Hip Arthroscopy Debridement Combined with Multiple Small‐Diameter Fan‐Shaped Low‐Speed Drilling Decompression in the Treatment of Early and Middle Stage Osteonecrosis of the Femoral Head: 14 Years Follow‐Up

Abstract

Objective

Osteonecrosis of the femoral head (ONFH) is a disease that occurs frequently in young and middle‐aged people. Because of its high disability rate, it affects the ability to work, so the early treatment of this disease is particularly important. This retrospective study aimed to evaluate the clinical efficacy of hip arthroscopy combined with multiple small‐diameter fan‐shaped low‐speed drilling decompression (MSFLD) in treating early‐mid stage ONFH (ARCO II‐IIIA) compared to MSFLD, with at least 10‐year follow‐up.

Methods

A total of 234 patients who underwent hip arthroscopy and MSFLD for ONFH from 1998 to 2012 were analyzed retrospectively. This study enrolled patients between 18 and 60 years old with ARCO stage II‐III A, diagnosed clinically and through imaging, in accordance with the 2021 guidelines for the treatment of ONFH. Clinical data, including demographics, operation mode, BMI, pre‐ and postoperative Harris score, and femoral head survival rate, were collected. Patients were divided into hip arthroscopy + MSFLD and MSFLD groups based on the operation mode. The t‐test was used to compare the postoperative efficacy, Harris scores, and survival rates of the femoral head between the two groups.

Results

Among the 234 patients, 160 cases were followed up, including 92 cases in the hip arthroscopy + MSFLD group and 68 cases in MSFLD group, the follow‐up rate was 68.38%, and the follow‐up time was (10–22)14.11 ± 3.06 years. The Harris score (80.65 ± 6.29) in the hip arthroscopy + MSFLD group was significantly higher than that in the MSFLD group (p = 0.00), and the survival rate of femoral head (5‐year survival rate was 84.78%, 10‐year survival rate was 23.91%) was also higher than that in the MSFLD group (5‐year survival rate was 63.24%, 10‐year survival rate was 8.82%). The 5‐year and 10‐year survival rates of patients with ARCO II were 82.11% and 28.42%, which were better than 54% and 33% for ARCO III A. The femur head survival rate of alcoholic ONFH (5‐year survival rate 61.54%, 10‐year survival rate 9.23%) was significantly higher than that of other types of ONFH.

Conclusion

Clinical follow‐up of at least 10 years suggests that hip arthroscopy combined with MSFLD is an effective treatment for early‐mid stage ONFH, with good clinical effect and high survival rate of femoral head.

Hip arthroscopy combined with MSFLD improves clinical outcomes and prolongs femoral head survival in early‐mid stage osteonecrosis of the femoral head (ONFH). This retrospective study demonstrates higher postoperative Harris scores and longer femoral head survival times in the hip arthroscopy + MSFLD group compared to the MSFLD group, supporting the efficacy of this combined treatment approach for ONFH.

Introduction

Osteonecrosis of the femoral head (ONFH) is a condition characterized by the interruption of mechanical circulation, intravascular perfusion blockage, or external compression of blood vessels leading to microvascular damage and subsequent bone cell death, which can be attributed to a variety of factors including trauma, steroid use, alcohol consumption, and metabolic disorders. This results in a series of pathological changes, including bone cell death, increased intraosseous pressure, subchondral bone degeneration, collapse of the articular surface, and joint space narrowing, ultimately resulting in irreversible disfigurement of the hip joint. There are over 20 million existing ONFH patients worldwide, with approximately 5–7.5 million cases in China and 15–20 million new cases annually. ¹ , ² , ³ The disability rate of this disease is high, significantly decreasing labor ability; therefore, preserving femoral head morphology and function is crucial for the improvement of life quality.

Several surgical methods are currently available for preserving the hip, such as core decompression (CD), bone grafting, vascularized muscle flap or fibula grafting, and implantation of a porous tantalum rod. ⁴ While these methods delay the progression of osteonecrosis to some extent, they have certain limitations. For instance, procedures like vascularized muscle flaps or fibula grafts, although capable of removing dead bone completely, are complicated and traumatic with long postoperative external fixation times that affect joint function recovery. On the other hand, while the CD is minimally invasive, it fails to remove necrotic lesions completely, reduces subchondral bone support, and does not directly observe intra‐articular lesions. Moreover, due to the large diameter of the drill bit, femoral neck and femoral head bones are significantly damaged, leading to insufficient long‐term support and acceleration of the femoral head's collapse process. ⁵ Li et al. ⁶ developed a multiple small‐diameter fan‐shaped low‐speed drilling decompression (MSFLD) operation using a 3.0‐mm Kirschner to conduct multidirectional, different depth, and slow drilling decompression for the femoral head's necrosis region. With the development of arthroscopic technology, the scope of indications for hip arthroscopic surgery is expanding, which can not only directly observe the pathological changes of hip joint, but also treat the intraarticular lesions. Hip arthroscopy combined with MSFLD can observe intraarticular lesions, incision of anterior articular capsule to reduce intracapsular pressure; clean up proliferative synovium, trim cartilage, remove inflammatory substances, effectively reduce pain, improve treatment effect.

The purpose of this study is: (1) To evaluate the long‐term clinical efficacy of hip arthroscopy combined with multiple small‐diameter fan‐shaped low‐speed drilling decompression (hip arthroscopy + MSFLD) and MSFLD alone (MSFLD group) in treating early to mid‐stage (ARCOII‐III A) ONFH patients. The underlying aim is to determine the most effective treatment strategy through a long‐term follow‐up period of at least 10 years; (2) To explore the effectiveness of MSFLD in the treatment of early to mid‐stage ONFH. The aim is to uncover the potential and key role of MSFLD in ONFH treatment, providing new insights and strategies for clinical treatment.

Materials and Methods

Patient Selection Criteria

After obtaining institutional review board approval (S2021‐018‐01), we retrospectively reviewed the ONFH database in our hospital from February 1, 1998, to December 30, 2012, and identified 234 patients who underwent hip arthroscopy and/or MSFLD. The patients included 169 males and 65 females with age at the time of surgery of 39.61 ± 9.74 years (range 18–58). The etiology of the osteonecrosis was steroid use in 108 hips (46.2%), alcohol abuse in 97 hips (41.5%), and idiopathic in 29 hips (12.4%). The diagnosis of osteonecrosis was made based on the clinical history, X radiographs, MRI or CT findings. Inclusion criteria involved (i) patients aged 18–60 years, (ii) ARCO II‐III A stage ONFH, (iii) follow‐up for more than 10 years, (iv) confirmed by clinical and radiographic diagnosis (anteroposterior and lateral radiographs of both hips). ⁷ , ⁸ Exclusion criteria included individuals with ONFH (i) caused by acetabular dysplasia, malignancies, joint infections, those requiring continued high‐dose hormonal therapy due to primary disease, patients with traumatic ONFH, (ii) and individuals with a history of previous hip surgery. ⁹ , ¹⁰ , ¹¹ , ¹² All cases were informed of the general process, advantages and disadvantages of the two surgical protocols after diagnosis, and were divided into the hip arthroscopy + MSFLD group or the MSFLD group according to patient preference (Figure 1).

FIGURE 1.

CONSORT flow diagram of patient selection methods.

Diagnosis of ONFH and Classification Methods

In this study, the diagnosis of ONFH was established based on patient complaints (pain in the hip or groin area), history (such as hip trauma, corticosteroid use, alcohol abuse, or occupation as a diver), and radiographic signs. The X‐rays of the hip joint in the anteroposterior and frog position typically reveal bone sclerosis, cystic degeneration, and the “crescent sign” in the early stage, along with signs of sclerosis between the necrotic area and normal area. In late stages, the femoral head loses its original spherical structure due to collapse and presents with degenerative arthritis.

The consensus regarding the classification criteria for steroid‐induced ONFH (GA‐ONFH) includes the following: (1) patients should have a history of using >2 g of prednisolone or its equivalent within a 3‐month period; (2) osteonecrosis should be diagnosed within 2 years after the usage of glucocorticoids, and (3) patients should not have any other risk factors besides glucocorticoids. ¹³ , ¹⁴ , ¹⁵ The consensus on alcohol‐associated ONFH (AA‐ONFH) includes the following: (1) patients should have a history of consuming >400 mL/week of pure ethanol for more than 6 months; (2) ONFH should be diagnosed within 1 year after consuming this dose of alcohol, and (3) patients should not have any other risk factors. ¹³ , ¹⁶

Surgical Technique

All patients underwent hip arthroscopy by a single fellowship‐trained surgeon (LIU Yujie, Chief Physician, Professor of Orthopaedic Surgery). In the hip arthroscopy + MSFLD group, after general anesthesia was administered, patients were placed in a modified supine position, and traction was applied to the hip. ⁶ The affected limb was maintained at 15° of internal rotation, 15° of internal adduction, and 15° of forward flexion. Using the assistance of a C‐arm image intensifier, an anterolateral (AL) portal was established, followed by the creation of mid‐anterior portals (MA) under arthroscopic monitoring. Radiofrequency was used to incise the capsular ligaments between the two portals and release intraarticular pressure. The outer edge of the acetabulum, labrum, acetabular fossa, intra‐articular cartilage, and femoral neck were examined. It was observed that patients with higher ARCO stages exhibited more severe synovial hyperplasia, congestion, edema, and cartilage damage compared to patients with stage I under arthroscopic observation. Synovial membrane and cartilage debris in the hip joint were removed with a shaver to eliminate hyperplastic, hypertrophic, and hyperemic tissue (Figure 2). The weight‐bearing cartilage of the femoral head was probed, and floating articular cartilage was palpable in some patients. For patients with severe local cartilage stripping, the cartilage edge was trimmed to create a stable edge. If a hyperplastic osteophyte was detected in the outer edge of the acetabulum or femoral neck region, it was removed. In this study, capsular suturing was not performed in any cases to achieve adequate decompression of intraosseous pressure.

FIGURE 2.

Arthroscopic imaging of ONFH in the early and middle stages. (A) There is plenty of inflammatory synovial congestion and edema present in the hip joint affected by ONFH. (B) An inflammatory fat pad can be observed at the acetabular floor, with a visible blood clot indicating inflammatory changes. (C) Palpable floating articular cartilage is found in the weight‐bearing area of the femoral head. (D) ONFH with acetabular labral injury is detected.

Guided by C‐arm fluoroscopy, a 3.0‐mm Kirschner wire was drilled into the necrotic area of the femoral head until the subchondral bone using a low‐speed electric drill approximately 8 cm distal to the tip of the greater trochanter of the femur. The same method was used to sectionally drill 3–5 holes in the necrotic area, which were distributed evenly (Figure 3).

FIGURE 3.

C‐arm fluoroscopy during MSFLD. A 3.0‐mm Kirschner wire was used to slowly drill fan‐shaped holes 3–5 times from the distal end of the greater trochanter to the necrotic area of the femoral head, achieving the surgical goal of adequate decompression.

In the MSFLD group, patients underwent combined spinal‐epidural anesthesia or general anesthesia and only underwent MSFLD surgery without hip arthroscopy.

Rehabilitation Protocol

The rehabilitation exercise regimen can be divided into three phases. In the first 3 months post‐surgery, patients should avoid bearing weight on the injured limb. During this stage, patients can perform ankle joint movements on the bed to promote lower limb blood circulation and prevent the formation of deep vein thrombosis. At the same time, they can do some lightweight upper limb and core muscle exercises, as well as appropriate cold and hot compresses to alleviate pain and swelling. From 3 months to 1 year, patients can begin to try partially bearing weight on the affected limb and walk with the aid of crutches or walkers under the guidance of a physical therapist. In addition, it is necessary to do balance training such as standing on one foot and coordination exercises like lateral walking. ¹⁷ In the stage after 1 year, if there are no signs of hip bone collapse and the patient has no pain symptoms, strength training such as squats and leg lifts can be started to strengthen the thigh and hip muscles. Meanwhile, aerobic exercises such as cycling, swimming, etc., can enhance cardiopulmonary function and promote muscle recovery. Throughout the rehabilitation process, the guidance of professionals is essential to prevent overuse or injury to the surgical area.

Preoperative and Postoperative Clinical Data Collection

Preoperative Harris scores and etiological classification of the hip joint were obtained by reviewing cases, and preoperative X‐rays of the hip joint were taken to determine ARCO classification. X‐ray data were reviewed 3 months, 1 year, 3 years, and 5 years after surgery, and hip function was scored. The function of the hip joint was evaluated through telephone and outpatient examinations, and the progress of femoral head necrosis was assessed through anteroposterior and lateral X‐ray films at the last follow‐up. Hip function was measured using the Harris score. ¹⁸ The survival rate of patients with femoral head necrosis was analyzed using the Cox survival curve. Figure 4 provides typical case images.

FIGURE 4.

A 37‐year‐old male with a history of heavy drinking and right hip joint pain for 3 months was diagnosed with alcoholic ONFH. (A) Anteroposterior radiograph of pelvis before operation. (B) Three months after operation. (C) One year and three months after operation. (D) Three years after operation. (E) Five and a half years after operation. (F) Eight years after operation. (G) Twelve years after operation.

Statistical Analysis

Statistical analysis was performed using SPSS (version 26.0, IBM, Armonk, NY, USA) software to describe the observation indicators. SPSS was used to calculate the agreement between the two evaluators. Frequency and percentage were used to describe count data, while measurement data were described by⁻x ± s. T test or analysis of variance was used to compare the measurement data between groups. p < 0.05 was considered statistically significant. Schoenfeld residual method was utilized to test the proportional hazards hypothesis. Based on the results, the decision to establish time‐dependent covariates into the model was made, followed by the generation of a femoral head survival time analysis curve. Kaplan–Meier curves were calculated to analyze hip survivorship, using conversion to THA as the endpoint.

Results

Patient Demographics

Between 1998 and 2012, a total of 234 ONFH patients underwent either hip arthroscopy + MSFLD or MSFLD. Nineteen patients were excluded based on exclusion criteria. Out of the remaining 215 patients, 160 (68.38%) were available for follow‐up evaluation, while 42 patients were lost to follow‐up, nine refused to participate, and five died of other causes. The loss rate was 16.0%. The final cohort consisted of 92 patients who underwent hip arthroscopy + MSFLD and 68 patients who underwent MSFLD for ONFH. The mean follow‐up duration was 14.11 ± 3.06 years (range, 10–22). Of the patients, 93 were male and 67 were female, with a mean age of 39.53 years (range, 18–60). The consistency of the patients’ evaluation by the two physicians was quite good (Cronbach's alpha score = 0.817). Patient demographics and preoperative radiographic data are summarized in Table 1.

TABLE 1.

Baseline data of patients with ONFH.

	Hip arthroscopy + MSFLD group N = 92	MSFLD group N = 68	p Value
Gender (male/female)	54/38	39/29	0.184
Age (years)	38.21 ± 8.73	41.31 ± 10.24	0.065
Mean follow‐up time (years)	14.24 ± 3.54	14.10 ± 3.03	0.597
Steroid induced ONFH	14/33	13/21	0.198
Alcoholic ONFH	36/3	17/4	0.618
Idiopathic ONFH	4/2	9/4	0.454
ARCO stage II	28/26	24/17	0.419
ARCO stage IIIA	26/12	15/12	0.298
BMI (kg/m2)	25.19 ± 3.38	24.98 ± 4.13	0.110
Preoperative Harris score	64.62 ± 5.66	61.81 ± 7.14	0.060

Abbreviations: ARCO, Association Research Circulation Osseous; BMI, Body mass index; MSFLD, multiple small‐diameter fan‐shaped low‐speed drilling decompression; ONFH, Osteonecrosis of the femoral head.

Patient‐Reported Outcomes

There was no statistically significant difference in Harris scores between the two patient groups before surgery (p = 0.797). There was no statistically significant difference in ONFH caused by different etiologies (p = 0.606). At the last follow‐up, both groups exhibited significantly improved Harris scores compared to before surgery. The Harris scores of the hip arthroscopy + MSFLD group increased from 64.62 ± 5.66 points prior to surgery to 80.65 ± 6.29 points, indicating a statistically significant difference (p = 0.008); the Harris scores of the MSFLD group also showed an increase from 61.81 ± 7.14 points before surgery to 73.70 ± 5.49 points, with a statistically significant difference (p = 0.023). The postoperative Harris score of hip arthroscopy + MSFLD group was significantly higher than that of MSFLD group (p = 0.000) (Table 2). During the final follow‐up, there was a statistically significant improvement in Harris scores between ARCO II‐III A stage patients (p = 0.000). Moreover, the improvement in Harris scores for ARCO II stage patients was significantly greater than that of ARCO III A stage patients (p = 0.003).

TABLE 2.

Follow up of ONFH.

	Hip arthroscopy + MSFLD group	MSFLD group	p Value
Harris score postoperative	80.65 ± 6.29	73.70 ± 5.49	0.000
Steroid‐induced ONFH	79.38 ± 6.61	73.15 ± 5.04	0.000
Alcoholic ONFH	82.76 ± 6.28	74.10 ± 5.97	0.000
Idiopathic ONFH	80.54 ± 4.79	75.33 ± 6.06	0.000
ARCO Stage II	82.66 ± 4.68	74.39 ± 5.42	0.000
ARCO Stage IIIA	77.59 ± 7.24	72.71 ± 5.51	0.003

Note: The horizontal axis of the table shows two groups; the vertical axis shows the types and stages of ONFH. The content is its corresponding Harris rating.

Femoral Head Survival Rate

In this study, the 5‐year survival rate of the femoral head in the hip arthroscopy + MSFLD group was 84.78% (78/92) and the 10‐year survival rate was 23.91% (22/92). In the MSFLD group, the 5‐year survival rate was 63.24% (43/68) and the 10‐year survival rate was 8.82% (6/68) (Figure 5). The difference between the two groups was statistically significant. The 5‐year and 10‐year survival rates of alcoholic ONFH were 8.64% (49/60) and 26.67% (16/60) respectively, which were better than those of steroid induced ONFH (5‐year survival was 70.37% (57/81), 10‐year survival was 2.47% [2/81]), and idiopathic ONFH (5‐year survival was 73.68% (14/19), 10‐year survival was 15.79% [3/19]), the difference was statistically significant. The 5‐year survival rate of patients with ARCO II was 82.11% (78/95), which was better than 61.54% (40/65) in ARCO III A. The 10‐year survival rate of patients with ARCO II was 28.42% (27/95), which was also better than 9.23% (6/65) in ARCO III A.

FIGURE 5.

ONFH survival analysis of different surgical methods.

Discussion

The research group conducted at least 10 years of follow‐up on 160 cases of ONFH and performed a comparative analysis of Harris hip scores and femoral head survival rate between the two groups of patients. The results showed that the postoperative improvement of Harris score was better in the hip arthroscopy + MSFLD group than in the MSFLD group, and it could obtain better survival rate, delay the progression of femoral head necrosis, and postpone the timing of THA surgery.

Early ONFH involves bone marrow cell necrosis, dead bone absorption, early creeping substitution, and repair and reconstruction of necrotic bone tissue histopathologically. In this study, postoperative Harris scores of all types of ONFH improved compared to preoperative scores, with alcohol‐induced ONFH having longer femoral head survival rate than steroid‐induced ONFH. Hatanaka et al. ¹⁹ reported that the efficacy of alcohol‐induced ONFH was superior to that of steroid‐induced ONFH. Cui et al. ²⁰ conducted a multicenter epidemiological survey on 6395 ONFH patients and found that 46% of steroid‐induced ONFH were complicated with autoimmune diseases such as systemic lupus erythematosus, resulting in faster postoperative progression. Fukushima et al. ²¹ also confirmed through observation and follow‐up of 1502 cases of ONFH that the efficacy of steroid‐induced ONFH was inferior, and had a higher conversion rate to THA than other types. Our team suggests that most cases of steroid‐induced ONFH require continued steroid use, which may compromise clinical efficacy and accelerate disease progression. In this study, patients at ARCO stage II had better efficacy and prognosis than those at stage IIIA, indicating that ONFH treatment efficacy is closely related to disease staging. ²² Landgraeber et al. ²³ treated ONFH patients with an improved drilling decompression method, achieving a 100% treatment success rate in stage IIA patients compared to 61.5% in stage IIC patients, suggesting that as the disease course worsens, the treatment effect gradually decreases. ²⁴

In this study, intraarticular lesions of ONFH observed by hip arthroscopy included acetabular labral injury, weight‐bearing area cartilage injury, synovial hyperplasia, congestion and edema, vascular proliferation, and turbidity of joint fluid. Severe cases may lead to chondrolysis or joint loose body formation. Hip arthroscopy directly observes internal hip joint structure and surface damage to the femoral head, accurately assessing the extent of femoral head necrosis. Li et al. ⁶ suggest that high intra‐osseous pressure of the femoral head causes hip pain; synovial hyperplasia and loose bodies cause joint swelling and effusion; and chondrolysis and subchondral bone exposure limit joint mobility and induce discomfort symptoms. In a prospective study comparing the accuracy of MRI and diagnostic arthroscopy in staging ONFH, 36% of femoral head collapse and cartilage lesions in 52 hip patients were not detected by MRI, while hip arthroscopy achieved accurate diagnoses and staging of necrotic conditions. In the early stages of this disease, MSFLD combined with hip arthroscopic debridement can observe intra‐articular lesions; incise the anterior joint capsule to reduce intra‐articular pressure; clean up proliferative synovium, trim cartilage, and remove inflammatory substances, effectively reducing pain, improving efficacy, and prolonging femoral head survival. ²⁵ , ²⁶ , ²⁷ Ashberg et al. ²⁸ found that joint cartilage damage accelerates joint degeneration, significantly reduces Harris scores, and doubles the THA conversion rate compared to the control group. Arriaza et al. ²⁹ treated patients with ONFH and cartilage injuries with hip arthroscopic surgery, and after repairing the articular cartilage, 85% of patients experienced significant pain relief. ³⁰ In early‐to‐mid‐stage ONFH patients, inflammatory factors are present in the joint cavity, which can accelerate the degeneration of intra‐articular structures.

In addition to arthroscopic treatment of intraarticular lesions, we also applied MSFLD decompression technology to overcome the shortcomings of traditional core decompression drilling with large diameter, insufficient subchondral bone support, accelerated collapse of the femoral head and peripheral fractures. Advantages of MSFLD are: (1) multiple drilling holes with small diameters provide a cumulative decompression area that is not inferior to CD, with equivalent or better decompression effects ³¹ , ³² ; (2) distribution of the decompression channels in a fan‐shaped pattern reaches any necrotic area while minimizing bone loss and preserving supportive structures between bone channels, thus effectively preventing femoral head collapse after decompression ³³ ; (3) low‐speed drilling does not generate high heat, avoiding thermal damage to the cancellous bone caused by frictional heat. ²⁹ , ³⁴ Li et al. ⁶ performed MSFLD on ARCO stage I‐II ONFH patients using the narrow‐diameter multi‐channel decompression method, and they observed significant improvements in all indicators compared to advanced‐stage disease, including treatment efficacy, collapse rate of subchondral bone, lesion size, marrow edema grading, Harris score, visual analog scale for pain, and other indicators.

In the course of treatment, in addition to decompression of the femoral head, secondary lesions of the hip joint cannot be ignored. Serong et al. ³³ found that over 95% of ONFH patients had pathological changes, including cam deformity, acetabular labral abnormality, and cartilage injury, which could lead to early joint degeneration. Shoji et al. ³⁴ evaluated and measured the intra‐articular damage of the femoral head, acetabular labrum, and cartilage in 41 ONFH patients using hip arthroscopy. Patients with cartilage degeneration and acetabular labrum injury had a significant reduction in joint space width after surgery. Kawano et al. ³⁵ pointed out that in ARCO III or higher stage cases, severe synovitis and mechanical factors such as cartilage injury in the joint can accelerate the progression of hip osteoarthritis and reduce patient satisfaction. This further confirms that combined hip joint therapy can achieve good therapeutic effects for early‐to‐mid‐stage ONFH.

In this study, through hip arthroscopy, it was found that there were intra‐articular changes including cartilage degeneration, synovial hyperplasia and joint effusion at an early stage of ONFH, which was different from our traditional cognition (After the collapse of the femoral head, the articular surface becomes uneven, and the matching relationship between the femoral head and the acetabulum is disturbed, resulting in obvious cartilage wear and narrowing of the joint space, leading to hip osteoarthritis.). However, the patient's hip pain symptoms were relieved after surgical joint cleaning, so we speculated that ONFH might be a total joint disease. In the early and middle stages of ONFH, there are extra‐articular lesions of the femoral head itself and intraarticular synovial hyperplasia and cartilage destruction, which work together to accelerate the necrosis of the femoral head. ³² Femoral head necrosis has both internal and external factors, so it is necessary to deal with both internal and external joint lesions in order to achieve satisfactory curative effect.

This study has the following limitations: (1) in order to fully follow up postoperative cases, this study needs to follow up a large number of cases for >10 years. However, due to changes in patients' contact information and addresses over time, the dropout rate is high; (2) the cases collected in this study are all from one hospital, which is a single‐center retrospective clinical study, so the results may have selection bias; (3) the Harris score is not a patient‐reported score, but rather a score given by a physician based on a patient's condition. However, the score was widely used more than a decade ago, and it was included in the patient's medical records that year. The patient's own memory of the joint pain and mobility before the operation will be distorted. Therefore, in order to restore the actual situation before and after surgery, the research group decided to use the change of Harris score to evaluate the improvement of the condition.

Prospects of Clinical Application

The utilization of hip arthroscopy in conjunction with Multiple Small Fenestration Low‐speed Drilling (MSFLD) presents substantial advantages in treating osteonecrosis of the femoral head (ONFH). This minimally invasive approach significantly mitigates surgical invasiveness, thereby considerably reducing the risk of patient complications and expediting recovery time. Furthermore, the precision of hip arthroscopy, when amalgamated with the targeted nature of drilling decompression, dramatically amplifies treatment efficacy at initial to mid‐stages of ONFH. Despite the learning curve and extensive training required to master this technique, its advantages are undeniable. Once expertise is attained, the benefits to patients significantly surpass those of traditional methods. In addition, the safety of this technique has been comprehensively corroborated. The integration of hip arthroscopy with drilling decompression not only yields superior clinical outcomes, it also greatly eclipses traditional methods in regard to cost‐effectiveness. Consequently, this technique holds profound clinical application value for ONFH treatment.

Conclusion

Following a clinical follow‐up of at least 10 years, our study suggests that hip arthroscopy combined with MSFLD in treating early to mid‐stage (ARCO II‐III A) ONFH is more effective in improving femoral head survival and achieving long‐term clinical outcomes than MSFLD alone. This underscores the pivotal role of MSFLD in the treatment of early to mid‐stage ONFH, offering new strategies for clinical treatment.

Ethics Statement

Ethics approval and consent to participate. Human subjects research was approved by the Ethics Committee of Chinese PLA General Hospital and informed consent was obtained from all participants.

Conflict of Interest Statement

The authors have no relevant financial or non‐financial interests to disclose. The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. There is no conflict of interest that exists in the submission of this manuscript, and manuscript is approved by all authors for publication.

Author Contributions

All authors had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Zhao Gang, Liu Yujie, Li Chunbao designed the study, analyzed and interpreted data, and wrote the manuscript. Zhao Gang collected the data, performed statistical analysis, and critically reviewed the manuscript. Zheng Yongjun, Li Zhongli, Wang Mingxin contributed to data interpretation and critically reviewed the manuscript. Li Chunbao, Liu Yujie contributed to study design, data collection, and critically reviewed the manuscript. All authors have read and approved the final manuscript. In addition, all authors participated in the conception and design of the study, acquisition and interpretation of data, as well as the revising and final approval of the manuscript. Finally, all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding Information

This study was supported by the National Natural Science Foundation of China (Grant Number 82072517), National key R & D plan (Grant Number 2019YFE0126300), Military medicine innovation project of PLA General Hospital (Grant Number CX19004), and the Natural Science Foundation of Beijing Municipality (Grant Number 7192195). Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members.

Consent for Publication

All authors have reviewed and approved the final version of the manuscript and consent for publication in Clinical Orthopaedics and Related Research.

Data Availability Statement

The datasets used during the current study are available from the corresponding author on reasonable request.