Case Study: Left Hip Core Decompression with

A 45-year-old male with known avascular necrosis of bilateral hips presented to our office to discuss the management of the left hip. The patient previously had a right total hip replacement for avascular necrosis. He was originally diagnosed with AVN of bilateral hips five years ago. Subsequently, secondary to the collapse of the right hip he underwent a total arthroplasty.

The patients described constant pain in the left hip more so for the past year. The pain was mild in intensity and a dull ache in character. There was no radiation of pain and the pain would increase after walking for more than 10 blocks. There was no associated swelling or fever.

The patient was diagnosed with nephrotic syndrome as an adolescent. He had a long history of injectable steroids for kidney disease. The patient reported complete relief from pain after total arthroplasty on the right side.

The patient worked as an administrator for a firm and his work involved sitting for prolonged periods of time. He was a nonsmoker and a nondrinker and had no known drug allergies. He was currently taking Lisinopril and spironolactone for hypertension and kidney disease.

On physical examination, his gait was steady and coordinated. There was no evidence of exaggerated lumbar lordosis. There was no functional or structural scoliosis. The bilateral shoulders, iliac spines, patella, and the malleolus were at the same level.

On the supine examination, the skin overlying the left hip was normal with no scar or sinus tracts. There was no swelling or inguinal lymphadenopathy in the left groin. There was a well-healed surgical scar on the postero-lateral aspect of the right hip consist of previous surgery.

There was mild tenderness at the left anterior joint line. Both the anterior superior iliac spines were at the same level. There was no evidence of any leg length discrepancy. The range of motion of the left hip was normal. There were no fixed deformities in the left hip.

The examination of the lower spine, right hip, and the bilateral ankles and knees were normal. There was no distal neurological deficit and bilateral lower extremity pulses were palpable and comparable. The bulk and tone of both lower extremities were normal.

An X-ray was obtained which suggested a normal artificial joint on the right side. The left hip suggested some sclerosis with an intact spherical head of the femur. There was no crescent sign or any collapse.

Preoperative X-ray of the pelvis with both hips showing intact artificial joint on the right side and AVN of the left hip.

Anteroposterior view of the left hip showing pre-collapse avascular necrosis of the left hip.

An MRI was obtained which was consistent with the previous diagnosis of avascular necrosis of the left hip.

The patient had Ficat & Arlet stage 2A AVN of the left hip. The patient was educated about the possibility of progression of avascular necrosis and collapse of the left hip.

After careful consideration of the patient’s condition, physical examination, and imaging studies, he was advised to undergo a left hip core decompression with stem cell injection. He was informed about the attempt to increase vascularity and reduce the intramedullary pressure of the left hip with the procedure. Risks, benefits, and potential complications were explained to the patient and his wife at length. He agreed with the plan.

DIAGNOSIS(ES): Left hip avascular necrosis.

OPERATION: Aspiration of stem cells from the left iliac crest and concentrating them using the harvest system and core decompression with an injection of stem cells into the left hip.

ESTIMATED BLOOD LOSS: Minimal.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room after obtaining informed consent and signing the correct surgical site. The risks, benefits, and alternatives were extensively discussed with the patient prior to the procedure.

The patient was brought to the operating room, and the patient was anesthetized by the anesthesiologist. The patient was then definitively positioned on the fracture table and fluoroscopy was performed. The left hip was then draped and prepped along with the left iliac crest in the usual sterile manner.

Jamshidi needle was inserted into the left iliac crest and about 180 ml of fluid was aspirated. The aspirate was processed using the harvest system. The two guidewires were then placed into the left hip under fluoroscopic control in a percutaneous manner. Core decompression was performed at the location of the avascular necrosis.

Anteroposterior view of the left hip showing pre-collapse avascular necrosis of the left hip.

Core Decompression at the site of avascular necrosis.

Concentrated stem cells were then injected into the defect after removal of the guidewires. The injection was performed after tilting the table towards the other side. Cutaneous tissues were closed. The skin was closed using Monocryl. Sterile dressing was then applied over the wound, and the patient was then transferred to the postoperative care unit in stable condition.

Postoperative image after core decompression and injection of stem cell harvest.

The patient’s vitals remained stable after the procedure. There was no distal neurological deficit after the procedure. He was allowed to bear weight as tolerated with support after the procedure. The post-operative pain was managed with pain medications.

The patient followed up after three months of post suture removal. He was walking without support and had a full range of motion. He follows up regularly for surveillance of the progression of avascular necrosis.

Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.