35.9)
2‒4 mm	57 (10.3)	17 (6.7)	19 (7.6)	21 (39.6)
>4 mm	13 (2.3)	3 (1.2)	5 (2.1)	5 (9.4)
MRI bone marrow edema/ n (%)	206 (37.1)	92 (36.2)	80 (32.1)	34 (64.2)	<0.001
No	350 (63.0)	162 (63.8)	169 (67.9)	19 (35.8)	<0.001
Mild	162 (29.1)	80 (31.5)	58 (23.3)	24 (45.3)
Severe	44 (7.9)	12 (4.7)	22 (8.8)	10 (18.9)
MRI class/ n (%)					<0.001
Grade 1	508 (91.5)	208 (82.2)	247 (99.2)	53 (100.0)
Grade 2	286 (51.4)	143 (56.3)	137 (55.0)	6 (11.3)
Grade 3	252 (45.3)	106 (41.7)	105 (42.2)	41 (77.4)
Grade 4	18 (3.2)	5 (2.0)	7 (2.8)	6 (11.3)
MRI degeneration/ n (%)	138 (24.8)	62 (24.4)	52 (20.9)	24 (45.3)	0.001
Follow-up duration/month	81.81±51.85	84.15±52.41	81.37±51.15	72.68±52.39	0.337
Last HHS/point	84.70±11.82	85.73±11.61	85.23±11.51	77.58±11.89	<0.001
Last HHS level/ n (%)					<0.001
HHS ≥90 points	241 (43.3)	120 (47.3)	115 (46.2)	6 (11.3)
HHS 80‒89 points	149 (26.8)	65 (25.6)	66 (26.5)	18 (34.0)
HHS 70‒79 points	105 (18.9)	44 (17.3)	45 (18.1)	16 (30.2)
HHS ≤69 points	61 (11.0)	25 (9.8)	23 (9.2)	13 (24.5)
HHS change from baseline/score	9.23±17.02	8.01±16.22	9.30±17.47	14.58±17.86	0.041
THA/ n (%)	33 (5.9)	10 (3.9)	13 (5.2)	10 (18.9)	<0.001

Item	Overall ( n=370)	No synovitis group ( n=168)	Mild synovitis group ( n=162)	Severe synovitis group ( n=40)	P value
Age/year	33.40±10.01	33.64±9.82	33.12±10.26	33.50±10.02	0.893
Age level/ n (%)					0.151
<30 years	142 (38.4)	67 (39.9)	64 (39.5)	11 (27.5)
30‒39 years	136 (36.8)	56 (33.3)	58 (35.8)	22 (55.0)
40‒50 years	69 (18.6)	37 (22.0)	28 (17.3)	4 (10.0)
>50 years	23 (6.2)	8 (4.8)	12 (7.4)	3 (7.5)
Female/ n (%)	74 (20.0)	41 (24.4)	29 (17.9)	4 (10.0)	0.083
Operation side (right)/ n (%)	82 (22.2)	37 (22.0)	36 (22.2)	9 (22.5)	0.998
Bilateral ONFH/ n (%)	228 (61.6)	103 (61.3)	96 (59.3)	29 (72.5)	0.303
Education/ n (%)					0.351
Literacy, primary school	5 (1.4)	0 (0)	4 (2.6)	1 (2.8)
Middle or high school	166 (47.7)	74 (47.1)	74 (47.7)	18 (50.0)
Collage or higher	177 (50.9)	83 (52.9)	77 (49.7)	17 (47.2)
Ethnic minorities/ n (%)	7 (1.9)	2 (1.2)	4 (2.5)	1 (2.5)	0.665
Married/ n (%)	282 (76.2)	127 (75.6)	121 (74.7)	34 (85.0)	0.378
Household income per person/ n (%)					0.476
<1 000 yuan	28 (8.1)	11 (7.1)	16 (10.3)	1 (2.8)
1 000‒1 999 yuan	43 (12.4)	18 (11.5)	18 (11.6)	7 (19.4)
2 000‒2 999 yuan	69 (19.9)	34 (21.8)	28 (18.1)	7 (19.4)
3 000‒3 999 yuan	87 (25.1)	34 (21.8)	41 (26.5)	12 (33.3)
4 000‒5 000 yuan	58 (16.7)	30 (19.2)	22 (14.2)	6 (16.7)
>5 000 yuan	62 (17.9)	29 (18.6)	30 (19.4)	3 (8.3)
Weight baseline/kg	67.40±13.46	67.05±13.37	67.00±12.76	70.70±16.59	0.333
Height baseline/cm	168.97±8.84	168.03±10.63	169.68±7.14	169.79±7.07	0.251
Smoking history/ n (%)	185 (50.3)	79 (47.6)	82 (50.6)	24 (60.0)	0.368
Comorbidities/ n (%)	169 (45.9)	81 (48.8)	74 (45.7)	14 (35.0)	0.290

Item	Overall ( n=370)	No synovitis group ( n=168)	Mild synovitis group ( n=162)	Severe synovitis group ( n=40)	P value
Age/year	33.40±10.01	33.64±9.82	33.12±10.26	33.50±10.02	0.893
Age level/ n (%)					0.151
<30 years	142 (38.4)	67 (39.9)	64 (39.5)	11 (27.5)
30‒39 years	136 (36.8)	56 (33.3)	58 (35.8)	22 (55.0)
40‒50 years	69 (18.6)	37 (22.0)	28 (17.3)	4 (10.0)
>50 years	23 (6.2)	8 (4.8)	12 (7.4)	3 (7.5)
Female/ n (%)	74 (20.0)	41 (24.4)	29 (17.9)	4 (10.0)	0.083
Operation side (right)/ n (%)	82 (22.2)	37 (22.0)	36 (22.2)	9 (22.5)	0.998
Bilateral ONFH/ n (%)	228 (61.6)	103 (61.3)	96 (59.3)	29 (72.5)	0.303
Education/ n (%)					0.351
Literacy, primary school	5 (1.4)	0 (0)	4 (2.6)	1 (2.8)
Middle or high school	166 (47.7)	74 (47.1)	74 (47.7)	18 (50.0)
Collage or higher	177 (50.9)	83 (52.9)	77 (49.7)	17 (47.2)
Ethnic minorities/ n (%)	7 (1.9)	2 (1.2)	4 (2.5)	1 (2.5)	0.665
Married/ n (%)	282 (76.2)	127 (75.6)	121 (74.7)	34 (85.0)	0.378
Household income per person/ n (%)					0.476
<1 000 yuan	28 (8.1)	11 (7.1)	16 (10.3)	1 (2.8)
1 000‒1 999 yuan	43 (12.4)	18 (11.5)	18 (11.6)	7 (19.4)
2 000‒2 999 yuan	69 (19.9)	34 (21.8)	28 (18.1)	7 (19.4)
3 000‒3 999 yuan	87 (25.1)	34 (21.8)	41 (26.5)	12 (33.3)
4 000‒5 000 yuan	58 (16.7)	30 (19.2)	22 (14.2)	6 (16.7)
>5 000 yuan	62 (17.9)	29 (18.6)	30 (19.4)	3 (8.3)
Weight baseline/kg	67.40±13.46	67.05±13.37	67.00±12.76	70.70±16.59	0.333
Height baseline/cm	168.97±8.84	168.03±10.63	169.68±7.14	169.79±7.07	0.251
Smoking history/ n (%)	185 (50.3)	79 (47.6)	82 (50.6)	24 (60.0)	0.368
Comorbidities/ n (%)	169 (45.9)	81 (48.8)	74 (45.7)	14 (35.0)	0.290

Outcome	n (%)	Model 1	Model 2	Model 3
THA or last HHS<80 points
No synovitis group	71 (28.0)	1.00	1.00	1.00
Mild synovitis group	71 (28.5)	1.11 (0.79‒1.57)	1.06 (0.71‒1.59)	1.06 (0.72‒1.56)
Severe synovitis group	32 (60.4)	2.70 (1.61‒4.53)	2.45 (1.43‒4.21)	2.06 (1.21‒3.53)
Last HHS<80 points
No synovitis group	69 (27.2)	1.00	1.00	1.00
Mild synovitis group	68 (27.3)	1.10 (0.77‒1.56)	1.07 (0.71‒1.61)	1.06 (0.71‒1.58)
Severe synovitis group	29 (54.7)	2.53 (1.50‒4.29)	2.25 (1.29‒3.94)	1.86 (1.06‒3.26)
THA
No synovitis group	10 (3.9)	1.00	1.00	1.00
Mild synovitis group	13 (5.2)	1.38 (0.56‒3.40)	0.83 (0.31‒2.20)	0.78 (0.29‒2.12)
Severe synovitis group	10 (18.9)	5.60 (2.09‒15.03)	1.96 (0.63‒6.04)	1.79 (0.61‒5.24)