Management of stage I and II A/B avascular necrosis of femoral head with core decompression autologous cancellous bone grafting and platelet rich plasma factors
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0975-2870.169881
Background: Avascular necrosis (AVN) of the femoral head is a progressive disease that generally affects patients in the third through fifth decades of life; if left untreated, it leads to complete deterioration of the hip joint. Treatments range from simple decompression of the femoral head, to bone grafting of the involved area, or by using a vascularized fibular graft with varying degree of success. In most instances, the disease progresses further causing secondary arthritis. We present a study of management of early stage AVN (stage I and II A/B of Ficat Arlet classification) with core decompression autologous cancellous bone grafting along with platelet rich plasma. Aims: To evaluate the results of the above modality in the management of AVN of the hip. Settings and Design: This prospective study of 30 cases was done during the period of 2011-2013. Materials and Methods: Patients with stage I and II A/B were treated with the above modality and were followed up for 1-year. The results were evaluated on the basis of progression or remission of the disease by radiographic studies, preoperative and postoperative Harris hip score (HHS), age and sex distribution. Statistical Analysis Used: Primer software for calculating the statistical data was used and paired t-test was applied to all the data. Results: Show males were more affected than females and average age group of presentation in stage I and II was 29 years (22-55). The most common cause was idiopathic followed by steroid use. Average preoperative HHS was 56.80 and postoperative HHS was 79.73. 60% (18) showed remission of the disease (radiographically) compared to preoperative stage at 1-year follow-up, in 30% (9) disease did not progress further and 10% (3) progressed and required arthroplasty. Conclusion: Management of stage I and II A/B AVN of femur showed good satisfactory results in terms of disease remission and prevention of the further progress of the disease by the above method at 1-year follow-up and further follow-up is awaited. Keywords: Avascular necrosis of head of femur, core decompression, platelet rich plasma, precollapse stage
Avascular necrosis (AVN) or osteonecrosis of the femoral head involves the head of femur, with osteocytes of the femoral head dying along with the bone marrow, subchondral fracture, and ultimately collapse. In the end stages of the disease with collapse of femoral head, severe arthritic changes may be seen on both sides of the joint. [1] There are two forms of osteonecrosis: Traumatic (the most common form) and atraumatic. AVN usually affects people between 30 and 50 years of age; about 10,000-20,000 people develop AVN of the femoral head in the US each year. [2] The clinical presentation of AVN depends on the age of the patient. In the elderly who have sustained a subcapital fracture, AVN is often heralded by increasing pain and a radiograph that shows fixation failure, collapse of the femoral head, or both. In younger patients, AVN usually arises without any fracture and pain is the most common presenting feature. [3] Management of AVN depends on the age of the patient, size of the lesion, and stage of the disease. In the elderly who develop AVN following a hip fracture, total hip arthroplasty is the treatment of choice. In younger patients with AVN, determining the size of the lesion is important as this has a direct influence on the prognosis. The size is best determined by MRI. Small lesions (<15% of the femoral head) may resolve without treatment. Large lesions (>50% of the femoral head) tend to progress to collapse of the head and secondary osteoarthritis, despite treatment. [3] A review of the recent literature regarding nonoperative management with a bisphosphonate, anticoagulant, and vasodilators and biophysical modalities have demonstrated efficacy in reducing pain and delaying disease progression in early stage osteonecrosis. Though it has been considered still insufficient, to support their routine use in the treatment or prevention of osteonecrosis of the hip. [4] The operative treatments range from simple core decompression of the femoral head and lower the intraosseous pressure, to bone grafting of the involved area either directly after dislocating the hip and elevating the involved segment, or by using a vascularized fibular graft placed up the center of the femoral neck from the lateral cortex. There have been a number of osteotomies described whose purpose is to remove the affected area of the femoral head from the weight-bearing axis of the hip: The varus and valgus osteotomies and more complex rotational osteotomies. [3] The advantage of core decompression is based on the belief that the procedure relieves intraosseous pressure caused by venous congestion, allowing improved vascularity, and possibly slowing the progression of the disease. Several authors noted that the results of core decompression are better than the results of nonoperative treatment. Review of the literature currently supports the use of core decompression for the treatment of Ficat stage I and IIA small central lesions in young, nonobese patients who are not taking steroids. This surgery is relatively simple to perform and has a very low complication rate. [1] Successful results after core decompression with structural bone grafting for the treatment of osteonecrosis of the femoral head have been reported in 50-80% of patients. Structural bone grafting techniques after core decompression have been described using cortical bone, cancellous bone, vascularized bone graft, and debridement of necrotic bone from the femoral head, each with promising results. [1] The number and variety of procedures indicate both the lack of a clearly superior treatment and the undesirability of total hip arthroplasty for the treatment of osteonecrosis because of its high rate of failure. [5],[6],[7],[8] Factors that contribute to the high rate of failure include the relatively young age and long life expectancy of the patients as well as the poor quality of the femoral bone and the possible persistent defects in bone mineral metabolism. [9] Platelet rich plasma (PRP) was initially developed in the 1970s. Platelets play a crucial role in the normal healing response of connective tissues by local secretion of growth factors and recruitment of reparative cells. [10] Daif concluded that direct application of the PRP along the fracture lines may enhance the bone regeneration in the mandibular fracture. [11] Meury T KLSTAM demonstrated that in the presence of PRP, the mesenchymal stem cells (MSC) differentiated into bone forming cells when introduced at fracture sites where MSC are abundant. [12] The past studies and references show that introduction of PRP can cause the increased and faster bone regeneration. Thus, making it a viable option for management of AVN of the femoral head in pre collapse stages. This study was performed to evaluate the efficacy of the procedure. Further comparative studies will be performed to study the efficacy of this procedure with other available procedures. Aims and objectives To study the effect of core decompression with autologous cancellous bone grafting and PRP on healing in AVN of the femoral head.
The patients were evaluated for hip pain and 30 patients fulfilling the following criteria were included in this study. All the patients with stage I and II A/B (Ficat Arlet classification) AVN of hip, patients with age group above 20 and <60 years of both sexes, and patients with either unilateral or bilateral disease. The patients with stage III and IV of Ficat Arlet classification, patients below 20 and above 60 years of age were excluded from the study. A detailed history of the patients was recorded to find out the cause. Movements at the hip were noted. Preoperative Harris hip score (HHS) was calculated for each patient. Patients were evaluated with X-rays and MRI. On the day of surgery, a blood bank technician collected one bag (350 ml) of blood from the patient ½ h before the surgery. This blood was transferred to the blood bank. The blood was centrifuged to separate it into three layers which were red blood cell, buffy coat, and plasma. Then buffy coat and plasma was separated into another bag and once more the bag was centrifuged. Finally after two cycles of centrifuge there were three bags: One containing packed cell volume (PCV), one PRP, and one platelet poor plasma. PRP and PCV were immediately sent to the operation theatre. PRP was used for the procedure and PCV was transfused postoperative to the patient with all transfusion precautions. All the patients presenting with bilateral side were operated on one side in single sitting. Preoperative anesthesia fitness was taken from anesthetist. The patient was taken supine on a fracture table. Preoperative 1.5 g of cefuroxime was given intravenously 15 min prior to incision. Cancellous graft was harvested from iliac crest and filled in two 2cc syringes, which was cut from front. Quadrants of necrosis were predetermined from MRI and standard core decompression was done with 8 mm coring reamer directing that quadrant [Figure 1]. All the dead material was curetted out with small curettes. The table was tilted towards the opposite side. A long spinal needle was introduced in the track in the necrotic quadrant. The track was filled with cancellous graft filled in the syringe. PRP was filled in 10cc syringe and was mixed with 0.4 ml of CaCl 2 to activate it. This mixture was instilled in the necrotic quadrant through the spinal needle [Figure 2]. The hole of core decompression track was closed with a cortical piece which was removed with a large hollow meal from iliac crest. The wound was closed in layers. The patient was kept inclined towards opposite side for the night.
Of 30 patients with AVN, there were 24 male patients and 6 female patients. The mean age was 30.4 years with a minimum of 22 years and maximum 55 years. 70% of the patients were in the age group between 21 and 30 years. In our study, we had 14 patients with bilateral disease, 10 patients with right side affection and 6 patients with left side affection. The grade of affection of both hips of all patients are given in [Table 1]. As we did not operated bilateral side in single sitting, we had 16 patients operated for the right side and 14 patients operated for the left side. Among the operated patients, there were 16 patients with stage IIA, 9 patients with stage IIB and 5 patients with stage I disease. The mean ± standard deviation (SD) of preoperative HHS was 56.8 ± 5.01.
The patients were followed up for 1-year and evaluated with MRI at 6 months and 1-year. Also, HHS was recorded after 1-year. At the end of 1-year, there were 18 patients who showed remission of the disease, 9 patients showed limitation to the preoperative stage and 3 patients progressed to a further stage. The postoperative mean ± SD HHS was 79.73 ± 13.92. There were 4 patients with excellent HHS, 16 patients with good, 7 patients with fair, and 3 patients with poor HHS at 1-year follow-up. On applying the paired t-test, the P value for pre- and post-operative HHS was <0.001.
AVN or osteonecrosis of the femoral head is a multifactorial disease, the final outcome of which is osteoarthritis of the hip joint which makes total hip arthroplasty unavoidable to lead a normal pain free life. Recent literature also shows that AVN, which was usually seen in elderly age group, has an increasing incidence in the young population. So, if arthroplasty is done in such a young patient, there arises a need for revision arthroplasty which becomes unavoidable due to increased life expectancy. Thus various studies have been conducted to diagnose the disease in early stages that is, in precollapse stage, and different treatment methods have been explored to halt the disease process and prevent progression of arthritis with varying degrees of success. [13],[14],[15],[16] In our study of 30 cases of precollapse AVN treated with core decompression with bone grafting and PRP, the analysis of the results was made in terms of age distribution, sex distribution, side of involvement, stage of the disease, complications, and final clinical assessment using HHS. The mean age of patients in our study was 30.4 years with a maximum of 55 years and minimum of 22 years. Also, 26 (86.67%) patients were below 40 years of age. Thus, we concluded that AVN of the hip is prevalent in the younger population which could be associated with the multifactorial cause and fast moving life. In our study, there were 24 males and 6 females. Thus, we concluded that males were more frequently affected than females and there was a male:female ratio of 4:1. A thorough search of the literature did not reveal any association of idiopathic AVN with sex, but there are published studies with more number of males than females. Even Etemadifar et al. [17] did not find any association of AVN with sex. In the cluster of patients who were included in our study, there were 14 patients with bilateral affections, 10 patients with only right hip affection, and 6 patients with only left side involvement. This data did not have any statistical significance to show that there was any association of AVN with a side of involvement. We found that maximum patients in our study had bilateral involvement which was also seen in a study by Etemadifar et al. [17] In our study, we found that most common stage of AVN at presentation was stage II-A 53.33% according to Ficat Arlet classification. Among the other hips included in the study there were 30% of hips in stage II-B and 16.67% in stage I. Post collapse hips that is, stage III and IV were not included in the study. Steinberg et al. [18] found in their study of 312 hips in 208 patients that maximum patients were in stage II-A according to Ficat Arlet classification. Many western studies have reported stage I to be more common than stage II-A which could be due to better diagnostic methods and facilities and also aware and educated patient compared to Indian population where patients do not seek early medical attention. Mean preoperative HHS was 56.8 in our study with a standard deviation of +5.02. Yan et al. [19] in their study reported a mean preoperative HHS of 58 points (range, 46-89). Berend et al. [16] in their study on the management of osteonecrosis found that average preoperative score was 54.5 points. These findings of preoperative mean HHS coincide with our present study. Mean postoperative HHS at 1-year was 79.73 in our study with a standard deviation of +13.68. Yan et al. [19] showed that there was a mean improvement of 86 points (range, 70-94) in their study after a 2 years follow-up. Berend et al. [16] found that the postoperative average improvement in HHS was 81.0 points at an average of 4 years. This advocates a further long-term follow-up of all the patients included in this study as these patients were followed up only for 1-year. There was an average improvement of 22.93 points in the HHS at 1-year postoperatively which was significant (P < 0.001). According to HHS as described by Harris [20] there should be an average increase of 20 points in pre- and post-operative HHS to consider the treatment as effective. A mean difference of 21 points was observed by Yoshioka et al. [14] in their study on hips treated with core decompression and the bone marrow aspirate infiltrate. According to the evaluation criteria of HHS, we found that 100% of all cases had a poor score preoperatively. At 1-year follow-up 13.33% (4 cases) had excellent results, 53.34% (16 cases) had good results, 23.33% (7 cases) had fair results, and only 10% (3 cases) had poor outcome in our study. In a study conducted by Martin et al., [21] they found that 21% (16 hips) had a failure who were treated with the bone marrow aspirate and PRP. In another study by Yoshioka et al. [14] they found 1 out of 6 hips failed and total hip replacement (THR) was necessary. Gangji et al. [22] did a comparative study between core decompression and core decompression with bone marrow and after 5 years follow-up found that 8 of 11 hips failed after core decompression and only 3 of 13 hips failed in bone marrow group. In the year 1999 Louie stated that in patients with the mean age of 34 years the success rate was 73%. [23] Later in 2009 Biswal et al. reviewed 50 patients including 60 hips with a mean age of 28 years, who underwent transtrochanteric rotational osteotomy. It was concluded that out of 60, 10 hips showed progressive collapse, 7 hips suffered progressive varus deformity, occurrence of stress fractures of the femoral neck in 3 hips whereas infection on 1 hip. [24] In a study modified transtrochanteric rotational osteotomy was carried out in 39 patients including 43 hips. It was concluded that the mentioned procedure was an effective in delaying the progression of collapse of osteonecrosis of femoral head. [25]
The core decompression with bone grafting and PRP is a viable option for treatment of early stage (stage I and II A/B) or precollapse AVN of femoral head, in terms of improvement in ability to perform daily activities and delaying or halting the process of necrosis of the femoral head. This procedure helps in preserving the natural joint which is the goal in younger individuals as replacing the joint at the young age will need a subsequent revision because the implants itself have their self life. In our study we conclude that, adding PRP to the conventional core decompression and bone grafting, which showed fair to good results in literature, gives additional good to excellent results at a short-term follow-up in precollapse stage of osteonecrosis of hip but long-term follow-up is awaited. Further comparative studies are required to assess the improvement scores of the above procedure and the procedures mentioned in the literature. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1], [Figure 2]
[Table 1]
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