CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 386, pp. 71–78
Core Decompression
Core Decompression With Bone Grafting
for Osteonecrosis of the Femoral Head
Marvin E. Steinberg, MD; Peter G. Larcom, MD;
Brereton Strafford, MD; W. Bartley Hosick, MD; Arturo Corces, MD;
Roy E. Bands, MD; and Karen E. Hartman, BSN
Although core decompression is one of the more
popular procedures for treating avascular necro-
sis, considerable controversy exists concerning its
safety and effectiveness. The current authors re-
view the results of a prospective study of 406 hips
in 285 patients treated by one surgeon with core
decompression and bone grafting. Patients were
followed up for 2 to 14 years. The outcome was
determined by the change in the Harris hip score,
quantitative radiographic measurements, and
need for total hip replacement. These hips were
compared with 55 hips in 39 patients treated non-
operatively and with historic controls. Five com-
plications occurred after 406 procedures includ-
ing two fractures that resulted from falls during
the first postoperative month. Of the 312 hips in
208 patients with a minimum 2-year followup,
36% of hips (113 hips in 90 patients) required hip
replacement at a mean of 29 months: 18 of 65 hips
(28%) with Stage I disease; 45 of 133 hips (34%)
with Stage II disease; three of 13 hips (23%) with
Stage III disease; and 45 of 92 hips (49%) with
Stage IV disease. Before femoral head collapse
(Stages I and II combined) hip replacement was
From the Department of Orthopaedic Surgery, University
of Pennsylvania School of Medicine, Philadelphia, PA.
Reprint requests to Marvin E. Steinberg, MD, Depart-
ment of Orthopaedic Surgery, 3400 Spruce Street,
Philadelphia, PA 19104.
71
© 2001 Lippincott Williams & Wilkins, Inc.
performed in 10 of 77 hips (14%) with small le-
sions (A), 33 of 68 hips (48%) with intermediate
lesions (B), and 20 of 48 hips (42%) with large le-
sions (C). Results as determined by changes in
Harris hip scores and radiographic progression
were similar. Patients who underwent core de-
compression and bone grafting have a very low
complication rate. In patients treated before fem-
oral head collapse, the outcome is significantly
better than in patients who received symptomatic
treatment. The results are correlated with the
stage and the size of the necrotic lesion.
It has been well documented that without spe-
cific treatment approximately 70% to 80% of
hips with clinically established avascular
necrosis have radiologic and clinical progres-
sion, which leads to collapse of the femoral
head.7,9,10,16,18,19 Most of these hips eventually
undergo total hip replacement or other types of
arthroplasty. Because this is a condition seen
primarily in younger adults, several prophylac-
tic procedures have been performed in patients
with the earlier stages of avascular necrosis in
an attempt to halt progression and encourage
repair. Of these procedures, core decompres-
sion perhaps is the most frequently used.
Although there have been several studies on
 Clinical Orthopaedics
72 Steinberg et al and Related Research

core decompression, their conclusions have
been different and much uncertainty about the
safety and effectiveness of this procedure re-
mains.2–5,7–11,16–20 The goal of the current
study is to help resolve some of these issues.
In 1980, after experiencing poor results treat-
ing patients with avascular necrosis conserva-
tively, the authors began to perform a modified
type of core decompression with supplemental
cancellous bone graft. By July 1997, 406 pro-
cedures were performed by the senior author.
These procedures form the basis of the current
study.
MATERIALS AND METHODS
Patients were placed on a fracture table with an im-
age intensifier in place. Through a lateral approach,
an 8-mm core of bone was removed from the cen-
ter of the necrotic lesion using Michele trephines
(Life Instruments Corp, Braintree, MA). The core
reached to within 5 mm of the articular surface. Us-
ing the same entry site in the lateral femoral cortex,
two, 6-mm cores of bone were removed from the
periphery of the lesion. The viable cancellous bone
obtained from the intertrochanteric region then was
thinned with a rongeur and placed very loosely into
the central core. The two smaller core tracks were
left open (Fig 1). Additional bone was placed at the
cortical margin of the femur to promote healing of
the surgical defect. In several instances the proce-
dure was performed on both hips with the patient
under the same anesthetic. Patients then were
allowed partial weightbearing using crutches for
3 months.
Patients were seen in followup every 3 months
for the first year, every 6 months for the second
year, and yearly thereafter. Immediately before
surgery and at each followup patients were evalu-
ated clinically by the use of Harris hip scores6 and
by good quality anteroposterior (AP) and lateral ra-
diographs. Magnetic resonance imaging (MRI)
was used to evaluate radiographic lesions preoper-
atively. Early postoperative complications were
observed. For those patients who required addi-
tional surgery, total hip replacement was the pro-
cedure of choice for virtually all patients.
Two subgroups of patients were treated with
electrical stimulation in addition to the core de-
compression and grafting. One group of 74 patients
received a constant direct current stimulation to the
necrotic segment by means of a cathode coiled
about the graft and attached to an Osteostim ®
(Telectronics, Englewood, CO) or an Orthofuse ®
(DePuy, Warsaw, IN).14 A second group of 20 pa-
tients was treated with capacitive coupling by
means of surface electrodes applied anteriorly and

A B

Fig 1A–B. (A) Schematic drawing showing the technique for performing core decompression with the
Michele trephine in place. (B) Schematic drawing of decompression channels showing central bone
grafts in place. (Reproduced with permission from Steinberg ME, Brighton CT, Bands RE, Hartman KM:
Capacitive coupling as an adjunctive treatment for avascular necrosis. Clin Orthop 261:11–18, 1990.)
Number 386
May, 2001 Core Decompression 73

posteriorly to the skin directly over the femoral
head and connected to a portable power unit.13
Between July 1980 and July 1997, 406 hips in
285 patients with avascular necrosis were treated
with core decompression and bone grafting. This
group of patients was evaluated to determine the in-
cidence of postoperative complications. Two hun-
dred forty-five patients (338 hips) were operated on
before December 1994. Of this group, five patients
(eight hips) died and 13 patients (18 hips) could not
be located for a 2-year followup. These patients
were excluded, leaving 312 hips in 227 patients
with a minimum 2-year followup which were eval-
uated to determine the effectiveness of core de-
compression with bone grafting.
These hips were compared with 55 hips in 39
patients treated at the authors’ institution before
1980 by protected weightbearing alone and with
published reports of other series.7–10,16–19
Results were determined by the change in Har-
ris hip scores from preoperative evaluation to the
last followup visit, the radiographic resolution or
progression as determined by the University of
Pennsylvania system for staging avascular necro-
sis14,15 (Table 1), and by the need for subsequent to-
tal hip replacement arthroplasty.
RESULTS
The mean age of the patients at the time of de-
compression and grafting was 37 years (range,
19–65 years). Forty-one percent of patients
were women and 59% were men. Hip in-
volvement was unilateral in 35% of patients
and bilateral in 65%. The followup for the pri-
mary study group of 227 patients was between
3 and 155 months with a mean of 48 months.
This group included patients who underwent
total hip replacement before the minimum 2-
year followup. The mean followup for patients
who required total hip replacement was 29
months (range, 3–155 months) (Fig 2). For
those patients who did not require total hip re-
placement, the mean followup was 63 months

TABLE 1. University of Pennsylvania System for Staging Avascular

Necrosis
Stage Criteria

0 Normal or nondiagnostic radiograph, bone scan, MRI

I Normal radiographs, abnormal bone scan, MRI scan, or both
A. Mild ( 15% of femoral head affected)
B. Moderate (15%–30%)
C. Severe ( 30%)
II Cystic and sclerotic changes in femoral head
A. Mild (15% of femoral head affected)
B. Moderate (15%–30%)
C. Severe ( 30%)
III Subchondral collapse (crescent sign) without flattening
A. Mild ( 15% of articular surface)
B. Moderate (15%–30%)
C. Severe ( 30%)
IV Flattening of femoral head
A. Mild (15% of surface and 2 mm depression)
B. Moderate (15%–30% of surface or 2–4 mm depression)
C. Severe (30% of surface or 4 mm depression)
V Joint narrowing iand/or acetabular changes
A. Mild y Average of femoral head involvement,
B. Moderate t as determined in Stage IV, and estimated
C. Severe acetabular involvement
VI Advanced degenerative changes

(Reprinted with permission from Steinberg ME, Brighton CT, Corces A, et al: Osteonecrosis of the femoral head. Results
of core decompression and grafting with and without electrical stimulation. Clin Orthop 249:199–208, 1989.)
 Clinical Orthopaedics
74 Steinberg et al and Related Research

Fig 2. Graph showing the num-

ber of hips requiring total hip re-
placement at specific intervals af-
ter decompression and grafting.

(range, 23–146 months). The mean followup pulmonary embolism; one proximal femoral
for the 39 patients (55 hips) who did not un- thrombophlebitis; one pneumonia; and two
dergo surgery was 21 months. fractures sustained in falls during the first
Etiologic factors and associated conditions month after surgery. One of these fractures was
are shown in Table 2. Preoperatively, hips an intertrochanteric fracture going through the
were placed in the following stages according surgical defect in the lateral cortex and the
to the University of Pennsylvania system for other was a subcapital fracture.
staging14 (Table 1): Stage 1, 69 hips (22%);
Stage II, 133 hips (43%); Stage III, 13 hips Results of Electrical Stimulation
(4%); Stage IV, 92 hips (29%); Stage V, five Seventy-four hips in 74 patients were treated
hips (2%). with supplemental direct current in addition to
the core decompression and grafting. Initially
Complications it seemed that these patients had a slightly bet-
In the 285 patients (406 hips) who had under- ter outcome than the patients treated without
gone decompression and grafting, there were electrical stimulation regarding Harris hip
five complications: one massive but nonfatal scores, radiographic progression, and the need
for total hip replacement.14 On subsequent
evaluation, however, no significant differences
between these groups were observed.
TABLE 2. Etiologic Factors and No clinical or radiographic differences were
Associated Conditions observed between the 20 control hips and 20
experimental hips in the group of patients who
Percentage of
Etiologic Factors Hips Affected were treated with capacitive coupling, either
early or late in the study.13
Steroids 47% Because there were no differences between
Alcohol 19%
patients treated with supplementary electrical
Steroids and alcohol 15%
Idiopathic 14% stimulation and those treated with decompres-
Miscellaneous 11% sion and grafting alone, these groups were
Associated Conditions combined for all subsequent analyses.
Allergic states 31%
Systemic lupus erythematosus 18% Outcome
Gastrointestinal disorders 13% One hundred thirteen hips (in 90 patients) of
Central nervous system problems 9%
the 312 hips (in 208 patients) (36.2%) required
Organ transplantation 7%
total hip replacement at a mean of 29 months
Number 386
May, 2001
from core decompression (range, 3–155
months). Sixty percent of the total hip replace-
ments occurred during the first 2 years, 29%
occurred between 2 and 5 years, and 11% oc-
curred after 5 years (Fig 2). Of the 39 patients
(55 hips) treated by protected weightbearing
alone, 77% underwent arthroplasty at a mean
of 21 months from the onset of symptoms.
For the entire group, the mean preoperative
Harris hip score was 73 points (range, 25–100
points). The postoperative score was 71 points
(range, 3–100 points) for a mean loss of 2
points. Hips that required total hip replace-
ment had 69 points preoperatively and 45
points postoperatively, for a mean loss of 24
points. Those hips who did not require hip re-
placement had 74 points preoperatively and 85
points postoperatively, for a gain of 11 points.
There was a high incidence of radiographic
progression, even in patients who did well clin-
ically. Thirty-nine percent of hips in patients
who did not require hip replacement were ra-
diographically stable as compared with only
19% of hips in patients who required hip re-
placement. For the entire group, the mean stage
preoperatively was Stage II-C (range, Stage I-
A–Stage V-B) with the mean stage at last fol-
lowup Stage III-C (range, Stage I-A–Stage V-
C). The progression in hips requiring hip
replacement was from Stage III-A to Stage IV-
C or 12⁄3 stages. In hips not requiring total hip
replacement, the mean stage progressed from
Stage II-C to Stage III-A or 1⁄3 stage.
Etiologic Factors
Total hip replacement was required in 39% of
patients taking corticosteroids, in 38% of pa-
tients with excessive alcohol intake, in 52% of
those patients in whom steroid and alcohol
were implicated, and in 33% of patients with
idiopathic osteonecrosis. Thus, no clear rela-
tionship to etiology was observed except in
patients exposed to a combination of steroids
and alcohol in whom the prognosis seemed to
be somewhat worse. There did not seem to be
any difference in outcome in those patients in
whom the insult was limited to the preopera-
tive period as compared with those who con-
Core Decompression 75
tinued to take corticosteroids or those who had
excessive alcohol intake after surgery.
Relationship of Stage to Outcome
As expected, the outcome generally was
worse in patients with more advanced stages
of avascular necrosis. Results as determined
by the need for total hip replacement, clinical
course, and radiographic progression were
similar. Hips that were in earlier radiographic
stages preoperatively generally also were in
earlier stages at final followup in the group of
patients who did not require total hip replace-
ment. This was not true for patients who un-
derwent hip replacement, because this proce-
dure was not performed until significant
collapse had occurred, usually Stage IV-C or
beyond. Radiographic progression had to be
evaluated with caution, because less progres-
sion was possible in hips initially with more
advanced stages. Harris hip scores were higher
for hips in earlier stages preoperatively and at
final followup; however the changes in score
that occurred during this interval were similar
for all stages. The correlation between stage
and hip replacement is shown in Figure 3. The
results in the patients who underwent decom-
pression and grafting are compared with the
results in 55 control hips in 39 patients treated
by protected weightbearing alone.14 This fig-
ure does not indicate the results for patients
with Stage I disease who were treated nonop-
eratively because MRI was not available at
this time and therefore no hips were graded as
Stage I.
In each stage, nonoperative treatment led
to approximately twice the number of patients
requiring hip replacement as did decompres-
sion and grafting. The survivorship of femo-
ral heads in patients treated with decompres-
sion and grafting was approximately three
times that of hips in patients treated by limited
weightbearing. This is noteworthy because
the mean followup for hips treated nonopera-
tively was only 21 months, as compared with
a mean of 48 months for hips undergoing
surgery. There was no significant difference
in the percentage of hips requiring replace-

76 Steinberg et al
ment in Stages I, II, and III, but as a group
these hips required fewer replacements than
hips treated after collapse (Stage IV). The
similarity in outcome between patients with
Stage III disease (crescent sign) and patients
with Stages I and II disease emphasizes the
importance of grouping these patients sepa-
rately and not including patients with Stage
III disease with patients who have undergone
femoral head flattening (Stage IV). Even in
patients with Stage IV disease a better out-
come resulted after surgery than after nonop-
erative treatment. Although a large number of
patients with Stage IV disease underwent de-
compression and grafting, these were limited
to patients whose hips had relatively small or
intermediate amounts of collapse (Stage IV-A
and Stage IV-B) and who had minimal pain or
disability.
Clinical Orthopaedics
and Related Research
Fig 3. Graph showing the
percentage of hips requiring
total hip replacement arthro-
plasty by stage of avascular
necrosis for patients whose
hips were controls and for
patients who underwent de-
compression and grafting.
Relationship of Lesion Size to Outcome
To determine the effect of lesion size on out-
come, hips which were in Stages I and II before
surgery, (precollapse) were evaluated together.
Figure 4 shows the percentage of hip replace-
ments required in hips with Stage I and II dis-
ease that had small (A), intermediate (B), and
large (C) lesions. Patients with small lesions
had a significantly better outcome than patients
with intermediate or large lesions (p  0.05)
but there was no difference between these lat-
ter two groups. The results as determined by
radiographic progression and change in Harris
hip score were similar to the results as indi-
cated by the need for hip replacement. Radi-
ographs evaluated on a 21-point scale showed
progression by 1.1, 4.2, and 4.3 points; and the
Harris hip score showed an improvement of
10.6 and 3.3 points, and the loss of 3.6 points,
Fig 4. Graph showing the relation-
ship between total hip replacement
and the size of the necrotic lesion
for hips with Stages I and II disease
before femoral head collapse.
Number 386
May, 2001
respectively for hips with small (A), interme-
diate (B), and large (C) lesions.
DISCUSSION
Core decompression was described by Arlet
and Ficat in 1964.1 By 1980, they had per-
formed more than 800 cases.4,5 In 1985, Ficat4
reported on 133 hips with Stages I and II dis-
ease treated by core decompression. He re-
ported “good to very good results” in 90% of
these hips on clinical evaluation and in 79% on
radiographic evaluation. In 1986, Camp and
Colwell2 retrospectively reviewed 42 core de-
compressions performed by 13 different sur-
geons. Sixty percent of hips treated before col-
lapse failed either clinically or radiographically
and all hips treated after collapse were consid-
ered clinical failures. Four patients sustained
fractures after surgery. A question regarding
the safety of this procedure was raised. In 1955,
Koo et al8 reported only symptomatic relief af-
ter core decompression but no effect in pre-
venting femoral head collapse when compared
with nonoperative treatment in a small number
of patients with avascular necrosis of the hip. In
a comprehensive review of the literature, Mont
et al9 reviewed 42 reports involving 2205 hips.
Core decompression was used to treat 1206
hips and 819 hips were treated nonoperatively.
Satisfactory results were observed in 64% of
the hips in patients who were treated by core de-
compression, but in only 23% of those hips in
patients who were treated nonoperatively. In
hips evaluated before collapse, good results
were obtained in 71% of patients who were
treated by core decompression as compared
with only 35% of patients who were treated
nonoperatively.
It is not entirely clear why such a disparity
exists between the various reports on outcome
of core decompression.2,3,7,10,11,16–20 Unfortu-
nately, it is difficult to compare different stud-
ies because many variables are present. These
variables include technical factors, inclusion
criteria, the methods for following progres-
sion or resolution, demographic differences,
and the means used to determine outcome.
Core Decompression 77
Several methods have been used to evaluate
radiographic status and many have indicated
stage alone without attempting to measure le-
sion size. It now is recognized that the extent
of the necrotic lesion is an important factor in
determining outcome, and that without quan-
titative measurements, an accurate evaluation
of radiographic progression or resolution can-
not be made.12
The current study includes a large number
of patients operated on by one surgeon and fol-
lowed up for as many as 14 years. A standard-
ized operative approach was used in all cases,
and patients were evaluated prospectively us-
ing clinical and objective radiographic criteria.
In the current series, the 80% to 90% satisfac-
tory results that were reported by some early
investigators were not achieved, but it was
shown that if properly performed the proce-
dure had an extremely low incidence of com-
plications and was effective in treating patients
with earlier stages of avascular necrosis as
compared with patients who were treated non-
operatively or patients who received sympto-
matic treatment. Although patients with a sig-
nificant degree of collapse, pain, or disability
did not undergo decompression and grafting,
the results of surgery in patients with Stages
IV-A and B disease seemed to be better than
the results of patients who received conserva-
tive treatment. Significant differences in out-
come were observed in patients with Stages I
and II disease who had small lesions, as op-
posed to those patients with larger lesions. This
emphasized the importance of measuring le-
sion size and stage, and indicates that in hips
treated before femoral head collapse lesion
size seems to be more important than stage
alone in determining outcome. It is of interest
that these results were similar to those reported
by Mont et al9 in their comprehensive review
of the literature. All patients in the current se-
ries were treated with core decompression and
bone grafting. No attempt was made to deter-
mine the effect of the graft itself.
During the past several years, numerous ap-
proaches to prophylactic treatment of hips with
avascular necrosis have been described.9,17

78 Steinberg et al
Many of these procedures are technically diffi-
cult and the incidence of postoperative compli-
cations is significant. Nevertheless, encourag-
ing results have been reported by a limited
number of investigators using these tech-
niques.9,17 Currently core decompression, with
or without bone grafting, has its advocates, as
do other approaches to treating avascular
necrosis. There are certain advantages and dis-
advantages to each procedure. Prospective,
multicenter studies are need using identical and
objective parameters to compare the safety and
effectiveness of these various procedures. Once
these become available, it will be possible to
make valid comparisons between these ap-
proaches and establish the specific indications
and contraindications for each.
References
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dans 1’osteonecrose primative. Observations histo-
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3. Fairbank AC, Bhatia D, Jinnah RH, et al: Long-term
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