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Nontraumatic avascular necrosis of the femoral head

Arthroscopic and navigation-supported core decompression

Atraumatische avaskuläre Femurkopfnekrose

Arthroskopisch und navigationsgestützte Hüftkopfanbohrung

  • Surgical Techniques
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Operative Orthopädie und Traumatologie Aims and scope Submit manuscript

Abstract

Objective

The aim is to address core decompression and pathologies of the femoral head, treating them during the same procedure. Furthermore, radiation exposure will be reduced.

Indications

Femoral head necrosis ARCO (Association Research Circulation Osseous) stages I–III.

Contraindications

Progressive femoral head necrosis as ARCO stages IIIC–IV.

Surgical technique

Arthroscopically navigated core decompression of the femoral head using an established optoelectronic system with fluoro-free software module. First, hip joint arthroscopy was performed and further pathologies were treated. Second, core decompression was navigated by a navigation pointer and drill sleeve to reach the correct target point. After visualization, the procedure is repeated 3–5 times.

Postoperative management

Limited weight bearing of the operated leg (20 kg) for 10–14 days. Active or passive continuous motion machine for 4 weeks. Adjuvant postoperative indomethacin therapy for 10 days to reduce pain and bone marrow edema.

Results

From May 2018 to January 2019, 7 patients (male = 4; 40 ± 9 years) underwent arthroscopically navigated core decompression with 2 (29%) and 5 (71%) patients being classified as ARCO II and III, respectively. Preoperatively, all patients reported load-dependent pain. In all cases, we could identify synovitis, which results in soft tissue release and synovectomy. Furthermore, 4 of 7 patients had an additional labrum lesion, which is addressed by refixation or shrinking.

Discussion

Compared to the conventional technique, this fluoro-free navigation procedure allows more precise drilling. Moreover, additional pathologies, as found in all our cases, could be simultaneously addressed. The intraoperative radiation exposure for the patient and surgical team could also be reduced. Although arthroscopically assisted core decompression requires more preparation time, there are advantages over conventional surgery.

Zusammenfassung

Operationsziel

Funktionserhalt der Hüfte durch Hüftkopfanbohrung sowie die Behandlung von Begleitpathologien durch Hüftarthroskopie und Reduktion der intraoperativen Strahlenbelastung.

Indikationen

Hüftkopfnekrose Stadium ARCO (Association Research Circulation Osseous) I–III.

Kontraindikationen

Fortgeschrittene Hüftkopfnekrose ARCO IIIC–IV.

Operationstechnik

Arthroskopisch gestützte Hüftkopfanbohrung mit optoelektronischem System ohne zusätzliche Strahlenbelastung. Zuerst Hüftgelenkarthroskopie und Behandlung etwaiger Begleitpathologien. Danach navigierte Hüftkopfanbohrung, wobei ein Navigationspointer arthroskopisch an den nekrotischen Hüftkopfanteil eingebracht wird. Visualisierung durch gleichzeitiges Einbringen einer navigierten Bohrhülse, sodass die Navigationsgeräte die exakte Bohrrichtung ohne zusätzliche Strahlenbelastung visuell am Navigationsmonitor darstellen. Das Prozedere wird 3‑ bis 5‑mal durchgeführt.

Postoperatives Weiterbehandlung

Teilbelastung des operierten Beins mit 20 kg für 10–14 Tage. Passive oder aktive Bewegungsmaschine für 4 Wochen. Adjuvante Indometacin-Therapie für 10 Tage zur Reduktion von Schmerzen und Knochenmarködem.

Ergebnisse

Von Mai bis Dezember 2018 wurden 7 Patienten (m = 4; 40 ± 9 Jahre) durch eine arthroskopisch gestützte navigierte Hüftkopfanbohrung behandelt, wobei 2 Patienten ARCO II (29 %) und 5 Patienten ARCO III (71 %) hatten. Präoperativ litten alle Patienten unter belastungsabhängigem Hüftschmerz. In allen Fällen zeigte sich eine Synovialitis, die mit Synovektomie und Weichteilrelease adressiert wurde. Zudem hatten 4/7 Patienten eine zusätzliche therapiebedürftige Labrumläsion.

Diskussion

Das Verfahren ermöglicht im Vergleich zur konventionellen Operationstechnik eine präzisere Hüftkopfanbohrung. Zudem konnten vorliegende Pathologien, die in allen Fällen vorhanden waren, durch die Hüftgelenkarthroskopie gleichzeitig behandelt werden. Die intraoperative Strahlenbelastung für Patient und Operationsteam wurde deutlich reduziert. Obwohl die arthroskopisch gestützte Hüftkopfanbohrung deutlich mehr Vorbereitungszeit benötigt, bietet sie Vorteile gegenüber der konventionellen Operationstechnik.

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Authors and Affiliations

  1. Department of Orthopedic, Trauma and Plastic Surgery, Division of Arthroscopy, Joint Surgery and Sport Injuries, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany

    Jan Theopold & Pierre Hepp

  2. Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany

    Sarah Armonies, Philipp Pieroh & Andreas Roth

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  1. Jan Theopold
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  2. Sarah Armonies
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  3. Philipp Pieroh
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  4. Pierre Hepp
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  5. Andreas Roth
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Corresponding author

Correspondence to Jan Theopold.

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Conflict of interest

J. Theopold, S. Armonies, P. Pieroh, P. Hepp and A. Roth declare that they have no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.

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M. Tingart, Aachen

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R. Himmelhan, Mannheim

The authors J. Theopold and S. Armonies contributed equally to this publication.

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Theopold, J., Armonies, S., Pieroh, P. et al. Nontraumatic avascular necrosis of the femoral head. Oper Orthop Traumatol 32, 107–115 (2020). https://doi.org/10.1007/s00064-019-00643-w

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  • DOI: https://doi.org/10.1007/s00064-019-00643-w

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