Core Decompression Versus Nonoperative Management of Osteonecrosis of the Ankle: A Systematic Review

Introduction: The purpose of this study is to investigate the efficacy of core decompression for treating osteonecrosis of the ankle, including the distal tibia and talus, compared to nonoperative management. A systematic review was performed to specifically evaluate: (1) clinical results (patient-reported pain as well as functional scores, physician clinical reported assessment); (2) radiographic outcomes (i.e., radiographic progression of collapse); and (3) need for further procedures. Materials and Methods: A search of PubMed, EMBASE, and the Cochrane Library found eight reports that fit the inclusion criteria for core decompression or nonoperative management of osteonecrosis of the ankle. Four studies totaling 194 ankles diagnosed with osteonecrosis that underwent core decompression were analyzed. An additional four papers examined 64 ankles diagnosed with osteonecrosis that underwent nonoperative management. Level of evidence of the studies ranged from II to IV. Outcomes of core decompression and nonoperative management analyzed clinical scores such as the American Foot and Ankle Severity Score (AOFASS) and Mazur ankle grading system. Radiographic progression was studied with Ficat and Arlet as well as Hawkins scores. Results: Overall, there was an improvement in clinical scores and decreased radiographic progression in ankles treated with core decompression. AOFASS scores rose from 41.5 + 0.7 to 89 + 0.7, while the mean Mazur score increased from 34.5 + 0.7 preoperatively to 91.5 + 0.7 postoperatively. After core decompression, only 21% (40 out of 194 ankles) progressed radiographically to Ficat and Arlet stage III or IV postoperatively. Furthermore, core decompression showed less requirement for further surgical management compared to nonoperative management. Conclusions: Osteonecrosis of the ankle is not as commonly encountered in practice compared to other joints, such as the hips and knees. The results of this study suggest that core decompression is a successful option for treating osteonecrosis of the ankle.