Do modern techniques improve core decompression outcomes for hip osteonecrosis?

Functional and HIP survivorship outcomes of free Vascularized fibula graft in the management of post COVID-19 Osteonecrosis of femur head: A prospective case series

Aim & objectives

To evaluate functional and radiological outcomes of Free Vascularized Fibula grafting in management of Covid-19 associated Osteonecrosis of Femur Head.

Design

Prospective Case Series.

Methods

14 hips (10 patients) with ONFH following COVID-19 were treated with Free Vascularized Fibula graft from June 2021 to December 2022 and were subsequently evaluated monthly for 6 months and then every 3 months post operatively for functionality (Harris Hip Score), Femur head collapse and related complications.

Results

Mean age of patients was 29.3 years (Range: 20-38 years). 14 diseased hips were classified on the basis of Steinberg classification as 4 stage 2B, 4 stage 3B and 6 stage 3C. The average follow up period was 2.1 years (Range: 12 months-34 months).Eight of fourteen hips survived and six progressed to collapse. Mean HHS at final follow-up was 68.3 in comparison to 65.8 pre-operatively. 4 fair and 4 poor HH scores were converted to 4 excellent and 4 good scores post-operatively.Two late complications were noted-one FHL contracture and one CPN neuroma.

Conclusion

Free Vascularized Fibula Graft, as a hip salvage modality, showed optimal results in the treatment of COVID-19 related ONFH, which is associated with aggressive disease course and extensive involvement of femur head.

Evaluation of the Tensor Fascia Lata Muscle Pedicle Bone Grafting Technique in the Management of Avascular Necrosis of the Femoral Head: An Observational Clinical Study

BACKGROUND

Osteonecrosis of the hip is defined as necrosis of the bone tissue due to some form of vascular insult, subsequently leading to the collapse of the femoral head and secondary osteoarthritis, which leads to pain and impaired joint function. This disease is widely known to affect middle-aged groups; however, in the Indian population, even younger people are more commonly affected. The disease has a debilitating effect on the activities of daily living (ADL) and the productivity of individuals and has financial consequences. With the increased utilization of magnetic resonance imaging (MRI) in society, the disease is diagnosed in its early stages. Hip-preserving surgery like tensor fascia lata (TFL) muscle pedicle iliac bone grafting should be given a chance to preserve the native femoral head.

METHODOLOGY

At a tertiary care teaching hospital in Gorakhpur, India, an observational clinical study was carried out. This study comprised 40 patients, ages 18-50 years, with femoral head osteonecrosis (stages II and III of the Ficat-Arlet staging system), who came to our institute's orthopedic outpatient department. Patients were treated with multiple drillings, curettage, and cheilectomy of the femoral head, in addition to TFL muscle pedicle bone grafting. The Harris hip score (HHS) was utilized to assess the clinical results, and the radiological assessment focused on signs of revascularization.

RESULT

In our study, the most prevalent age group was 20-30 years (67.5%), with a male predominance (85%). Among our cohort of 40 patients, the HHS indicated excellent outcomes (90-100) in 14 cases (35%), good outcomes (80-89) in 19 cases (47.5%), fair outcomes (70-79) in six cases (15%), and poor outcomes (<70) in one case (2.5%), at the time of the final follow-up. The final follow-up period varied from one to 10 years.

CONCLUSION

TFL muscle pedicle bone grafting procedure provides excellent clinical and radiological outcomes, especially in young patients in whom femoral head-preserving surgery is preferred over total hip arthroplasty. This procedure is effective in both early and advanced stages of femoral head osteonecrosis, provided there are no arthritic changes. It reduces symptoms and improves functional outcomes.

A Current Review in the Orthopedic Management of Osteonecrosis of the knee Secondary to Treatment of Pediatric Hematologic Malignancy

Acute Lymphoblastic Leukemia is the most prevalent pediatric hematologic malignancy. The treatment for this illness has advanced significantly, now touting a 90% cure rate. Although these patients often become disease free, treatment can leave devastating effects that last long after their disease burden is alleviated. A commonly experienced result of treatment is osteonecrosis (ON), often occurring in weight bearing joints. Uncertainty exists in the optimal treatment of this cohort of patients. In this review, we describe the etiology and suspected pathogenesis of ON, as well as treatment options described in the literature.

Core decompression combined with platelet-rich plasma-augmented bone grafting for femur head necrosis: a systematic review and meta-analysis

BACKGROUND

The clinical potential of biologic augmentation in core decompression and bone grafting for femoral head necrosis is widely acknowledged, with platelet-rich plasma (PRP) being a frequently employed biologic adjunct. However, its clinical application is not standardized, and high-level evidence is lacking. This study aimed to evaluate the efficacy and safety of core decompression and bone grafting combined with PRP for femur head necrosis.

METHODS

Several databases were systematically retrieved for randomized controlled trials comparing core decompression and bone grafting combined with or without PRP. A systematic review and meta-analysis were conducted following the PRISMA 2020 and AMSTAR 2 guidelines. The study is registered with PROSPERO under the code CRD42022361007, and it is also listed in the research registry under the identification number reviewregistry1537.

RESULTS

Eleven studies with 642 participants (742 hips) were included. The pooled estimates revealed that when core decompression and bone grafting were combined with PRP, the Harris hip score (mean difference: 7.98; 95% CI: 5.77-10.20; P <0.001), visual analog scale (SMD: -0.68; 95% CI: -0.96 - -0.40; P <0.001) and the pain component of Harris hip score (SMD: 8.4; 95% CI: 4.12-12.68; P <0.001), and reduction of radiographic progression [risk ratio (RR): 0.40; 95% CI: 0.27-0.59; P <0.001] were superior to core decompression and bone grafting alone. Fewer patients with treatment failure (RR: 0.27; 95% CI: 0.14-0.52; P <0.001) and higher good-to-excellent results (RR: 1.48; 95% CI: 1.17-1.86; P <0.001) were observed in treatment groups than control groups. Meanwhile, the pooled analysis substantiated the superior safety profile of PRP (RR: 0.29; 95% CI: 0.11-0.77; P =0.01).

CONCLUSIONS

The combination of core decompression and bone grafting with PRP is superior to the approach without PRP, demonstrating enhanced effectiveness in terms of function, pain relief, and radiographic progression. Additionally, it results in lower rates of treatment failure and adverse events. However, further high-quality RCTs are needed to evaluate their effectiveness due to methodological and implementation limitations observed in the existing evidence.

Partial femoral head replacement: a new innovative hip-preserving approach for treating osteonecrosis of the femoral head and its finite element analysis

Purpose: Controversy remains regarding the optimal treatment for stage III Osteonecrosis of the femoral head (ONFH). This study presents, for the first time, the precise treatment of stage III ONFH using the "substitute the beam for a pillar" technique and performs a comparative finite element analysis with other hip-preserving procedures. Methods: A formalin-preserved femur of male cadavers was selected to obtain the CT scan data of femur. The proximal femur model was reconstructed and assembled using Mimics 20.0, Geomagic, and UG-NX 12.0 software with four different implant types: simple core decompression, fibula implantation, porous tantalum rod implantation, and partial replacement prosthesis. The finite element simulations were conducted to simulate the normal walking gait, and the stress distribution and displacement data of the femur and the implant model were obtained. Results: The peak von Mises stress of the femoral head and proximal femur in the partial replacement of the femoral head (PRFH) group were 22.8 MPa and 37.4 MPa, respectively, which were 3.1%-38.6% and 12.8%-37.4% lower than those of the other three surgical methods. Conclusion: The PRFH group exhibits better mechanical performance, reducing stress and displacement in the ONFH area, thus maintaining femoral head stability. Among the four hip-preserving approaches, from a biomechanical perspective, PRFH offers a new option for treating ONFH.

A Comparative Analysis of Osteochondritis Dissecans and Avascular Necrosis: A Comprehensive Review

Musculoskeletal disorders, standing as the fifth leading cause of disability-adjusted life years globally, present significant challenges in orthopedics. Osteochondritis dissecans (OCD) and avascular necrosis (AVN) are distinct but closely related conditions within this spectrum, impacting patients' quality of life with pain, limited mobility, and dysfunction. OCD, involving cartilage and bone detachment in joints, predominantly affects young athletes, but its exact etiology and optimal management remain subjects of ongoing research. Conversely, AVN, marked by bone tissue death due to compromised blood supply, is linked to systemic factors like corticosteroid use and traumatic injuries. Diagnosis for both conditions relies on radiography and magnetic resonance imaging. Conservative treatment for AVN includes the use of a cane or crutches, pharmacological therapy, or physical therapy. On the other hand, in OCD, the primary approach is activity/sports restriction. Surgical treatment options for AVN patients encompass core decompression, bone grafting, or, in the most advanced cases, total hip arthroplasty. OCD may be surgically treated through subchondral drilling or fixation of unstable lesions. Advanced cases of OCD involve cartilage salvage with resurfacing techniques. The presentation of differences between these conditions enhances our understanding, facilitating improved diagnosis and management strategies.

Evaluation of core decompression outcome in systemic lupus erythematosus with hip osteonecrosis: a retrospective cohort study

BACKGROUND

Osteonecrosis is a major cause of morbidity for patients with systemic lupus erythematosus (SLE). Although core decompression is an approved and trusted technique to prevent further joint deterioration, this surgical method seems to be less beneficial for SLE patients. We aimed to evaluate the outcomes of core decompression in SLE patients with primary stages of femoral head osteonecrosis.

METHODS

In this study, 23 patients (39 affected hip joints) with osteonecrosis of the femoral head with stage II of the disease, based on the Ficat-Arlet classification system, underwent core decompression. Also, patients demographic characteristics, clinical data, medication history, comorbidities, immunological findings, hip plain radiographs, history of total hip arthroplasty after core decompression, and patients satisfaction with joint function according to the Oxford hip score questionnaire were obtained.

RESULTS

In the study, 53.8% of affected joints showed signs of radiographic deterioration in follow-up imaging. Sixty-one and a half percent (61.5%) of patients had unsatisfactory joint performance. A third (33.3%) of affected hip joints underwent total hip arthroplasty up to 5 years from core decompression. SLE patients with a history of receiving bisphosphonate were 83.2% less dissatisfied with their joint function than patients without a history of bisphosphonate use (P < 0.02). Of the 23 studied cases, the mean cumulative dose of prednisolone before and after core decompression surgery was 46.41 mg and 14.74 mg respectively. Besides, one case (2.6%) that had a high anti-phospholipid antibodies level during follow-up did not have any radiographic deterioration, and 9 cases (23.1%) had some degrees of radiographic deterioration.

CONCLUSIONS

The patients group that used bis-phosphonate, had a higher level of satisfaction with joint function after core decompression. Patients with high-level anti-phospholipid antibodies are related to a poor prognosis after core decompression.

Functional Outcome Analysis of Autologous Stromal Vascular Fraction (SVF) (Sahaj Therapy®) Using Direct Sonication in Osteonecrosis of the Femoral Head (ONFH): A 6-Year Follow-Up Study

Introduction

We investigated the safety, efficacy, functional, and clinical outcomes of intra-osseous implantation of mechanically isolated, autologous stromal vascular fraction (SVF), an Australian patented direct ultrasonication technology (Sahaj Therapy®) in osteonecrosis of the femoral head (ONFH).

Materials and Methods

A total of 32 cases of ONFH were enrolled in the study after confirming with an MRI of the affected hip. All cases were treated with an intra-osseous autologous SVF implantation [4-5 cc with the cellular dosage of 8.0 × 107 cells with a viability of > 85% SVF cells] on the same surgical sitting. All the cases were followed up clinically, functionally, and radiologically at regular intervals. A comparison of mean HOOS scores at different follow-ups was done using Paired 't'-test. A P value of < 0.05 was considered significant.

Results

In our study, male preponderance was seen (53.1%). According to the modified Ficat and Arlet classification, the most common grade of ONFH was grade 2 [right: 25 hips and left: 25 hips]. There was a statistically significant improvement in the mean HOOS score of the right hip (n = 10) and left hip (n = 9) from preoperative time till 72 months (P < 0.05). The follow-up MRI of the affected hips shows improved osteogenesis without any further worsening of the contour of the femoral head. No adverse effects were seen in any of the study participants.

Conclusion

For individuals with ONFH, treated with intra-osseous autologous SVF implantation in the same surgical procedure is an innovative and promising treatment modality. Even after 6 years of follow-up, the study participants with ONFH have shown good clinical and functional outcomes with autologous SVF.

Preclinical models for studying corticosteroid-induced osteonecrosis of the femoral head

Nontraumatic osteonecrosis of the femoral head (ONFH) is a refractory condition that commonly results in femoral head collapse and degenerative arthritis of the hip. In the early stages, surgical procedures for hip preservation, including core decompression (CD), have been developed to prevent progressive collapse of the femoral head. Optimization of bone regeneration and biological augmentation may further enhance the therapeutic efficacy of CD for ONFH. Thus, combining CD with cell-based therapy has recently been proposed. In fact, patients treated with cell-based therapy using autologous bone marrow concentrate demonstrate improved survivorship of the femoral head, compared with conventional CD alone. Preclinical research studies to investigate adjunctive therapies for CD often utilize the rabbit model of corticosteroid-induced ONFH. Mesenchymal stem cells (MSCs) are known to promote osteogenesis and angiogenesis, and decrease inflammation in bone. Local drug delivery systems have the potential to achieve targeted therapeutic effects by precisely controlling the drug release rate. Scaffolds can provide an osteoconductive structural framework to facilitate the repair of osteonecrotic bone tissue. We focused on the combination of both cell-based and scaffold-based therapies for bone tissue regeneration in ONFH. We hypothesized that combining CD and osteoconductive scaffolds would provide mechanical strength and structural cell guidance; and that combining CD and genetically modified (GM) MSCs to express relevant cytokines, chemokines, and growth factors would promote bone tissue repair. We developed GM MSCs that overexpress the anti-inflammatory, pro-reconstructive cytokines platelet-derived growth factor-BB to provide MSCs with additional benefits and investigated the efficacy of combinations of these GM MSCs and scaffolds for treatment of ONFH in skeletally mature male New Zealand white rabbits. In the future, the long-term safety, efficacy, durability, and cost-effectiveness of these and other biological and mechanical treatments must be demonstrated for the patients affected by ONFH.

Invasive electrical stimulation in the treatment of avascular osteonecrosis of the femoral head - mid-term results

The study aimed to evaluate the outcomes of osteonecrosis of the femoral head (ONFH) in adults after surgical treatment including invasive electromagnetic osteostimulation (E-Stim). Further, the influence of disease stage and several comorbidities on the joint preservation rate should be examined. Sixty patients (66 hip joints) with ONFH were included in this retrospective cross-sectional analysis (mean follow-up: 58 months, 19-110 months). Potential ONFH risk factors and comorbidities (ONFH stage, age, sex, alcohol, smoking, cortisone medication, chemotherapy) were recorded. The influence of specific parameters on the joint preservation rates was evaluated by a multivariate logistic regression analysis. Finally, patients with preserved hip joints underwent an assessment of their last available X-rays. The joint preservation rate depended on the initial ONFH Steinberg stage (I+II: 82.8%, III: 70.8%, ≥ IVa: 38.5%). Initially collapsed ONFH (p ≤ 0.001) and cortisone therapy (p = 0.004) significantly decreased the joint preservation rates. In case of progressed ONFH, the presence of ≥ 2 risk factors resulted in higher THA conversion rates (stage III: OR 18.8; stage ≥IVa: OR 12). In 94% of the available X-rays, the ONFH stage improved or did not progress. No complications could be attributed to the E-Stim device or procedure. The present surgical protocol including minimally invasive E-Stim revealed high joint preservation rates for non-collapsed ONFH after mid-term postoperative follow-up. Especially in progressed ONFH, the-risk profile seems to be crucial and hence, for joint preserving surgery, careful patient selection is recommended.

Efficacy of autologous stem cell therapy in femoral head avascular necrosis: a comparative study

OBJECTIVE

Avascular necrosis of the femoral head is a disease usually seen in middle-aged individuals. Although many aetiological factors have been blamed, there are still aetiological factors that have not been fully elucidated. Although treatment options show a wide range, early and appropriate treatment is of great importance to preserve the hip joint. In our study, we compared the results of core decompression and core decompression combined with bone marrow mesenchymal stem cell implantation in patients with avascular necrosis of the femoral head.

MATERIAL METHOD

In this retrospective study, Steinberg stage 1-2 patients operated on for avascular necrosis of the femoral head between 2018 and 2023 were analysed. Separate groups were formed from patients who underwent isolated core decompression and core decompression + bone marrow mesenchymal stem cell implantation. Age, gender, Steinberg staging, aetiology of the disease, follow-up period, progression to hip arthroplasty, Vas scores, Harris hip scores (HHS), and complications were evaluated. Harris hip scores at preoperative and 2-year follow-up periods; VAS scores at preoperative, 3-month, 6-month, 1-year, and 2-year follow-up periods were analysed.

RESULTS

In the study, 44 patients were analysed. While 25 patients underwent core decompression only (group 1), 19 patients underwent core decompression and bone marrow mesenchymal stem cell implantation (group 2). The mean age of the patients in group 1 was 39.3 ± 6.5 years, and the mean age of the patients in group 2 was 38.4 ± 6.7 years. The mean follow-up was 31.85 ± 4.4 months in group 1 and 32.2 ± 4.1 months in group 2. Total hip arthroplasty was performed in 2 of the patients in group 1 (one of the patients underwent total hip arthroplasty at month 28 and the other at month 33).

CONCLUSION

The treatment of avascular necrosis of the femoral head varies according to various staging methods. Early diagnosis of the disease and correct treatment are very important for the patient's quality of life in the future. In our research, we found that patients who received both core decompression and stem cell implantation for early-stage avascular necrosis of the femoral head exhibited decreased pain at the 6-month, 1-year, and 2-year follow-up examinations. Additionally, their hip function improved at the 24-month mark according to the HHS evaluation.

Core decompression is superior to nonoperative management for humeral head osteonecrosis: a systematic review

BACKGROUND

Much of the literature on osteonecrosis has traditionally focused on the hip, which remains the most common site for this disease. The shoulder and the knee are the second most frequently affected sites (both approximately 10% of the incidence). There are a variety of techniques for managing this disease, and it is important to optimize this for our patients. This review aimed to compare the results of core decompression (CD) vs. nonoperative modalities for the treatment of osteonecrosis of the humeral head, including (1) success rate defined as lack of progression to further procedures (shoulder arthroplasty) and no need for further intervention; (2) clinical results (patient-reported pain and functional scores); and (3) radiological outcomes.

METHODS

We queried PubMed and found 15 reports that fit the inclusion criteria for studies concerning the use of CD as well as studies discussing nonoperative treatment for stage I-III osteonecrotic lesions of the shoulder. A total of 9 studies encompassed 291 shoulders that underwent CD analyzed at a mean follow-up of 8.1 years (range, 67 months-12 years), and 6 studies examined 359 shoulders that underwent nonoperative management at a mean follow-up of 8.1 years (range, 35 months-10 years). Outcomes of CD and nonoperative management included success rate, number of shoulders requiring shoulder arthroplasty, and evaluation of several normalized patient-reported outcomes. We also assessed radiographic progression (pre- to postcollapse or further collapse progression).

RESULTS

The mean success rate of CD for avoiding further procedures was 76.6% (226 of 291 shoulders) in stage I through stage III. Stage III shoulders avoided shoulder arthroplasty in 63% (27 of 43 shoulders). Nonoperative management resulted in a success rate of 13%, P < .001. In the CD studies, 7 of 9 showed improvements in clinical outcome measurements compared with 1 of 6 of the nonoperative studies. Radiographically, there was less progression in the CD group (39 of 191 shoulders [24.2%]) vs. the nonoperative group (39 of 74 shoulders [52.3%]) (P < .001).

CONCLUSIONS

Given the high success rate and positive clinical outcomes reported, CD is an effective method for management, especially when compared with nonoperative treatment methods for stage I-III osteonecrosis of the humeral head. The authors believe that it should be used as treatment to avoid arthroplasty in patients who have osteonecrosis of the humeral head.

Does transepiphyseal drilling and closure of the greater trochanter in early Legg-Calve-Perthes disease improve natural history?

PURPOSE

There is no consensus regarding treatment of Legg-Calve-Perthes disease (LCPD). The most common sequel of the disease is coxa breva and overgrowth of the greater trochanter (GT). Our purpose was to examine the effectiveness of transepiphyseal drilling combined with closure of the GT apophysis in patients with LCPD.

METHODS

During 2013-2018, we treated 16 consecutive cases of LCPD. Average age was 7.5 (range 6-10) years; nine patients were in early fragmentation, five in late fragmentation and one in reossification stages. Treatment protocol included hip arthrography, percutaneous drilling of the femoral head epiphysis, percutaneous tenotomy of adductor longus and epiphysiodesis of the GT apophysis.

RESULTS

Mean follow-up was 38 months. One patient was lost to follow-up. All patients had a limp prior to surgery. However, at latest follow-up, 10/15 patients had no limp, 11 patients had substantial improvement in hip range of motion. On radiographs, nine patients had Stulberg type 1-2, one type 3 and five type 4-5. There was no change in the epiphysio-trochanteric distance in any patient. Eight out of nine patients treated in the early fragmentation stage had good clinical and radiographic outcome. Most patients treated in late fragmentation stage had Stulberg 4-5 hip and required additional procedures.

CONCLUSIONS

Based on our preliminary experience, our protocol can be effective in the treatment of patients with LCPD in the initial or early fragmentation stages by improving the clinical and radiographic outcomes of the disease. This minimally invasive approach does not compromise any future treatment options.

LEVEL OF EVIDENCE

IV.

Clinical outcomes of autologous platelet-rich plasma and bone marrow mononuclear cells grafting combined with core decompression for Association Research Circulation Osseous II-IIIA stage non-traumatic osteonecrosis of the femoral head

PURPOSE

This study aimed to investigate the efficacy and safety of autologous platelet-rich plasma (PRP) and bone marrow mononuclear cells (BMMCs) grafting combined with core decompression (CD) in the treatment of Association Research Circulation Osseous (ARCO) II-IIIA stage non-traumatic osteonecrosis of the femoral head (ONFH).

METHODS

The clinical data of 44 patients (44 hips) with non-traumatic ONFH from December 2018 to December 2019 were retrospectively reviewed. Twenty-four patients underwent CD combined with autologous PRP and BMMCs grafting (PRP+BMMCs group), and 20 patients underwent core decompression alone (CD group). During a minimum follow-up of 36 months, radiographic outcomes were evaluated using X-ray, radiographic failure rates were compared, and Harris hip score (HHS) and visual analog scale (VAS) were selected to evaluate clinical outcomes. The percentage of patients with minimal clinically important difference (MCID) in both groups was analyzed. Clinical failure was defined as further total hip arthroplasty (THA) with Kaplan-Meier survival analysis. Surgical complications were recorded.

RESULTS

All patients had well healed wounds, and no complications such as infection and thrombosis occurred. HHS and VAS scores in both the PRP+BMMCs and CD groups were better than those preoperatively (P<0.05). At the last follow-up, the HHS and VAS scores of the PRP+BMMCs group were significantly better than those of the CD group (P<0.05). In ARCO II-IIIA stage, 66.7% of the PRP+BMMCs group and 30.0% of the CD group achieved the MCID (P<0.05). The clinical and imaging failure rates in the PRP+BMMCs group were 12.5% and 20.8%, respectively, compared with 40.0% and 50.0% in the CD group (P<0.05). In ARCO II stage, the MCID, clinical and imaging failure rates of PRP+BMMCs group and CD group were 66.7% and 33.3% (P<0.05), 4.8% and 33.3% (P<0.05), 14.3% and 44.4% (P<0.05), respectively. The PRP+BMMCs group had better hip survival rate compared with CD group (P<0.05).

CONCLUSION

CD combined with autologous PRP and BMMCs grafting is a safe and effective method for the treatment of ARCO II-IIIA stage non-traumatic ONFH, especially for ARCO II stage, effectively reducing the collapse rate of the femoral head and delaying or even avoiding THA.

Core decompression vs. allogenic non-vascularized bone grafting in patients with osteonecrosis of the femoral head

Background

Core decompression and allogenic non-vascularized bone grafting are used in the early stage of osteonecrosis of the femoral head for a period. Since the comparison of the core decompression and allogenic non-vascularized bone grafting are less reported, the purpose of our study was to investigate the difference of two procedures in patients with the osteonecrosis of the femoral head.

Methods

Between January 2018 and January 2019, 59 patients (64 hips) were divided into core decompression group and non-vascularized bone grafting group according to their procedures. The primary outcomes are visual analog score (VAS) and Harris hip score. Survivorship was analyzed with the collapse of the femoral head or conversion to total hip arthroplasty (THA) as the endpoint.

Results

At the final follow-up, two hips underwent THA in the core decompression group and three hips in the allogenic non-vascularized bone grafting group. The radiographic survival rates were 76.9% and 77.3%, respectively, in both groups. The VAS of the core decompression group was 6.08 ± 1.164 and 3.30 ± 1.431 before and 2 years after operation (P < 0.05), respectively. The VAS of the allogenic non-vascularized bone grafting group was 6.00 ± 1.209 and 3.15 ± 1.537 before and 2 years after operation (P < 0.05), respectively. The Harris hip score of the core decompression group was 52.49 ± 6.496 before operation, and 2 years after operation, it increased by 81.14 ± 8.548 (P < 0.05); The Harris hip score of allogenic the non-vascularized bone grafting group was 53.56 ± 5.925 and 81.33 ± 7.243 before and 2 years after operation (P < 0.05), respectively. In the core decompression group, body mass index (BMI) >25 kg/m2 was correlated with the collapse of femoral head or conversion to THA [P < 0.05; 95% confidence interval (CI), 0.006-1.334], and Association Research Circulation Osseous (ARCO) III was correlated with the collapse of femoral head or conversion to THA (P < 0.05; 95% CI, 2.514-809.650). In the allogenic non-vascularized bone grafting group, age, BMI, and ARCO stage were significantly associated with the collapse of femoral head or conversion to THA (P > 0.05).

Conclusion

The clinical survival rate of the femoral head in the core decompression group was slightly better than that in the allogenic non-vascularized bone grafting group. There was no significant difference in the radiographic survival rate of the femoral head between the two groups. Both groups can alleviate pain and improve functional of patients, but there was no significant difference in the degree of improvement. In the core decompression group, BMI >25 kg/m2 and ARCO III correlated with the collapse of femoral head or conversion to THA. In the allogenic non-vascularized bone grafting group, no association was found between age, BMI, and ARCO stage and the collapse of femoral head or conversion to THA.

Level of evidence

III.

Prognostic factors in the management of osteonecrosis of the femoral head: A systematic review

BACKGROUND

Several hip preserving techniques have been described for the management of osteonecrosis of the femoral head (ONFH). This systematic review identified prognostic factors in the treatment of ONFH that are associated with treatment failure and conversion to total hip arthroplasty (THA).

MATERIAL AND METHODS

This study followed the PRISMA guidelines. The literature search was conducted in November 2021. All clinical trials comparing two or more treatments for femoral head osteonecrosis were accessed. A multivariate analysis was performed to investigate the association between baseline characteristics and the surgical outcome. A multiple linear model regression analysis through the Pearson Product-Moment Correlation Coefficient (r) was used.

RESULTS

Data from 88 articles (6112 procedures) were retrieved. Female gender was associated with increased time to THA (P = 0.03) and reduced rate of THA (P = 0.03). Longer symptom duration before treatment was associated with shorter time to failure (P = 0.03). Increased pre-treatment VAS was associated with reduced time to failure (P = 0.03) and time to THA (P = 0.04). Reduced pre-treatment hip function was associated with increased rate of THA (P = 0.02) and failure (P = 0.005). Patient age and BMI, aetiology, time from surgery to full weight bearing and the side did not show evidence of a statistically significant association with the surgical outcome.

CONCLUSION

Male gender, longer symptom duration before treatment, higher VAS scores, and lower HHS scores were negative prognostic factors after treatment for osteonecrosis of the femoral head.

Long-term outcomes of arthroscopic synovectomy and core decompression through multiple small bone holes for early-stage avascular necrosis of the femoral head

OBJECTIVE

This study described a minimally invasive approach for the management of early-stage avascular necrosis of the femoral head, which integrated arthroscopic intra-articular decompression and core decompression by drilling multiple small holes.

METHOD

A total of 126 patients with 185 hip avascular necrosis were included between March 2005 and January 2008, and the hips were classified, based on the Association Research Circulation Osseous staging system, into stage I (n = 43), stage II (n = 114), and stage III (n = 28). Arthroscopic intra-articular inspection and debridement, along with drilling of multiple small holes for core decompression, were performed. The Modified Harris hip score system and radiographs were used to assess the pre- and post-surgery outcomes.

RESULTS

One hundred and three patients (involving 153 hips) were followed up successfully for an average of 10.7 ± 3.4 years (range: 9-12 years). After surgery, the overall survival rate was 51.6% (79 hips), and the clinical survival rates were 79%, 72%, 52%, 32%, and 10% for patients with stage I, IIa, IIb, IIc, and III, respectively. The outcomes of patients with Association Research Circulation Osseous Stages I or IIA were better than those of other stages, while hips with a large necrotic area had poor results. This approach preserved the original biomechanical strength of the femoral head after core decompression and eliminated arthritis factors in the hip joint.

CONCLUSION

The core decompression with multiple small-size holes is an effective method for treating early-stage avascular necrosis of the femoral head, particularly in those with pathological changes in the hip joint.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

Worldwide research trends on femur head necrosis (2000-2021): a bibliometrics analysis and suggestions for researchers

Background

Osteonecrosis of the femoral head (ONFH) is a common and stubborn disease. The main causes are venous stasis of the femoral head, arterial blood supply damage, bone cell and bone marrow death, and bone tissue necrosis and subsequent repair obstacles. Over the past 22 years, the number of papers on ONFH has, overall, continued to increase.

Methods

Using bibliometrics, we investigated the trends, frontiers, and hotspots of global scientific output in the past 22 years. We searched Science Citation Index Expanded (SCIE) of the Web of Science Core Collection (WoSCC) and retrieved information associated with papers and records published between 2000 and 2021. We used VOSviewer and CiteSpace to conduct bibliometric analysis and visual analysis on the overall distribution of annual output, major countries, active institutions, journals, authors, commonly cited literature, and keywords. The impact and quality of the papers were assessed using the global citation score (GCS).

Results

We retrieved a total of 2006 articles and reviews. Over the past 22 years, the number of publications (NP) increased. China ranked first in terms of NP, while the United States had the highest h-index and the highest number of citations (NC). Shanghai Jiao Tong University and International Orthopaedics were the institution and periodical, respectively. The paper written by Mont et al. in 2006 had the highest total GCS score, at 379. The top three keywords were "ischemic necrosis", "osteonecrosis", and "hip joint". Although there was a fluctuation in publications associated with ONFH, overall, the NP increased. China was the most prolific in this area, while the United States was the most influential country. The top 3 authors in terms of NP were Zhang, Motomura, and Zhao. Areas of focus in ONFH over recent years include signal pathway, genetic differentiation, glucocorticoid-induced osteogenesis, induced ischemic necrosis and osteogenesis.

Conclusions

Our bibliometrics analysis revealed the research hotspots and rapid development trends of ONFH research in the past 22 years. The most critical indicators [researchers, countries, research institutions, and journals publishing osteonecrosis of the femoral head (ONFH) research] relevant to the research hotspots in the field of ONFH research were analyzed.

The effects of nano-hydroxyapatite/polyamide 66 scaffold on dog femoral head osteonecrosis model: a preclinical study

The lack of mechanical support in the bone tunnel formed after CD often results in a poor therapeutic effect in ONFH. The n-HA/P66 has excellent biocompatibility and mechanical properties and has been widely used in bone regeneration. The present study aimed to evaluate the effects of n-HA/P66 scaffold treatment in a dog model of ONFH. A FEA was performed to analyze the mechanical changes in the femoral head after CD and n-HA/P66 scaffold or tantalum rod implantation. Fifteen male beagles were selected to establish the model of ONFH by liquid nitrogen freezing method, and the models were identified by x-ray and MRI 4 weeks after modeling and randomly divided into three groups. Nine weeks later, femoral head samples were taken for morphology, micro-CT, and histological examination. The FEA showed that the n-HA/P66 scaffold proved the structural support in the bone tunnel, similar to the tantalum rod. The morphology showed that the femoral head with n-HA/P66 implantation is intact, while the femoral heads in the model group and CD group are collapsing. Moreover, the micro-CT results of the n-HA/P66 scaffold group were better than the model group and the CD group, and the interface between the n-HA/P66 scaffold and bone tissue is blurred. Furthermore, the histological result also verifies the alterations in micro-CT, and bone tissue grows in the bone tunnel with n-HA/P66 scaffold implanted while few in the CD group. The CD results in a lack of mechanical support in the femoral head subchondral bone and bone tunnel high stress. The n-HA/P66 scaffold implantation can provide mechanical support and relieve high stress induced by CD. The n-HA/P66 scaffold can treat femoral head necrosis and provide the bone tissue growth scaffold for the femoral head after CD to promote bone tissue regeneration.

Predictors of Core Decompression Success in Patients with Femoral Head Avascular Necrosis

Background

Avascular necrosis of the femoral head typically occurs in the young population. Core decompression in the precollapse stage provides pain relief and preservation of the femoral head. The results of core decompression vary considerably despite the early diagnosis. Clinicians concur that primary treatment should focus on preserving the natural surface of the joint. This study investigated the predictive risk factors of failure in femoral head decompression.

Methods

We retrospectively reviewed 135 patients and 207 hips (77 male (127 hips) and 58 female (80 hips)) who underwent core decompression (mean age: 34.7 years [age range: 21-71]) from April 2010 to December 2017. All patients were followed by a mean of 57 months. All hips were in the precollapse stage (Ficat I, II).

Results

A total of 207 hips were treated with core decompression surgery, and the overall success rate was 58%. The higher grade of Kerboul, Ficat, ARCO classifications, multifocal avascular necrosis of the femoral head, smoking, opium, and corticosteroids were significantly associated with a higher failure rate after core decompression in univariate analysis. In multivariate logistic regression analysis, the Kerboul and Ficat classifications, alcohol consumption, and multifocal avascular necrosis of the femoral head were significantly correlated with core decompression failure. The most common predictive factors in core decompression failure were Ficat II, Kerboul stage 3, multifocal avascular necrosis of the femoral head, and alcohol consumption.

Conclusion

In conclusion, we had an overall 58 % success rate in core decompression of femoral head avascular necrosis. Based on the results of this study, imaging evaluation and imaging-based classifications are the most valuable predictor factors for the success of core decompression. Consistent with previous reports, corticosteroid was not a significant predictor of core decompression failure.

A Retrospective Observational Study to Compare the Outcome of Various Treatment Modalities of Idiopathic Avascular Necrosis of Hip

Background

Avascular necrosis (AVN) of hip of the femoral head is increasingly seen in young age, disabling them in their productive years of life. Available treatment options need to be evaluated.

Aim

The aim was to compare the outcome of various treatments at different stages of AVN hip.

Materials and Methods

A retrospective observational study was done in patients with idiopathic AVN hip, who had undergone different treatment modalities. The data of the included patients at different time intervals were compared. All patients were graded with the help of Harris Hip Score (HHS), and their outcome was evaluated.

Results

The age distribution of patients showed that nearly 80% of them were below the age of 50 years. The patients were presenting more often in Ficat and Arlet stage 4 compared to earlier stages. The patients in stage 1 were treated by core decompression alone, which produced good-to-excellent results in 4 of 7 (57.1%) patients. Patients in stage 2 and 3 were treated by core decompression with fibular bone grafting and had good-to-excellent results in 6 of 8 (75%) patients. In stage 4 of disease, cemented total hip replacement (THR) was done, and it produced good-to-excellent results in 13 of 15 (86.6%) patients.

Conclusion

In the early stage of disease, core decompression with and without bone grafting produced satisfactory results. In an advanced stage of AVN, THR is an excellent treatment option.

[The importance of removing osteonecrosis during treatment of femoral head osteonecrosis]

Atraumatic femoral head necrosis (aFHN) in adults is estimated to be the leading cause of approximately 10% of all hip prosthesis implantations. Due to the relatively frequent occurrence of aFHN at a young age, the possibility of a joint-preserving intervention should be examined. This includes the classic "core decompression" and modifications based on it. There are different data on the success rates of this method. Reasons for treatment failure could include a lack of clearance of the necrosis zone. The clearance of the necrosis zone is taken into account by alternative surgical procedures for the treatment of aFHN. These are the "trap-door procedure", the "light-bulb procedure" and "advanced core decompression". The current state of knowledge on these procedures is reviewed in this keynote article. It is shown that the extensive excision of femoral head necrosis is of particular importance. None of the procedures mentioned can currently be recommended in preference over the others.

Avascular Necrosis of Femoral Head-Overview and Current State of the Art

Avascular necrosis (AVN) of the femoral head is caused by disruption of the blood supply to the proximal femur. The alterations in the blood supply may occur following a traumatic event or result from a non-traumatic cause. Femoral neck fracture and hip dislocation and associated surgical procedures, corticosteroid therapy, and alcohol abuse frequently lead to AVN development. Type of fracture (displaced or undisplaced) and time between injury and surgery are the most critical factors in assessing the risk of developing AVN. Diagnosis of AVN can be established based on patients’ complaints, medical history, and radiographic findings. There is no consensus on the treatment of patients with AVN to date. Non-surgical methods are dedicated to patients in the early pre-collapse stages of the disease and consist of pharmacotherapy and physiotherapy. Surgery is recommended for patients with advanced disease.

An injectable self-adaptive polymer as a drug carrier for the treatment of nontraumatic early-stage osteonecrosis of the femoral head

Core decompression (CD) with the elimination of osteonecrotic bone is the most common strategy for treating early-stage nontraumatic osteonecrosis of the femoral head (ONFH). Adjuvant treatments are widely used in combination with CD as suitable methods of therapy. Existing augmentations have to be fabricated in advance. Here, we report a novel injectable glycerin-modified polycaprolactone (GPCL) that can adapt to the shape of the CD cavity. GPCL shows great flowability at 52.6 °C. After solidification, its compressive modulus was 120 kPa at body temperature (37 °C). This excellent characteristic enables the polymer to provide mechanical support in vivo. In addition, GPCL acts as a carrier of the therapeutic agent zoledronic acid (ZA), demonstrating sustained release into the CD region. ZA-loaded GPCL was injected into ONFH lesions to treat early-stage nontraumatic cases. Compared to that in the CD group, CD+ZA-loaded GPCL injection preserved bone density and increased the collagen level in the femoral head. At the interface between the GPCL and CD tunnel wall, osteogenesis was significantly promoted. In addition, morphological evaluations revealed that the femoral heads in the CD+ZA-GPCL group exhibited improved pressure resistance. These results suggest a strategy effective to preserve the bone density of the femoral head, thus decreasing the possibility of femoral head collapse. This novel injectable polymer has, therefore, considerable potential in clinical applications.

Nonoperative and Operative Bone and Cartilage Regeneration and Orthopaedic Biologics of the Hip: An Orthoregeneration Network (ON) Foundation Hip Review

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and, optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electromagnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the hip, including osteonecrosis (aseptic necrosis) involving bone marrow, bone, and cartilage, and chondral injuries involving articular cartilage, synovium, and bone marrow. Promising and established treatment modalities for osteonecrosis include nonweightbearing; pharmacological treatments including low molecular-weight heparin, prostacyclin, statins, bisphosphonates, and denosumab, a receptor activator of nuclear factor-kB ligand inhibitor; extracorporeal shock wave therapy; pulsed electromagnetic fields; core decompression surgery; cellular therapies including bone marrow aspirate comprising mesenchymal stromal cells (MSCs aka mesenchymal stem cells) and bone marrow autologous concentrate, with or without expanded or cultured cells, and possible addition of bone morphogenetic protein-2, vascular endothelial growth factor, and basic fibroblast growth factor; and arterial perfusion of MSCs that may be combined with addition of carriers or scaffolds including autologous MSCs cultured with beta-tricalcium phosphate ceramics associated with a free vascularized fibula. Promising and established treatment modalities for chondral lesions include autologous platelet-rich plasma; hyaluronic acid; MSCs (in expanded or nonexpanded form) derived from bone marrow or other sources such as fat, placenta, umbilical cord blood, synovial membrane, and cartilage; microfracture or microfracture augmented with membrane containing MSCs, collagen, HA, or synthetic polymer; mosaicplasty; 1-stage autologous cartilage translation (ACT) or 2-stage ACT using 3-dimensional spheroids; and autologous cartilage grafting; chondral flap repair, or flap fixation with fibrin glue. Hip pain is catastrophic in young patients, and promising therapies offer an alternative to premature arthroplasty. This may address both physical and psychological components of pain; the goal is to avoid or postpone an artificial joint. LEVEL OF EVIDENCE: Level V, expert opinion.

Outcomes of free vascularized fibular graft for post-traumatic osteonecrosis of the femoral head

INTRODUCTION

Osteonecrosis of the femoral head (ONFH) can occur after traumatic injuries of the hip. Surgical treatment with total hip arthroplasty (THA) may not produce lifelong viability in younger patients. Free vascularized fibular graft (FVFG) has become a reliable method to delay or even avoid THA in this patient population by aiming to correct loss of viable bone through vascularized autologous bone transfer. The purpose of this study was to evaluate the longevity and outcomes of FVFG for traumatic hip injuries resulting in ONFH.

METHODS

We performed a retrospective review of our institutional database of patients who had undergone FVFG from 1980-2006 for post-traumatic ONFH and had a minimum follow-up of 5 years. Data collected included demographics, pre-operative Urbaniak ONFH staging, Harris Hip scores (HHS), SF-12 scores, and conversion to THA.

RESULTS

Seventy-two hips in 68 patients met inclusion criteria. Mean follow-up was 11.6 years (range 5.1-33.2 years). Etiology included femoral neck fracture in 36 patients (61%), hip dislocation in 7 (12%), trauma without fracture or dislocation in 11 (19%), and femoral neck nonunion in 5 (8%). The most common stage at presentation was stage IV (48 patients). Graft survival at final follow-up (mean 10.9 years) was 64%, with mean time to conversion to THA of 8.4 years in those that did not survive (36%). There was no difference between THA conversion rates in hips with pre-collapse (Stage I and II) versus impending or post-collapse (Stage III or IV) lesions (p = 0.227). In hips with surviving grafts at final follow-up, mean HHS improved from 56.7 to 77.3 (SD 24.57, range 69-93), a mean improvement of 20.6 (p < 0.001).

CONCLUSIONS

Our study reveals improvement in HHS in surviving FVFG and an acceptable overall THA conversion rate at mid to long term follow-up in Urbaniak stage I through IV hips. FVFG remains a viable option for treatment in younger patients with pre- and post-collapse (stage IV) ONFH lesions secondary to hip trauma.

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.

Hip preserving procedures for osteonecrosis of the femoral head after collapse

Osteonecrosis of the femoral head (ONFH) affects mainly young patients and causes secondary hip osteoarthritis if remains untreated. Several operative treatments have been introduced with successful outcomes in the early stages. However, in late stages of ONFH treatment may be challenging due to the progressive nature of disease and many surgeons prefer arthroplasty option after collapse. Considering the size, age and etiology an effort should be made to preserve hip joint selected patients with early collapse or minimal arthritic changes. The purpose of the current review is to discuss the results of joint preserving procedures for late stages of ONFH.

Glucocorticoid-induced osteonecrosis in systemic lupus erythematosus patients

Osteonecrosis (ON) is a complex and multifactorial complication of systemic lupus erythematosus (SLE). ON is a devastating condition that causes severe pain and compromises the quality of life. The prevalence of ON in SLE patients is variable, ranging from 1.7% to 52%. However, the pathophysiology and risk factors for ON in patients with SLE have not yet been fully determined. Several mechanisms for SLE patients' propensity to develop ON have been proposed. Glucocorticoid is a widely used therapeutic option for SLE patients and high-dose glucocorticoid therapy in SLE patients is strongly associated with the development of ON. Although the hips and knees are the most commonly affected areas, it may be present at multiple anatomical locations. Clinically, ON often remains undetected until patients feel discomfort and pain at specific sites at which point the process of bone death is already advanced. However, strategies for prevention and options for treatment are limited. Here, we review the epidemiology, risk factors, diagnosis, and treatment options for glucocorticoid-induced ON, with a specific focus on patients with SLE.

Arthroscopic Approach to Preservation of the Hip with Avascular Necrosis

Avascular necrosis (AVN) of the hip is a devastating disease that affects middle-aged adults with poor outcomes if not treated in its early stages. In recent years, subchondroplasty with calcium phosphate solution has shown promising results. Concomitant intra-articular pathologies, including femoroacetabular impingement and chondral lesions, have been described in hips affected by AVN. These should be addressed at the time of surgery to lower the risk of failure. In this Technical Note, we describe an arthroscopic approach to femoral head subchondroplasty with precollapse lesion in AVN affected hip, combined with labral reconstruction and acetabular chondral treatment.

Nomogram to predict collapse-free survival after core decompression of nontraumatic osteonecrosis of the femoral head

Background

Nontraumatic osteonecrosis of the femoral head (NONFH) is a devastating disease, and the risk factors associated with progression into collapse after core decompression (CD) remain poorly defined. Therefore, we aim to define risk factors associated with collapse-free survival (CFS) after CD of precollapse NONFH and to propose a nomogram for individual risk prediction.

Methods

According to the baseline characteristics, clinical information, radiographic evaluations, and laboratory examination, a nomogram was developed using a single institutional cohort of patients who received multiple drilling for precollapse NONFH between January 2007 and December 2019 to predict CFS after CD of precollapse NONFH. Furthermore, we used C statistics, calibration plot, and Kaplan-Meier curve to test the discriminative ability and calibration of the nomogram to predict CFS.

Results

One hundred and seventy-three patients who underwent CD for precollapse NONFH were retrospectively screened and included in the present study. Using a multiple Cox regression to identify relevant risk factors, the following risk factors were incorporated in the prediction of CFS: acute onset of symptom (HR, 2.78; 95% CI, 1.03–7.48; P = 0.043), necrotic location of Japanese Investigation Committee (JIC) C1 and C2 (HR, 3.67; 95% CI, 1.20–11.27; P = 0.023), necrotic angle in the range of 250–299°(HR, 5.08; 95% CI, 1.73–14.93; P = 0.003) and > 299° (HR, 9.96; 95% CI, 3.23–30.70; P < 0.001), and bone marrow edema (BME) before CD (HR, 2.03; 95% CI, 1.02-4.02; P = 0.042). The C statistics was 0.82 for CFS which revealed good discriminative ability and calibration of the nomogram.

Conclusions

Independent predictors of progression into collapse after CD for precollapse NONFH were identified to develop a nomogram predicting CFS. In addition, the nomogram could divide precollapse NONFH patients into prognosis groups and performed well in internal validation.

Extracorporeal Shockwave Therapy Modulates the Expressions of Proinflammatory Cytokines IL33 and IL17A, and Their Receptors ST2 and IL17RA, within the Articular Cartilage in Early Avascular Necrosis of the Femoral Head in a Rat Model

Avascular necrosis (AVN) of the femoral head (AVNFH) is a disease caused by injury to the blood supply of the femoral head, resulting in a collapse with osteonecrosis and damage to the articular cartilage. Extracorporeal shockwave therapy (ESWT) has been demonstrated to improve AVNFH owing to its anti-inflammation activity, angiogenesis effect, and tissue regeneration in clinical treatment. However, there are still so many pieces of the jigsaw that need to be fit into place in order to ascertain the mechanism of ESWT for the treatment of AVNFH. The study demonstrated that ESWT significantly protected the trabecular bone volume fraction BV/TV (P < 0.01) and the trabecular thickness (P < 0.001), while in contrast, the trabecular number and trabecular separation were not significantly different after treatment as compared with AVNFH. ESWT protected the articular cartilage in animal model of AVNFH. The levels of IL1-β and IL33 were significantly induced in the AVNFH group (P < 0.001) as compared with Sham and ESWT groups and reduced in ESWT group (P < 0.001) as compared with AVNFH group. In addition, the expression of the receptor of IL33, ST2, was reduced in AVNFH and induced after ESWT (P < 0.001). The expression of IL17A was induced in the AVNFH group (P < 0.001) and reduced in the ESWT group (P < 0.001). Further, the expression of the receptor of IL17A, IL17RA, was reduced in the AVNFH group (P < 0.001) and improved to a normal level in the ESWT group as compared with Sham group (P < 0.001). Taken together, the results of the study indicated that ESWT modulated the expression of IL1-β, pro-inflammatory cytokines IL33 and IL17A, and their receptors ST2 and IL17RA, to protect against loss of the extracellular matrix in the articular cartilage of early AVNFH.

Therapeutic Study of Thermosensitive Hydrogel Loaded with Super-Activated Platelet Lysate Combined with Core Decompression Technology for the Treatment of Femoral Head Necrosis

Super activated platelet lysate (sPL) is a derivative of platelet-rich plasma (PRP) that contains high levels of several growth factors. In this study, we synthesized a temperature-sensitive hydrogel that contained temperature-sensitive Poly(DL-lactide-glycolide-glycolide acid) (PLGA), SrCl2, and HA, and loaded it with different concentrations of sPL. The hydrogel showed satisfactory encapsulation efficiency and release of the growth factors in a sustained manner, indicating its suitability as a drug carrier. The sPL-loaded hydrogel was inserted into the necrotic femoral head of a rat model and core decompression was applied and resulted in significantly accelerated bone repair and regeneration. Therefore, encapsulation of sPL in a hydrogel scaffolding may be an effective strategy for treating femoral head necrosis.

Core decompression with bone marrow aspirate concentrate in post collapse avascular necrosis of hip: A systematic review and meta-analysis

BACKGROUND

Avascular necrosis (AVN) of femoral head is commonly seen in middle age groups and in its advanced stages, it is a common indication for total hip replacements (THRs). These patients invariably require revision surgeries in their lifetime and modalities to delay the first arthroplasty are necessary. Core decompression (CD) with bone marrow aspirate concentrate (BMAC) have proved successful in early stages of AVN, but their role in advanced stages remains unclear. The present review was done to assess the same.

RESEARCH QUESTION

Is CD and BMAC combination effective in delaying radiographic progression and THRs in post collapse stages of AVN hip?

METHODOLOGY

A systematic review and meta-analysis was conducted to determine the overall efficacy of CD and BMAC in post collapse stages of AVN hip and to specifically compare primary outcomes like radiographic progression along with need of THR, with CD alone.Three data bases (PubMed, EMBASE and SCOPUS) were searched to identify relevant articles.

RESULTS

The present review included 12 studies with 3 studies included in the meta-analysis. There were 270 hips across the 12 studies out of which 196 hips were treated with CD + BMAC.

PRIMARY OUTCOMES

39.8% cases worsened from stage 3 to stage 4, while the overall incidence of THR in stages 3 and 4 was 38.3%. On comparison with CD alone the combination of CD + BMAC did not show any enhanced efficacy in either delaying progression (Odds ratio of 1.41 (95% CI = 0.55-3.62) or in conversion to THR (Odds Ratio: 0. 92; 95% CI = 0.41-2.06).

CONCLUSION

CD can be considered in stage 3 of AVN in younger population to delay the need of arthroplasty, before severe head distortion and arthritis sets in, and can be supplemented with bone strut grafts or tantalum rods, for supporting the articular cartilage. BMAC that has shown better results in early AVN, has not shown any additional benefits when compared to CD alone in advanced cases.

Modified Kerboul Angle Predicts Outcome of Core Decompression With or Without Additional Cell Therapy

BACKGROUND

Core decompression is the most common procedure for early-stage osteonecrosis of the femoral head (ONFH). This study investigated outcomes of core decompression with/without bone marrow aspirate concentrate (BMAC), based on the Kerboul combined necrotic angles using magnetic resonance imaging.

METHODS

We reviewed 66 patients (83 hips) with early ONFH, Association Research Circulation Osseous stages I-IIIa, who underwent core decompression alone (26 patients, 33 hips) or in combination with BMAC (40 patients, 50 hips). Survival rate and progressive collapse were analyzed using the Kaplan-Meier method, and conversion to total hip arthroplasty (THA) was evaluated. Subgroup analyses based on the modified Kerboul angle were performed: grade I (<200°), grade II (200°-249°), grade III (250°-299°), and grade IV (≥300°).

RESULTS

Mean follow-up was 36 ± 23 months. Femoral head collapse with BMAC (16 hips, 32%) was significantly lower than without BMAC (19 hips, 58%, P = .019). Conversion THA was significantly lower with BMAC (28%) than without (58%, P = .007). Survival rates among groups showed significant differences (P = .017). In grade I, 0/12 hips with BMAC collapsed while 3/9 (33%) without BMAC collapsed (P = .063); in grade II, 2/16 hips (12%) with BMAC collapsed while 7/13 (54%) without BMAC collapsed (P = .023). There was no significant difference in collapse with (64%) or without (82%) BMAC in grade III-IV hips (P = .256).

CONCLUSION

Core decompression with/without BMAC had a high failure rate, by increasing disease progression and the necessity for THA, for combined necrotic angles >250°. In our study, addition of BMAC had more reliable outcomes than isolated core decompression for precollapse ONFH if the combined necrotic angles were <250°.

Core Decompression and Biological Treatment in Osteonecrosis of the Hip due to Systemic Lupus Erythematosus, 8-year Follow-up: A Case Report

BACKGROUND: Osteonecrosis most commonly affects the femoral head, especially in middle-aged adults. It can be caused by trauma, chronic inflammation, or infection. It leads to collapse of the entire femoral head and culminates with total hip replacement. CASE REPORT: A 29-year-old female with systemic lupus erythematosus (SLE) had a chief complaint of bilateral hip pain. She was diagnosed with early osteonecrosis of the femoral head (FICAT stage II) using magnetic resonance imaging and core decompression surgery was performed using three small diameter (4 mm) drillings and added biological treatment. She was evaluated with a visual analog scale (VAS), Harris hip score (HHS), and plain radiography in the pre-operative stage and post-operative follow-up. RESULTS: Functional outcome at 8-year follow-up showed improvement with significantly decreased VAS (pre-operative: 5, post-operative: 0), significant improvement of HHS from 52.725 points (poor) pre-operative to 92.025 points (excellent) post-operative, and subsided femoral head lesion. CONCLUSIONS: Surgical decompression and biological treatment result in decreased intraosseous pressure and enhanced osteogenesis. It can restrict the SLE disease progression and limit the number of cell death.

Single Stage Simultaneous Core Decompression for Ficat Stage I and II Bilateral Femoral Head Osteonecrosis among Hip Surgeries done in a Tertiary Care Centre: A Descriptive Cross-sectional Study

INTRODUCTION

Osteonecrosis of femoral head is a disease affecting young individuals and often occurs in bilateral hips. The purpose of this study is to find out the prevalence of single stage simultaneous core decompression for Ficat stage I and II bilateral femoral head osteonecrosis among total hip surgeries done in a tertiary care center.

METHODS

A descriptive cross-sectional study was conducted at a tertiary care trauma centre from April 2017 and March 2020. Ethical approval was obtained from the Institutional Review Committee prior to data collection (Reference no: 673/2077/78). Convenience sampling was done. Patients undergoing hip surgeries were included in the study. Patients with missing data were excluded. Patients operated upto Ficat Stage IIb femoral head osteonecrosis were followed up. Data was analysed using the Statistical Package for Social Sciences version 22.0. Point estimate at 95% Confidence Interval was calculated along with frequency and percentage for binary data.

RESULTS

Out of 916 patients who underwent hip surgeries, 12 (1.31%) (0.57-2.04 at 95% Confidence Interval) underwent single stage simultaneous core decompression. Idiopathic cause in 6 (50%) and prolonged corticosteroid usage in 4 (33.33%) were the leading causes. Twelve (50%) of the treated hips were in Ficat stage IIa. At the end of one year, of the 11 patients who followed up, 12 (54.5%) hips had a good Harris hip outcome.

CONCLUSIONS

Our study showed that a small proportion of hip surgeries were single stage simultaneous bilateral core decompression for osteonecrosis of femoral head in our setting. Our findings were similar to studies done internationally with a very low complication rate.

Osteonecrosis of the hip: is there a difference in the survivorship of total hip arthroplasty with or without previous vascular iliac bone grafting?

Background

Osteonecrosis of the femoral head (ONFH) is a debilitating condition. Vascularized iliac bone graft (VIBG) is a joint-preserving surgery to improve blood supply to the avascular portion of the femoral head which may delay secondary osteoarthritis and total hip arthroplasty (THA). However, whether VIBG will affect the subsequent THA survivorship and outcomes are still uncertain.

Methods

Implant survivorship and clinical outcomes were compared between 27 patients who had undergone prior VIBG and 242 patients who had only undergone THA for ONFH. Baseline characteristics and the postoperative Harris Hip Score (HHS) were also recorded and compared between the two groups. Implant survivorship was determined using Kaplan-Meier survival analysis.

Results

The overall implant survival for all patients who had a primary diagnosis of ONFH and eventually underwent THA was 92.9%. There was no significant difference in the implant survivorship between the group who directly received THA (survivorship of 93%) and the group which failed VIBG and was subsequently converted to THA (survivorship of 91.9%) (p = 0.71). In addition, higher THA revision rates were associated with smokers and drinkers.

Conclusions

VIBG may be a reasonable option as a “buy-time” procedure for ONFH. Even if conversion to THA is eventually required, patients may be reassured that the overall survivorship and clinical outcomes may not be compromised. Patients are recommended to give up smoking and binge drinking prior to THA to increase implant survival rate.

Treatment of aseptic osteonecrosis of the femoral head: Historical aspects

The treatment of aseptic osteonecrosis (ON) of the femoral head has been the subject of numerous therapeutic and surgical proposals due to the absence of medical treatment with proven efficacy. For many years, the goal of surgical treatment was to avoid total hip replacement (THR) with uncertain survival in patients considered too young (30-50 years) for this procedure. Numerous conservative treatments were thus proposed: core decompression with numerous variants, non-vascularized and vascularized bone grafts, intertrochanteric and rotational transtrochanteric osteotomies, cementing. The lack of a common classification and a lack of knowledge of natural history complicated the interpretation of the results for a long time. Nevertheless, it appeared that these treatments were effective only in the very early stages and among these in the limited ONs, medial rather than central and especially lateral, with discrepancies according to etiologies apart from sickle cell disease recognized by all as being pejorative. For the same reason, partial arthroplasties have been attempted and abandoned in turn: femoral head total and partial resurfacing and femoral prosthesis. The most recent advances are stem-cell-enhanced core decompression and progress in total arthroplasty, whose reliability has made it possible to extend the indications to increasingly younger patients seeking treatment with guaranteed or near-guaranteed efficacy. Most of the other interventions have disappeared or almost disappeared because of their lack of effectiveness especially in extensive and post-fracture ONs, sometimes because of their complexity and the length of their post-operative management, and also because they complicate and penalize a future total arthroplasty. This argues for early detection of ON at an early stage where the "head can be saved" by stem cell augmented core decompression, a minimally invasive treatment that leaves the chances of success of a THR intact.

The outcome of hyperbaric oxygen therapy versus core decompression in the non-traumatic avascular necrosis of the femoral head: Retrospective Cohort Study

Background

Core decompression (CD) has been used in the treatment of pre-collapse stages avascular necrosis (AVN) with good results. Hyperbaric oygen therapy (HBO) was used as a non-invasive treatment for pre-collapse stages osteonecrosis with favorable results. This study aimed to compare the outcomes of HBO versus CD in stage II of non-traumatic AVN of the femoral head.

Methods

Data were collected retrospectively for patients with non-traumatic AVN of the femoral head that was confirmed by MRI and underwent HBO or CD between January 2010 and December 2018, with a minimum follow-up of 12 months. Oxford Hip Score (OHS), radiographic progression, and Short-Form 12(SF12) were used to assess the outcomes.

Results

Nineteen patients with 23 stage II AVN of the femoral head were included, 12 (52.2%) in CD, and 11 (47.8%) in the HBO group with an average follow-up of 34.2 ± 18.4 months.

66.7% of patients in CD and 81.8% in the HBO group achieved satisfactory hip function outcome with statistically significant mean Oxford Hip Score (35.8 ± 6.7 and 35.5 ± 5.1) (P 0.009 & .003) respectively.

No statistical difference of OHS and SF12 (PCS &MCS) was found between the two groups (P 0.202, 0.128 & .670 respectively).

Eight (34.7%) cases progressed to a higher radiological stage at one year follow-up. The rate of progression was not statistically significant between both groups (P 0.469) with no statistical difference of OHS and SF12 (PCS & MCS) in the progressed group (P 0.747, 0.648 & 0.416) respectively.

Conclusion

This study showed that the HBO is promising and as effective as CD in the treatment of non-traumatic pre-collapsed AVN of the femoral head. Hence, HBO could be used as an alternative non-invasive treatment option.

•

Osteonecrosis (AVN) of the femoral head is a potentially disabling disorder.

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Core decompression (CD) is the gold standard treatment for the pre-collapse stages.

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Hyperbaric oxygen therapy (HBO) is a new treatment option with favorable results.

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No consensus regarding the best method for the pre-collapse stages AVN.

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Both options achieved a significant satisfactory hip function outcome with no difference between the two.

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.

Long-term survival and clinical outcomes of non-vascularized autologous and allogeneic fibular grafts are comparable for treating osteonecrosis of the femoral head

Background

Osteonecrosis of the femoral head (ONFH) is a disabling disease, which often involves young patients. Recently, various hip-preserving surgeries were recommended to delay total hip arthroplasty (THA).

Questions/purposes

This study aimed to compare clinical outcomes and survival rate in the long-term follow-up between core decompression combined with a non-vascularized autologous fibular graft (group A) and an allogeneic fibular graft (group B) for the treatment of ONFH.

Patients and methods

We retrospectively evaluated 117 patients (153 hips) with ONFH (Association Research Circulation Osseous [ARCO] stages IIa to IIIc) who underwent the abovementioned hip-preserving surgeries between January 2003 and June 2012. The mean (range) follow-up times (years) were 12.9 (7–16) and 9.3 (6–16) in groups A and B, respectively. Clinical outcomes were assessed using the Harris Hip Score (HHS), visual analog scale (VAS) score, and forgotten joint score (FJS). A survival analysis was performed using the Kaplan-Meier method. The end point was THA.

Results

Groups A and B showed postoperative improvements, respectively, in HHS from 65 ± 7.2 to 80.3 ± 14.5 and from 66 ± 5.9 to 82.4 ± 13.6 (p < 0.05), and in VAS score from 6.3 ± 1.1 to 2.3 ± 1.6 and from 6.1 ± 1 to 2.2 ± 2.2 (p < 0.05). However, no significant differences in the HHS, VAS score, and hip FJS at the last follow-up (p > 0.05) and 15-year survival rate (84.1% and 86%, respectively, p > 0.05) were found between groups A and B.

Conclusions

Autologous and allogeneic fibular grafts can attain equally good clinical outcomes and high survival rates in long-term follow-up, and thus can greatly delay THA owing to good bone osseointegration and sufficient mechanical support. Notably, the ratio of failure will increase when patients were more than 37 years old.

Level of evidence

Level III, therapeutic study

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02246-3.

Culture-Expanded Autologous Adipose-Derived Mesenchymal Stem Cell Treatment for Osteonecrosis of the Femoral Head

Backgroud

Outcomes of traditional treatment for osteonecrosis of the femoral head (ONFH) are not always satisfactory. Hence, cell-supplementation therapy has been attempted to facilitate necrotic-tissue regeneration. Adipose-derived mesenchymal stem cell (ADMSC) transplantation is potentially advantageous over bone marrow-derived MSC implantation, but its outcomes for ONFH remain unclear. The aim of this study was to determine 2-year radiological and clinical outcomes of culture-expanded autologous ADMSC implantation for ONFH.

Methods

Eighteen hips with necrotic lesions involving ≥ 30% of the femoral head were included. ADMSCs were harvested by liposuction and culture expanded for 3 passages over 3 weeks. With a 6-mm single drilling, ADMSCs were implanted into the necrotic zone. All patients underwent magnetic resonance imaging (MRI), single-photon emission computed tomography/computed tomography (SPECT/CT) at screening and 6 months, 12 months, and 24 months postoperatively. The primary outcome was the change in the size of necrotic area on MRI. Secondary outcomes were changes in clinical scores and radioisotope uptake on SPECT/CT. Conversion total hip arthroplasty (THA) was defined as the endpoint.

Results

Preoperatively, the necrotic lesion extent was 63.0% (38.4%–96.7%) of the femoral head. The mean Harris hip score was 89.2, the University of California at Los Angeles (UCLA) score was 5.6, and Western Ontario and McMaster Universities Arthritis index (WOMAC) was 79.4. Three patients underwent THA and 1 patient died in an accident. Finally, 11 patients (14 hips) were available for ≥ 2-year follow-up. At the last follow-up, no surgery-related complications occurred, and 14 of 17 hips (82%) were able to perform daily activities without THA requirement. There was no significant decrease in lesion size between any 2 intervals on MRI. However, widening of high signal intensity bands on T2-weighted images inside the necrotic lesion was observed in 9 of 14 hips (64%); 11 of 14 hips (79%) showed increased vascularity on SPECT/CT at 2 years postoperatively. No significant differences were observed between preoperative and 24-month mean Harris hip score (89.2 vs. 88.6), WOMAC (79.4 vs. 75.7), and UCLA score (5.6 vs. 6.2).

Conclusions

Our outcomes suggest that culture-expanded ADMSC implantation is a viable option for ONFH treatment without adverse events.

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.

Disassembly of bilateral bipolar heads within 10 years after hip hemiarthroplasties for avascular necrosis of femoral heads: a case report

Prosthetic joint surgeries, total hip arthroplasty (THA) or bipolar hemiarthroplasty (BHA) and joint preservation surgeries can be performed for avascular osteonecrosis of femoral head (ONFH) with collapse. Although excellent surgical results have been reported, long-term survivorship and postoperative complications are a great concern. The purpose of this study was to report a case of bilateral disassembly of bipolar heads within 10 years after BHA for ONFH. A 61-year-old man, whose occupation was carpenter, underwent bilateral BHA for ONFH at another hospital when he was 57 years old. He had acute right hip pain during working and visited our institute. Radiographs revealed intra-articular (outer and inner head) disassembly of the right bipolar head, and conversion to THA was performed. Five years later, he had contralateral (left) hip pain. Radiographs revealed disassembly of bipolar head, as had occurred with the right hip, and similar conversion surgery was performed for the left hip. Marked wear and detachment of the polyethylene bearings of the outer head and failure of the locking mechanism between a skirted 22-mm-diameter inner head and polyethylene insert were observed in both hips at each revision surgery. Degeneration of the acetabulum were also observed in both hips. The failure of the self-centering mechanism because of degenerative change of the acetabulum, impingement of the outer head and neck, and high activity seemed to be the causes of disassembly of the bilateral bipolar heads. Therefore, it is important to select the type of prostheses depending on the age, activity and occupation of each patient.

What are the outcomes of core decompression without augmentation in patients with nontraumatic osteonecrosis of the femoral head?

Purpose

Core decompression (CD) of the femoral head is performed to preserve the hip in avascular necrosis (AVN). The outcome following this procedure differs based on the medical centre and the technique. Also, the time to total hip replacement (THR) and the percentage of patients subsequently undergoing a THR are controversial.

Methods

A systematic review was performed following PRISMA guidelines. The search included CENTRAL, MEDLINE, EMBASE, Scopus, AMED and Web of Science Core Collection databases. Studies reporting the outcome of CD for AVN were assessed. Studies using additional implants, vascularized grafts or any type of augmentation were excluded. Quality assessment was performed using the Joanna Briggs Institute Critical Appraisal Checklist (JBI CAC) tool.

Trial registration

International prospective register of systematic reviews (PROSPERO) - CRD42018100596.

Results

A total of 49 studies describing 2540 hips were included. The mean weighted follow-up time was 75.1 months and the mean age at surgery was 39 years. Twenty-four of 37 studies reported improvement in all outcome scores, whilst 9/37 studies report only partial improvement post-operatively. Four studies (4/37) described poor clinical outcomes following intervention. Data was pooled from 20 studies, including 1134 hips with a weighted mean follow-up of 56 months. The percentage of hips undergoing THR averaged 38%. The time to THR had a weighted mean of 26 months after CD.

Conclusion

Pooled results from 1134 hips and of these nearly 80% with early stage of osteonecrosis, showed that approximately 38% of patients underwent a total hip replacement at an average of 26 months following core decompression without augmentation.

Electronic supplementary material

The online version of this article (10.1007/s00264-020-04790-9) contains supplementary material, which is available to authorized users.

Management of osteonecrosis of the femoral head

Aims

Earlier studies dealing with trends in the management of osteonecrosis of the femoral head (ONFH) identified an increasing rate of total hip arthroplasties (THAs) and a decreasing rate of joint-preserving procedures between 1992 and 2008. In an effort to assess new trends in the management of this condition, this study evaluated the annual trends of joint-preserving versus arthroplasties for patients aged < or > 50 years old, and the incidence of specific operative management techniques.

Methods

A total of 219,371 patients with ONFH were identified from a nationwide database between 1 January 2009 and 31 December 2015. The mean age was 54 years (18 to 90) and 105,298 (48%) were female. The diagnosis was made using International Classification of Disease, Ninth revision, Clinical Modification (ICD-9-CM) and Tenth Revision, Clinical Modification (ICD-10-CM) procedure codes. The percentage of patients managed using each procedure during each year was calculated and compared between years. The trends in the use of the types of procedure were also evaluated.

Results

The rate of joint-preserving procedures was significantly higher in patients aged < 50 years compared with those aged > 50 years (4.93% vs 1.52%; p < 0.001). For the overall cohort, rates of arthroplasty were far greater than those for joint-preserving procedures. THA was the most commonly performed procedure (291,114; 94.03%), while osteotomy (3,598; 1.16%), partial arthroplasty (9,171; 2.96%), core decompression (1,200; 0.39%), and bone graft (3,026; 0.98%) were performed markedly less frequently. The annual percentage of patients managed using a THA (93.56% to 89.52%; p < 0.001), resurfacing (1.22% to 0.19%; p < 0.001), and osteotomy (1.31% to 1.05%; p < 0.001) also decreased during the study period.

Conclusion

We found that patients with ONFH have been most commonly managed with non-joint-preserving procedures. Our findings provide valuable insight into the current management of this condition and should increase efforts being made to save the hip joint. Cite this article: Bone Joint J 2020;102-B(7 Supple B):122–128.

Core Decompression Combined with Implantation of Autologous Bone Marrow Concentrate with Tricalcium Phosphate Does Not Prevent Radiographic Progression in Early Stage Osteonecrosis of the Hip

Backgroud

Untreated osteonecrosis of the femoral head ultimately leads to secondary coxarthrosis. The aim of this study was to determinate if the core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate could be used to prevent radiographic progression of early stage osteonecrosis of the hip. We also sought to determine whether this treatment improved clinical outcomes and reduced the need for total hip arthroplasty.

Methods

Eighteen hips were included in the present study. All of them underwent core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate between 2007 and 2012. The cell concentrate was obtained from the posterior iliac crest and processed and implanted during the same surgical procedure. Patient demographic data, clinical data including modified Harris hip score, and radiological data were collected preoperatively, postoperatively, and during the follow-up period. Also, survival endpoints were analyzed: time of femoral head collapse and need for total hip arthroplasty.

Results

The mean age of patients was 37.8 years (standard deviation [SD], 9.31 years). The mean follow-up was 68.9 months (SD, 15.0 months). In most cases (70.6%), the etiology of the osteonecrosis of the femoral head was corticosteroid use; in the remaining cases, secondary to alcohol use. Core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate did not prevent progression to collapse (< 80% at 5 years) although modified Harris hip scores improved. Overall median survival with the total hip arthroplasty as endpoint was 23 months (95% confidence interval [CI], 14.9 to 31.1 months). Overall median survival time with any degree of collapse as endpoint was 7 months (95% CI, 2.0 to 12.0 months).

Conclusions

The results obtained in this study suggest that core decompression combined with implantation of autologous bone marrow concentrate and tricalcium phosphate will not prevent radiographic progression of early stage osteonecrosis of the hip. These finding also suggest that the absence of indications for hip replacement alone is not an indicator of good response to the treatment, and it is important to note the radiological results.

A Comparison of Transphyseal Neck-Head Tunneling and Multiple Epiphyseal Drilling on Femoral Head Healing Following Ischemic Osteonecrosis: An Experimental Investigation in Immature Pigs

BACKGROUND

Two operative procedures are currently advocated to stimulate the necrotic femoral head healing in children with Legg-Calve-Perthes disease: transphyseal neck-head tunneling (TNHT) and multiple epiphyseal drilling (MED). The purpose of this study was to compare the bone healing and physeal function after treatment with TNHT or MED in a piglet model of ischemic osteonecrosis.

METHODS

Eighteen piglets were induced with osteonecrosis by surgically placing a ligature tightly around the right femoral neck. One week later, the piglets were assigned to 1 of 3 treatment groups (n=6/group): (1) local nonweight bearing only (NWB), (2) TNHT plus NWB, or (3) MED plus NWB. The unoperated left femoral heads were used as normal controls. The animals were euthanized at 8 weeks after osteonecrosis induction. Histologic, histomorphometric, radiographic, microcomputed tomography (CT), and calcein-labeling assessments were performed. Statistical analysis included a 1-way ANOVA.

RESULTS

Micro-CT analyses showed higher femoral head bone volume in the MED group compared with the TNHT and the NWB groups (P<0.01). The MED group had a higher mean trabecular number (P<0.001) and new bone formation (P=0.001) based on calcein-labeling parameters compared with the TNHT and the NWB groups. In addition, the osteoclast number per bone surface was lower in the MED group compared with the NWB group (P=0.001). Histologic and micro-CT assessments of the proximal femoral physis revealed a larger physeal disruption at the site of physeal drilling in the TNHT group compared with the MED group. However, no significant differences in physeal elongation (P=0.61) and femoral neck length (P=0.31) were observed between the treatment groups.

CONCLUSIONS

MED produced a higher bone volume and stimulated greater bone formation than the TNHT or the NWB alone. Both procedures did not produce a significant physeal growth disturbance during the study period.

CLINICAL RELEVANCE

This preclinical study provides evidence that MED produces more favorable bone healing than the TNHT in a large animal model of Legg-Calve-Perthes disease.