Aims. The value of core decompression (CD) in the treatment of osteonecrosis of the femoral head (ONFH) remains controversial. We conducted a systematic review and meta-analysis to evaluate whether CD combined with other treatments could improve the clinical and radiological outcomes of ONFH patients compared with CD alone. Methods. We searched the PubMed, Embase, Web of Science, and Cochrane Library databases until June 2020. All randomized controlled trials (RCTs) and clinical controlled trials (CCTs) comparing CD alone and CD combined with other measures (CD + cell therapy, CD + bone grafting, CD + porous tantalum rod, etc.) for the treatment of ONFH were considered eligible for inclusion. The primary outcomes of interest were Harris Hip Score (HHS), ONFH stage progression, structural failure (collapse) of the femoral head, and conversion to total hip arthroplasty (THA). The pooled data were analyzed using Review Manager 5.3 software. Results. A total of 20 studies with 2,123 hips were included (CD alone = 768, CD combined with other treatments = 1,355). The combination of CD with other therapeutic interventions resulted in a higher HHS (mean difference (MD) = 6.46, 95% confidence interval (CI) = 2.10 to 10.83, p = 0.004) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (MD = −10.92, 95% CI = -21.41 to -4.03, p = 0.040) and a lower visual analogue scale (VAS) score (MD = −0.99, 95% CI = -1.56 to -0.42, p < 0.001) than CD alone. For the rates of disease stage progression, 91 (20%) progressed in the intervention group compared to 146 (36%) in the control group (odds ratio (OR) = 0.32, 95% CI = 0.16 to 0.64, p = 0.001). In addition, the intervention group had a more significant advantage in delaying femoral head progression to the collapsed stage (OR = 0.32, 95% CI = 0.17 to 0.61, p < 0.001) and reducing the odds of conversion to THA (OR = 0.35, 95% CI = 0.23 to 0.55, p < 0.001) compared to the control group. There were no serious adverse events in either group. Subgroup analysis showed that the addition of cell therapy significantly improved clinical and radiological outcomes compared to CD alone, and this approach appeared to be more effective than other therapies, particularly in precollapse (stage I to II) ONFH patients. Conclusion. There was marked heterogeneity in the studies. There is a trend towards improved clinical outcomes with the addition of stem cell therapy to CD. Cite this article: Bone Joint Res 2021;10(7):445–458

Aims. Osteonecrosis (ON) can cause considerable morbidity in young people who undergo treatment for acute lymphoblastic leukaemia (ALL). The aims of this study were to determine the operations undertaken for ON in this population in the UK, along with the timing of these operations and any sequential procedures that are used in different joints. We also explored the outcomes of those patients treated by core decompression (CD), and compared this with conservative management, in both the pre- or post-collapse stages of ON. Methods. UK treatment centres were contacted to obtain details regarding surgical interventions and long-term outcomes for patients who were treated for ALL and who developed ON in UKALL 2003 (the national leukaemia study which recruited patients aged 1 to 24 years at diagnosis of ALL between 2003 and 2011). Imaging of patients with ON affecting the femoral head was requested and was used to score all lesions, with subsequent imaging used to determine the final grade. Kaplan-Meier failure time plots were used to compare the use of CD with non surgical management. Results. Detailed information was received for 85 patients who had developed ON during the course of their ALL treatment. A total of 206 joints were affected by ON. Of all joints affected by ON, 21% required arthroplasty, and 43% of all hips affected went on to be replaced. CD was performed in 30% of hips affected by ON. The majority of the hips were grade 4 or 5 at initial diagnosis of ON. There was no significant difference in time to joint collapse between those joints in which CD was performed, compared with no joint-preserving surgical intervention. Conclusion. There is a high incidence of surgery in young people who have received treatment for ALL and who have developed ON. Our results suggest that CD of the femoral head in this group of patients does not delay or improve the rates of femoral head survival. Cite this article: Bone Joint J 2021;103-B(3):589–596

Thirty shoulders, in 20 patients, which had undergone core decompression for symptomatic avascular necrosis of the humeral head were reviewed 2 to 14 years later (average 5.6). Twenty-two showed good or excellent clinical results; the other eight shoulders had required arthroplasty. All 14 shoulders with stage I or II radiological changes (Ficat and Arlet 1980) at operation had good or excellent results. We advocate early core decompression for symptomatic avascular necrosis of the humeral head

We performed 41 core decompressions in 32 patients for stage I or stage II osteonecrosis of the femoral head. The intra-osseous pressure at the intertrochanteric level was raised in 28 (68%) and there was histological confirmation of necrosis in 36 hips (88%). After a follow-up of 10 to 84 months (mean 31) nine of the 12 stage I hips (75%) showed significant clinical or radiological deterioration; no evidence of necrosis had been found in the core specimens of the other three hips. Of the 29 hips in stage II, 25 (86%) showed significant radiological deterioration, and only five (17%) had improved clinically. We believe that once necrosis has occurred, core decompression will not significantly influence the subsequent course of the disease

Aims. One method of femoral head preservation following avascular necrosis (AVN) is core decompression and insertion of a tantalum rod. However, there may be a high failure rate associated with this procedure. The purpose of this study was to document the clinical and radiological outcomes following total hip arthroplasty (THA) subsequent to failed tantalum rod insertion. Patients and Methods. A total of 37 failed tantalum rods requiring total hip arthroplasty were identified from a prospective database. There were 21 hips in 21 patients (12 men and nine women, mean age 37 years, 18 to 53) meeting minimum two year clinical and radiographic follow-up whose THAs were carried out between November 2002 and April 2013 (mean time between tantalum rod implantation and conversion to a THA was 26 months, 6 to 72). These were matched by age and gender to individuals (12 men, nine women, mean age 40 years, 18 to 58) receiving THA for AVN without prior tantalum rod insertion. Results. There were no functional outcome differences between the two groups. Tantalum residue was identified on all post-operative radiographs in the tantalum group. Linear wear rates were comparable between groups with no evidence of catastrophic wear in either group. Conclusion. In the short term, tantalum rod implantation does not demonstrate an adverse effect on subsequent total joint replacement surgery. There is however, a high rate of retained tantalum debris on post-operative radiographs and thus there is an unknown risk of accelerated articular wear necessitating longer term study. Cite this article: Bone Joint J 2016;98-B:1175–9

We have studied the long-term results of core decompression as the sole treatment for Ficat stages I, II and III ischaemic necrosis of 128 femoral heads in 90 patients. The 5-, 10- and 15-year survival rates for the three stages were respectively: stage I 100%, 96% and 90%; stage II 85%, 74% and 66%; and stage III 58%, 35% and 23%. At a mean follow-up of 11 years (4.5 to 19), 55 hips had failed (43%). No further surgery had been needed for 88% of stage-I, 72% of stage-II and 26% of stage-III hips; but despite the generally satisfactory clinical results, 56% of the hips had progressed radiographically by at least one Ficat stage. Complications of the core procedure included four fractures, all from postoperative falls, and one head perforation due to technical error. We conclude that core decompression delays the need for total hip replacement in young patients with ischaemic necrosis

Bone-marrow oedema syndrome (BMOS) of the hip gives a characteristic MRI pattern, in association with severe pain, non-specific focal loss of radiological density and a positive bone scan. In our MRI-controlled study, nine patients with non-traumatic BMOS in ten hips all had core decompression. Bone-marrow pressure measurements and intraosseous venography in five cases showed pathological values. All patients had immediate relief of pain, with return of MRI signals to normal after three months. Regular review was continued for at least 24 months with serial clinical radiological and MRI assessment. At a mean follow-up of 33 months all patients remained free of pain with normal radiographs and MR scans. The histological evaluation of undecalcified sections obtained from eight core decompressions confirmed the presence of bone-marrow oedema, with necrotic and reparative processes involving bone and marrow similar to those of early avascular necrosis but with no evidence of 'osteoporosis'. These findings support the assumption that BMOS may be the initial phase of non-traumatic avascular necrosis. In most patients BMOS will have a self-limiting course, but the duration of symptoms may be reduced by core decompression treatment

We have reviewed 54 hips in 46 patients from 2 to 14 years after a joint-preserving operation for idiopathic avascular necrosis of the femoral head. The choice between core decompression (17 hips), bone grafting (18), rotation osteotomy (15) or varus osteotomy (4) was determined by the stage and location of the area of necrosis. The overall success rate was unexpectedly low at 60%. Core decompression and bone grafting by our techniques gave poor long-term results, but those of rotation or varus osteotomies, performed with care for the correct indications, were better. The indications for each procedure are discussed: osteotomy is best when the area of necrosis is shallow and localised in the medial or anterior portion of the femoral head

From 1974 to 1981, we performed 28 core decompressions of the distal femur for pathologically confirmed avascular necrosis. At a mean follow-up of 54 months (range 20 to 140 months) and using the Ficat stages, all seven cases in stage I and stage II had good results. Of 21 cases in stage III, 11 cases had good results, four had poor results, and six needed total knee replacement. There were no significant orthopaedic complications. The procedure is worthwhile and will be more accurate with new methods of imaging

We performed a randomised trial on 37 hips (33 patients) with early-stage osteonecrosis (ON). After the initial clinical evaluation, including plain radiography and MRI, 18 hips were randomly assigned to a core-decompression group and 19 to a conservatively-treated group. All the patients were regularly followed up by clinical evaluation, plain radiography and MRI at intervals of three months. Hip pain was relieved in nine out of ten initially symptomatic hips in the core-decompression group but persisted in three out of four initially painful hips in the conservatively-treated group at the second assessment (p < 0.05). At a minimum follow-up of 24 months, 14 of the 18 core-decompressed hips (78%) and 15 of the 19 non-operated hips (79%) developed collapse of the femoral head. By survival analysis, there was no significant difference in the time to collapse between the two groups (log-rank test p = 0.79). Core decompression may be effective tin symptomatic relief, but is of no greater value than conservative management in preventing collapse in early osteonecrosis of the femoral head

Avascular necrosis (AVN) is a serious complication of high-dose chemotherapy for haematological malignancy in childhood. In order to describe its incidence and main risk factors and to evaluate the current treatment options, we reviewed 105 children with a mean age of 8.25 years (1 to 17.8) who had acute lymphoblastic or acute myeloid leukaemia, or a non-Hodgkin’s lymphoma. Overall, eight children (7.6%) developed AVN after a mean of 16.8 months (8 to 49). There were four boys and four girls with a mean age of 14.4 years (9.8 to 16.8) and a total of 18 involved sites, 12 of which were in the femoral head. All these children were aged > nine years (p < 0.001). All had received steroid treatment with a mean cumulative dose of prednisone of 5967 mg (4425 to 9599) compared with a mean of 3943 mg (0 to 18 585) for patients without AVN (p = 0.005). No difference existed between genders and no thrombophilic disorders were identified. Their initial treatment included 11 core decompressions and two bipolar hip replacements. Later, two salvage osteotomies were done and three patients (four hips) eventually needed a total joint replacement. We conclude that AVN mostly affects the weight-bearing epiphyses. Its risk increases with age and higher steroid doses. These high-risk patients may benefit from early screening for AVN.

Cite this article: Bone Joint J 2013;95-B:1708–13.

Introduction and Objective. Osteoarthritis of the knee joint is common in old age population in every part of world. Pain is the major source of disability in patients with osteoarthritis of the knee joint. Subchondral bone marrow is richly innervated with nociceptive pain fibers and may be a source of pain in patients with symptomatic degenerative joint disease. Current therapy for managing bone marrow oedema is core decompression (CD), combining core decompression and injection of hydroxyapatite cement or autologus chondrocyte supplementtion. But all of this work has been done in femoral head and authors documented good result with minimal complication. There are various studies in literature suggesting treatment to repair BME by restoring support and relieving abnormal stresses with accepted internal fixation and bone stimulating surgical techniques in relieving knee OA pain. In this study, we present efficacy of knee arthroscopy with adjunctive core decompression and supplementation with structural scaffold to improve self-rated visual analog scale (VAS) pain scores, rate of conversion to arthroplasty, and patient satisfaction levels. Materials and Methods. The study included patients aged between 40 and 75 years old, with pain in the knee for at least six months, associated with high-signal MRI lesion on T2 sequences, on the tibia or femur. Trephine was used as the bone decompression instrument. Trephine has a diameter of 8–10 mm and operation with trephine requires that a cortical incision window be made prior to decompression treatment, thus necessitating strict disinfection. This procedure was done under spinal anesthesia. After diagnostic arthroscopy, decompression was done under C –ARM in desired area on MRI. After decompression, defect was filled with Poly ester urea's scaffold impregnated with BMAC. Results. Patients were assessed using the visual analog pain scale and the KOOS score, one week before surgery and one, three, six, 12, and 24 weeks after the procedure. MRI images were analyzed Lesions were mapped and measured in the axial, coronal, and sagittal views to plan the injection site and the trajectory of the cannula used for the procedure. Radiographs using anteroposterior, profile, and Rosenberg views of the knee and lower limb were performed to classify the lesion according to the Kellgren-Lawrence classification and to assess lower limb alignment. Evaluation using the KOOS showed a mean total score in the preoperative period of 38.44 points and of 60.7, 59.08, 56.92, 64.40, and 71.36 points at one, three, six, 12, and 24 weeks after surgery, respectively. In the VAS assessment, mean was 7.8 points preoperatively and 2.8, 2.6, 2.5, 1.3, and 0.5 points in the same periods. Conclusions. Hence it can be Concluded that this new innovative technique has provided significant improvements in the parameters of pain and functional capacity in the short-term assessment

Corticosteroids are prescribed for the treatment of many medical conditions and their adverse effects on bone, including steroid-associated osteoporosis and osteonecrosis, are well documented. Core decompression is performed to treat osteonecrosis, but the results are variable. As steroids may affect bone turnover, this study was designed to investigate bone healing within a bone tunnel after core decompression in an experimental model of steroid-associated osteonecrosis. A total of five 28-week-old New Zealand rabbits were used to establish a model of steroid-induced osteonecrosis and another five rabbits served as controls. Two weeks after the induction of osteonecrosis, core decompression was performed by creating a bone tunnel 3 mm in diameter in both distal femora of each rabbit in both the experimental osteonecrosis and control groups. An in vivo micro-CT scanner was used to monitor healing within the bone tunnel at four, eight and 12 weeks postoperatively. At week 12, the animals were killed for histological and biomechanical analysis. In the osteonecrosis group all measurements of bone healing and maturation were lower compared with the control group. Impaired osteogenesis and remodelling within the bone tunnel was demonstrated in the steroid-induced osteonecrosis, accompanied by inferior mechanical properties of the bone. We have confirmed impaired bone healing in a model of bone defects in rabbits with pulsed administration of corticosteroids. This finding may be important in the development of strategies for treatment to improve the prognosis of fracture healing or the repair of bone defects in patients receiving steroid treatment

Introduction. Without intervention 80% of hips with osteonecrosis (ON) will progress. Core decompression has shown favorable results (60–80% survivorship) in early stage ON, and recently, bone marrow aspirate concentration (BMAC) injection into the decompressed femoral head has been proposed to stimulate healing of the necrotic lesion and improve outcomes and survivorship. Methods. We retrospectively reviewed the clinical and radiographic outcomes of 42 hips in 26 patients who underwent core decompression with BMAC for ON with a minimum of 1 year follow up. We evaluated pre-op visual analog pain scores (VAS), Steinberg class based on radiographs, as well as Kerboul angle as measured on MRI. Clinical outcomes were reported as change in VAS at final follow up, advancement in Steinberg classification based on radiographs at final follow up, or decision to proceed with THA. Results. At final follow up, VAS scores had improved from 7 to 2.6 (P<0.05). A total of 33 of 42 hips (78.5%) had stable radiographs without collapse or progression to a higher Steinberg class, while a total of 9 of 42 hips (21.4%) went on to THA. Of the patients that went on to THA, all had a pre-operative Steinberg classification of 2C or higher, and the pre-op Kerboul angle in this cohort was 243, compared to 171 in the group that did not go on to THA (p<0.05). In patients with pre-op Steinberg class 2B or less, there was no advancement in radiographic grade, whereas 61% of patients with pre-op Steinberg grade 2C or higher progressed on to a more advanced stage. Conclusion. Core decompression with BMAC significantly improves clinical symptoms and helps prevent the advancement of ON when performed on patients in whom ON is classified as Steinberg class 2B or less, or in whom the Kerboul angle is 180 or less. For any tables or figures, please contact the authors directly

Osteonecrosis of the femoral head (ONFH) is a debilitating, painful, progressive, and refractory disease that has multiple etiologic risk factors. It is caused by bone cell death, which itself has various causes, leading to femoral head collapse and subsequent osteoarthritis. ONFH primarily influences patients aged from 20 to 50 years; in addition, bilateral hip joints are involved in 75% of patients. Causes include use of corticosteroids, alcohol abuse, previous trauma, hemoglobinopathy, Gaucher disease, coagulopathies, and other diseases. No pharmacologic treatment has been shown to be effective for early ONFH. Outcomes of total hip arthroplasty (THA) for these young and active patients have some drawbacks, primarily due to the young age of these patients, limited lifetime and durability of the implants and their fixation, and the skeletal manifestations of osteonecrosis. As a result of these concerns, there has been an increased focus on early interventions for ONFH aimed at preservation of the native articulation. Core decompression is currently the most widely accepted surgical treatment at the early stage of avascular osteonecrosis (AVN); however, due to limited efficacy, its use has been debated. There is currently no standardised protocol for evaluating and treating osteonecrosis of the femoral head in adults in the United States. Although total hip replacement is the most frequent intervention for treatment of post-collapse (Steinberg stage-IIIB, IVB, V, and VI) osteonecrosis; core decompression is the most commonly offered intervention for symptomatic, pre-collapse (Steinberg stage-IB and IIB) osteonecrosis. Less frequently offered treatments include non-operative, pharmacologic or modality management, osteotomy, vascularised and non-vascularised bone-grafting, hemiarthroplasty, resurfacing and arthrodesis. A promising, minimally invasive, core decompression procedure combined with a mesenchymal stem cell grafting technique which restores vascularity and heals osteonecrotic lesions has become popularised. This procedure is called a bone marrow aspirate concentrate (BMAC) procedure. During a BMAC, mesenchymal stem cells (in the form of concentrated iliac crest bone marrow) are injected through a core decompression tract into the area of necrosis in the femoral head. Most patients with early (pre-collapse) disease have excellent results at 2 to 5 years of clinical follow-up. Patients are weight bearing as tolerated on crutches after the procedure for 6 weeks, and are able to go home on the same day or next day after surgery with minimal pain. We can report on the early, promising results of 300 patients with ONFH treated with BMAC in the United States by two expert hip surgeons with at least 75%-80% survivorship. The care of adults with osteonecrosis of the femoral head is highly variable. This paper will discuss the various non-operative and operative treatment algorithms for ONFH available today. We will also report on a promising, new technique (BMAC), which improves the efficacy of traditional core decompression for early ONFH. The goal of treatment of early ONFH is to avoid THA in young, active patients and this talk will discuss those interventions and treatments which help accomplish that goal

Introduction. The purpose of this study was to analyze trends in the surgical management of ON in recent years. Specifically, we evaluated the annual prevalences of: 1) joint preserving procedures (osteotomies and core decompression/grafts) and 2) joint non-preserving procedures (total hip arthroplasties [THAs], revision THAs, partial THAs) for the treatment of osteonecrosis of the femoral head (ONFH) between 2009 and 2016. Background. A total of 406,239 ONFH patients who were treated between 2009 and 2016 were identified from a nationwide database. Treatment procedures were extracted using ICD-9-CM and ICD-10-CM procedure codes. Annual rates of each of the above procedures were calculated and the trends in the procedure types were also evaluated. Chi-square tests were performed to compare the annual prevalence of each procedure. The mean annual prevalence over the 8-year study period was calculated for each procedure. Results. Throughout the study period, the number of joint preserving procedures steadily increased by 27%. In the earliest year studied, 2009, 41% (n=19,559) of the total procedures for ONFH were joint-preserving compared to 52% (n=13,715) in 2016. The rates of joint non-preserving procedures decreased (59 to 48%) over the same period (Figure 1). There was a decreasing annual prevalence of THAs (88 to 82%), revision THAs (2.0 to 1.4%), partial THAs (3.4 to 2.3%), osteotomies (4.2 to 3.2%), and core decompression (1.9 to 1.4%) throughout the study period (p<0.001). Throughout the 8-year period, THA was most commonly performed (mean annual prevalence 83%) whereas osteotomies (3.7%), partial THA (2.8%), core decompression/graft (1.9%), and revision THA (1.5%) were less commonly performed. Conclusion. In order to better understand trends in ONFH management, this study evaluated the annual prevalence of 5 commonly performed procedures. Although earlier data indicated decreasing rates of joint preserving procedure, this study found ONFH management has shifted more towards these procedures. For any tables or figures, please contact the authors directly

Core decompression is a common treatment for early stage osteonecrosis of the femoral head due to the simplicity of the procedure and the positive results of this intervention. A number of different core decompression methods exist: including methods backfilled by a bone graft material and those without filling. Due to the inherent desire that the core decompression defect regenerate healthy bone, reduce pain, and stave off the need for total hip arthroplasty for some period of time, this surgically created defect is an excellent application for the use of a bone graft substitute. Recently, an injectable calcium sulfate (CaSO. 4. )/calcium phosphate (CaPO. 4. ) composite graft has become available for use in the treatment of surgically created defects. The synthetic graft is an injectable composite of CaSO. 4. , tricalcium phosphate (TCP) granules, and brushite that hardens in situ. The triphasic resorption pattern exhibited by this material in vitro and in pre-clinical canine studies has indicated that the CaSO. 4. matrix resorbs at early time points to reveal a longer resorbing CaPO. 4. scaffold for bone onlay. In a canine proximal humerus model, the use of this material in a critical bone defect has demonstrated a regenerate with higher compressive strength at 13 week time points than defects treated with CaSO. 4. alone, defects treated with autograft, and normal untreated bone. By 26 weeks, the regenerated bone within the defect resembled normal bony architecture with similar mechanical properties. Early clinical series have indicated similar results to the canine studies. Reports of early clinical findings have included a 12 patient benign bone tumor series with 4–12 month follow up and a core decompression series of 38 Ficat stage I–III hips with 6–16 month follow up. Preliminary radiological results in the bone tumor series showed peripheral resorption of the injectable CaSO. 4. /CaPO. 4. composite with new bone formation along the resorbing edge. Clinically, patients in the bone cyst series have not experienced fractures or additional surgery and all patients have displayed full functional recovery. In the core decompression series, 32 of the 38 hips experienced pain relief and within the subset of 30 symptomatic hips, 24 had pain relief. These results, although preliminary, are promising outcomes. Collectively, the pre-clinical and preliminary clinical results indicate that the use of an injectable CaSO. 4. /CaPO. 4. composite could prove to be of benefit in core decompression of the femoral head. The staged resorption and dense bone formation evidenced in canine studies would be desirable in core decompression techniques where healthy bony ingrowth is the goal. Due to the straightforward compilation and use of this composite, the incorporation of this material as a backfill matrix into the core decompression procedure is technically simple. Although additional studies are certainly merited, these early clinical results are encouraging

Introduction. The treatment osteonecrosis of the femoral head remains uncertain. Core decompression is the standard technique for the early stages (ARCO I and II). A new alternative is core decompression combined with the insertion of an osteonecrosis rod. This implant is supposed to reduce the intraosseous pressure and to give additional structural support. The aim of this study was to evaluate the clinical and radiological outcome via magnetic resonance imaging (MRI) of this new technique. Methods. Twenty-three patients were included in this study. All patients underwent a core decompression combined with the insertion of an osteonecrosis rod. Results. A survival rate of 44 % (10 of 23 patients) was found. The conversion to a total hip arthroplasty was performed after a mean interval of 529 days (range, 120 to 1348 days) because of persistence of pain or destruction of the joint. In five cases, a conversion to a long-stem hip arthroplasty, in seven cases to a short-stem arthroplasty, and in one case in an external hospital, to a hip resurfacing was performed. The majority of patients within the surviving group revealed an almost unchanged stage (mean follow-up of 477 days). In two cases, a radiological regression was obvious. A follow-up MRI of one of those patients showed complete regression. Conclusion. The outcome after core decompression combined with the insertion of a tantalum osteonecrosis intervention implant did not show superior results compared to core decompression. This is in contrast to prior studies. In addition, the surgical procedure and rehabilitation was prolonged and the costs higher than for isolated core decompression. An advantage is low risk of fracture post-operatively. In the case of conversion to total hip arthroplasty, no problems appeared during explantation of the tantalum implant

Introduction: Osteonecrosis of the femoral head is a devastating disease that often progresses to hip joint destruction necessitating total hip arthroplasty. The use of core decompression is typically recommended for patients with early small and medium-sized lesions. The reported efficacy of this procedure has been variable. Recently, various adjustments to the surgical technique have been described. There has been interest in performing multiple drillings under fluoroscopic guidance and combining core decompression with electrical stimulation and/or biological adjunctive growth factors. In order to assess whether the efficacy of this procedure has improved during the last 15 years using modern techniques, we compared recently reported radiographic and clinical success rates to results of surgeries performed prior to 1992. In addition, we evaluated the outcomes of our cohort of 52 patients (79 hips) who were treated with multiple small diameter drillings. Method: A systematic review utilizing the Medline and Embase bibliographic databases found 59 studies meeting our inclusion criteria that were related to core decompression and osteonecrosis. The mean age for patients was 39 years (range, 9 to 83 years), and the mean follow-up was 56 months (range, 1 to 228 months). From these reports, there were 1,429 hips treated prior to 1992 and 1,957 hips since 1992. Other than the smaller percentage of Ficat stage III cases in the later studies, the reported etiologies and the stratification of preoperative Ficat stage were similar in the two strata of groups with the majority of patients being Ficat stage I and II and corticosteroids and alcohol being the most frequently reported associated diagnosis. From our institution, we identified 52 patients (79 hips) who had a core decompression utilizing a multiple small diameter (3 millimeters) technique at mean follow-up of 65 months. The outcome parameters collected for each core decompression patient at our institution and from the reports in literature were the number and percentage of patients who required additional surgeries, were clinical failures, or had radiographic progression of the disease. Results: Overall, the success rates were higher for the studies that reported core decompressions performed during the last 15 years compared to procedures that were done prior to 1992. The proportion of patients surviving without additional surgery increased from 57% (range, 28 to 97%) in the earlier studies to 67% (range, 18 to 100%) in the more recent reports. Similarly, the radiographic success also increased from 54% (range, 0 to 94%) for the pre-1992 cohort to 59% (range, 22 to 90%). While clinical success increased from 57% (range, 28 to 94%) in the pre-1992 procedures to 61% (range, 29 to 90%) in reports from the last 15 years, this improvement was not statistically significant. Stratification by Ficat stage showed that there were significantly fewer patients who were Ficat stage III after 1992 suggesting that patient selection was the primary reason for the improvement in outcomes. For hips classified as Ficat stage II, there was an increase in clinical success and reduced percentage of patients requiring additional surgery in the more recent reports. The results of our cohort of patients were similar to other reports in the last 15 years. Patients who had small lesions and were Ficat stage I prior to treatment had the best results with 79% showing no radiographic progression. Discussion: The results of the present study do not provide adequate evidence to suggest that recent techniques provide better clinical scores or radiographic outcomes. However, the additional accumulation of successful reports in the last decade confirms that core decompression is a safe and effective procedure for the treatment of early stages of osteonecrosis of the femoral head. Furthermore, these results suggest that proper patient selection can improve outcomes for this procedure. Based on the results of our experience as well as that of other studies, we will use core decompression to treat patients who have early small and medium-sized lesions and are Ficat stage I or II. Additionally, the mid-term follow-up of the multiple small diameter core decompression patients at our institution was longer than most studies, and had a success rate similar to, or higher than other reports, which confirms the use of this technique as the authors’ preferred method

Introduction: Osteonecrosis is a devastating disease which can affect multiple joints including the distal radius. Although there are a number of studies that have reported the clinical outcomes of patients treated for osteonecrosis of the hip, knee, shoulder, and other locations, there are no known studies that have evaluated the outcome of patients who have this disease in the distal radius. The purpose of this study was to assess the characteristics of atraumatic, symptomatic osteonecrosis of the distal radius. In addition, based on reports that have shown the safe and effective use of core decompressions to treat early stages of osteonecrosis in other joints, we assessed whether this treatment modality also would provide pain relief and delay progression of the disease in the distal radius. Methods: A review of 434 osteonecrosis patient records from the past 7 years in our prospectively collected database identified 4 patients (6 wrists) who had the disease in the distal radius. Two of these patients also had the disease in the ulna. All 4 patients were women, and their mean age was 46 years (range, 37 to 52 years). Clinical and radiographic outcomes were assessed at a mean of 39 months (range, 12 to 84) following treatment with core decompression. The clinical evaluations were conducted using the Michigan Hand Outcomes Questionnaire (MHQ). The reported pre-operative MHQ component scores for function, completion of everyday activities, pain, completion of work activities, overall appearance of the hands, and patient satisfaction were compared to the results of the MHQ at final follow-up. Radiographic success of the core decompressions was based on whether there was any progression in the stage of the disease. Results: The most common risk factor for this cohort of patients was corticosteroids with 3 of the 4 patients having reported prior use. Other risk factors included alcohol consumption on a regular basis (n = 2), tobacco abuse (n = 2), blood dyscrasia (n = 2), and systemic lupus erythematosus (n = 1). Additionally, all 4 patients had multifocal osteonecrosis (affecting at least four separate anatomic sites. Overall, the patients reported a mean improvement in MHQ score (from 65% to 84%). Stratified by category, satisfaction improved from 64% to 88%, overall hand function increased from 64% to 81%, and pain was reduced from 60% to 25%, for pre- and post-operative values, respectively. One patient (2 wrists) required additional core decompressions in each wrist at one year following surgery but reported sustained improvement in her MHQ for both wrists at two years following her second core decompressions. There were no complications associated with the core decompressions, and there was no radiographic progression in the stage of the disease in any of the cases. Discussion: Osteonecrosis of the distal radius is rarely found in patients with this disease (< 1%). It can be found in patients with osteonecrosis of other joints who have a symptomatic wrist and may have more than one risk factor. It can be readily diagnosed with x-rays and/or MRI. The results of the present study suggest that core decompression is a safe and effective treatment modality for symptomatic osteonecrosis of the wrist at the distal radius and/or ulna. Although the level of improvement in MHQ varied for each case, all patients reported reduced pain and improved function at final follow-up without any apparent complications. Based on these results, we recommend the use of core decompressions to alleviate the symptoms and to possibly delay the progression of distal radius osteonecrosis