Clinical study of double-channel core decompression combined with medullary cavity irrigation for non-traumatic osteonecrosis of femoral head_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

MA Jinhui ¹ , LI Hongxu ² , LIU Haoyang ² , WANG Bailiang ¹ , WANG Weiguo ¹ , GAO Fuqiang ¹ ,  SUN Wei ³ ,  CHENG Liming ¹

1. Department of Orthopedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, P. R. China;
2. Peking University China-Japan Friendship School of Clinical Medicine, Beijing, 100029, P. R. China;
3. Department of Orthopedic Surgery, Chengdu Hip-Preserving Femoral Head Orthopedic Hospital , Chengdu Sichua, 610036, P. R. China;

Corresponding author：

SUN Wei, Email: 412292973@qq.com; CHENG Liming, Email: drchengliming@126.com

Keywords：

Osteonecrosis of femoral head; core decompression; medullary cavity irrigation; bone marrow edema

DOI：

10.7507/1002-1892.202501039

Video：

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Objective To compare the effects of double-channel core decompression (CD) combined with medullary cavity irrigation with those of simple CD on progression of collapse and clinical outcomes in non-traumatic osteonecrosis of the femoral head (ONFH). Methods A retrospective analysis was conducted on the clinical data of 19 patients (30 hips) with non-traumatic ONFH who underwent double-channel core decompression (CD) combined with medullary cavity irrigation and admitted between January 2024 and October 2024 (CD+irrigation group). According to a 1:2 ratio, 54 patients (60 hips) who underwent simple CD and were matched in terms of age, gender, and body mass index (BMI) were included as the control group (CD group). There was no significant difference in baseline data such as age, gender, BMI, ONFH type, preoperative ARCO stage, visual analogue scale (VAS) score for pain, and Harris score between the two groups (P>0.05). The postoperative discharge time and occurrence of complications were recorded for both groups. The VAS scores before operation and at discharge after operation were compared, and the differences between pre- and post-operation (change values) were calculated for intergroup comparison. The Harris scores before operation and at discharge and 3 months after operation were also compared. During follow-up, X-ray film, CT, and MRI were performed for reexamination. The ARCO stage and bone marrow edema stage were evaluated at 3 months after operation and compared with those before operation to determine whether there was radiological progression or relief. Results All incisions in both groups healed by first intention after operation, with no incision non-healing, infection, femoral neck fracture, or other operation-related complications. All patients were followed up 90-257 days. The follow-up time of the CD+irrigation group was (146.8±27.7) days, and that of the CD group was (164.3±48.2 days); there was no significant difference between the two groups (t=1.840, P=0.069). There was no significant difference in the discharge time between the two groups (P>0.05). At discharge after operation, the VAS score of the CD+ irrigation group was significantly lower than that of the CD group (P<0.05), and the change value was significantly higher than that of the CD group (P<0.05). The Harris scores at discharge and 3 months after operation in the CD+irrigation group were significantly higher than those in the CD group (P<0.05). The Harris score gradually increased with time, and the differences between different time points were significant (P<0.05). Radiological reexamination showed that there was no significant difference in the ARCO stage and the incidence of radiological progression between the two groups at 3 months after operation (P>0.05); however, the bone marrow edema stage and the degree of bone marrow edema relief in the CD+irrigation group were better than those in the CD group, with significant differences (P<0.05). Conclusion Double-channel CD combined with medullary cavity irrigation can significantly alleviate hip joint pain and improve joint function in patients with non-traumatic ONFH, reduce the degree of bone marrow edema in the femoral head, and delay the progression of ONFH.

1.	Tan B, Li W, Zeng P, et al. Epidemiological study based on China Osteonecrosis of the Femoral Head Database. Orthop Surg, 2021, 13(1): 153-160.
2.	Mont MA, Salem HS, Piuzzi NS, et al. Nontraumatic osteonecrosis of the femoral head: where do we stand today?: A 5-year update. J Bone Joint Surg (Am), 2020, 102(12): 1084-1099.
3.	Cohen-Rosenblum A, Cui Q. Osteonecrosis of the femoral head. Orthop Clin North (Am), 2019, 50(2): 139-149.
4.	Adapala NS, Yamaguchi R, Phipps M, et al. Necrotic bone stimulates proinflammatory responses in macrophages through the activation of toll-like receptor 4. Am J Pathol, 2016, 186(11): 2987-2999.
5.	Andreev D, Liu M, Weidner D, et al. Osteocyte necrosis triggers osteoclast-mediated bone loss through macrophage-inducible C-type lectin. J Clin Invest, 2020, 130(9): 4811-4830.
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9.	Kim HKW, Park MS, Alves do Monte F, et al. Minimally invasive necrotic bone washing improves bone healing after femoral head ischemic osteonecrosis: an experimental investigation in immature pigs. J Bone Joint Surg (Am), 2021, 103(13): 1193-1202.
10.	中国微循环学会骨微循环专业委员会. 股骨头坏死临床诊疗技术专家共识(2022年). 中国修复重建外科杂志, 2022, 36(11): 1319-1326.
11.	Hua KC, Yang XG, Feng JT, et al. The efficacy and safety of core decompression for the treatment of femoral head necrosis: a systematic review and meta-analysis. J Orthop Surg Res, 2019, 14(1): 306. doi: 10.1186/s13018-019-1359-7.
12.	Saini U, Jindal K, Rana A, et al. Core decompression combined with intralesional autologous bone marrow derived cell therapies for osteonecrosis of the femoral head in adults: A systematic review and meta-analysis. Surgeon, 2023, 21(3): e104-e117.
13.	Wang BL, Sun W, Shi ZC, et al. Treatment of nontraumatic osteonecrosis of the femoral head with the implantation of core decompression and concentrated autologous bone marrow containing mononuclear cells. Arch Orthop Trauma Surg, 2010, 130(7): 859-865.
14.	刘树仁. 长管状骨髓腔冲洗对原发骨质疏松影响的实验研究. 石家庄: 河北医科大学, 2008.
15.	Andre G, Boschetto F, Gokani V, et al. Ex vivo study of detergent-assisted intraosseous bone wash treatment of osteonecrosis. J Orthop Res, 2023, 41(7): 1482-1493.
16.	Chan WP, Liu YJ, Huang GS, et al. MRI of joint fluid in femoral head osteonecrosis. Skeletal Radiol, 2002, 31(11): 624-630.
17.	Iida S, Harada Y, Shimizu K, et al. Correlation between bone marrow edema and collapse of the femoral head in steroid-induced osteonecrosis. AJR Am J Roentgenol, 2000, 174(3): 735-743.
18.	莫亮. 基于股骨头坏死“血瘀”理论探讨围塌陷期骨髓水肿的病理机制. 广州: 广州中医药大学, 2023.
19.	Kim J, Lee SK, Kim JY, et al. CT and MRI findings beyond the subchondral bone in osteonecrosis of the femoral head to distinguish between ARCO stages 2 and 3A. Eur Radiol, 2023, 33(7): 4789-4800.
20.	Meier R, Kraus TM, Schaeffeler C, et al. Bone marrow oedema on MR imaging indicates ARCO stage 3 disease in patients with AVN of the femoral head. Eur Radiol, 2014, 24(9): 2271-2278.
21.	Hatanaka H, Motomura G, Ikemura S, et al. Differences in magnetic resonance findings between symptomatic and asymptomatic pre-collapse osteonecrosis of the femoral head. Eur J Radiol, 2019, 112: 1-6.

1. Tan B, Li W, Zeng P, et al. Epidemiological study based on China Osteonecrosis of the Femoral Head Database. Orthop Surg, 2021, 13(1): 153-160.
2. Mont MA, Salem HS, Piuzzi NS, et al. Nontraumatic osteonecrosis of the femoral head: where do we stand today?: A 5-year update. J Bone Joint Surg (Am), 2020, 102(12): 1084-1099.
3. Cohen-Rosenblum A, Cui Q. Osteonecrosis of the femoral head. Orthop Clin North (Am), 2019, 50(2): 139-149.
4. Adapala NS, Yamaguchi R, Phipps M, et al. Necrotic bone stimulates proinflammatory responses in macrophages through the activation of toll-like receptor 4. Am J Pathol, 2016, 186(11): 2987-2999.
5. Andreev D, Liu M, Weidner D, et al. Osteocyte necrosis triggers osteoclast-mediated bone loss through macrophage-inducible C-type lectin. J Clin Invest, 2020, 130(9): 4811-4830.
6. 张斌, 杨志刚, 杨晓斐, 等. 应用改良双套管脉冲持续冲洗结合负压封闭引流技术治疗骨髓炎. 骨科, 2017, 8(6): 433-438.
7. 花然亮. 骨髓冲洗去除对骨形成影响的实验研究. 石家庄: 河北医科大学, 2008.
8. Alves do Monte F, Sung Park M, Gokani V, et al. Development of a novel minimally invasive technique to washout necrotic bone marrow content from epiphyseal bone: A preliminary cadaveric bone study. Orthop Traumatol Surg Res, 2020, 106(4): 709-715.
9. Kim HKW, Park MS, Alves do Monte F, et al. Minimally invasive necrotic bone washing improves bone healing after femoral head ischemic osteonecrosis: an experimental investigation in immature pigs. J Bone Joint Surg (Am), 2021, 103(13): 1193-1202.
10. 中国微循环学会骨微循环专业委员会. 股骨头坏死临床诊疗技术专家共识(2022年). 中国修复重建外科杂志, 2022, 36(11): 1319-1326.
11. Hua KC, Yang XG, Feng JT, et al. The efficacy and safety of core decompression for the treatment of femoral head necrosis: a systematic review and meta-analysis. J Orthop Surg Res, 2019, 14(1): 306. doi: 10.1186/s13018-019-1359-7.
12. Saini U, Jindal K, Rana A, et al. Core decompression combined with intralesional autologous bone marrow derived cell therapies for osteonecrosis of the femoral head in adults: A systematic review and meta-analysis. Surgeon, 2023, 21(3): e104-e117.
13. Wang BL, Sun W, Shi ZC, et al. Treatment of nontraumatic osteonecrosis of the femoral head with the implantation of core decompression and concentrated autologous bone marrow containing mononuclear cells. Arch Orthop Trauma Surg, 2010, 130(7): 859-865.
14. 刘树仁. 长管状骨髓腔冲洗对原发骨质疏松影响的实验研究. 石家庄: 河北医科大学, 2008.
15. Andre G, Boschetto F, Gokani V, et al. Ex vivo study of detergent-assisted intraosseous bone wash treatment of osteonecrosis. J Orthop Res, 2023, 41(7): 1482-1493.
16. Chan WP, Liu YJ, Huang GS, et al. MRI of joint fluid in femoral head osteonecrosis. Skeletal Radiol, 2002, 31(11): 624-630.
17. Iida S, Harada Y, Shimizu K, et al. Correlation between bone marrow edema and collapse of the femoral head in steroid-induced osteonecrosis. AJR Am J Roentgenol, 2000, 174(3): 735-743.
18. 莫亮. 基于股骨头坏死“血瘀”理论探讨围塌陷期骨髓水肿的病理机制. 广州: 广州中医药大学, 2023.
19. Kim J, Lee SK, Kim JY, et al. CT and MRI findings beyond the subchondral bone in osteonecrosis of the femoral head to distinguish between ARCO stages 2 and 3A. Eur Radiol, 2023, 33(7): 4789-4800.
20. Meier R, Kraus TM, Schaeffeler C, et al. Bone marrow oedema on MR imaging indicates ARCO stage 3 disease in patients with AVN of the femoral head. Eur Radiol, 2014, 24(9): 2271-2278.
21. Hatanaka H, Motomura G, Ikemura S, et al. Differences in magnetic resonance findings between symptomatic and asymptomatic pre-collapse osteonecrosis of the femoral head. Eur J Radiol, 2019, 112: 1-6.

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