Hip Decompression with Bone Marrow Aspirate Concentrate and Platelet-Rich Plasma
Injection for Osteonecrosis of the Femoral Head
#MMPMID41195244
Tai TW
; Guarin Perez SF
; Restrepo DJ
; Sierra RJ
JBJS Essent Surg Tech
2025[Oct]; 15
(4
): ? PMID41195244
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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Following injection, the cannula is withdrawn another 1 cm, and demineralized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 concentrateONFH = osteonecrosis of the
femoral headPRP = platelet-rich plasmaAP = anteroposteriorTHA = total hip
arthroplastyARCO = Association Research Circulation Osseous classificationMRI =
magnetic resonance imaging.
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