The use of biologics to improve patient-reported outcomes in hip preservation

Safety and Efficacy of Bone-Marrow Aspirate Concentrate in Hip Osteoarthritis: A Systematic Review of Current Clinical Evidence

Introduction

Hip osteoarthritis (OA) is one of the leading causes of disability and morbidity worldwide. It is estimated to affect 9.2% individuals globally with age over 45 years. Conventional treatment modalities have limitations and side-effects. To overcome these limitations, over the last decade, there has been an increased interest in the use of orthobiologics derived from autologous sources including platelet-rich plasma (PRP), bone-marrow aspirate concentrate (BMAC) and adipose tissue derived formulations. This review qualitatively presents the in-vitro, pre-clinical, clinical and on-going clinical studies exploring the safety and efficacy of BMAC for management of hip OA.

Materials and methods

The electronic database search was done through PubMed, Embase, Web of Science, Scopus, ProQuest and Google Scholar till February 2024. The search terms used were "osteoarthritis" OR "hip osteoarthritis" OR "orthobiologics" OR "efficacy or use of orthobiologic treatment" OR "bone-marrow concentrate" OR "bone-marrow aspirate concentrate", AND "BMAC". The inclusion criteria were clinical studies of any level of evidence written in the English language, published till February 2024, evaluating the safety and efficacy of intra-articular administration of BMAC for the management of hip OA.

Results

A total of 5 studies were included in this review for qualitative data synthesis. The total number of patients who participated in the study was 182, ranging from 4 to 112 in a single study. No adverse events were reported throughout the duration of the study. In addition, intra-articular administration of BMAC led to reduced pain, and improved function and overall quality of life (QoL).

Conclusion

The results from this review demonstrated that administration of BMAC is safe and potentially efficacious in terms of reducing pain, improving function and overall QoL of patients with hip OA in short- and mid-term average follow-up based on the included studies. Nonetheless, more adequately powered, multi-center, prospective, double-blind, non-randomized and randomized controlled trials with long-term follow-up are warranted to establish long-term safety and efficacy of BMAC for management of hip OA and justify its routine clinical use.

Orthobiologics as an adjunct in treatment of femoroacetabular impingement syndrome: cell-based therapies facilitate improved postoperative outcomes in the setting of acetabular chondral lesions-a systematic review

PURPOSE

To evaluate studies utilizing orthobiologics in the management of femoroacetabular impingement syndrome (FAIS) to (1) assess the indications for usage, and (2) analyze patient-reported outcome measures (PROM) following treatment. It was hypothesized that orthobiologics would (1) be utilized for symptomatic FAIS in the setting of labral or chondral pathology, and (2) improve PROM at most recent follow-up.

METHODS

The Pubmed, Ovid Medline, Cochrane, and Web of Science databases were searched for clinical studies evaluating orthobiologics [hyaluronic acid (HA), platelet-rich plasma (PRP), or cell-based therapy (CBT) for treatment of FAIS. Exclusion criteria included orthobiologics used in conjunction with cartilage transfer or scaffolding procedures and a primary indication other than FAIS. Data collection included patient demographics, indications, and baseline and most recent PROM.

RESULTS

Eleven studies (one level I, four level II, four level III, and two level IV evidence) met inclusion criteria, consisting of 440 patients with mean ages ranging from 32.8 to 47 years. All 11 studies demonstrated an improvement in PROM from baseline to most-recent follow-up. Four studies administered PRP either intraoperatively or the day after surgery as an adjunct to labral repair. CBT was used intraoperatively in the setting of acetabular chondral lesions (three studies) and labral repair (one study). When comparing to a control group at most recent follow-up, three PRP cohorts demonstrated similar PROM (n.s.), while one PRP group exhibited worse visual analog pain scores (2.5 vs. 3.4, p = 0.005) and modified Harris Hip Scores (mHHS) (82.6 vs. 78.7, p = 0.049). The four CBT studies reported favorable results compared to a control group, with a significantly higher mHHS at most recent follow-up or mean improvement from baseline in Hip Outcome Score-Activities of Daily Living (p < 0.05). Three studies reported on HA, which was utilized exclusively in the nonoperative setting.

CONCLUSIONS

Intraoperative PRP and CBT have been commonly reported in the setting of hip arthroscopy for labral repairs and acetabular chondral lesions, respectively. The CBT cohorts demonstrated more favorable PROM at most recent follow-up when compared to a control group, though these results should be interpreted with caution due to heterogeneity of orthobiologic preparations.

LEVEL OF EVIDENCE

IV.

Editorial Commentary: Hip Arthroscopy in Patients With Early Degeneration Who Receive Intra-Articular Bone Marrow Aspirate Concentrate Can Achieve Outcomes Similar to Nonarthritic Patients

The management of patients with early joint degeneration is challenging. In this setting, biologic interventions, from platelet-rich plasma to bone marrow aspirate concentrate (BMAC) to hyaluronic acid, may be beneficial. Recent research, with 2-year follow-up, shows that patients with early degenerative changes (Tönnis grade 1 or 2) who received intra-articular injection of BMAC after hip arthroscopy procedure had improvements in outcomes similar to nonarthritic patients (Tönnis 0) with symptomatic labral tears who underwent arthroscopy and did not receive BMAC. Although confirmatory investigation using patients with early degenerative changes as a control is required, it is possible that with BMAC, patients with early degenerative changes of their hip could achieve functional outcomes similar to patients with nonarthritic hips.

Orthobiologic Injections for the Treatment of Hip Osteoarthritis: A Systematic Review

The use of orthobiologics is gaining increasing interest as a minimally invasive treatment for hip osteoarthritis (OA). The aim of this study was to investigate the evidence about the safety and efficacy of these products. A systematic review of the literature was performed according to the PRISMA and Cochrane guidelines. The study quality was assessed using the RoB 2.0 for randomized controlled trials (RCTs) and the modified Coleman Methodology Score (mCMS) for all studies. A total of 20 clinical studies (735 patients) was identified, 12 on PRP injections and eight on cell-based therapies (five from bone marrow, two from adipose tissue, and one from amniotic fluid). The publication trend increased over time, with over 50% of articles published from 2019. The literature analysis showed only six RCTs, all on PRP injections. The mCMS showed an overall fair methodology (mean score 59.4). While the number of studies and their methodology are still limited, the available evidence suggests safety and overall promising results, with the treatment success being inversely proportional to the severity of OA. Further high-level controlled trials are needed before drawing more definitive conclusions on the real potential of orthobiologics for the injective treatment of patients affected by hip OA.

Safety of intraarticular corticosteroid injection preceding hip and knee arthroplasty: a systematic review and meta-analysis amid resolving COVID-19 arthroplasty restrictions

Intraarticular corticosteroid injection (ICSI) is a widely practiced management for hip and knee osteoarthritis. Imposed delays to arthroplasty during coronavirus disease 2019 pandemic have led us to postulate that many patients have opted for recent ICSI. We compared the odds of prosthetic joint infection (PJI) in patients who were or were not administered ICSI within 12 months prior to hip or knee arthroplasty. A systematic search of PubMed, Embase, The Cochrane Library and Web of Science was performed in February 2021, with studies assessing the effect of ICS on PJI rates identified. All studies, which included patients that received ICSI in the 12 months prior to primary hip and knee arthroplasty, were included. In total 12 studies were included: four studies with 209 353 hips and eight studies with 438 440 knees. ICSI administered in the 12 months prior to hip arthroplasty increased the odds of PJI [odds ratio (OR) = 1.17, P = 0.04]. This was not the case for knees. Subgroup analysis showed significantly higher odds of PJI in both hip [OR = 1.45, P = 0.002] and knee arthroplasty [OR = 2.04; P = 0.04] when ICSI was within the preceding 3 months of surgery. A significantly higher odds of PJI were seen in patients receiving ICSI within the 12 months prior to hip arthroplasty. Subgroup analysis showed increased odds of PJI in both hip and knee arthroplasty, in patients receiving ICSI within 3 months prior to their arthroplasty. We recommend delaying knee arthroplasty for at least 3 months after ICSI and possibly longer for hip arthroplasty.