Core decompression and biotechnologies in the treatment of avascular necrosis of the femoral head

Increasing trend toward joint-preserving procedures for hip osteonecrosis in the United States from 2010 to 2019

INTRODUCTION

The incidence of osteonecrosis of the femoral head is estimated at about 10 to 20,000 patients annually, and, when left untreated, 80% or more of cases progress to femoral head collapse. A series of joint-preserving procedures have been developed to prevent/delay the need for hip arthroplasty. The aim of this study was to provide a five-year update: (1) evaluating temporal trends of arthroplasty vs. joint-preservation techniques such as core decompression, bone grafting, osteotomies, and arthroscopy; (2) determining proportions of procedures in patients aged less than vs. over 50 years; and (3) quantifying rates of specific operative techniques.

METHODS

A total of 10,334 patients diagnosed with osteonecrosis of the femoral head and having received hip surgery were identified from a nationwide database between 1 January 2010 and 31 December 2019, by using the International Classification of Disease, the Ninth/Tenth revision (ICD-9/10) codes. The percentage of patients managed by each operative procedure was calculated annually. To identify trends, patients were grouped by age under/over 50 years and divided into a joint-preserving and a non-joint-preserving (arthroplasty) group. Chi-squared tests were performed to compare the total number of procedures per year.

RESULTS

Rates of arthroplasty far exceeded those for joint-preserving procedures. However, from 2015 to 2019, significantly more joint-preserving procedures were performed than in 2010 to 2014 (4.3% vs. 3.0%, P < 0.001). Significantly more joint-preserving procedures were performed in patients aged < 50 years relative to those ≥ 50 years (7.56% vs. 1.86%, P < 0.001). Overall, total hip arthroplasty was the most common procedure (9,814; 94.97%) relative to core decompression (331; 3.20%), hemiarthroplasty/resurfacing (102; 0.99%), bone grafting (48; 0.46%), and osteotomy (5; 0.05%).

CONCLUSION

Management of patients who have osteonecrosis of the femoral head continues to be predominantly arthroplasty procedures, specifically, total hip arthroplasty. Our findings suggest a small, but significant trend toward increased joint-preserving procedures, especially in patients under 50 years. In particular, the proportion of patients receiving core decompression has increased significantly from 2015 to 2019 relative to prior years.

Microrna-206 induces hypoxic necrosis of femoral head by inhibiting VEGF/PI3K/AKT signaling pathway

The most common form of non-traumatic necrosis of the femoral head is anoxic necrosis of the femoral head, which is a metabolic disease, mainly involving young and middle-aged people. Apoptosis and its related signal regulation pathway play an important role in the occurrence and development of hypoxic necrosis of the femoral head. In order to investigate the possible pathological manifestations of miR-206 and VEGF/PI3K/AKT signal pathway genes and their interactions in hypoxic necrosis of the femoral head, this paper intended to systematically study the expression and regulation mechanism of miR-206 and VEGF/PI3K/AKT signal pathway genes. The interaction between miR-206 and VEGF/PI3K/AKT signaling pathway and its regulation on apoptosis, differentiation and proliferation of human osteoblast cell line hFOB1.19 (SV40 transfer of human osteoblasts) were studied by double luciferase reporter gene analysis, overexpression and inhibition of miR-206, and gene silencing of VEGF/PI3K/AKT signaling pathway. After 24 h and 48 h of intervention with MicroRNA 206 on osteoblasts, it was found that the fluorescence intensity of caspase-3 was higher than that of 0 h group (p < 0.05). This paper has provided an important research basis for the research of femoral head necrosis and the development of new diagnosis and therapeutic drugs for this kind of disease. It also has provided a reference for the further promotion of the chemotherapy drug delivery system.

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.

Undiagnosed Bilateral Avascular Necrosis of the Femur in a Young Male Caused by COVID-19 Steroid Injections

Osteonecrosis is a degenerative bone disease brought on by a change in subchondral blood flow and characterized by the loss of bone cellular components. Other names for it include ischemic bone necrosis, aseptic necrosis, and avascular necrosis. Long bones' epiphyses in weight-bearing joints are typically impacted. In extreme cases, a joint may completely collapse or subchondral bone may be obliterated. Avascular necrosis, which most frequently affects joints, especially the femoral head, occurs when the blood supply to the bones is diminished. In this article, we will explain the clinical case of a 40-year-old man who's been complaining about hip pain for two months. The patient went to Acharya Vinobha Bhave Rural Hospital (AVBRH) with the same complaint and underwent some tests; upon inspection, it was discovered that the patient had bilateral avascular femoral head necrosis. For avascular necrosis (AVN) of the left femoral head, the patient had core decompression surgery. Once post-operative physical therapy was initiated, the condition significantly improved, and it also served to prevent additional abnormalities. The goal of this case study is to examine the therapeutic strategies essential for treating bilateral femoral head avascular necrosis.

Multiple Drilling with Recombinant Human Bone Morphogenetic Protein-2 in Korean Patients with Non-Traumatic Osteonecrosis of the Femoral Head: A Prospective Randomized Pilot Study with a Minimum Two-Year Follow-Up

We sought to determine whether multiple drilling (MD) combined with the injection of recombinant human bone morphogenetic protein-2 (rhBMP-2) and β-tricalcium phosphate (β-TCP) could improve survival of the femoral head in pre-collapse lesions of non-traumatic osteonecrosis of the femoral head (ONFH) as compared with MD alone. We conducted a single-site, off-label, comparative and prospective cohort study between November 2017 and May 2019. We enrolled 25 hips (25 patients) with non-traumatic ONFH (Ficat–Arlet stage 2A or less). We performed a survival analysis, and the primary outcome was the occurrence of femoral head collapse on follow-up radiograph. Our cohort consisted of 11 men and 9 women of age 52.5 ± 8.8 years and a body mass index of 24.3 ± 3.0 kg/m². The femoral heads were preserved in 9 hips (45.0%) and collapsed in 11 hips (55.0%) at the final follow-up; mean survival to collapse was 6.9 (range 2.8–13.5) months. There were no significant differences in the survival of the femoral head between the MD alone group and the MD with rhBMP-2 and β-TCP group (five hips survived, 50% vs. four hips survived, 40%, respectively; p = 0.83). MD combined with the injection of rhBMP-2 and β-TCP did not improve femoral head survival compared to MD alone in the pre-collapse non-traumatic ONFH lesion.

Influence of less invasive hip preservation surgery on subsequent hip arthroplasty for osteonecrosis of the femoral head

The purpose of this study was to evaluate the outcomes of total hip arthroplasty (THA) following less invasive hip-preserving procedures (LIHPs) and present a critical overview of the literature to aid in better result interpretation. The search time was from the establishment of the database to September 2021, and the outcome indicators were extracted and analyzed by Cochrane Collaboration Review Manager software (RevMan version 5.4). Finally, 10 articles were included in this meta-analysis by searching Chinese databases and English databases. Three of them were published in Chinese, and the remaining studies were published in English. LIHP was further divided into the tantalum rod implantation group and the non-tantalum rod implantation group. The results showed that prior tantalum rod implantation increased the difficulty of conversion to THA, which was reflected mainly in the longer operative time [weighted mean difference (WMD) = 24.50, 95% confidence interval (CI) = 14.09–34.91, P < 0.00001] and greater intraoperative blood loss (WMD = 114.74, 95% CI = 33.52–195.96, P = 0.006), while no significant difference was found between the non-tantalum rod implantation group and the control group. Simultaneously, easier intraoperative fracture [odds ratio (OR) = 5.88, 95% CI = 0.93–37.05, P = 0.06] and stem malalignment (OR = 4.17, 95% CI = 1.18–14.71, P = 0.03) in the LIHP group tended to be observed than in the control THA group. However, there was no significant difference in cup anteversion and inclination angle, ectopic ossification, postoperative Harris Hip Score and survivorship between the LIHP group and the control group. Although LIHP increased the difficulty of the conversion to THA, it does not detrimentally affect the clinical results of subsequent THA in the mid-term follow-up.

C/EBPα regulates the fate of bone marrow mesenchymal stem cells and steroid-induced avascular necrosis of the femoral head by targeting the PPARγ signalling pathway

BACKGROUND

The imbalance of osteogenic/adipogenic differentiation of bone marrow mesenchymal stem cells (BMSCs) is closely related to steroid-induced avascular necrosis of the femoral head (SANFH). We aimed to investigate the epigenetic mechanism of intramedullary fat accumulation and continuous osteonecrosis after glucocorticoid (GC) withdrawal in SANFH.

METHODS

An SANFH model was established in SD rats, which received an intermittent high GC dose for the first 4 weeks followed by an additional 4 weeks without GC. We explored the synergistic effects and mechanisms of C/EBPα and PPARγ on the differentiation of BMSCs by lentivirus-mediated gene knockdown and overexpression assays. A chromatin immunoprecipitation assay was performed to identify epigenetic modification sites on PPARγ in vivo and in vitro.

RESULTS

In the SANFH model, intramedullary fat was significantly increased, and the transcription factors C/EBPα and PPARγ were upregulated simultaneously in the femoral head. In vitro, C/EBPα promoted adipogenic differentiation of BMSCs by targeting the PPARγ signalling pathway, while overexpression of C/EBPα significantly impaired osteogenic differentiation. Further studies demonstrated that histone H3K27 acetylation of PPARγ played an important role in the epigenetic mechanism underlying SANFH. C/EBPα upregulates the histone H3K27 acetylation level in the PPARγ promoter region by inhibiting HDAC1. Additionally, inhibiting the histone acetylation level of PPARγ effectively prevented adipogenic differentiation, thus slowing the progression of SANFH.

CONCLUSIONS

Our results demonstrate the molecular mechanism by which C/EBPα regulates PPARγ expression by acetylating histones and revealed the epigenetic phenomenon in SANFH for the first time.

Skeletal regeneration for segmental bone loss: Vascularised grafts, analogues and surrogates

Massive segmental bone defects (SBD) are mostly treated by removing the fibula and transplanting it complete with blood supply. While revolutionary 50 years ago, this remains the standard treatment. This review considers different strategies to repair SBD and emerging potential replacements for this highly invasive procedure. Prior to the technical breakthrough of microsurgery, researchers in the 1960s and 1970s had begun to make considerable progress in developing non autologous routes to repairing SBD. While the breaktthrough of vascularised bone transplantation solved the immediate problem of a lack of reliable repair strategies, much of their prior work is still relevant today. We challenge the assumption that mimicry is necessary or likely to be successful and instead point to the utility of quite crude (from a materials technology perspective), approaches. Together there are quite compelling indications that the body can regenerate entire bone segments with few or no exogenous factors. This is important, as there is a limit to how expensive a bone repair can be and still be widely available to all patients since cost restraints within healthcare systems are not likely to diminish in the near future. STATEMENT OF SIGNIFICANCE: This review is significant because it is a multidisciplinary view of several surgeons and scientists as to what is driving improvement in segmental bone defect repair, why many approaches to date have not succeeded and why some quite basic approaches can be as effective as they are. While there are many reviews of the literature of grafting and bone repair the relative lack of substantial improvement and slow rate of progress in clinical translation is often overlooked and we seek to challenge the reader to consider the issue more broadly.

Mid- to long-term results of modified avascular fibular grafting for ONFH

Free vascularized fibular grafting was reported a favorable method to prevent the collapse of the femoral head. This study analyzed the mid- to long-term outcomes of avascular fibular grafting (AVFG) for osteonecrosis of the femoral head (ONFH) with 6- to 8-year follow-up. From March 2009 to March 2012, 34 patients (48 hips) were diagnosed with ONFH operated with AVFG in Jiangsu Province Hospital of traditional Chinese Medicine. We retrospectively reviewed the clinic outcomes of these patients and evaluated the differences in outcomes by diverse stages [Association Research Circulation Osseous (ARCO)] and types [China–Japan Friendship Hospital (CJFH) classification] annually. The hip survival rate, Harris hip score (HHS), activity level and imaging stability were calculated. The average follow-up time was 6.7 years. At the last follow-up, 34 of 48 hips survived totally. According to the ARCO stage, the overall clinical success rate for hip preserving were 76.0% (19/25) in II stage, 85.7% (12/14) in IIIA stage and 33.3% (3/9) in IIIB stage. Referring to the CJFH classification system, the hip survival rate were 100% (2/2) in M type, 90.9% (10/11) in C type, 77.8% (14/18) in L1 type, 57.1% (8/14) in L2 type and 0% (0/3) in L3 type. The mean visual analog scale (VAS) score, HHS and Western Ontario McMaster Osteoarthritis index (WOMAC) were significantly improved at the final follow-up compared with pre-operative values (P < 0.001). The AVFG operation can increase the hip function and improve patients’ lives quality. The mid- to long-term efficacy can satisfy fundamental life requirements, especially for those early-stage and small-scale patients who suffer ONFH to avoid or put off the time of total hip arthroplasty surgery.

Hip preserving procedures for osteonecrosis of the femoral head after collapse

Osteonecrosis of the femoral head (ONFH) affects mainly young patients and causes secondary hip osteoarthritis if remains untreated. Several operative treatments have been introduced with successful outcomes in the early stages. However, in late stages of ONFH treatment may be challenging due to the progressive nature of disease and many surgeons prefer arthroplasty option after collapse. Considering the size, age and etiology an effort should be made to preserve hip joint selected patients with early collapse or minimal arthritic changes. The purpose of the current review is to discuss the results of joint preserving procedures for late stages of ONFH.

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.

Relationship between hip joint medial space ratio and collapse of femoral head in non-traumatic osteonecrosis: a retrospective study

To retrospectively analyze the medial space ratio (MSR) of the hip joint to evaluate its efficacy in predicting osteonecrosis of femoral head (ONFH)-induced collapse and its impacts on the mechanical environment of necrotic femoral head. In this retrospective analysis of traditional Chinese medicine, non-traumatic ONFH (NONFH) patients from January 2008 to December 2013 were selected. The patients were divided into collapse group and non-collapse group based on whether the femoral head collapsed. The anatomical parameters including center–edge (CE) angle, sharp angle, acetabular depth ratio and MSR were evaluated. Receiver operating characteristic curves were estimated to evaluate the sensitivity and specificity of MSR and CE angle in collapse prediction. The results showed that 135 patients (151 hips) were included in this study. The differences in CE angle and MSR between collapse group and non-collapse group were statistically significant. The mean survival time of the hips of patients with MSR &lt;20.35 was greater (P &lt; 0.001) than that of patients with MSR &gt;20.35. The ONFH patients with MSR &gt;20.35 were prone to stress concentration. We could conclude that the hip joint MSR and CE angle strongly correlated with the collapse of NONFH. The specificity of MSR is higher than that of CE angle. When MSR is &gt;20.35, the collapse rate of ONFH will increase significantly.

Implantation of autologous Expanded Mesenchymal Stromal Cells in Hip Osteonecrosis through Percutaneous Forage: Evaluation of the Operative Technique

Bone forage to treat early osteonecrosis of the femoral head (ONFH) has evolved as the channel to percutaneously deliver cell therapy into the femoral head. However, its efficacy is variable and the drivers towards higher efficacy are currently unknown. The aim of this study was to evaluate the forage technique and correlate it with the efficacy to heal ONFH in a multicentric, multinational clinical trial to implant autologous mesenchymal stromal cells expanded from bone marrow (BM-hMSCs). Methods: In the context of EudraCT 2012-002010-39, patients with small and medium-sized (mean volume = 13.3%, range: 5.4 to 32.2) ONFH stage II (Ficat, ARCO, Steinberg) C1 and C2 (Japanese Investigation Committee (JIC)) were treated with percutaneous forage and implantation of 140 million BM-hMSCs in a standardized manner. Postoperative hip radiographs (AP—anteroposterior and lateral), and MRI sections (coronal and transverse) were retrospectively evaluated in 22 patients to assess the femoral head drilling orientation in both planes, and its relation to the necrotic area. Results: Treatment efficacy was similar in C1 and C2 (coronal plane) and in anterior to posterior (transverse plane) osteonecrotic lesions. The drill crossed the sclerotic rim in all cases. The forage was placed slightly valgus, at 139.3 ± 8.4 grades (range, 125.5–159.3) with higher dispersion (f = 2.6; p = 0.034) than the anatomical cervicodiaphyseal angle. Bonferroni’s correlation between both angles was 0.50 (p = 0.028). More failures were seen with a varus drill positioning, aiming at the central area of the femoral head, outside the weight-bearing area (WBA) (p = 0.049). In the transverse plane, the anterior positioning of the drill did not result in better outcomes (p = 0.477). Conclusion: The forage drilling to deliver cells should be positioned within the WBA in the coronal plane, avoiding varus positioning, and central to anterior in the transverse plane. The efficacy of delivered MSCs to regenerate bone in ONFH could be influenced by the drilling direction. Standardization of this surgical technique is desirable.

Osteonecrosis of the Femoral Head Safely Healed with Autologous, Expanded, Bone Marrow-Derived Mesenchymal Stromal Cells in a Multicentric Trial with Minimum 5 Years Follow-Up

Background: Osteonecrosis (ON) of the femoral head represents a potentially severe disease of the hip where the lack of bone regeneration may lead to femoral head collapse and secondary osteoarthritis, with serious pain and disability. The aim of this European, multicentric clinical trial was to prove safety and early efficacy to heal early femoral head ON in patients through minimally invasive surgical implantation of autologous mesenchymal stromal cells (MSC) expanded from bone marrow (BM) under good manufacturing practices (GMP). Methods: Twenty-two patients with femoral head ON (up to ARCO 2C) were recruited and surgically treated in France, Germany, Italy and Spain with BM-derived, expanded autologous MSC (total dose 140 million MSC in 7 mL). The investigational advanced therapy medicinal product (ATMP) was expanded from BM under the same protocol in all four countries and approved by each National Competent Authority. Patients were followed during two years for safety, based on adverse events, and for efficacy, based on clinical assessment (pain and hip score) and imaging (X-rays and MRIs). Patients were also reviewed after 5 to 6 years at latest follow-up for final outcome. Results: No severe adverse event was recalled as related to the ATMP. At 12 months, 16/20 per protocol and 16/22 under intention-to-treat (2 drop-out at 3 and 5 months) maintained head sphericity and showed bone regeneration. Of the 4 hips with ON progression, 3 required total hip replacement (THR). At 5 years, one patient (healed at 2 years visit) was not located, and 16/21 showed no progression or THR, 4/21 had received THR (all in the first year) and 1 had progressed one stage without THR. Conclusions: Expanded MSCs implantation was safe. Early efficacy was confirmed in 80% of cases under protocol at 2 years. At 5 years, the overall results were maintained and 19% converted to THR, all in the first year.

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.

Extracorporeal shockwave therapy combined with multiple drilling and intramedullary drug injection for treating early-stage Femur Head Necrosis: Protocol for a randomized controlled trial

BACKGROUND

Early diagnosis and treatment of the osteonecrosis of the femoral head (ONFH), a refractory disease, is imperative to prevent femoral head collapse; however, the existing solutions remain controversial. This study assessed the safety and efficacy of extracorporeal shock wave therapy (ESWT) combined with multiple drilling and intramedullary drug injection, a novel cocktail therapy, as a randomized controlled trial (RCT) model to postulate an alternative therapy for patients with early-stage ONFH.

METHODS

Femoral head necrosis patients aged 20 to 60 years with stage ARCO I-II were recruited. One hundred twenty eligible participants were randomized into four groups in a 1:1:1:1 ratio: extracorporeal shock wave therapy combined with multiple drilling and intramedullary drug injection (group EMI), extracorporeal shock wave therapy (group E), multiple drilling combined with intramedullary drug injection (group MI), and multiple drilling ("positive" control group; group M). The primary outcomes included effective rate, subchondral collapse rate of the femoral head, lesion size, and grade of bone marrow edema. Secondary outcomes included the Harris Hip Score and the visual analog scale. All outcomes were measured at the screening visit (baseline) and at the planned time intervals during treatment and follow-up, and the efficacy was statistically analyzed according to the intention-to-treat sub-populations and per-protocol sub-populations.

OBJECTIVES

To examine the clinical efficacy of ESWT combined with multiple drilling and intramedullary drug injection to provide a safe and more effective method for treating early-stage ONFH.

TRIAL REGISTRATION NUMBER

ChiCTR1900020888; Pre-results.

Fibula allograft propping as an effective treatment for early-stage osteonecrosis of the femoral head: a systematic review

BACKGROUND

Osteonecrosis of the femoral head (ONFH) causes severe hip dysfunction. Left untreated, 80% of patients experience femoral head collapse, and 65-70% of patients require total hip arthroplasty (THA). Therefore, effective treatment is very important for ONFH.

OBJECTIVE

To examine the effectiveness of fibula allografting for the treatment of early-stage ONFH METHODS: A systematic review was conducted by searching PubMed, EMBASE, and Web of Science databases using "avascular necrosis" or "ischemic necrosis" or "osteonecrosis" and "femoral head" and "fibula*," and checking the references of primary articles and reviews. Two independent authors completed the study selection separately. We extracted the following details from each article: characteristics of the patients, clinical efficacy evaluation (Harris hip score [HSS], radiographic outcomes, the rate of conversation to total hip arthroplasty [THA], and adverse effects).

RESULTS

A total of 213 articles were selected from PubMed (n = 45), EMBASE (n = 77), Web of Science (n = 203), and other sources (n = 10). After checking the articles, five articles were included in the final analysis. The average age of patients involved in this review was 34.48 years. The studies investigated fibula allografts to treat ONFH in 394 hips with a mean follow-up of 49.06 months. HHS was improved from 62.73 to 86.94. Radiographic progression was found in 33.66% of hips. The failure rate of head-saving surgery by THA was 14.5%. No patients had serious postoperative complications.

LIMITATIONS

The number of articles included in the study was small, and all studies were single-center studies. Most studies were retrospective with a low level of evidence. Surgical procedures were not identical with different follow-up times.

CONCLUSION

Although there are some limitations to our approach, this systematic review supports fibula allografting as a simple, effective treatment for early-stage ONFH, which presents less postoperative complications, and has a satisfactory clinical effect. We consider it to be worthy of promotion as a therapy for ONFH.

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).

Joint-preserving procedures for osteonecrosis of the femoral head

Osteonecrosis of the femoral head is a poorly understood condition that may lead to progressive destruction of the hip joint. Its incidence is common between the third and fifth decades of life and it is the diagnosis behind 5–18% of annually performed total hip arthroplasties (THAs) in the USA.

Regarding the high rate of complications of THA in that age group, authors have agreed on the importance of joint-preservation techniques for this disease but techniques vary to establish a generally accepted algorithmic approach.

Surgical head-preserving procedures, core decompression with or without graft, stem cell augmentation, or biologic adjuncts, vascularized bone grafting, and proximal femoral osteotomies have all been published on with heterogeneous results and with limited evidence to date.

Consensus states that the prognosis of patients with osteonecrosis of the femoral head can be significantly improved with early diagnosis and timely intervention.

Cite this article: EFORT Open Rev 2019;4:647-658. DOI: 10.1302/2058-5241.4.180073

Nontraumatic avascular necrosis of the femoral head : Arthroscopic and navigation-supported core decompression

OBJECTIVE

The aim is to address core decompression and pathologies of the femoral head, treating them during the same procedure. Furthermore, radiation exposure will be reduced.

INDICATIONS

Femoral head necrosis ARCO (Association Research Circulation Osseous) stages I-III.

CONTRAINDICATIONS

Progressive femoral head necrosis as ARCO stages IIIC-IV.

SURGICAL TECHNIQUE

Arthroscopically navigated core decompression of the femoral head using an established optoelectronic system with fluoro-free software module. First, hip joint arthroscopy was performed and further pathologies were treated. Second, core decompression was navigated by a navigation pointer and drill sleeve to reach the correct target point. After visualization, the procedure is repeated 3-5 times.

POSTOPERATIVE MANAGEMENT

Limited weight bearing of the operated leg (20 kg) for 10-14 days. Active or passive continuous motion machine for 4 weeks. Adjuvant postoperative indomethacin therapy for 10 days to reduce pain and bone marrow edema.

RESULTS

From May 2018 to January 2019, 7 patients (male = 4; 40 ± 9 years) underwent arthroscopically navigated core decompression with 2 (29%) and 5 (71%) patients being classified as ARCO II and III, respectively. Preoperatively, all patients reported load-dependent pain. In all cases, we could identify synovitis, which results in soft tissue release and synovectomy. Furthermore, 4 of 7 patients had an additional labrum lesion, which is addressed by refixation or shrinking.

DISCUSSION

Compared to the conventional technique, this fluoro-free navigation procedure allows more precise drilling. Moreover, additional pathologies, as found in all our cases, could be simultaneously addressed. The intraoperative radiation exposure for the patient and surgical team could also be reduced. Although arthroscopically assisted core decompression requires more preparation time, there are advantages over conventional surgery.

Effectiveness of neuromuscular electrical stimulation and ibuprofen for pain caused by necrosis of the femoral head: A retrospective study

This retrospective study analyzed the effectiveness of neuromuscular electrical stimulation (NMES) for pain relief caused by necrosis of femoral head (NFH).Totally, 80 cases of patients with NFH were analyzed and then were assigned to a treatment group or a control group in this study. Of these, 40 cases in the treatment group received ibuprofen and NMES therapy. The other 40 cases in the control group received ibuprofen alone. Cases in both groups were treated for a total of 6 weeks. The primary outcome of pain intensity was measured by a visual analog scale (VAS). The secondary outcome was assessed by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). In addition, adverse events (AEs) were also recorded in each case. All outcomes were evaluated before and after the treatment.After treatment, patients in the treatment group showed more effectiveness in pain relief, as measured by VAS (P < .01) and WOMAC sub-pain scale (P < .01), except stiffness, as evaluated by WOMAC sub-stiffness scale (P = .07), and function, as assessed by WOMAC sub-function scale (P = .09), than patients in the control group. Additionally, no significant differences in AEs were detected between 2 groups.This study found that NMES may be helpful for pain relief in patients with NFH.

Osteonecrosis of the Femoral Head: Etiology, Investigations, and Management

Femoral head osteonecrosis is a condition caused by a compromise of the blood supply of the femoral head. The precarious blood supply of the head and its role as a major weight-bearing joint makes it one of the most common bones to be affected by osteonecrosis. We describe the etiology, clinical presentation, investigations and common management options used nowadays to treat it.

Deer thymosin beta 10 functions as a novel factor for angiogenesis and chondrogenesis during antler growth and regeneration

BACKGROUND

Deer antlers are the only known mammalian organ with vascularized cartilage that can completely regenerate. Antlers are of real significance as a model of mammalian stem cell-based regeneration with particular relevance to the fields of chondrogenesis, angiogenesis, and regenerative medicine. Recent research found that thymosin beta 10 (TMSB10) is highly expressed in the growth centers of growing antlers. The present study reports here the expression, functions, and molecular interactions of deer TMSB10.

METHODS

The TMSB10 expression level in both tissue and cells in the antler growth center was measured. The effects of both exogenous (synthetic protein) and endogenous deer TMSB10 (lentivirus-based overexpression) on antlerogenic periosteal cells (APCs; nonactivated antler stem cells with no basal expression of TMSB10) and human umbilical vein endothelial cells (HUVECs; endothelial cells with no basal expression of TMSB10) were evaluated to determine whether TMSB10 functions on chondrogenesis and angiogenesis. Differences in deer and human TMSB10 in angiogenesis and molecular structure were determined using animal models and molecular dynamics simulation, respectively. The molecular mechanisms underlying deer TMSB10 in promoting angiogenesis were also explored.

RESULTS

Deer TMSB10 was identified as a novel proangiogenic factor both in vitro and in vivo. Immunohistochemistry revealed that TMSB10 was widely expressed in the antler growth center in situ, with the highest expression in the reserve mesenchyme, precartilage, and transitional zones. Western blot analysis using deer cell lines further supports this result. Both exogenous and endogenous deer TMSB10 significantly decreased proliferation of APCs (P < 0.05), while increasing the proliferation of HUVECs (P < 0.05). Moreover, deer TMSB10 enhanced chondrogenesis in micromass cultures and nerve growth as assessed using a dorsal root ganglion model (P < 0.05). Deer TMSB10 was proangiogenic using models of chicken chorioallantoic membrane, tube formation, and aortic arch assay. At the molecular level, endogenous deer TMSB10 elevated the expression of vascular endothelial growth factor (VEGF), VEGF-B, VEGF-C, and VEGF-D, and VEGFR2 and VEGFR3 in HUVECs (P < 0.05).

CONCLUSIONS

Deer TMSB10, in contrast to its human counterpart, was identified as a novel stimulating factor for angiogenesis, cartilage formation, and nerve growth, which is understandable given that deer antlers (as the arguably fastest mammalian growing tissue) may require this extra boost during a period of rapid growth and regeneration.

Clinical and Radiographic Alterations in Bilateral Avascular Necrosis of the Femoral Head Following Laser Acupuncture: A Case Report

Introduction: Avascular necrosis (AVN) of the femoral head is an increasingly common cause of musculoskeletal disability with unknown etiology. Traumatic and non-traumatic factors can be effective in its occurrence. About 50% of cases are bilateral. The underlying treatment is prosthetic replacement surgical procedure. Case Presentation: We report a case of bilateral AVN of femoral heads who was a candidate for prosthetic replacement surgery but improved significantly, using laser acupuncture. The patient was a 55-year-old woman with a diagnosis of bilateral osteonecrosis of the femoral head for five years. As the patient declined the surgical option, laser acupuncture was started for pain control. Regarding the signs of bilateral femoral head recovery (according to the MRI scan criteria), a total of 3 courses of laser acupuncture (each course was 20 sessions) with 2 months intervals was performed. Ten acupuncture points: Li4, Li11, St36, SP6, LIV3, GB4, GB5, GB6, GB13, GB14, GB20, GB30, GB31, GB34, were irradiated bilaterally using red 650 nm laser, 100 mW, 1505 Hz frequency, duty cycle 50 3 J/point and near infrared 810 nm laser, 100 mW, 1705 Hz frequency, duty cycle 50 3 J/point, for 2 minutes. The patient received 3 laser therapy courses. During the first-course, laser therapy was done every other day to reduce pain. For the second and third courses, according to pain decrease, therapy was done every week. Results: The results of the MRI scans and x-ray studies show progressive regeneration of the right femoral head from VI to B II and of the left from V to C II (based on the standard table of Pennsylvania). Conclusion: It seems that this procedure may be mentioned in future research projects, especially in cases with high risks of surgery.

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.