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Long-term outcomes of arthroscopic synovectomy and core decompression through multiple small bone holes for early-stage avascular necrosis of the femoral head

Long-term outcomes of arthroscopic synovectomy and core decompression through multiple small bone... Objective This study described a minimally invasive approach for the management of early-stage avascular necrosis of the femoral head, which integrated arthroscopic intra-articular decompression and core decompression by drilling multiple small holes. Method A total of 126 patients with 185 hip avascular necrosis were included between March 2005 and January 2008, and the hips were classified, based on the Association Research Circulation Osseous staging system, into stage I (n = 43), stage II (n = 114), and stage III (n = 28). Arthroscopic intra-articular inspection and debridement, along with drilling of multiple small holes for core decompression, were performed. The Modified Harris hip score system and radiographs were used to assess the pre- and post-surgery outcomes. Results One hundred and three patients (involving 153 hips) were followed up successfully for an average of 10.7 ± 3.4 years (range: 9–12 years). After surgery, the overall survival rate was 51.6% (79 hips), and the clinical survival rates were 79%, 72%, 52%, 32%, and 10% for patients with stage I, IIa, IIb, IIc, and III, respectively. The outcomes of patients with Association Research Circulation Osseous Stages I or IIA were better than those of other stages, while hips with a large necrotic area had poor results. This approach preserved the original biomechanical strength of the femoral head after core decompression and eliminated arthritis factors in the hip joint. Conclusion The core decompression with multiple small-size holes is an effective method for treating early-stage avascular necrosis of the femoral head, particularly in those with pathological changes in the hip joint. Level of evidence Therapeutic study, Level IV. Keywords Synovectomy, Core decompression, Avascular necrosis of femoral head, Hip Quanbo Ji and Xiaoya Li contributed equally to the work. Introduction Avascular necrosis (AVN) of the femoral head has *Correspondence: Guoqiang Zhang been one of the challenging research subjects [1–4]. zhanggq75@yeah.net Currently, core decompression of the hip represents the Department of Orthopaedics, General Hospital of Chinese People’s most common method for the treatment of early stage Liberation Army, Beijing 100853, China © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Ji et al. Arthroplasty (2023) 5:17 Page 2 of 8 AVN [5]. However, what is the optimal decompression of the People’s Liberation Army (Beijing, China) from technique remains controversial. March 2005 to January 2008. Our inclusion criteria The Association Research Circulation Osseous were (1) patients with early-stage AVN (ARCO stage (ARCO) classification is a commonly used staging I to III); (2) patients with either unilateral or bilateral system for the assessment of AVN of the femoral head. involvement; (3) symptomatic patients who complained The ARCO classifies ANV of the femoral head into stage of pain, stiffness or limited range of motion in the 0 to VI. Among them, stage I to III refer to the early affected joint, among others; (4) patients who had not stages of AVN with normal joint space and virtually undergone any previous surgical treatment for avascular normal femoral head. There are many femoral head- necrosis; (5) patients who were not contraindicated for preserving techniques, such as core decompression [6, the proposed intervention or treatment being studied; (6) 7], vascularized or non-vascularized bone grafting [8, patients who provided informed consent to participate 9], and osteotomy [10]. Smith et  al. [11] reviewed 12 in the study; (7) patients who were willing and able to articles (702 hips) published between 1979 and 1991 comply with the study protocol, including attending on core decompression for the early stages of AVN. follow-up appointments and completing study-related The successful rates of stage I, II, and III AVN were assessments and (4) patients who failed to complete the 78%, 62%, and 41%, respectively. However, the core entire follow-up. The study excluded patients with ARCO decompression techniques vary widely with surgical stage 0, as this stage typically involves asymptomatic approaches, the number of drill holes, and the diameter AVN that tends to be treated non-surgically. For patients of the trephine. Many publications support multiple with ARCO stage I, diagnosis was based on findings drilling as an appropriate core decompression alternative. of MRI and/or bone scintigraphy. Patients with ARCO Marker et  al. [12] reviewed 1337 core decompression stage II had radiographic evidence of sclerotic, cystic, operations before 1992 and 1268 operations after 1992. or osteoporotic changes in the femoral head. Those They found the survival rates increased from 59% (range, with ARCO stage III showed a subchondral fracture 29–85%) to 70% (range, 39–100%) after a mean follow-up on radiographs, often referred to as the "crescent sign". period of 38  months. However, the shortcomings of this Patients with ARCO stage IV radiographically showed conventional core decompression are the use of large- evidence of flattening of the femoral head, while those diameter trephine that weakens the supporting strength with ARCO stage V exhibited both flattening of the of the femoral head. It may overly damage the articular femoral head and osteoarthritic changes, such as cartilage when the trephine is inserted into the joint decreased joint space and acetabular changes. Finally, space [13, 14]. In addition, synovitis and synovial fluid patients with ARCO stage VI suffered from complete accumulation in the joint space may lead to further hip joint destruction. Patients with ARCO stage IV to VI pain because the pathological changes are left untreated were removed because a severe collapse of the femoral [15–17]. To improve the conventional techniques, we head could not be corrected/managed with minimally initially performed synovectomy, followed by core invasive treatments. Traumatic AVN was ruled out decompression through multiple small bone holes because assessment of the femoral head was probably created on the femoral head. We hypothesized that this difficult due to the anatomical changes. Finally, 126 combined procedure might yield more favorable clinical eligible patients (185 hips) were treated with arthroscopy- outcomes. assisted core decompression through multiple small bone This retrospective study aimed to use arthroscopic tunnels. AVN of the femoral head was staged by a senior synovectomy and core decompression for the orthopedic surgeon. All operations were performed by treatment of early-stage AVN of the femoral head. The the same surgical team. decompression was performed through multiple small bone holes created on the femoral head. We also assessed Surgical technique the long-term outcomes of the treatment. The operation was performed under general anesthesia. The supine position is preferred since it facilitates Materials and methods arthroscopy without entailing traction. We made three This project was a prospective single-arm case series portals, i.e., an anterior peri-trochanteric portal, a study, and was approved by the institutional review posterior peri-trochanteric portal, and a lateral portal boards of the hospitals involved. Informed consent and (2  cm proximal to the greater trochanter). Under Health Insurance Portability and Accountability Act fluoroscopic guidance, we introduced an 18 gauge, 25-cm consent were obtained from all the patients. long spinal needle from the lateral aspect of the hip into Recruited were 168 patients with AVN of the femoral the joint, parallel to the femoral neck. We injected 10 mL head who received treatment in the General Hospital of normal saline to expand the joint space and confirmed Ji  et al. Arthroplasty (2023) 5:17 Page 3 of 8 the needle position by checking continuous outflow. the joint. Using a 3-mm Steinmann pin, we made a drill The needle facilitated the introduction of a 0.8-mm hole in the AVN area. Under the fluoroscopic control to guide wire into the joint space, and the needle was then ensure proper placement, the surgeon then introduced withdrawn. We introduced a cannulated obturator with a a small drill or other instrument into the femoral head. 5-mm arthroscopy cannula over the guide wire. Then, an The instrument was used to remove a small core of bone anterolateral (or posterolateral) portal was created 2  cm from the center of the femoral head, creating a channel anterior (or posterior) to the lateral portal in the same for decompression. Under arthroscopic and fluoroscopic way. Other cannulae were introduced under fluoroscopic guidance, core decompression was performed either guidance. Then, a camera was introduced into the hip manually or by employing a low-speed power drill. joint from the portal. The synovium in the superolateral, This allowed for decompression of the necrotic bone lateral, and inferolateral regions and surrounding the and reduction of pressure within the femoral head. The acetabular fossa was removed from another portal procedure was performed arthroscopically to minimize as needed (Fig.  1A, B, C, D). The synovial debris was tissue trauma and allow for faster recovery. removed with 8000 mL of normal saline. A drainage tube was placed through one of the portals. Cartilage lesions Postoperative management of the femoral head and acetabulum were assessed Rehabilitation exercises such as abductor strengthening (Fig.  2A, B). The AVN area was located based on the and movement of the hip were encouraged two days after preoperative X-ray. The articular cartilage over the AVN surgery. The patients were required to bear half of the area was smoothed using the radio-frequency technique. body weight and walk with a cane or crutch held in the During the procedure, the surgeon first made a small contralateral hand. The patients undergoing bilateral core incision in the skin overlying the femoral head, and decompression walked with two crutches. Six weeks after then inserted an arthroscope to visualize the interior of surgery, full weight-bearing was allowed as tolerated. Fig. 1 Arthroscopic photos showing hip synovitis. A Synovial hypertrophy; B Hyperemia; C Hyperplasia; D Synovectomy is complete Ji et al. Arthroplasty (2023) 5:17 Page 4 of 8 Fig. 2 Arthroscopic photos of the right hip showing the cartilage lesions. A Acetabular cartilage damage; B Cartilage damage of femoral head However, high-impact loading movements such as [18]. The preoperative body mass index (BMI) was jumping and landing were restricted. If the patients measured. The identification of the different stages showed an asymptomatic hip and no radiographic of ARCO in the study is based on imaging scans. evidence of head collapse 3  months after surgery, all These imaging scans can provide detailed information usual activities, including high-impact loading activities, about the extent and severity of avascular necrosis were allowed. The primary endpoint is typically the in the femoral head, which can be used for staging preservation of the femoral head and the prevention of and grading against the ARCO classification system. the need for total hip replacement. Secondary endpoints Hip function was assessed in terms of the modified include pain relief, improved range of motion, and Harris Hip Score, with most limitations listed as 0 and functional status. The patient returned for follow-ups no limitations as 100 [19]. Hip pain during weight- 3 months, 6 months, and every year after surgery. X-rays bearing was assessed on a 10-mm visual analogue are useful for evaluating bone structure and detecting scale (VAS) (0  mm, no pain; 10  cm, worst pain) [20]. Hip synovitis was diagnosed on the basis of the changes in bone density. MRI, on the other hand, can intraoperative findings, including synovial hyperplasia, detect early changes in the bone and provide a more hypertrophy, hyperemia, and swelling, and the severity detailed view of the soft tissues surrounding the joint. was arthroscopically classified into grade I and II [21]. u Th s, X-rays or magnetic resonance imaging (MRI) were The extent of cartilage lesion of the femoral head and taken at the follow-up visits. acetabulum was categorized into grade I and II based on arthroscopic evaluation [22]. Failed surgery was Assessment defined as the need for secondary surgery or a modified The patient’s education level was rated, based on the HHS less than 75 points. Recurrence of head collapse International Standard Classification of Education, on or increased collapse of more than 2 mm on X-ray was a 0–8 scale, including low levels (0–3, early childhood also deemed a failure. "Overall survival rate" refers to education, primary education, and high school) and the percentage of patients who are still alive after a high levels (4–8, education beyond high school, certain period of time, typically measured in years, including bachelor’s, master’s, and doctoral degree) following the diagnosis or treatment of a particular Ji  et al. Arthroplasty (2023) 5:17 Page 5 of 8 disease or condition. On the other hand, "clinical Table 1 Demographics and preoperative characteristics of 126 patients (185 hips) survival rates" refer to the percentage of patients who are still alive after a certain period of time, typically Age, mean (range; year) 38 (17–58) measured in years, following the diagnosis or treatment Male: female (n) 95: 31 of a particular disease or condition. Right: left (n) 92: 93 Unilateral: bilateral involvement 89: 43 Statistical analysis Education level, n (%) We compared the preoperative and postoperative Harris Low 55 (44) Hip Scores of the hip using a paired t-test. Survivorship High 71 (56) analysis was performed by using the Kaplan–Meier Etiologic factors, n (hip) method. A P < 0.05 (two-tailed) was considered Alcohol abuse 53 (85) statistically significant. The analyses were carried out Steroid use 48 (70) using the SPSS version 22.0 (SPSS Inc, Chicago, IL, USA). Unknown causes 25 (30) Body mass index 26 ± 6.2 Results < 25, n (%) 43 (34) Our study recruited 126 patients (185 hips involved) 25–30, n (%) 65 (52) (Fig. 3), including 95 males and 31 females. The mean age > 30, n (%) 18 (14) at surgery was 38  years (range, 17–58  years) (Table  1). ARCO classification, hip (%) According to preoperative MRI, 43 hips were rated Stage I 43 (23) ARCO stage I, 114 stage II (114 hips), and 28 stage III. Stage II 114 (62) The mean preoperative modified HHS was 65.0 ± 10.1 Stage III 28 (15) and the mean VAS was 9.1 ± 0.5. Intraoperatively, hip Modified Harris Hip Score 65 ± 10.1 synovitis was found in 153 (83%) hips, and cartilage Visual analogue scale (mm) 9.1 ± 0.5 lesion of the femoral head in 51 hips (Table 2). No wound Data are shown as mean ± standard deviation infection, deep vein thrombosis, fracture developed and no revision decompression was performed. In our series, 23 patients (32 hips; including 9 completely followed up, in which 2 hips scored 80 points ARCO stage I, 15 stage II, and 8 stage III AVN) lost to on modified HHS scale and the daily activities were not follow-up. A total of 103 patients (153 hips) completed affected. Surgery failed in 74 hips, including 7, 49 and 18 the follow-ups, and the mean follow-up period lasted hips with ARCO stage I, II and III AVN, respectively. The 10.7 ± 3.4 years (range, 9–12 years).At the final follow-up, mean modified HHS was 70.15 ± 4.3, and the mean VAS the overall survival rate was 52% (79 hips) (Table  3). was 9.1 ± 0.5. There were significant differences between The clinical survival rates of stage I, IIa, IIb, IIc, and III preoperative and postoperative modified HHS (P = 0.02) AVN were 79%, 72%, 52%, 32%, and 10%, respectively and VAS (P = 0.01). (Table  4). All 20 hips with ARCO stage III AVN were Fig. 3 Flow diagram of 168 patients with avascular necrosis of the femoral head Ji et al. Arthroplasty (2023) 5:17 Page 6 of 8 Table 2 Intraoperative findings in 126 patients (185 hips) Table 5 Comparison of modified Harris Hip Scores (categorized by the ARCO) measured preoperatively and at the last follow-up Synovitis: No Synovitis, Hip ARCO Time Modified HHS t P Value Stage I 19: 24 Stage II 52: 31 Stage I Before operation 70.15 ± 4.3 -18.88 < 0.01 Stage III 28: 0 Last follow-up 93.33 ± 5.92 Synovitis Severity, Hip (%) Stage II Before operation 68.5 ± 8.3 -14.73 < 0.01 Grade I 86 (46) Last follow-up 87.3 ± 5.5 Grade II 67 (36) Stage III Before operation 56.7 ± 11.2 -7.03 < 0.01 Cartilage Lesion of Femoral Head, Hip (%) Last follow-up 84.4 ± 7.8 Grade I 22 (11) ARCO Association Research Circulation Osseous, HHS Harris Hip Score; Data are Grade II 29 (16) shown as mean ± standard deviation Stage II 23 (12) Stage III 28 (15) treatments (34 hips) failed within 5 years, and the failure Acetabular Cartilage Lesion, Hip (%) 51 (27) rate decreased rapidly thereafter. Secondary total hip Intraoperative findings in Association Research Circulation Osseous (ARCO) replacement was performed in 29 hips, and vascularized stage I to III bone grafting in 5 hips. The remaining 7 patients (10 hips) declined to receive a second surgery due to the cost-related concern. Table 3 Outcomes of 103 patients (153 hips) at the final follow-up Discussion Follow-up, mean (range), year 10.7 ± 3.4 (9–12) In this study, the intra-articular decompression through Modified Harris Hip Score 70.15 ± 4.3 hip arthroscope plus core decompression by drilling Visual analogue scale (mm) 9.1 ± 0.5 multiple small holes was found to be an effective method Survival rate, hip (%) 79 (51) for treating early-stage avascular necrosis of the femoral Data are shown as mean ± standard deviation head, particularly in those with pathological changes in the hip joint. AVN of the femoral head is a condition where the blood Table 4 Clinical and radiographic outcomes categorized by supply to the femoral head is reduced. The condition the Association Research Circulation Osseous (ARCO) stage of might result from traumatic or non-traumatic factors and avascular necrosis eventually leads to the collapse of the femoral head [1, Stage I IIa IIb IIc III 23, 24]. Furthermore, AVN of the femoral head is linked to pathological synovial reaction, hypertrophy, effusion, Hip undergoing surgery (n) 43 33 41 40 28 and an increase in intra-articular pressure [2, 4, 25–28]. Hip at the last follow up (n) 34 28 35 36 20 To understand the correlation between intra-articular Clinical survival (n) 27 20 18 12 2 pressure of the hip joint and blood flow to the femoral Clinical failure head in animal models, a microsphere of radioactively- Modified Harris Hip Score < 75 (n) 2 4 7 8 9 labeled red cells was used. Additionally, the extent of Secondary surgery (n) 5 4 10 16 9 blood supply to the femoral head was quantitatively Clinical survival rate (%) 79 72 52 32 10 assessed using the hydrogen washout technique. The Radiographic survival (n) 24 20 16 8 2 results revealed a positive correlation between the Radiographic failure increased intra-articular and intra-osseous pressure, Additional collapse (n) 5 4 9 12 9 which led to a reduced blood flow to the femoral head. Secondary surgery (n) 5 4 10 16 9 The data provided evidence that lowering the intra- Radiographic survival rate (%) 71 72 45 23 10 articular and intra-osseous pressure might be a treatment option for AVN. The ARCO system is based on the extent of AVN in The modified HHSs categorized by the stages of the femoral head, as determined by imaging studies AVN are shown in Table  5. Synovial fluid accumulation such as MRI or CT scans. The system assigns a stage improved significantly on MRI. The necrotic area of the to a patient based on the size of the necrotic lesion, the femoral head was minimized, and the edema alleviated. location of the lesion within the femoral head, and the Treatment failures due to aggressive collapse (> 2 mm) presence or absence of subchondral collapse. The system happened in 30 patients (44 hips). Among them, most Ji  et al. Arthroplasty (2023) 5:17 Page 7 of 8 accomplished under arthroscopic guidance. Ruch et  al. also contains a grading system to rate the severity of the reported favorable outcomes using hip arthroscopy disease on the basis the degree of subchondral collapse to guide the placement of core decompression in and the extent of femoral head involvement. In this study, the hip [32]. In this study, our result suggested that we chose the ARCO system for several reasons. First, the the arthroscopic intra-articular decompression in ARCO system is widely recognized and used by clinicians combination with core decompression using multiple and researchers to classify and stage AVN, which renders small drill holes could effectively reduce pressure on the it easier to compare results across studies. Second, femoral head, thus preserving its structural integrity and the ARCO system provides a standardized method for obviating collapse. evaluating the extent and severity of AVN, which informs Our study has several limitations that need to be treatment decisions and outcome prediction. Finally, the addressed. Firstly, we didn’t compare arthroscopic intra- ARCO system is relatively easy to use and applicable to articular decompression and drilling decompression most imaging studies, which makes it a practical tool for using conventional surgical techniques such as Kirschner clinical research. wire for avascular necrosis of femoral head. Further While hip arthroscopy was first introduced in 1931, its research is warranted to make such comparison. extensive application has been hampered by the difficult Secondly, due to the large number of patients, the accessibility of the hip joint. With advances in surgical surgeries were performed by the same surgical team technique and instruments, the procedure has become but not by the same surgeon. Hence, the effect of the increasingly doable and feasible for surgeons. As a result, techniques might be influenced by surgeons’ preference, hip arthroscopy has gained popularity in recent years, experience, and operative skills. Additionally, a long-term consistently accomplishing better clinical outcomes [14, follow-up and a larger sample size are needed to identify 16, 29, 30]. Our clinical case series demonstrated that the functions and complications associated with this hip arthroscopy allows clinicians to comprehensively surgical technique.  evaluate the hip joint, thereby facilitating the removal of all inflamed synovial tissues by washing. This approach especially benefited patients who exhibited noticeable synovitis in the hip joint. Our study yielded better clinical Conclusion outcomes when compared to previous reports. The combination of arthroscopic synovectomy and core Opening channels for re-vascularization of the femoral decompression through multiple small bone holes is a head via core decompression has been seen as a working safe and efficacious surgical technique for the treatment strategy for decreasing intra-osseous pressure in the of early stages of AVN of femoral head, and might achieve initial stage of AVN [6, 31]. Arthroscopic intra-articular favorable long-term outcomes. decompression prevents femoral head collapse by Acknowledgements removing loose bodies and debris from the joint space. We thank Yujie Liu, Zhongli Li, Wei Chai, Patrick Shu-Hang Yung, Pauline Po-Yee This procedure involves the use of a small camera to Lui, Kaiming Chan for their help during this research. visualize the hip joint’s interior and remove any damaged Authors’ contributions or diseased tissue, which can mitigate inflammation Q.J. and G.Z. participated in the performance of the operations. Q.Z. and promote healing. Additionally, removing debris can completed the measurement work. Q.J. and G.Z. wrote the manuscript. X.L., S.L., L.G., M.N., P.X. and P.R. performed the statistical analysis. G.Z. conceived the enlarge the joint space, thus reducing pressure on the idea of the study. All authors contributed to the writing of the manuscript and femoral head. Due to the femoral head’s spherical shape, approved the final manuscript. the extent of core decompression under arthroscopic Funding control cannot be accurately assessed without intra- This study was supported by the National Natural Science Foundation articular monitoring. Lin et  al. conducted a study using of China (82272558, 81472094, 81902250) and Beijing Nova Program a fresh adult cadaveric femur specimen to investigate (Z201100006820132). the impact of drilling holes of different diameters on the Availability of data and materials structural properties of femoral head. They found that All data and materials are available on reasonable request. larger pore diameter and single tract core decompression could significantly weaken the femoral head. On the Declarations other hand, the use of multiple small diameter (2.5– Ethics approval and consent to participate 3.0  mm) low-speed drillings could equally achieve Ethical approval was obtained from the local ethical committee of the core decompression and opening of vascular channels Chinese PLA General Hospital, Beijing China. All procedures performed were while preserving the biomechanical strength of the in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later femoral head. However, the precise placement of the amendments or comparable ethical standards. drillings without penetrating the cortex could only be Ji et al. Arthroplasty (2023) 5:17 Page 8 of 8 Consent for publication associations of education and occupation with cognitive ability in older All authors read and approved the final manuscript, and consented to age. BMC Geriatr. 2021;21(1):346. publication. 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Long-term outcomes of arthroscopic synovectomy and core decompression through multiple small bone holes for early-stage avascular necrosis of the femoral head

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Springer Journals
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Copyright © The Author(s) 2023
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2524-7948
DOI
10.1186/s42836-023-00181-8
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Abstract

Objective This study described a minimally invasive approach for the management of early-stage avascular necrosis of the femoral head, which integrated arthroscopic intra-articular decompression and core decompression by drilling multiple small holes. Method A total of 126 patients with 185 hip avascular necrosis were included between March 2005 and January 2008, and the hips were classified, based on the Association Research Circulation Osseous staging system, into stage I (n = 43), stage II (n = 114), and stage III (n = 28). Arthroscopic intra-articular inspection and debridement, along with drilling of multiple small holes for core decompression, were performed. The Modified Harris hip score system and radiographs were used to assess the pre- and post-surgery outcomes. Results One hundred and three patients (involving 153 hips) were followed up successfully for an average of 10.7 ± 3.4 years (range: 9–12 years). After surgery, the overall survival rate was 51.6% (79 hips), and the clinical survival rates were 79%, 72%, 52%, 32%, and 10% for patients with stage I, IIa, IIb, IIc, and III, respectively. The outcomes of patients with Association Research Circulation Osseous Stages I or IIA were better than those of other stages, while hips with a large necrotic area had poor results. This approach preserved the original biomechanical strength of the femoral head after core decompression and eliminated arthritis factors in the hip joint. Conclusion The core decompression with multiple small-size holes is an effective method for treating early-stage avascular necrosis of the femoral head, particularly in those with pathological changes in the hip joint. Level of evidence Therapeutic study, Level IV. Keywords Synovectomy, Core decompression, Avascular necrosis of femoral head, Hip Quanbo Ji and Xiaoya Li contributed equally to the work. Introduction Avascular necrosis (AVN) of the femoral head has *Correspondence: Guoqiang Zhang been one of the challenging research subjects [1–4]. zhanggq75@yeah.net Currently, core decompression of the hip represents the Department of Orthopaedics, General Hospital of Chinese People’s most common method for the treatment of early stage Liberation Army, Beijing 100853, China © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Ji et al. Arthroplasty (2023) 5:17 Page 2 of 8 AVN [5]. However, what is the optimal decompression of the People’s Liberation Army (Beijing, China) from technique remains controversial. March 2005 to January 2008. Our inclusion criteria The Association Research Circulation Osseous were (1) patients with early-stage AVN (ARCO stage (ARCO) classification is a commonly used staging I to III); (2) patients with either unilateral or bilateral system for the assessment of AVN of the femoral head. involvement; (3) symptomatic patients who complained The ARCO classifies ANV of the femoral head into stage of pain, stiffness or limited range of motion in the 0 to VI. Among them, stage I to III refer to the early affected joint, among others; (4) patients who had not stages of AVN with normal joint space and virtually undergone any previous surgical treatment for avascular normal femoral head. There are many femoral head- necrosis; (5) patients who were not contraindicated for preserving techniques, such as core decompression [6, the proposed intervention or treatment being studied; (6) 7], vascularized or non-vascularized bone grafting [8, patients who provided informed consent to participate 9], and osteotomy [10]. Smith et  al. [11] reviewed 12 in the study; (7) patients who were willing and able to articles (702 hips) published between 1979 and 1991 comply with the study protocol, including attending on core decompression for the early stages of AVN. follow-up appointments and completing study-related The successful rates of stage I, II, and III AVN were assessments and (4) patients who failed to complete the 78%, 62%, and 41%, respectively. However, the core entire follow-up. The study excluded patients with ARCO decompression techniques vary widely with surgical stage 0, as this stage typically involves asymptomatic approaches, the number of drill holes, and the diameter AVN that tends to be treated non-surgically. For patients of the trephine. Many publications support multiple with ARCO stage I, diagnosis was based on findings drilling as an appropriate core decompression alternative. of MRI and/or bone scintigraphy. Patients with ARCO Marker et  al. [12] reviewed 1337 core decompression stage II had radiographic evidence of sclerotic, cystic, operations before 1992 and 1268 operations after 1992. or osteoporotic changes in the femoral head. Those They found the survival rates increased from 59% (range, with ARCO stage III showed a subchondral fracture 29–85%) to 70% (range, 39–100%) after a mean follow-up on radiographs, often referred to as the "crescent sign". period of 38  months. However, the shortcomings of this Patients with ARCO stage IV radiographically showed conventional core decompression are the use of large- evidence of flattening of the femoral head, while those diameter trephine that weakens the supporting strength with ARCO stage V exhibited both flattening of the of the femoral head. It may overly damage the articular femoral head and osteoarthritic changes, such as cartilage when the trephine is inserted into the joint decreased joint space and acetabular changes. Finally, space [13, 14]. In addition, synovitis and synovial fluid patients with ARCO stage VI suffered from complete accumulation in the joint space may lead to further hip joint destruction. Patients with ARCO stage IV to VI pain because the pathological changes are left untreated were removed because a severe collapse of the femoral [15–17]. To improve the conventional techniques, we head could not be corrected/managed with minimally initially performed synovectomy, followed by core invasive treatments. Traumatic AVN was ruled out decompression through multiple small bone holes because assessment of the femoral head was probably created on the femoral head. We hypothesized that this difficult due to the anatomical changes. Finally, 126 combined procedure might yield more favorable clinical eligible patients (185 hips) were treated with arthroscopy- outcomes. assisted core decompression through multiple small bone This retrospective study aimed to use arthroscopic tunnels. AVN of the femoral head was staged by a senior synovectomy and core decompression for the orthopedic surgeon. All operations were performed by treatment of early-stage AVN of the femoral head. The the same surgical team. decompression was performed through multiple small bone holes created on the femoral head. We also assessed Surgical technique the long-term outcomes of the treatment. The operation was performed under general anesthesia. The supine position is preferred since it facilitates Materials and methods arthroscopy without entailing traction. We made three This project was a prospective single-arm case series portals, i.e., an anterior peri-trochanteric portal, a study, and was approved by the institutional review posterior peri-trochanteric portal, and a lateral portal boards of the hospitals involved. Informed consent and (2  cm proximal to the greater trochanter). Under Health Insurance Portability and Accountability Act fluoroscopic guidance, we introduced an 18 gauge, 25-cm consent were obtained from all the patients. long spinal needle from the lateral aspect of the hip into Recruited were 168 patients with AVN of the femoral the joint, parallel to the femoral neck. We injected 10 mL head who received treatment in the General Hospital of normal saline to expand the joint space and confirmed Ji  et al. Arthroplasty (2023) 5:17 Page 3 of 8 the needle position by checking continuous outflow. the joint. Using a 3-mm Steinmann pin, we made a drill The needle facilitated the introduction of a 0.8-mm hole in the AVN area. Under the fluoroscopic control to guide wire into the joint space, and the needle was then ensure proper placement, the surgeon then introduced withdrawn. We introduced a cannulated obturator with a a small drill or other instrument into the femoral head. 5-mm arthroscopy cannula over the guide wire. Then, an The instrument was used to remove a small core of bone anterolateral (or posterolateral) portal was created 2  cm from the center of the femoral head, creating a channel anterior (or posterior) to the lateral portal in the same for decompression. Under arthroscopic and fluoroscopic way. Other cannulae were introduced under fluoroscopic guidance, core decompression was performed either guidance. Then, a camera was introduced into the hip manually or by employing a low-speed power drill. joint from the portal. The synovium in the superolateral, This allowed for decompression of the necrotic bone lateral, and inferolateral regions and surrounding the and reduction of pressure within the femoral head. The acetabular fossa was removed from another portal procedure was performed arthroscopically to minimize as needed (Fig.  1A, B, C, D). The synovial debris was tissue trauma and allow for faster recovery. removed with 8000 mL of normal saline. A drainage tube was placed through one of the portals. Cartilage lesions Postoperative management of the femoral head and acetabulum were assessed Rehabilitation exercises such as abductor strengthening (Fig.  2A, B). The AVN area was located based on the and movement of the hip were encouraged two days after preoperative X-ray. The articular cartilage over the AVN surgery. The patients were required to bear half of the area was smoothed using the radio-frequency technique. body weight and walk with a cane or crutch held in the During the procedure, the surgeon first made a small contralateral hand. The patients undergoing bilateral core incision in the skin overlying the femoral head, and decompression walked with two crutches. Six weeks after then inserted an arthroscope to visualize the interior of surgery, full weight-bearing was allowed as tolerated. Fig. 1 Arthroscopic photos showing hip synovitis. A Synovial hypertrophy; B Hyperemia; C Hyperplasia; D Synovectomy is complete Ji et al. Arthroplasty (2023) 5:17 Page 4 of 8 Fig. 2 Arthroscopic photos of the right hip showing the cartilage lesions. A Acetabular cartilage damage; B Cartilage damage of femoral head However, high-impact loading movements such as [18]. The preoperative body mass index (BMI) was jumping and landing were restricted. If the patients measured. The identification of the different stages showed an asymptomatic hip and no radiographic of ARCO in the study is based on imaging scans. evidence of head collapse 3  months after surgery, all These imaging scans can provide detailed information usual activities, including high-impact loading activities, about the extent and severity of avascular necrosis were allowed. The primary endpoint is typically the in the femoral head, which can be used for staging preservation of the femoral head and the prevention of and grading against the ARCO classification system. the need for total hip replacement. Secondary endpoints Hip function was assessed in terms of the modified include pain relief, improved range of motion, and Harris Hip Score, with most limitations listed as 0 and functional status. The patient returned for follow-ups no limitations as 100 [19]. Hip pain during weight- 3 months, 6 months, and every year after surgery. X-rays bearing was assessed on a 10-mm visual analogue are useful for evaluating bone structure and detecting scale (VAS) (0  mm, no pain; 10  cm, worst pain) [20]. Hip synovitis was diagnosed on the basis of the changes in bone density. MRI, on the other hand, can intraoperative findings, including synovial hyperplasia, detect early changes in the bone and provide a more hypertrophy, hyperemia, and swelling, and the severity detailed view of the soft tissues surrounding the joint. was arthroscopically classified into grade I and II [21]. u Th s, X-rays or magnetic resonance imaging (MRI) were The extent of cartilage lesion of the femoral head and taken at the follow-up visits. acetabulum was categorized into grade I and II based on arthroscopic evaluation [22]. Failed surgery was Assessment defined as the need for secondary surgery or a modified The patient’s education level was rated, based on the HHS less than 75 points. Recurrence of head collapse International Standard Classification of Education, on or increased collapse of more than 2 mm on X-ray was a 0–8 scale, including low levels (0–3, early childhood also deemed a failure. "Overall survival rate" refers to education, primary education, and high school) and the percentage of patients who are still alive after a high levels (4–8, education beyond high school, certain period of time, typically measured in years, including bachelor’s, master’s, and doctoral degree) following the diagnosis or treatment of a particular Ji  et al. Arthroplasty (2023) 5:17 Page 5 of 8 disease or condition. On the other hand, "clinical Table 1 Demographics and preoperative characteristics of 126 patients (185 hips) survival rates" refer to the percentage of patients who are still alive after a certain period of time, typically Age, mean (range; year) 38 (17–58) measured in years, following the diagnosis or treatment Male: female (n) 95: 31 of a particular disease or condition. Right: left (n) 92: 93 Unilateral: bilateral involvement 89: 43 Statistical analysis Education level, n (%) We compared the preoperative and postoperative Harris Low 55 (44) Hip Scores of the hip using a paired t-test. Survivorship High 71 (56) analysis was performed by using the Kaplan–Meier Etiologic factors, n (hip) method. A P < 0.05 (two-tailed) was considered Alcohol abuse 53 (85) statistically significant. The analyses were carried out Steroid use 48 (70) using the SPSS version 22.0 (SPSS Inc, Chicago, IL, USA). Unknown causes 25 (30) Body mass index 26 ± 6.2 Results < 25, n (%) 43 (34) Our study recruited 126 patients (185 hips involved) 25–30, n (%) 65 (52) (Fig. 3), including 95 males and 31 females. The mean age > 30, n (%) 18 (14) at surgery was 38  years (range, 17–58  years) (Table  1). ARCO classification, hip (%) According to preoperative MRI, 43 hips were rated Stage I 43 (23) ARCO stage I, 114 stage II (114 hips), and 28 stage III. Stage II 114 (62) The mean preoperative modified HHS was 65.0 ± 10.1 Stage III 28 (15) and the mean VAS was 9.1 ± 0.5. Intraoperatively, hip Modified Harris Hip Score 65 ± 10.1 synovitis was found in 153 (83%) hips, and cartilage Visual analogue scale (mm) 9.1 ± 0.5 lesion of the femoral head in 51 hips (Table 2). No wound Data are shown as mean ± standard deviation infection, deep vein thrombosis, fracture developed and no revision decompression was performed. In our series, 23 patients (32 hips; including 9 completely followed up, in which 2 hips scored 80 points ARCO stage I, 15 stage II, and 8 stage III AVN) lost to on modified HHS scale and the daily activities were not follow-up. A total of 103 patients (153 hips) completed affected. Surgery failed in 74 hips, including 7, 49 and 18 the follow-ups, and the mean follow-up period lasted hips with ARCO stage I, II and III AVN, respectively. The 10.7 ± 3.4 years (range, 9–12 years).At the final follow-up, mean modified HHS was 70.15 ± 4.3, and the mean VAS the overall survival rate was 52% (79 hips) (Table  3). was 9.1 ± 0.5. There were significant differences between The clinical survival rates of stage I, IIa, IIb, IIc, and III preoperative and postoperative modified HHS (P = 0.02) AVN were 79%, 72%, 52%, 32%, and 10%, respectively and VAS (P = 0.01). (Table  4). All 20 hips with ARCO stage III AVN were Fig. 3 Flow diagram of 168 patients with avascular necrosis of the femoral head Ji et al. Arthroplasty (2023) 5:17 Page 6 of 8 Table 2 Intraoperative findings in 126 patients (185 hips) Table 5 Comparison of modified Harris Hip Scores (categorized by the ARCO) measured preoperatively and at the last follow-up Synovitis: No Synovitis, Hip ARCO Time Modified HHS t P Value Stage I 19: 24 Stage II 52: 31 Stage I Before operation 70.15 ± 4.3 -18.88 < 0.01 Stage III 28: 0 Last follow-up 93.33 ± 5.92 Synovitis Severity, Hip (%) Stage II Before operation 68.5 ± 8.3 -14.73 < 0.01 Grade I 86 (46) Last follow-up 87.3 ± 5.5 Grade II 67 (36) Stage III Before operation 56.7 ± 11.2 -7.03 < 0.01 Cartilage Lesion of Femoral Head, Hip (%) Last follow-up 84.4 ± 7.8 Grade I 22 (11) ARCO Association Research Circulation Osseous, HHS Harris Hip Score; Data are Grade II 29 (16) shown as mean ± standard deviation Stage II 23 (12) Stage III 28 (15) treatments (34 hips) failed within 5 years, and the failure Acetabular Cartilage Lesion, Hip (%) 51 (27) rate decreased rapidly thereafter. Secondary total hip Intraoperative findings in Association Research Circulation Osseous (ARCO) replacement was performed in 29 hips, and vascularized stage I to III bone grafting in 5 hips. The remaining 7 patients (10 hips) declined to receive a second surgery due to the cost-related concern. Table 3 Outcomes of 103 patients (153 hips) at the final follow-up Discussion Follow-up, mean (range), year 10.7 ± 3.4 (9–12) In this study, the intra-articular decompression through Modified Harris Hip Score 70.15 ± 4.3 hip arthroscope plus core decompression by drilling Visual analogue scale (mm) 9.1 ± 0.5 multiple small holes was found to be an effective method Survival rate, hip (%) 79 (51) for treating early-stage avascular necrosis of the femoral Data are shown as mean ± standard deviation head, particularly in those with pathological changes in the hip joint. AVN of the femoral head is a condition where the blood Table 4 Clinical and radiographic outcomes categorized by supply to the femoral head is reduced. The condition the Association Research Circulation Osseous (ARCO) stage of might result from traumatic or non-traumatic factors and avascular necrosis eventually leads to the collapse of the femoral head [1, Stage I IIa IIb IIc III 23, 24]. Furthermore, AVN of the femoral head is linked to pathological synovial reaction, hypertrophy, effusion, Hip undergoing surgery (n) 43 33 41 40 28 and an increase in intra-articular pressure [2, 4, 25–28]. Hip at the last follow up (n) 34 28 35 36 20 To understand the correlation between intra-articular Clinical survival (n) 27 20 18 12 2 pressure of the hip joint and blood flow to the femoral Clinical failure head in animal models, a microsphere of radioactively- Modified Harris Hip Score < 75 (n) 2 4 7 8 9 labeled red cells was used. Additionally, the extent of Secondary surgery (n) 5 4 10 16 9 blood supply to the femoral head was quantitatively Clinical survival rate (%) 79 72 52 32 10 assessed using the hydrogen washout technique. The Radiographic survival (n) 24 20 16 8 2 results revealed a positive correlation between the Radiographic failure increased intra-articular and intra-osseous pressure, Additional collapse (n) 5 4 9 12 9 which led to a reduced blood flow to the femoral head. Secondary surgery (n) 5 4 10 16 9 The data provided evidence that lowering the intra- Radiographic survival rate (%) 71 72 45 23 10 articular and intra-osseous pressure might be a treatment option for AVN. The ARCO system is based on the extent of AVN in The modified HHSs categorized by the stages of the femoral head, as determined by imaging studies AVN are shown in Table  5. Synovial fluid accumulation such as MRI or CT scans. The system assigns a stage improved significantly on MRI. The necrotic area of the to a patient based on the size of the necrotic lesion, the femoral head was minimized, and the edema alleviated. location of the lesion within the femoral head, and the Treatment failures due to aggressive collapse (> 2 mm) presence or absence of subchondral collapse. The system happened in 30 patients (44 hips). Among them, most Ji  et al. Arthroplasty (2023) 5:17 Page 7 of 8 accomplished under arthroscopic guidance. Ruch et  al. also contains a grading system to rate the severity of the reported favorable outcomes using hip arthroscopy disease on the basis the degree of subchondral collapse to guide the placement of core decompression in and the extent of femoral head involvement. In this study, the hip [32]. In this study, our result suggested that we chose the ARCO system for several reasons. First, the the arthroscopic intra-articular decompression in ARCO system is widely recognized and used by clinicians combination with core decompression using multiple and researchers to classify and stage AVN, which renders small drill holes could effectively reduce pressure on the it easier to compare results across studies. Second, femoral head, thus preserving its structural integrity and the ARCO system provides a standardized method for obviating collapse. evaluating the extent and severity of AVN, which informs Our study has several limitations that need to be treatment decisions and outcome prediction. Finally, the addressed. Firstly, we didn’t compare arthroscopic intra- ARCO system is relatively easy to use and applicable to articular decompression and drilling decompression most imaging studies, which makes it a practical tool for using conventional surgical techniques such as Kirschner clinical research. wire for avascular necrosis of femoral head. Further While hip arthroscopy was first introduced in 1931, its research is warranted to make such comparison. extensive application has been hampered by the difficult Secondly, due to the large number of patients, the accessibility of the hip joint. With advances in surgical surgeries were performed by the same surgical team technique and instruments, the procedure has become but not by the same surgeon. Hence, the effect of the increasingly doable and feasible for surgeons. As a result, techniques might be influenced by surgeons’ preference, hip arthroscopy has gained popularity in recent years, experience, and operative skills. Additionally, a long-term consistently accomplishing better clinical outcomes [14, follow-up and a larger sample size are needed to identify 16, 29, 30]. Our clinical case series demonstrated that the functions and complications associated with this hip arthroscopy allows clinicians to comprehensively surgical technique.  evaluate the hip joint, thereby facilitating the removal of all inflamed synovial tissues by washing. This approach especially benefited patients who exhibited noticeable synovitis in the hip joint. Our study yielded better clinical Conclusion outcomes when compared to previous reports. The combination of arthroscopic synovectomy and core Opening channels for re-vascularization of the femoral decompression through multiple small bone holes is a head via core decompression has been seen as a working safe and efficacious surgical technique for the treatment strategy for decreasing intra-osseous pressure in the of early stages of AVN of femoral head, and might achieve initial stage of AVN [6, 31]. Arthroscopic intra-articular favorable long-term outcomes. decompression prevents femoral head collapse by Acknowledgements removing loose bodies and debris from the joint space. We thank Yujie Liu, Zhongli Li, Wei Chai, Patrick Shu-Hang Yung, Pauline Po-Yee This procedure involves the use of a small camera to Lui, Kaiming Chan for their help during this research. visualize the hip joint’s interior and remove any damaged Authors’ contributions or diseased tissue, which can mitigate inflammation Q.J. and G.Z. participated in the performance of the operations. Q.Z. and promote healing. Additionally, removing debris can completed the measurement work. Q.J. and G.Z. wrote the manuscript. X.L., S.L., L.G., M.N., P.X. and P.R. performed the statistical analysis. G.Z. conceived the enlarge the joint space, thus reducing pressure on the idea of the study. All authors contributed to the writing of the manuscript and femoral head. Due to the femoral head’s spherical shape, approved the final manuscript. the extent of core decompression under arthroscopic Funding control cannot be accurately assessed without intra- This study was supported by the National Natural Science Foundation articular monitoring. Lin et  al. conducted a study using of China (82272558, 81472094, 81902250) and Beijing Nova Program a fresh adult cadaveric femur specimen to investigate (Z201100006820132). the impact of drilling holes of different diameters on the Availability of data and materials structural properties of femoral head. They found that All data and materials are available on reasonable request. larger pore diameter and single tract core decompression could significantly weaken the femoral head. On the Declarations other hand, the use of multiple small diameter (2.5– Ethics approval and consent to participate 3.0  mm) low-speed drillings could equally achieve Ethical approval was obtained from the local ethical committee of the core decompression and opening of vascular channels Chinese PLA General Hospital, Beijing China. All procedures performed were while preserving the biomechanical strength of the in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later femoral head. However, the precise placement of the amendments or comparable ethical standards. drillings without penetrating the cortex could only be Ji et al. Arthroplasty (2023) 5:17 Page 8 of 8 Consent for publication associations of education and occupation with cognitive ability in older All authors read and approved the final manuscript, and consented to age. BMC Geriatr. 2021;21(1):346. publication. 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Journal

Arthroplasty – Springer Journals

Published: Apr 1, 2023

Keywords: Synovectomy; Core decompression; Avascular necrosis of femoral head; Hip

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