Structural augmentation with biomaterial-loaded allograft threaded cage for the treatment of femoral head osteonecrosis

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.

Bone tissue engineering for treating osteonecrosis of the femoral head

Osteonecrosis of the femoral head (ONFH) is a devastating and complicated disease with an unclear etiology. Femoral head-preserving surgeries have been devoted to delaying and hindering the collapse of the femoral head since their introduction in the last century. However, the isolated femoral head-preserving surgeries cannot prevent the natural progression of ONFH, and the combination of autogenous or allogeneic bone grafting often leads to many undesired complications. To tackle this dilemma, bone tissue engineering has been widely developed to compensate for the deficiencies of these surgeries. During the last decades, great progress has been made in ingenious bone tissue engineering for ONFH treatment. Herein, we comprehensively summarize the state-of-the-art progress made in bone tissue engineering for ONFH treatment. The definition, classification, etiology, diagnosis, and current treatments of ONFH are first described. Then, the recent progress in the development of various bone-repairing biomaterials, including bioceramics, natural polymers, synthetic polymers, and metals, for treating ONFH is presented. Thereafter, regenerative therapies for ONFH treatment are also discussed. Finally, we give some personal insights on the current challenges of these therapeutic strategies in the clinic and the future development of bone tissue engineering for ONFH treatment.

Comparison of current treatment strategy for osteonecrosis of the femoral head from the perspective of cell therapy

Aims: The purpose of our study is to compare the effects of core decompression (CD) and bone grafting (BG) on osteonecrosis of the femoral head (ONFH). And evaluate the efficacy of CD based on cell therapy to provide guidance for the dose and number of cells. Methods: We searched PubMed, Embase, and the Cochrane Library between 2012 and 2022, with keywords including "osteonecrosis of the femoral head", "core decompression" and "bone grafting". We selected comparative studies of CD and BG, and the comparison of CD combined with bone marrow (BM) transplantation and CD alone. Changes in hip pain were assessed by VAS, hip function were assessed by HHS and WOMAC, and THA conversion rate was used as an evaluation tool for femoral head collapse. From these three aspects, the dose of bone marrow and the number of cells transplantation were subgroup analyzed. Results: Eleven studies were used to compare the efficacy of CD and BG. There was no significant difference in HHS, and the THA conversion rate of BG was significantly lower than that of CD. Thirteen CD studies based on cell therapy were included in the meta-analysis. Bone marrow aspiration concentrate (BMAC) can significantly improve VAS (mean difference (MD), 10.15; 95% confidence intervals (CI) 7.35 to 12.96, p < 0.00001) and reduce THA conversion rate (odds ratio (OR), 2.38; 95% CI 1.26 to 4.47, p = 0.007). Medium dose bone marrow fluid has a lower p-value in THA conversion rate. The p values of bone marrow mononuclear cells (BMMC) of 10⁹ magnitude in VAS score were lower. Conclusion: In general, there is no consensus on the use of BG in the treatment of ONFH. The enhancement of cell-based CD procedure shows promising results. Using 20 mL BMAC and 10⁹ magnitude BMMC is likely to achieve better results.

Lack of Conclusive Evidence of the Benefit of Biologic Augmentation in Core Decompression for Nontraumatic Osteonecrosis of the Femoral Head: A Systematic Review

PURPOSE

To assess whether biologic augmentation in addition to core decompression (CD), compared with CD alone, improves clinical and radiographic outcomes in the treatment of nontraumatic osteonecrosis of the femoral head (ONFH). Our hypothesis was that biologic augmentation would reduce the progression of osteonecrosis and therefore also the rate of conversion to total hip arthroplasty (THA).

METHODS

A systematic review was performed in accordance with the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) statement. Six databases were searched: Central, MEDLINE, Embase, Scopus, AMED, and Web of Science. Studies comparing outcomes of CD versus CD plus biologic augmentation (with or without structural augmentation), with a reported minimum level of evidence of III and ≥24 months of follow-up, were eligible. Procedural success was conceptualized as (1) avoidance of conversion to THA and (2) absence of radiographic disease progression. Risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklists. A quantitative analysis of heterogeneity was undertaken.

RESULTS

We included studies reporting on 560 hips in 484 patients. Biologic augmentation consisted of bone marrow stem cells in 10 studies, bone morphogenic protein in 2, and platelet-rich plasma in 1. Three studies used additional structural augmentation. The median maximum follow-up time was 45 months. Only 4 studies reported improvement in all clinical scores in the augmentation group. Seven studies observed a reduction in the rate of radiographic progression, and only 5 found reduced rates of conversion to THA when using augmentation. A high risk of bias and marked heterogeneity was found, with uncertainty about the study designs implemented, analytical approaches, and quality of reporting.

CONCLUSION

Current evidence is inconclusive regarding the benefit of biologic augmentation in CD for nontraumatic ONFH, because of inconsistent results with substantial heterogeneity and high risk of bias.

LEVEL OF EVIDENCE

III, systematic review of level I, II, and III studies.

Comparison of cell therapy and other novel adjunctive therapies combined with core decompression for the treatment of osteonecrosis of the femoral head : a systematic review and meta-analysis of 20 studies

Aims

The value of core decompression (CD) in the treatment of osteonecrosis of the femoral head (ONFH) remains controversial. We conducted a systematic review and meta-analysis to evaluate whether CD combined with other treatments could improve the clinical and radiological outcomes of ONFH patients compared with CD alone.

Methods

We searched the PubMed, Embase, Web of Science, and Cochrane Library databases until June 2020. All randomized controlled trials (RCTs) and clinical controlled trials (CCTs) comparing CD alone and CD combined with other measures (CD + cell therapy, CD + bone grafting, CD + porous tantalum rod, etc.) for the treatment of ONFH were considered eligible for inclusion. The primary outcomes of interest were Harris Hip Score (HHS), ONFH stage progression, structural failure (collapse) of the femoral head, and conversion to total hip arthroplasty (THA). The pooled data were analyzed using Review Manager 5.3 software.

Results

A total of 20 studies with 2,123 hips were included (CD alone = 768, CD combined with other treatments = 1,355). The combination of CD with other therapeutic interventions resulted in a higher HHS (mean difference (MD) = 6.46, 95% confidence interval (CI) = 2.10 to 10.83, p = 0.004) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (MD = −10.92, 95% CI = -21.41 to -4.03, p = 0.040) and a lower visual analogue scale (VAS) score (MD = −0.99, 95% CI = -1.56 to -0.42, p < 0.001) than CD alone. For the rates of disease stage progression, 91 (20%) progressed in the intervention group compared to 146 (36%) in the control group (odds ratio (OR) = 0.32, 95% CI = 0.16 to 0.64, p = 0.001). In addition, the intervention group had a more significant advantage in delaying femoral head progression to the collapsed stage (OR = 0.32, 95% CI = 0.17 to 0.61, p < 0.001) and reducing the odds of conversion to THA (OR = 0.35, 95% CI = 0.23 to 0.55, p < 0.001) compared to the control group. There were no serious adverse events in either group. Subgroup analysis showed that the addition of cell therapy significantly improved clinical and radiological outcomes compared to CD alone, and this approach appeared to be more effective than other therapies, particularly in precollapse (stage I to II) ONFH patients.

Conclusion

There was marked heterogeneity in the studies. There is a trend towards improved clinical outcomes with the addition of stem cell therapy to CD.

Cite this article: Bone Joint Res 2021;10(7):445–458.

Multiple drilling is not effective in reducing the rate of conversion to Total hip Arthroplasty in early-stage nontraumatic osteonecrosis of the femoral head: a case-control comparative study with a natural course

BACKGROUND

To determine whether multiple drilling is effective in postponing the need for total hip arthroplasty (THA) in early-stage nontraumatic osteonecrosis of the femoral head (ONFH).

METHODS

We identified 514 patients who were diagnosed with early-stage ONFH between January 2008 and December 2018. One hundred ninety-six patients underwent multiple drilling, and 318 patients had a natural course of progression. One hundred fifty-nine patients were selected for each group after case-control matching for preoperative demographics and modified Ficat and Arlet stage. The rates of THA conversion were compared. We also performed Cox regression to identify risk factors associated with THA conversion in patients who underwent multiple drilling.

RESULTS

Kaplan-Meier survivorship with an endpoint of THA for nontraumatic reasons were not significantly different between the multiple drilling group (75.6, 95% confidence interval 67.8-83.4%) and the natural course group (72.2, 95% confidence interval 64.8-79.6%) at 5 years (log-rank, P = .191). In the Cox regression model, a larger extent of necrotic lesion, bone marrow edema (BME), and higher postoperative work intensity significantly increased the risk of THA conversion (P < .05). Among patients treated with autogenous bone grafting, there was a lower risk of failure in patients with necrotic lesion less than 15% (P < .05).

CONCLUSIONS

Multiple drilling is not effective in reducing the rate of THA conversion in early-stage nontraumatic ONFH. The risk of conversion to THA after multiple drilling is increased by a larger extent of necrotic lesion, presence of BME, and higher postoperative work intensity in patients with early-stage ONFH.

TRIAL REGISTRATION

The trial was registered in the Chinese Clinical Trial Registry ( ChiCTR2000035180 ) dated 2 August 2020.

Clinical study on minimally invasive treatment of femoral head necrosis with two different bone graft materials

PURPOSE

To investigate the clinical efficacy and safety of two different bone graft materials in the minimally invasive treatment of early and middle stage femoral head necrosis.

METHODS

A total of 36 patients (39 hips) with avascular necrosis of the femoral head were divided into autologous iliac bone group (ABG) and bioceramics bone group (BBG). Both groups were treated with minimally invasive thick channel decompression to remove dead bone of femoral head. The ABG was treated with autologous iliac bone graft, and BBG was treated with β-tricalcium phosphate bone graft. The operation time, intra-operative blood loss, haemoglobin, and haematocrit were recorded at three and seven days post-operatively. The clinical efficacy and safety were evaluated by Harris score and imaging examination before, and after treatment and at follow-up stages.

RESULTS

The patients were followed up for 24 to 45 (average 29.27 ± 3.56) months. The BBG was significantly better than the ABG in terms of operation time, intra-operative blood loss, haemoglobin, and haematocrit value at three days. Compared with pre-operative, the Harris score of the two groups at 12 months after operation was significantly improved. The Harris score and the imaging evaluation of the last follow-up exhibited significantly better outcome in BBG than those of ABG.

CONCLUSION

Bioceramics and autologous iliac bone minimally invasive treatment of early and medium-term femoral head necrosis exhibited satisfactory clinical efficacy in the short and medium-term. The bioceramics graft materials have the advantages of reducing trauma, bleeding, operation time, and quick recovery of post-operative functions.

Guidelines for clinical diagnosis and treatment of osteonecrosis of the femoral head in adults (2019 version)

Osteonecrosis of the femoral head (ONFH) is a common and refractory disease in orthopaedic clinics. The number of patients with ONFH is increasing worldwide every year. There are an estimated 8.12 million patients with nontraumatic osteonecrosis in China alone. Treatment of nontraumatic osteonecrosis has always been a clinical challenge for orthopaedic surgeons. To further standardize diagnosis and treatment of ONFH, these guidelines provide not only basic diagnosis, treatment, and evaluation systems for ONFH but also expert advice and standards in many aspects, including epidemiology, aetiology, diagnostic criteria, pathological staging, prevention and treatment options, and postoperative rehabilitation. The aetiological factors of ONFH can currently be divided into two major categories: traumatic and nontraumatic; however, the specific pathological mechanism of ONFH is not completely clear. Currently, the staging system of ONFH formulated by the Association Research Circulation Osseous is widely used in clinical practice. Based on the changes in the intraosseous blood supply at different stages, the corresponding nonsurgical and surgical treatments are recommended, and when there are risk factors for possible ONFH, certain preventive measures to avoid the occurrence of osteonecrosis are recommended. These guidelines provide brief classification criteria and treatment regimen for osteonecrosis. Specification of the aetiology, treatment plan based on comprehensive consideration of the different stages of osteonecrosis, hip function, age, and occupation of the patients are important steps in diagnosis and developing treatment strategies.

TRANSLATIONAL POTENTIAL OF THIS ARTICLE

New advances in the epidemiology, etiology, pathophysiology, imaging, diagnosis and treatment of ONFH have been renewed in this revision. This guideline can be used for reference by orthopedic professionals and researchers, and for standardized diagnosis and treatment management under the clinical guidance, which is conducive to the prevention, treatment and further research of ONFH, improving the diagnosis and treatment level, making patients' symptoms under good control, and improving their quality of life.

Mid-term outcomes of arthroscopic-assisted Core decompression of Precollapse osteonecrosis of femoral head-minimum of 5 year follow-up

Background

Osteonecrosis of the femoral head (ONFH) is a progressive disease that leads to collapse and the development of secondary arthritis. The preferred management of ONFH remains controversial. Arthroscopic-assisted management of ONFH is a new and evolving approach for hip preservation. We hypothesis that arthroscopy is able to improve ONFH outcomes by achieving accurate and minimally invasive decompression while successfully addressing concomitant intraarticular pathologies resulting in reliable mid-term outcomes.

Methods

This was a retrospective cohort analysis. All patients had atraumatic ONFH with a precollapse lesion and a minimum follow-up of 5 years.

Results

A total cohort of 11 hips (8 patients) was identified. The mean patient follow-up was 7 years ±1.48 years (range, 64—118 months). The Ficat-Alret classification found on preoperative imaging was Stage I—3 (27.2%), IIa—4 (36.4%), and IIb—4 (36.4%) hips. Four (36.4%) hips experienced mechanical issues, including locking, catching, and buckling. The most common concomitant pathology addressed at the time of arthroscopy, was labral repair/debridement—8 (73%), followed by microfracture—7 (64%). At final follow-up, 6 hips (54.5%) had not converted to THA. Upon further stratification, Stage I—100%, Stage IIa—75%, for a combined 87%, had not converted to THA, in contrast, 100% of hips categorized as Stage IIb had converted to THA. Ficat-Alret staging, especially Stage IIb, was significantly associated with conversion to THA. (p-value = 0.015) There were 0% major or minor complications.

Conclusions

To our knowledge, this is the longest reported follow-up of arthroscopic-assisted management of ONFH. Arthroscopic-assisted management is a promising surgical approach that provides safe, accurate, and minimally invasive decompression, resulting in reliable results with an acceptable conversion rate to THA.

Level of evidence

Level IV, Case Series.

Pericollapse Stage of Osteonecrosis of the Femoral Head: A Last Chance for Joint Preservation

Objective:

To propose a new definition of the pericollapse stage of osteonecrosis of the femoral head (ONFH) and review its significance in disease diagnosis and treatment selection.

Data Sources:

A search for eligible studies was conducted in three electronic databases including PubMed, Cochrane Library, and Embase up to August 10, 2018, using the following keywords: “osteonecrosis”, “prognosis”, and “treatment”.

Study Selection:

Investigations appraising the clinical signs, symptoms, and imaging manifestations in different stages of ONFH were included. Articles evaluating the prognosis of various joint-preserving procedures were also reviewed.

Results:

The pericollapse stage refers to a continuous period in the development of ONFH from the occurrence of subchondral fracture to early collapse (<2 mm), possessing specific imaging features that mainly consist of bone marrow edema and joint effusion on magnetic resonance imaging (MRI), crescent signs on X-ray films, and clinical manifestations such as the sudden worsening of hip pain. Accumulating evidence has indicated that these findings may be secondary to the changes after subchondral fractures. Of note, computed tomography provides more information for identifying possible subchondral fractures than does MRI and serves as the most sensitive tool for grading the pericollapse lesion stage. The pericollapse stage may indicate a high possibility of progressive disease but also demonstrates satisfactory long- and medium-term outcomes for joint-preserving techniques. In fact, if the articular surface subsides more than 2 mm, total hip arthroplasty is preferable.

Conclusions:

The pericollapse stage with distinct clinical and imaging characteristics provides a last good opportunity for the use of joint-preserving techniques. It is necessary to separate the pericollapse stage as an independent state in evaluating the natural progression of ONFH and selecting an appropriate treatment regimen.

Lantern-shaped screw loaded with autologous bone for treating osteonecrosis of the femoral head

Background

Treatment for osteonecrosis of the femoral head (ONFH) in young individuals remains controversial. We developed a lantern-shaped screw, which was designed to provide mechanical support for the femoral head to prevent its collapse, for the treatment of ONFH. The purpose of this study was to investigate the efficacy and safety of the lantern-shaped screw loaded with autologous bone for the treatment of pre-collapse stages of ONFH.

Methods

Thirty-two patients were randomly divided into two groups: the lantern-shaped screw group (core decompression and lantern-shaped screw loaded with autogenous bone) and the control group (core decompression and autogenous bone graft). During 36 months follow-up after surgery, treatment results in patients were assessed by X-ray and computed tomography (CT) scanning as well as functional recovery Harris hip score (HHS).

Results

Successful clinical results were achieved in 15 of 16 hips (94%) in the lantern-shaped screw group compared with 10 of 16 hips (63%) in the control group (p = 0.0325). Successful radiological results were achieved in 14 of 16 hips (88%) in the lantern-shaped screw group compared with 8 of 16 hips (50%) in the control group (P = 0.0221).

Conclusion

The lantern-shaped screw loaded with autologous bone for the treatment of pre-collapse stages of ONFH is effective and results in preventing progression of ONFH and reducing the risk of femoral head collapse.

Trial registration

The trial registration number: ChiCTR-TRC-13004078 (retrospectively registered at 2013-11-28).

[Strategy and discussion of hip joint preserving surgery treatments for adult osteonecrosis of the femoral head]

As a common disease in orthopedics, osteonecrosis of the femoral head (ONFH) frequently occurs among young and middle-aged people. Hip joint preserving surgery has attracted more and more attention due to the fact that artificial joint prosthesis has a certain useful life and the rate of hip joint revision is high and the higher risk of many complications. There are a large number of operative methods for preserving hip joint in clinical practice without definitive effectiveness. How to choose appropriate surgical methods at the right time is also a continuous understanding. The pathological process of necrosis of the femur helps to choose the choice of the femoral head necrosis for the treatment of hip operation. Core decompression and impaction bone grafting with simple operative methods can relieve internal pressure of femoral head and pain symptoms, but they cannot remove necrotic bone completely. Hence, they are only used for ONFH in the early stage. Vascularized bone transplantation can fill defects of the former, as it can not only completely remove necrotic bone, but also provide bone graft with nourishing vessels for femoral head, being beneficial to reconstruct the bone structure of femoral head. Subsequently, the application of tantalum rod can provide mechanical support for femoral head to prevent the collapse of femoral head. Hip joint preserving surgery, in recent years, has been performed increasingly, and has obtained improvement in clinical effects. The multiple combination of a variety of its operative methods provides more effective treatments for ONFH. It is an essential notion that hip joint preserving surgery, however with any operative method, should as far as possible select a surgical plan with little trauma, simple methods, and little injury of hip joint bone structure based on ensuring the effectiveness.

Chinese Guideline for the Diagnosis and Treatment of Osteonecrosis of the Femoral Head in Adults

The treatment of adult osteonecrosis of the femoral head (ONFH), with 8.12 million patients in China, remains a challenge to surgeons. To standardize and improve the efficacy of the treatment of ONFH, Chinese specialists updated the experts' suggestions in March 2015, and an experts' consensus was given to provide a current basis for the diagnosis, treatment and evaluation of ONFH. The current guideline provides recommendations for ONFH with respect to epidemiology, etiology, diagnostic criteria, differential diagnosis, staging, treatment, as well as rehabilitation. Risk factors of non-traumatic ONFH include corticosteroid use, alcohol abuse, dysbarism, sickle cell disease and autoimmune disease and others, but the etiology remains unclear. The Association Research Circulation Osseous (ARCO) staging system, including plain radiograph, magnetic resonance imaging, radionuclide examination, and histological findings, is frequently used in staging ONFH. A staging and classification system was proposed by Chinese scholars in recent years. The major differential diagnoses include mid-late term osteoarthritis, transient osteoporosis, and subchondral insufficiency fracture. Management alternatives for ONFH consist of non-operative treatment and operative treatment. Core decompression is currently the most common procedure used in the early stages of ONFH. Vascularized bone grafting is the recommended treatment for ARCO early stage III ONFH. This guideline gives a brief account of principles for selection of treatment for ONFH, and stage, classification, volume of necrosis, joint function, age of the patient, patient occupation, and other factors should be taken into consideration.

An evidence-based guide to the treatment of osteonecrosis of the femoral head

Non-traumatic osteonecrosis of the femoral head is a potentially devastating condition, the prevalence of which is increasing. Many joint-preserving forms of treatment, both medical and surgical, have been developed in an attempt to slow or reverse its progression, as it usually affects young patients. However, it is important to evaluate the best evidence that is available for the many forms of treatment considering the variation in the demographics of the patients, the methodology and the outcomes in the studies that have been published, so that it can be used effectively. The purpose of this review, therefore, was to provide an up-to-date, evidence-based guide to the management, both non-operative and operative, of non-traumatic osteonecrosis of the femoral head. Cite this article: Bone Joint J 2017;99-B:1267-79.

Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today? A Ten-Year Update

➤ Although multiple theories have been proposed, no one pathophysiologic mechanism has been identified as the etiology for the development of osteonecrosis of the femoral head. However, the basic mechanism involves impaired circulation to a specific area that ultimately becomes necrotic.➤ A variety of nonoperative treatment regimens have been evaluated for the treatment of precollapse disease, with varying success. Prospective, multicenter, randomized trials are needed to evaluate the efficacy of these regimens in altering the natural history of the disease.➤ Joint-preserving procedures are indicated in the treatment of precollapse disease, with several studies showing successful outcomes at mid-term and long-term follow-up.➤ Studies of total joint arthroplasty, once femoral head collapse is present, have described excellent outcomes at greater than ten years of follow-up, which is a major advance and has led to a paradigm shift in treating these patients.➤ The results of hemiresurfacing and total resurfacing arthroplasty have been suboptimal, and these procedures have restricted indications in patients with osteonecrosis of the femoral head.

A current review of non-vascularized bone grafting in osteonecrosis of the femoral head

Over the past three decades, non-vascularized bone grafts have been demonstrated to be viable treatments for pre- and early post-collapse osteonecrosis of the femoral head; however, there are limited reviews on this topic. Therefore, the purposes of this review are to (1) provide a summary of the different surgical techniques and their respective clinical outcomes and (2) evaluate new adjunct therapies. Originally, non-vascularized bone grafting was performed using the Phemister technique with varying results. More recently, newer techniques such as the lightbulb and trapdoor are used to place non-vascularized bone grafts with excellent results. The addition of various biological agents has demonstrated positive results; however, further studies are needed to confirm the best appropriate indications and to elucidate long-term results.

Combination treatment of biomechanical support and targeted intra-arterial infusion of peripheral blood stem cells mobilized by granulocyte-colony stimulating factor for the osteonecrosis of the femoral head: a randomized controlled clinical trial

The objective of this study was to determine the benefits of combination treatment with mechanical support and targeted intra-arterial infusion of peripheral blood stem cells (PBSCs) mobilized by granulocyte-colony stimulating factor (G-CSF) via the medial circumflex femoral artery on the progression of osteonecrosis of the femoral head (ONFH). Fifty-five patients (89 hips) with early and intermediate stage ONFH were recruited and randomly assigned to combination treatment or mechanical support treatment (control group). All hips received mechanical support treatment (porous tantalum rod implantation). Then, hips in the combination treatment group were performed targeted intra-arterial infusion of PBSCs. At each follow-up, Harris hip score (HHS) and Association Research Circulation Osseous (ARCO) classification were used to evaluate the symptoms and progression of osteonecrosis. Total hip arthroplasty (THA) was assessed as an endpoint at each follow-up. At 36 months, 9 of the 41 hips (21.95%) in the control group progressed to clinical failure and underwent THA whereas only 3 of the 48 hips (6.25%) in the combination treatment group required THA (p = 0.031). Kaplan-Meier survival analysis showed a significant difference in the survival time between the two groups (log-rank test; p = 0.025). Compared to the control group, combination treatment significantly improved the HHS at 36 months (p = 0.003). At the final follow-up examination, radiological progression was noted in 13 of 41 hips (31.71%) for the control group, but in only 4 of 48 hips (8.33%) for the combination treatment group (p = 0.005). The overall collapse rates were 15.15% (5/33 hips) and 8.11% (3/37 hips) in the control and combination treatment groups, respectively. Targeted intra-arterial infusion of PBSCs is capable of enhancing the efficacy of biomechanical support in the treatment of ONFH. This clinical trial confirmed that the combination treatment might be a safe and feasible choice for the treatment of early or intermediate stages of ONFH.

Unilateral free vascularized fibula shared for the treatment of bilateral osteonecrosis of the femoral head

Between June 2007 and May 2008, 21 patients with bilateral osteonecrosis of the femoral head were surgically treated with implantation of free vascularized fibula obtained from the unilateral donor site. All patients were followed up clinically and radiographically for an average of 3.5 years. The evaluation included operative duration, blood loss, Harris hip score, incidence of complications, and radiological examinations. The time for fibular harvesting was 20min on average. Total operative duration was 100-240min, with an average of 150min. Blood loss averaged 300ml. All transplanted fibula integrated well to the femoral head 3.5years postoperatively with no severe complications observed. The results revealed that unilateral free vascularized fibula is effective for the treatment of bilateral osteonecrosis of the femoral head.

Which factors influence preservation of the osteonecrotic femoral head?

BACKGROUND

Although surgeons use many procedures to preserve the femoral head in patients with hip osteonecrosis, there is no consensus regarding the best procedure.

QUESTIONS/PURPOSES

We raised the following questions: (1) Is one surgical treatment preferred based on published data? (2) What are the rates of radiographic progression or conversion to THA after treatment of pre- and postcollapse hips? (3) Does lesion size in the femoral head influence progression? And (4) does the extent of involvement of the weightbearing surface of the femoral head influence outcome?

METHODS

We searched MEDLINE and Scopus for articles published between 1998 and 2010. We included only articles assessing an operative intervention for hip osteonecrosis and having a level of evidence of I to IV. We included 54 of the 488 reviewed manuscripts.

RESULTS

No procedure was superior to others. In pre- and postcollapse hips, 264 of 864 hips (31%) and 419 of 850 hips (49%), respectively, exhibited radiographic disease progression. There were lower failure rates when the lesion involved less than 15% of the femoral head or had a necrotic angle of less than 200° (14%-25%) and when the osteonecrotic lesion involved only the medial 1/3 of the weightbearing surface (4.6%).

CONCLUSIONS

The best treatment of precollapse lesions is difficult to determine due to the limitations of the available literature. However, the data suggest operative intervention prevents collapse of small lesions of the femoral head or when there is a limited amount of the weightbearing surface involved. Patients with head collapse have a high progression rate after a femoral head-saving procedure.