Arthroscopic Treatment of Labral Tears and Concurrent

Avascular Necrosis of the Femoral Head in Young Adults

David M. Beck, M.D., Brian K. Park, M.D., Thomas Youm, M.D., and
Theodore S. Wolfson, B.S.E.

Abstract: Avascular necrosis (AVN) of the femoral head is a progressive disease affecting young adults that results in
collapse of the femoral head and subsequent degenerative joint disease. Although precollapse stages of AVN can be
successfully treated with core decompression, making the diagnosis is often difficult given alternative sources of hip pain in
this age group. We propose that arthroscopic-assisted core decompression of the femoral head offers an effective method
of addressing AVN of the femoral head as well as coexistent hip disorders in the same operation. This article describes in
detail the technique used to perform an arthroscopic-assisted core decompression of the femoral head, and a companion
video demonstrating the procedure is included. Our experience suggests that arthroscopic-assisted core decompression can
be used as an alternative to open core decompression, while simultaneously addressing other sources of hip pain, with
successful outcomes.

A lthough arthroscopy has been available to the

orthopaedic community since its development in
1931,1 hip arthroscopy has only recently become
popular. A growing number of indications for hip
arthroscopy have caused the number of procedures to
increase 18-fold between 1999 and 2009.2 In this article
we propose that arthroscopic-assisted core decompres-
sion for avascular necrosis (AVN) of the femoral head is
1 more utility of hip arthroscopy.
Osteonecrosis of the femoral head is a common
condition, with up to 20,000 new cases annually,
accounting for about 10% of all total hip replacements.3,4
Patients with osteonecrosis of the femoral head present
with symptoms at a mean age of 38 years, nearly identical
to the age in patients who have symptomatic femo-
roacetabular impingement (FAI) and labral tears.3 In
fact, magnetic resonance imaging scans of patients
undergoing workups for FAI and labral pathology can
From the School of Medicine (D.M.B.) and Hospital for Joint Diseases
(B.K.P., T.Y., T.S.W.), New York University, New York, New York, U.S.A.
D.M.B. had completed this work as a medical student at New York
University School of Medicine. The authors report the following potential
conflict of interest or source of funding: T.Y. is a consultant for Arthrex.
Received March 19, 2013; accepted June 7, 2013.
Address correspondence to David M. Beck, M.D., Thomas Jefferson
University Hospital, 1015 Walnut Street, Room 801, Philadelphia, PA,
19107. E-mail: dmb010@jeffersonhospital.org
Ó 2013 by the Arthroscopy Association of North America. Open access
under CC BY-NC-ND license.
2212-6287/13189
http://dx.doi.org/10.1016/j.eats.2013.06.005
occasionally show an incidental, silent, precollapse
osteonecrosis of the femoral head (Fig 1). The presence of
concomitant FAI and labral pathology in a patient with
early-stage AVN certainly confounds the situation. Is
it the labral pathology or the osteonecrosis that needs to
be treated? Physical examination maneuvers are not
specific enough for these hip conditions to dictate
whether it is the AVN or the FAI that needs to be treated.
Hip arthroscopy gives us the potential to treat both types
of pathology at the same time.
We propose that core decompression for osteonecrosis
of the femoral head can be effectively performed with
hip arthroscopy. In addition, the technique provides
a method to address both the AVN and coexistent
hip disorders in the same operationdnamely, labral
pathology and cam and pincer lesions associated with
FAI. This technical note and accompanying video (Video
1) will describe in detail our methods for performing
arthroscopic-assisted core decompression of the hip.
Surgical Technique
The patient is placed on either a fracture table or
Amsco surgical table (Steris, Mentor, OH) with a hip
arthroscopy traction attachment in the supine position
(Fig 2, Table 1). In addition to standard hip arthroscopy
instruments, a guide pin, a cannulated low-profile
reamer (Arthrex, Naples, FL), a guide pin offset guide,
a bone marrow aspiration kit, and grafts/biological
implants/biocomposite screws are required for core
decompression. The operative hip joint is distracted

Arthroscopy Techniques, Vol 2, No 4 (November), 2013: pp e367-e371 e367

e368
Fig 1. On this T2-weighted axial magnetic resonance imaging
cut, an osteonecrotic lesion and concomitant labral tear are
visualized.
with traction. A large fluoroscope must be positioned
between the patient’s legs to obtain proper cross-table
lateral imaging during the procedure for accurate core
decompression. Diagnostic arthroscopy is performed
after standard mid-anterior and anterolateral portals
are established and an interportal capsulotomy is
created. At this point, the chondrolabral junction is
examined. If a labral injury or cam/pincer lesion is
identified, labral takedown and repair and/or pincer
resection is performed before core decompression. The
Fig 2. Patient placed in supine position on fracture table with
C-arm fluoroscope positioned between legs.
D. BECK ET AL.
Table 1. Technical Tips
Pearls
If using hip arthroscopy traction attachment, replace nonoperative
leg holder with operative leg holder to allow for manipulation of
nonoperative extremity for C-arm positioning.
Confirm ability to obtain anteroposterior and cross-table lateral
views before draping.
Traction may be released during guide pin insertion then reapplied
before core decompression to minimize traction time.
Use arthroscopic curved curette to prevent migration of guide pin
during reaming.
Deep venous thrombosis prophylaxis is recommended
postoperatively.
Pitfalls
Beware of extended traction time because correct insertion of
guide pin can take some time.
Avoid reaming into articular surface by always visualizing joint
arthroscopically.
femoral head is then probed for cartilage softening and
a lack of subchondral support indicative of femoral head
osteonecrosis. By use of fluoroscopy, an incision is made
at the lateral cortex of the proximal femur and a guide
pin is inserted up the femoral neck and into the AVN
lesion. Anteroposterior and lateral images must be taken
to confirm accurate placement of the guide pin into the
lesion (Figs 3 and 4). AVN lesions tend to be anterior and
superior. Accurate insertion of the guide pin is confirmed
arthroscopically by advancing the guide pin into the area
of chondral softening or irregularity. A cannulated low-
profile reamer is then inserted over the guide pin and
under direct arthroscopic visualization and fluoroscopy,
Fig 3. Anteroposterior fluoroscopic image of arthroscopic
guide pin placement into area of osteonecrosis.
 ARTHROSCOPIC CORE DECOMPRESSION OF HIP
Fig 4. Lateral fluoroscopic image of arthroscopic guide pin
placement into area of osteonecrosis.
ensuring no penetration of the articular cartilage (Figs 5
and 6). Bone marrow aspirate is then taken from the
ipsilateral iliac crest and used to soak a biocomposite
screw for 5 to 10 minutes. Again, appropriate screw
depth is confirmed with fluoroscopy and direct visuali-
zation. The screw is advanced over the guidewire to
provide subchondral support. Alternatively, calcium
Fig 5. A cannulated low-profile reamer (Arthrex) is advanced
over a guide pin to the osteonecrotic lesion. Arthroscopy is
used to confirm that reaming is not carried into the hip joint.
e369
Fig 6. An arthroscopic image shows the guide pin penetrated
through the femoral head and into the joint as positioned in
Fig 5.
phosphate may be injected into the decompressed fem-
oral head, as shown in Video 1. Traction is then released,
and the peripheral compartment is entered. At this
point, cam pathology is addressed if present. After a final
inspection of the joint space and surroundings, all
instruments are removed and the portal and decom-
pression sites are closed with sutures (Fig 7).
Fig 7. The reamer and guide pin are removed, and the core
track may be visualized.
e370 D. BECK ET AL.
Discussion
The occurrence of AVN of the hip during early
adulthood makes joint preservation of utmost impor-
tance to maintain these individuals’ societal role and
level of activity. In precollapse osteonecrosis, core
decompression is an effective method of altering the
natural progression of the disease and may help avoid
performing total hip arthroplasty in young patients.
Stulberg et al.5 reported the first prospective random-
ized study to show that core decompression was more
effective than conservative noneweight-bearing treat-
ment. Five years later, a complete review by Mont
et al.6 of 42 articles reporting on 2,025 hips showed that
core decompression resulted in satisfactory clinical
results in 63.5% of hips at any stage of AVN versus
22.7% of nonoperatively managed hips. When limiting
the study to precollapse hips only, the rate of successful
results increased to 71% versus 34.5%. Most surgeons
now endorse an algorithm that provides core decom-
pression for symptomatic precollapse stages.4,7-9
Although the literature shows that symptomatic AVN
can be effectively treated with core decompression, the
treatment of asymptomatic AVN is not as clear. Often,
patients undergoing workups for symptomatic AVN
may have an incidental finding of asymptomatic AVN
of the contralateral hip. Alternatively, as in the cases
presented in this article, silent AVN may be found on
magnetic resonance imaging in the workup of labral
pathology and FAI in young patients. In a meta-analysis
of 16 studies comprising 664 patients, Mont et al.10
investigated the natural history of asymptomatic AVN
and found that 59% of these hips progressed to become
symptomatic and/or undergo collapse. Furthermore,
larger and more laterally located lesions had a higher
incidence of progression than small, medially based
lesions. The authors concluded that aside from small,
medially based osteonecrotic lesions, asymptomatic,
precollapse AVN of the femoral head should be
managed surgically.
Other authors have described arthroscopic techniques
in the diagnosis and treatment of osteonecrosis. Sekiya
et al.11 compared plain radiographs, magnetic resonance
imaging, and arthroscopic visualization of osteonecrotic
lesions and proposed that arthroscopy is a required co-
mponent in staging AVN. Guadilla et al.12 described an
arthroscopic technique with core decompression of the
femoral head using several intra-articular drill holes
at the head-neck junction and injection of platelet-rich
plasma. One study in the German literature reported an
86% success rate in patients undergoing arthroscopic-
assisted core decompression in precollapse AVN of the
femoral head.13 Furthermore, an additional study in
the Chinese literature reported that arthroscopic core
decompression is more effective than traditional closed
core decompression in early-stage AVN.14 However, the
surgical techniques of these 2 outcome studies were
unable to be obtained. Moreover, none of the previously
mentioned studies addressed concomitant treatment of
FAI-type pathology and silent AVN.
Both FAI and labral tears are frequently diagnosed in
young adults, and they may occur in conjunction with
AVN. We believe that the use of hip arthroscopy will
allow surgeons to examine alternate sources of hip pain
at the time of core decompression for AVN and will
ensure that all potential generators of hip pain are
addressed. This is certainly preferable to only treating
either the FAI or the AVN at the index procedure and
then potentially having to repeat surgery in the future if
the hip pain does not completely resolve. Furthermore,
this technique allows direct visualization of the articular
surface, which may help in avoiding overly aggressive
reaming and articular injury. Potential risks of the
procedure include increased traction time, minimally
increased incidence of septic arthritis associated with
arthroscopy, and increased pain after treatment because
of the combination of procedures. In our experience
with this technique, we have not encountered any
increased complications. Hip arthroscopy can be used to
effectively treat AVN of the femoral head while simul-
taneously addressing other conditions.
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