CORE HIP DECOMPRESSION SURGERY IN INDORE

What Is Core Hip Decompression? 

Core hip decompression is a surgical procedure performed to relieve the compression on the femoral head (ball of the hip joint) in patients with femoral head ischemia (blood supply) and/or early-stage avascular necrosis (AVN). The procedure opens up the increased pressure in the medullary cavity of the femur, restores blood supply and can slow down the progression of bone death. 

Avascular necrosis of the femoral head (also called osteonecrosis) is a condition where the blood supply to the bone becomes inadequate causing the cells to die. This may be caused by a fractured femur, chronic corticosteroid treatment, alcohol abuse, sickle cell disease, idiopathic (of unknown origin) or other causes. 

The goal of core hip decompression is to make a tunnel through the femoral neck into the ischemic region of the femoral head and occasionally, inserting a strut of fibula (bone from the small calf bone) into the tunnel. This allows blood flow to “decompress” the higher pressure inside the femoral head, revascularization (blood vessels regrow), and can stop or reduce the rate of necrosis. 

This is a procedure that is most effective if done early in the disease process, before there is significant structural collapse of the femoral head. It is a hip preservation procedure that is used to preserve the patient’s hip joint and prevent or delay hip replacement. 

Avascular Necrosis: Disease Background 

Avascular necrosis is a condition in which the blood flow to the femur’s head is blocked. The bone tissue becomes necrosis (blocked blood flow). As time passes, the dead bone becomes weak and crumbly and may break. 

The disease generally stages as follows: Stage 0-I: imaging change(s) but little/no symptoms. Stage II: Bone necrosis and pressure in bone; patients become painful. Stage III: Collapse of femoral  head structure starts. Stage IV: Advanced disease with significant collapse and secondary. 

Hip Osteoarthritis. 

Importance of early intervention is that a joint-preserving procedure may be the only choice if Stage III collapse has occurred, and hip replacement may be required. Core hip decompression is most effective when the structural collapse is not extensive (Stages I II and early Stage III). 

Indications for Core Hip Decompression 

Core hip decompression may be used when: The patient has an AVN that has been diagnosed with a lack of blood to the femoral head (Stages I-II and early III), when the patient has pain or functional limitation related to AVN, conservative treatment (rest, medications) has failed to improve symptoms, the patient wishes to remain with the natural hip joint, there is adequate bone stock which has not progressed to advanced collapse, and the patient has a good overall health and is able to tolerate surgery. 

Outcomes should be realistically expected: Although decompression can halt disease progression, it can only alleviate pain in many patients and does not ensure that hip replacement will never be needed in all patients. 

The surgeon will thoroughly review imaging and clinical data to consider whether the patient is a good candidate for the procedure. 

Surgical Technique for Core Hip Decompression 

Hip decompression is usually done under general or spinal anesthesia. Patient is placed on his/her back or on their side, depending on the surgeon’s preference. 

A cut into the skin is made to reach the femoral neck. The location of the incision depends on the surgical technique chosen. The usual approach is the lateral so that direct access to the anterolateral femoral neck can be obtained.

Femoral neck bone is exposed. With the help of fluoroscopy (real-time X-ray imaging), a drill or cannulated system is placed to form a hole from the lateral femoral neck into the ischemic region of the femoral head. 

The tunnel is drilled using sequentially larger drills in the direction of the ischaemic area as determined with the pre-operative imaging, from the lateral cortex (outside of the bone) of the femoral neck towards the ischaemic area. The tunnel is placed very carefully so as not to damage the hip joint cartilage. 

Once the tunnel reaches the ischemic area, decompression is achieved by the  removal of necrotic bone and relief of increased intramedullary pressure.  A bone biopsy can be taken to confirm the diagnosis of necrosis and determine whether the surrounding bone is viable. 

In some cases, especially if a fibular strut graft is to be used, a piece of fibula bone is removed from the small calf bone. This graft is inserted into the tunnel to support the weak femoral head and to enhance revascularization. 

Surgical incision is closed carefully in layers. Weight bearing restrictions are placed following surgery to allow healing to occur and to avoid pathological fracture of the decompression area.

Fibular Strut Graft 

Fibular strut graft is generally used for larger lesions or if further structural support is required. The fibula is the smaller of  the two calf bones. A piece of fibula is gently removed, leaving the blood vessels and nerve intact which run down the leg and foot. 

The fibular graft is then put in place in the tunnel, which helps support the bone graft and encourages the growth of new bone. The graft provides scaffolding to stop the collapse until new bone has been laid down. 

The fibular graft requires an additional incision in the calf (which takes 30-45 mins to harvest) and increases time. In a lot of patients, however, the graft offers substantial advantages by helping to support the femoral head during healing and to increase revascularization. 

Recovery after Core Hip Decompression 

Post-core decompression care and recovery demands careful management of weight-bearing to ensure healing of the decompression site. In some cases, immediate postoperative period includes the use of a brace (abduction brace) that holds the hip opened, ice, and elevation, along with the use of pain medications. 

The initial weight-bearing is usually limited for the first 6-8 weeks until the bone has healed. Crutches or walker is used initially, then, as tolerated, a cane is used. X-rays are taken periodically to see if the bones at the decompression have healed. 

The loading phase is delayed until 6-8 weeks after surgery when the bone has healed. Pathological fracture at the area of decompression can result from premature weight-bearing. 

Physical therapy includes progressive ROM exercises, gentle strengthening exercises as weight bearing allows. As the weight bearing tolerance improves, normal gait pattern returns. 

Return to normal activities is slow and takes 3-6 months.  High impact activities, running and jumping are usually delayed for at least 6+ months to reduce stress to the healing femoral head. 

Outcomes of Core Hip Decompression

The results of primary hip(deep) decompression are variable, but generally good as long as the patient is a good surgical candidate. In various published series, the success rate (assessed as pain relief and arrest or slowing disease progression) is 70-90% when performed in early disease. 

For early disease (Stages I-II) there is a higher likelihood of successful outcomes. Many patients experience pain relief with the decompression and the disease process is halted or slowed, and the hip joint preserved. 

In late disease when there is a lot of collapse, prognosis is less certain.  In some patients, good pain relief is achieved even in severe cases. If the disease progresses, others will need to undergo hip replacement surgery eventually after decompression surgery. 

Long-term studies indicate that the hip joint will remain viable for many years following a successful decompression surgery, and in many patients, this procedure will prevent hip replacement surgery or delay it for many years. 

The use of fibular strut grafting has been shown to improve outcomes over that of decompression alone, especially in larger lesions. 

Complications  

If the weight bearing is too heavy too soon after the surgery, a fracture may develop at the decompression site. This is prevented by careful compliance of the weight bearing restrictions. 

Some patients have extensive disease and may not heal even after decompression, or other factors may delay healing, leading to a collapse of the femur head. 

Prophylactic antibiotics result in very few cases of infections at the surgical site. If harvesting of the fibula is done, there may be a risk of fibular nerve injury, which should be avoided by taking care to protect the nerve. If harvesting technique results in denervation of the calf muscle, weakness is uncommon. 

Anesthesia complications are possible in any surgical patient. Hip Preservation vs. Hip Replacement 

Core hip decompression is a hip preserving procedure to preserve the patient’s natural hip joint and is used to delay or avoid hip replacement surgery. 

A hip replacement is a very effective and long-lasting surgery, but it substitutes the natural hip joint for a man-made joint. The hip replacement generally provides a superior pain relief experience when compared to the hip preservation procedures, however, this comes with the sacrifice of losing the natural joint, may require further surgery and some limitations in activities. 

Hip preservation surgeries such as core decompression may be performed for patients with the early stages of AVN and help preserve the hip joint while potentially avoiding a hip replacement. Hip replacement is the better choice as the first line of treatment for older patients or those with advanced disease. 

Dr. Sanjay Rawat will discuss in detail the treatment options and guide patients to the most apt one for their condition and objectives. 

Why Dr. Sanjay Rawat is to be preferred for Core Hip Decompression? 

Dr. Sanjay Rawat has a lot of experience in performing hip preservation surgery, including core hip decompression. He has the experience of selecting the right patient for the right surgery, with a careful technique and comprehensive postoperative management to ensure optimal results.

Dr. Rawat knows the natural history of AVN, when to consider a hip-preserving procedure, and when to consider hip replacement, as well as the different surgical techniques such as fibular strut grafting. 

He takes a patient-centred approach, discussing treatment options, realistic outcomes and complete after-care.  Dr. Sanjay Rawat’s hip preservation care is consistently satisfying and rewarding to patients.

Schedule Your Consultation 

If you have femoral head ischemia or early-stage AVN and are interested in hip preserving treatment options, Dr. Sanjay Rawat invites you to schedule a  consultation. He will evaluate your hip condition, discuss treatment options,  and help you make an informed decision about your care. 

Contact Dr. Sanjay Rawat‘s office today to explore core hip decompression.