"Advanced core decompression" (ACD) is a treatment option for osteonecrosis of the femoral head (ONFH) that aims at complete removal of the necrotic tissue using a percutaneous expandable reamer and refilling of the head with an osteoconductive bone-graft substitute. The objective of this study was to evaluate if the success of ACD depends on the amount of necrotic tissue remaining after the procedure and how efficiently the necrotic tissue can be removed with the current reamer. Three-dimensional models of proximal femora including ONFH were generated from the preoperative MRIs of 50 patients who underwent ACD. Best-case removal was calculated by geometrical analysis. In 28 of 50 cases, postoperative MRI was used to determine how much necrotic tissue had been removed. Prognostic values and correlations were evaluated in order to assess success or failure of the treatment. The amount of preoperative and remaining necrosis correlates significantly with treatment failure. The larger both volumes are, the more likely it is that treatment will fail. In patients with remaining necrosis of less than 1000 mm(3), no treatment failure was observed. The amount of necrosis actually removed differed significantly from the amount calculated as the best possible result. Simulation of the removal procedure showed that complete removal is not possible. These results led to the conclusion that the success of ACD depends on the amount of necrotic tissue remaining in the femoral head after the procedure. Modifications to the instrument are necessary to increase the amount of necrotic tissue that can be removed.
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