MEdicine

2. A study of core decompression & free fibular strut
grafting in the management of Ficat-Arlet grade 1,2 &
3 osteonecrosis of femoral head in adults
Details of Presenter:
Dr. S.Akshay Viswadhar
2nd YEAR Post Graduate
Department of Orthopaedics
Mallareddy Institute of Medical Sciences
Details of Co-Author:
Dr. J.Ashok Vardhan Reddy
Professor
Department of Orthopaedics
Mallareddy Institute of Medical Sciences

3. • Osteonecrosis or avascular necrosis of the femoral head is a painful condition that occurs when the blood
supply to the head of the femur is disrupted.
• Incidence rate varies from 20,000 to 25,000 cases per year (6)
• It is a multifactorial disease that can result in significant clinical morbidity and affects patients of any age,
including young, active patients
• Late sequelae of femoral head osteo-necrosis include femoral head collapse and subsequent degeneration of
the hip joint.[1]
• If not managed timely, leads to the collapse of femur head eventually requiring hip arthroplasty.
• Early presentation of avascular necrosis of femur head may be painless; however the ultimate presentation is
painful limitation of hip motion. Passive movements of hip are also restricted.

4. • There is a high chance of bilateral presentation, Careful clinical history is important to find any of the risk
factors
• The Harris hip score is one of the most common clinical scales used for assessing the hip status.[2]
• Core decompression is a hip preserving surgical procedure that is used to treat avascular necrosis (AVN) of
the femoral head by which, the time to a total hip replacement (THR) can be delayed.[2,3]
• The rationale for the use of core decompression is based on the concept that increased intra-medullary
pressure is involved in the pathogenesis of avascular necrosis.
• The aim of the procedure of core decompression is to decrease the intramedullary pressure and thus arrest
or reverse the process of avascular necrosis before it is evident radiographically.[3]
• Fibular Bone grafting has been added to the core decompression in an effort to provide structural support,
or to act as scaffolding for repair and allow remodelling of subchondral bone.[4]

5. AIM
To study the outcome of core decompression with free fibular strut grafting surgery in Ficat-Arlet grade 1,2 &
3 osteonecrosis of femoral head in adults
OBJECTIVES
1. To study & categorize avascular necrosis of hip into Ficat-Arlet staging.
2. To correlate preoperative function of hip with radiological findings.
3. To analyze the post operative function using Harris Hip Score[2].

6. INCLUSION CRITERIA

7. EXCLUSION CRITERIA

8. METHODOLOGY
• All the patients in our study were first examined in the Out Patient Department. Patient particulars were
noted as name, age, sex, registration number, occupation, pain with detailed characteristic, limp, duration
of symptoms, progression of symptoms, deformity, support required to walk or not, any history of
trauma and history of other joint pain. History of risk factors like steroids and alcoholism was also noted.
• Local as well as systemic examination (CNS, Cardiorespiratory and GI) was done to rule out any other
associated disorder or multiple joint involvements or any other bony abnormalities.
• Oral and parenteral NSAIDs available in the hospital were used to relieve pain
• Routine blood investigations like Hemoglobin level, bleeding and clotting time, blood urea, serum
creatinine, blood grouping, random blood sugar, Electro cardiograph (ECG), urine routine, chest
radiographs & Pelvis Xray was obtained.

9. • MRI hip was obtained & radiographic assessment was done for confirmation of
avascular necrosis of hip & its grade.
• Patients with confirmed avascular necrosis of hip along with clinical findings of Ficat-
Arlet grade 1,2 & 3 were admitted into the study.
• Patients were assessed before surgery using Harris Hip Score
• Pre anesthetic checkup was done
• Patients fit for surgery were operated upon by Core Decompression and free Fibular
Strut Grafting

11. • Under strict aseptic precautions, after anesthesia patient is kept on fracture table in Supine
position.
• A limited skin incision is made over the lateral aspect of the proximal femur end at the tip of
greater trochanter and carried out to a point just 3cm below the greater trochanter parallel
the femoral shaft.
• Dissection is carried down to the bone after dividing the fascia lata and retracting the vastus
lateralis muscle
• A guide wire is placed along the femoral neck into the area of femoral head necrosis using C-
arm guidance within approximately 5 mm of the subchondral plate into necrotic area of femoral
head & reaming is done along the K-wire to the necrotic area.

12. • The necrotic bone is curetted & scooped out
• The fibular strut graft taken from ipsilateral leg using the middle third fibula & inserted into the
tunnel created and gently hammered to reach the subchondral bone in the desired area.
• Finally, vastus muscle and fascia latae will be repaired with interrupted sutures. Wound will be
thoroughly irrigated and closed in layers

13. Pre - OP Post OP

15. • Sutures were be removed 12-14 days after surgery
• Patients allowed partial weight bearing after 3 weeks from operative day depending on pain
• Patients followed up at 1 month, 3 months & 6 months after surgery and assessed using Harris hip
score
Follow up Assessment
1 month: partial weight bearing Harris Hip Score:
3 month: full weight bearing. Harris Hip Score:
6 month: full weight bearing Harris Hip Score:

17. Harris Hip Score

18. Motion
Total degrees of Flexion
o None
o 0 >8
o 8 > 16
o 16 > 24
o 24 > 32
o 32 > 40
o 40 > 45
o 45 > 55
o 55 > 65
o 65 > 70
o 70 > 75
o 75 > 80
o 80 > 90
o 90 > 100

19. • In this study majority of the patients belong to the age group of 31-40 years and most of them were
males. Male female ratio was 4:1
• Out of 28 hips, 26 hips had pain relief immediately after operation.
• In follow up, at 3 months 22 hips had complete pain relief and at 6 months and final follow up 19
had no pain.
• So it suggests that majority of patients (67.86%) had pain relief after procedure.
• Out of 28 hips, though 19 hips had no complication, 8 hips showed further advancement of the
disease resulting into arthritis. One hip had superficial infection initially which subsided after
debridement.
Results

20. Pain Relief after Surgery
Risk Factors Final Result

21. • If we exclude noncompliant patient, success rate was 92.3%.
• The average success rate was 82.61% after core decompression and bone grafting.
• The patients who had less than 60 Harris hip score on presentation had poorer outcome.
• Patients who had less than 80 degrees of flexion also had poorer outcome.
• Majority of the hips (89.28%) did not require any other secondary procedure; however 2 hips
worsened requiring total hip replacement surgery.
CONCLUSION

22. • Study suggests that core decompression with fibular bone grafting is an effective procedure for the
treatment of early stage AVN of the femoral head.
• Similar results were also found in various other studies so we concur with age group of 20-40 years.
• In our study primarily males are more commonly affected (80%) as compared to females, (M:F- 4:1).
• Though this study is small we suggest, MRI grading along with clinical features put together give
accurate prognosis for the outcome of the surgery and give excellent result when patients are carefully
selected.

23. DISCUSSION
• Avascular necrosis (AVN) is defined as cellular death of bone components due to interruption of the
blood supply; the bone structures then collapse, resulting in bone destruction, pain, and loss of joint
function.
• The AVN of femur head, a disease with many etiological factors is usually associated with many risk
factors but mostly two-thirds of this is related to corticosteroid intake and alcohol abuse, rest are
mainly Idiopathic.
• Clinically the pain may be minimal at onset, but if no active intervention is done it may worsen
gradually, affecting the activity of daily living. Young population is mostly affected and if it is not
managed by early, it cause the collapse of femur head and after that the only management option is
hip arthroplasty.

26. Thankyou