Regenerative therapies increase survivorship of avascular necrosis of the femoral head: a systematic review and meta-analysis

Implantation of Culture-Expanded Bone Marrow Derived Mesenchymal Stromal Cells for Treatment of Osteonecrosis of the Femoral Head

BACKGROUND

Although core decompression (CD) with stem cell for the treatment of osteonecrosis of the femoral head (ONFH) showed promising results in many reports, the efficacy remains uncertain. We aimed to evaluate the efficacy of CD with culture-expanded autologous bone marrow-derived mesenchymal stem cell (BM-MSC) implantation in early stage ONFH.

METHODS

A total of 18 patients (22 hips) with ONFH who underwent CD with culture-expanded BM-MSC implantation from September 2013 to July 2020 were retrospectively reviewed. The median age was 35.0 years [interquartile range (IQR), 28.5-42.0], and the median follow-up period was 4.0 years (IQR, 2.0-5.3). The median number of MSCs was 1.06 × 108. To evaluate radiographic and clinical outcomes, Association Research Circulation Osseous (ARCO) classifications, Japanese Investigation Committee classification, combined necrotic angle (CNA) visual analogue scale (VAS) and Harris Hip Score (HHS) were checked at each follow-up.

RESULTS

The preoperative stage of ONFH was ARCO 2 in 14 hips and ARCO 3a in 8 hips. The ARCO staging was maintained in 7 hips in ARCO 2 and 4 hips in ARCO 3a. The radiographic failure rate of ARCO 2 and 3a was 14.3 and 50%, respectively. Furthermore, CNA decreased to more than 20° in 6 hips (four were ARCO 2 and two were ARCO 3a).There was no significant difference in the VAS and HHS (P = 0.052 and P = 0.535, respectively). Total hip arthroplasty was performed in 4 hips.

CONCLUSION

CD with culture-expanded autologous BM-MSCs showed promising results for the treatment of early stage ONFH.

Designing and synthesis of injectable hydrogel based on carboxymethyl cellulose/carboxymethyl chitosan containing QK peptide for femoral head osteonecrosis healing

Femoral head necrosis is a debilitating disorder that typically caused by impaired blood supply to the hip joint. In this study, a novel injectable hydrogel based on Oxidized Carboxymethyl Cellulose (OCMC)-Carboxymethyl Chitosan (CMCS) polymers containing an angiogenesis stimulator peptide (QK) with a non-toxic crosslinking interaction (Schiff based reaction) was synthesized to enhance angiogenesis following femoral head necrosis in an animal model. The physicochemical features of fabricated injectable hydrogel were analyzed by FTIR, swelling and degradation rate, rheometry, and peptide release. Also, the safety and efficacy were evaluated following an in vitro hydrogel injection study and an avascular necrosis (AVN) animal model. According to the results, the hydrogel exhibited an appropriate swelling ratio and water uptake (>90 %, 24 h) as well as a suitable degradation rate over 21 days accompanied by a continuous peptide release. Also, data showed that hydrogels containing QK peptide boosted the proliferation, differentiation, angiogenesis, and osteogenic potential of both Bone Marrow mesenchymal Stem Cells (BM-MSCs) and human umbilical vein endothelial cells (HUVECs) (****p < 0.0001 and ***p < 0.001, respectively). Furthermore, molecular and histological evaluations significantly demonstrated the overexpression of Runx2, Osteocalcin, Collagen I, VEGF and CD34 genes (**p < 0.01 and ***p < 0.001, respectively), and also femoral head necrosis was effectively prohibited, and more blood vessels were detected in defect area by OCMC-CMCS hydrogel containing QK peptide (bone trabeculae >9000, ***p < 0.001). In conclusion, the findings demonstrate that OCMC-CMCS-QK injectable hydrogel could be considered as an impressive therapeutic construct for femoral head AVN healing.

Mesenchymal Stem Cell Therapy for Bone Repair of Human Hip Osteonecrosis with Bilateral Match-Control Evaluation: Impact of Tissue Source, Cell Count, Disease Stage, and Volume Size on 908 Hips

We investigated the impact of mesenchymal stem cell (MSC) therapy on treating bilateral human hip osteonecrosis, analyzing 908 cases. This study assesses factors such as tissue source and cell count, comparing core decompression with various cell therapies. This research emphasizes bone repair according to pre-treatment conditions and the specificities of cell therapy in osteonecrosis repair, indicating a potential for improved bone repair strategies in hips without femoral head collapse. This study utilized a single-center retrospective analysis to investigate the efficacy of cellular approaches in the bone repair of osteonecrosis. It examined the impact on bone repair of tissue source (autologous bone marrow concentrate, allogeneic expanded, autologous expanded), cell quantity (from none in core decompression alone to millions in cell therapy), and osteonecrosis stage and volume. Excluding hips with femoral head collapse, it focused on patients who had bilateral hip osteonecrosis, both pre-operative and post-operative MRIs, and a follow-up of over five years. The analysis divided these patients into seven groups based on match control treatment variations in bilateral hip osteonecrosis, primarily investigating the outcomes between core decompression, washing effect, and different tissue sources of MSCs. Younger patients (<30 years) demonstrated significantly better repair volumes, particularly in stage II lesions, than older counterparts. Additionally, bone repair volume increased with the number of implanted MSCs up to 1,000,000, beyond which no additional benefits were observed. No significant difference was observed in repair outcomes between different sources of MSCs (BMAC, allogenic, or expanded cells). The study also highlighted that a 'washing effect' was beneficial, particularly for larger-volume osteonecrosis when combined with core decompression. Partial bone repair was the more frequent event observed, while total bone repair of osteonecrosis was rare. The volume and stage of osteonecrosis, alongside the number of injected cells, significantly affected treatment outcomes. In summary, this study provides comprehensive insights into the effectiveness and variables influencing the use of mesenchymal stem cells in treating human hip osteonecrosis. It emphasizes the potential of cell therapy while acknowledging the complexity and variability of results based on factors such as age, cell count, and disease stage.

Trans-Arterial Stem Cell Injection (TASI): The Role of Interventional Radiology in Regenerative Medicine

Regenerative medicine is taking a step forward in treating multiple diseases. The possibility of renewing damaged tissues with stem cells has become a topic of interest in recent decades. Still a relatively new research topic, many issues in this discipline are being addressed, from cell culturing to the study of different graft materials, and, moreover, cell delivery. For instance, direct intravenous injection has a big downfall regarding its lack of precision and poorly targeted treatment. Trans-arterial and direct percutaneous infusion to the aimed tissue/organ are both considered ideal for reaching the desired region but require image guidance to be performed safely and precisely. In this context, interventional radiology becomes pivotal for providing different cell delivery possibilities in every case. In this review, we analyze different basic stem cell therapy concepts and the current and future role of interventional radiology with a focus on trans-arterial delivery.

Regenerative therapies for femoral head necrosis in the past two decades: a systematic review and network meta-analysis

BACKGROUND

Regenerative techniques combined with core decompression (CD) are commonly used to treat osteonecrosis of the femoral head (ONFH). However, no consensus exists on regeneration therapy combined with CD that performs optimally. Therefore, we evaluated six regenerative therapies combined with CD treatment using a Bayesian network meta-analysis (NMA).

METHODS

We searched PubMed, Embase, Cochrane Library, and Web of Science databases. Six common regeneration techniques were categorized into the following groups with CD as the control group: (1) autologous bone graft (ABG), (2) autologous bone graft combined with bone marrow aspirate concentrate (ABG + BMAC), (3) bone marrow aspirate concentrate (BMAC), (4) free vascular autologous bone graft (FVBG), (5) expanded mesenchymal stem cells (MSCs), and (6) platelet-rich plasma (PRP). The conversion rate to total hip arthroplasty (THA) and progression rate to femoral head necrosis were compared among the six treatments.

RESULT

A total of 17 literature were included in this study. In the NMA, two of the six treatment strategies demonstrated higher response in preventing the progression of ONFH than CD: MSCs (odds ratio [OR]: 0.098, 95% confidence interval [CI]: 0.0087-0.87) and BMAC (OR: 0.27, 95% CI: 0.073-0.73). Additionally, two of the six treatment strategies were effective techniques in preventing the conversion of ONFH to THA: MSCs (OR: 0.062, 95% CI: 0.0038-0.40) and BMAC (OR: 0.32, 95% CI: 0.1-0.074). No significant difference was found among FVBG, PRP, ABG + BMAC, ABG, and CD in preventing ONFH progression and conversion to THA (P > 0.05).

CONCLUSIONS

Our NMA found that MSCs and BMAC were effective in preventing ONFH progression and conversion to THA among the six regenerative therapies. According to the surface under the cumulative ranking value, MSCs ranked first, followed by BMAC. Additionally, based on our NMA results, MSCs and BMAC following CD may be necessary to prevent ONFH progression and conversion to THA. Therefore, these findings provide evidence for the use of regenerative therapy for ONFH.

New Technique of Reverse Bone Grafting With Core Decompression and Enriching With Regenerative Medicine Techniques for Grade 2 and Grade 3 Avascular Necrosis of Both Hips

Early avascular necrosis (AVN) of the hip poses a significant clinical challenge, requiring prompt recognition and intervention to mitigate long-term complications. A case report describing a 30-year-old man with bilateral hip AVN is presented here. In addition, to reverse bone grafting and core decompression of both hips, the patient had platelet-rich plasma (PRP) infiltration in the right hip and bone marrow aspirate concentrate (BMAC) infiltration in the left hip. This method attempted to stop the disease's development and promote hip regeneration in both. Significant pain reduction and postoperative functional gains in both hips are seen in this instance. These results highlight the potential of combined orthopedic and regenerative therapies in young individuals with hip AVN and highlight the necessity of early intervention for maintaining long-term hip function.

A Comprehensive Review of Treatment Strategies for Early Avascular Necrosis

Avascular necrosis (AVN), characterised by compromised blood supply leading to bone necrosis, poses a significant challenge in orthopaedic and rheumatologic practice. This review comprehensively examines early AVN treatment strategies, including aetiology and risk factors, clinical presentation, conservative and surgical approaches, emerging therapies, and rehabilitation. Key findings underscore the importance of early detection, personalised treatment plans, and a multidisciplinary approach involving orthopaedic specialists, rheumatologists, and physical therapists. The implications for clinical practice emphasise individualised care, staying abreast of emerging therapies, and patient education. Recommendations for future management strategies highlight the need for imaging technology advancements, regenerative therapies integration, and ongoing research into genetic and molecular pathways. As the field continues to evolve, translating research findings into clinical practice holds promise for improving outcomes and enhancing the overall quality of life for individuals affected by AVN.

Extracellular vesicles from human umbilical cord mesenchymal stem cells prevent steroid-induced avascular necrosis of the femoral head via the PI3K/AKT pathway

Extracellular vesicles (EVs) secreted by human umbilical cord mesenchymal stem cells (hucMSC) have excellent therapeutic potential for many diseases. The aim of this study was to define the role of hucMSC-EVs in the prevention and treatment of steroid-induced avascular necrosis of the femoral head (SANFH). After establishing the SANFH rat model, the effects of hucMSC-EVs were assessed by measuring the microstructure of the femoral head using HE staining, micro-computed tomography (micro-CT), and TUNEL staining. The administration of hucMSC-EVs caused a significant reduction to glucocorticoids (GCs)-induced osteoblast apoptosis and empty lacuna of the femoral head, while effectively improving the microstructure. HucMSC-EVs rescued the deactivation of the phosphatidylinositol 3-kinase (PI3K)/protein kinase B (AKT) signaling pathway induced by GCs, and reversed the proliferation and migration of osteoblasts inhibited by GCs. In addition, hucMSC-EVs attenuated the inhibitory effects of GCs on rat osteoblast osteogenesis, angiogenesis of endothelial cells, and prevented osteoblast apoptosis. However, the promoting effects of hucMSC-EVs were abolished following the blockade of PI3K/AKT on osteoblasts. hucMSC-EVs were found to prevent glucocorticoid-induced femoral head necrosis in rats through the PI3K/AKT pathway.

Prognosis of hip osteonecrosis after cell therapy with a calculator and artificial intelligence: ten year collapse-free survival prediction on three thousand and twenty one hips

PURPOSE

Several reports have identified prognostic factors for hip osteonecrosis treated with cell therapy, but no study investigated the accuracy of artificial intelligence method such as machine learning and artificial neural network (ANN) to predict the efficiency of the treatment. We determined the benefit of cell therapy compared with core decompression or natural evolution, and developed machine-learning algorithms for predicting ten year collapse-free survival in hip osteonecrosis treated with cell therapy. Using the best algorithm, we propose a calculator for "prognosis hip osteonecrosis cell therapy (PHOCT)" accessible for clinical use.

METHODS

A total of 3145 patients with 5261 osteonecroses without collapses were included in this study, comprising 1321 (42%) men and 1824 (58%) women, with a median age of 34 (12-62) years. Cell therapy was the treatment for 3021 hips, core decompression alone for 1374 hips, while absence of treatment was the control group of 764 hips. First, logistic regression and binary logistic regression analysis were performed to compare results of the three groups at ten years. Then an artificial neural network model was developed for ten year collapse-free survival after cell therapy. The models' performances were compared. The algorithms were assessed by calibration, and performance, and with c-statistic as measure of discrimination. It ranges from 0.5 to 1.0, with 1.0 being perfect discrimination and 0.5 poor (no better than chance at making a prediction).

RESULTS

Among the 3021 hips with cell therapy, 1964 hips (65%) were collapse-free survival at ten years, versus 453 (33%) among those 1374 treated with core decompression alone, and versus 115 (15%) among 764 hips with natural evolution. We analyzed factors influencing the prediction of collapse-free period with classical statistics and artificial intelligence among hips with cell therapy. After selecting variables, a machine learning algorithm created a prognosis osteonecrosis cell therapy calculator (POCT). This calculator proved to have good accuracy on validation in these series of 3021 hip osteonecroses treated with cell therapy. The algorithm had a c-statistic of 0.871 suggesting good-to-excellent discrimination when all the osteonecroses were mixed. The c-statistics were calculated separately for subpopulations of categorical osteonecroses. It retained good accuracy, but underestimated ten year survival in some subgroups, suggesting that specific calculators could be useful for some subgroups. This study highlights the importance of multimodal evaluation of patient parameters and shows the degree to which the outcome is modified by some decisions that are within a surgeon's control, as the number of cells to aspirate, the choice of injecting in both the osteonecrosis and the healthy bone, the choice between unilateral or bilateral injection, and the possibility to do a repeat injection.

CONCLUSION

Many disease conditions and the heterogeneities of patients are causes of variation of outcome after cell therapy for osteonecrosis. Predicting therapeutic effectiveness with a calculator allows a good discrimination to target patients who are most likely to benefit from this intervention.

Volume and location of bone regeneration after autologous expanded mesenchymal stromal cells in hip osteonecrosis : a pilot study

AIMS

Successful cell therapy in hip osteonecrosis (ON) may help to avoid ON progression or total hip arthroplasty (THA), but the achieved bone regeneration is unclear. The aim of this study was to evaluate amount and location of bone regeneration obtained after surgical injection of expanded autologous mesenchymal stromal cells from the bone marrow (BM-hMSCs).

METHODS

A total of 20 patients with small and medium-size symptomatic stage II femoral head ON treated with 140 million BM-hMSCs through percutaneous forage in the EudraCT 2012-002010-39 clinical trial were retrospectively evaluated through preoperative and postoperative (three and 12 months) MRI. Then, 3D reconstruction of the original lesion and the observed postoperative residual damage after bone regeneration were analyzed and compared per group based on treatment efficacy.

RESULTS

The mean preoperative lesion volume was 18.7% (SD 10.2%) of the femoral head. This reduced to 11.6% (SD 7.5%) after three months (p = 0.015) and 3.7% (SD 3%) after one year (p < 0.001). Bone regeneration in healed cases represented a mean 81.2% (SD 13.8%) of the initial lesion volume at one year. Non-healed cases (n = 1 stage progression; n = 3 THAs) still showed bone regeneration but this did not effectively decrease the ON volume. A lesion size under mean 10% (SD 6%) of the femoral head at three months predicted no ON stage progression at one year. Regeneration in the lateral femoral head (C2 under Japanese Investigation Committee (JCI) classification) and in the central and posterior regions of the head was predominant in cases without ON progression.

CONCLUSION

Bone regeneration was observed in osteonecrotic femoral heads three months after expanded autologous BM-hMSC injection, and the volume and location of regeneration indicated the success of the therapy.Cite this article: Bone Joint Res 2022;11(12):881-889.

Bioactivation of scaffolds in osteonecrosis

Avascular osteonecrosis (AVN) due to local ischemia leads to an inhomogeneous osseous defect, which can be treated by resection and with bone substitute materials in a joint-preserving treatment. Due to the underlying risk profile of AVN, the mostly subchondral localization and the size of the local bone defect, bone regeneration is impaired. Therefore, bioactivation of the applied bone substitute materials prior to application is highly desirable. Apart from the use of growth factors and other soluble substances, the autologous application of location-typical cells and tissue is a useful alternative to support the bone healing properties of scaffolds. This article presents various methods to activate scaffolds for bone stimulation and discusses these techniques with respect to recent data from the literature.

Comparison of the outcome of different bone grafts combined with modified core decompression for the treatment of ARCO II stage femoral head necrosis

PURPOSE

Treatment of ONFH at an early stage is a challenging issue. The modified minimally invasive core decompression combined with bone graft implantation remains controversial. This study aimed to compare the early-middle outcomes of four groups with different bone grafts.

METHODS

A total of 182 patients (192 hips) with ONFH at the ARCO II stage were randomly divided into four groups. The free fibular graft group (FFG), free vascularized fibular graft group (FVFG), autologous iliac bone group (ABG), and β-tricalcium bioceramics phosphate graft (β-TCPG) group. Each group was treated with the modified minimally invasive core decompression and bone graft implantation. The operation time and blood loss were recorded by the same observer. The clinical outcome was evaluated by the Harris Hip Score and VAS score (before, 14 days after surgery, and at the last follow-up). The radiographic progression of ONFH was evaluated at least 36 months of follow-up.

RESULTS

All cases were successful without any complications after the operation. The patients were followed up for 42 to 48 (44.62 ± 1.81) months. There were statistically significant differences among the four groups in operation time (F value = 1520.67; P < 0.01) and blood loss (F value = 5366.81; P < 0.01). The Harris Hip Score in each group was improved significantly from pre-operation to last follow-up (all P < 0.01). At the last follow-up, the difference in the Harris Hip Score in each group was not statistically significant (F value = 0.54; P = 0.984). The VAS scores in each group were decreased significantly from the pre-operation to14 days after surgery (all P < 0.01). At 14 days after surgery, the difference in the VAS score in each group was not statistically significant (F value = 0.64; P = 0.59). At the last follow-up, three hips collapsed on the femoral head in the FFG group, two in the FVFG group, two in the ABG group, and three in the β-TCPG group.

CONCLUSION

The four different bone graft implantation showed satisfactory early-middle outcomes. As compared to other bone grafts, the β-TCP bioceramics graft has the advantages of shorter operation time and lesser blood loss. It may be a choice as a bone graft for the treatment of ONFH at an early stage.

Tissue Engineering Strategies for Treating Avascular Necrosis of the Femoral Head

Avascular necrosis (AVN) of the femoral head commonly leads to symptomatic osteoarthritis of the hip. In older patients, hip replacement is a viable option that restores the hip biomechanics and improves pain but in pediatric, adolescent, and young adult patients hip replacements impose significant activity limitations and the need for multiple revision surgeries with increasing risk of complication. Early detection of AVN requires a high level of suspicion as diagnostic techniques such as X-rays are not sensitive in the early stages of the disease. There are multiple etiologies that can lead to this disease. In the pediatric and adolescent population, trauma is a commonly recognized cause of AVN. The understanding of the pathophysiology of the disease is limited, adding to the challenge of devising a clinically effective treatment strategy. Surgical techniques to prevent progression of the disease and avoid total hip replacement include core decompression, vascular grafts, and use of bone-marrow derived stem cells with or without adjuncts, such as bisphosphonates and bone morphogenetic protein (BMP), all of which are partially effective only in the very early stages of the disease. Further, these strategies often only improve pain and range of motion in the short-term in some patients and do not predictably prevent progression of the disease. Tissue engineering strategies with the combined use of biomaterials, stem cells and growth factors offer a potential strategy to avoid metallic implants and surgery. Structural, bioactive biomaterial platforms could help in stabilizing the femoral head while inducing osteogenic differentiation to regenerate bone and provide angiogenic cues to concomitantly recover vasculature in the femoral head. Moreover, injectable systems that can be delivered using a minimal invasive procedure and provide mechanical support the collapsing femoral head could potentially alleviate the need for surgical interventions in the future. The present review describes the limitations of existing surgical methods and the recent advances in tissue engineering that are leading in the direction of a clinically effective, translational solution for AVN in future.

Efficacy of various core decompression techniques versus non-operative treatment for osteonecrosis of the femoral head: a systemic review and network meta-analysis of randomized controlled trials

Background

Various Joint-preserving therapy (JPT) methods have been performed and tried in recent decades, but their results and efficacy were inconsistent and controversial. The purpose of this study is to evaluate its effectiveness and whether there are statistical differences in treatment between different interventions based on published RCT studies.

Methods

Following the PRISMA-NMA checklist, Medline, EMBASE, Web of Science, and Cochrane Library databases were searched and collected related RCT studies. The sources were searched from inception up to October 30, 2020. The primary outcomes including the rate of radiographic progression and conversion to THA and the secondary outcome -Harris Hip Scores (HHS) were extracted and compared in a Network meta-analysis.

Results

Seventeen RCT studies involving 784 patients (918 hips) with seven interventions including CD (core decompression), CD + BG (bone graft), CD + TI (tantalum rod implantation), CD + CT (Cell therapy), CD + BG + CT, VBG (vascularized bone graft), and nonsurgical or conservative treatment for ONFH were evaluated. In the radiographic progression results, CD + CT showed a relatively better result than CD, CD + BG and non-surgical treatment, the surface under the cumulative ranking curve (SUCRA) plot displayed that CD + CT (96.4%) was the best, followed by CD (64.1%).In conversion to THA results, there were no significant differences between the JPT methods and non-surgical treatment. In HHS, there was also no significant difference, other than CD + BG showed a statistical difference than non-surgical treatment only in terms of Cis, but the SUCRA was highest in non-surgical treatment (80.5%) followed by CD + CT (72.8%).

Conclusions

This Net-work meta-analysis demonstrated that there was no statistical difference in the outcome of radiographic progression and conversion to THA, also in HHS, other than CD + CT showed a relatively superior result in radiographic progression than nonsurgical treatment, namely, it’s maybe an effective method for delaying disease progression or reducing disease development based on current evidence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04808-2.

Protective Effect of Human Umbilical Cord Mesenchymal Stem Cells in Glucocorticoid-induced Osteonecrosis of Femoral Head

OBJECTIVE

To evaluate the effect of human umbilical cord mesenchymal stem cells (hUC-MSCs) on preventing rats from glucocorticoid-induced osteonecrosis of femoral head (GCONFH) in the early stage in vivo and to investigate the possible mechanism of hUC-MSCs in regulating the balance of osteogenesis and adipogenesis.

METHODS

All rats were randomly divided into 3 groups: control group (C group), model group (M group), and intervention group (I group). The model of GC-ONFH was developed by a sequential administration of lipopolysaccharide and methylprednisolone. The rats in the I group were treated with caudal vein injection of hUC-MSCs. Six weeks later, the blood samples were obtained to measure the activity of alkaline phosphatase (ALP) and the content of triglyceride (TG) in serum, and the femoral heads were harvested and observed by hematoxylin-eosin staining, Micro-CT, Western blot and real-time quantitative polymerase chain reaction.

RESULTS

After intervention of hUC-MSCs, the necrosis rate of femoral head decreased from 83% (10/12) to 33% (4/12), the rate of empty bone lacuna was significantly decreased, the activity of ALP increased significantly, the content of TG decreased significantly, the bone density increased obviously, the expression of RUNX2 and Col I increased significantly and the expression of PPARγ decreased significantly.

CONCLUSION

These results revealed that caudal vein injection of hUC-MSCs can effectively reduce the incidence of GC-ONFH in rats by increasing ALP activity and reducing TG content in serum, increasing bone mineral density, promoting the expression of RUNX2 and Col I, and inhibiting the expression of PPARγ.

Core Decompression with Local Administration of Zoledronate and Enriched Bone Marrow Mononuclear Cells for Treatment of Non-Traumatic Osteonecrosis of Femoral Head

Objective

To investigate the efficacy and safety of core decompression (CD) with local administration of zoledronate and enriched bone marrow mononuclear cells (BMMCS) for the treatment of non‐traumatic osteonecrosis of femoral head (ONFH).

Methods

A total of 17 patients (30 hips) diagnosed with stage II and III ONFH according to the 2019 revised Association for Research on Osseous Circulation (ARCO) staging criteria from 2012 to 2014 were retrospectively reviewed. The patients received the following therapy: the BMMCs and zoledronate were injected into the necrotic zone, respectively, along with CD. The mean age of the patients was 36.8 years; 14 were men and three were women. All patients included had non‐traumatic ONFH and a minimum follow‐up of 5 years, which ended when total hip arthroplasty (THA) was performed. Imaging modalities, including plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI) were taken pre‐ and postoperatively. Harris hip score (HHS) was used to evaluate the functional outcomes of femoral head necrosis. Kaplan–Meier analysis was adopted to determine the probability of survivorship with THA as the end point in this series of patients. The correlation between radiological progression or THA and related risk factors were further analyzed. All complications were recorded.

Results

With THA as the follow‐up endpoint, All patients were followed up for an average of 69.1 ± 20.5 months (range, 18–95 months). Preoperative imaging found six hips (20%) at ARCO stage II, 14 hips (46.7%) at stage IIIA, 10 hips (33.3%) at stage IIIB. Fourteen hips (46.7%) shown progression radiologically, while six hips (20%) underwent TKA among these patients with hip preservation. The cumulative survival was 80% (95% CI, 0.608–905) at 5 years with THA as the end point. HHS improved from 63.3 ± 8.7 preoperatively to 74.6 ± 20.6 postoperatively (P = 0.000). Radiological progression was found to be associated with ARCO stage, Japanese Investigation Committee (JIC) type, and corticosteroid exposure (P = 0.047; P = 0.012; P = 0.031). However, no correlation was found between conversion to THA and the known risk factors. No major complication was reported, with only four patients complaining about general weakness and muscle soreness, and all disappeared within 2–3 days.

Conclusions

The novel treatment modality could relieve pain, delay the progression of collapse, which might be an effective and safe method for hip preservation of early and mid‐term ONFH. However, the effect of this method may be related to ARCO stage, JIC type, and corticosteroid exposure.

Arthroscopic evaluation of the synovial membrane and its relationship with histological changes and biomarkers in equine joint disease

The synovial membrane (SM) presents itself with distinctive characteristics during arthroscopic procedures in cases of osteoarthritis (OA) as well as osteochondritis dissecans (OCD) in horses. Most of the arthroscopic findings of the SM are limited to a description of a nonspecific inflammation state. In the present study, the macroscopic and histological aspects of the SM in OA and OCD horses were compared to those of healthy horses. The expression of interleukin (IL) in SM was also investigated. Besides, the concentrations of ILs and keratan sulfate (KS) in the synovial fluid (SF), and the molecular weights of the SF hyaluronic acid (HA) were also determined and correlated to the macroscopic and histological aspects of SM. This study included 10 healthy horses (control group), 12 horses with OA, and 12 with OCD. Macroscopic scores of the SM were higher in the OA group in comparison to the control and OCD groups. However, histological scores between OA and OCD were not different, and both were higher than the control group. Only in the OA group, there was a correlation between macroscopic and histological aspects of the SM, especially between volume and quantity of villi with perivascular inflammatory cells and synovial proliferation. The OA group has shown decreased expression of IL-10 in the SM, lower IL-10 and KS, and higher IL-1β and IL-6 in the SF in comparison to the control and OCD groups. There was a significant negative correlation between the macroscopic aspect of the SM and the molecular weights AH in the OA group. There was no correlation between the macroscopic aspect of the SM and all dosages in the OA and OCD group. In the OA joints, the evaluation of the shape of the SM during arthroscopy promotes a better indicator for joint inflammatory or tissue repair processes, while in the osteochondritic joints, investigation of the histological aspects are recommended to rule out an incipient OA development process. Both are helpful and should be considered to guide the postoperative treatment.

Perspective: Why and How Ubiquitously Distributed, Vascular-Associated, Pluripotent Stem Cells in the Adult Body (vaPS Cells) Are the Next Generation of Medicine

A certain cell type can be isolated from different organs in the adult body that can differentiate into ectoderm, mesoderm, and endoderm, providing significant support for the existence of a certain type of small, vascular-associated, pluripotent stem cell ubiquitously distributed in all organs in the adult body (vaPS cells). These vaPS cells fundamentally differ from embryonic stem cells and induced pluripotent stem cells in that the latter possess the necessary genetic guidance that makes them intrinsically pluripotent. In contrast, vaPS cells do not have this intrinsic genetic guidance, but are able to differentiate into somatic cells of all three lineages under guidance of the microenvironment they are located in, independent from the original tissue or organ where they had resided. These vaPS cells are of high relevance for clinical application because they are contained in unmodified, autologous, adipose-derived regenerative cells (UA-ADRCs). The latter can be obtained from and re-applied to the same patient at the point of care, without the need for further processing, manipulation, and culturing. These findings as well as various clinical examples presented in this paper demonstrate the potential of UA-ADRCs for enabling an entirely new generation of medicine for the benefit of patients and healthcare systems.

Pro-Angiogenic and Osteogenic Effects of Adipose Tissue-Derived Pericytes Synergistically Enhanced by Nel-like Protein-1

An important objective of vascularized tissue regeneration is to develop agents for osteonecrosis. We aimed to identify the pro-angiogenic and osteogenic efficacy of adipose tissue-derived (AD) pericytes combined with Nel-like protein-1 (NELL-1) to investigate the therapeutic effects on osteonecrosis. Tube formation and cell migration were assessed to determine the pro-angiogenic efficacy. Vessel formation was evaluated in vivo using the chorioallantoic membrane assay. A mouse model with a 2.5 mm necrotic bone fragment in the femoral shaft was used as a substitute for osteonecrosis in humans. Bone formation was assessed radiographically (plain radiographs, three-dimensional images, and quantitative analyses), and histomorphometric analyses were performed. To identify factors related to the effects of NELL-1, analysis using microarrays, qRT-PCR, and Western blotting was performed. The results for pro-angiogenic efficacy evaluation identified synergistic effects of pericytes and NELL-1 on tube formation, cell migration, and vessel formation. For osteogenic efficacy analysis, the mouse model for osteonecrosis was treated in combination with pericytes and NELL-1, and the results showed maximum bone formation using radiographic images and quantitative analyses, compared with other treatment groups and showed robust bone and vessel formation using histomorphometric analysis. We identified an association between FGF2 and the effects of NELL-1 using array-based analysis. Thus, combinatorial therapy using AD pericytes and NELL-1 may have potential as a novel treatment for osteonecrosis.

Combining autologous bone marrow buffy coat and angioconductive bioceramic rod grafting with advanced core decompression improves short-term outcomes in early avascular necrosis of the femoral head: a prospective, randomized, comparative study

Background

Treatment of avascular necrosis of the femoral head (ANFH) in young patients remains a clinical challenge. A current controversy is whether hip-preserving surgery results in better outcomes. The adverse effects of hip-preserving surgery are associated with the fill material for the necrotic areas. This study aims to evaluate the early effects of autologous bone marrow buffy coat (BBC) and angioconductive bioceramic rod (ABR) grafting with advanced core decompression (ACD) on early ANFH.

Methods

Forty-four (57 hips) patients with early ANFH from 2015 to 2020 were recruited for this study. They were randomized into two groups: group A received ACD, BBC, and ABR grafting; group B received treatment of ACD with β-tricalcium phosphate (β-TCP) granules and ABR grafting. The outcomes were assessed using the Harris Hip Scores (HHS) and survival rate analysis. The follow-up endpoint was defined as conversion to total hip arthroplasty (THA).

Results

Forty patients (51 hips) were ultimately included in this study for analysis. Compared with group B, patients in group A had higher postoperative function score (P = 0.032) and postoperative Harris Hip Scores (HHS) (P = 0.041). Kaplan-Meier analysis showed a trend that the survivorship of the femoral head was higher in group A than in group B.

Conclusion

The short-term follow-up results showed that the autologous bone marrow buffy coat and angioconductive bioceramic rod grafting with advanced core decompression is effective in the treatment of early ANFH.

Trial registration

Chictr.org.cn, ChiCTR2000039595. Retrospectively registered on 11 February 2015.

LRRC17 regulates the bone metabolism of human bone marrow mesenchymal stem cells from patients with idiopathic necrosis of femoral head through Wnt signaling pathways: A preliminary report

Idiopathic necrosis of the femoral head (INFH) is a common disease with unknown cause. Its successful treatment relies on the repair of the necrotic bone. The application of autologous mesenchymal stem cells (MSCs) has shown great promise in saving the patients from undergoing total hip arthroplasty. Leucine-rich repeat-containing 17 (LRRC17) is less expressed in patients with femoral head necrosis and LRRC17 can inhibit bone degradation. However, it remains unknown whether LRRC17 plays a role in the pathogenesis of INFH. The present study aimed to investigate the potential role and mechanism of LRRC17 in the pathogenesis and treatment of INFH. It was found that despite the similar cell morphology and MSC surface marker expressions of human bone marrow MSCs (BMSCs) isolated from patients with INFH (INFH-hBMSC) and femoral neck fracture (FNF) (FNF-hBMSC), INFH-hBMSC had higher percentage of apoptosis (P<0.05), as well as lower osteogenic potential and higher adipogenic potential (both P<0.05). However, there was no difference in cell proliferation between FNF-hBMSC and INFH-hBMSC (P>0.05). It was also confirmed that the expression of LRRC17 was lower in the bone tissue and hBMSCs from patients with INFH compared with patients with FNF (P<0.05). Overexpression of LRRC17 promoted osteogenesis and inhibited the adipogenesis in hBMSCs, accompanied with the increase of Wnt3a and β-catenin expressions, and the decrease of Wnt5a and receptor activator of nuclear factor κ-B ligand (Rankl) expressions (all, P<0.05). Furthermore, knockout of LRRC17 in hBMSCs inhibited the expression levels of osteogenic and promoted adipogenic markers, while decreasing Wnt3a and β-catenin expressions, and increasing Wnt5a and Rankl expressions (all, P<0.05). The present preliminary study suggested that imbalanced bone metabolism may be involved in the pathogenesis of INFH. The modulation of the LRRC17 gene may delay or even restore the balance of osteogenic and adipogenic differentiation in autologous BMSCs derived from patients with INFH, providing a new target for the treatment of INFH.

Implantation of autologous Expanded Mesenchymal Stromal Cells in Hip Osteonecrosis through Percutaneous Forage: Evaluation of the Operative Technique

Bone forage to treat early osteonecrosis of the femoral head (ONFH) has evolved as the channel to percutaneously deliver cell therapy into the femoral head. However, its efficacy is variable and the drivers towards higher efficacy are currently unknown. The aim of this study was to evaluate the forage technique and correlate it with the efficacy to heal ONFH in a multicentric, multinational clinical trial to implant autologous mesenchymal stromal cells expanded from bone marrow (BM-hMSCs). Methods: In the context of EudraCT 2012-002010-39, patients with small and medium-sized (mean volume = 13.3%, range: 5.4 to 32.2) ONFH stage II (Ficat, ARCO, Steinberg) C1 and C2 (Japanese Investigation Committee (JIC)) were treated with percutaneous forage and implantation of 140 million BM-hMSCs in a standardized manner. Postoperative hip radiographs (AP—anteroposterior and lateral), and MRI sections (coronal and transverse) were retrospectively evaluated in 22 patients to assess the femoral head drilling orientation in both planes, and its relation to the necrotic area. Results: Treatment efficacy was similar in C1 and C2 (coronal plane) and in anterior to posterior (transverse plane) osteonecrotic lesions. The drill crossed the sclerotic rim in all cases. The forage was placed slightly valgus, at 139.3 ± 8.4 grades (range, 125.5–159.3) with higher dispersion (f = 2.6; p = 0.034) than the anatomical cervicodiaphyseal angle. Bonferroni’s correlation between both angles was 0.50 (p = 0.028). More failures were seen with a varus drill positioning, aiming at the central area of the femoral head, outside the weight-bearing area (WBA) (p = 0.049). In the transverse plane, the anterior positioning of the drill did not result in better outcomes (p = 0.477). Conclusion: The forage drilling to deliver cells should be positioned within the WBA in the coronal plane, avoiding varus positioning, and central to anterior in the transverse plane. The efficacy of delivered MSCs to regenerate bone in ONFH could be influenced by the drilling direction. Standardization of this surgical technique is desirable.

Osteonecrosis of the Femoral Head Safely Healed with Autologous, Expanded, Bone Marrow-Derived Mesenchymal Stromal Cells in a Multicentric Trial with Minimum 5 Years Follow-Up

Background: Osteonecrosis (ON) of the femoral head represents a potentially severe disease of the hip where the lack of bone regeneration may lead to femoral head collapse and secondary osteoarthritis, with serious pain and disability. The aim of this European, multicentric clinical trial was to prove safety and early efficacy to heal early femoral head ON in patients through minimally invasive surgical implantation of autologous mesenchymal stromal cells (MSC) expanded from bone marrow (BM) under good manufacturing practices (GMP). Methods: Twenty-two patients with femoral head ON (up to ARCO 2C) were recruited and surgically treated in France, Germany, Italy and Spain with BM-derived, expanded autologous MSC (total dose 140 million MSC in 7 mL). The investigational advanced therapy medicinal product (ATMP) was expanded from BM under the same protocol in all four countries and approved by each National Competent Authority. Patients were followed during two years for safety, based on adverse events, and for efficacy, based on clinical assessment (pain and hip score) and imaging (X-rays and MRIs). Patients were also reviewed after 5 to 6 years at latest follow-up for final outcome. Results: No severe adverse event was recalled as related to the ATMP. At 12 months, 16/20 per protocol and 16/22 under intention-to-treat (2 drop-out at 3 and 5 months) maintained head sphericity and showed bone regeneration. Of the 4 hips with ON progression, 3 required total hip replacement (THR). At 5 years, one patient (healed at 2 years visit) was not located, and 16/21 showed no progression or THR, 4/21 had received THR (all in the first year) and 1 had progressed one stage without THR. Conclusions: Expanded MSCs implantation was safe. Early efficacy was confirmed in 80% of cases under protocol at 2 years. At 5 years, the overall results were maintained and 19% converted to THR, all in the first year.

Does augmented core decompression decrease the rate of collapse and improve survival of femoral head avascular necrosis? Case-control study comparing 184 augmented core decompressions to 79 standard core decompressions with a minimum 2 years' follow-up

INTRODUCTION

Avascular necrosis of the femoral head often progresses to femoral head collapse if not treated. Conservative treatment yields highly variable results and is not standardised, mainly because it is typically evaluated in small patient populations. This led us to conduct a large retrospective comparative study with the goals of 1) analysing survival and functional outcomes, 2) looking for differences in survival between core decompression techniques (standard versus augmented), and 3) studying the risk factors for femoral head collapse and revision by arthroplasty.

HYPOTHESIS

Core decompression limits the number of patients who suffer femoral head collapse requiring arthroplasty at 2 years' follow-up.

METHODS

This multicentre, comparative, retrospective study analysed 330 patient records (1975-2016) where at least 2 years' follow-up was available. Sixty-two patients were excluded from the analysis: 5 had a stage III with collapse, 5 were lost to follow-up, 2 died within 24 months of the procedure and 50 had incomplete data. The study included 263 patients with a mean age of 42 years (15.7-70). In the Ficat classification, there were 51 cases of stage I necrosis, 186 cases of stage II and 22 cases of stage II with crescent sign (transition stage). The Kerboull angle on radiographs was between 5° and 20° in 40 patients, between 20° and 40° in 107 patients, between 40° and 60° in 52 patients and more than 60° in 29 patients. A standard core decompression was done in 79 patients and an augmented one in 184 patients. The more severe AVN cases (stage II) were more likely to be treated by augmented CD (160/184 patients, 87%) than by standard CD (48/79 patients, 61%) (p<0.001).

RESULTS

In the 263 patients, the overall survival (no arthroplasty at 2 years) was 73% (196/263). At 2 years, the survival rate (without arthroplasty) was 71% (56/79) in the standard CD group versus 76% (140/184) in the augmented CD group. This difference was significant when adjusted for Ficat stage and Kerboull angle [HR=0.457, 95% CI (0.247-0.844) (p=0.012)]. When the survival data was adjusted to the Ficat stage, augmented CD was better than standard CD with 10-year survival of 58.1% vs. 57.9% (p=0.0082). More than 30% necrosis volume increased the risk of failure [HR=3.291 95%CI (1.494-7.248) (p=0.0031)]. Also, a Kerboull angle above 60° increased the risk of failure [HR=3.148 95%CI (1.346-7.5) (p=0.0083)].

CONCLUSION

After 2 years, CD for non-collapsed femoral head AVN prevents collapse and revision to arthroplasty in 73% of cases (196/268). Augmented CD improves the 2-year survival and the long-term survival after adjusting for preoperative characteristics (Kerboullangle and Ficat stage). The risk of collapse and need for arthroplasty is greater in patients with 30% necrosis volume on MRI and Kerboull angle above 60°.

LEVEL OF EVIDENCE

III; retrospective case-control study.

Addition of Bone Marrow Stem Cells Therapy Achieves Better Clinical Outcomes and Lower Rates of Disease Progression Compared With Core Decompression Alone for Early Stage Osteonecrosis of the Femoral Head: A Systematic Review and Meta-Analysis

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a cause of hip pain and early joint arthrosis in the young patient. Nonarthroplasty interventions aim to decompress vascular congestion in the femoral head and stimulate new bone growth to prevent progression and collapse. Therefore, the purpose of this study is to evaluate the available evidence on the effect of adjuvant bone marrow stem cells (BMSCs) for early stage ONFH.

METHODS

We performed a systematic review of the MEDLINE, PubMed, Embase, and Cochrane databases in search of published reports comparing the core decompression (CD) with/without adjuvant BMSCs for ONFH. The cohort was divided into two groups: (1) CD with BMSCs (intervention) and (2) CD alone (control subject). The various outcome parameters including hip pain and function, progression of ONFH, rate of revision surgeries, and complications were analyzed. Data were extracted and aggregated for meta-analysis. Cases with staging beyond Ficat II, UPENN II, or ARCO II were excluded.

RESULTS

Of the published reports, 16 met our inclusion criteria with an aggregated 583 hips in the intervention and 468 hips in the control subject groups, respectively. Addition of bone marrow cells to CD resulted in lower hip pain score (VAS) (MD = -10.88, 95% CI = -16.84 to -4.92, P = 0.003) and higher HHS score (MD = 5.59, 95% CI = 1.13 to 10.04, P = 0.01) compared with CD alone at the 24-month follow-up. For rates of progression to higher stages, 138 progressed in the intervention group compared with 202 in the control subject group (P = 0.0002). Finally, subsequent patients who required total hip arthroplasty surgery were lower in the intervention group (22.5% versus 42.3%, P = 0.001).

CONCLUSIONS

Despite heterogeneous and poor data, there is evidence that addition of bone marrow cells to CD appears to result in better clinical outcomes and lower rates of disease progression compared with cored decompression alone.

LEVEL OF EVIDENCE

Therapeutic Level III.

Stem cell therapy for osteonecrosis of femoral head: Opportunities and challenges

Osteonecrosis of the femoral head (ONFH) is a progressive disease with a complex etiology and unclear pathogenesis, resulting in severe hip pain and dysfunction mainly observed in young patients. Although total hip arthroplasty (THA) is the most effective treatment for patients with ONFH in the terminal stage, the results of THA in young patients or active populations are often not favorable, with some complications related to the prosthesis. With the development of biotechnology, an increasing number of studies pay attention to use of stem cells for the treatment of ONFH. Stem cells are characterized by the ability to self-renew and differentiate into multiple cell types, including differentiation into osteoblasts and endothelial cells to mediate bone repair and angiogenesis. Furthermore, stem cells can offer growth factors to promote blood supply in the necrotic regions by paracrine effects. Therefore, stem cell therapy has become one of the hip-preserving alternatives for ONFH. This review summarized the current trends in stem cell therapy for ONFH, from clinical applications to related basic research, and showed that an increasing number of studies have confirmed the effectiveness of stem cell therapy in ONFH. However, many unsolved problems and challenges in practical applications of stem cell therapy still exist, such as patient selection, standardized procedures, safety assessment, and the fate of transplanted cells in the body. Additional studies are required to find ideal cell sources, appropriate transplantation methods, and the optimal number of cells for transplantation.

•

Diversities in repair processes present a challenge in the targeted treatment of ONFH.

•

Osteogenesis and angiogenesis are the primary mechanisms of MSCs treatment in ONFH.

•

Systematic safety assessment and cell tracing are necessary for stem cell therapy.

•

Optimal numbers and methods of cell transplantation need to be further confirmed.

Team approach: Management of osteonecrosis in children with acute lymphoblastic leukemia

With current treatments for acute lymphoblastic leukemia (ALL), the overall prognosis for survival is favorable. Increasing emphasis is placed on recognizing and managing the long-term consequences of ALL and its treatment, particularly involving osteonecrosis. Early osteonecrosis diagnosis and management may improve outcomes and is best accomplished through coordinated teams that may include hematologic oncologists, radiologists, orthopedic surgeons, physical therapists, and the patient and their family. Magnetic resonance imaging is the "gold standard" for diagnosis of early-stage and/or multifocal osteonecrosis. Treatments for osteonecrosis in ALL patients are risk stratified and may include observation, corticosteroid or chemotherapy adjustment, and pharmaceutical or surgical approaches.

Efficacy and safety of stem cell therapy for the early-stage osteonecrosis of femoral head: a systematic review and meta-analysis of randomized controlled trials

Background

Osteonecrosis of femoral head (ONFH) is a seriously degenerative disease with no effective therapies to slow its progression. Several studies have reported short-term efficacy of stem cells on early-stage ONFH. However, its long-term effect was still unclear especially on progression events. This study was performed to evaluate the long-term efficacy and safety of stem cells and analyze its optimal age group and cell number.

Methods

Our review was registered on PROSPERO (http://www.crd.york.ac.uk/PROSPERO), registration number CRD42020136094. Following PRISMA guideline, we searched 8 electronic databases on January 5, 2020, and rigorous random controlled trials (RCTs) utilizing stem cell therapy on early-stage ONFH were included. Quality and bias were analyzed. Pooled analysis was performed to assess difference between various outcomes.

Results

A total of 13 RCTs (619 patients with 855 hips) were included. The application of stem cells significantly delayed collapse of femoral head(I², 70%; RR, 0.54; 95% CI, 0.33 to 0.89; P < .00001) and total hip replacement (THR) (I², 68%; RR, 0.55; 95% CI, 0.34 to 0.90; P = .02) in the long term. It effectively decreased the events of collapse of femoral head (≥ 60 months) (I², 0%; RR, 0.37; 95% CI, 0.28 to 0.49; P < .00001) and THR (> 36 months) (I², 0%; RR, 0.32; 95% CI, 0.23 to 0.44; P < .00001). There existed a beneficial effect for patients under 40 (Collapse of femoral head: I², 56%; RR, 0.41; 95% CI, 0.23 to 0.76; P = .004) (THR: I², 0%; RR, 0.31; 95% CI, 0.23 to 0.42; P < .00001). In addition, quantity of stem cells at 10⁸ magnitude had better effects on disease progression events (I², 0%; RR, 0.34; 95%CI, 0.16 to 0.74; P = .007). Besides, there were no significant differences on adverse events between the stem cell group and control group (I², 0%; RR, 0.82; 95% CI, 0.39 to 1.73; P = .60).

Conclusion

Our findings build solid evidence that stem cell therapy could be expected to have a long-term effect on preventing early-stage ONFH patients from progression events, such as collapse of femoral head and total hip replacement. Furthermore, patients under 40 may be an ideal age group and the optimal cell number could be at 10⁸ magnitude for this therapy. Further studies including strict RCTs are required to evaluate a clear effect of stem cells on ideal patient profile and the procedures of implantation.

Hip survival after plain core decompression alone versus bone morphogenetic protein and/or bone marrow reinjection with core decompression for avascular osteonecrosis of the femoral head: a retrospective case control study in ninety two patients

INTRODUCTION

Injecting bone marrow or bone morphogenetic protein 7 (BMP) during core decompression for avascular osteonecrosis (AVN) may improve survival. We hypothesized that adding a complementary technique (injection of BMP and/or non-concentrated bone marrow) to core decompression would reduce the number of patients requiring a subsequent total hip arthroplasty (THA).

METHODS

We retrospectively reviewed 92 cases from 2003 to 2018 with a minimum of 2 years of follow-up and an average follow-up of 64 months (24-204). Twenty-four patients had a core decompression (CD) (26.1% (24/92)), 25 had a CD associated with reinjection of bone marrow and BMP (rhBMP7) (27.2% (25/92)), and 43 patients had a CD with bone marrow reinjection (46.7% (43/92)).

RESULTS

Hip survival after CD was 66.3% (61/92) at two years and 59.8% (55/92) at 10 years. CD with bone marrow and BMP reinjection had a better hip survival at ten years (HR: 0.492 (CI95%: 0.254-0.952) p = 0.035). A volume of necrosis greater than 30% (HR = 12.97 (CI95 [3.88-43.3] (p < 0.001))) and a Kerboul angle greater than 60° (HR: 12.5 (CI95 [2.84-54.6] (p < 0.001))) were risk factors for a subsequent THA.

CONCLUSIONS

CD is an interesting non-invasive technique to preserve the native hip after AVN of the femoral head. Reinjection of bone marrow and/or BMP improved CD hip survival.

Bone marrow concentrate injections for the treatment of osteoarthritis: evidence from preclinical findings to the clinical application

Purpose

To investigate the available literature on the use of bone marrow aspirate concentrate (BMAC) and summarize the current evidence supporting its potential for the injective treatment of joints affected by osteoarthritis (OA).

Methods

A systematic literature search was conducted on three electronic databases (PubMed, Embase, and Cochrane Library) in April 2020, using the following string: “((bone marrow concentrate) OR (BMC) OR (bone marrow aspirate concentrate) OR (BMAC)) AND (osteoarthritis)”, and inclusion criteria: clinical and preclinical (animal) studies of any level of evidence, written in English language, and evaluating the intra-articular or subchondral use of BMAC for the injective treatment of OA joints.

Results

The publication trend remarkably increased over time. A total of 22 studies were included in the qualitative data synthesis: four preclinical studies and 18 clinical studies, for a total number of 4626 patients. Safety was documented by all studies, with a low number of adverse events. An overall improvement in pain and function was documented in most of the studies, but the clinical studies present significant heterogeneity, few patients, short-term follow-up, and overall poor methodology.

Conclusion

There is a growing interest in the field of BMAC injections for the treatment of OA, with promising results in preclinical and clinical studies in terms of safety and effectiveness. Nevertheless, the current knowledge is still preliminary. Preclinical research is still needed to optimize BMAC use, as well as high-level large controlled trials to better understand the real potential of BMAC injections for the treatment of patients affected by OA.

Treatment of avascular osteonecrosis of femoral head by core decompression and platelet-rich plasma: a prospective not controlled study

PURPOSE

Core decompression is a surgical option since the 1960s for hip osteonecrosis treatment. This technique promotes bone repair by reducing intramedullary pressure, but this is not often enough to stop the progression of necrosis. The aim of this study was to associate core decompression with the regenerative stimulus provided by platelet-rich plasma (PRP) and compare our results with other regenerative techniques.

METHODS

Femoral head osteonecrosis was prospectively evaluated in 30 hips (22 patients, 15-60 years) treated by core decompression and PRP graft. Patients presented monolateral or bilateral osteonecrosis in stage I-IIA-IIB according to Arlet and Ficat classification. The outcome was assessed by changes in Harris Hip Score (HHS) and the need for total hip replacement (THA).

RESULTS

The mean preoperative HHS was 64 points, at two years from surgery was roughly 84 points. Sixteen of 30 hips showed osteonecrosis progression of the femoral head and were converted to THA. At the five year follow-up, the survival rate was 100% for patients at stage I, 67% for stage IIA, and 0% for stage IIB and was 68% and 32% for idiopathic and secondary osteonecrosis, respectively.

CONCLUSION

Core decompression combined with PRP could be indicated as a treatment for the I and IIA stages of osteonecrosis, as it significantly reduces joint pain and delays THA. This procedure should be avoided in AVNFH related to cortisone therapy because only a few benefits have been proven. It also has the advantage of being technically simple, minimally invasive, and free from complications.

Prognosis after autologous peripheral blood stem cell transplantation for osteonecrosis of the femoral head in the pre-collapse stage: a retrospective cohort study

OBJECTIVES

Autologous peripheral blood stem cell (auto-PBSC) transplantation is an effective therapeutic for the osteonecrosis of the femoral head (ONFH) but without prognosis estimation. This study mainly aimed to (1) determine whether auto-PBSC transplantation is a promising option, (2) assess the risk of hip-preservation failure, (3) achieve a predictive model of femoral head survival after the intervention, and (4) eventually identify clinical indications for auto-PBSC transplantation in future.

METHODS

After reviewing the in-patient database of the First Affiliated Hospital of Zhejiang Chinese Medicine University from June 2012 to June 2014, 37 eligible patients with Association Research Circulation Osseous stage I or II ONFH who were receiving intra-arterial infusion of auto-PBSCs were recruited. A case form was designed to retrieve relevant data. Hip-preservation failure was defined as the endpoint. All participants were stratified by the categorical risk of collapse, which was statistically tested through log-rank analysis. All significant factors were evaluated using Cox proportional hazards regression model, and a predictive nomogram plot was generated.

RESULTS

In total, 47 hips were followed up for 53.96 ± 21.09 months; the median survival time was 60.18 months. Among the predictors, body mass index (BMI; P = 0.0015) and Harris hip score (HHS; P < 0.0001) independently affected femoral head survival. Patients with BMI ≥ 24 kg/m² exhibited a 2.58 times higher risk of hip-preservation failure [95% confidence interval (CI), 1.32-5.45] than those with BMI < 24 kg/m², whereas those with HHS ≥ 70 exhibited a 0.19 times lower risk (95% CI, 0.09-0.38) than those with HHS < 70. Hazard ratios associated with age (P = 0.042), BMI (P = 0.012), HHS (P = 0.022), and necrotic volume (P = 0.000) were 1.038 (95% CI, 1.001-1.075), 1.379 (95% CI, 1.072-1.773), 0.961 (95% CI, 0.928-0.994), and 1.258 (95% CI, 1.120-1.412), respectively. A nomogram plot (score test P = 0.000; C-index = 0.8863) was available for the orthopedic doctor to predict hip survival probability.

CONCLUSIONS

The results suggest that intra-arterial infusion of auto-PBSCs prolongs femoral head survival. Age, BMI, HHS, and necrotic volume can influence the efficacy of this intervention. This study was approved by ethics committee of the trial center, number 2019-KL-075-01.

Correlation between the efficacy of stem cell therapy for osteonecrosis of the femoral head and cell viability

Background

Osteonecrosis of the femoral head (ONFH) is a common disease that greatly affects the quality of life of patients. Repair of the necrotic area is key to successful treatment. Currently, the combination of stem cell transplantation and decompression is used clinically to promote the repair of necrotic areas based on the characteristics of stem cells. However, a considerable number of patients do not achieve a satisfactory outcome in terms of repair of the femoral head necrotic area, and it is very important to determine the reasons for the poor curative effect. The aim of this study was to investigate the correlation between stem cell viability and the repair efficacy of stem cell therapy combined with core decompression for early-stage ONFH.

Methods

A total of 30 patients with idiopathic ONFH underwent core decompression combined with autologous stem cell transplantation. The Harris hip score (HHS) and difference in necrosis area before and after surgery were measured. The mean repair ratio was set as the threshold to divide the patients into group A (ratio above the mean) and group B (ratio below the mean). The ultrastructure, proliferative capacity, and multidirectional differentiation ability were compared between the groups.

Results

At 9 months after surgery, the HHS and magnetic resonance imaging (MRI) findings improved by varying degrees. Based on the mean repair ratio of (62.2 ± 27.0)%, the threshold for dividing the patients into groups A and B was set to 62.2%. Better repair (group A) was associated with more rapid proliferation and a healthier ultrastructure. The cells in group A showed stronger specific staining signifying osteogenic and chondrogenic differentiation; alkaline phosphatase (ALP) activity, an indicator of osteogenic differentiation, was higher in group A than in group B (OD, 2.39 ± 0.44 and 1.85 ± 0.52; p <  0.05).

Conclusions

The quality of implanted stem cells is closely related to treatment efficacy and determines whether the defective self-repair in the necrotic area can be corrected to enhance repair and thus achieve the desired therapeutic outcome.

Trial registration

The trial registration number: ChiCTR-ORC-17011698 (retrospectively registered at 2017-06-19).

Acetabular avascular necrosis following high-dose steroid treatment and chemotherapy for leukemia : Computer tomography analysis of treatment with impaction bone grafting

Avascular necrosis (AVN) of the bone is thought to be a serious complication of treatment for acute lymphoblastic leukemia (ALL). The acetabulum is an unusual area to be affected by AVN, and there are currently no reports of successful joint salvage procedures found in the literature. We present a case of a 20-year-old man with ALL who was diagnosed with debilitating AVN of both acetabula 2 years following initial diagnosis of ALL and treatment with a multi-agent chemotherapy regimen including high-dose corticosteroids. After unsuccessful treatment with bisphosphonate therapy, the acetabular AVN underwent bilateral curettage and impaction bone grafting to prevent collapse of subchondral fractures with the hope of salvaging both hip joints. Computer tomography (CT) of the AVN affected areas, pre- and post-bone impaction grafting, demonstrated healing of the subchondral fractures and a doubling of bone density that was maintained at 2 years after surgery. The patient resumed full weight-bearing at 3 months after first surgery, continues to ambulate unrestricted, and remains pain free 3 years post-surgery.

Ten-year results of concentrated autologous bone marrow aspirate transplantation for osteonecrosis of the femoral head: a retrospective study

BACKGROUND

Idiopathic osteonecrosis of the femoral head (ONFH) occurs at a relatively younger age. It is therefore important to prevent the resultant femoral head collapse and requirement of total hip arthroplasty in these patients. In 2003, we initiated concentrated autologous bone marrow aspirate transplantation (CABMAT), a joint-preserving treatment for ONFH, at our institution. Here, we report the long-term results of CABMAT treatment.

METHODS

We retrospectively collated and analyzed the demographic and treatment data of 69 patients (109 hips) with idiopathic ONFH treated with CABMAT between April 2003 and April 2008.

RESULTS

Totally, 44 patients (21 men, 23 women, 80 hips) completed the 10-year follow-up. The follow-up rate was 73.4%, and the mean follow-up period was 12.0 (range, 10.0-15.4) years. The mean age of the patients was 42.2 (range, 16.3-70.5) years. Using the Association Research Circulation Osseous (ARCO) classification system for preoperative analysis, 12, 31, 32, and 5 hips were classified as stages 1, 2, 3, and 4, respectively. The overall rate of conversion to total hip arthroplasty (THA) was 34% (27/80 hips). In a multivariate regression analysis, the preoperative stage of ONFH and the body mass index were found to correlate significantly with conversion to THA. Totally, 43 hips (of 80) were classified as belonging to the pre-collapse stage (i.e., stages 1 or 2). The overall collapse rate and the THA-conversion rate of these hips were estimated to be 49% (21/43) and 14% (6/43), respectively.

CONCLUSIONS

On the basis of our long-term findings, the minimally invasive and feasible CABMAT therapy can be utilized as one of a joint-preserving treatment for ONFH.

New Advances in Stem Cell Therapy for Osteonecrosis of the Femoral Head

Osteonecrosis of the femoral head (ONFH) is a common refractory orthopedic disease with multiple etiologies that more frequently occurs in middle-aged and young people. ONFH is the main cause of hip replacement in young patients. Since Professor Hernigou first reported the use of stem cells in the treatment of early stage ONFH, a large number of studies have demonstrated the potential of stem cells in the treatment of adult patients with ONFH. With the rise of interdisciplinary stem cell therapy combined with platelet-rich plasma therapy, gene therapy or other methods have gradually attracted the attention of researchers. This article summarizes the current advances in stem cell therapy for ONFH, as well as the problems and challenges, which may provide reference for further research.

Hip arthrodiastasis combined with core decompression and diamond concept for postcollapse femoral head avascular necrosis

In postcollapse hip avascular necrosis (AVN), the femoral head cannot be salvaged, necessitating total hip replacement. We report a case of a 39-year-old woman who developed idiopathic femoral head AVN with marked symptoms and radiological evidence of articular surface collapse. We treated her with core decompression combined with the 'diamond concept' (implantation of bone marrow concentrate, a growth factor and bone graft substitute) and distracted the hip joint with external fixator. Four years postoperatively the articular surface has been restored and the patient reports excellent quality of life. Hip arthrodiastasis with core decompression and 'diamond concept' regeneration could be considered a treatment option in advanced AVN of the femoral head.

Biomarkers of bone healing induced by a regenerative approach based on expanded bone marrow-derived mesenchymal stromal cells

BACKGROUND

Safety and feasibility of a regenerative strategy based on the use of culture-expanded mesenchymal stromal cells (MSCs) have been investigated in phase 2 trials for the treatment of nonunion and osteonecrosis of the femoral head (ONFH). As part of the clinical study, we aimed to evaluate if bone turnover markers (BTMs) could be useful for predicting the regenerative ability of the cell therapy product.

MATERIALS AND METHODS

The bone defects of 39 patients (nonunion: n = 26; ONFH: n = 13) were treated with bone marrow-derived MSCs, expanded using a clinical-grade protocol and combined with biphasic calcium phosphate before implantation. Bone formation markers, bone-resorption markers and osteoclast regulatory proteins were measured before treatment (baseline) and after 12 and 24 weeks from surgery. At the same time-points, clinical and radiological controls were performed to evaluate the bone-healing progression.

RESULTS

We found that C-Propeptide of Type I Procollagen (CICP) and C-terminal telopeptide of type-I collagen (CTX) varied significantly, not only over time, but also according to clinical results. In patients with a good outcome, CICP increased and CTX decreased, and this trend was observed in both nonunion and ONFH. Moreover, collagen biomarkers were able to discriminate healed patients from non-responsive patients with a good diagnostic accuracy.

DISCUSSION

CICP and CTX could be valuable biomarkers for monitoring and predicting the regenerative ability of cell products used to stimulate the repair of refractory bone diseases. To be translated in a clinical setting, these results are under validation in a currently ongoing phase 3 clinical trial.

A Retrospective Study to Compare the Efficacy and Postoperative Outcome of Total Hip Arthroplasty with Internal Screw Fixation in Patients with Avascular Necrosis of the Femoral Head

Background

This retrospective study compared the effects of total hip arthroplasty (THA) and traditional surgery using internal screw fixation for the treatment of avascular necrosis (AVN) of the femoral head.

Material/Methods

Two hundred and seventy patients with bilateral AVN of the femoral head were admitted for elective surgery, and 176 patients underwent THA (the THA group), and 94 patients underwent closed reduction screw fixation (the traditional surgery group). The Harris hip score (HHS) was used pre-operatively and to evaluate postoperative outcome.

Results

The mean operation time in the traditional surgery group (82.6±15.6 min) was significantly less compared with the THA group (104.8±14.2 min) (P=0.001). Intraoperative blood loss in the traditional surgery group (219.8±21.6 mL) was significantly less compared with the THA group (339.4±29.4 mL) (P=0.001). After treatment, the mean HHS score of the THA group (76.5±9.2 points) was significantly increased when compared with the traditional surgery group (61.4±10.5 points) (P=0.001). Disease recurrence rate in the THA group was significantly reduced compared with the traditional surgery group (P=0.001). The mean quality of life score of the THA group (85.5±6.4 points) was significantly higher than that of the traditional surgery group (73.4±8.8 points) (P=0.001).

Conclusions

Compared with closed reduction screw fixation, THA for AVN of the femoral head effectively reduced the length of hospital stay, time to recovery, and achieved an improved clinical outcome.

Effectiveness of neuromuscular electrical stimulation and ibuprofen for pain caused by necrosis of the femoral head: A retrospective study

This retrospective study analyzed the effectiveness of neuromuscular electrical stimulation (NMES) for pain relief caused by necrosis of femoral head (NFH).Totally, 80 cases of patients with NFH were analyzed and then were assigned to a treatment group or a control group in this study. Of these, 40 cases in the treatment group received ibuprofen and NMES therapy. The other 40 cases in the control group received ibuprofen alone. Cases in both groups were treated for a total of 6 weeks. The primary outcome of pain intensity was measured by a visual analog scale (VAS). The secondary outcome was assessed by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). In addition, adverse events (AEs) were also recorded in each case. All outcomes were evaluated before and after the treatment.After treatment, patients in the treatment group showed more effectiveness in pain relief, as measured by VAS (P < .01) and WOMAC sub-pain scale (P < .01), except stiffness, as evaluated by WOMAC sub-stiffness scale (P = .07), and function, as assessed by WOMAC sub-function scale (P = .09), than patients in the control group. Additionally, no significant differences in AEs were detected between 2 groups.This study found that NMES may be helpful for pain relief in patients with NFH.

Unusual indication of Cell therapy for hip osteonecrosis after pregnancy

PURPOSE

Osteonecrosis is a rare event during or after pregnancy. Due to the low number of cases, there is no report of long-term results after conservative surgery in this population.

METHOD

From 1992 to 2010, 145 consecutive female patients with unilateral symptomatic (94 stage I and 51 stage II) left hip osteonecrosis (ON) related to pregnancy were treated between 4 and 16 months after delivery with percutaneous mesenchymal stem cell (MSC) injection obtained from bone marrow concentration. The average total number of MSCs (counted as number of colonies forming units-fibroblast) injected in the hip was 185 000 ± 65 000 cells (range 95 000-240 000 cells).

RESULTS

At the most recent follow-up (average 15 years after hip surgery, range 8-25 years), among the 145 hips included in the study, 4 hips (2.7%) had collapsed and were treated with total hip arthroplasty (THA). Thirty-two of the 94 stage I had progressed to stage II; and 4 of the 51 stage II had progressed to stage III and collapse. The other 141 hips (97.3%) were without collapse and pain free. On MRI, as percentage of the volume of the femoral head, the osteonecrosis had decreased from 34.5% pre-operatively to 6% at the most recent follow-up. For women who had other children after treatment, a subsequent pregnancy was not associated with osteonecrosis.

CONCLUSION

Patients with hip osteonecrosis following pregnancy had a low conversion rate to THA when treated early with cell therapy.

Osteonecrosis of the femoral head: genetic basis

PURPOSE

Genetic factors and hereditary forms of osteonecrosis of the femoral head (ONFH) have been elucidated through genetic association studies. The significance of these cases is that they suggest an alternative hypothesis to the development of the disease. This review presents a summary of single nucleotide polymorphisms (SNPs) and other genetic mutation variations found in association with ONFH, including our recent identification of a novel mutation in the transient receptor potential vanilloid 4 (TRPV4) gene in association with inherited ONFH. The purpose of this review is to consolidate and categorize genetic linkages according to physiological pathways.

METHODS

A systematic review of literature from PubMed and Google Scholar was undertaken with a focus on genetic linkages and hereditary case studies of the disease. Recent genetic analysis studies published after 2007 were the focus of genetic linkages in non-hereditary cases.

RESULTS

The summary of these genetic findings identifies biological processes believed to be involved in the development of ONFH, which include circulation, steroid metabolism, immunity, and the regulation of bone formation.

CONCLUSION

Taken together, these associations may lead to new pathways of bone repair and remodeling while opening new avenues for therapeutic targets. Knowledge of genetic variations could help identify individuals considered to be at higher risk of developing ONFH and prevent the multiple hit effect.

A contemporary view of platelet-rich plasma therapies: moving toward refined clinical protocols and precise indications

The positive extensive clinical experience with platelet-rich plasma (PRP) in different medical areas has prompted researchers to explore clinical opportunities for optimized PRP therapies. PRP is safe but we have to make it more effective. The growing diversity of formulations and presentations enrich the field of PRP research and offer hope to refine clinical indications. Moving toward targeting the right disease phenotypes with the right PRP formulation or combination product (PRP + cell products) can offer opportunities to change treatment options in osteoarthritis and nonhealing wounds. Both are active areas of research that could offer opportunities, although cost efficacy is still an open question. Our position is to believe that these serious disease areas are likely to benefit from PRP therapies.

History of concentrated or expanded mesenchymal stem cells for hip osteonecrosis: is there a target number for osteonecrosis repair?

PURPOSE

Despite multiple possible treatments, the risk of collapse remains the main problem of osteonecrosis. Heart failure (HF). In an effort to address the reverse this issue, curative strategies with regenerative medicine are increasingly being considered. The aim of this technology is to halt or reverse progression of the disease to collapse.

MATERIAL AND METHODS

The pioneering report by Hernigou published in 2002 was the first pilot study suggesting that injection of bone marrow stem cells was a safe approach able to improve osteonecrosis in patients with early stages. Since then, an impressive number of studies and trials employing unselected BM-derived cells (1000 the last 2 years) showed that delivery of those cells to the site of osteonecrosis during core decompression was somehow able to ameliorate the patient with osteonecrosis. In order to translate the promise of this cell therapy into better clinical benefit, many questions need to be addressed. In this review, we therefore analyzed current clinical experience of the literature and our experience of 4000 cases to address these questions and particularly the number of cells that should be injected.

RESULTS

After almost 20 years of clinical research in this field, we are still far from having drawn conclusions on the number of cells we should inject in regenerating hip osteonecrosis. Findings are difficult to interpret due to heterogeneity of causes of osteonecrosis, as well as differences in the cells count, sample quality, and stages of osteonecrosis. The authors address specific issues, as cell quality, cell numbers, volume of osteonecrosis, concentration of cells, and ex vivo expansion. Bone marrow mesenchymal stem cells are supposed to be "functionally competent," but are collected from the bon, marrow of patients with diseases and risk factors of osteonecrosis. The recipient organ (bone osteonecrosis) is a tissue where several alterations have already occurred. These questions are addressed in this review.

CONCLUSION

In this review, we analyzed current clinical experience regarding cell therapy and address issues that should be a guide for future cell-based therapeutic application in osteonecrosis.

Stem cell therapy in bilateral osteonecrosis: computer-assisted surgery versus conventional fluoroscopic technique on the contralateral side

PURPOSE

Surgical management of osteonecrosis with core decompression with stem cell therapy is a new procedure. The technique is performed with fluoroscopic guidance. This study attempts to determine if computer-navigated technique can improve the procedure.

METHODS

Thirty consecutive patients with bilateral symptomatic osteonecrosis without collapse were included in this study during the year 2011. A prospective, randomized, and controlled study was conducted on 60 hips (bilateral osteonecrosis) using conventional fluoroscopy technique on one side and computer-based navigation on the contralateral side. Bone marrow aspirated from the two iliac crests was mixed before concentration. Each side received the same volume of concentrated bone marrow and the same number of cells 110,000 ± 27,000 cells (counted as CFU-F).

RESULTS

Computer navigation achieved better parallelism to the ideal position of the trocar, with better trocar placement as regards to tip-to-subchondral distance and ideal centre position within the osteonecrosis for injection of stem cells. Using computer navigation took fewer attempts to position the trocar, used less fluoroscopy time, and decreased the radiation exposure as compared with surgery performed with conventional fluoroscopy. At the most recent follow-up (6 years), increasing the precision with computer navigation resulted in less collapse (7 versus 1) and better volume of repair (13.4 versus 8.2 cm³) for hips treated with the computer-assisted technique.

CONCLUSIONS

The findings of this study suggest that computer navigation may be safely used in a basic procedure for injection of stem cells.