Accessibility Tools

跳至主要内容

You must be a logged-in member of UHMS or a subscriber to the UHMS Journal in order to download the articles listed within these pages. If you are a member or subscriber, please log in using the Log In button above. If you would like to purchase a membership or a subscription, use the buttons below.

Join the UHMS
Purchase a Subscription

Search UHM/UBR

Hyperbaric oxygen therapy for avascular necrosis of the femoral head: A case report

Hyperbaric oxygen therapy for avascular necrosis of the femoral head: A case report

 

Adam Pearl, MD1,2 and Steven Pearl, MD3,4

 

1 John D Dingell VAMC, Detroit, MI, USA

2 HCA Aventura Medical Center, Department of Emergency Medicine, Aventura, FL, USA

3 Ascension Rochester, Wound Healing and Hyperbaric Center, Rochester, MI, USA

4 CoreWell Health East, Center of Hyperbaric Oxygen, Royal Oak, MI, USA

 

ABSTRACT

The hip is the most common location for avascular necrosis of the femoral head (AVN), with an estimated incidence in the United States of 10,000 to 20,000 new cases per year. The current standard of care for early disease is core decompression, with bone marrow injections becoming more commonplace. Hyperbaric oxygen enhances oxygen delivery to tissue, promotes an anti-inflammatory and pro-healing environment, and helps initiate angiogenesis. We believe that these properties of HBO2 make it a unique tool for AVN and applied it in conjunction with the standard of care for our patient.

Keywords: avascular necrosis; avn; hip; hyperbaric oxygen; traumatic injury 

Key Points: Avascular necrosis of the hip can be caught in its early stages to hopefully prevent the need for total hip arthroplasty. We applied hyperbaric oxygen therapy in conjunction with the standard of care, core decompression, in hopes of aiding in a faster, full recovery for our patient.

INTRODUCTION 

Avascular necrosis (AVN) of the femoral head results from a disruption in blood flow to the bone, thus leading to bone loss and pain [1]. This is often a multifactorial disease with several risk factors identified, such as corticosteroid use, alcohol, trauma, autoimmune diseases, Perthes, and sickle cell disease [2]. However, many cases tend to be idiopathic [2]. The hip is the most common location for AVN, with an estimated incidence in the United States of10,000-20,000 new cases per year [3,4]. The most common treatment in the early stages of the disease is currently transosseous decompression of the femoral head [1]. Later stages of the disease often require total hip arthroplasty (THA) [2]. AVN is estimated to be the diagnosis leading to 5-18% of THAs in the United States, with similar rates seen in other countries [2]. THA has seen satisfactory results when AVN was the indicating diagnosis, with one study demonstrating as many as 98% of patients seeing complete relief from pain, 95% returning to all normal activities, and a 37-point increase in Average Hip Disability and Osteoarthritis Outcomes Score for Joint Replacement scores [5].

            In the older population, THA for AVN is a very suitable choice. However, in the pediatric and young adult population, the duration of implant survival and the need for revision surgery may become an issue. Although one study saw a 98.8% revision-free survival rate at 19-month-follow-up, long-term data are scarce.5 Recently, however, Vanstockstraeten et al. examined the long-term implant survival in patients under 35 who underwent THA for AVN [6]. The average follow-up was 18.0 +/- 5.3 years. When examining revision for aseptic loosening, cemented stems saw 100% survival at 15 years and 95.1% at 20 years. When examining revision for any other reason, uncemented cups saw a 90% survival at 20 years, while cemented cups saw a survival of 43.1%.6

            Conservative measures, particularly in the early stages of AVN, are also an option. One such treatment involves harvesting bone marrow aspirate from the pelvis and performing a decompression followed by bone marrow aspirate concentrate (BMAC) injection. Although this is a newer procedure, early results show promise as an alternative to a major procedure such as THA. Studies have shown significant improvement in function scores following this procedure and radiologic evidence of improvement with 12-month follow-up [1,7]. A similar study with a two-year follow-up demonstrated a significant increase in Harris Hip Score (HHS) and a decrease in visual analog score [8]. Notably, however, five of the 22 hips required THA within two years [7]. 

            Hyperbaric oxygen (HBO2) therapy has scarce literature regarding AVN treatment. One study compared HBO2 to standard conservative therapy, core decompression [8]. Twenty-three hips with non-traumatic stage II AVN of the femoral head were examined: 12 in the core decompression group and 11 in the HBO2 group. The average follow-up was 34.2 months, with 66.7% of those in the core decompression group and 81.8% in the HBO2 group achieving significantly improved Oxford Hip Scores (p = 0.009 and p = 0.003, respectively). Eight of the 23 hips progressed to a higher stage, confirmed via radiographs at one year, but there was no statistically significant difference between the groups [8]. A similar study compared HBO2 therapy to no treatment at all for stage I AVN [8]. Twelve patients were selected via results on MRI with lesions 4mm or thicker and 12.5mm or longer, and HBO2 therapy was given for 100 days. It was found that 81% of patients in the HBO2 group had a normal MRI after treatment, as compared to 17% in the untreated group.9

            There are currently 14 CMS-approved indications for hyperbaric oxygen therapy, and the UHMS Hyperbaric Oxygen Therapy Committee regularly reviews these indications for safety, efficacy, and cost-effectiveness. In many cases, HBO2 yields direct cost savings by successfully resolving a high percentage of difficult and expensive disorders. AVN, however, has been approved by the Hyperbaric Oxygen Committee as a 15th indication. The common denominator between the diseases with HBO2 indications is tissue compromised by hypoxia and/or hypovascularity and resultant inflammation and cell/tissue necrosis. HBO2 has the immediate effect of oxygenating compromised tissues, and by creating a steep oxygen gradient, hyperbaric oxygen stimulates angiogenesis, reduces fibrosis, mobilizes and increases stem cells, and potentiates oxidative white blood cell killing of bacteria. It has been studied extensively for osteonecrosis secondary to radiation (osteoradionecrosis of bone and soft tissues). Typical therapeutic conditions allow plasma concentrations of oxygen to reach over 20 times that of breathing atmospheric air [10]. More oxygen is delivered to the tissues in need by inducing a state of hyperoxia. Additionally, HBO2 therapy has been shown to increase angiogenesis, upregulate mediators of tissue repair, and downregulate tissue-damaging molecules [11,12]. 

CASE 

The patient is a 34-year-old female who had a traumatic dislocation of the left hip while skiing. Her hip was reduced under anesthesia in a timely manner, but she developed avascular necrosis of the femoral head. The diagnosis was made via MRI with perfusion protocol, which demonstrated a large joint effusion, full-thickness anterior-superior chondral labral separation, a complete tear of the ligament of teres, and a 1.4cm area of full-thickness cartilage loss along the medial-superior femoral head. It was also noted that there was posterior capsular dehiscence and no evidence of perfusion to the left femoral epiphysis. She was subsequently prescribed celecoxib and tramadol PRN. 

            After a discussion with her orthopedic surgeon, more conservative measures were decided to avoid a total hip arthroplasty. The patient underwent core decompression with an injection of autologous bone marrow under general anesthesia. 60mL of bone marrow was extracted from the patient’s left iliac crest, of which 10 mL were injected into the weight-bearing portion of the femoral head. The procedure was successful with no complications.

            The patient then presented to the hyperbaric oxygen clinic. After evaluation, we decided upon 40 treatments of 100% oxygen at 2.0 atm with no air breaks. The treatment was 90 minutes daily, five days per week. Follow-up MRI with perfusion protocol was done 128 days after the original, after 25 treatments. It demonstrated improved perfusion and increased enhancement to the majority of the epiphysis, with less than 15% showing non-enhancement. This was all in the posterior region. No interval osteonecrosis was appreciated, and there was an improvement in the posterior capsular dehiscence. The patient completed 32 treatments but opted out of the last eight due to traveling. 

DISCUSSION

Core decompression for AVN of the hip has demonstrated success in the early stages of the disease [13]. A study of 80 hips diagnosed with Stage II osteonecrosis of the femoral head demonstrated improved Harris Hip Scores, Visual Analog Scores, and physical function and pain components of the SF-36 with HBO and core decompression compared to HBO alone [13]. This procedure has also been shown to be highly cost effective when delaying the need for total hip arthroplasty for five years, gaining cost effectiveness with each year thereafter [14]. Due to its efficacy and cost effectiveness, it has maintained its position as the gold standard for early AVN of the hip. Newer techniques have involved the addition of bone marrow aspirate concentrate (BMAC), which also shows efficacy in AVN treatment. The mechanism by which HBO2 therapy works, and its well-studied promotion of angiogenesis lend to a possible benefit for AVN when combined with standard treatment. 

            The trimodal therapy that our patient underwent sought to address all roots of AVN: Coredecompression removes the necrotic tissue; BMAC injection provides new progenitor cells to promote healing and new growth; and HBO2 therapy delivers necessary oxygen, promotes angiogenesis, and creates an anti-inflammatory/pro-repair environment. The main goal is to prevent the need for THA in the future, aiming for cost-effectiveness and maintenance of the physical function of the patient’s native hip. 

            A recent Blue Cross Blue Shield study demonstrated an average cost of $30,124 US for a primary THA, with some geographic areas reaching as high as $73,987 [15]. In our patient’s situation, a revision surgery would be inevitable due to her age. This has associated physical and economic burdens, as revision THA has been shown to have charges up to 76.0% higher than matched primary surgeries and higher infection rates [16]. 

CONCLUSION

Avascular necrosis is a prevalent hip disease, with an estimated annual incidence of 10,000 to 20,000 cases in the United States alone. Later stages of the disease often necessitate a total hip arthroplasty, which is a physical and economic burden to the patient. The current gold standard of early conservative management is core decompression, with an increasing number of surgeons utilizing BMAC therapy in conjunction. Unfortunately, current literature is scarce on this topic, and further trials are necessary to assess the true efficacy of HBO2 therapy for hip AVN. However, due to hyperbaric oxygen’s mechanism of action and our patient’s success, we believe it is a suitable choice and should be considered to aid in healing AVN after core decompression.

REFERENCES

  1. Velkovski V, Shabani I, Kamnar V, et al. Analysis of results after surgical application of bone marrow aspirate stem cell concentrate in the treatment of avascular necrosis of femoral head. Prilozi. 2023; 29;44(1): 79-87.
  2. Yakkanti R, Haziza S, Wasserman N, et al. Relative frequency of avascular necrosis of the hip as indication for primary total hip arthroplasty in the USA vs. India. J Orthop. 2022 Dec 5;36:1-6.
  3. Matthews A, Davis D, Fish M, Stitson D. Avascular necrosis. StatPearls. 2022.
  4. Barney J, Piuzzi N, Akhondi H. Femoral head avascular necrosis. StatPearls. 2022.
  5. Whitmarsh-Brown M, Christ A, Lin A, et al. Modernizing our understanding of total hip arthroplasty in the pediatric and young adult patient: A single-center experience. J Pediatr Orthop. 2023. 1;43(4): e290-298.
  6. Vanstockstraeten S, Ghijselings S, Vles G, andSimon J. Excellent long-term survival rate of polished, tapered, cemented stems in patients aged 35 years or younger with avascular necrosis or inflammatory arthritis of the hip. J Orthop. 2022. 37(5): 897-904.
  7. Cuervas-Mons M, Narbona J, Laguna R, and Vaquero J. Autologous concentrated bone marrow graft in the treatment of femoral head avascular necrosis: Clinical outcome after two years of follow up in a non-controlled prospective study.Rev Esp Cir Ortop Traumatol. 2013. 57(2): 106-110.
  8. Moghamis I, Alhammoud AA, Kokash O, Alhaneedi GA. The outcome of hyperbaric oxygen therapy versus core decompression in the non-traumatic avascular necrosis of the femoral head: Retrospective cohort study. Ann Med Surg. 2021 Jan 30;62: 450-454.
  9. Reis N, Schwartz O, Militianu D, et al. Hyperbaric oxygen therapy as a treatment for stage-I avascular necrosis of the femoral head. J Bone Joint Surg Br. 2003 Apr;85(3):371-375. 
  10. Kahle A and Cooper J. Hyperbaric physiological and pharmacological effects of gases. StatPearls, 2022.
  11. Buckley C and Cooper J. Hyperbaric oxygen effects on angiogenesis. StatPearls. 2022.
  12. Lindenmann J, Kamolz L, Graier W, Smolle J, andSmolle-Juettner F. Hyperbaric oxygen therapy and tissue regeneration: A literature survey. Biomedicines. 2022;10(12): 3145.
  13. Bozkurt I, Yalcin N, Uluyardimci E, and Akgul E. Combination of hyberbaric oxygen and core decompression therapies improve outcomes in the treatment of hip osteonecrosis. Hip Int. 2022;32(6):759-765.
  14. Soohoo N, Vyas S, Manunga J, et al. Cost-effectiveness analysis of core decompression. J Orthop. 2005;21(5): 670-681.
  15. Blue Cross Blue Shield. A study of cost variations for knee and hip replacement surgeries in the U.S. The extreme cost variation in healthcare. 2015.
  16. Renkawitz T, Voellner F, Craiovan B, et al. Revision surgery in total joint replacement is cost-intensive. Biomed Res Int.Sep 25; 2018:8987104.

DOI:10.22462/644