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«PacifiCare’s medical management guidelines represent the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. They are ...»

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A few studies afford some evidence that, within a given stage, larger lesions and lesions in a central or lateral, as opposed to medial, position are less likely to be treated successfully with core decompression. As mentioned previously, Bozic et al. also found that hips in the precystic phase of stage II were dramatically more likely to survive than hips with stage II lesions that were cystic or sclerocystic. (Mont et al., 1998; Bozic et al., 1999; Lavernia and Sierra, 2000) Core decompression did not compare favorably with VBG in two studies or with osteotomy in another, but lack of randomization and other study weaknesses limit conclusions. Kane et al. conducted a prospective comparison in which patients were assigned to core decompression (19 hips) or VBG (20 hips) according to surgeon preference. Joint survival at 2 years was 36% for stage II disease and 60% for stage III disease in the core decompression group. The survival rates for VBG were 100% and 67%, respectively. The sample size in this study was so small that subgroup comparisons do not permit conclusions. In a retrospective review, Scully et al. (1998) studied 98 hips in a core decompression group and 614 hips in a VBG group. They observed the following survival rates (core decompression versus VBG): 100% versus 100% (stage I), 65% versus 89% (stage II), and 21% versus 81% (stage III). The stage II and III comparisons were highly significant. There are some threats to the validity of this study's comparisons. The two procedures were performed at Core Decompression For Avascular Necrosis - Commercial Medical Management Guideline different institutions and appear to have occurred over different time frames. Patients in the core decompression group were older; the difference exhibited a trend toward significance for stage II and was statistically significant for stage III.

Lastly, 13% (79/614) of hips in the VBG group had AVN due to trauma whereas only 1 of 98 hips in the core decompression group had traumatic AVN. The effect of these differences is not clear.

Simank et al. (2001) found that patients treated with core decompression (94 hips) were 67% more likely than patients treated with osteotomy (83 hips) to require subsequent total hip replacement over a mean follow-up of 9 years, although the relative risk calculation was not significant. This may not be a useful comparison for a number of reasons. As the authors acknowledge, osteotomy patients may be more likely to postpone further surgery, having already endured the morbidity associated with a more complicated procedure. Another bias potentially in favor of the osteotomy results was that about half of the patients treated with osteotomy also had a core decompression procedure although the authors do report that the relative risk of failure did not differ significantly between patients treated only with osteotomy and those who received the double procedure. Furthermore, core decompression is not generally considered to be an alternative to osteotomy, or partial joint arthroplasty; rather, it is intended to delay both osteotomy and complete arthroplasty.

The proportion of patients obtaining good or excellent results in terms of pain and function scores was consistent with joint survival rates. Simank et al. (2001) were the only authors to report inclusion of asymptomatic patients. The only complications reported were two femoral fractures, representing an 11% complication rate, in the study by Kane et al.

(1996); one hematoma in Bozic et al. (1999); and one deep vein thrombosis in Lavernia and Sierra (2000).

The studies that investigated core decompression as an adjunct to other procedures, such as demineralized bone matrix (DBM), (Ciombor and Aaron, 2001) VBG, (Steinberg et al., 2001) or autologous bone marrow grafting, (Gangji et al., 2004; Hernigou and Beaujean, 2002) did not permit conclusions regarding the effect of core decompression on outcomes.

While core decompression combined with DBM or autologous bone marrow grafting had better outcomes than core decompression alone, and the combined use of core decompression plus VBG was more effective than conservative treatment with partial weight bearing, these studies did not contain a group of patients who had undergone DBM or autologous bone marrow grafting without core decompression.

Only one prospective uncontrolled study evaluated core decompression by percutaneous drilling. The purpose of this technique is to avoid open core tracts, which can predispose a patient to subtrochanteric fracture. After a mean follow-up period of 2 years, 80% of hips that had stage I disease at baseline and 57% of hips at stage II had a successful outcome (defined as delay of further surgery plus a Harris hip score of at least 70). (Mont et al., 2004) Core Decompression in the Shoulder, Knee, and Ankle: Evidence regarding the effectiveness of core decompression for joints other than the hip is limited to studies conducted at the Johns Hopkins University School of Medicine. No asymptomatic patients were included in these studies, and no complications were reported.

Humeral Head (Shoulder): One small (n=46 patients, 67 shoulders), retrospective, uncontrolled study, (LaPorte et al.,

1998) provided weak but positive evidence of the long-term effectiveness of core decompression in delaying secondary surgery for AVN of the humeral head, not only in the precollapse stages but also in stage III. Joint survival rates for stages I, II, III, and IV were 94%, 88%, 70%, and 14%, respectively, after a mean follow-up of 10 years. In an earlier report on the institution's earliest experience with core decompression in the humeral head, the authors commented that because the glenoid is shallower and less conforming than the acetabulum and the shoulder is not a weight-bearing joint, deterioration of shoulder function may not occur until advanced stages of AVN. They postulated that core decompression for stage III or even stage IV AVN may be more appropriate for the shoulder than for the hip. (Mont et al., 1993) Femoral Condyle or Distal Femur (Knee): One retrospective, uncontrolled study (n=248 knees), provided weak but positive evidence of the long-term effectiveness of core decompression in delaying secondary surgery in the early stages of AVN of the femoral condyle. A second core decompression procedure was performed in 16% of patients; the criteria Core Decompression For Avascular Necrosis - Commercial Medical Management Guideline for repeat core decompression were not reported. Only 7 knees were at stage III at the time of diagnosis. The overall survival rate for knees included in the 2000 report (stages I through III) was 79%, based on a mean of 7 years of follow-up (minimum of 2 years). (Mont et al., 2000) Comparability of these results (Mont et al., 2000) with those of future studies may be limited. First, patients were selected for core decompression only after 3 months of conservative treatment failed to relieve symptoms. This is a reasonable selection process but not one reported by other authors. Results from core decompression might have been more favorable in patients whose symptoms had not already been shown to be unresponsive to conservative treatment. Secondly, 16% of patients had two, rather than one, core decompression procedures for AVN in the knee, which may have inflated results.





Talus (Ankle): Another very small retrospective analysis (n=32 ankles) provides very weak but positive evidence of effectiveness in treating AVN of the talus. The rate of joint survival over a mean follow-up period of 7.3 years was 91%.

Five ankles were at stage III AVN at the time of diagnosis; the remainder was at stage II. As in the knee studies, comparability with future studies is limited because core decompression was performed only in patients who had not responded to conservative treatment. However, because AVN in the talus appears to be rare, the authors had to start the time frame for their retrospective review in 1974, which may make it difficult to study this condition. (Delanois et al, 1998) Mandibular Condyle: Osteonecrosis of the mandibular condyle has only recently been reported, and there is limited information on the efficacy of core decompression. In 8 of 9 patients (16 joints) with histologically confirmed osteonecrosis of the mandible, core decompression resulted in substantial pain reduction over a mean follow-up period of 34 months. (Chuong et al., 1995) In a second group of 8 patients (15 joints) with more severe lesions, core decompression with bone grafting resulted in significant clinical improvement in 11 joints during the follow-up period (mean 28 months).

No studies that provide substantial new evidence regarding core decompression for avascular necrosis were identified in a February 2009 literature search.

Additional Search Terms:

Gaucher disease, Koehler disease, Legg-Calve'-Perthes disease, Legg-Perthes disease, sickle cell anemia, systemic lupus erythematosus References and Resources Resources Aigner N, Schneider W, Eberl V, Knahr K. Core decompression in early stages of femoral head osteonecrosis - an MRIcontrolled study. Int Orthop. 2002;26(1):31-35.

Bozic KJ, Zurakowski D, Thornhill TS. Survivorship analysis of hips treated with core decompression for nontraumatic osteonecrosis of the femoral head. J Bone Joint Surg Am. 1999;81(2):200-209.

Chuong R, Piper MA, Boland TJ. Osteonecrosis of the mandibular condyle. Pathophysiology and core decompression.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995 May;79(5):539-45.

Ciombor DM, Aaron RK. Biologically augmented core decompression for the treatment of osteonecrosis of the femoral head. Tech Orthop. 2001;16(1):32-38.

Delanois RE, Mont MA, Yoon TR, et al. Atraumatic osteonecrosis of the talus. J Bone Joint Surg Am. 1998;80(4):529Gangji V, Hauzeur JP, Matos C, et al. Treatment of osteonecrosis of the femoral head with implantation of autologous bone-marrow cells. A pilot study. J Bone Joint Surg Am. 2004;86-A(6):1153-1160.

Core Decompression For Avascular Necrosis - Commercial Medical Management Guideline Hayes, Inc. Directory. Core decompression for atraumatic avascular necrosis of the hip. Lansdale, PA: Hayes, Inc.;

January, 2006. Updated January 2009.

Hernigou P, Beaujean F. Treatment of osteonecrosis with autologous bone marrow grafting. Clin Orthop Relat Res.

2002;(405):14-23.

Iorio R, Healy WL, Abramowitz AJ, Pfeifer BA. Clinical outcome and survivorship analysis of core decompression for early osteonecrosis of the femoral head. J Arthroplasty. 1998;13(1):34-41.

Kane SM, Ward WA, Jordan LC, et al. Vascularized fibular grafting compared with core decompression in the treatment of femoral head osteonecrosis. Orthopedics. 1996;19(10):869-872.

LaPorte DM, Mont MA, Mohan V, et al. Osteonecrosis of the humeral head treated by core decompression. Clin Orthop Relat Res. 1998;(355):254-260.

Lavernia CJ, Sierra RJ. Core decompression in atraumatic osteonecrosis of the hip. J Arthroplasty. 2000;15(2):171-178.

Maniwa S, Nishikori T, Furukawa S, et al. Evaluation of core decompression for early osteonecrosis of the femoral head.

Arch Orthop Trauma Surg. 2000;120(5-6):241-244.

Markel DC, Miskovsky C, Sculco TP, et al. Core decompression for osteonecrosis of the femoral head. Clin Orthop Relat Res. 1996;(323):226-233.

Mont MA, Baumgarten KM, Rifai A, et al. Atraumatic osteonecrosis of the knee. J Bone Joint Surg Am. 2000;82(9):1279Mont MA, Jones LC, Pacheco I, Hungerford DS. Radiographic predictors of outcome of core decompression for hips with osteonecrosis stage III. Clin Orthop Relat Res. 1998;(354):159-168.

Mont MA, Maar DC, Urquhart MW, et al. Avascular necrosis of the humeral head treated by core decompression. A retrospective review. J Bone Joint Surg Br. 1993;75(5):785-788.

Mont MA, Ragland PS, Etienne G. Core decompression of the femoral head for osteonecrosis using percutaneous multiple small-diameter drilling. Clin Orthop Relat Res. 2004;(429):131-138.

Powell ET, Lanzer WL, Mankey MG. Core decompression for early osteonecrosis of the hip in high risk patients. Clin Orthop Relat Res. 1997;(335):181-189.

Scully SP, Aaron RK, Urbaniak JR. Survival analysis of hips treated with core decompression or vascularized fibular grafting because of avascular necrosis. J Bone Joint Surg Am. 1998;80(9):1270-1275.

Simank HG, Brocai DRC, Brill C, Lukoschek M. Comparison of results of core decompression and intertrochanteric osteotomy for nontraumatic osteonecrosis of the femoral head using Cox regression and survivorship analysis. J Arthroplasty. 2001;16(6):790-794.

Steinberg ME, Larcom PG, Strafford B, et al. Core decompression with bone grafting for osteonecrosis of the femoral head. Clin Orthop Relat Res. 2001;(386):71-78.

Core Decompression For Avascular Necrosis - Commercial Medical Management Guideline History/Updates Policy update. CMS information updated. Deleted CPT codes 27070 and 27071 from the coding section. Added diagnosis codes and procedure code 27999 to 3/13/2009 the coding section. Policy 2008T0219E archived.

–  –  –

Contact Information For questions regarding this policy, send an email to the Medical Technology Interpretation Service at medical_drug_interpretation@uhc.com with the word "Medical" in the subject line.

Coding The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only.

Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.

–  –  –

This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation.

Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific Core Decompression For Avascular Necrosis - Commercial Medical Management Guideline benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.



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