OSTEONECROSIS OF FEMORAL HEAD: OUTCOME OF CORE DECOMPRESSION WITH CANCELLOUS BONE GRAFTING

Dr Arvind Kumar, Dr Sudhirkumar Rawat, Dr Parth Deshmukh, Dr Ajay Mandloi, Dr Jainish Patel, Dr Amit Patel, Dr Anirudh Bansal and Dr Vikramjit Singh Baath. Department of orthopaedics, SBKS medical college and research centre, Pipariya, Vadodara, Gujarat. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


ISSN: 2320-5407
Int. J. Adv. Res. 5(4), 1773-1777 1774 osteonecrosis of femoral head aim is to preserve the joint in the early stages (Modified Ficat and Arlet classicfication) FAS 1, 2 and to delay the replacement surgery in advanced cases.
Principle of core decompression is it relives intraosseous pressure caused by venous congestion, allowing improved vascularity and possibly slows down the progression of the avascular necrosis of femoral head. This study describes early results of treatment of avascular necrosis of femoral head by decompression and cancellous bone grafting.

Material and Methods:-
A prospective analytic interventional study was carried out from 2014 to 2016 in our institution, Department of Orthopaedics SBKS medical college and Dhiraj general hospital Pipariya, Vadodara, Gujarat .Total 50 patients (70 hips) in which diagnosis of osteonecrosis of femoral head was made clinical examination was performed in all patients revealed pain with range motion and ambulation. Limitation of internal rotation in both flexion and extension were found with passive internal rotation and extension being particularly painful. Further evaluation was done with plain x rays and MRI scan. Study group includes 50 patients. 35 males and 15 females.20 patients (40 hips) with bilateral involvement and 30 patients with unilateral involvement. Bilaterally affected patients were operated in same sitting. Patients were staged according to modified ficat and arlet classification. All the patients belongs to stge 1 and stage 2 of femoral head osteonecrosis. The age of patients in study group ranged from 20 to 45 years the mean age was 32.5 years.
Operative Procedure:-Under general anesthesia or spinal anesthesia , supine position on standard operating table. Percutaneous two guide wire was passed under guidance of image intensifier. Tip of guide wire was directed into the centre of most necrosed portion of the head of femur. After achieving proper insertion of guide wires in necrotic area of femoral head it was confirmed on AP and lateral view on image intensifier, then 3-5 cm incision was taken on base of the guide wire, fascia lata is splited in line of incision. Then guide wire over reamed with 6mm reamer. Then all necrotic material was qurrated out with qurret. Depressed articular margin was elevated and Cancellous bone grafting was inserted in the both tracts. Then wound was closed in layers.
Cancellous bone graft was taken from anterior iliac crest. Under general or spinal anaesthesia . A 3 to 4 cm incision is located over the iliac creast (contralateral side in unilateral cases) posterior to the ASIS to protect the lateral cutaneous nerve . After incision the skin and subcutaneous layers, sharply incise the white facial confluence of gluteal/tensor and abdominal musculature over the iliac crest and the periosteum. Periosteum is elevated with periosteal elevator and cancellous graft is harvested with bon gauge. And wound is closed layer wise.

Post Operative Cares:-
For the ASIS graft site compression bandage was applied until removal of sutures. Active range of motion exercise of knee and ankle started during the immediate postoperative period. partial weight bearing started after 6 weeks post operatively. Full weight bearing with walker started after 3 months. We have given alendronate to all patients post operatively.
Evaluation:-Patients were followed up at 1 month, 3 months 6 months 1 year and one and half years and 2 years. Evaluation of the patients regards to pain, distance walk with or without support , climbing of stairs, sitting, squatting and clinically examined range of movements of hip using Harris hip scoring system, according to which the score <70 was poor, 70-79 -fair, 80-89 -good, 90-100 excellent. Follow up check x ray were taken.

Results:-
The patients had good clinical improvement with relief of pain and range of motion improvements. In unilateral case left hip was involved in 18 cases and 12 hips involved in right. Bilateral involvement is seen in 20 cases (40 hips). Treating ischemia of femoral head has become more common since many of the cases are detected in early stage. Early diagnosis before the appearance of radiological changes is very important of avascular necrosis. Diagnosis is based on clinical examination, bone scan, CT scan and MRI. X-ray is of very limited significance in early stage of the disease.MRI has dramatically improved the diagnosis of avascular necrosis, especially in the early stages when there are only bone marrow changes Core decompression reduces the symptoms of pre collapse stage of ischemic necrosis because of reduction of pressure in compartment. There is no significant role of conservative management in osteoporosis of femoral head. The ideal treatment modality should be simple, reproducible and withlow morbidity and mortality.the main advantages of non vascularized graft are significant reduction in pain, early mobilization, easy and technically less demanding procedure, less chance of donor side morbidity, less chance of iatrogenic subtrochentric fractures and shorter operative time.

Conclusion:-
AVN primarily affacts the young active adults which leads to increase morbidity and functional disability. Our aim of treatment is to delay the progression of the disease. Efficacy of core decompression with cancellous bone 44% 12% 16% 28% Idiopathic