Core decompression: Looking Further, Thinking Beyond!!!

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Newer advances in the field has made surgeons once again looking at Core decompression as an important procedure for treating avascular necrosis of the femoral head. The talk is about the newer development in the field of the Core decompression and how the newer techniques are transforming the way the surgeons take care of this important problem.

Text of Core decompression: Looking Further, Thinking Beyond!!!

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2. Why is there a need to think beyond & Look further? 3. Lack of consistency! 4. Consistently inconsistentAt ten years (Fairbank JBJS 1995):Stage I 96% survivalStage II 74% survivalStage III 35% survivalDifferent studies different Results! Wide variation insuccess ratesEveryone thinks his technique is the best and has theleast failuresText Book Campbell supports use for Ficat I and II Asmall central lesions in young, non obese patients whoare not on steroids 5. ConventionallyThe goal was todecompress the femoralhead, increase vascularflow, and alleviate pain. 6. Looking further...Technical enhancementTechnological enhancementSupplemental techniques with CDPredict failures of core decompression? 7. Thinking Beyond!!!Halting the process!Repair the tissue!Regenerate from scratch! 8. Looking further...Percutaneous Expandable reamerArthroscopy & Track EndoscopyBiomechanical InputsAdjuncts 9. Expandable reamers 10. Expandable reamers1. Decompress Femoral Head 3. Percutaneous Expandable Reamer2. Place Working Cannula4. Debride Dead Bone 11. Track EndoscopyFirst tunnel endoscopy: the aim is verified, because the core track walls progress clearly from the reddish vital bone (VB) ofthe 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 theexpandable reamer appear to be vital and bleeding, thus confirming theadequate debridement. 12. Arthroscopy assisted CD 13. VAC application 14. Improving BiomechanicsDefinitively safer, May be better in large pre collapse lesionProximal Subtrochanteric RegionMargin of error - 20mm 15. Local DeferoxaminePromotes angiogenesis by up regulating VEGFAnalysis showed increased local BMP 2, OCN, Hyoxiainduced factor (HIF)Consequently increase bone healingTraditionally a chelating agentEspecially useful in Sickle cell diseases 16. Local PEMFFirst described by Eftekar in1984Weak EM waves found to beangiogenic and osteogenicNo benefit. (Windisch et al) 17. Thinking Further!!! 18. Healing trinity 19. the GyanApplication of osteogenic + angiogenic cells incombination with growth factors supported by appropriatescaffolds 20. SCAFFOLDSNatural or SyntheticTantalum RodsAlginate beadsDBMAllograftsFibula - Vascularised/Non 21. Porous Tantalum RodsBypass the morbidity ofthe autograftsHowever shown ingrowthin less than 25% casesFractures reported afterremoval. 22. Alignate beads + MSCBiopolymer made ofseaweedScaffold + CellsAlignate beads provideoptimal environment forosteogenic differentiationNano sized HA crystals,CaPo4 & Collagen 23. Scaffolds 24. BMC & Stem CellsBone marrow concentrate contains two type of cells -Mesenchymal stem cells ( MSC) and Endothelialprogenitor cellsMsc maintain the ability to mitotic application without lossof specific biomolecular character of differntiating inmultiple mesenchymal phenotypes: Osteoblats,chondrocyte and adipocytes.EPS have role in angiogenesis & neovascularisation 25. Growth factor strategyGF are produced by osteogenic cells, Platelets andinflamatory cells.Include BMPs, IGF, PDGF, TGF 1, FGFHelp in chemo attraction, migration and proliferation anddifferentiation of MSC into chondroblast or osteoblasts.In case of AVN osteogenic potential is haranassed andosteogenic GF viz TGF beta superfamily 26. ConventionallyClosest to trinity -90% 27. Our trialApproved by EC & IRB25 patients in each groupConcentrated BMAScaffold - HA TCP crystals vs Gelfoam 28. Our TechniqueMarrow aspirated from Illiac crestSupine position on traction table3 incision each side (6); 3 angles; 3 mlsApprox 50 - 60 ml collectionCentrifuged - concentrated to 10 cc. 29. SStteeppss ooff HHaarrvveesstt 30. iinnvveennttoorryy 31. MMaarrrrooww ttrraannssffeerr bbaagg 32. SSccrruubb uupp 33. LLaannddmmaarrkkss 34. HHeeppaarriinn && AACCDD 35. TTeecchhnniiqquuee -- ttiippss 36. VViiddeeooss 37. SSccaaffffoollddssG bone Gelfoam 38. OOuurr SSttuuddyyCompare it with historical dataPain, Function evaluationComparison of tow sacffoldsEndpoint is conversion to THREarly Results expected 2016 March 39. MY Ideal ChoiceCore Decompression entered proximal Subtroch areaMultiple drills if large lesionSingle drill for smaller central lesion; use expanderreamerScaffold: Autograft or DBM or Alignate beadsStem cell: Concentrated Bone marrowGrowth Factors: BMP 2 40. Thank you