Surgical options for Osteonecrosis
Surgical management of Osteonecrosis
In early, reversible stages of ON, several surgical procedures have been developed with the aim of preventing progression. Of these, core decompression of the femoral head has been most commonly performed and investigated. The rationale for this operation is that if increased intraosseous pressure can be relieved, vascular perfusion can then be enhanced and help prevent progression of the lesion. Several studies comparing core decompression with nonoperative management have shown favorable results, with success rates in the range of 47% to 84% for stage I to III disease. Core decompression has also shown some benefit when used to treat knee and humerus ON. Vascularized fibula grafting into the femoral head has been shown in several studies to be extremely promising, with 5-year hip survival rates of 81% to 89% for stage II to IV disease. However, there is a high complication rate (19%), so this procedure is a consideration only in medical communities in which a skilled surgeon with experience in this technique is available. In general lesions <30% of the femoral head have the best results. Initial studies using autologous mesenchymal stem cells inserted into the femoral head after core decompression have shown encouraging results.
In the nonreversible stages of ON (particularly stages V to VI), the goal of surgical intervention is to restore joint function and relieve associated pain. The effectiveness and reliability of total hip arthroplasty (replacement) have made earlier procedures attempting to achieve these goals obsolete.
