Purpose
To evaluate the effectiveness of core decompression (CD) with concomitant arthroscopic treatment of intra-articular pathologies for improving outcomes for patients with osteonecrosis of the femoral head (ONFH) and intra-articular pathology and to compare results with patients undergoing isolated CD.
Methods
A systematic literature review was conducted using PubMed, MEDLINE, and Cochrane Library databases through July 2024, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies comparing CD with and without hip arthroscopy (HA) were included, provided they reported patient-reported outcomes (PROs), survivorship, or total hip arthroplasty (THA) conversion rates. Studies were excluded if HA was solely diagnostic. Quality was assessed using Methodological Index for Non-Randomized Studies and Risk Of Bias In Non-randomised Studies- of Interventions. Data extracted included demographics, surgical techniques, PROs, and THA-free survivorship.
Results
Six studies (4 Level III, 2 Level IV) met the inclusion criteria, comprising 632 hips with mean ages ranging from 35.5 to 41.1 years. All studies reported pre- and postoperative Harris Hip Score, and one included visual analog scale pain scores. Patients undergoing CD with HA had significantly greater postoperative Harris Hip Score (71.41-93.33) and improved THA-free survivorship compared with CD alone. Three of four comparative studies showed significantly lower THA conversion rates and femoral head collapse in the HA group. However, no study directly showed that HA improved bone healing.
Conclusions
CD with HA results in better PROs and femoral head survivorship compared with CD alone, likely because of intra-articular pathology treatment and improved joint function. Core decompression with concomitant hip arthroscopy to address intra-articular pathology should be considered for pre-collapse ONFH.
Level of Evidence
Level IV, systematic review of Level III and IV studies.
Osteonecrosis of the femoral head (ONFH) is a debilitating condition characterized by the interruption of blood supply, leading to bone cell death and eventual collapse of the femoral head. ,, This condition primarily affects young and middle-aged adults, often resulting in severe hip dysfunction and arthritis if left untreated. ,, ONFH progresses through distinct stages, from early asymptomatic phases to femoral head collapse, with the majority of untreated cases culminating in the need for total hip arthroplasty (THA). ,,,
Early intervention is key in preserving the femoral head and delaying or avoiding joint replacement surgery. Core decompression (CD) has long been a cornerstone of treatment for early-stage ONFH, with the aim to relieve intraosseous pressure, promote revascularization, and slow disease progression. ,, Traditionally, CD involves the drilling of a large channel into the necrotic area, reducing intraosseous pressure, and stimulating new bone formation. The combination of hip arthroscopy (HA) with CD has emerged as a promising strategy to enhance the outcomes of avascular necrosis treatment. , HA allows for direct visualization and treatment of concomitant intra-articular abnormalities, such as labral tears, synovitis, and cartilage damage, which often are present in patients with ONFH. ,, Arthroscopy also can facilitate a more precise decompression under direct visualization, which ensures that the drill trajectory does not inadvertently violate the articular cartilage. , However, comparative studies directly evaluating outcomes between isolated CD and combined CD with HA remain limited, with inconsistent methodologies and conflicting results.
This purposes of this systematic review were to evaluate the effectiveness of CD with concomitant arthroscopic treatment of intra-articular pathologies for improving outcomes for patients with ONFH and intra-articular pathology and to compare results to patients undergoing isolated CD. We hypothesized that patients undergoing CD with concomitant HA would show significantly greater postoperative patient-reported outcomes (PROs) when compared with baseline and to patients undergoing isolated CD, along with increased survivorship (defined by lower rates of conversion to THA) after undergoing this combined treatment approach.
Methods
This study was performed in accordance with the ethical standards in the 1964 Declaration of Helsinki. This study was carried out in accordance with relevant regulations of the U.S. Health Insurance Portability and Accountability Act. Details that might disclose the identity of the subjects under study have been omitted. This study was approved by the institutional review board (institutional review board ID: 20242189).
Literature Search
This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. A literature search of the PubMed, Embase, and Cochrane Library databases was conducted on July 5, 2024. Across all 3 databases, key words included in the search query were “((core decompression) OR (avascular necrosis) OR (osteonecrosis)) AND ((hip arthroscopy) OR (hip scope)) AND ((outcomes) OR (follow up)).” The search strategy was registered with PROSPERO (PROSPERO ID # CRD42024571945). The articles selected for review were independently reviewed by 2 authors (A.K. and P.P.S). The full-text studies that were assessed were used for citation searching to further identify relevant articles not obtained in the initial database search.
Study Eligibility
Criteria for inclusion in this review included case-series and comparative clinical studies examining patients with nontraumatic osteonecrosis of the femoral head undergoing a CD procedure with concomitant HA. Studies with HA were not included if the arthroscopy was solely diagnostic. Minimum 2-year follow-up outcome measures or survivorship were required to be reported for inclusion. Exclusion criteria were case reports, technique articles, case series of <10 patients, non−English-language studies, and studies that include CD with a diagnostic HA. Studies were examined and excluded if the studies used a prior cohort to avoid duplication.
Quality Assessment
The methodologic quality of the included studies was graded with the Methodological Index of Non-Randomized Studies criteria and Risk Of Bias In Non-randomised Studies- of Interventions. , Two reviewers (A.K. and R.Q.) separately evaluated each study, and disagreements were resolved by discussion. An interobserver agreement percentage between the 2 reviewers was calculated.
Data Collection
Data extracted from the studies included title, author, year, journal, level of evidence, and dates of study inclusion. Additional data extraction included demographics, length of follow-up, number of hips, radiographic findings, intraoperative findings, and procedures performed. Outcomes extracted included survivorship, baseline PROs, and most recent PROs.
Statistical Analysis
The effect size of Harris Hip Score (HHS) improvement from pre- to postoperation within the concomitant CD and arthroscopy cohort was calculated (R Version 4.4.0, R. Foundation for Statistical Computing, Vienna, Austria). The study effect size was also computed for the mean difference in change of HHS between the concomitant CD and arthroscopy cohort versus the isolated CD cohort. Data pooling was avoided between studies, and continuous variables reported by subgroups within an individual study were combined using Cochrane’s formula. Statistical significance was indicated using P =.05.
Results
Study Characteristics
The database search consisted of 222 studies, and an additional 3 articles identified through citation searching ( Fig 1 ). After the removal of 53 duplicates, a further 153 studies were removed after title screening. Of the remaining studies, 19 were reviewed for eligibility. Thirteen studies were then excluded because they either were published in a non-English language (2), lacked intra-articular assessments (3), were technique articles (7), or were published on techniques without patient reported outcomes (1). This selection process left 6 studies to be included within the systematic review. ,,,,,
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart of included studies.
The 6 articles were published from 2017 to 2024, which included 4 Level III ,,, and 2 Level IV , studies. Three of the studies ,, reported the latest follow-up data, the remaining 3 studies ,, used either a minimum of 2-year, 5-year, or 10-year follow-up, respectfully. The average Methodological Index of Non-Randomized Studies score of the studies was 11.5 for the noncomparative studies and 16.5 for the comparative studies with an interobserver agreement of 90.5% between reviewers. Common methodologic domains of weakness included no prospective calculation of study size and greater than 5% loss to follow-up ( Table 1 ).
Table 1
Summary of Included Studies
| Author | Article Title | Year of Publication | Journal | Study Design | Length of Follow-Up | Dates of Study Inclusion | Level of Evidence | Average MINORS Score | Average ROBINS Score | Indications | Core Decompression Technique |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Ji et al. | Long-term Outcomes of Arthroscopic Synovectomy and Core Decompression Through Multiple Small Bone Holes for Early-Stage Avascular Necrosis of the Femoral Head | 2023 | Arthroplasty | Prospective single-arm case series | 10.7 ± 3.4 yr (range, 9-12 yr) | 2005-2008 | IV | 9/16 | Serious risk |
Early-stage AVN ARCO I-III symptomatic
no previous surgical treatment for AVN |
Hole drilled into center of the femoral head
Decompression was performed either manually or by using a low-speed power drill |
| Li et al. | Long-term Outcome of Multiple Small-diameter Drilling Decompression Combined with Hip Arthroscopy versus Drilling Alone for Early Avascular Necrosis of the Femoral Head | 2017 | Chinese Medical Journal | Comparative cohort study | 57.6 mo (range: 17-108 mo) | 2006-2010 | III | 14/22 | Moderate risk | Small- or medium-sized Ficat stage I or stage II (early stage) osteonecrosis | 3-5 drilled holes, distributed in a fan shape, through one common entry point at metaphyseal region opposite the superior portion of the lesser trochanter, using a 3-mm wire. |
| Nazal et al. | Mid-term Outcomes of Arthroscopic-Assisted Core Decompression of Precollapse Osteonecrosis of Femoral Head—Minimum of 5 Year Follow-Up | 2019 | BMC Musculoskeletal Disorders | Case series | 7 yr ±1.48 yr (range, 64-118 mo) | 2014-2018 | IV | 9/16 | Serious risk | Radiographic findings of stage 0, I, IIa, and IIB based on Ficat-Alret | A 9-mm cannulated reamer was inserted over the guide pin for core decompression. The target of the reamer was the center of the necrotic area. |
| Yang et al. | Mid-term Clinical Outcomes of “Light Bulb” Core Decompression with Arthroscopic Assistance in Peri-collapse Osteonecrosis of the Femoral Head: A Retrospective Comparative Study | 2024 | Orthopaedic Surgery | Retrospective comparative study | 38.3 ± 18.9 mo (range, 24-90 mo) | 2007-2013 | III | 14/22 | Moderate risk | II and IIIA ARCO stage for ONFH | Light bulb technique; Single hole, 10-mm reamer introduced to the necrotic area, to create a bone tunnel in the head-neck junction. Bone particles + bioceramic particles used to fill the necrotic area. |
| Zhao et al. | Hip Arthroscopy Debridement Combined with Multiple Small-Diameter Fan-Shaped Low-Speed Drilling Decompression in the Treatment of Early and Middle Stage Osteonecrosis of the Femoral Head: 14 Years Follow-Up | 2024 | Orthopaedic Surgery | Retrospective cohort study | 14.24 ± 3.54 yr | 1998-2012 | III | 14/22 | Serious risk | ARCO II-IIIA stage ONFH | 3-5 fan-shaped small-diameter holes distributed evenly from the greater trochanter to the necrotic area of the femoral head using a 3-mm wire. |
| Zhao et al. | Intramedullary core decompression combined with endoscopic intracapsular decompression and debridement for pre-collapse non-traumatic osteonecrosis of the femoral head | 2023 | Journal of Orthopaedic Surgery and Research | Comparative cohort study | 2-yr minimum (range not given) | 2015-2019 | III | 14/22 | Moderate risk | ARCO stage I and stage II (early ONFH) | 3-mm Kirschner wire drilled into necrotic area in fan shape in multiple directions. When drilled close to the necrotic area, drill stopped and wire hammered to reach a site 3-5 mm under the cartilage to avoid necrosis of bone cells |
NOTE. Data are presented as means ± standard deviation or n (%).
ARCO, Association Research Circulation Osseous Classification; AVN, avascular necrosis; ONFH, osteonecrosis of the femoral head.
Indications
Similar indications were reported across all 6 studies, which either used the Association Research Circulation Osseous (ARCO) classification stages or Ficat-Arlet avascular necrosis classification stages as the key factor. , Of the 4 studies using ARCO, only 2 included early osteonecrosis of the femoral head (Stage I), , whereas the remaining studies focused on Stages II and III. , In contrast, both studies using the Ficat included early ONFH by denoting stage I and II as indicators ( Table 1 ). ,
CD Technique
A variety of techniques were used and observed in the included studies. Zhao et al. and Zhao et al. initially performed arthroscopy followed by traditional CD. Li et al., Nazal et al., and Ji et al. performed arthroscopy and maintained arthroscopic visualization to assist with traditional CD. Finally, Yang et al. performed arthroscopy under which they opened a cortical window at the level of the head-neck junction for the decompression and bone grafting. Three studies used a fan-shaped CD with multiple small-diameter holes into the necrotic area. ,, Ji et al. drilled a hole into the center of the femoral head and performed decompression manually or with a low-speed power drill. Nazal et al. used a guide pin followed by a reamer to target the center of the necrotic area. Yang et al. used the light-bulb technique, which consists of placing a 10-mm reamer through a single hole into the necrotic area. Subsequently, bone and bioceramic particles were used to fill the necrotic area ( Table 1 ).
Patient Characteristics
The 6 studies included 408 hips that underwent CD with concomitant HA and 224 hips that underwent isolated CD for the treatment of avascular necrosis ( Table 2 ). For the CD and concomitant HA group, the mean age and body mass index ranged from 35.5 to 39.7 and 22.8 to 26.7, respectively. All studies reported on patient populations that were less than 50% female, ranging from 11.1% to 41.3% female. For the isolated CD group, the mean age and body mass index ranged from 35.2 to 41.31 and 21.6 to 25.0. Li et al. did not report body mass index data ( Table 2 ).
Table 2
Radiographic and Intraoperative Information of Included Studies
| Author | Number of Hips Included | Demographics | Imaging Findings | Intraoperative Findings | Intra-Articular Arthroscopic Procedures Performed |
|---|---|---|---|---|---|
| Ji et al. | 185 |
Female: 31 (24.6%)
Age: 38 yr (17-58) BMI: 26 ± 6.2 Left hips: 93 (50.3%) |
ARCO Staging:
Stage I: 43 (23.2%) Stage II: 114 (61.6%) Stage III: 28 (15.1%) |
Synovitis:
Stage I: 19 (44.2%) Stage II: 52 (62.7%) Stage III: 28 (100%) Synovitis Severity: Grade I: 86 (46%) Grade II: 67 (36%) Cartilage lesion of femoral head: Grade I: 22 (11%) Grade II: 29 (16%) Stage II ARCO: 23 (12%) Stage III ARCO: 51 (27%) Acetabular cartilage lesion: 51 (27%) |
Synovectomy
± labral debridement |
| Li et al. |
CD + Scope: 43
CD: 55 |
Scope + CD:
Female: 11 (42.3%) Age: 37.4 ± 10.3 yr CD: Female: 16 (47.1%) Age: 35.2 ± 11.8 yr |
Scope + CD
Ficat staging Stage I: 12 (27.9%) Stage II: 31 (72.1%) CD Ficat staging: Stage I: 17 (30.9%) Stage II: 38 (69.1%) |
Not mentioned |
Labrum fixation or resection
Labral debridement ± Synovectomy ± Chondroplasty ± Traction |
| Nazal et al. | 11 |
Female: 1 (12.5%)
Age: 36.4 ± 9.2 yr BMI: 26.7 ± 3 Left hips: 7 (63.6%) |
CEA: 30.5° ± 3.4°
Ficat-Alret classification: Stage I: 3 (27.2%) Stage IIa: 4 (36.4%) Stage IIb: 4 (36.4%) |
Cartilage wear: 5 (45.4%)
Synovitis: 2 (18.1%) Labral tear: 4 (36.4%) Pincer lesion: 2 (18.1%) Cam lesion: 1 (9.1%) Chondral defect: 3 (27.3%) |
Microfracture: 5 (45.4%)
Synovectomy: 2 (18.1%) Labral debridement: 2 (18.1%) Femoral osteoplasty: 1 (9.1%) Acetabular osteoplasty: 2 (18.1%) Labral repair: 2 (18.1%) |
| Yang et al. |
Scope + CD: 18
CD: 21 |
Scope + CD:
Female: 2 (11.1%) Age: 39.7 ± 8.5 yr BMI: 22.8 ± 2.9 CD: Female: 3 (14.3%) Age: 40.8 ± 10.2 yr BMI: 21.6 ± 2.9 |
Scope + CD:
ARCO staging: Stage II: 13 (72.2%) Stage III: 5 (27.8%) CD: ARCO Staging: Stage II: 17 (81.0%) Stage III: 4 (19.0%) |
Cartilage wear: 15 (83.3%)
Synovitis: 12 (66.7%) Labral tear: 4 (22.2%) Cartilage collapse: 4 (22.2%) Cam lesion: 2 (11.1%) Chondroma: 1 (5.6%) Chondral defect: 2 (11.1%) |
Microfracture: 14 (77.8%)
Reduction of Cartilage Collapse: 4 (22.2%) Synovectomy: 12 (66.7%) Labral debridement: 3 (16.7%) Femoral osteoplasty: 1 (5.6%) Labral repair: 1 (5.6%) |
| G. Zhao et al. |
Scope + CD: 92
CD: 68 |
Scope + CD
Female: 38 (41.3%) Age: 38.2 ± 8.7 yr BMI: 25.2 ± 3.4 CD Female: 29 (42.6%) Age: 41.3 ± 10.2 yr BMI: 25.0 ± 7.1 |
Scope + CD
ARCO Staging: Stage II: 54 (56.25%) Stage IIIA: 30 (39.58%) CD ARCO Staging: Stage II: 41 (60.3%) Stage IIIA: 27 (39.7%) |
Not mentioned- Noted more severe changes with higher ARCO stages |
Synovectomy
Labral debridement ± cartilage trimming ± acetabuloplasty ± femoroplasty |
| Y. Zhao et al. |
Scope + CD: 59
CD: 80 |
Scope + CD
Female: 22 (37.3%) Age: 35.5 ± 9.8 yr BMI: 23.5 ± 2.3 CD Female: 32 (66.7%) Age: 37.7 ± 10.5 yr BMI: 24.7 ± 1.8 |
Scope + CD
ARCO Staging: Stage I: 18 (30.5%) Stage II: 41 (73.2%) CD ARCO Staging: Stage I: 21 (26.3%) Stage II: 59 (73.8%) |
Not mentioned |
Synovectomy
Labral debridement Capsulotomy without repair Negative-pressure drainage tube placed and removed within 48 hours |
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