Who performs a core decompression procedure in a patient with avascular necrosis?

Core Decompression for Avascular Necrosis is Performed by Orthopedic Surgeons

Core decompression for avascular necrosis (AVN) of the hip or other joints is performed by orthopedic surgeons who specialize in joint preservation procedures. This surgical intervention is considered the primary surgical option for early-stage avascular necrosis before subchondral collapse occurs 1.

Rationale for Orthopedic Surgeon Performance

Core decompression is a specialized orthopedic procedure that requires:

1. Expertise in joint anatomy and biomechanics
2. Experience with bone drilling techniques
3. Knowledge of avascular necrosis pathophysiology
4. Ability to assess necrotic volume and disease staging
5. Familiarity with post-operative rehabilitation protocols

Orthopedic surgeons are specifically trained in these areas and routinely perform procedures involving bone and joint preservation.

Procedural Setting Requirements

The procedure is typically performed in:

• Operating rooms equipped for orthopedic procedures
• Settings with fluoroscopic imaging capabilities for precise guidance
• Facilities with appropriate surgical equipment for bone drilling and grafting

Adjunctive Techniques Often Combined with Core Decompression

Modern core decompression procedures may be augmented with:

• Autologous bone marrow cell injection 1, 2
• Vascular fibular grafting 1
• Electric stimulation 1, 3
• Tantalum rod insertion 3
• Bone grafting 3
• Orthobiologics (mesenchymal stem cells, platelet-rich plasma) 3

These adjunctive techniques require specialized orthopedic training and equipment.

Evidence Supporting Core Decompression

Core decompression has shown particular efficacy in:

• Early-stage AVN (pre-collapse) 1, 4
• Skeletally immature patients with sickle cell disease-related AVN 2
• Cases with smaller necrotic volume (<30% of femoral head) 1

In a study of pediatric patients with sickle cell disease, core decompression with bone marrow aspirate concentrate showed promising results, with 78% of skeletally immature patients demonstrating reconstitution of the femoral head 2.

Limitations and Considerations

Despite its widespread use, core decompression:

• May not prevent disease progression in all cases 5
• Is less effective in advanced stages with articular collapse 1
• Has varying success rates depending on the underlying cause of AVN
• May require progression to total joint replacement if unsuccessful 1

Multidisciplinary Approach

While orthopedic surgeons perform the actual procedure, optimal management of AVN often involves:

• Hematologists (for underlying conditions like sickle cell disease)
• Rheumatologists (for inflammatory conditions)
• Physical therapists (for rehabilitation)
• Pain management specialists

Conclusion

Core decompression is firmly within the domain of orthopedic surgery. Vascular surgeons are not typically involved in this procedure, as it primarily addresses bone pathology rather than vascular repair. The procedure aims to reduce intraosseous pressure, improve blood flow, and potentially allow for new bone formation in areas of necrosis.