What are the next steps in managing a patient post bilateral core decompression with bone marrow aspirate injection, on topical fluocinolone acetonide 0.01% for sebosporiasis, with normal labs and negative autoimmune and HIV screens?

Post-Bilateral Core Decompression Management for Avascular Necrosis

Continue protected weight-bearing postoperatively and implement regular radiographic surveillance every 3-6 months to monitor for femoral head collapse, while maintaining the current topical fluocinolone acetonide regimen at once weekly maximum to minimize systemic corticosteroid exposure that could worsen osteonecrosis. 1, 2

Immediate Postoperative Protocol

Weight-Bearing Restrictions:

• Maintain protected weight-bearing to prevent fracture of the decompressed femoral heads 2
• This is critical given bilateral involvement, requiring careful mobility planning and potential assistive devices

Corticosteroid Exposure Minimization:

• Limit topical fluocinolone acetonide 0.01% to once weekly maximum rather than twice weekly 1
• Even topical corticosteroids represent a risk factor that worsens prognosis in avascular necrosis 1
• Consider non-corticosteroid alternatives for sebopsoriasis management to eliminate this modifiable risk factor

Surveillance Strategy

Radiographic Monitoring:

• Obtain radiographs every 3-6 months initially to detect early femoral head collapse 2
• Regular follow-up is essential as the procedure's success depends on preventing progression to articular collapse 1, 2

CT Imaging:

• Use CT to monitor the precise extent of necrotic lesion evolution 2
• Necrotic volume <30% of femoral head predicts <5% progression to collapse 2
• Volumes >30% carry dramatically higher collapse risk 3

MRI Assessment:

• Consider serial MRI to quantify necrotic volume changes and assess for repair tissue formation 4
• In successful cases, expect decrease in necrotic volume over time (from average 44.8% to 12% of femoral head volume) 4

Contralateral Hip Evaluation

Bilateral Disease Screening:

• 70-80% of nontraumatic avascular necrosis cases are bilateral 1
• Since you underwent bilateral core decompression, both hips require identical surveillance protocols
• Monitor both hips symmetrically for progression despite treatment

Critical Prognostic Factors to Monitor

High-Risk Features Requiring Intensified Surveillance:

• Corticosteroid exposure (even topical) - present in your case 1
• Necrotic volume >30% of femoral head 3
• Kerboul angle >60° (HR 12.5 for subsequent arthroplasty) 3
• Age >40 years 1
• Pre-operative Ficat stage III disease 1

Expected Outcomes with Bone Marrow Aspirate

Realistic Expectations:

• Hip survival at 2 years: approximately 78% 5
• Hip survival at 5 years: approximately 54-72% depending on disease extent 5, 4
• Bone marrow injection reduces risk of total hip arthroplasty by approximately 3-fold compared to core decompression alone (odds ratio 0.10) 4
• However, obesity (BMI ≥30) and extent of disease remain independent predictors of progression despite treatment 5

Post-Collapse Contingency Planning

Indications for Conversion to Arthroplasty:

• Articular collapse on radiographs (transition from pre-collapse to Ficat stage III-IV) 1
• Progressive pain despite conservative management
• Functional limitation interfering with activities of daily living
• Single site growing disproportionately or new symptoms suggesting progression 6

When Core Decompression Fails:

• Proceed directly to hemiarthroplasty or total hip arthroplasty 1, 2
• Success rates decline dramatically once articular collapse occurs 1

Modifiable Risk Factor Management

Eliminate Additional Insults:

• Minimize all corticosteroid exposure (systemic and topical) 1
• Avoid alcohol consumption if applicable 1
• Maintain healthy BMI, as obesity (BMI ≥30) independently predicts progression 5
• Optimize management of any underlying autoimmune conditions without additional corticosteroids

Red Flags Requiring Urgent Re-evaluation

• New or worsening hip pain suggesting progression 2
• Inability to bear weight suggesting fracture or collapse
• Radiographic evidence of femoral head collapse on surveillance imaging 1, 2
• Development of mechanical symptoms (catching, locking) suggesting articular damage