Core decompression in osteonecrosis of the femoral head: risk-factor-dependent outcome evaluation using survivorship analysis

Abstract

The results of core decompression of the femoral head in the treatment of osteonecrosis are analyzed. This study includes 94 hips in 74 patients with a followup time ranging between 18 months and 15 years (average 6 years). There had been no need for further surgery 2 years postoperatively in 85% of the hips with preoperative Steinberg stages 0, I and II when compared with 66% with preoperative stages III, IV and V. At 4 years postoperatively the corresponding figures are 73 compared to 55%; and 6 years postoperatively 69 compared to 49%. This difference was significant (P=0.0402). Further significant risk factors are corticosteroid administration, smoking and alcohol intake. The results of core decompression are good when the preoperative lesion is at Steinberg stage 0, I and II and the patient does not present with other risk factors. In cases with risk factors the outcome is significantly less good. The procedure is not indicated in the presence of advanced disease.Résumé Dans cette étude nous avons analysé les résul-tats de la décompression de la tête fémorale chez des patients avec ostéonécrose de la tête du fémur. 94 hanches de 74 patients ont été analysées. La durée de suivi a varié entre 18 mois et 15 ans. Deux ans après la décom-pression les résultats ont été satisfaisants (aucune reintervention chirurgicale) dans 85% des cas avec une nécrose préoperatoire dans les stades de Steinberg 0, I ou II. Avec les stades III, IV ou V les résultats ont été satisfaisant dans 66% des cas. Quatre ans après la décompres-sion les résultats satisfaisant ont été 73% (0, I ou II) et 55% (III, IV ou V). Six ans après la décompression les résultats satisfaisant ont été 69% et 49%. Les traitements avec corticoide, l'alccol et la nicotine augmentent le risque d'une ré intervention chirurgicale après la decompression d'une maniére significative. Les résultats de la decompréssion sont bons, si la 1ésion de la nécrose n'excéde pas le stade II de Steinberg et s'il n'a pas autres facteurs risque. Avec des facteurs de risque les résultats dé-clinent significativement. Dans les stades de Steinberg III, IV ou V la décompression n'est pas indiquée. IntroductionOsteonecrosis of the femoral head (ONFH) is a disease of unknown pathology. The natural history normally progresses to femoral head arthrosis with the need for total hip replacement (THR) [4]. Nonoperative treatment, such as limited weight-bearing, has been shown to be of little value. About 80% of conservatively treated patients require THR [21]. Core decompression (CD) is a treatment option that has been in use since the 1960s [4,10]. Although widely used, published clinical results are inconsistent and range from disappointing [1,8,14] to encouraging [3,25,27].This study was undertaken to evaluate the postoperative success of CD as judged by the need for re-operation, radiographic progression and clinical outcome, by using survivorship analysis. Patients and methodsIn 1997 we performed a retrospective study of patients who had undergone a CD procedure as treatment fo...

Cost-effectiveness Analysis of Core Decompression

“…Limited data exist in the literature documenting successful results in controlled trials at 5-and 10-year follow-up on patients that have undergone core decompression of the hip. Existing studies have indicated promising results that meet or exceed these goals after core decompression, but control groups are often inadequate [1][2][3][4][5][6][7][8][9][10][11]. More rigorous evaluation of core decompression is required to document its true efficacy and resulting cost-effectiveness.…”

“…As a result, core decompression is likely to have poor cost-effectiveness in these cases of latestage disease. Patients with extensive femoral head involvement or a history of long-term steroid use are also likely to demonstrate clinical efficacy below these levels [3][4][5][6][7][8][9][10][11]. The use of core decompression in these subgroups is not supported in this analysis.…”

“…There has been a wide range of results reported on the efficacy of core decompression [3][4][5][6][7][8][9][10][11]. The clinical results abstracted from the literature review are summarized in Appendix A.…”

“…The primary complication included in the model following core decompression is subtrochanteric hip fracture requiring operative intervention. This complication has been infrequently reported, but rates as high as 5% have been published [3][4][5][6][7][8][9][10][11]. An intermediate value of 2% was selected for the reference case, and sensitivity analysis was used to examine the effect of rates in the range of 0% to 5%.…”

A current review of core decompression in the treatment of osteonecrosis of the femoral head

“…In a systematic literature review, Marker et al [12] evaluated the clinical and radiographic outcomes of core decompression in surgeries done before [13][14][15][16][17][18][19][20][21][22] and after 1992 [1,2,10,[23][24][25][26][27][28][29][30][31] (n=1268 and 1337 hips, respectively). The authors demonstrated that in procedures performed before 1992, 41 % of hips required additional surgery after a mean follow-up of 65 months (range, 3 to 216 months).…”