Advanced Hip AVN options?

[IkeBoy18]

Have a patient with a bad hip, not a surgical candidate.

MRI
Impression
1. Severe left hip arthritis with moderate flattening of the femoral head contour suggestive of advanced AVN
2. Moderate diffuse labral fraying. Moderate capsular thickening also seen.

Options for treatment? Any success with regenerative for pain? RF? Ive never done a hip RF.

Thanks in advance!

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[callmeanesthesia]

Have a patient with a bad hip, not a surgical candidate.

MRI
Impression
1. Severe left hip arthritis with moderate flattening of the femoral head contour suggestive of advanced AVN
2. Moderate diffuse labral fraying. Moderate capsular thickening also seen.

Options for treatment? Any success with regenerative for pain? RF? Ive never done a hip RF.

Thanks in advance!

I’ve done one bilateral hip RFA - severe COPD, pulmonologist wouldn’t clear for THA, steroid injections only lasting a couple months and not objectively seeming to do much for his pain scores. Just saw him, RFA was about 9 months ago. Pain score a 4 when it was always 8-10 before. I basically winged it on the technique after reading up on the targets since I don’t have cooled RFA. Used bipolar technique. I think I posted pictures in the pictures thread.

 

[drrosenrosen]

This is a great RF candidate. Check some of the previous threads, that discuss technique

 

[Doctodd]

once the hip is too far gone, regen doesnt really work vs a knee.

 

[PinchandBurn]

I’ve done one bilateral hip RFA - severe COPD, pulmonologist wouldn’t clear for THA, steroid injections only lasting a couple months and not objectively seeming to do much for his pain scores. Just saw him, RFA was about 9 months ago. Pain score a 4 when it was always 8-10 before. I basically winged it on the technique after reading up on the targets since I don’t have cooled RFA. Used bipolar technique. I think I posted pictures in the pictures thread.

nice job.

can you re post those pics?

Also can you do a hip STEROID injection on someone with AVN? I had a patient that i sent to ortho thinking I couldnt/shouldnt inject

 

[MitchLevi]

nice job.

can you re post those pics?

Also can you do a hip STEROID injection on someone with AVN? I had a patient that i sent to ortho thinking I couldnt/shouldnt inject

I've done it out of desperation but it won't work. You may get 5 days of benefit at best. Basically injected to help them tread water while waiting to see the surgeon.

PRP in this type of joint is a waste of money.

 

[RoloTomassi]

I've seen some articles about intraosseous BMAC but no experience. A well trained (Andrews Institute) local sports med guy reports good results.

 

[thecentral09]

What’s the cpt code for hip RF? Does it get reimbursed?

 

[bedrock]

What’s the cpt code for hip RF? Does it get reimbursed?

Just generic nerve RFA code. Peanuts for time spent unless HOPD doc.

 

[GoBeers]

I've had lousy success with RFA conventional. Sadly I feel like most end up on opioid therapy until surgery but most surgeons wont do an arthroplasty until 60yr old which sucks

 

[callmeanesthesia]

Found my previous post:
Pictures of the Week

 

[cowboydoc]

I've seen some articles about intraosseous BMAC but no experience. A well trained (Andrews Institute) local sports med guy reports good results.

C’mon, man!?! Is BMAC going to regrow a collapsed femoral head?

Is someone going to suggest stim, too?

 

[RoloTomassi]

C’mon, man!?! Is BMAC going to regrow a collapsed femoral head?

Is someone going to suggest stim, too?

Didn't say that. May not be applicable in this case/severity but there are case studies of bone growth and pain improvement with IO orthobiologics I believe. OP asked about regen.

 

[lobelsteve]

Core decompression?

 

[SSdoc33]

Core decompression?

nobody does them anymore, unless the surgeon is 80. plus, they dont work

 

[lobelsteve]

Core decompression

During a core decompression, the inner layer of bone is removed to reduce pressure and allow for increased blood flow, often to treat abascular necrosis.

stanfordhealthcare.org

They should stop advertising them.

A current review of core decompression in the treatment of osteonecrosis of the femoral head

The review describes the following: (1) how traditional core decompression is performed, (2) adjunctive treatments, (3) multiple percutaneous drilling technique, and (4) the overall outcomes of these procedures. Core decompression has optimal outcomes ...

www.ncbi.nlm.nih.gov

Just a starting point.

 

[Ferrismonk]

Regen article I have saved.

 

[deleted131481]

I've had lousy success with RFA conventional. Sadly I feel like most end up on opioid therapy until surgery but most surgeons wont do an arthroplasty until 60yr old which sucks

Similar experience with RFA.

Have you tried tramadol/butrans/norco 5 bid?

 

[GoBeers]

Similar experience with RFA.

Have you tried tramadol/butrans/norco 5 bid?

that's what I end up doing for some patients, but admittedly age is a big factor too when deciding to provide chronic opioids for this...

 

[SSdoc33]

Core decompression

During a core decompression, the inner layer of bone is removed to reduce pressure and allow for increased blood flow, often to treat abascular necrosis.

stanfordhealthcare.org

They should stop advertising them.

A current review of core decompression in the treatment of osteonecrosis of the femoral head

The review describes the following: (1) how traditional core decompression is performed, (2) adjunctive treatments, (3) multiple percutaneous drilling technique, and (4) the overall outcomes of these procedures. Core decompression has optimal outcomes ...

www.ncbi.nlm.nih.gov

Just a starting point.

Bone is dying.... so lets just hollow out the middle of it. That'll do the trick.

Seriously i saw this in med school.and residency, but not for a decade and i work with a bunch of different joint guys. Interesting to hear what the ortho people may say if you cross posted this....

 

[bedrock]

Bone is dying.... so lets just hollow out the middle of it. That'll do the trick.

Seriously i saw this in med school.and residency, but not for a decade and i work with a bunch of different joint guys. Interesting to hear what the ortho people may say if you cross posted this....

My previous ortho partner would offer this and said it worked about 50% of the time, but it was helpful for many.

 

[Ducttape]

Just generic nerve RFA code. Peanuts for time spent unless HOPD doc.

HOPD docs do not get paid differently. the facility does.

i know you know that, but for newer members...

Regen article I have saved.

this is more of a review article and not a study. essentially a review article of the lead author's work in the field.

and it is more pointedly for early osteonecrosis.

I've had lousy success with RFA conventional. Sadly I feel like most end up on opioid therapy until surgery but most surgeons wont do an arthroplasty until 60yr old which sucks

not a great option.

then again, most of the osteonecrosis patients i have seen are the sickle cell patients that have already been on high dose opioid therapies for years, either by prescription or frequent weekly ER visits.

 

[Norepi]

Any experience with femoral+obturator PNS, or God forbid (gasp) SCS for this? Or are most people just going to try butrans and call it a day?

 

[lobelsteve]

Any experience with femoral+obturator PNS, or God forbid (gasp) SCS for this? Or are most people just going to try butrans and call it a day?

Neuropathic treatment for purely mechanical pain. How about NO.

 

[Agast]

Don’t you guys already have SCS patients who develop leg pain that’s not covered by their programming, and on further exam you realize they have a bad hip? Why would you try Stim on a bad hip then.

 

[MitchLevi]

Replace the hip, try occasional shots, meds, PT and keep your weight down.

Peripheral nerve, dorsal column or DRG stimulation will have ZERO effect on this and will result in our not being able to use it for anyone in the future.

You cannot fix everything.

If you have attendings that are teaching you this BS I'd recommend you confront them very specifically about why stim of any type would work to treat a dead hip.