presenting a novel technic to treat avascular necrosis of hip.AVN hip is a challenge for any orthopaedic surgeon especially in precollapse stage. here dr mohamed ashraf and dr jyothis george from govt TD medical college alleppey kerala india demonstrate a novel and effective method to arrest the progression of disease to collapse.instead of performing a conventional core decompression they do multiple micro core decompression through safe surgical dislocation of GANTZ .in addition they are supplementing the procedure with intralesional infiltration of zolidronic acid to prevent structural collapse.

1. Safe surgical dislocation [SSD] for avascular
necrosis hip [AVN]
Slide master
DR MOHAMED ASHRAF ,PROFESSOR
DR JYOTHIS GEORGE,ASSISTANT
PROFESSOR
GOVT TD MEDICAL COLLEGE
ALLEPPEY,KERALA,INDIA
drashraf369@gmail.com

2. MICROCORE
DECOMPRESSION AND
BISPHOSPHONATE
INFILTRATION BY
SAFE SURGICAL
DISLOCATION FOR
AVN HIP

3. AVN
 Disabling disease
 Leads to destruction of the hip joint
Both the Diagnosis and appropriate
treatment poses difficulty in the minds of
all orthopaedic surgeons

5. • Once the disease has advanced some efforts must be taken to delay
– speed of progression of collapse
– total hip replacement.
• In young adults in their 20's-40's arthroplasty is best deferred as
much as possible

6. • Non surgical treatment modalities for the
preservation of necrotic femoral head have been
very time consuming and uniformly unsuccessful

7. Role of Core decompression who have cystic changes in
the femoral head on xray ?

8. • Jones analyzed nine studies and showed core
decompression performed in the precollapse stage,
failed to prevent the progressive collapse(in 218 of
369 patients (59%)
» American Academy of Orthopaedic Surgeons; 1994. p.
499-512
• What % collapse in core
decompression?

9. multiple drilling is safer and less invasive than single coring in SCD,
significantly longer time before the collapse (mean 42.3 months vs. 22.6
months, P = 0.011) and the lower rate of collapse within 3 years after
operation (55.0% vs. 85.7%)

14. POSITIONING

15. INCISION

16. TROCHANTER OSTEOTOMY

17. CAPSULOTOMY

19. CAPSULOTOMY

20. FEMORAL HEAD DISLOCATION

22. • TECHNIQUE
• 3.2MM DRILL BIT

24. OSTEOPHYTE REMOVAL

25. LOOSE CHONDRAL DEFECT

26. LOOSE CHONDRAL DEFECT

27. LABRUM

30. • Reduction in the rate of collapse

31. MULTIPLE EVIDENCE

32. Suppresses biochemical markers of bone
resorption ------1 year

33. MULTIPLE DRILLING
+
BISPHOSPHONATE
=
 91% of patients with Stage II disease and 62% of patients with
Stage III disease had not required THA in alendronate group

37. DATA
• Age group of 33 -51 year
• Study period 2013 -2018
• Prospective, non randomised method with 2 years follow up done
• 42 patients with modified Ficat and Arlet stage II AVN hip were
studied.
• 29 patients were managed with CD and 13 patients with MCD with
intralesional bisphosphonate infiltration via ganz SSD of hip.
• The functional (Harris hip score) and radiological outcome is
assessed every 6 months.

38. RESULTS

39. • Out of 42 cases, 2 patients managed by CD and 1 patient in
MCD with intralesional bisphosphonate infiltration failed to
followup

40. 28.6
71.4
SEX
FEMALE
MALE

41. SIDE
19
15
8
SIDE
LEFT
RIGHT
BILATERAL

42. 81
19
STEROID INTAKE
ABSENT
PRESENT

43. 61.9
38.1
SMOKING
PRESENT
ABSENT

44. ALCOHOL INTAKE
54.8
45.2 PRESENT
ABSENT

45. 0
10
20
30
40
50
CAD CKD COPD DLP DM HTN NIL
COMORBIDITIES
COMORBIDITIES

46. 69
31
SURGICAL PROCEDURE
CORE DECOMPRESSION
SSD+MCD+BISPHOSPHO
NATE

49. DELAYED TROCHANTER UNION (3
MONTHS)

51. CORE DECOMPRESSION

52. 13 OUT OF 29 PATIENTS IN CD GROUP HAD
RADIOLOGICAL PROGRESSION OF DISEASE AT
2 YEARS

53. • MCD

54. SUPERFICIAL INFECTION

55. FUNCTIONAL OUTCOME
CD SSD+MCD+BISPHOSPHONATE

56. 0
10
20
30
40
50
60
70
80
90
100
CORE DECOMPRESSION
SSD+MCD+BISPHOSPH

57. CONCLUSION
• SSD provides 360 axis view to femoral head and acetabulum
• MCD addresses peripheral and central lesions
• Radiological transformation of femoral head is noted in MCD
group.
• MCD curbs disease progression on long term follow up.
• Core decompression had better Harris hip score on short term
follow up but on long term follow up MCD had superior results.
• Needs future follow up.

58. Want to visualise ????

59. Addressing the pathology at micro level??

60. Remove the structural stability???

61. Answer:
• MICROCORE DECOMPRESSION
AND BISPHOSPHONATE
INFILTRATION BY SAFE
SURGICAL DISLOCATION

63. References:
1 The Journal of bone and journal of surgery
2 American academy of orthopaedic surgeons
3 Campbell’s operative orthopaedics
Statististical analysis: Dr Sreelal P ( Assosciate Prof, Department of Community Medicine,
AIMS,Kochi)

64. THANK
YOU

65. ANY QUESTIONS?