Does Adjunction of Autologous Osteoblastic Cells Improve the Results of Core Decompression in Early-stage Femoral Head Osteonecrosis? A Double-blind, Randomized Trial

The efficacy of core decompression combined with regenerative therapy in early femoral head necrosis: a systematic review and meta-analysis involving 954 subjects

Background

The debate continues on whether combining core decompression (CD) with regenerative therapy provides a more effective treatment for early femoral head necrosis than CD alone. This systematic review and meta-analysis endeavored to assess its efficacy.

Methods

We systematically searched PubMed, Web of Science, and Cochrane Library through July 2024 for RCTs and cohort studies evaluating the impact of core decompression (CD) with regenerative therapy versus CD alone in early-stage osteonecrosis (ARCO I, II or IIIa or Ficat I or II) of the femoral head (ONFH). Bias was evaluated using the Cochrane ROB 2.0 for RCTs and the Newcastle-Ottawa Scale (NOS) for cohort studies. The primary outcome was disease progression, measured by the incidence of staging advancement and total hip arthroplasty (THA) conversion. Clinical outcomes, including VAS, HHS, WOMAC, and Lequesne index, were secondary measures. Subgroup analyses were performed for variables such as age, BMI, follow-up period, and dosage in the bone marrow aspirate concentrate (BMAC) group, with results depicted in forest plots.

Results

This study represented a total of seven RCTs (mean follow-up time 36.57 months) and eight cohort trials (mean follow-up time 74.18 months) involving 954 hips. CD, when combined with agents, exhibited considerably enhanced efficacy over CD alone (risk ratio (RR) = 0.55 (95% CI 0.39-0.77), p < 0.001, I 2 = 54%) and 0.59 (95% CI 0.43-0.81), p = 0.001, I 2 = 51%), respectively). However, a significant difference was exclusive to the CD combined with BMAC group in terms of stage progression outcomes (stage progression, RR = 0.47 (95% CI 0.28-0.78), p = 0.004, I 2 = 67%); THA conversions, RR = 0.41 (95% CI 0.32-0.52), p < 0.001, I 2 = 43%). Secondary outcomes (VAS, HHS, WOMAC score and Lequesne index) showed improved results when CD was combined with other regenerative agents, such as bone mesenchymal stem cells (BMSCs) and bone morphogenetic proteins (BMPs), etc. In the reported data, the regenerative group demonstrated significantly higher rates of subjective improvement in pain and functional outcomes compared to those in the CD group (71.74% (66/92) vs. 56.38% (53/94). Subgroup analysis revealed superior outcomes in the low-dose (less than 20 mL) BMAC group and patients aged under 40 years old in stage progression rate and THA conversion rate.

Conclusion

CD, when combined with regenerative therapy, can diminish hip pain and enhance functionality, but its ability to slow disease progression remains uncertain. BMAC presents a more substantiated efficacy evidence than other agents, with low-doses of BMAC in patients under 40 years potentially slowing ONFH progression. Nonetheless, the high heterogeneity and relatively short follow-up time of these studies make it difficult to draw accurate conclusions, which necessitates verification through future trials comparing CD versus CD combined with regenerative therapy, with a focus on extended follow-up periods.

Systematic Review Registration

identifier CRD42023467873.

Orthobiologic therapies delay the need for hip arthroplasty in patients with avascular necrosis of the femoral head: A systematic review and survival analysis

PURPOSE

The aim of this systematic review and survival analysis was to quantify the benefits of orthobiologic augmentation therapies for the treatment of avascular necrosis (AVN) of the femoral head and identify the most effective approach to delay the need for total hip arthroplasty (THA).

METHODS

A systematic review of the literature was performed on PubMed, Scopus, and Cochrane on clinical studies on orthobiologic therapies used alone or as an augmentation to core decompression or other procedures to address hip AVN. A qualitative analysis of the different biological therapies applied was performed. Afterward, the results of these procedures were quantitatively analysed to document their survivorship from THA compared to treatment groups without orthobiologics. Kaplan-Meier analysis was performed for all studies and then by categorising orthobiologics into treatment subgroups.

RESULTS

A total of 106 studies were included (4505 patients). Different orthobiologic approaches have been evaluated: cell-based therapies including bone marrow aspirate concentrate (BMAC) and bone marrow mesenchymal stromal cells (BM-MSCs), platelet-rich plasma (PRP), or other bioactive molecules applied in the osteonecrotic area or as intra-arterial injections. The survival analysis at 120 months documented a higher (p < 0.0005) cumulative survivorship with orthobiologics (69.4%) compared to controls (48.5%). The superiority was shown specifically for BMAC (p < 0.0005), BM-MSCs (p < 0.0005), intra-arterial (p < 0.0005) and PRP (p = 0.011) approaches, but the direct comparison of these approaches with their controls confirmed benefits only for BMAC (p < 0.0005).

CONCLUSION

This systematic review and survival analysis demonstrated that orthobiologics have the potential to improve survivorship in patients affected by hip AVN. In particular, the specific analysis of different orthobiologic products supported relevant benefits for BMAC augmentation in terms of survival from the need for THA, while no clear benefits were confirmed for other orthobiologics.

LEVEL OF EVIDENCE

Level III.

Advances in mechanism and management of bone homeostasis in osteonecrosis: a review article from basic to clinical applications

Osteonecrosis, characterized by bone cell death leading to impaired bone recovery, causes challenges in bone homeostasis maintenance. Bone homeostasis relies on the delicate balance between osteoclasts and osteoblasts, encompassing a series of complex and strictly regulated biological functions. Current treatments, including conservative therapies and surgeries, often fall short of expected outcomes, necessitating a reorientation towards more effective therapeutic strategies according to the pathogenesis. In this review, we hierarchically outlined risk factors, emerging mechanisms, and last-decade treatment approaches in osteonecrosis. By connecting mechanisms of bone homeostasis, we proposed future research directions should be focused on elucidating risk factors and key molecules, performing high-quality clinical trial, updating practice, and accelerating translational potential.

Comparative analysis of surgical interventions for osteonecrosis of the femoral head: a network meta-analysis of randomized controlled trials

BACKGROUND

Despite several surgical options, there remains no consensus regarding the optimal approach for osteonecrosis of the femoral head (ONFH), a prevalent and refractory disease. To determine the most suitable treatment modality, we compared randomized controlled trials (RCTs) that evaluated multiple surgical treatments for ONFH using a Bayesian network meta-analysis (NMA).

METHODS

The outcomes of 11 different surgical treatments were assessed using NMA comparisons of the rate of progression of femoral head necrosis, the rate of conversion to total hip arthroplasty, and improvement of the Harris hip score (HHS). A random effects model was used to analyze the odds ratio (OR) or mean difference, and risk of bias was assessed using the Cochrane risk of bias assessment tool for randomized trials. The confidence of the results was assessed using the confidence in network meta-analysis tool.

RESULTS

A total of 18 RCTs were included in the meta-analysis. Compared with core decompression (CD), the forest plot showed that autologous bone grafting (ABG), free fibula grafting (FFG), vascularized bone grafting (VBG), autologous bone grafting combined with bone marrow aspirate concentrate (ABG + BMAC), and biomaterial grafting combined with vascularized bone grafting (BMG + VBG) delayed ONFH progression. Among them, ABG + BMAC showed the most promising results (OR 0.019; 95% confidence interval [CI] 0.0012-0.25). However, upon comparing CD with different surgical modalities, no significant differences were found in preventing total hip arthroplasty. Furthermore, we cannot draw conclusions regarding the HHS due to attribution and high heterogeneity across the studies.

CONCLUSION

Overall, ABG, VBG, FFG, ABG + BMAC, and BMG + VBG showed significant results in preventing ONFH progression compared with that shown by CD. Based on the surface under the cumulative ranking, ABG + BMAC was the most effective. Moreover, all treatments involving bone grafting were found to be effective, possibly indicating the necessity of its use in the treatment of ONFH.