EP2.4 Bilateral Avascular Necrosis (AVN) of the Femoral Head a multimodal hip preservation approach with Hip Arthroscopy, Core Decompression, BMAC and bone substitutes

Abstract Background Avascular necrosis of the femoral (AVN) head is a disabling disease that affects function, mobility, and quality of life in the young adult. Hip preservation techniques, including hip arthroscopy, retrograde core decompression and bone marrow aspirate concetrate (BMAC) delivery and placement, have emerged as promising alternatives in AVN in its early stages. However, evidence on a comprehensive multimodal approach in bilateral avascular necrosis disease remains limited. Methods A 25-year-old male presented with bilateral hip pain. Physical examination revealed positive FABER, FADDIR and log roll tests bilaterally, Magnetic Resonance Imaging (MRI) confirmed bilateral AVN: on the LEFT HIP: an ARCO IIB, Steinberg IIIA and Ficat II stages, and on the RIGHT HIP: an ARCO IIA, Steinberg I and Ficat I stages. The patient underwent an uneventful left hip arthroscopy, demonstrating a cartilage step-off, in the weight-bearing zone of the femoral head, a labral tear was present, acetabular cartilage and ligamentum teres had no arthroscopic signs of lesion. The labral tear was tackled in a standard fashion with 1.8- and 2.8-mm anchors. Posteriorly with fluoroscopic assistance and guidance, we confirm the location of the necrotic lesion, followed by an exhaustive examination and palpation which is performed with an arthroscopic hook (ballotment test) palpatory in the site of necrosis on the femoral head, we continue with a retrograde femoral head decompression and with autologous BMAC and bone grafting. Postoperative management included non-weight-bearing on the hip, metabolic optimization and treatment with enoxaparin for 1 month followed by aspirin for 6 months, ibandronic acid for 6 months, and vitamin D supplementation adjusted by laboratory levels (25-hydroxy vitamin D). Clinical and a complete radiological follow-up was conducted over 12 months. Results At 1 year follow up, the patient demonstrated significant clinical improvement with resolution of hip pain and restoration of function. MRI imaging showed a complete resolution of the osteonecrotic lesions in both femoral heads, without evidence of progression or collapse. Functional outcome scores, such as the Modified Harris Hip Score (mHHS) demonstrated an improvement of more than 30 points at one year of follow up. Conclusion A multimodal hip preservation approach combined with arthroscopic-assisted retrograde core decompression, BMAC, structural bone grafting, and a systematic metabolic optimization and treatment resulted in excellent clinical and radiological outcomes in bilateral AVN of the hip. this approach may effectively halt disease progression and avid the need for a arthroplasty in the young adult patient, with a complete MRI-confirmed radiological resolution. Clinical relevance This case highlights the synergistic role of Hip Arthroscopy, retrograde core decompression, BMAC placement at the necrosis site plus the systematic medical treatment to achieve good to excellent results in a patient presenting bilateral AVN of the femoral head.