Micro-core decompression combined with intralesional zoledronic acid as a treatment of osteonecrosis of femoral head: a novel technique

Authors

  • Muhammed Ashraf Department of Orthopaedics, Government T. D. Medical College, Alappuzha, Kerala, India
  • Jyothis George Department of Orthopaedics, Government T. D. Medical College, Alappuzha, Kerala, India
  • Ibad Sha I. Department of Orthopaedics, Government T. D. Medical College, Alappuzha, Kerala, India

DOI:

https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20203060

Keywords:

Intra-lesional bisphosphonate, Avascular necrosis hip, Hip preservation surgery, Micro core-decompression

Abstract

Background: Avascular necrosis (AVN)/osteonecrosis of the femoral head is a debilitating condition affecting the hip joint and is one of the most common causes of total hip replacement. The available treatments include pharmacological and surgical options with total hip arthroplasty (THA) being the mainstay of treatment. This present study is a novel technique of combining micro core decompression with intra-lesional bisphosphonate as a treatment for osteonecrosis of the hip.

Methods: A prospective study of 19 hips was done. There were 11 males and 4 females ranging 42-63 years. Four hips were stage I, ten hips were stage IIA, three hips were stage IIb and two hips were stage III.  16 hips (40%) had stage IIb and 24 hips (60%) had stage III ONFH. The minimum period of follow up was 24 months. All patients were assessed according to the Harris hip score. The operative procedure includes decompressing the avascular area with drilling then injecting the zoledronic acid locally.

Results: The mean preoperative modified Harris hip score in stage I (n=4), stage IIa (n=10), stage IIb (n=3) and stage III (n=2) were 81.9, 72.7, 68.8 and 59.2 respectively. The mean postoperative modified Harris hip score at two years in stage I, stage IIa, stage IIb and stage III were 97.3, 91.1, 88.4 and 82.5 respectively.

Conclusions: We found that the use of micro core-decompression with intra-lesional bisphosphonate will provide higher chances towards hip preservation especially in late cases or cases with larger lesions where core decompression may not be successful.

 

References

Baig SA, Baig MN. Osteonecrosis of the Femoral Head: Etiology, Investigations, and Management. Cureus. 2018;10(8):3171.

Kakaria HL, Sharma AK, Sebastian B. Total Hip Replacement in Avascular Necrosis of Femoral Head. Med J Armed Forces India. 2005;61(1):33‐5.

Vardhan H, Tripathy SK, Sen RK, Aggarwal S, Goyal T. Epidemiological Profile of Femoral Head Osteonecrosis in the North Indian Population. Indian J Orthop. 2018;52(2):140‐6.

Boskey AL, Raggio CL, Bullough PG, Kinnett JG. Changes in the bone tissue lipids in persons with steroid and alcohol-induced osteonecrosis. Clin Orthop Relat Res. 1983;172:289-95.

Matsuo K, Hirohata T, Sugioka Y, Ikeda M, Fukuda A. Influence of alcohol intake, cigarette smoking, and occupational status on idiopathic osteonecrosis of the femoral head. Clin Orthop Relat Res. 1988;234:115-23.

Koo KH, Kim R, Kim YS, Ahn IO, Cho SH, Song HR, et al. Risk period for developing osteonecrosis of the femoral head in patients on steroid treatment. Clin Rheumatol. 2002;21:299-303.

Angeler MJ, Gianakos A, Villa J, Ni A, Lane J. Current concepts on osteonecrosis of the femoral head. World J Orthop. 2015;6:590-601.

Lieberman JR, Berry DJ, Mont MA, Aaron RK, Callaghan JJ, Rajadhyaksha AD, et al. Osteonecrosis of the hip: management in the 21st century. Instr Course Lect. 2003;52:337-55.

Sen RK. Management of avascular necrosis of femoral head at pre-collapse stage. Indian J Orthop. 2009;43:6-16.

Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. 1995;77:459-74.

Dayan AY, Chang C, Greenspan A, Shoenfeld Y, Gershwin ME. Pathogenesis and natural history of osteonecrosis. Seminars Arthritis Rheumatism. 2002;32(2):94-124.

Chen CH, Chang JK, Lai KA, Hou SM, Chang CH, Wang GJ. Alendronate in the prevention of collapse of the femoral head in nontraumatic osteonecrosis: a two-year multicenter, prospective, randomized, double-blind, placebo-controlled study. Arthritis Rheum. 2012;64:1572-8.

Peled E, Bejar J, Barak M, Orion E, Norman D. Core decompression and alendronate treatment of the osteo-necrotic rat femoral head: computer-assisted analysis. Int J Exp Pathol. 2013;94:212-6.

Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N, Berlemann U. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br. 2001;83(8):1119-24.

Polkowski GG, Callaghan JJ, Mont MA, Clohisy JC. Total Hip Arthroplasty in the Very Young Patient. J Am Academy Orthopaedic Surg. 2012;20(8):487-97.

Arlet J, Ficat RP. Forage-biopsie de la tete femorale dans 1’osteonecrose primitive; Observations histopathologiques portant sur huit foranes. Rev Rhum Ed Fr. 1964;31:257-64.

Marker DR, Seyler TM, Ulrich SD, Srivastava S, Mont MA. Do modern techniques improve core decompression outcomes for hip osteonecrosis. Clin Orthop Relat Res. 2008;466(5):1093.

Rajagopal M, Samora BJ, Ellis TJ. Efficacy of core decompression as treatment for osteonecrosis of the hip: a systematic review. Hip Int J Clin Exp Res Hip pathol Ther. 2012;22(5):489.

Mohanty SP, Singh KA, Kundangar R, Shankar V. Management of non-traumatic avascular necrosis of the femoral head: a comparative analysis of the outcome of multiple small diameter drilling and core decompression with fibular grafting. Musculoskeletal Surg. 2017;101:59-66.

Kim SY, Kim DH, Park IH. Multiple drilling compared with core decompression for the treatment of osteonecrosis of the femoral head. J Bone Joint Surg Br. 2004;86:149.

Song WS, Yoo JJ, Kim YM, Kim HJ. Results of Multiple Drilling Compared with Those of Conventional Methods of Core Decompression. Clin Orthopaedics Related Res. 2007;454:139-46.

Li J, Li ZL, Zhang H, Su XZ, Wang KT, Yang YM. Long-term Outcome of Multiple Small-diameter Drilling Decompression Combined with Hip Arthroscopy versus Drilling Alone for Early Avascular Necrosis of the Femoral Head. Chinese Med J. 2017;130(12):1435-40.

Müller I, Vaegler M, Holzwarth C, Tzaribatchev N, Pfister SM, Schutt B, et al. Secretion of angiogenic proteins by human multipotent mesenchymal stromal cells and their clinical potential in the treatment of avascular osteonecrosis. Leukemia. 2008;22:2054-61.

Kawate K, Yajima H, Ohgushi H, Kotobuki N, Sugimoto K, Ohmura T, et al. Tissue-engineered approach for the treatment of steroid-induced osteonecrosis of the femoral head: Transplantation of autologous mesenchymal stem cells cultured with beta-tricalcium phosphate ceramics and free vascularized fibula. Artif Organs. 2006;30:960-2.

Zhang C, Zeng B, Xu Z, Song W, Shao L, Jing D, et al. Treatment of femoral head necrosis with free vascularized fibula grafting: a preliminary report. Microsurgery. 2005;25:305-9.

Fang T, Zhang EW, Sailes FC, McGuire RA, Lineaweaver WC, Zhang F. Vascularized fibular grafts in patients with avascular necrosis of femoral head: A systematic review and meta-analysis. Arch Orthop Trauma Surg. 2013;133:1-10.

Agarwala S, Jain D, Joshi VR, Sule A. Efficacy of alendronate, a bisphosphonate, in the treatment of AVN of the hip: a prospective open-label study. Rheumatology. 2005;44:352-9.

Agarwala S, Shah SB. Ten-year follow-up of avascular necrosis of femoral head treated with alendronate for 3 years. J Arthroplasty. 2011;26:1128-34.

Nishii T, Sugano N, Miki H, Hashimoto J, Yoshikawa H. Does alendronate prevent collapse in osteonecrosis of the femoral head. Clin Orthop Relat Res. 2006;443:273-9.

Chen CH, Chang JK, Lai KA, Hou SM, Chang CH, Wang GJ. Alendronate in the prevention of collapse of the femoral head in nontraumatic osteonecrosis: A two-year multicenter, prospective, randomized, double-blind, placebo-controlled study. Arthritis Rheum. 2012;64:1572-8.

Lai KA, Shen WJ, Yang CY, Shao CJ, Hsu JT, Lin RM. The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. A randomized clinical study. J Bone Joint Surg Am. 2005;87:2155-9.

Wang JA. Evidence for Using Alendronate to Treat Adult Avascular Necrosis of the Femoral Head: A Systematic Review. Med Sci Monitor. 2014;20:2439-47.

Kumar V, Shahi AK. Nitrogen containing bisphosphonates associated osteonecrosis of the jaws: A review for past 10 years literature. Dent Res J. 2014;11(2):147‐53.

Wei, Biao, Ge, Xiang. Treatment of osteonecrosis of the femoral head with core decompression and bone grafting. Hip Int J Clin Experimental Res Hip Pathology Therapy. 2011;21:206-10.

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Published

2020-08-26

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Original Research Articles