Core Decompression For Avascular Necrosis Research Articles

Poster 222: High Rates of Conversion to Total Hip Arthroplasty After Core Decompression for Avascular Necrosis of the Hip

Objectives: Avascular necrosis (AVN) of the hip is caused by interruption of blood flow to the femoral head, resulting in pain, loss of joint function, and eventual hip arthritis. Core decompression may be performed for early AVN with a goal of improving symptoms and potentially delaying the need for THA. The effectiveness of this procedure is generally not well understood given the relatively rare nature of hip AVN. The predictors of conversion to THA after core decompression are not well defined. Core decompression is also not without potentially devastating complications, including femoral neck fractures, though estimation of true incidence of complications has been limited by sample sizes in prior investigations. The purpose of this study is to utilize a large payor database to determine time to THA after core compression, assess predictors of early conversion to THA, and to examine complications after hip core decompressions. We hypothesize that less than 25% of patients who had a hip core decompression will convert to THA at two year follow up, we also hypothesize that age at time of core decompression will be a predictor of conversion to THA. Methods: Using Current Procedural Terminology codes, we queried the Mariner PearlDiver dataset for patients who underwent hip core decompression from 2010 to 2020. Patient demographics were recorded and subsequent THA conversion within 2 years after surgery were tracked. Patient demographic factors, including, age, sex, obesity, diabetes, prior fractures, steroid use, tobacco use, or alcohol use, were evaluated as possible predictors of early conversion to THA. International Classification of Diseases, codes were used to identify complications at 90 days and 2 years after core decompression. Multiple linear regression was used to test if the patient demographics significantly predicted conversion to THA and a Cox-Survival plot was performed. Statistical significance was defined as p<.05. Results: Between 2010-2020, 555 patients underwent hip core decompression. Within 2 years of core decompression, 209 patients converted to THA (37.6%) and one patient converted to hemiarthroplasty. Average age for patients converting to THA was 47.7 years compared to those who did not convert 43.4 (95% CI 2.1 – 6.2 years, p < .001). Most patients who converted to a THA were between age 50-59 (Figure 1). Age was the only risk factor for conversion to THA as the following variables were not associated: Sex, obesity, diabetes, prior fracture, steroid use, tobacco use, or alcohol use. Cox survival plot demonstrated a high risk of conversion to THA within two years of core decompression with the highest risk within the first 200-days (Figure 2). 90-day complication rate was 2.9% and the complication rate at 2 years was 5.2%. The most common complication was femoral neck fracture at both time points (68.7% of compilations at 90 days and 75.9% at 2 years). There was no significant difference in demographics between those that had complications and those that did not at 90 days. At 2 years after surgery patients that smoked (OR 0.39 p = .02) or had a prior fracture (OR 0.23; p = .02) were more likely to have had complications. Conclusions: There is a high failure rate following core decompression for hip AVN with over one third of patients converting to THA within 2 years. Patients older than age 50 had the highest rates of conversion to THA. While the overall complication rate is low at 90 days and 2 years, patients should be counseled regarding the risk for femoral neck fracture. Further research is needed regarding predictors of success after core decompression.

Hip Arthroscopy and Core Decompression for Avascular Necrosis of the Femoral Head Using a Specific Aiming Guide: A Step-by-Step Surgical Technique

Avascular necrosis of the femoral (AVN) head is a disabling disease that affects function, mobility, and quality of life in the young adult. Its pathology involves blood circulation disruption of the femoral head and subchondral infarction. This leads to cartilage thinning, femoral head depression, and cartilage breakage, which results in hip osteoarthritis. In the past decade the prevalence of intraarticular pathology has been almost 95%, this revealed with hip arthroscopy (HA). HA and core decompression (CD) of the femoral head can be used effectively and concomitantly to treat AVN with excellent results, HA allows for excellent visualization of the hip joint cartilage, allowing treatment of femoroacetabular impingement syndrome (FAIS) and intra-articular pathology. Our technique demonstrates that retrograde core decompression with allograft and mixed bone matrix is an excellent choice of treatment in the early stages of AVN/ONFH. The femoral head–specific aiming guide is very reliable, is simple to use arthroscopically if placed in the posterolateral portal of the hip, and offers exact pin placement at the necrotic site, as well as less operative time and less radiation to the patient and surgical team.

Autologous stem cell implantation with core decompression for avascular necrosis of the femoral head using a new device.

Autologous stem cell progenitor implantation into necrotic lesions of the femoral head has previously been described as a potential treatment for avascular necrosis (AVN), on the basis that there is a reduced number of functioning stem cells in the marrow within the necrotic segment. We present a case series of patients with AVN that underwent core decompression with autologous stem cell implantation using a new device. The records and imaging of patients with AVN of the femoral head treated by a single surgeon were retrospectively reviewed. All patients were treated with core decompression and stem cell progenitor implantation, using the PerFuse system. Preoperatively, demographic information, AVN staging (as per Ficat and Arlet classification) and visual analogue pain scores (VAS) of the hips were recorded. These results were compared with postoperative VAS and imaging, with further review on the progression of AVN. We treated 14 hips in 13 patients with an average follow up of 12 months. Patients with Ficat I-II were selected for the procedure. The average preoperative VAS was 3.9. Postoperatively, this dropped to 2.6, with over half of patients reporting at least a two-point decrease in pain. Eight of the 14 treated hips showed no radiological progression of the disease, while six showed femoral head collapse requiring total hip arthroplasty (THA) at an average of ten months after treatment. Our early findings indicate that hip decompression with stem cell progenitor implantation for AVN of the femoral head provides symptomatic relief and may be beneficial in arresting progression of disease using this simple new device.

Autologous stem cell implantation with core decompression for avascular necrosis of the femoral head

ObjectiveAvascular necrosis (AVN) of the femoral head is a painful, progressive disease that can lead to limited mobility and early hip replacement. Autologous stem cell implantation into the necrotic lesion of the femoral head has been described, on the basis that patients with AVN have a reduced number of stem cells in the marrow. In this study, we aim to describe our technique for decompression of the hip with autologous implantation of stem cells for AVN of the femoral head, as well as retrospectively analyze our results. MethodsThe records and imaging of patients with avascular necrosis of the femoral head treated by a single surgeon were retrospectively reviewed. All patients were treated with the combination of core decompression with autologous stem cell implantation from the iliac crest. Preoperatively, demographic information, stage of AVN per Association Research Circulation Osseous (ARCO) classification on magnetic resonance imaging and radiograph, and visual analogue pain scores (VAS) of the hip were recorded. Postoperatively, VAS were recorded and imaging was reviewed for progression of AVN or evidence of femoral head collapse. Statistical analysis was conducted comparing pre and postoperative VAS scores. ResultsOverall, we treated 43 hips in 28 patients with autologous stem cell implantation, with an average follow up of 16 months. Patients ranged from ARCO Ia to ARCO IIc classification of AVN. The average pre-operative visual analogue scale (VAS) of pain was 7.8. Post operatively, the average VAS score decreased to 2.5 (p < 0.0001), with 78% of patients reporting at least a 50% decrease in pain. 40 of the 43 operatively treated hips showed no radiologic progression of the disease during the follow up period, while 3 of the 43 hips had evidence of femoral head collapse and needed subsequent total hip arthroplasty at an average of 17 months after the initial decompression. ConclusionOur findings indicate that hip compression with autologous stem cell implantation for AVN of the femoral head provides significant symptomatic relief and may be beneficial in arresting progression of disease.

Results of Arthroscopically-Assisted Core Decompression for Avascular Necrosis of the Proximal Humerus

Objectives:Avascular necrosis (AVN) of the proximal humerus treatment is challenging. Early recognition and treatment prior to collapse may potentially prevent or delay subsequent progression. Arthroscopically-assisted core decompression of the proximal humerus is one treatment option for AVN. However, there is little published data regarding outcomes of this procedure. This study represents the largest-to-date cohort of patients who underwent arthroscopically-assisted core decompression of the proximal humerus.Methods:A retrospective review was performed to analyze the outcomes of patients who underwent arthroscopically-assisted core decompression for proximal humeral AVN. All patients had associated shoulder pain that had failed non-operative management. A comprehensive review of operative reports and imaging were examined to verify the use of an arthroscopically-assisted surgical technique without violation of the articular surface. Concomitant shoulder pathology was surgically addressed at the time of decompression. Patient charts were retrospectively reviewed for pre- and post-operative pain as well as shoulder range of motion. Pre-operative and post-operative x-rays were examined for evidence of progression of AVN lesions. A review of documentation for post-operative shoulder injections or repeat surgery was completed. Subjective American Shoulder and Elbow (ASES) outcomes were compared pre- and post-operativelyResults:Eleven consecutive patients and 13 consecutive shoulders were identified who underwent arthroscopically-assisted core decompression of the proximal humerus AVN by the two senior surgeons from 2004-2013. No patients were excluded. Six males and five females were identified with an average age of 45 years at surgery. Average follow-up length was 2.6 years. Four shoulders underwent synovectomy and core decompression alone. Concomitant procedures included rotator cuff repair in 5, subacromial decompression in 4, distal clavicle excision in 6, and biceps tenodesis in 1 shoulder(s). Radiographically, the majority of shoulders (8) remained stable without progressive sclerosis or collapse. Two shoulders demonstrated progressive sclerosis, and articular collapse was seen in 1 shoulder. The average pre-operative ASES score was 19.3, compared to 44.8 at post-operative follow-up (p=.001). Pre-operative shoulder elevation averaged 156 degrees, while post-operative range of motion averaged 170 degrees (p=.81). The majority of patients had mild or moderate pain pre-operatively, while 4 patients required narcotics for severe pre-operative pain. Visual analogue pain averaged 8.4 pre-operatively, compared to 4.9 at most recent follow-up (p=.0004). While post-operative pain initially improved in all patients, the majority of patients had return of mild, intermittent pain with longer follow-up. Two patients who took narcotics pre-operatively continued to require narcotics at final follow-up. Six shoulders had undergone therapeutic shoulder injections post-operatively. No patient had required repeat surgery.Conclusion:Arthroscopically-assisted core decompression is an option for the treatment of proximal humeral AVN. Visual analogue pain and ASES functional outcomes were reliably improved at average follow-up of 2.6 years. Three shoulders demonstrated radiographic AVN progression, while the majority of lesions remained stable. Six shoulders underwent post-operative injections for pain.

Modern Radiological Postoperative Diagnostics of the Hip Joint in Children and Adults.

The assessment of bone healing and loosening of endoprosthesis material was long the primary indication for postoperative projection radiography and CT imaging of the hip joint following trauma and endoprosthesis implantation. With the increasing number of joint-preserving surgery, e. g. of surgical hip luxation and hip arthroscopy for the treatment of femoroacetabular impingement (FAI), high-resolution imaging of intra-articular pathologies before and after surgery has become increasingly important. In this review article, diagnostic imaging of the hip joint is presented following common trauma surgery and orthopedic surgery interventions. The imaging modalities of projection radiography, CT and MRI including direct MR-arthrography are discussed with regard to their diagnostic capability in the postoperative assessment of the hip joint. Among others topics, imaging is discussed following hip arthroplasty, following surgical hip luxation and arthroscopic interventions for the treatment of FAI, as well as following core decompression for avascular necrosis of the femoral head. Moreover, orthopedic interventions of the hip joint in children and adolescents are presented and the dedicated reporting of postoperative imaging is outlined. • Consolidation of osteotomies and position of implants should be assessed in postoperative imaging. • MRI is useful for confirming correct articulation after treatment of congenital hip dislocation. • Radiologically assessable complications after total hip replacement are inlay wear, loosening, dislocation, periarticular ossifications and infection. • MRI can detect and classify pseudotumours in cases of metal-metal pairing after total hip replacement.

Multiple drilling compared with standard core decompression for avascular necrosis of the femoral head in sickle cell disease patients

Sickle cell disease (SCD) is the most common cause of avascular necrosis of femoral head (ANFH) in childhood. Advances in medical treatment led to improved life expectancy of such patients. SCD-related ANFH frequently progress to total collapse of the femoral head necessitating hip replacement. However, SCD patient are at more risk of intra- and post-operative complications and suboptimal outcome of total hip arthroplasty. Hence, it is imperative to preserve the femoral head as long as possible. Between September 1992 and June 2007, 94 core decompression procedures were done to SCD patients who had modified Ficat stage I, IIA and IIB ANFH. Sixty one patients underwent a classical 8-mm drilling and 33 patients underwent 3.2-mm diameter MD technique. Patients were followed up for minimum of 2years and were evaluated for clinical and Harris Hip Score improvement and for radiological progression. All 19 hips that had Ficat stage I had significant reduction of pain and improvement of Harris Hip Score. No patient has required further surgery. Among the 39 hips with Ficat IIA at time of procedure, 80% of hips which underwent CD and 78% of MD cases had significant reduction of pain and improvement of HHS. Those patients showed no radiographic progression of the disease. The remaining, 20% CD and 22% MD eventually progressed radiologically to grade III or grade IV and had HHS less than 75 at last visit. In the 36 cases with Ficat IIB, 52% CD and 52.8% MC had significant reduction of pain and improvement of HHS. The rest showed no improvement in pain and function, and progressed to stage IV; 11 of them underwent THA and one patient refused surgery. While multiple drilling is safer and less invasive than single coring in SCD, there is no statistically significant difference in outcome or complication rate between both procedures done for ANFH in patients with SCD.

Minimal Invasive Percutaneous Core Decompression For Avascular Necrosis of Femoral Head

Medtronic METRxTM system was originally designed for microdiscectomy which provide access to spine with less trauma. This system is special designed metal tubes (dilators) with progressive increase in size. These dilators when inserted sequentially from small to large size will gradually separate the muscle, so that an opening is created for the surgical instruments to work in. With modified technique, we apply this system to be used in core decompression of femoral head.

The perioperative complication rate of orthopedic surgery in sickle cell disease: Report of the national sickle cell surgery study group

Orthopedic disease affects the majority of sickle cell anemia patients of which aseptic necrosis of the hip is the most common, occurring in up to 50% of patients. We conducted a multicentered study to determine the perioperative complications among sickle cell patients assigned to different transfusion regimens prior to orthopedic procedures: 118 patients underwent 138 surgeries. The overall serious complication rate was 67%. The most common of these were excessive intraoperative blood loss, defined as in excess of 10% of blood volume. The next most common complication was sickle cell-related events (acute chest syndrome or vaso-occlusive crisis), which occurred in 17% of cases. While preoperative transfusion group assignment did not predict overall complication rates, higher risk procedures were associated with significantly higher rates of overall complications. Transfusion complications were experienced by 12% of the patients. Two patients died following surgery. Both deaths were associated with an acute pulmonary event. The 52 patients undergoing hip replacements experienced the highest rate of complications with excessive intraoperative blood loss occurring in the majority of patients. Sickle cell-related events occurred in 19% of patients, and surgical complications occurred after 15% of hip replacements and included postoperative hemorrhage, dislocated prosthesis, wound abscess, and rupture of the femoral prosthesis. There were twenty-two hip coring procedures. Acute chest syndrome occurred in 14% of the patients. Overall, decompression coring was a safer, shorter operation. A randomized prospective trial to determine the perioperative and long-term efficacy of core decompression for avascular necrosis of the hip in sickle cell disease is needed. In conclusion, this study demonstrates a high rate of perioperative complications despite compliance with sickle cell perioperative care guidelines. Pulmonary complications and transfusion reactions were common. This study supports the results previously published by the National Preoperative Transfusion in Sickle Cell Disease Group. These results stated that a conservative preoperative transfusion regimen to bring hemoglobin concentration to between 9 and 11 g/dl was as effective as an aggressive transfusion regimen in which the hemoglobin S level was lowered to 30%. Am. J. Hematol. 62:129–138, 1999. © 1999 Wiley-Liss, Inc.

The perioperative complication rate of orthopedic surgery in sickle cell disease: report of the National Sickle Cell Surgery Study Group.

Orthopedic disease affects the majority of sickle cell anemia patients of which aseptic necrosis of the hip is the most common, occurring in up to 50% of patients. We conducted a multicentered study to determine the perioperative complications among sickle cell patients assigned to different transfusion regimens prior to orthopedic procedures: 118 patients underwent 138 surgeries. The overall serious complication rate was 67%. The most common of these were excessive intraoperative blood loss, defined as in excess of 10% of blood volume. The next most common complication was sickle cell-related events (acute chest syndrome or vaso-occlusive crisis), which occurred in 17% of cases. While preoperative transfusion group assignment did not predict overall complication rates, higher risk procedures were associated with significantly higher rates of overall complications. Transfusion complications were experienced by 12% of the patients. Two patients died following surgery. Both deaths were associated with an acute pulmonary event. The 52 patients undergoing hip replacements experienced the highest rate of complications with excessive intraoperative blood loss occurring in the majority of patients. Sickle cell-related events occurred in 19% of patients, and surgical complications occurred after 15% of hip replacements and included postoperative hemorrhage, dislocated prosthesis, wound abscess, and rupture of the femoral prosthesis. There were twenty-two hip coring procedures. Acute chest syndrome occurred in 14% of the patients. Overall, decompression coring was a safer, shorter operation. A randomized prospective trial to determine the perioperative and long-term efficacy of core decompression for avascular necrosis of the hip in sickle cell disease is needed. In conclusion, this study demonstrates a high rate of perioperative complications despite compliance with sickle cell perioperative care guidelines. Pulmonary complications and transfusion reactions were common. This study supports the results previously published by the National Preoperative Transfusion in Sickle Cell Disease Group. These results stated that a conservative preoperative transfusion regimen to bring hemoglobin concentration to between 9 and 11 g/dl was as effective as an aggressive transfusion regimen in which the hemoglobin S level was lowered to 30%.

Core Decompression for Avascular Necrosis of the Distal Femur; Long Term Followup

Seventy-nine knees (45 patients) with a diagnosis of avascular necrosis of the distal femur treated between 1978 and 1989 were evaluated. All patients had a corticosteroid association (had been treated with >30 mg of prednisone for >2 weeks predating by at least 6 months the onset of avascular necrosis). Thirty-two knees were managed with protected weightbearing and rest. Core decompression was performed at a minimum of 3 months after the onset of symptoms in another 47 knees. The knees treated with protected weightbearing had an average asymptomatic period of only 11 months and all but 6 (18%) proceeded to total knee replacement within 6 years. Core decompression yielded good or excellent results in 73% of the knees at an average followup of 11 years (range, 4-16 years). Of the 13 knees with failed core decompression, 7 were asymptomatic for greater than 5 years. A subset of 26 knees from each group was matched for age, gender, diagnosis, Ficat and Arlet Stage, and length of followup. The matched noncore group had 23% survival as compared with 74% survival in the core group. This long term followup suggests that core decompression may slow the rate of symptomatic progression of avascular necrosis of the knee. In addition, core decompression may extend the symptom free interval in certain patients and may delay the need for more extensive procedures such as total knee arthroplasty.

Core decompression for avascular necrosis of the femoral head: correlation between long-term results and preoperative MR staging.

A long-term radiographic follow-up study was conducted on 24 patients (34 hips) who underwent core decompression of the femoral head for avascular necrosis (AVN). The purpose of the study was to assess the potential correlation between the extent of AVN, as determined with preoperative magnetic resonance (MR) imaging, and development of collapse. The preoperative MR results were classified into four categories: group A, no AVN; group B, less than 25% involvement of the weight-bearing portion of the femoral head; group C, 25%-50% involvement; and group D, more than 50% involvement. Histologic evidence of AVN was found in all 34 hips. Collapse occurred in none of the hips in groups A and B (n = 12), in three of seven hips (43%) in group C, and in 13 of 15 hips (87%) in group D. It is concluded that MR estimation of the extent of femoral head involvement with AVN may help in predicting which femoral heads will collapse shortly after core decompression, so that this invasive procedure can be avoided in patients at risk.