Predictors of Core Decompression Success in Patients with Femoral Head Avascular Necrosis

Document Type : RESEARCH PAPER

Authors

Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran

Abstract

Background: Avascular necrosis of the femoral head typically occurs in the young population. Core decompression 
in the precollapse stage provides pain relief and preservation of the femoral head. The results of core decompression 
vary considerably despite the early diagnosis. Clinicians concur that primary treatment should focus on preserving the 
natural surface of the joint. This study investigated the predictive risk factors of failure in femoral head decompression.
Methods: We retrospectively reviewed 135 patients and 207 hips (77 male (127 hips) and 58 female (80 hips)) who 
underwent core decompression (mean age: 34.7 years [age range: 21-71]) from April 2010 to December 2017. All 
patients were followed by a mean of 57 months. All hips were in the precollapse stage (Ficat I, II). 
Results: A total of 207 hips were treated with core decompression surgery, and the overall success rate was 58%. 
The higher grade of Kerboul, Ficat, ARCO classifications, multifocal avascular necrosis of the femoral head, smoking, 
opium, and corticosteroids were significantly associated with a higher failure rate after core decompression in univariate 
analysis. In multivariate logistic regression analysis, the Kerboul and Ficat classifications, alcohol consumption, and 
multifocal avascular necrosis of the femoral head were significantly correlated with core decompression failure. The 
most common predictive factors in core decompression failure were Ficat II, Kerboul stage 3, multifocal avascular 
necrosis of the femoral head, and alcohol consumption. 
Conclusion: In conclusion, we had an overall 58 % success rate in core decompression of femoral head avascular 
necrosis. Based on the results of this study, imaging evaluation and imaging-based classifications are the most valuable 
predictor factors for the success of core decompression. Consistent with previous reports, corticosteroid was not a 
significant predictor of core decompression failure.
Level of evidence: III

Keywords

Main Subjects


1. Lieberman JR, Berry DJ, Montv MA, et al. Osteonecrosis 
of the Hip: Management in the Twenty-first Century. 
JBJS. 2002;84(5):834-53.
2. Mont MA, Jones LC, Hungerford DS. Nontraumatic 
osteonecrosis of the femoral head: ten years 
later. J Bone Joint Surg Am. 2006;88(5):1117-32. 
doi:10.2106/jbjs.E.01041
3. Mont MA, Ragland PS, Etienne G. Core decompression 
of the femoral head for osteonecrosis using 
percutaneous multiple small-diameter drilling. Clin 
Orthop Relat Res. 2004;(429):131-8. doi:10.1097/01.
blo.0000150128.57777.8e
4. Yu X, Zhang D, Chen X, Yang J, Shi L, Pang Q. 
Effectiveness of various hip preservation treatments 
for non-traumatic osteonecrosis of the femoral 
head: A network meta-analysis of randomized 
controlled trials. J Orthop Sci. 2018;23(2):356-364. 
doi:10.1016/j.jos.2017.12.004
5. Jamshidi MM, Moharrami A, Sharifpour S, Mafi AR, 
Mortazavi SJ. The Role of Spinopelvic Parameters 
in Total Hip Arthroplasty: A Current Concept 
Review. Journal of Orthopedic and Spine Trauma. 
2022;8(2):40-3.doi:10.18502/jost.v8i2.9308
6. Mirghaderi SP, Sharifpour S, Moharrami A, et al. 
Determining the accuracy of preoperative total hip 
replacement 2D templating using the mediCAD® 
software. J Orthop Surg Res. 2022 Apr 10;17(1):222.
doi:10.1186/s13018-022-03086-5
7. Mortazavi SMJ, Ghadimi E, Ardakani MV, et al. Risk 
factors of dislocation after total hip arthroplasty in 
patients with developmental dysplasia of the hip. Int 
Orthop. 2022;46(4):749-759. doi: 10.1007/s00264-
021-05294-w.
8. Mirghaderi SP, Baghdadi S, Salimi M, Shafiei SH. 
Scientometric Analysis of the Top 50 Most-Cited 
Joint Arthroplasty Papers: Traditional vs Altmetric 
Measures. Arthroplast Today.2022;15:81-92. doi: 
10.1016/j.artd.2022.03.001.
9. Mirghaderi SP, Hoveidaei AH, Sheikhbahaei E, 
Motififard M, Moradi N, Moradi M. Femoral Stem 
Dislocation Caused by Trunnionosis Along with 
Adverse Local Tissue Reaction; A Case Report and 
a New Technique of Head to Cone Cementing. Arch 
Bone Jt Surg.2022;10(10):911-915. doi: 10.22038/
ABJS.2022.61214.3005.
10.Mirghaderi SP, Raeini AG, Gholamshahi H, Mortazavi 
SMJ, Shafiei SH, Sheikhvatan M. Content Validity and 
Reliability of the Persian Version of the Forgotten Joint 
Score Questionnaire in Patients Undergoing Total Hip 
Arthroplasty. Arthroplast Today 2022;15:40-42. doi: 
10.1016/j.artd.2022.01.031.
11.Mirghaderi SP, Sheikhbahaei E, Salimi M, et al. 
COVID-19 infection rate after urgent versus 
elective total hip replacement among unvaccinated 
individuals: A multicenter prospective cohort amid 
the COVID-19 pandemic. Ann Med Surg (Lond) 
2022;80:104307. doi: 10.1016/j.amsu.2022.104307. 
12.Moharrami A, Mirghaderi SP, Hoseini-Zare N, 
et al. Restoring femoral medial offset could 
reduce pelvic obliquity following primary total 
hip arthroplasty, an observational study. Int 
Orthop.2022;46(12):2765-2774. doi: 10.1007/
s00264-022-05506-x. 
13.Sheikhbahaei E, Mirghaderi SP, Moharrami A, Habibi D, 
Motififard M, Mortazavi SMJ. Incidence of Symptomatic 
COVID-19 in Unvaccinated Patients Within One Month 
After Elective Total Joint Arthroplasty: A Multicenter 
Study. Arthroplast Today.2022;14:110-115. doi: 
10.1016/j.artd.2022.01.024. 
14.Ebrahimpour A, Sadighi M, Hoveidaei AH, et al. 
Surgical Treatment for Bisphosphonate-related 
Atypical Femoral Fracture: A Systematic Review. Arch 
Bone Jt Surg. 2021;9(3):283-296. doi:10.22038/
abjs.2020.52698.2608
15.Hong YC, Luo RB, Lin T, Zhong HM, Shi JB. 
Efficacy of alendronate for preventing collapse of 
femoral head in adult patients with nontraumatic 
osteonecrosis. Biomed Res Int. 2014;2014:716538. 
doi:10.1155/2014/716538
16.Uzun G, Mutluoglu M, Ersen O, Yildiz S. Hyperbaric 
oxygen therapy in the treatment of osteonecrosis of 
the femoral head: a review of the current literature. 
Undersea Hyperb Med. 2016;43(3):189-99. 
17.Oliaei S, SeyedAlinaghi S, Mehrtak M, et al. The effects 
of hyperbaric oxygen therapy (HBOT) on coronavirus 
disease-2019 (COVID-19): a systematic review. Eur J 
Med Res.2021;26(1):96. doi: 10.1186/s40001-021-
00570-2. 
18.Al-Jabri T, Tan JYQ, Tong GY, et al. The role of electrical 
stimulation in the management of avascular necrosis 
of the femoral head in adults: a systematic review. 
BMC Musculoskelet Disord. 2017;18(1):319-319. 
doi:10.1186/s12891-017-1663-5
19.Lee J-Y, Kwon J-W, Park J-S, et al. Osteonecrosis of 
Femoral Head Treated with Extracorporeal Shock 
Wave Therapy: Analysis of Short-term Clinical 
Outcomes of Treatment with Radiologic Staging. 
Hip Pelvis. 2015;27(4):250-257. doi:10.5371/
hp.2015.27.4.250
20.Yan ZQ, Chen YS, Li WJ, et al. Treatment of osteonecrosis 
of the femoral head by percutaneous decompression 
and autologous bone marrow mononuclear cell 
infusion. Chin J Traumatol. 2006;9(1):3-7. 
21.Pierce TP, Jauregui JJ, Elmallah RK, Lavernia CJ, Mont 
MA, Nace J. A current review of core decompression 
in the treatment of osteonecrosis of the femoral head. 
Curr Rev Musculoskelet Med. 2015;8(3):228-32. 
doi:10.1007/s12178-015-9280-0
22.Ficat RP. Idiopathic bone necrosis of the femoral 
head. Early diagnosis and treatment. J Bone Joint Surg Br. 1985;67(1):3-9. doi:10.1302/0301-620x.67b1. 
3155745
23.Kapadia BH, Banerjee S, Cherian JJ, Jauregui JJ, 
Mont MA. Principles of Core Decompression for 
Osteonecrosis of the Hip. In: Koo K-H, Mont MA, Jones 
LC, eds. Osteonecrosis. Springer Berlin Heidelberg; 
2014:279-284.
24.Song WS, Yoo JJ, Kim Y-M, Kim HJ. Results of multiple 
drilling compared with those of conventional 
methods of core decompression. Clin Orthop Relat 
Res.2007;454:139-46. doi: 10.1097/01.blo.0000 
229342.96103.73. 
25.Liu ZH, Guo WS, Li ZR, et al. Porous tantalum rods 
for treating osteonecrosis of the femoral head. Genet 
Mol Res. 2014;13(4):8342-52. doi:10.4238/2014.
October.20.10
26.Nadeau M, Séguin C, Theodoropoulos JS, Harvey EJ. 
Short term clinical outcome of a porous tantalum 
implant for the treatment of advanced osteonecrosis 
of the femoral head. Mcgill J Med. 2007;10(1):4-10. 
27.Zhang Y, Li L, Shi ZJ, Wang J, Li ZH. Porous tantalum rod 
implant is an effective and safe choice for early-stage 
femoral head necrosis: a meta-analysis of clinical 
trials. Eur J Orthop Surg Traumatol. 2013;23(2):211-
7. doi:10.1007/s00590-012-0962-7
28.Steinberg ME, Larcom PG, Strafford B, et al. 
Core Decompression With Bone Grafting for 
Osteonecrosis of the Femoral Head. Clin Orthop 
Relat Res.2001;(386):71-8. doi: 10.1097/00003086-
200105000-00009.
29. Li X, Xu X, Wu W. Comparison of bone marrow 
mesenchymal stem cells and core decompression in 
treatment of osteonecrosis of the femoral head: a metaanalysis. Int J Clin Exp Pathol. 2014;7(8):5024-30. 
30.Gangji V, Hauzeur JP, Matos C, De Maertelaer V, Toungouz 
M, Lambermont M. Treatment of osteonecrosis of 
the femoral head with implantation of autologous 
bone-marrow cells. A pilot study. J Bone Joint Surg 
Am. 2004;86(6):1153-60. doi:10.2106/00004623-
200406000-00006
31.Marker DR, Seyler TM, Ulrich SD, Srivastava S, Mont MA. 
Do modern techniques improve core decompression 
outcomes for hip osteonecrosis? Clin Orthop Relat 
Res. 2008;466(5):1093-103. doi:10.1007/s11999-
008-0184-9
32.Gardeniers J. A new international classification of 
osteonecrosis of the ARCO-committee on terminology 
and classification. ARCO news. 1992;4:41-46. 
33.Kerboul M, Thomine J, Postel M, d’Aubigné RM. The 
conservative surgical treatment of idiopathic aseptic 
necrosis of the femoral head. J Bone Joint Surg 
Br.1974;56(2):291-6. 
34.Mortazavi SMJ, Moharrami A, Shafiei H, Ebrahimzadeh 
MH, Karimi M. Unapproved Weight Gain Supplement 
as a Cause of Avascular Necrosis: A Cautionary Report. 
Arch Bone Jt Surg. 2019;7(6):561-565. 
35. Lavernia CJ, Sierra RJ. Core decompression in atraumatic 
osteonecrosis of the hip. J Arthroplasty. 2000;15(2):171-
8. doi:10.1016/s0883-5403(00)90132-3
36.Hua KC, Yang XG, Feng JT, et al. The efficacy and safety 
of core decompression for the treatment of femoral 
head necrosis: a systematic review and meta-analysis. 
J Orthop Surg Res. 2019;14(1):306. doi:10.1186/
s13018-019-1359-7
37.Hyodo K, Yoshioka T, Sugaya H, et al. Predicting risk 
factors of total hip arthroplasty conversion after 
concentrated autologous bone marrow aspirate 
transplantation for the treatment of idiopathic 
osteonecrosis of the femoral head: a retrospective 
review of 213 hips at a mean follow-up of 5 years. The 
Journal of Hip Surgery. 2017;1(01):007-013. 
38.Tomaru Y, Yoshioka T, Sugaya H, et al. Ten-year results 
of concentrated autologous bone marrow aspirate 
transplantation for osteonecrosis of the femoral head: 
a retrospective study. BMC Musculoskelet Disord. 
2019;20(1):410. doi:10.1186/s12891-019-2797-4
39.Smith SW, Fehring TK, Griffin WL, Beaver WB. Core 
decompression of the osteonecrotic femoral head. 
J Bone Joint Surg Am.1995;77(5):674-80. doi: 
10.2106/00004623-199505000-00003. 
40.Scully SP, Aaron RK, Urbaniak JR. Survival analysis 
of hips treated with core decompression or 
vascularized fibular grafting because of avascular 
necrosis. J Bone Joint Surg Am. 1998;80(9):1270-5. 
doi:10.2106/00004623-199809000-00004
41.Amanatullah DF, Strauss EJ, Di Cesare PE. Current 
management options for osteonecrosis of the femoral 
head: part 1, diagnosis and nonoperative management. 
Am J Orthop (Belle Mead NJ). 2011;40(9):E186-92.