Core Decompression:Core Decompression:Looking further thinking Looking further thinking

beyond!!!beyond!!!

Core Decompression:Core Decompression:Looking further thinking Looking further thinking

beyond!!!beyond!!!

Dr Vaibhav BagariaDr Vaibhav BagariaJoint replacement & Sports surgeonJoint replacement & Sports surgeon

Care hospital & Origyn ClinicCare hospital & Origyn ClinicNagpurNagpur

Dr Vaibhav BagariaDr Vaibhav BagariaJoint replacement & Sports surgeonJoint replacement & Sports surgeon

Care hospital & Origyn ClinicCare hospital & Origyn ClinicNagpurNagpur

MOACON 2014Akola

Why is there a need to think beyond & Look further?

Lack of consistency!

Consistently inconsistent

Different studies different Results! Wide variation in success rates

Everyone thinks his technique is ‘the best’ and has the ‘least failures’

Text Book Campbell “ supports use for Ficat I and II A small central lesions in young, non obese patients who are not on steroids”

At ten years (Fairbank JBJS 1995): Stage I – 96% survivalStage II –74% survivalStage III – 35% survival

Conventionally

The goal was to decompress the femoral head, increase vascular flow, and alleviate pain.

Looking further...

Technical enhancement

Technological enhancement

Supplemental techniques with CD

Predict failures of core decompression?

Thinking Beyond!!!

Halting the process!

Repair the tissue!

Regenerate from scratch!

Looking further...

Percutaneous Expandable reamer

Arthroscopy & Track Endoscopy

Biomechanical Inputs

Adjuncts

Expandable reamers

Expandable reamers

2. Place Working Cannula4. Debride Dead Bone

1. Decompress Femoral Head 3. Percutaneous Expandable Reamer

Track Endoscopy

First tunnel endoscopy: the aim is verified, because the core track walls progress clearly from the reddish vital bone (VB) of the neck (A) through a transitional zone (B) toward the white-gray avascular tissue of the lesion (C).

Second tunnel endoscopy: the walls of the chamber created by the expandable reamer appear to be vital and bleeding, thus confirming the adequate debridement.

Arthroscopy assisted CD

VAC application

Improving Biomechanics

Definitively safer, May be better in large pre collapse lesion

Proximal Subtrochanteric RegionMargin of error - 20mm

Local Deferoxamine

Promotes angiogenesis by up regulating VEGF

Analysis showed increased local BMP 2, OCN, Hyoxia induced factor (HIF)

Consequently increase bone healing

Traditionally a chelating agent

Especially useful in Sickle cell diseases

Local PEMF

First described by Eftekar in 1984

Weak EM waves found to be angiogenic and osteogenic

No benefit. (Windisch et al)

Thinking Further!!!

Healing trinity

the “Gyan”

Application of osteogenic + angiogenic cells in combination with growth factors supported by appropriate scaffolds

SCAFFOLDS

Tantalum Rods

Alginate beads

DBM

Allografts

Fibula - Vascularised/Non

Natural or Synthetic

Porous Tantalum Rods

Bypass the morbidity of the autografts

However shown ingrowth in less than 25% cases

Fractures reported after removal.

Alignate beads + MSC

Biopolymer made of seaweed

Scaffold + Cells

Alignate beads provide optimal environment for osteogenic differentiation

Nano sized HA crystals, CaPo4 & Collagen

Scaffolds

BMC & Stem Cells

Bone marrow concentrate contains two type of cells - Mesenchymal stem cells ( MSC) and Endothelial progenitor cells

Msc maintain the ability to mitotic application without loss of specific biomolecular character of differntiating in multiple mesenchymal phenotypes: Osteoblats, chondrocyte and adipocytes.

EPS have role in angiogenesis & neovascularisation

Growth factor strategy

GF are produced by osteogenic cells, Platelets and inflamatory cells.

Include BMPs, IGF, PDGF, TGF 1, FGF

Help in chemo attraction, migration and proliferation and differentiation of MSC into chondroblast or osteoblasts.

In case of AVN osteogenic potential is haranassed and osteogenic GF viz TGF beta superfamily

ConventionallyClosest to trinity -90%

Our trial

Approved by EC & IRB

25 patients in each group

Concentrated BMA

Scaffold - HA TCP crystals vs Gelfoam

Our Technique

Marrow aspirated from Illiac crest

Supine position on traction table

3 incision each side (6); 3 angles; 3 mls

Approx 50 - 60 ml collection

Centrifuged - concentrated to 10 cc.

Steps of HarvestSteps of HarvestSteps of HarvestSteps of Harvest

inventoryinventoryinventoryinventory

Marrow transfer bagMarrow transfer bagMarrow transfer bagMarrow transfer bag

Scrub upScrub upScrub upScrub up

LandmarksLandmarksLandmarksLandmarks

Heparin & ACDHeparin & ACDHeparin & ACDHeparin & ACD

Technique - tipsTechnique - tipsTechnique - tipsTechnique - tips

VideosVideosVideosVideos

ScaffoldsScaffoldsScaffoldsScaffolds

G bone Gelfoam

Our StudyOur StudyOur StudyOur Study

Compare it with historical data

Pain, Function evaluation

Comparison of tow sacffolds

Endpoint is conversion to THR

Early Results expected 2016 March

Compare it with historical data

Pain, Function evaluation

Comparison of tow sacffolds

Endpoint is conversion to THR

Early Results expected 2016 March

MY Ideal Choice

Core Decompression entered proximal Subtroch area

Multiple drills if large lesion

Single drill for smaller central lesion; use expander reamer

Scaffold: Autograft or DBM or Alignate beads

Stem cell: Concentrated Bone marrow

Growth Factors: BMP 2

Thank you