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1、Core Decompression for Osteonecrosis of the hip,Clin Orthop.2004;418:29-33,DEVELOPMENT OF CORE DECOMPRESSION OF THE FEMORAL HEAD,Core decompression of the hip is the most common procedure currently used to treat the early stages of ON of the femoral head. Ficat and Arlet then hypothesized that ON co
2、uld be treated successfully by decompressing the femoral head.,The goal of core decompression was to decompress the femoral head pressure, restore normal vascular flows, and alleviate pain in the hip.Even though numerous studies have been published no general consensus has been developed regarding p
3、atient selection, surgical technique, classification systems used, or postoperative treatment of these patients.,CLASSIFICATION AND STAGING,The purpose of any classification system is to provide guidelines for treatment and prognosis. Over the years, numerous different classifications systems have b
4、een developed to evaluate patients with ON of the femoral head but currently, there is no standard unified classification system used by all investigators. There is general agreement that the prognosis for a patient with ON of the hip is influenced by the extent and the location of the necrotic area
5、 in the femoral head and whether there is involvement of the acetabulum.,Ficat and Arlet originally developed a four-stage classification system based on radiographic changes and the functional exploration of bone that included intraosseous venography and measurement of bone marrow pressure (Table 1
6、).,Since that time, numerous different classification systems have been developed but the University of Pennsylvania System of Classification and Staging has the most potential as a useful clinical and research tool. Because it included MRI evaluations, which allow for the quantification of the exte
7、nt of femoral head involvement (Table 2).,CORE DECOMPRESSION,There have been numerous extensive literature reviews published assessing the clinical results of core decompression. Smith et al reviewed 12 articles published between 1979 and 1991 that included 702 hips with an average followup of 38 mo
8、nths. Using the University of Pennsylvania Staging System, successful results were reported as follows: Stage I, 78%; Stage II, 62%; and Stage III, 41%.,Mont and associates assessed 42 reports in which 1206 hips were treated by core decompression and 819 hips were treated by various nonoperative mea
9、ns. nonoperative treatment was not successful. Only 23% of hips in 21 studies had a satisfactory clinical result when treated nonoperatively. In 24 studies, 65% of the hips treated with core decompression had an overall satisfactory clinical result. Furthermore, when assessing hips treated before co
10、llapse, good results were obtained in 71% of the hips treated with core decompression and in 35% of hips treated nonoperatively.,Stulberg et al compared core decompression alone with conservative treatment in a prospective randomized study that included 55 hips. Core decompression was successful in
11、70% of the hips that were either Ficat Stage I, II, or III. In contrast, there was limited success with nonoperative treatment (Ficat Stage I, 20%; Ficat Stage II, 0%; Ficat Stage III, 10%). It was concluded that core decompression was more effective than nonoperative treatment for patients with ear
12、ly stages of ON.,Koo and associates did a randomized trial on 71 hips that were treated by core decompression or nonoperatively. Radiographic progression was seen in 72% of the hips treated with core decompression and in 79% of the hips that were treated symptomatically. Seventy-two percent of the h
13、ips treated with a core decompression eventually required a THA and 68% of the hips treated symptomatically required a THA. The investigators concluded that there was no significant advantage in the outcome when patients with ON of the femoral head were treated with core decompression.,Smith and ass
14、ociates evaluated 114 hips and showed that there was a significant decrease in satisfactory results when a crescent sign was present. The success rate in hips with Ficat Stage I ON was 81% but in hips with the crescent sign or definitive collapse of the femoral head the success rates were 20% and 0%
15、,Steinberg analyzed 205 patients (297 hips) with a minimum 2-year followup. The stage of the hip, according to the University of Pennsylvania Classification System, and the lesion site clearly influenced the success rates of core decompression.,Aaron et al evaluated 118 hips with Ficat Stage II or I
16、ll ON which was treated with core decompression and core decompression and human DBM . Survival percent is show below:,There also has been an interest in combining core decompression of the femoral head with bone grafting or electrical stimulation or both to enhance bone repair in the femoral head.
17、Steinberg et al found no advantage to supplementing core decompression with either direct current or capacitative coupling.,Bozic et al studied 54 hips that had ON of the femoral head with a mean duration of followup of 120 months (range, 24-196 months). A successful result was defined as one in whi
18、ch the hip was asymptomatic with no progression of the disease. An unsuccessful result was defined as radiographic failure or clinical failure or both. The authors showed that the significant predictors of overall failure included an advanced preoperative radiographic stage, a short duration of symptoms, and the use of corticosteroids. No association was seen between age, gender, excessive intake of alcohol or renal transplantation and a successful outcome.,
