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

Mid-term Clinical Outcomes of "Light Bulb" Core Decompression with Arthroscopic Assistance in Peri-collapse Osteonecrosis of the Femoral Head: A Retrospective Comparative Study

OBJECTIVE

Nontraumatic osteonecrosis of the femoral head (ONFH) is commonly encountered in orthopedics. Without early clinical intervention, most patients with peri-collapse of the ONFH will develop femoral head necrosis and eventually require hip replacement surgery. The aim of this study is to evaluate clinical outcomes in patients with ONFH who underwent "light bulb" core decompression (CD) with arthroscopic assistance and to compare them with the outcomes of those treated with traditional procedures.

METHODS

A retrospective review of patients with Stage II and IIIA (Peri-collapse) radiographic findings based on the Association Research Circulation Osseous (ARCO) stage for ONFH who underwent "light bulb" CD with or without arthroscopic assistance by a single-surgeon team between March 2014 and December 2018 was performed. All patients were followed up for a minimum of 2 years. The visual analogue scale (VAS) pain score, Harris hip score (HHS), and radiological imaging were evaluated. The categorical parameters were analyzed by chi-square test and the continuous variables conforming to a normal distribution were analyzed by Student's t-test.

RESULTS

The study included a total of 39 patients (18 and 21 patients in the with and without arthroscopic assistance groups, respectively), with a mean age of 40.3 years and a mean follow-up of 22.2 months. Overall, there was a better VAS score in the arthroscopic assistance group than in the control group (p < 0.05), There was a significant difference in HHS (80.1 ± 9.2 vs 75.1 ± 12.7) at the last follow-up (p < 0.05). The rate of good and excellent outcomes was 94%. Similarly, there was no significant difference in the total rate of complications or conversion to THA.

CONCLUSION

With arthroscopic assistance, "light bulb" CD could be achieved via hip arthroscopy with less trauma, and it offered the opportunity for more precise evaluation and monitoring for therapy and yielded better VAS scores after surgery and better hip function outcomes at the last follow-up.

Bone marrow edema of the knee: a narrative review

Bone marrow edema (BME) is a frequent MRI finding in patients with knee pain. According to the etiology, BME of the knee can be classified into three main categories: ischemic, mechanic, and reactive. The diagnosis may be difficult, because of the specificity of symptoms and the poor radiographic findings. MRI is the gold standard, showing an area of altered signal of the bone with an high signal intensity on fat-suppressed, T2 weighted images, usually in combination with an intermediate or low signal intensity on T1 weighted images. Bone marrow edema tends to be self-limiting and, in most cases, resolves without any consequences in a varying amount of time. However, since it may evolve to complete joint destruction, early diagnosis and correct treatment are crucial to prevent the articular degeneration. Conservative therapy is the first step, with no weight-bearing for 3 to 6 weeks on the affected side, in combination with the administration of anti-inflammatory drugs or painkillers to manage symptoms. In non-responding forms and more advanced stages, minimally invasive preservative surgery can provide significant results, with subchondroplasty and core decompression being the two main procedures available. Knee arthroplasty, both total (TKA) or unicompartmental (UKA), is the only effective option when the degradation of cartilage is diffuse and in patients with subchondral bone collapse.

Overexpression of miR-532-5p restrains oxidative stress response of chondrocytes in nontraumatic osteonecrosis of the femoral head by inhibiting ABL1

This study is to probe into the meaning of serum miR-532-5p in nontraumatic osteonecrosis of the femoral head (ONFH), and a molecular mechanism of miR-532-5p in the development of nontraumatic ONFH. This study enrolled 96 patients diagnosed with nontraumatic ONFH and 96 patients with femoral neck fracture. The levels of miR-532-5p, ABL1, MMP-3, MMP-13, and cleaved-caspase3 were determined. Radiographic progression was assessed by ARCO staging system. Visual analog scale (VAS) and Harris hip score (HHS) were employed for evaluation of the symptomatic severity of nontraumatic ONFH. Cell viability and apoptosis in chondrocytes isolated from clinical samples were investigated with CCK-8 and flow cytometry. The levels of lactic dehydrogenase (LDH), superoxide dismutase (SOD), and malondialdehyde (MDA), mitochondrial membrane potential (ΔΨm), and reactive oxygen species (ROS) were determined. miR-532-5p was downregulated in tissues and serum of patients with nontraumatic ONFH, negatively related with ARCO staging and VAS, and positively correlated with HHS. Cell apoptosis, LDH, MDA, and ROS strengthened, while cell viability, ΔΨm, and SOD reduced in chondrocytes of nontraumatic ONFH patients. ABL1 was upregulated in cartilage tissues from nontraumatic ONFH patients. miR-532-5p targeted ABL1, and overexpressed miR-532-5p alleviated nontraumatic ONFH-induced oxidative stress damage of chondrocytes by restraining ABL1. miR-532-5p ameliorated oxidative stress injury in nontraumatic ONFH by inhibiting ABL1.

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.

Hip effusion/synovitis influences results after multiple drilling core decompression for bone marrow edema syndrome of hip

BACKGROUND

At present, it is not known whether hip effusion/synovitis affects the therapeutic effect of multiple drilling core decompression (MDCD) in patients with bone marrow edema syndrome of hip (BMESH). The aims were to assess hip effusion/synovitis and its relationship with results of MDCD in patients with BMESH.

METHODS

The data of undergoing arthroscopic-assisted MDCD for treatment of BMESH with hip effusion/synovitis by one surgeon were retrospectively reviewed from the associated medical records at the Affiliated Hospital of Zunyi Medical University (2016-2019). Seven patients (9 hips) participated in this study. Patients were followed up at 1, 2, 3, 6, 12 and 24 months. Data included demographics and clinical outcomes. The pre- and postoperative pain and functional outcomes were measured with the visual analogue scale (VAS), Harris Hip Score (HHS), Hip Outcome Score Activities of Daily Living subscale (HOS-ADL), International Hip Outcome Tool-12 (iHOT-12) and range of motion (ROM).

RESULTS

Seven patients (9 hips) were followed up. Disappearance of hip pain immediately obtained at rest after surgery. All of 7 patients returned to their former activity level at postoperative 3 months, bone marrow edema had disappeared on Magnetic Resonance Imaging (MRI). The VAS, HHS, HOS-ADL, iHOT-12, and ROM at postoperative 1 month had a significant difference (P < 0.05) compared with preoperative. It was also statistically significant (P < 0.05) when compared with other time points. At the final follow-up, all patients had no limited ROM, which was symmetrical with the contralateral of hip joint. Hip effusion/synovitis were observed in 9 hips. Labral tears, cartilage fissure, and loose bodies were observed in 1 hip, respectively. Kirschner wire tracks bleeding occurred in 1 hip. No other complications occurred.

CONCLUSIONS

Hip effusion/synovitis could affect the clinical outcomes after MDCD in patients with BMESH. Arthroscopic procedure of hip effusion/synovitis can shorten postoperative pain relief time, disappearance time of bone marrow edema on MRI. It can simultaneously diagnose and treat other concomitant intraarticular pathologies, and be a safe operation with fewer complications.

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

The indications for core decompression surgery in patients with ARCO stage I-II osteonecrosis of the femoral head: a new, comprehensive prediction system

Background

Core decompression (CD) is considered the most popular treatment method for patients with Association Research Circulation Osseous (ARCO) stage I-II osteonecrosis of the femoral head (ONFH). However, the definitive indication for CD is currently not well established.

Methods

This was a retrospective cohort study. Patients who were diagnosed with ARCO stage I-II ONFH and who underwent CD were included. According to the prognosis, the patients were divided into two groups: collapse of the femoral head after CD and noncollapse of the femoral head. Independent risk factors for the failure of CD treatment were identified. Subsequently, a new scoring system that included all these risk factors was built to help estimate the individual risk of CD failure in patients who were planning to undergo CD.

Results

The study included 1537 hips after decompression surgery. The overall failure rate of CD surgery was 52.44%. Seven independent prognostic factors for failed CD surgery were identified, such as male sex (HR = 75.449; 95% confidence interval (CI), 42.863-132.807), Aetiology (Idiopathic HR = 2.762; 95% CI, 2.016–3.788, Steroid-induced HR = 2.543; 95% CI, 1.852–3.685), if the patient had a seated occupation (HR = 3.937; 95% CI, 2.712–5.716), age (HR = 1.045; 95% CI, 1.032–1.058), haemoglobin level (HR = 0.909; 95% CI, 0.897–0.922), disease duration (HR = 1.217; 95% CI, 1.169–1.267) and the combined necrosis angle (HR = 1.025; 95% CI, 1.022–1.028). The final scoring system included these seven risk factors, and the area under the curve of this scoring system was 0.935 (95% confidential interval = 0.922–0.948).

Conclusion

This new scoring system might provide evidence-based medical proof for determining whether a patient with ARCO stage I - II ONFH might benefit from CD surgery. This scoring system is crucial for making clinical decisions. Consequently, this scoring system is recommended before CD surgery, which could help determine the potential prognosis of patients.

Intramedullary core decompression combined with endoscopic intracapsular decompression and debridement for pre-collapse non-traumatic osteonecrosis of the femoral head

BACKGROUND

The effect of core decompression on the treatment of pre-collapse non-traumatic osteonecrosis of the femoral head (ONFH) is still limited. This study aimed to explore the efficacy of core decompression combined with intra-articular decompression (debridement of the hip joint and incision of the hip capsule) under hip arthroscopic guidance in patients with pre-collapse ONFH.

METHODS

The clinical data of 101 patients with pre-collapse ONFH were analysed retrospectively. Sixty patients (80 hips) received small-diameter multi-channel core decompression alone in first half review period (group B). Forty-one patients (59 hips) were treated with small-diameter multi-channel core decompression combined with intra-articular decompression under hip arthroscopy guidance in second half review period (group A). The surgical duration; intraoperative bleeding; intra-articular pressure(IAP) before and after surgery; length of hospital stay; hospitalisation expenses; visual analogue scale (VAS) score before, 1 week, 4 weeks, 3 months and 1 year after surgery; and Harris score of the hip joint before, 3 months and 1 year after surgery were recorded and compared between group A and group B. X-ray examination was performed every month to observe the collapse of the femoral head within 2 years after surgery, which was compared using the Kaplan-Meier survival curve analysis.

RESULTS

When the two groups were compared, the surgical duration was longer and hospitalisation expenses were higher in group A than in group B (P < 0.05). However, the VAS score and the Harris score of the hip joint after surgery improved significantly compared with those before surgery (P < 0.05), which were more apparent in group A than in group B (P < 0.05). X-ray examination revealed that 6 hips in group A and 22 in group B received femoral head collapse at the 2-year follow-up. The survival rate of the femoral head in group A was significantly higher than that in group B (P < 0.05).

CONCLUSION

Small-diameter multi-channel core decompression combined with intra-articular decompression (debridement of the hip joint and incision of the hip capsule) under hip arthroscopic guidance for treating early ONFH can more effectively alleviate joint pain, improve joint function and delay ONFH progression.

Osteonecrosis of the Femoral Head. Optimizing the Early-Stage Joint-Preserving Surgical Treatment?

Osteonecrosis of the femoral head (ONFH) is a debilitating condition with various etiologies. Comprehension of the pathophysiology of the disease is limited, adding to the challenge of devising a clinically effective treatment strategy. High clinical suspicion and magnetic resonance imaging aid early diagnosis, leading to less invasive and more effective treatment. Recent advancements in joint-preserving surgical treatment have led to improved outcomes, reduced pain, and a higher hip survival rate for early onset osteonecrosis of the femoral head compared with more invasive approaches such as total hip replacement. Core decompression is the gold standard procedure to relieve the ischemic area of the femoral head and is crucial in the early stage of osteonecrosis. The addition of biologic regenerative agents to core decompression is auspicious as they can introduce new cells to the area of necrosis, osteoinductive and osteoconductive agents, while enhancing healing and cellular repair. Adjunctive bone marrow-derived cell therapies have been advocated, potentially aiding the regenerative process. Arthroscopic core decompression and robot-assisted orthopaedic surgery are believed to improve the precision of graft placement, decreasing radiation and operative time. The current study provides a comprehensive review and update of the literature surrounding the latest developments regarding joint-preserving surgical treatment for patients with osteonecrosis of the femoral head.

An overview of pathophysiology and treatment options of osteonecrosis of femoral head in sickle cell disease

Osteonecrosis of the femoral head (ONFH) is the most prevalent musculoskeletal pathologic manifestation of sickle cell disease (SCD) resulting in an osteonecrotic event. This review aimed to summarize mechanisms involved in pathophysiology of ONFH and treatment options available in Saudi Arabia to treat SCD patients with complication of osteonecrotic event. The pathophysiology of ONFH include genetic and micro particles involvement. The progression of osteonecrosis involves reduced levels of bioactive compounds in peripheral blood mononuclear cells and elevated CD4+T circulating levels to stimulate pro-inflammatory cytokines contributing to inflammation at target site. Initial treatment approach is pharmacological agents use to mitigate risk. Further, bone morphogenetic protein stimulation initiate bone formation and treatment can be improved with the use of bone morphogenetic protein, total hip arthroplasty and cell therapies. This review provides baseline information for future studies to be carried out in Saudi Arabia to improve treatment options in SCD patients with ONFH.

Arthroscopic Core Decompression for Avascular Necrosis of the Femoral Head Using Multiple Small-Diameter Tunnels

Avascular necrosis of the femoral head (AVNFH) is a debilitating disease that requires early intervention to prevent subchondral collapse and irreversible damage leading to premature hip replacement. Patients presenting with AVNFH can have concomitant intra-articular pathology, including femoroacetabular impingement (FAI), that contributes to their hip pain and dysfunction. It is important to restore the native hip anatomy in addition to providing revascularization of necrotic areas to reduce pain, improve function, and maximize efforts to preserve the joint. The purpose of this Technical Note is to describe our preferred arthroscopic approach to core decompression through the femoral neck in combination with femoral osteoplasty to address AVNFH and FAI in a single-staged and minimally invasive procedure.

Updates on Management of Avascular Necrosis Using Hip Arthroscopy for Core Decompression

Osteonecrosis of the femoral head (ONFH) is caused when circulation within the femoral head is disrupted. Etiology of this disease is characterized by either traumatic events or atraumatic risk factors, such as chronic alcohol consumption or glucocorticoid use. ONFH commonly presents as pain in the groin, gluteus muscles, and/or knee with reductions in internal rotation range of motion of the hip. ONFH pathology can be confirmed with radiographic or advanced imaging and characterized by stage, size and location of the lesion. Treatment for ONFH consists of conservative and therapeutic methods as well as surgical intervention. Historically, ONFH has been treated using total hip arthroplasty (THA), but with increasing incidence in a younger, active population, measures to preserve the native hip joint have been explored. Recent advancements in hip arthroscopy and arthroscopy-assisted core decompression have led to improved outcomes, reduced pain and higher hip survival rate for early onset ONFH compared with more invasive approaches such as THA. Biologic treatments combined with arthroscopic core decompression have also shown improved outcomes and quality of life in few reports, suggesting a potential role for biologic adjuncts. The current study provides a comprehensive review and update on the literature surrounding arthroscopy-assisted core decompression for patients with ONFH.

Femoral cartilage damage occurs at the zone of femoral head necrosis and can be accurately detected on traction MR arthrography of the hip in patients undergoing joint preserving hip surgery

The primary purpose was to answer the following question: What is the location and pattern of necrosis and associated chondrolabral lesions and can they be accurately detected on traction MR arthrography compared with intra-operative findings in patients undergoing hip preservation surgery for femoral head necrosis (FHN)? Retrospective, diagnostic case series on 23 patients (23 hips; mean age 29 ± 6 years) with diagnosis of FHN undergoing open/arthroscopic joint preserving surgery for FHN and pre-operative traction MR arthrography of the hip. A MR-compatible device for weight-adapted application of leg traction (15-23 kg) was used and coronal, sagittal and radial images were acquired. Location and pattern of necrosis and chondrolabral lesions was assessed by two readers and compared with intra-operative findings to calculate diagnostic accuracy of traction MR arthrography. On MRI all 23 (100%) hips showed central FHN, most frequently antero-superiorly (22/23, 96%) where a high prevalence of femoral cartilage damage was detected (18/23, 78%), with delamination being the most common (16/23, 70%) damage pattern. Intra-operative inspection showed central femoral head cartilage damage most frequently located antero-superiorly (18/23, 78%) with femoral cartilage delamination being most common (14/23, 61%). Traction MR arthrography enabled detection of femoral cartilage damage with a sensitivity/specificity of 95%/75% for reader 1 and 89%/75% for reader 2. To conclude, femoral cartilage damage occurs at the zone of necrosis and can be accurately detected using traction MR arthrography of the hip which may be helpful for surgical decision making in young patients with FHN.

Arthroscopic Approach to Preservation of the Hip with Avascular Necrosis

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

Ten-year results of mesenchymal stromal cell transplantation augmented with vascularised bone grafts for advanced osteonecrosis of the femoral head

Background

A prospective, open-label clinical trial, in which transplantation of cultured autologous bone marrow-derived multipotent mesenchymal stromal cells in combination with vascularised bone grafts for the treatment of post-collapse extensive osteonecrosis of the femoral head in ten patients, was conducted previously. The aim of this study was to assess the 10-year clinical and radiographic results of that study.

Methods

Patients were evaluated for radiographic progression of osteonecrosis of the femoral head using anteroposterior radiographs at 10 years postoperatively. Clinical score and hip function, including the timed up and go test, were also estimated.

Results

Osteoarthritic changes in the affected hip were found in five of the ten patients, two of whom had undergone total hip arthroplasty at 7 and 9 years postoperatively. Five of the six cases (83.3%) in which pre-operative femoral head collapse was less than 3 mm, had no further collapse. On the other hand, all four cases in which pre-operative femoral head collapse was ≥3 mm, showed osteoarthritic changes within 10 years. The average clinical score significantly improved postoperatively and was maintained at 10 years.

Conclusions

Considering that eight of 10 post-collapse cases could avoid total hip arthroplasty conversion with good clinical results for 10 years and five of 6 post-collapse cases (collapse <3 mm) could avoid further collapse and osteoarthritic changes for 10 years, mesenchymal stromal cell transplantation in combination with vascularised bone grafts could be an effective treatment for post-collapse osteonecrosis of the femoral head.

[Treatment of osteonecrosis of the femoral head with vascularized bone grafting]

Objective

To summarize the current progress of vascularized bone grafting in the treatment of osteonecrosis of the femoral head (ONFH), and to provide reference for treatment of ONFH.

Methods

The literature at home and abroad on the treatment of ONFH with vascularized bone grafting was reviewed, and the mechanism, operating methods and effectiveness, indications, and complications were summarized.

Results

Vascularized bone grafting is a commonly used clinical hip-preserving operation. By replacing necrotic bone tissue with vascularized bone, it can rebuild the blood circulation system, promote the healing of the necrotic area, and provide biomechanical support for the necrotic area of the femoral head, prevent the joint surface collapse. The main operations include the vascularized iliac bone flap grafting, the vascularized greater trochanter bone flap grafting, and the vascularized fibular grafting. The clinical application has achieved certain effectiveness, and the different procedures are suitable for different types of patients. The procedures need to be selected based on the patient's overall condition, the cause of ONFH, the necrosis stage, and the degree of the evaluation.

Conclusion

Vascularized bone grafting has a definite effectiveness in the treatment of ONFH in the young and middle-aged. It can significantly improve hip joint function, control the further development of the disease to a great extent, effectively delay or even avoid hip arthroplasty. It is a reliable hip-preserving operation worthy of promotion.

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

Background

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

Questions/purposes

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

Patients and methods

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

Results

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

Conclusions

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

Level of evidence

Level III, therapeutic study

Supplementary Information

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

Arthroscopic assessment of concomitant intraarticular pathologies in patients with osteonecrosis of the femoral head

This study's purpose is to arthroscopically assess the occurrence of intraarticular pathologies in patients with osteonecrosis of the femoral head (OFNH) and to compare arthroscopic with radiologic findings. In a retrospective cohort analysis of ONFH patients undergoing combined core decompression (CD) and hip arthroscopy, concomitant intraarticular pathologies were qualitatively and quantitatively assessed by means of arthroscopy. Intraoperative findings were compared with preoperative radiodiagnostics. Descriptive statistics were performed with results displaying type, degree and prevalence of co-pathologies. Based on a cohort of 27 hips with ONFH at ARCO stages II and III, 26 (96.3%) presented with concomitant intraarticular findings. Cam-deformity (n = 22; 81.5%), labral defects (n = 23; 85.2%) and chondral defects (n = 20; 74.1%) were the most frequent. Four hips (14.8%) had foveal ligament anomalies. Intraoperative detection of cam-deformity positively correlated with radiologically assessed pathologic α angles (p = 0.09). Radiologic evaluation of the acetabular labrum distinctly differed from arthroscopic findings. Reliable statements concerning the cartilage status were not possible due to the great difference in quality of the magnetic resonance imaging (MRIs). The results of this study revealed an arthroscopically proven prevalence of co-pathologies in >95% of patients with ONFH. Cam-type deformity, labral anomalies and chondral defects were the most frequent. Comparison of arthroscopic and radiologic findings showed coherent results regarding cam-deformity but revealed distinct difficulties in the assessment of the labral and chondral status emphasizing the need for standardization of preoperative radiodiagnostics. Moreover, it still has to be evaluated whether combined CD and arthroscopy can improve on the overall outcomes achieved by performance of CD only.

The Protective Effect of Luteolin in Glucocorticoid-Induced Osteonecrosis of the Femoral Head

Glucocorticoid-induced osteonecrosis of the femoral head (GIONFH) is a frequently occurring type of nontraumatic osteonecrosis. A failure of the timely treatment can eventually result in the collapse of the subchondral bone structure. Luteolin (Lut), a compound extracted from Rhizoma Drynariae, is reported to possess multiple pharmacological properties including anticancer, antioxidant, antiapoptosis, and antiinflammatory properties. However, whether Lut has a protective effect on the development of GIONFH remains unclear. In this study, we evaluated the effect of Lut on Dexamethasone (Dex)-induced STAT1/caspase3 pathway in vitro and evaluated GIONFH model in vivo. In vitro, Lut inhibited the upregulation of Dex-induced phospho-STAT1, cleaved caspase9, and cleaved caspase3. In addition, Lut inhibited Dex-induced expression of Bax and cytochrome c and increased the expression of B cell lymphoma-2(Bcl-2). In vivo, Lut decreased the proportion of empty lacunae in rats with GIONFH. Taken together, these findings indicate that Lut may have therapeutic potential in the treatment of GIONFH. Further, this effect might be achieved by suppressing mitochondrial apoptosis of osteoblasts via inhibition of STAT1 activity.

Treatments of avascular osteonecrosis of the hip: Current treatments

Conservative treatments for aseptic osteonecrosis of the femoral head have their ancestor in the core decompression of the femoral neck, recommended by Ficat. Due to inconsistent results, this treatment has been optimized by either vascularized fibular grafting, or by injecting autologous stem cells into the necrotic zone. The French promoters have published long-term results, showing efficacy in the early stages of the disease, where the femoral head has not yet lost its sphericity. Over the last 10years, comparative studies, sometimes randomized, opposing them to simple core decompression, have been published by non-promoters, confirming the possibility of stabilization or even regression of necrosis area. But these techniques are not easy to implement. Cell therapy requires treatment of marrow samples by centrifugation to obtain a pellet with a high concentration of haematopoietic cells. The now proven long-term efficacy as well as the safety of this technique make it the method of choice for treating young patients detected at the sub-radiological stage by MRI. Unfortunately, many are seen late with detached cephalic cartilage or collapsed femoral head and have no other option than total hip arthroplasty. This technique is very reliable. With alumina ceramics, results of more than 20years show the absence of wear and osteolysis, although other complications such as instability or periprosthetic fractures may occur in these young and active patients.

Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today?: A 5-Year Update

➢. Clinicians should exercise a high level of suspicion in at-risk patients (those who use corticosteroids, consume excessive alcohol, have sickle cell disease, etc.) in order to diagnose osteonecrosis of the femoral head in its earliest stage. ➢. Nonoperative treatment modalities have generally been ineffective at halting progression. Thus, nonoperative treatment is not appropriate in early stages when one is attempting to preserve the native joint, except potentially on rare occasions for small-sized, medially located lesions, which may heal without surgery. ➢. Joint-preserving procedures should be attempted in early-stage lesions to save the femoral head. ➢. Cell-based augmentation of joint-preserving procedures continues to show promising results, and thus should be considered as an ancillary treatment method that may improve clinical outcomes. ➢. The outcomes of total hip arthroplasty in the setting of osteonecrosis are excellent, with results similar to those in patients who have an underlying diagnosis of osteoarthritis.