Tai, Ta‐Wei

Background: Hip decompression effectively treats early-stage osteonecrosis of the femoral head (ONFH) by slowing disease progression and potentially delaying joint replacement. Biological adjuvants like bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP) support bone regeneration and improve outcomes 1–7 . The present video article demonstrates a simple, coreless hip decompression technique with BMAC and PRP injection for early-stage ONFH. Description: The procedure is performed in the same operating room setting as traditional core decompression, with the patient supine on a radiolucent table for fluoroscopic guidance. One or both legs are draped free for access to the iliac crests. Bone marrow is harvested percutaneously from the anterior superior iliac crest with a trocar needle kit, centrifuged, and prepared for injection. We recommend precoating needles and syringes with 1:1,000 heparin to prevent clotting. The BioCUE System (Zimmer Biomet) is typically utilized for centrifugation. Hip decompression is performed with use of a trocar and cannula (PerFuse System; Zimmer Biomet), with subsequent injection through the cannula into the femoral head. A 0.5-cm skin incision is made. The trocar is placed lateral to the femur and advanced percutaneously through the lateral femoral cortex, with a starting point proximal to the lesser trochanter. The trocar is then advanced along the femoral neck into the necrotic region by performing mallet strikes on the instrument’s strike cap. Anteroposterior and frog-leg lateral views assist in positioning the trocar within the necrotic area. Internal leg rotation, which aligns the patella upward, helps position the trocar horizontally parallel to the floor. Positioning is adjusted using repeated imaging as needed. Once the patient is positioned, the trocar is removed, leaving the cannula in place. With the cannula retracted 1 cm, a 30-mL syringe is utilized to inject BMAC and PRP into the necrotic lesion. Because of sclerotic resistance, substantial pressure is needed, but retraction of the cannula helps. Following injection, the cannula is withdrawn another 1 cm, and demineralized bone matrix is injected to prevent escape of the BMAC. Alternatives: Alternative treatments for ONFH include traditional core decompression with a sliding hip screw drill or an X-REAM device (Stryker), both of which carry a higher risk of fracture because of the larger diameter of the tract and require limited weightbearing postoperatively. Bone-cement injection can stabilize the femoral head but lacks regenerative properties. Core decompression with either BMAC or PRP alone, rather than in combination, also serves as an alternative treatment strategy. Open approaches, like osteotomy, are more invasive, have longer recovery times, and may complicate future hip arthroplasty if unsuccessful. Rationale: This technique enables minimally invasive hip decompression and delivery of adjuvant cell therapy or grafting, typically without the use of power instruments. This approach avoids the risk of injuring the bone due to the heat from power tools, protecting the BMAC injection site. Patients are generally discharged the same day and permitted full weight-bearing immediately, even in bilateral surgeries. Expected Outcomes: Hip decompression for ONFH has shown variable rates of success 8,9 , but adding BMAC or PRP may improve outcomes 1–3 . Houdek et al. reported that among 35 hips treated with decompression plus BMAC and PRP for corticosteroid-induced ONFH, 88% avoided THA at 3 years 2 and 70%, at 7 years 3 . Patients with grade-1 or 2 Kerboul angles had a 90% survivorship rate, underscoring the benefits of BMAC and PRP. Important Tips: Insert the trocar into the lateral cortex, positioned distal to the vastus ridge and proximal to the lesser trochanter, to reduce iatrogenic subtrochanteric fracture risk. Avoid advancing closer than 5 mm to the subchondral cortex to prevent joint-surface disruption or collapse, especially with eccentric lesions. If resistance occurs during injection, retract the cannula a few millimeters laterally to increase delivery space and reduce pressure. Acronyms and Abbreviations: BMAC = bone marrow aspirate concentrate ONFH = osteonecrosis of the femoral head PRP = platelet-rich plasma AP = anteroposterior THA = total hip arthroplasty ARCO = Association Research Circulation Osseous classification MRI = magnetic resonance imaging

Abstract The Guardian table is widely utilized for combined hip arthroscopy and periacetabular osteotomy (PAO) due to its postless traction design and the ability to perform both procedures without the need for redraping. This retrospective cohort study reports one surgeon’s use of the Guardian table extension during combined hip arthroscopy and PAO and the occurrence of intraoperative posterior column fractures. Seventy-two consecutive PAO procedures performed at a single institution between February 2023 and January 2025 were analysed. Procedures involving concomitant hip arthroscopy (n = 26) utilized the Guardian table, whereas those without arthroscopy (n = 46) used a conventional radiolucent table. Patient demographics, clinical data, and complications were reviewed. Additionally, mechanical testing quantified table stability by measuring peak absolute acceleration (‘table bounce’) using accelerometry during simulated malleting. The incidence of intraoperative posterior column fractures was significantly higher with the Guardian table (4/26, 15.4%) compared to the conventional table (0/46, 0%; P = .0062). Mechanical testing demonstrated significantly greater table bounce for the Guardian table (69.1 ± 3.4 m/s2 versus 28.2 ± 4.4 m/s2, P < .001). Patient characteristics and surgical complexity did not differ significantly between fracture and non-fracture cases. These findings suggested that the Guardian table extension system was associated with increased risk of posterior column fractures, likely due to lack of distal support and stability. Surgeons should consider alternative table setups or intraoperative support modifications to mitigate this risk during PAO procedures.

Background: An extended trochanteric osteotomy (ETO) is commonly used to improve exposure and facilitate femoral component removal in revision total hip arthroplasty (THA). An additional medial corticotomy may be used in conjunction with an ETO to correct a femoral deformity, particularly varus remodeling in association with a failed femoral component. This study evaluated the outcomes of combining an ETO with a medial corticotomy in revision THA, with emphasis on implant fixation, femoral alignment, bone union, and clinical outcomes. Methods: Of the 612 ETOs performed between 2003 and 2013, 13 patients (9 men and 4 women) underwent ETO combined with a medial corticotomy to correct varus remodeling, representing 2% of all ETOs during that period. The average follow-up was 8 ± 3.5 years. The mean age at surgery was 67 ± 13.5 years. The mean body mass index was 32 ± 7.7 kg/m 2 . Radiographs were reviewed to measure preoperative and postoperative femoral deformity, time to consolidation, and femoral fixation. Clinical outcomes were evaluated using the Harris Hip Score (HHS). Results: All patients had preoperative varus femoral deformity (mean 16.3° ± 5.7°). The mean postoperative alignment was 4.3 ± 1.6° varus achieving an average correction of 12° (95% CI −15.7 to −8.3, p < 0.0001). Both the ETO and the medial corticotomy consolidated in 10 of 11 patients (91%) with available 1-year radiographs at a mean of 11 ± 7.7 months. The mean HHS improved significantly from 42 preoperatively to 82 at 5-year follow-up (p = 0.0002). Complications related to the ETO and corticotomy occurred in 4 patients (30%), including 1 intraoperative fracture, 1 postoperative greater trochanteric fracture, 1 nonunion of the medial corticotomy, and 1 postoperative wound-hematoma. All femoral components remained well fixed at final follow-up. Conclusion: The combination of ETO and medial corticotomy in revision THA effectively corrected femoral alignment in patients with a preoperative varus deformity and was associated with significant functional improvement at the final follow-up. Level of Evidence: Level IV . See Instructions for Authors for a complete description of levels of evidence.