Multiple drilling is not effective in reducing the rate of conversion to Total hip Arthroplasty in early-stage nontraumatic osteonecrosis of the femoral head: a case-control comparative study with a natural course

Enze Zhao,Zunhan Liu,Yuhan Li,Zongke Zhou,Xuetao Yang,Wei-Nan Zeng

doi:10.1186/s12891-021-04418-y

Abstract

BackgroundTo determine whether multiple drilling is effective in postponing the need for total hip arthroplasty (THA) in early-stage nontraumatic osteonecrosis of the femoral head (ONFH).MethodsWe identified 514 patients who were diagnosed with early-stage ONFH between January 2008 and December 2018. One hundred ninety-six patients underwent multiple drilling, and 318 patients had a natural course of progression. One hundred fifty-nine patients were selected for each group after case-control matching for preoperative demographics and modified Ficat and Arlet stage. The rates of THA conversion were compared. We also performed Cox regression to identify risk factors associated with THA conversion in patients who underwent multiple drilling.ResultsKaplan-Meier survivorship with an endpoint of THA for nontraumatic reasons were not significantly different between the multiple drilling group (75.6, 95% confidence interval 67.8–83.4%) and the natural course group (72.2, 95% confidence interval 64.8–79.6%) at 5 years (log-rank, P = .191). In the Cox regression model, a larger extent of necrotic lesion, bone marrow edema (BME), and higher postoperative work intensity significantly increased the risk of THA conversion (P < .05). Among patients treated with autogenous bone grafting, there was a lower risk of failure in patients with necrotic lesion less than 15% (P < .05).ConclusionsMultiple drilling is not effective in reducing the rate of THA conversion in early-stage nontraumatic ONFH. The risk of conversion to THA after multiple drilling is increased by a larger extent of necrotic lesion, presence of BME, and higher postoperative work intensity in patients with early-stage ONFH.Trial registrationThe trial was registered in the Chinese Clinical Trial Registry (ChiCTR2000035180) dated 2 August 2020.

Highlights

To determine whether multiple drilling is effective in postponing the need for total hip arthroplasty (THA) in early-stage nontraumatic osteonecrosis of the femoral head (ONFH)
Nontraumatic osteonecrosis of the femoral head (ONFH) is a clinical entity originating from impaired circulation of femoral head terminal blood flow, if not treated effectively, leading to femoral head collapse and, arthritis of the hips
There appears to be a consensus that core decompression or multiple drilling is more effective than nonoperative management for early-stage Osteonecrosis of the femoral head (ONFH), the meta-analysis and review are on the basis of a few older small-scale randomized studies with shortterm follow-up, which only provide limited quality of evidence [11, 12]

Summary

Introduction

To determine whether multiple drilling is effective in postponing the need for total hip arthroplasty (THA) in early-stage nontraumatic osteonecrosis of the femoral head (ONFH). Core decompression of the femoral head is a wellestablished joint-preserving procedure proposed to treat early-stage ONFH. To overcome the limitations of this surgery, the multiple small-diameter drilling technique has been introduced and can provide the same benefit as core decompression [4] In theory, this technique is a minimally invasive intervention that partly removes necrotic bone, provides mechanical support, and does not change the anatomic structure of the femoral head [3, 5,6,7,8,9,10]. There is few studies evaluating the efficacy of multiple drilling regimens in conversion to THA by comparing early-stage ONFH patients undergoing multiple drilling with the natural course

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