Intraosseous Pressure Measurements Research Articles

Intraosseous pressure measurement during iliac bone marrow biopsy: its feasibility and difference of IOP in diseased marrow and non-diseased marrow.

The purposes of this study were (1) to establish the feasibility and safety of an imaging-guided technique for intraosseous pressure (IOP) measurement in a large cohort of patients, and (2) to compare IOP values between normal and diseased bone marrow. Adult patients undergoing CT-guided marrow biopsy were prospectively and consecutively enrolled from November 2020 to February 2022. IOP measurements were obtained connecting the biopsy needle to a monitoring device using a standard arterial line setup. Clinical data including sex, age and pathology results were obtained. Student t test and Pearson correlation were used for continuous variables comparisons. Univariable analyses were performed using Fisher's exact test. A P value of .05 was considered statistically significant. A total of 139 participants were initially enrolled, and four were excluded during technique optimization. There were no complications related to the measurement technique. Ninety participants (90/135, 67%) had histology confirming marrow pathology. The participants in the diseased marrow group were older than those in the normal marrow group (63 ± 14 vs. 55 ± 14years; P < .01). There was no difference in mean IOP between both groups (66 ± 23 vs. 64 ± 28mmHg; P = .69). There was no correlation between mean arterial blood pressure and mean IOP (P = .08). There was no difference in IOP measurements between patients with normal and diseased marrow undergoing CT-guided biopsy. IOP does not appear to be influenced by systemic blood pressure. No complication occurred during the procedures.

GRANGER CAUSALITY ANALYSIS BETWEEN INTRA-OSSEOUS PRESSURE AND ARTERIAL BLOOD PRESSURE IN AFRICAN GREY PARROTS (PSITTACUS ERITHACUS)

Monitoring blood pressure helps a clinical veterinarian assess various conditions in birds. Blood pressure is not only a bio-indicator of renal or cardiovascular disease but is also a vital indicator for anesthesia. Anesthetic- and sedation-related mortality is higher in birds than dogs or cats. The traditional method of blood pressure measurement in mammals mainly relies on indirect methods. However, indirect blood pressure measurement is not reliable in birds, making the direct method the only gold standard. Although an arterial catheter can provide continuous real-time arterial pressure in birds, the method requires technical skill and is limited by bird size, and is thus not practical in birds with circulatory collapse. Intra-osseous (IO) blood pressure is potentially related to arterial pressure and may be a much easier and safer technique that is less limited by animal size. However, the relationship between IO pressure and arterial blood pressure has not been established. This study used mathematical methods to determine the relationship between IO pressure and arterial blood pressure. The Granger causality (G.C.) theory was applied in the study and used to analyze which pressure signal was leading the other. Our findings suggest that IO pressure is G.C. by arterial blood pressure; thus, the use of IO pressure measurements as an alternative to arterial blood pressure measurement is a rational approach.

A measuring technique for intra-osseous pressure

Pulsatile intra-osseous pressures result in bone remodeling, and therefore may affect lesion growth and response to treatment. However, there is no known method used to measure intra-osseous pressures. The purpose of this study is to describe a novel image-guided technique for measuring intra-osseous pressures. This study was IRB-approved and HIPAA compliant. Written informed consent was obtained. Intra-osseous pressure measurements were performed during a CT-guided bone marrow biopsy in eight patients (6 male, 2 female) with mean age 66 ± 13years (median 72, range 45-87) and suspected or known bone marrow disease. Bone marrow pressure measurements were obtained connecting the biopsy needle to a dedicated monitor using a standard arterial line setup. Monitor data was collected at 5-s intervals in order to record continuous pressure measurements for 2min. Pressure measurements were successfully performed in all 8 patients. The mean bone marrow pressures were 36.8 ± 7.2mmHg (median 37.7, range 24.7-47.4). The peak and trough pressures varied by 11%, and the standard deviation of mean pressure measurement varied by 18%. Our findings for marrow pressure measures most closely approximate the pressure profile of the venous system. We describe a novel and minimally invasive technique able to provide functional data of bone marrow. This technique has the potential to provide insights into normal and diseased bone marrow and may be helpful to evaluate features of cystic and vascular tumors that may be amenable to percutaneous treatments.

An in vitro model to explore subchondral perfusion and intraosseous pressure

BackgroundLittle is known about subchondral perfusion physiology. We developed a 3Rs (Replace, Reduce, Refine) compliant in vitro calf foot model to explore perfusion and intraosseous pressure (IOP).MethodsCalf feet were catheterised and perfused with serum. IOP was measured at three sites, the metacarpal diaphysis (MCD), metacarpal subchondral epiphysis (MCS) and proximal phalanx diaphysis (PPD) using intraosseous needles with pressure transducers and digital recorders. Fresh (< 4 h post mortem) and old feet (> 4 h post mortem) were perfused at different pressures, with and without a proximal tourniquet.ResultsThere was a wide range in basal IOP with a mean IOP of 30.0 mmHg, SD 14.4, range 7.6 mmHg to 52.7 mmHg (n = 40 records) in 15 subjects. There was no significant difference between the three sites tested (p = 0.54, 0.12 and 0.051). At each individual site IOP correlated with perfusion pressure (r = 0.993). With a proximal venous tourniquet, IOP increased from 15.1 mmHg (SD 11.3 mmHg) to 44.9 mmHg (SD 24 mmHg), p < 0.0001, n = 9. Filling and emptying curves during perfusion and with using a tourniquet were similar, indicating that the model behaves in an elastic hydrodynamic manner. In fresh feet IOP peaked after about 1 min irrespective of perfusion pressure, possibly due to auto regulation. Older feet showed a continuously rising IOP and became oedematous. There was no significant difference in IOP between fresh and old feet perfused with serum at 150 cms pressure for 1 min.ConclusionThough basal intraosseous pressure varies, IOP behaves predictably. IOP measurements reflect the perfusion microclimate at the individual needle tip. This 3Rs compliant model will be used for further exploration of subchondral perfusion physiology with loading.

Factors affecting intraosseous pressure measurement

BackgroundAlthough a raised intraosseous pressure (IOP) has been found in osteoarthritis and osteonecrosis, the normal physiology of subchondral circulation is poorly understood. We developed an animal model and explored the physiology of normal subchondral perfusion and IOP.MethodsIn 21 anaesthetised rabbits, 44 intraosseous needles were placed in the subchondral bone of the femoral head (n = 6), femoral condyle (n = 7) or proximal tibia (n = 31). Needles were connected to pressure transducers and a chart recorder. In 14 subjects, the proximal femoral artery and vein were clamped alternately. In five subjects, arterial pressure was measured simultaneously in the opposite femoral artery.ResultsThe average IOP at all 44 sites was 24.5 mmHg with variability within SD 6.8 and between subjects SD 11.5. IOP was not significantly influenced by gender, weight, site or size of a needle. Needle clearance by flushing caused a prolonged drop in IOP whereas after clearance by aspiration, recovery was rapid. IOP recordings exhibited wave patterns synchronous with the arterial pulse, with respiration and with drug circulation time. There was a correlation between IOP and blood pressure (13 sites in 5 subjects, Pearson correlation 0.829, p < 0.0005). There was a correlation between IOP and the associated pulse pressure (PP) in 44 sites among 21 subjects (Pearson correlation 0.788, p < 0.001). In 14 subjects (31 sites), arterial occlusion caused a significant reduction in IOP and loss of PP (p < 0.0001). Venous occlusion significantly raised IOP with preservation of the PP (p < 0.012).ConclusionOur study shows that subchondral cancellous bone behaves as a perfused tissue and that IOP is mainly a reflection of arterial supply. A single measure of IOP is variable and reflects only perfusion at the needle tip rather than being a measure of venous back pressure. Alternate proximal vessel clamping offers a new means of exploring the physiology of subchondral perfusion. We describe a model that will allow further study of IOP such as during loading.

Vascularity of femoral head and its assessment after femoral neck fractures

Femoral neck fracture has an annual incidence of 1 per 1000 population; in young patients, functional prognosis is not good due to risk of osteonecrosis. Femoral head vascularity is mostly contributed by retinacular vessels and lateral epiphyseal artery. The vascular impact is due to displacement, interrupting retinacular vessel, interrupting ligament teres vascularization, and increased intracapsular pressure, producing a tamponade effect leading to osteonecrosis. This study reviewed the different methods of assessment of femoral head vascularity after femoral neck fractures. There are many techniques for the assessment of residual femoral head vascularity after femoral neck fractures and for the assessment of post-traumatic osteonecrosis risk. Some invasive techniques are superselective angiography, intraosseous oxygen pressure measurement, or Doppler-laser hemodynamic measurement; others are noninvasive scintigraphy and conventional or dynamic magnetic resonance imaging (MRI). The future seems to lie with dynamic MRI, which gives new classification of femoral neck fractures, based on a noninvasive assessment of femoral head vascularity.

Factors affecting physiology of intraosseous pressure measurement

Factors affecting physiology of intraosseous pressure measurement

Assessment of Intraosseous Femoral Head Pressures During Cement Augmentation of the Perforated Proximal Femur Nail Antirotation Blade

The benefits of cement augmentation with fixation of osteoporotic pertrochanteric fractures have been previously demonstrated. The objective of this study was 3-fold: (1) To quantify the intraosseous pressure produced during cement augmentation of the perforated proximal femoral nail antirotation (PFNA) blades; (2) To assess whether the pressure generated is influenced by the injection rate; and (3) To assess the amount of force applied during the injection. Six pairs of human cadaveric femurs were used in the study. A basicervical osteotomy was performed, and the heads were instrumented with the PFNA blade. Each pair was randomly assigned into 1 of 2 groups: slow versus rapid injection with polymethylmethacrylate (PMMA) cement. In the slow group, the augmentation was performed using 6 consecutive 1 mL injections, each over 10 seconds. In the rapid group, each 1 mL injection was performed over 5 seconds. For intraosseous pressure measurements, transmitters were inserted to a depth of 5 mm at both the superior and inferior apices of the head. The reaction forces on the syringe were measured as well. There were no significant differences between the slow and rapid injection rates with respect to the peak pressures measured at the 6 time points immediately after cement injection. In both groups, elevations in pressure were transient and returned to baseline values within 30 seconds. The highest pressure recorded in the slow group was 37.3 and 30.7 mm Hg in the rapid group. The force required after each sequential injection increased in both groups; however, significantly higher forces were required to inject cement over 5 than 10 seconds (P = 0.036). This in vitro model is the first one to demonstrate that femoral head cement augmentation is associated with a small transient increase in intraosseous pressure with sequential fast and slow 1 mL injections of up to 6 mL PMMA. We conclude that cement augmentation of the perforated PFNA blade carries a low risk of pressure-induced avascular necrosis.

Sickle-cell hip necrosis and intraosseous pressure

Osteonecrosis of the femoral head (ONFH) is a frequent complication of sickle-cell disease. Numerous studies have demonstrated increased intraosseous pressure (IOP) in idiopathic necrosis and necrosis secondary to corticotherapy or alcohol poisoning. Several reports have testified to the clinical interest of decompression by drilling which, when performed in the early course of the pathology, can arrest or slow evolution. To the best of our knowledge, no studies have reported IOP increase in sickle-cell ONFH. The present study sought to show that intraosseous hyperpressure plays a role in the physiopathology of sickle-cell, like idiopathic, ONFH. Sixteen intraosseous pressure (IOP) measurements were taken: eight in adult sickle-cell disease patients, four in sickle-cell trait carrying ONFH patients (AS) and four in non-sickle-cell ONFH patients (AA). Arterial blood-pressure equipment with bone-puncture needle was used to measure IOP in the great trochanter body. Three IOP measurements were made after zero calibration: before drilling (direct pressure: IOP-1), after hyperpressure test but before drilling (IOP-2), and after drilling (IOP-3). The present, admittedly short, series displayed elevated predrilling IOP-1 and IOP-2, reduced after drilling (IOP-3). Abnormal IOP fell after drilling performed for evolutive symptomatic ONFH. Significant differences in IOP-1 and IOP-2 were found, these being higher in the "sickle-cell disease" and "sickle-cell trait carriers" groups (p<0.05). Only in the sickle-cell groups was there a significant correlation between pain score and hyperpressure level, with significantly reduced pain after drilling. The elevated IOP levels found in symptomatic sickle-cell hips were comparable to those reported in the literature. Ischemia due to femoral head sinusoid occlusion by falciform globules with secondary intraosseous hyperpressure is the cause of the pain and of the onset and evolution of ONFH. The drilling tunnel acts as a safety valve, achieving real decompression of the segment involved and immediate postoperative reduction in or disappearance of pain. Measuring pressure is of diagnostic interest in sickle-cell disease patients with symptomatic hips. Manometry can be performed independently of surgery, under local anesthesia, and provides early confirmation of ONFH in geographic regions in which MRI is not readily available. It can be carried out very straightforwardly, without pressure sensor, using a simple water column (physiological saline) and three-way tap. Peroperative comparison of IOP-1 and IOP-3 is a means of assessing the effectiveness of decompression drilling.

Preradiologic stage of idiopathic femur head necrosis demonstrated by intraosseous pressure measurement

Early identification is the focal point of efforts aimed toward efficient diagnosis and treatment of osteonecrosis. With the intraosseous pressure measurement method of Ficat and Arlet it is possible to determine the onset of this disease at the preradiological stage. At the Vienna-Speising Orthopedic Clinic 11 out of a total of 66 cases of idiopathic necroses of the femoral head were diagnosed at the preradiological stage. The only treatment given in these cases was decompression by removal of a bone cylinder. The follow-up examination after an average of 22 months revealed very good results in all cases, both subjectively and roentgenologically (stage deterioration did not occur in a single case).

The fixion proximal femur nailing system: biomechanical properties of the nail and a cadaveric study

The treatment of choice for early mobilization of hip fracture is surgery, which traditionally employs side plates and screws or intramedullary nails. We examined the biomechanical properties of a new proximal femoral nail system. The new expandable Fixion proximal femur nailing (PFN) system, made of stainless-steel alloy, consists of a nail, a peg and an anti-rotation pin. Upon positioning, the nail and peg are expanded to their maximal diameter. The current biomechanical study investigated: nail bending strength and stiffness, fatigue properties and hip peg strength. A cadaveric study that determined the effect of the expandable peg on the femoral head included subsidence testing, pull and torsion testing and intra-osseous pressure (IOP) measurements before and after expansion. Biomechanical properties of the new nail met ASTM F384 guideline requirements. The cadaver study yielded equivalent results for the pullout test between the peg and the hip screw, but found the peg superior in the torsion strength test. IOP during peg insertion and expansion was substantially lower than the threshold pressure that causes avascular necrosis. The biomechanical tests found the new system to be safe and able to provide good abutment of the nail to the bone. We conclude that the Fixion PFN system proved to be an effective proximal femur fracture fixation device.

The fixion proximal femur nailing system: biomechanical properties of the nail and a cadaveric study

The treatment of choice for early mobilization of hip fracture is surgery, which traditionally employs side plates and screws or intramedullary nails. We examined the biomechanical properties of a new proximal femoral nail system. The new expandable Fixion proximal femur nailing (PFN) system, made of stainless-steel alloy, consists of a nail, a peg and an anti-rotation pin. Upon positioning, the nail and peg are expanded to their maximal diameter. The current biomechanical study investigated: nail bending strength and stiffness, fatigue properties and hip peg strength. A cadaveric study that determined the effect of the expandable peg on the femoral head included subsidence testing, pull and torsion testing and intra-osseous pressure (IOP) measurements before and after expansion. Biomechanical properties of the new nail met ASTM F384 guideline requirements. The cadaver study yielded equivalent results for the pullout test between the peg and the hip screw, but found the peg superior in the torsion strength test. IOP during peg insertion and expansion was substantially lower than the threshold pressure that causes avascular necrosis. The biomechanical tests found the new system to be safe and able to provide good abutment of the nail to the bone. We conclude that the Fixion PFN system proved to be an effective proximal femur fracture fixation device.

Patellar hypertension syndrome in adolescence: a three-year follow up.

Anterior knee pain is one of the major causes of knee pain in an adolescent population. It has been suggested that raised intraosseous pressure may play an important role in the development of anterior knee pain in the young patient. A prospective clinical multicentre study with 27 adolescent patients presenting with anterior knee pain was performed. After failure to respond to conservative treatment, all patients agreed to undergo minimally invasive intraosseous pressure measurements in local anaesthesia. All 27 patients demonstrated a positive "pain provocation test" as a response to increased intrapatellar pressure and were decompressed with a new intraosseous drilling technique. The repeat intraosseous pressure measurement in 27 patients 1 year postoperatively revealed a significant reduction from 43.3+/-13.4 preoperatively to 24.1+/-4.2 mmHg (p<0.001). The pain relief was documented in the form of a reduced VAS from 7.6+/-1.4 to 2.1+/-1.1 cm after 3 years (p<0.001). Patients with anterior knee pain and a positive "pain provocation test" were diagnosed as suffering from a hypertension syndrome of the patella. We conclude that simple extraarticular patellar decompression may offer a valuable new form of treatment in this select group of adolescent patients with anterior knee pain.

Canine panosteitis: an idiopathic bone disease investigated in the light of a new hypothesis concerning pathogenesis. Part 1: Clinical and diagnostic aspects

Panosteitis, an idiopathic bone disease of young dogs, was investigated in the light of a new, empirically based hypothesis governing its pathogenesis. Extensive clinical observations suggest a close relationship between the incidence of this disease and the commercialization of various protein-rich, high-calorie dog foods. The theory of an "osseous compartment syndrome" provides a hypothetical pathogenesis, which corroborates this findings. An excessive accumulation of protein causes intraosseous edema due to its osmotic effects. Because bone is a rigid compartment, this leads to an increase in intramedullary pressure and compression of blood vessels. Subsequent osseous ischemia leads to a deficient metabolic state (decreased oxygenation, inadequate influx of nutritive substances, local acidosis, decreased removal of metabolites, disruption of local biochemical processes, etc.), and a vicious circle is created due to the resulting local inflammation. The disease is aggravated by increased metabolism due to excessive physical activity. Within the context of a pilot study, clinical, radiographic, scintigraphic and thermographic examinations and a therapeutic trial with benzopyron were carried out. In addition, more modern investigative tools, including osteomyelography, magnetic resonance tomography and intraosseous pressure measurements were used to provide objective data concerning the pathogenesis of panosteitis. In most cases, clinical remission was seen within days of monotherapy with the proteolytic substance, benzopyron (Cumartrin). This finding appears to corroborate our hypothesis.

A new concept in the treatment of anterior knee pain: patellar hypertension syndrome.

This prospective clinical study evaluated 69 patients (136 knees) presenting with anterior knee pain after failure to respond to conservative treatment. All patients agreed to undergo minimally invasive intraosseous pressure measurements of the patella under local anesthesia. Forty patients (50 knees) demonstrated a positive pain provocation test (the typical pain sensation could be reproduced by raising intrapatellar pressure) and were treated with a new method of intraosseous drilling and decompression. Ninety percent of the patients treated experienced pain relief >3 years postoperatively. Repeated intraosseous pressure measurements in 33 knees 1 year postoperatively confirmed objective intraosseous pressure reduction in 88%. Patients with anterior knee pain and a positive pain provocation test were labeled as hypertension syndrome of the patella. These results indicate simple extra-articular patellar decompression may offer a valuable new form of treatment in select patients with anterior knee pain, ie, hypertension syndrome of the patella.

Angiography, Scintigraphy, Intraosseous Pressure, and Histologic Findings in High-Risk Osteonecrotic Femoral Heads With Negative Magnetic Resonance Images

One hundred twenty-six hips of 68 patients who were suspected of having osteonecrosis or being at risk for osteonecrosis were studied with magnetic resonance (MR) imaging. Abnormal patterns on MR imaging characteristic of osteonecrosis were observed in 98 hips. The remaining 28 hips (22 patients) with negative MR images underwent superselective angiography of the medial femoral circumflex artery. Angiography showed interruption of the superior retinacular arteries in 13 hips (12 patients), including 6 of 7 symptomatic hips. Bone scans were performed on 8 of 13 hips angiographically positive for osteonecrosis. Decrease of radionuclide uptake (cold lesions) was observed in all 8 of these femoral heads. Thirteen femoral heads with interruption of superior retinacular arteries underwent intraosseous pressure measurement and core biopsy. Intraosseous pressure was elevated in 11 hips. The results of histologic study showed evidence of early necrosis in 10 femoral heads. This study indicates that there are a considerable number of femoral heads at high risk, even when they have negative MR images. They do, however, show positive findings on angiography, scintigraphy (cold lesions), intraosseous pressure measurement, and histologic study.

Evaluation of magnetic resonance imaging in the diagnosis of osteonecrosis of the femoral head. Accuracy compared with radiographs, core biopsy, and intraosseous pressure measurements.

The accuracy of magnetic resonance imaging in the detection of osteonecrosis of the femoral head was compared with that of other diagnostic methods in current use: plain radiography, bone-marrow pressure determinations, intramedullary venography, and histological examination of core-biopsy bone specimens. In the first phase of the study, forty-eight patients (ninety-six hips) who were at high risk for avascular necrosis were studied. Abnormal patterns on magnetic resonance imaging, consistent with those seen in necrosis, were found in all hips that were suspected of having Ficat Stage-2 or 3 changes on the basis of radiographic evidence of the disease. Abnormal patterns on magnetic resonance imaging that were characteristic of avascular necrosis were also observed in 17 per cent of the hips that were suspected of having Ficat Stage-0 changes and in 64 per cent of those that showed Stage-1 changes, all with no radiographic changes. In the second phase of the study, twenty-three of the ninety-six hips that were suspected of having early-stage necrosis of the femoral head but showed slight or no radiographic changes were studied by repeat radiographs, Ficat functional evaluations of bone, core biopsies of the femoral head, and magnetic resonance imaging. Of the twenty-three hips, eighteen (78 per cent) had positive changes on magnetic resonance imaging; nineteen (83 per cent) had positive histological evidence of necrosis; and fourteen (61 per cent) had positive findings by bone-marrow pressure studies and intramedullary venography. Although false-negative and false-positive results were observed with magnetic resonance imaging, the over-all results of this study suggest that magnetic resonance imaging may be useful for the early diagnosis of avascular necrosis.

Multimodality Approach to Osteonecrosis of the Femoral Head

Treatment of osteonecrosis of the femoral head appears to be effective when the disease is identified and treated early. Forty-one patients were evaluated with prospective laboratory assessment, anteroposterior and frog-lateral roentgenograms of both hips, intraosseous pressure measurements (IOP), magnetic resonance imaging (MRI), and 99mTc methylene diphosphonate planar and single-photon emission computerized tomographic (SPECT) bone imaging. Pathologic specimens were obtained in most patients. Preradiographic disease was identified in 26 hips and 11 of these were asymptomatic. Fifteen clinically symptomatic hips had normal plain roentgenograms, but abnormal protocol studies. Evaluation of sensitivity, specificity, and predictive value (positive and negative), respectively, in diagnosing osteonecrosis of the femoral head revealed the following percentages: 83%, 83%, 96%, and 48% for planar bone scanning; 91%, 78%, 94%, and 70% for SPECT; 87%, 83%, 96%, and 55% for MRI; 80%, 60%, 95%, and 25% for IOP; and 88%, 100%, 100%, and 25% for core biopsy. (There were few true negatives, thus specificity values are approximations.) The identification of preradiographic stages is possible, but difficult. MRI appears appealing at present, particularly in identifying disease in asymptomatic hips. However, there is no definitive method for noninvasive diagnosis. Pathologic confirmation in early stages is difficult.

Effect of indomethacin on regulation of juxta-articular bone blood-flow during joint tamponade. An experimental study in puppies

Prostaglandins are vasoactive substances which are assumed to play a major role in bone metabolism and bone repair. The purpose of the present study was to investigate the effect of indomethacin on the control of epiphyseal bone blood-flow. By means of simultaneous intra-osseous pressure (IOP) and regional blood flow (RBF) measurements in the distal femoral epiphysis (DFE), aspects of vascular control mechanisms in the distal femoral epiphysis were investigated during knee joint tamponade (50% of mean arterial pressure) before and after administration of indomethacin 7.5 mg/kg. Six dogs aged 3-4 months were investigated in fentanyl anaesthesia. Knee joint tamponade resulted in a significant increase in IOP and calculated venous resistance in the DFE, while no significant changes in regional blood-flow or arterial resistance were encountered. Administration of indomethacin did not affect this reaction. The results suggests that indomethacin 7.5 mg/kg does not influence the regulation of epiphyseal blood-flow during elevation of joint pressure indicating that prostaglandins play only a minor or no role in this regulation.

The Importance of Increased Intraosseous Pressure in the Development of Osteonecrosis of the Femoral Head: Implications for Treatment

Early diagnosis of osteonecrosis by radiograph, bone scan, CT scan, magnetic resonance imaging (MRI), intraosseous pressure measurement, or intraosseous venogram can lead to early successful treatment. For early (Ficat stages I and II) osteonecrosis of the hip, core decompression can provide diagnostic confirmation and pain relief and may prevent progression of disease. For more advanced disease (Ficat stages II and IV), osteotomy, endoprosthetic or bipolar prosthetic replacement, total hip arthroplasty, and arthrodesis are surgical options.