For cases of "pre-collapse" non-arthritic AVN, arthroscopic-assisted core decompression with or without bone graft to femoral head has been described. Gupta et al in Arthroscopy Techniques (attached) describes a simple way to assess status of articular cartilage and underlying subchondral bone. Use of scope also permits concomitant identification and treatment of central and peripheral compartment pathology for optimization of outcome. Here's a video (attached) showing femoral head cartilage. Pre-op MRI showed possible articular cartilage injury without collapse.

Article Arthroscopic-Assisted Core Decompression for Osteonecrosis o...

Thank you, Dr. Harris, for the references and the nice video.

Do you mean that hip joint arthroscopy may replace or even make obsolete MRI in the diagnostics of early stages of AVN (the cases indicated for core decompression ) ?    

I do not think arthroscopy will replace MRI, as the invasiveness and risk of surgery precludes it for exclusively diagnostic purposes. I think it's prognostic value at the time of core decompression (based on the pre-operative decision of a "pre-collapse" stage) is quite high. The therapeutic value is not just the core decompression (with or without bone graft), but also the concomitant treatment of labral tears and FAI if present. Although some use a calcium-based cement, others (myself included) use an iliac crest-derived bone marrow aspirate combination with demineralized bone matrix allograft putty in an injectable system into the core decompressed lesion.

Thank you, Dr. Harris. 

I understand that in your opinion hip arthroscopy is indicated in highly selected cases (i.e. the combination of AVN and FAI). 

Regards

This is a really good question that perfectly highlights the place of hip arthroscopy in diagnosis and treatment of hip diseases!!!

I do agree with all the answers already given and surgeries mentioned, but regarding HIP AVN - and as previously said - we're talking about a vascular bone disorder for which all the evidence-based treatments do not require any invasive or non-invasive  primary joint approach. As previously said, and except some side-related pathologies such as labrum defects, inflammatory lesions, loosed bodies, ..., for which arthroscopy might be primarily indicated, the most efficient treatments usually require (if necessary and possible) a bony trans-cervical approach for drilling and grafting, and not a joint approach or intra-articular vision. So, I'm not sure that pre-collapse non-arthritic AVN core decompressions might really be improved by arthroscopic-assisted techniques and that the assessment of articular cartilage and underlying subchondral bone status is useful enough to modify either diagnosis or therapeutic protocol. For diagnosis as well, I would not recommend to use such techniques that are not specific enough regarding MR Imaging...

The problem remains the same with complementary treatments such as Autologous Conditioned Serum (ACS) injections that do not require any intra-articular vision.

And we should remind some rare cases of AVN described after simple arthroscopy  that were related to vascular traction during joint expansion...

See: Hip Int. 2011 Sep-Oct;21(5):623-6. doi: 10.5301/HIP.2011.8693.

Avascular necrosis of the femoral head after hip arthroscopy.

Sener N1, Gogus A, Akman S, Hamzaoglu A.

Thank you, Thierry.

In fact my opinion entirely coincides with yours.

Regards

I think that arthroscopy of the hip is not necessary (diagnostic or therapeutic) in cases of AVN. I agree with Thierry about possible complications.

As the possible treatment, I recommend considering using PST -Pulsed Signal Therapy (magnetic resonance therapy) treatment to increase of an osteoblasts activity from the area adjacent to the area AVN. This process will enable rapid healing and prevent major damage to the hip head structure. I note that there is an effect on cartilage cells. I use this therapy as a treatment for rehabilitation after surgical treatment of the intraarticular fractures with very good clinical  results . This treatment is used in Western Europe (EN ISO 13485: 2003 ).

One has to consider also the origin of fem. head necrosis. In many cases you can find special noxae like chronic alkoholism, former work in toxic chemical processes, as well as professional divers. If one cannot motivate the patient to abstain from these activities medical therapies are of no use.

I think osteonecrosis at early stage is hard to be detected or distinguished using the hip arthroscopy, however, the arthroscopy might be useful for the treatment of pre-collapse.

Dr. Yuan, 

Please, could you give some data on the use of hip arthroscopy (intrarticular) for treatment of pre-collapse AVN ? 

Thank you all for your commentary. Please review the video I uploaded earlier in the comment thread. Please let me know if you think this is "pre-collapse" or "collapsed" based on its arthroscopic appearance.   This is an interesting discussion that hinges upon a good understanding of the biomechanical end-result of AVN on the subchondral bony support for the articular cartilage. In other words, how do we define "collapse"? It has exclusively been a radiographic phenomenon. Arthroscopic (risks of surgery recognized and understood) evaluation of AVN increases the sensitivity of detection of "collapse".

To answer your question one needs a juxtaposition of imaging and arthroscopic findings in your case. 

Thanks Joshua for these nice precisions... I've reviewed the video once again and what I can say for now is that I do agree with Prof. TANCHEV in his last answer: it's really difficult to relate with certitude these images to an AVN...

What I mean is that these images could have been taken with any chondromalacia, whatever it's origin. There is no real specificity and on my opinion that's the point; if it is an AVN, and of course it may be, it's probably a pre-collapse one but I don't think that we are able to fetch any supplementary informations from the arthroscopy (except negative findings) to assess the diagnosis. So if you agree with that point, don't you think we could get a safer (morbidity and mortality) and faster diagnosis with a simple MRI. In other words, is the incontestable sensitivity of the arthroscopy really useful in theses cases without any supplementary specific explorations (bone imaging)?

The second point is the following one: if not, do we have any arthroscopic treatment for these early cases that might be performant enough to change our diagnostic and therapeutic algorithm?

 Precollpase stage (stageII), I makea round hole at the base of head and make a 5mm hole. There after curettage and milling were perfomed. And I prefer to use a bone  graft and bone substitue in the these necrotic area. I prepare these procedure to report ISHA

  These procedure is nealy same other bone graft procedure as in AVN of femoral head, and we can do under arthroscopic control , Sometimes I hope to use a flesible reamer or expansion reamer which act as debride necrotic bone .

  These procedure need a three portals and one larger cannular (10 mm) as used in laparascopic surgery.

Dear Dr Tanchev

It's hard to say hip arthroscopy will be a gold standard treatment in ONFH, but I think it has emerged as a new option.

Mechanical symptoms (clicking, locking, ...) may be results of disorders such as labral tears, chondral flaps or even loose bodies which could  be addressed by hip arthroscopy and not by standard core decompression.

ON related synovitis that present in more than 2/3 of these patients also can be treated by arthroscopy in addition to any FAI.

*McCarthy J, Puri L, Barsoum W et al. Articular cartilage changes

in avascular necrosis: an arthroscopic evaluation. Clin Orthop

Relat Res 2003; 406: 64–70.

*Karantanas AH. Accuracy and limitations of diagnostic methods

for avascular necrosis of the hip. Expert Opin Med Diagn 2013; 7:

179–87.

very difficult question? after covid we start to see many patient with AVN due covid itself or steroid in relatively young population. so we need a strategy for these patients before offering an THA. arthroscopy can be used in Perthes disease In children's with good midterms outcomes. So, for reshaping CAM lesions, and gaining ROM. it could be a presedure for especially precollaps patients, and could also be a solution for callapse patients.