Analysis of Cell Therapies Used in Clinical Trials for the Treatment of Osteonecrosis of the Femoral Head: A Systematic Review of the Literature

Regenerative therapy in geriatric patients with low back pain

Low back pain (LBP) is a prevalent and debilitating condition, particularly among older adults, with degenerative spinal disease being a major contributor. Regenerative therapy, which aims to repair and regenerate damaged spinal structures, has shown promise in providing long-term pain relief and functional improvement. This review focuses on the application and efficacy of regenerative therapies such as mesenchymal stem cells, platelet-rich plasma, and atelocollagen in older patients with LBP. Despite the potential benefits, there is a notable scarcity of studies specifically targeting the older population, and those available often have small sample sizes and limited age-related analyses. Our findings underscore the need for more comprehensive and well-designed clinical trials to evaluate the effectiveness of these therapies in older patients. Future research should prioritize larger age-specific studies to establish regenerative therapy as a viable and effective treatment option for LBP in the aging population.

Stem cell therapy combined with core decompression versus core decompression alone in the treatment of avascular necrosis of the femoral head: a systematic review and meta-analysis

INTRODUCTION

Accumulated clinical trials had been focused on stem cell therapy in combination of core decompression (CD) in the treatment of avascular necrosis of the femoral head (ANFH). Nonetheless, the results were inconclusive. Here, we performed a systematic review and meta-analysis of previous randomized controlled trials (RCTs) and retrospective studies to assess whether combined stem cell augmentation with CD improved the outcomes of ANFH compared with CD alone.

METHODS

The current study included 11 RCTs and 7 retrospective studies reporting the clinical outcomes of a total of 916 patients and 1257 hips. 557 and 700 hips received CD and CD plus stem cell therapy, respectively. To compare CD with CD plus stem cell therapy, we examined the clinical evaluating scores, the occurrence of the femoral head, radiologic progression and conversion to total hip arthroplasty (THA).

RESULTS

Only 10 studies reported significantly greater improvement in hip functions while combining stem cell procedure with CD. The pooled results in subgroup analysis indicated that stem cell group had a lower collapse rate on a mid-term basis (P = 0.001), when combined with mechanical support (P < 0.00001), and with extracted stem cells (P = 0.0002). Likewise, stem cell group had a lower radiographic progression rate at 2- to 5-year follow-up [P = 0.003], when combined with structural grafting (P < 0.00001), and with extracted stem cells (P = 0.004). Stem cell therapy resulted in an overall lower THA conversion rate (P < 0.0001) except that at a follow-up longer than 5 years.

CONCLUSION

Stem cell therapy combined with core decompression was more effective in preventing collapse, radiographic progression and conversion to THA. Trial Registration The current protocol has been registered in PROSPERO with the registration number: CRD42023417248.

Trends in Surgical Management of Osteonecrosis of the Femoral Head: A 2010 to 2020 Nationwide Study

BACKGROUND

The incidence of osteonecrosis of the femoral head (ONFH) is estimated at more than 20,000 patients annually in the US. Our study aimed to provide a 10-year analysis: 1) evaluating total operative procedures with rates normalized to the population; 2) determining trends of arthroplasty versus joint-preserving procedures; and 3) quantifying specific operative techniques in patients <50 versus >50 years of age.

METHODS

A total of 64,739 patients who were diagnosed with ONFH and underwent hip surgery were identified from a nationwide database between 2010 and 2020. The percentage of patients managed by each operative procedure was calculated and normalized to the overall population annually. Patients were grouped into joint-preserving versus non-joint-preserving (arthroplasty) procedures, and divided by age under/over 50 years. Linear regression modeling was performed to evaluate trends/differences in procedural volume by year.

RESULTS

The number of operative procedures to treat ONFH has relatively declined from 2010 to 2020. The relative proportion of joint-preserving procedures increased (8.6% to 11.2%) during this time period. There were significantly more joint-preserving procedures in patients aged <50 years relative to >50 years (15.3% versus 2.7%, P < .001). Overall, THA was the most common procedure (57,033;88.1%) relative to hemiarthroplasty (3,875;6.0%), core decompression (2,730;4.2%), bone graft (467;0.7%), and osteotomy (257;0.4%).

CONCLUSION

Surgical management of patients who have ONFH remains predominantly arthroplasty procedures (94% overall). Our findings suggest an increase in joint-preserving procedures, particularly core decompression, in patients <50 years (15.3%). Our findings provide insight into surgical management trends for ONFH, and suggest opportunities for joint-preserving procedures.

Regenerative medicine for the treatment of chronic low back pain: a narrative review

Low back pain (LBP) is a common and important clinical problem. In addition to pain, patients are also affected by personal, social, and economic burdens. Intervertebral disc (IVD) degeneration is a common cause of LBP, further increasing the patient's morbidity and medical costs. The limitations of current treatment strategies for long-term pain relief mean that increasing attention has been paid to regenerative medicine. We carried out a narrative review to explore the roles of four types of regenerative medicine for treating LBP: marrow-derived stem cells, growth factors, platelet-rich plasma, and prolotherapy. Marrow-derived stem cells are regarded as an ideal cell source for IVD regeneration. Growth factors may stimulate the synthesis of extracellular matrix and attenuate or reverse the degenerative process in IVD, while platelet-rich plasma, which contains multiple growth factors, is thought to be a promising alternative therapy for IVD degeneration. Prolotherapy can initiate the body's inflammatory healing response to repair injured joints and connective tissues. This review summarizes the mechanisms, in vitro and in vivo studies, and clinical applications of these four types of regenerative medicine in patients with LBP.

The role of immune cells in modulating chronic inflammation and osteonecrosis

Osteonecrosis occurs when, under continuous stimulation by adverse factors such as glucocorticoids or alcohol, the death of local bone and marrow cells leads to abnormal osteoimmune function. This creates a chronic inflammatory microenvironment, which interferes with bone regeneration and repair. In a variety of bone tissue diseases, innate immune cells and adaptive immune cells interact with bone cells, and their effects on bone metabolic homeostasis have attracted more and more attention, thus developing into a new discipline - osteoimmunology. Immune cells are the most important regulator of inflammation, and osteoimmune disorder may be an important cause of osteonecrosis. Elucidating the chronic inflammatory microenvironment regulated by abnormal osteoimmune may help develop potential treatments for osteonecrosis. This review summarizes the inflammatory regulation of bone immunity in osteonecrosis, explains the pathophysiological mechanism of osteonecrosis from the perspective of osteoimmunology, and provides new ideas for the treatment of osteonecrosis.

A Cost-Effective Novel Surgical Technique of Core Decompression with Bone Marrow Aspiration Concentrate: A Preliminary Cadaveric Study

Introduction

Core decompression supplemented by stem cell incorporation is an upcoming field of research in avascular necrosis of the femoral head. Plugging the canal to avoid loss of the concentrate injected has been recognized as a crucial step to improve the efficacy of the procedure. We describe a new surgical technique that results in native bone plug formation and eliminates the need for any additional blocker.

Methodology

This pilot study was performed on 4 cadaveric proximal femurs. The standard technique was used for core decompression and bone marrow aspirate concentrate (BMAC) injection. Additionally, two more tracts were drilled, superolateral, and inferomedial to the primary tract.

Results

No leakage of the radiopaque dye was observed from the entry point of the primary tract, ensuring its complete blockage in all 4 cadaveric proximal femurs. This was confirmed by sectioning the femur specimens which manifested bone plug formation at the confluence of the three tracts.

Conclusion

Our technique is a unique and economical method of preventing leakage of BMAC through the entry point in the proximal femoral metaphysis. This may not only benefit patients but can also provide the groundwork for further research in this field.

Pre- and intraoperative decision-making challenges in hip arthroscopy for femoroacetabular impingement

There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI. Cite this article: Bone Joint J 2022;104-B(5):532-540.

The Dynamic Feature of Macrophage M1/M2 Imbalance Facilitates the Progression of Non-Traumatic Osteonecrosis of the Femoral Head

Non-traumatic osteonecrosis of the femoral head (NONFH) remains a common refractory disease with poorly understood pathogenesis. Macrophage M1/M2 imbalance and chronic inflammatory microenvironment have been suggested to be closely related to osteonecrosis. Here we describe direct visual evidence for the involvement of dynamic changes in macrophages and the chronic inflammatory microenvironment in human NONFH. Osteonecrosis induces inflammatory responses and macrophage enrichment in the reparative area, and the number of inflammatory cells and macrophages falls during progressive-to end-stage NONFH. Multiplex immunohistochemistry demonstrated that macrophage M1/M2 ratio increased from 3 to 10 during progressive-to end-stage. During the progressive-stage, new blood vessels formed in the reparative area, M2 macrophages accumulated in perivascular (M1/M2 ratio ∼0.05), while M1 macrophages were enriched in avascular areas (M1/M2 ratio ∼12). Furthermore, inflammatory cytokines were detected in synovial fluid and plasma using cytometric bead arrays. Interleukin (IL)-6 and IL-1β were persistently enriched in synovial fluid compared to plasma in patients with NONFH, and this difference was confirmed by immunohistochemistry staining. However, only IL-6 levels in plasma were higher in patients with progressive-stage NONFH than in osteoarthritis. Moreover, fibrosis tissues were observed in the necrotic area in progressive-stage and end-stage NONFH based on Sirius Red staining. Together, these findings indicate that macrophage M1/M2 imbalance facilitates the progression of NONFH, a chronic inflammatory disease characterized by chronic inflammation, osteonecrosis and tissue fibrosis in the local lesion. Inhibiting inflammation, promoting the resolution of inflammation, switching macrophages to an M2 phenotype, or inhibiting their adoption of an M1 phenotype may be useful therapeutic strategies against NONFH.

Emerging Biological Treatment Methods for Ankle Joint and Soft Tissue Conditions: Clinical Applications as Alternative or Adjuvant

In the past 2 decades, there has been a rapid expansion of clinical studies investigating the safety and efficacy of biological treatment methods for a wide range of diseases. These biological treatment methods increasingly are used in clinical practice based on limited available evidence. This article provides an overview of evidence on biological treatment methods for foot and ankle pathologies, including ankle osteoarthritis, osteochondral lesions of the talus, and Achilles tendinopathy.

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

INTRODUCTION

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

HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III; retrospective case-control study.

Mesenchymal stromal cells for osteonecrosis

Osteonecrosis (ON) is an acquired debilitating skeletal disorder, which is caused by a multitude of traumatic and non-traumatic etiological factors. Vascular damage, mechanical stress and increased intraosseous pressure have been discussed as contributors to ON. The optimal treatment of ON remains to be determined, since the current gold standard, core decompression, is insufficiently effective. Specific properties of mesenchymal stromal cells (MSCs) provide the rationale for their assessment in advanced stages of ON: Osteoinductive potential has been demonstrated and MSC preparations of suitable quality for use as medicinal products have been developed. Here we review the scant information on the use of allogeneic or autologous MSCs in advanced ON as well as potentially supportive data from pre-clinical studies with autologous bone marrow mononuclear cells (auto BM-MNCs), which have been studied quite extensively and the presumed therapeutic effect of which was attributed to the rare MSCs contained in these cell products. Outcomes in clinical trials with MSCs and auto-BM-MNCs remain preliminary and non-definitive, at best promising, with respect to their pharmacological effect. Clearly, though, the application of any of these cell therapies was technically feasible and safe in that it was associated with low complication rates. The heterogeneity of cell type and source, study protocols, cell manufacturing, cell properties, cell doses and surgical techniques might contribute to inconsistent results.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

10-year follow-up results of the prospective, double-blinded, randomized, controlled study on autologous bone marrow buffy coat grafting combined with core decompression in patients with avascular necrosis of the femoral head

Background

Avascular necrosis of the femoral head (ANFH) is a severely disabling disease of the hip. Several clinical trials have shown promising outcomes on the use of mesenchymal stem cells for the treatment of ANFH, but long-term clinical assessments are lacking. Previously, we reported the 2-year follow-up results of a prospective, double-blinded, randomized, controlled study on autologous bone marrow buffy coat grafting combined with core decompression in patients with ANFH. Here, we report the 10-year follow-up results of this study.

Methods

We recruited 43 (53 hips) patients from 2009 to 2010. The hips were randomly allocated to code decompression (CD) with or without bone marrow buffy coat (BBC) grafting. Participants underwent follow-up at 24, 60, and 120 months postoperatively. The visual analogue scale (VAS), Lequesne algofunctional index, and Western Ontario and McMaster Universities Arthritis Index (WOMAC) osteoarthritis scores were recorded. Survival rate analysis and prognostic factor analysis were performed. The endpoint was defined as progression to Ficat stage IV or conversion to hip arthroplasty.

Results

A total of 31 patients (41 hips) were included in the final analysis. The CD + BBC group had better subjective assessment scores than the CD group. The average survival times were 102.3 months and 78.1 months in the CD + BBC group and CD group, respectively (log-rank test, P = 0.029). In the univariate Cox proportional hazards regression model, age [hazard ratio (HR) = 1.079, P = 0.047] and preoperative Ficat stage (HR = 3.283, P = 0.028) indicated a high risk for progression, while the use of BBC (HR = 0.332, P = 0.042) indicated a low risk. Preoperative Ficat stage III was isolated as an independent risk factor for clinical failure in the multivariate model (HR = 3.743, P = 0.018).

Conclusion

The 10-year follow-up results of this prospective, double-blinded, randomized, controlled study showed that the use of autologous BBC in combination with core decompression was more effective than the use of core decompression alone.

Trial registration

ClinicalTrials.gov, NCT01613612. Registered on 13 December 2011—retrospectively registered

Automated in-process characterization and selection of cell-clones for quality and efficient cell manufacturing

Delivery of safe, effective and reliable cellular therapies, whether based on mesenchymal stromal cells (MSCs) or induced pluripotent stem cells (iPSCs), demand standardization of cell culture protocols. There is a need to develop automation platform that enables the users to generate culture expanded human cell populations that improves the quality and reduces batch-to-batch variation with respect to biological potential. Cell X™ robot was designed to address these current challenges in the cell fabrication industry. It utilizes non-invasive large field of view quantitative image analysis to guide an automated process of targeted "biopsy" (cells or media), "picking" (selection) of desired cells or colonies, or "weeding" (removal) of undesired cells, thus providing an unprecedented ability to acquire quantitative measurement in a complex heterogeneous cell environment "in process" and then to act on those measurements to define highly reproducible methods for cell and colony "management" based on application specific critical quality attributes to improve the quality of the manufactured cell lines and cell products.

Ethical and Practical Considerations for Integrating Cellular ("Stem Cell") Therapy into Clinical Practice

PURPOSE OF REVIEW

Cellular therapies, also known as "stem cell" interventions (SCI), have undergone a rapid popularization in the USA and worldwide. The current review aimed at outlining (1) the ethical challenges facing the implementation of SCI; (2) the applicability of the currently available SCI; and (3) recommendations to achieve ethical, well-regulated incorporation of SCI in the clinical setting.

RECENT FINDINGS

Concerns regarding the inadequate characterization, poor adverse effects disclosure, and unorthodox, often inappropriate, market practices have engendered a genuine concern regarding the SCI compliance with ethical standards. Six instances of litigation on the basis of misrepresentation or inappropriate informed consent were recorded between 2012 and 2018. Such concerns have been furthered by the loopholes in the regulatory aspect governing the use of SCI coupled with the unclear literature-reported efficacy and diverse spectrum of profess indications. Similarly, the application of SCI in the clinical field is yet to prove its value. The uncertain efficacy, coupled with obscure true-costs of utilization, impedes a value-based assessment. A multidisciplinary approach involving legislative and medical professional societies should continue to advance regulations that govern SCI. A well-regulated system that allows for the ethical integration of SCI with appositely evidenced-based described benefits and risks should be sought.

Autologous grafts in the treatment of avascular osteonecrosis of the femoral head

Background:

Osteonecrosis of the femoral head (ONFH) is a frequent orthopedic disease leading to destruction of the hip joint and disabling arthritis. Several procedures have been developed to treat the joint deterioration in case of osteonecrosis, trying to avoid or delay an intervention of total hip replacement, especially in young patients. The aim of this study was to analyze the use of autologous bone micrografts derived from cancellous bone in the management of avascular ONFH. The treatment described was implemented using the Rigenera® protocol to obtain autologous micrografts: small fragments of cancellous bone collected by femoral neck, disaggregated and injected in the necrotic area using an empty screw.

Materials and methods:

Twenty adult patients affected by avascular ONFH were enrolled in this study; all patients reported a preoperative intermittent coxo-arthrosis and limited function of intra and extra rotation of the hip. Inclusion criteria were an Oxford Hip Score between (OHS) 20 and 39, a Harris hip score (HHS) showing pre-operative poor results (lower than 70 points) and a stage II-IIIA and IIIB according with the classification proposed by the Association Research Circulation Osseous (ARCO).

Results:

Using an MRI evaluation, after six months, the authors observed a complete regression of necrotic area and the restoration of osseous structure. Clinical outcome has been evaluated at 6-12 and 24 months follow-up. At the final F.U. the HHS rised from poor to good results (mean value at final F.U of 84) while the OHS improved significantly already after 21 days from micrografts injection (mean 35.4 ± 7.5) with an increasing trend until to two-year final FU (mean 37.4 ± 9.5). The full recovery of daily and mild sport activities was reached after 20 and 90 days from intervention, respectively.

Conclusion:

The results of this study are suggestive for a new approach in the treatment of avascular ONFH assuming a process of bone regeneration based on a dual mechanism of action, biological and mechanical, induced by micrografts and injected using an empty screw as vehicle. (www.actabiomedica.it)

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Rogue stem cell clinics

Cell therapies hold significant promise for the treatment of injured or diseased musculoskeletal tissues. However, despite advances in research, there is growing concern about the increasing number of clinical centres around the world that are making unwarranted claims or are performing risky biological procedures. Such providers have been known to recommend, prescribe, or deliver so called ‘stem cell’ preparations without sufficient data to support their true content and efficacy. In this annotation, we outline the current environment of stem cell-based treatments and the strategies of marketing directly to consumers. We also outline the difficulties in the regulation of these clinics and make recommendations for best practice and the identification and reporting of illegitimate providers.

Cite this article: Bone Joint J 2020;102-B(2):148–154

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration

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

Use of Biologics as an Adjunct Therapy to Arthroscopic Surgery for the Treatment of Femoroacetabular Impingement: A Systematic Review

BACKGROUND

There has been a recent increase in the use of biologics in hip arthroscopy to assist in the management of femoroacetabular impingement (FAI).

PURPOSE

To analyze the current use of biologics for the treatment of FAI and its associated lesions.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A search of the PubMed, Medline, and EMBASE databases was performed in March 2019 with use of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The criterion for inclusion was observational, published research articles studying the therapeutic use of biologics as an adjuvant therapy during arthroscopic surgery for FAI; treatments included bone marrow aspirate concentrate, mesenchymal stem cells (MSCs), platelet-rich plasma (PRP), hyaluronic acid, growth factors, and autologous chondrocyte implantation (ACI) or autologous matrix-induced chondrogenesis (AMIC).

RESULTS

There were 9 studies that met the inclusion criteria, and a total of 674 patients were included across all studies. FAI was studied in all articles. Further, 7 studies (78%) also analyzed chondral injuries, and 3 studies also analyzed labral tears (33%). ACI or AMIC was used in 56% of studies and showed superior functional outcomes at short- and midterm follow-up versus debridement or microfracture. PRP did not improve the outcome of labral repairs at short-term follow-up.

CONCLUSION

The current literature regarding biologic adjuncts in hip arthroscopy is varied in quality, with only one level 1 study. The use of ACI/AMIC for medium-sized chondral lesions showed promising results in individual studies; however, these were of lower quality. To enable comparisons among future studies, investigators must ensure accuracy in the reporting of biologic preparations and formulations used and homogeneity in the type and severity of lesion treated.

Reliable assessment of bone marrow and bone marrow concentrates using automated hematology analyzer

Aim: A limiting factor in advancement of bone marrow based cell therapies is the lack of characterization of cell products delivered to patients. Methods: Using an automated hematology analyzer that can be implemented in clinical setting, the composition of bone marrow aspirates (n = 17 patients) and bone marrow concentrates (n = 12 patients) were assessed. ICC estimates were calculated for measuring reliability. Results: Bone marrow aspirates assessment resulted in excellent reliability for determining white blood cells (ICC - 0.96; 95% CI: 0.92-0.99), red blood cells (ICC - 0.9; 95% CI: 0.77-0.96), platelets (ICC - 0.93; 95% CI: 0.85-0.97) composition. Bone marrow concentrate assessment resulted in excellent reliability for determining white blood cells (ICC - 0.97; 95% CI: 0.93-0.99), platelets (ICC - 0.95; 95% CI: 0.89-0.99) and moderate reliability for red blood cells (ICC - 0.66; 95% CI: 0.36-0.87) composition. Conclusion: Modern automated hematology analyzers could assist to better characterize the cell therapy products to provide reliable and consistent outcomes.

A specific affinity cyclic peptide enhances the adhesion, expansion and proliferation of rat bone mesenchymal stem cells on β‑tricalcium phosphate scaffolds

Osteonecrosis of the femoral head (ONFH) is a common osteological disease. Treatment of ONFH prior to the collapse of the femoral head is critical for increasing therapeutic efficiency. Tissue engineering therapy using bone mesenchymal stem cells (BMSCs) combined with a scaffold is a promising strategy. However, it is currently unclear how to improve the efficiency of BMSC recruitment under such conditions. In the present study, a specific cyclic peptide for Sprague-Dawley rat BMSCs, CTTNPFSLC (known as C7), was used, which was identified via phage display technology. Its high affinity for BMSCs was demonstrated using flow cytometry and fluorescence staining. Subsequently, the cyclic peptide was placed on β-tricalcium phosphate (β-TCP) scaffolds using absorption and freeze-drying processes. Adhesion, expansion and proliferation of BMSCs was investigated in vitro on the C7-treated β-TCP scaffolds and compared with pure β-TCP scaffolds. The results revealed that C7 had a promoting effect on the adhesion, expansion and proliferation of BMSCs on β-TCP scaffolds. Therefore, C7 may be effective in future tissue engineering therapy for ONFH.

Osteonecrosis of the femoral head: pathophysiology and current concepts of treatment

Osteonecrosis of the femoral head is a disabling pathology affecting a young population (average age at treatment, 33 to 38 years) and is the most important cause of total hip arthroplasty in this population. It reflects the endpoint of various disease processes that result in a decrease of the femoral head blood flow.The physiopathology reflects an alteration of the vascularization of the fine blood vessels irrigating the anterior and superior part of the femoral head. This zone of necrosis is the source of the loss of joint congruence that leads to premature wear of the hip.Several different types of medication have been developed to reverse the process of ischemia and/or restore the vascularization of the femoral head. There is no consensus yet on a particular treatment.The surgical treatments aim to preserve the joint as far as the diagnosis could be made before the appearance of a zone of necrosis and the loss of joint congruence. They consist of bone marrow decompressions, osteotomies around the hip, vascular or non-vascular grafts.Future therapies include the use of biologically active molecules as well as implants impregnated with biologically active tissue. Cite this article: EFORT Open Rev 2019;4:85-97. DOI: 10.1302/2058-5241.4.180036.

Treatment of osteonecrosis of the femoral head by core decompression and implantation of fully functional ex vivo-expanded bone marrow-derived mesenchymal stem cells: a proof-of-concept study

Background

Based on several attributes involved in bone formation, bone marrow-resident mesenchymal stem cells (MSCs) have been employed in the treatment of patients suffering from femoral head osteonecrosis. Due to the low content of MSCs in the bone marrow, ex vivo expansion procedures are utilized to increase the cell number. Customarily, before administration of the resulting expanded cell product MSCs to the patient, its cellular identity is usually evaluated according to a set of “minimal phenotypic” markers, which are not modified by ex vivo processing. However, MSC functional (“reparative”) markers, which are severely impaired along the ex vivo expansion routine, are usually not assessed.

Patients and methods

In this proof-of-concept study, a cohort of five avascular osteonecrosis patients received an instillation of ex vivo-expanded autologous MSCs, manufactured under controlled conditions, with an aim to protect their functional (“reparative”) capacity.

Results and conclusion

Outcomes of this study confirmed the safety and effectiveness of the MSC-based therapy used. After a follow-up period (19–54 months), in all patients, the hip function was significantly improved and pain intensity markedly reduced. As a corollary, no patient required hip arthroplasty.

Optimizing Clinical Use of Biologics in Orthopaedic Surgery: Consensus Recommendations From the 2018 AAOS/NIH U-13 Conference

Concern that misinformation from direct-to-consumer marketing of largely unproven "biologic" treatments such as platelet-rich plasma and cell-based therapies may erode the public trust and the responsible investment needed to bring legitimate biological therapies to patients have resulted in calls to action from professional organizations and governing bodies. In response to substantial patient demand for biologic treatment of orthopaedic conditions, the American Academy of Orthopaedic Surgeons convened a collaborative symposium and established a consensus framework for improving and accelerating the clinical evaluation, use, and optimization of biologic therapies for musculoskeletal diseases. The economic and disease burden of musculoskeletal conditions is high. Of the various conditions discussed, knee osteoarthritis was identified as a "serious condition" associated with substantial and progressive morbidity and emerged as the condition with the most urgent need for clinical trial development. It was also recognized that stem cells have unique characteristics that are not met by minimally manipulated mixed cell preparations. The work group recommended that minimally manipulated cell products be referred to as cell therapy and that the untested and uncharacterized nature of these treatments be clearly communicated within the profession, to patients, and to the public. Minimum standards for product characterization and clinical research should also be followed. A framework for developing clinical trials related to knee OA was agreed upon. In addition to recommendations for development of high-quality multicenter clinical trials, another important recommendation was that physicians and institutions offering biologic therapies commit to establishing high-quality patient registries and biorepository-linked registries that can be used for postmarket surveillance and quality assessments.

Bone Marrow Aspirate Concentrate for Orthopaedic Use

Biological-based therapies are rapidly expanding for different musculoskeletal conditions because of their potential benefits including their minimal invasiveness, capacity for unprecedented healing, and potential for rapid recovery. In this regard, although several approaches have been reported in the literature, most of the body of the literature is increasingly based on platelet-rich plasma, bone marrow aspirate concentrate, and cell-based therapy studies. Although further basic science and clinical research is needed to elucidate the long-term outcome of these therapies in the treatment of several injuries, there is compelling evidence for their use for certain indications. The purpose of this article was to review the main aspects of bone marrow aspirate concentrate, which is one of the few forms of stem cell delivery approved by the Food and Drug Administration, and, furthermore, to critically assess the current evidence-based recommendations and identify potential avenues for development.

Proceedings of the signature series symposium "cellular therapies for orthopaedics and musculoskeletal disease proven and unproven therapies-promise, facts and fantasy," international society for cellular therapies, montreal, canada, may 2, 2018

The Signature Series Symposium "Cellular Therapies for Orthopaedics and Musculoskeletal Disease Proven and Unproven Therapies-Promise, Facts and Fantasy" was held as a pre-meeting of the 26^th International Society for Cellular Therapy (ISCT) annual congress in Montreal, Canada, May 2, 2018. This was the first ISCT program that was entirely dedicated to the advancement of cell-based therapies for musculoskeletal diseases. Cellular therapies in musculoskeletal medicine are a source of great promise and opportunity. They are also the source of public controversy, confusion and misinformation. Patients, clinicians, scientists, industry and government share a commitment to clear communication and responsible development of the field. Therefore, this symposium convened thought leaders from around the world in a forum designed to catalyze communication and collaboration to bring the greatest possible innovation and value to patients with musculoskeletal conditions.

Clinical efficiency of bone marrow mesenchymal stem cell implantation for osteonecrosis of the femoral head: a matched pair control study with simple core decompression

Background

To date, several trials have reported the use of mesenchymal stem cell (MSC) implantation for osteonecrosis of the femoral head (ONFH). However, the clinical outcomes have not been conclusive. This study compared the clinical and radiological results of bone marrow mesenchymal stem cell (BMMSC) implantation with traditional simple core decompression (CD) using a matched pair case–control design.

Methods

We retrospectively reviewed 100 patients with ONFH (106 hips) who had been treated by CD alone (50 patients, 53 hips) and CD + BMMSC implantation (50 patients, 53 hips) between February 2004 and October 2014. We assessed the total hip replacement arthroplasty (THA) conversion rate and ARCO (Association Research Circulation Osseous) stage progression. Survivor rate analysis was performed using the Kaplan–Meier method, and an additional THA was defined as the primary endpoints.

Results

The mean follow-up period was 4.28 years. There was a difference in the THA conversion rate between the CD (49%) and CD + BMMSC groups (28.3%) (p = 0.028). ARCO stage progression was noted in 20 of 53 hips (37.7%) in the CD group and 19 of 53 hips (35.8%) in the CD + BMMSC group. Among collapsed cases (ARCO stages III and IV), there was no difference in clinical failure rate between the two groups. Conversely, in the pre-collapse cases (ARCO stages I and II), only 6 of 30 hips (20%) progressed to clinical failure in the CD + BMMSC group, whereas 15 of 30 hips (50%) progressed to clinical failure in the CD group (p = 0.014). Kaplan–Meier survival analysis showed a significant difference in the time to failure between the two groups up to 10-year follow-up (log-rank test p = 0.031). There was no significant difference in terms of age (p = 0.87) and gender (p = 0.51) when comparing THA conversion rates between groups. No complication was noted.

Conclusions

These results suggest that implantation of MSCs into the femoral head at an early stage of ONFH lowers the THA conversion rate. However, ARCO stage progression is not affected by this treatment.

Trial registration

Retrospectively registered

Early Clinical Outcomes of Intra-Articular Injections of Bone Marrow Aspirate Concentrate for the Treatment of Early Osteoarthritis of the Hip and Knee: A Cohort Study

BACKGROUND

Bone marrow aspirate concentrate (BMC) is one of the few cell-based therapies available as a possible biological treatment for early osteoarthritis (OA). Its efficacy, safety, and benefit compared with other treatments are still to be determined.

OBJECTIVE

To assess the clinical outcomes of patients undergoing intra-articular injection of BMC for the treatment of early knee and hip OA.

DESIGN

Prospective, cohort study.

SETTING

Single institution, quaternary level of care.

PATIENTS

Nineteen patients (16 female and 3 male), totaling 25 joints (10 knees, 15 hips), treated with intra-articular BMC for early OA between 2014 and 2016. The mean age at time of the procedure was 58 ± 12.7 years (range, 30-80 years). The mean follow-up was 13.2 ± 6.3 months (range, 6-24 months). Inclusion criteria included ≥18 years; knee OA, Kellgren-Lawrence grade I-II; hip OA, Tönnis grade I-II; first-time intra-articular BMC therapy, after unsuccessful symptomatic and conservative treatments (ie, physical therapy, analgesics and anti-inflammatory drugs) for 6 months. Exclusion criteria included pregnancy; malignancy; rheumatologic diseases; infection; Kellgren-Lawrence grade III-IV; Tönnis grade III; and previous intra-articular injections or surgery.

INTERVENTIONS

All patients had autologous bone marrow aspirate harvested from the iliac crest and centrifuged to achieve BMC, for intra-articular injection.

MAIN OUTCOME MEASUREMENTS

The hypothesis was formulated before the study. Patient-reported outcomes measures were assessed preoperatively and at last follow-up using the Western Ontario and McMaster Universities Arthritis Index.

RESULTS

Western Ontario and McMaster Universities Arthritis Index improved from a baseline of 40.8 ± 18.3% to 20.6 ± 17% (P < .001) at final follow-up. The satisfaction rate was 63.2%. The minimal clinically important difference threshold of 9.15 points was reached by 64% of the patients. Two patients were converted to total hip arthroplasty at 8 months after BMC injection.

CONCLUSIONS

Intra-articular injections of BMC for the treatment of early knee or hip OA were safe and demonstrated satisfactory results in 63.2% of patients. Future studies are necessary to determine the efficacy of this technique and its safety profile.

LEVEL OF EVIDENCE

II.

Efficiency of Cell Therapy to GC-Induced ONFH: BMSCs with Dkk-1 Interference Is Not Superior to Unmodified BMSCs

Glucocorticoid-induced osteonecrosis of the femoral head (ONFH) is a hip disorder, and it threatens patients who require megadose of steroid therapies. Nowadays, no valid therapies can reverse the development of GC-induced ONFH once it occurs. Stem cell therapy to GC-induced ONFH would be a promising choice. Although the pathogenesis of GC-induced ONFH is not yet fully clear, Dickkopf-1 (Dkk-1) upregulated by excessive GC use, which hinders the canonical Wnt pathway, could be an explanation. Thus, the aim of the present work lies in investigating the efficiency of the allograft bone marrow stem cells (BMSCs) with Dkk-1 interference in preventing the progression of the GC-induced ONFH. Lentivirus-meditated Dkk-1 RNAi was introduced into BMSCs which was exposed to dexamethasone (10-6 mol/L) in vitro. This interference blocked Dkk-1 overexpression by GC and afterwards prompted the transduction of Wnt/β-catenin in which the Runx2 and PPARγ were upregulated and downregulated, respectively. Thus, the osteogenesis was promoted while adipogenesis was inhibited. In vivo, GC-induced ONFH rats were treated by allotransplantation of BMSCs with Dkk-1 interference, and the progression of the disease was prevented. However, the effects were not significantly superior to treatment with nongenetically modified or normal BMSCs.

Investigating clinical failure of core decompression with autologous bone marrow mononuclear cells grafting for the treatment of non-traumatic osteonecrosis of the femoral head

OBJECTIVE

This study aimed to analyze the clinical factors related to the failure of autologous bone marrow mononuclear cells grafting (BMMCG) following core decompression (CD) in early stage osteonecrosis of the femoral head (ONFH).

METHODS

In total, 148 patients (192 hips) underwent CD with autologous BMMCG for treatment of non-traumatic ONFH. The patients were classified by their ARCO staging and China-Japan Friendship Hospital (CJFH) typing system. All patients were clinically and radiographically followed up every three months during the first year and every six months in the following years. The clinical evaluation was conducted by pre- and post-operative Harris hip scores (HHS), while serial anteroposterior (AP) and frog lateral radiographs were used for post-operative radiographic evaluation.

RESULTS

There were 56 hips as clinical failure cases, and 50 hips (89.29%) of failure cases developed between three and ten months after operation. Based on CJFH classification system, type L2 showed more failure rate with 60.0% (9 of15). The Cox risk model showed that disease type was an independent risk factor for post-operative clinical failure (P = 0.042). Multivariate analysis of the Cox proportional-hazards model showed that type L1 had a hazard ratio (HR) of 0.286 (95% CI 0.100-0.816), type L3 with HR of 0.245 (95% CI 0.079-0.759), respectively.

CONCLUSION

Disease type is an important risk factor for autologous BMMCG combined with CD, and the degree of lateral pillar necrosis is a significant reference index for prognosis evaluation in early stage of ONFH.

Hip osteonecroses treated with calcium sulfate-calcium phosphate bone graft substitute have different results according to the cause of osteonecrosis: alcohol abuse or corticosteroid-induced

INTRODUCTION

The aim of the study was to assess the factors influencing the final results of treatment of the femoral head osteonecrosis (ONFH) with core decompression and bone substitute grafting. The special interest was focused on comparison between alcohol- and steroid-induced ONFHs.

MATERIAL AND METHODS

In this prospective study, a total of 53 patients (58 hips) in the mean age of 35.5 years were included: 29 had a history of alcohol use (32 hips) and 24 of steroid use (26 hips). The mean follow-up was 4.2 years (minimum 3 years).

RESULTS

At last follow-up, significant improvements were noted in the Harris Hip Score (HHS) (mean 44.0 vs 55.9 points, p < 0.00002) and VAS scores (mean 7.0 vs 5.8 points, p < 0.0002) for the whole ONFH cohort, comparing to pre-operative status. The degree of improvement did not differ between Ficat and Arlet grade II and grade III (mean 14.9 vs 6.2 points, respectively, p = 0.1). No change was found between the final and initial results in this group in the steroid group (HHS mean 42.2 vs 45.5 points, p = 0.5 and VAS mean 6.8 vs 6.5 points, p = 0.5), but the improvement was noted in the alcohol group (HHS mean 45.5 vs 64.4 points, p < 0.0001; VAS mean 7.1 vs 5.2 points, p < 0.0001) comparing to pre-operative status.

CONCLUSIONS

Presented treatment of ONFH significantly improves hip function, offers pain reduction, and gives similar functional improvement for hips scoring grade II and III on the Ficat and Arlet scale. A good response to operative treatment is seen in patients with alcohol-induced ONFH, but not in those with steroid-induced ONFH.

Effectiveness of various hip preservation treatments for non-traumatic osteonecrosis of the femoral head: A network meta-analysis of randomized controlled trials

BACKGROUND

Non-traumatic osteonecrosis of the femoral head (ONFH) is a refractory osteonecrosis disease caused by an abnormal blood supply to bone tissue. However, therapeutic hip preservation strategies are diverse, and the therapeutic outcomes are not ideal.

OBJECTIVE

A network meta-analysis was performed to assess the effect of hip preservation treatments on non-traumatic ONFH.

METHODS

We searched public electronic databases through May 15, 2017 using the following keywords: "femoral head necrosis osteonecrosis"; "femoral head osteonecrosis"; "osteonecrosis of femoral head"; "avascular necrosis of femoral head"; "necrosis of femoral"; and "random*". The primary outcome in the present analysis was the treatment failure rate. Secondary outcomes included the Harris hip and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores.

RESULTS

We included 21 articles assessing a total of 1415 hips in our analysis. In the network meta-analysis, the treatments were ranked by the surface under the cumulative ranking curve (SUCRA). Core decompression (CD) plus cytotherapy was most likely to reduce the treatment failure rate (SUCRA score = 18.9%), followed by alendronate treatment (SUCRA score = 17.8%), cocktail treatments (SUCRA score = 15.6%), extracorporeal shock wave therapy (ESWT) plus alendronate (SUCRA score = 15.4%), and avascular biomaterials plus cytotherapy (SUCRA score = 13.8%) in a frequentist framework; similar results were obtained in a Bayesian framework. For the secondary outcomes, ESWT was most likely to improve the Harris hip score (SUCRA score = 33.7%), followed by ESWT plus alendronate (SUCRA score = 33.1%) and cocktail (SUCRA score = 19.6%) treatments in a frequentist framework. A traditional analysis showed that the effect of CD plus cytotherapy was significantly better than the effect of CD alone in improving the WOMAC score (SMD, -6.01; 95% CI, -7.81 to -4.22; p < 0.001).

CONCLUSION

CD plus cytotherapy is a relatively superior treatment for reducing treatment failure rates in early and intermediate ONFH patients, and ESWT is the most effective treatment for improving Harris hip scores.

The biological basis for concentrated iliac crest aspirate to enhance core decompression in the treatment of osteonecrosis

Core decompression is a surgical procedure that is capable of salvaging the patient's own natural joint, if the operation is performed in the early stages of osteonecrosis, in which the articular surface has not collapsed. The addition of concentrated cells, aspirated from the iliac crest, to the core tract has been shown to enhance the viability of the femoral head, although large, prospective, randomized, blinded multicentre studies are lacking. The rationale for adding these cells to the core decompression tract is to provide osteoprogenitor and vascular progenitor cells to the area of decompressed dead bone, in order to facilitate tissue regeneration and repair. It has become increasingly evident that vast discrepancies exist in different series in regard to the criteria for patient selection, the surgical technique of core decompression, the methods for harvesting, processing, and injecting the cells, and the methodology for determining success or failure in a specific patient cohort. This paper reviews the salient points relevant to the treatment of osteonecrosis by core decompression with addition of concentrated iliac crest aspirates and poses important questions regarding the future successful application of this technique.

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

PURPOSE

The aim of this study was to document the available evidence on the use of regenerative techniques for the treatment of femoral head osteonecrosis (or avascular necrosis of femoral head, AVN) and to understand their benefit compared to core decompression (CD) alone in avoiding failure and the need for total hip replacement (THR).

METHODS

The search was conducted on three medical electronic databases according to PRISMA guidelines. The studies reporting number and timing of failures were included in a meta-analysis calculating cumulative survivorship with a Kaplan-Mayer curve. Moreover, the results on failures in treatment groups reported in RCT were compared with those documented in control groups, in order to understand the benefit of biological therapies compared to CD for the treatment of AVN.

RESULTS

Forty-eight studies were included in this systematic review, reporting results of different types of regenerative techniques: mesenchymal stem cell implantation in the osteonecrotic area, intra-arterial infiltration with mesenchymal stem cells, implantation of bioactive molecules, or platelet-rich plasma. Overall, reported results were good, with a cumulative survivorship of 80% after ten year follow-up, and better results when regenerative treatments were combined to CD compared to CD alone (89.9% vs 70.6%, p < 0.0001).

CONCLUSION

Regenerative therapies offer good clinical results for the treatment of AVN. The combination of CD with regenerative techniques provides a significant improvement in terms of survivorship over time compared with CD alone. Further studies are needed to identify the best procedure and the most suitable patients to benefit from regenerative treatments for AVN.

Recent Advances in Treatment of Coronary Artery Disease: Role of Science and Technology

Coronary artery disease (CAD) is one of the most common causes of death worldwide. In the last decade, significant advancements in CAD treatment have been made. The existing treatment is medical, surgical or a combination of both depending on the extent, severity and clinical presentation of CAD. The collaboration between different science disciplines such as biotechnology and tissue engineering has led to the development of novel therapeutic strategies such as stem cells, nanotechnology, robotic surgery and other advancements (3-D printing and drugs). These treatment modalities show promising effects in managing CAD and associated conditions. Research on stem cells focuses on studying the potential for cardiac regeneration, while nanotechnology research investigates nano-drug delivery and percutaneous coronary interventions including stent modifications and coatings. This article aims to provide an update on the literature (in vitro, translational, animal and clinical) related to these novel strategies and to elucidate the rationale behind their potential treatment of CAD. Through the extensive and continued efforts of researchers and clinicians worldwide, these novel strategies hold the promise to be effective alternatives to existing treatment modalities.