Determining lesion size in osteonecrosis of the femoral head

Background: Several studies have documented that the size of the osteonecrotic lesion in the femoral head is an essential parameter in determining prognosis and treatment. There are several methods currently available to measure lesion size, but no general agreement as to which is most useful. In the present study, three different radiographic methods for determining lesion size were evaluated and compared. Methods: Anteroposterior and lateral radiographs of forty-two hips with osteonecrosis were examined. The extent of osteonecrotic involvement of the femoral head was determined through the use of three different methods: the volume of necrosis by quantitative digital image analysis, and the angular measurements described by Kerboul et al. and Koo and Kim. Graphs were constructed to demonstrate these relationships. Results: Volumetric measurement appeared to be the most reliable. There was only a rough correlation with angular measurements. Several sources of error were noted when simple angular measurements of irregular, three-dimensional lesions were used. The Kerboul method routinely overestimated lesion size and designated 81% of the lesions as "large." The modified Koo and Kim method provided a more even distribution of lesion size and correlated with volumetric measurements in 74% of hips (thirty-one of forty-two hips). Conclusions: Quantitative volumetric measurements appear to be the most reliable method to measure the true size of a three-dimensional osteonecrotic lesion of the femoral head. Volumetric measurement is more accurate than angular measurement and can be performed easily with modern technology. Angular measurements, although somewhat simpler to use than volumetric measurements, may provide only a rough estimate of lesion size, partly due to the considerable differences in outline or location of the necrotic segments. Nevertheless, determination of lesion size must be part of a comprehensive system of staging of this disease, which includes the evaluation of other parameters, such as the extent and degree of articular surface involvement and the status of the hip joint and the acetabulum. Level of Evidence: Diagnostic Level III. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.