Newer advances in the field has made surgeons once again looking at Core decompression as an important procedure for treating avascular necrosis of the femoral head. The talk is about the newer development in the field of the Core decompression and how the newer techniques are transforming the way the surgeons take care of this important problem.

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MOACON 2014
Akola

2. Why is there a need to think beyond & Look further?

3. Lack of consistency!

4. Consistently inconsistent
At ten years (Fairbank JBJS 1995):
Stage I – 96% survival
Stage II –74% survival
Stage III – 35% survival
Different studies different Results! Wide variation in
success rates
Everyone thinks his technique is ‘the best’ and has the
‘least failures’
Text Book Campbell “ supports use for Ficat I and II A
small central lesions in young, non obese patients who
are not on steroids”

5. Conventionally
The goal was to
decompress the femoral
head, increase vascular
flow, and alleviate pain.

6. Looking further...
Technical enhancement
Technological enhancement
Supplemental techniques with CD
Predict failures of core decompression?

7. Thinking Beyond!!!
Halting the process!
Repair the tissue!
Regenerate from scratch!

8. Looking further...
Percutaneous Expandable reamer
Arthroscopy & Track Endoscopy
Biomechanical Inputs
Adjuncts

9. Expandable reamers

10. Expandable reamers
1. Decompress Femoral Head 3. Percutaneous Expandable Reamer
2. Place Working Cannula
4. Debride Dead Bone

11. Track Endoscopy
First tunnel endoscopy: the aim is verified, because the core track walls progress clearly from the reddish vital bone (VB) of
the neck (A) through a transitional zone (B) toward the white-gray avascular tissue of the lesion (C).
Second tunnel endoscopy: the walls of the chamber created by the
expandable reamer appear to be vital and bleeding, thus confirming the
adequate debridement.

12. Arthroscopy assisted CD

13. VAC application

14. Improving Biomechanics
Definitively safer, May be better in large pre collapse lesion
Proximal Subtrochanteric Region
Margin of error - 20mm

15. Local Deferoxamine
Promotes angiogenesis by up regulating VEGF
Analysis showed increased local BMP 2, OCN, Hyoxia
induced factor (HIF)
Consequently increase bone healing
Traditionally a chelating agent
Especially useful in Sickle cell diseases

16. Local PEMF
First described by Eftekar in
1984
Weak EM waves found to be
angiogenic and osteogenic
No benefit. (Windisch et al)

17. Thinking Further!!!

18. Healing trinity

19. the “Gyan”
Application of osteogenic + angiogenic cells in
combination with growth factors supported by appropriate
scaffolds

20. SCAFFOLDS
Natural or Synthetic
Tantalum Rods
Alginate beads
DBM
Allografts
Fibula - Vascularised/Non

21. Porous Tantalum Rods
Bypass the morbidity of
the autografts
However shown ingrowth
in less than 25% cases
Fractures reported after
removal.

22. Alignate beads + MSC
Biopolymer made of
seaweed
Scaffold + Cells
Alignate beads provide
optimal environment for
osteogenic differentiation
Nano sized HA crystals,
CaPo4 & Collagen

23. Scaffolds

24. BMC & Stem Cells
Bone marrow concentrate contains two type of cells -
Mesenchymal stem cells ( MSC) and Endothelial
progenitor cells
Msc maintain the ability to mitotic application without loss
of specific biomolecular character of differntiating in
multiple mesenchymal phenotypes: Osteoblats,
chondrocyte and adipocytes.
EPS have role in angiogenesis & neovascularisation

25. Growth factor strategy
GF are produced by osteogenic cells, Platelets and
inflamatory cells.
Include BMPs, IGF, PDGF, TGF 1, FGF
Help in chemo attraction, migration and proliferation and
differentiation of MSC into chondroblast or osteoblasts.
In case of AVN osteogenic potential is haranassed and
osteogenic GF viz TGF beta superfamily

26. Conventionally
Closest to trinity -90%

27. Our trial
Approved by EC & IRB
25 patients in each group
Concentrated BMA
Scaffold - HA TCP crystals vs Gelfoam

28. Our Technique
Marrow aspirated from Illiac crest
Supine position on traction table
3 incision each side (6); 3 angles; 3 mls
Approx 50 - 60 ml collection
Centrifuged - concentrated to 10 cc.

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34. HHeeppaarriinn && AACCDD

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37. VViiddeeooss

40. SSccaaffffoollddss
G bone Gelfoam

41. OOuurr SSttuuddyy
Compare it with historical data
Pain, Function evaluation
Comparison of tow sacffolds
Endpoint is conversion to THR
Early Results expected 2016 March

42. MY Ideal Choice
Core Decompression entered proximal Subtroch area
Multiple drills if large lesion
Single drill for smaller central lesion; use expander
reamer
Scaffold: Autograft or DBM or Alignate beads
Stem cell: Concentrated Bone marrow
Growth Factors: BMP 2

43. Thank you