Joint-preserving procedures for osteonecrosis of the femoral head

Implantation of Culture-Expanded Bone Marrow Derived Mesenchymal Stromal Cells for Treatment of Osteonecrosis of the Femoral Head

BACKGROUND

Although core decompression (CD) with stem cell for the treatment of osteonecrosis of the femoral head (ONFH) showed promising results in many reports, the efficacy remains uncertain. We aimed to evaluate the efficacy of CD with culture-expanded autologous bone marrow-derived mesenchymal stem cell (BM-MSC) implantation in early stage ONFH.

METHODS

A total of 18 patients (22 hips) with ONFH who underwent CD with culture-expanded BM-MSC implantation from September 2013 to July 2020 were retrospectively reviewed. The median age was 35.0 years [interquartile range (IQR), 28.5-42.0], and the median follow-up period was 4.0 years (IQR, 2.0-5.3). The median number of MSCs was 1.06 × 108. To evaluate radiographic and clinical outcomes, Association Research Circulation Osseous (ARCO) classifications, Japanese Investigation Committee classification, combined necrotic angle (CNA) visual analogue scale (VAS) and Harris Hip Score (HHS) were checked at each follow-up.

RESULTS

The preoperative stage of ONFH was ARCO 2 in 14 hips and ARCO 3a in 8 hips. The ARCO staging was maintained in 7 hips in ARCO 2 and 4 hips in ARCO 3a. The radiographic failure rate of ARCO 2 and 3a was 14.3 and 50%, respectively. Furthermore, CNA decreased to more than 20° in 6 hips (four were ARCO 2 and two were ARCO 3a).There was no significant difference in the VAS and HHS (P = 0.052 and P = 0.535, respectively). Total hip arthroplasty was performed in 4 hips.

CONCLUSION

CD with culture-expanded autologous BM-MSCs showed promising results for the treatment of early stage ONFH.

Subtrochanteric fracture after core decompression for osteonecrosis of the femoral head: a case report and literature review

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a common clinical disease. Improper treatment can lead to femoral head collapse and hip joint dysfunction. Core decompression is particularly important for early ONFH. However, subtrochanteric fractures after core decompression cause some clinical problems.

CASE PRESENTATION

This article describes a 34-year-old male patient with early ONFH. After core decompression, he suffered a subtrochanteric fracture of the femur while bearing weight on the affected limb when going up stairs. He was subsequently treated with open reduction and intramedullary nail fixation.

CONCLUSION

When core decompression is used to treat ONFH, the location or size of the drill hole, whether a tantalum rod or bone is inserted, and partial weight-bearing of the affected limb may directly affect whether a fracture occurs after surgery. It is hoped that this case report can provide a reference for clinical orthopedic surgeons in the treatment of early ONFH.

Network meta-analysis of invasive treatment for early-stage osteonecrosis of the femoral head

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a common disabling disease in orthopedics. Blocking the progression of ONFH in the early stage is essential for avoiding total hip replacement.

PURPOSES

The purpose of this study is to evaluate the effect of invasive treatment on early-stage ONFH.

METHODS

According to the PRISMA guidelines, relevant English databases were searched in August 2022 to collect published research. Extract result indicators and conduct network meta-analysis using R software.

RESULTS

A total of 15 RCTs were included. All patients were diagnosed with early-stage ONFH. The surface under the cumulative ranking curve (SUCRA) showed that CD + BMMSC and CD + PRP were the most effective in improving HHS. The results of the league table showed that CD + BMMSC was superior to CD alone. Meanwhile, the SUCRA for FR showed that CD + BG + BMMSC was the most likely to be the most effective in reducing FR. The league table revealed that CD + BG, CD + BG + BMMSC, and CD + BMMSC were superior to CD alone, with statistically significant differences.

CONCLUSION

Considering the HHS and FR, CD + BMMSC may be the optimal treatment option to effectively delay the progression of ONFH and restore the postoperative function of patients.

REGISTRATION NUMBER

The study protocol has been registered on the PROSPERO platform (CRD42023380169).

Preclinical models for studying corticosteroid-induced osteonecrosis of the femoral head

Nontraumatic osteonecrosis of the femoral head (ONFH) is a refractory condition that commonly results in femoral head collapse and degenerative arthritis of the hip. In the early stages, surgical procedures for hip preservation, including core decompression (CD), have been developed to prevent progressive collapse of the femoral head. Optimization of bone regeneration and biological augmentation may further enhance the therapeutic efficacy of CD for ONFH. Thus, combining CD with cell-based therapy has recently been proposed. In fact, patients treated with cell-based therapy using autologous bone marrow concentrate demonstrate improved survivorship of the femoral head, compared with conventional CD alone. Preclinical research studies to investigate adjunctive therapies for CD often utilize the rabbit model of corticosteroid-induced ONFH. Mesenchymal stem cells (MSCs) are known to promote osteogenesis and angiogenesis, and decrease inflammation in bone. Local drug delivery systems have the potential to achieve targeted therapeutic effects by precisely controlling the drug release rate. Scaffolds can provide an osteoconductive structural framework to facilitate the repair of osteonecrotic bone tissue. We focused on the combination of both cell-based and scaffold-based therapies for bone tissue regeneration in ONFH. We hypothesized that combining CD and osteoconductive scaffolds would provide mechanical strength and structural cell guidance; and that combining CD and genetically modified (GM) MSCs to express relevant cytokines, chemokines, and growth factors would promote bone tissue repair. We developed GM MSCs that overexpress the anti-inflammatory, pro-reconstructive cytokines platelet-derived growth factor-BB to provide MSCs with additional benefits and investigated the efficacy of combinations of these GM MSCs and scaffolds for treatment of ONFH in skeletally mature male New Zealand white rabbits. In the future, the long-term safety, efficacy, durability, and cost-effectiveness of these and other biological and mechanical treatments must be demonstrated for the patients affected by ONFH.

Predictive value of clinical features and CT radiomics in the efficacy of hip preservation surgery with fibula allograft

BACKGROUND

Despite being an effective treatment for osteonecrosis of the femoral head (ONFH), hip preservation surgery with fibula allograft (HPS&FA) still experiences numerous failures. Developing a prediction model based on clinical and radiomics predictors holds promise for addressing this issue.

METHODS

This study included 112 ONFH patients who underwent HPS&FA and were randomly divided into training and validation cohorts. Clinical data were collected, and clinically significant predictors were identified using univariate and multivariate analyses to develop a clinical prediction model (CPM). Simultaneously, the least absolute shrinkage and selection operator method was employed to select optimal radiomics features from preoperative hip computed tomography images, forming a radiomics prediction model (RPM). Furthermore, to enhance prediction accuracy, a clinical-radiomics prediction model (CRPM) was constructed by integrating all predictors. The predictive performance of the models was evaluated using receiver operating characteristic curve (ROC), area under the curve (AUC), DeLong test, calibration curve, and decision curve analysis.

RESULTS

Age, Japanese Investigation Committee classification, postoperative use of glucocorticoids or alcohol, and non-weightbearing time were identified as clinical predictors. The AUC of the ROC curve for the CPM was 0.847 in the training cohort and 0.762 in the validation cohort. After incorporating radiomics features, the CRPM showed improved AUC values of 0.875 in the training cohort and 0.918 in the validation cohort. Decision curves demonstrated that the CRPM yielded greater medical benefit across most risk thresholds.

CONCLUSION

The CRPM serves as an efficient prediction model for assessing HPS&FA efficacy and holds potential as a personalized perioperative intervention tool to enhance HPS&FA success rates.

The outcomes of total hip replacement in osteonecrosis versus osteoarthritis: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to compare the outcomes of THA in patients with osteonecrosis (ON) and those with osteoarthritis (OA).

METHODS

Four databases were searched from inception till December 2022 for original studies that compared the outcomes of THA in ON and OA. The primary outcome was the revision rate; the secondary outcomes were dislocation and Harris hip score. This review was conducted in line with PRISMA guidelines, and the risk of bias was assessed using the Newcastle-Ottawa scale.

RESULTS

A total of 14 observational studies with 2,111,102 hips were included, with a mean age of 50.83 ± 9.32 and 55.51 ± 8.95 for ON and OA groups, respectively. The average follow-up was 7.25 ± 4.6 years. There was a statistically significant difference in revision rate between ON and OA patients in favour of OA (OR: 1.576; 95%CI: 1.24-2.00; p-value: 0.0015). However, dislocation rate (OR: 1.5004; 95%CI: 0.92-2.43; p-value: 0.0916) and Haris hip score (HHS) (SMD: - 0.0486; 95%CI: - 0.35-0.25; p-value: 0.6987) were comparable across both groups. Further sub-analysis adjusting for registry data also showed similar results between both groups.

CONCLUSION

A higher revision rate, periprosthetic fracture and periprosthetic joint infection following total hip arthroplasty were associated with osteonecrosis of the femoral head compared with osteoarthritis. However, both groups had similar dislocation rates and functional outcome measures. This finding should be applied in context due to potential confounding factors, including patient's age and activity level.

Modified femoral neck rotational osteotomy with supercapsular approach as hip preservation surgery technique for osteonecrosis of femoral head in young patient: A case report

INTRODUCTION

Osteonecrosis of Femoral Head (ONFH) is a debilitating condition with multiple contributory etiological factors that can lead to significant hip pain and disability. All attempts should be taken to save the joint and postpone or avoid the necessity for a total hip arthroplasty (THA), particularly in young and active individuals.

CASE PRESENTATION

A 21-year-old female with 5-year history of Systematic Lupus Erythematosus (SLE) and long-term use of corticosteroids presented with left hip pain and limping that worsening over the past two months. She had a Leg Length Discrepancy (LLD) of 1 cm. After radiological examination, she was diagnosed with left ONFH FICAT II-III ARCO stage 3. The measured Kerboul angle was 1800, indicating a medium necrotic area. We performed joint preservation surgery through Femoral Neck Rotational Osteotomy (FNRO) using Hip Supercapsular Approach. On a 3-month evaluation, the patient's pain improved significantly, and radiographic evaluation showed good healing of the osteotomy site.

DISCUSSION

FNRO is a joint preservation surgery technique that aims to improve vascularization by moving the area of necrosis away from the weight-bearing region. The Hip Supercapsular Approach was chosen due to numerous advantages, such as short incisions, preservation of blood supply to the femoral head, and clear visualization of both necrotic lesion and healthy bone and cartilage.

CONCLUSION

Modified FNRO with Hip Supercapsular approach may be a promising surgical procedure for young patients with ONFH. It yields favorable results in terms of pain alleviation, improvement in joint functionality, and radiological outcomes while maintaining a minimally invasive setting.

Plasma 8-OHdG act as a biomarker for steroid-induced osteonecrosis of the femoral head

BACKGROUND

Oxidative stress was closely related to the occurrence and development of Steroid-induced osteonecrosis of the femoral head (SIONFH). 8-hydroxy-2'-deoxyguanosine (8-OHdG) is a important index of oxidative stress. The aim of this study is to investigate the role of 8-OHdG in the development of SIONFH.

METHODS

From May 2021 and November 2021, 33 patients diagnosed with SIONFH and 26 healthy controls were recruited in this study. Assessment included the radiography and pathology evaluation of clinical bone tissue, expression position and level of 8-OHdG, level of plasma 8-OHdG, as well as the receiver operating characteristic (ROC) curve.

RESULTS

We observed that expression levels of 8-OHdG in bone samples decreased with Association Research Circulation Osseous (ARCO) stages. Plasma 8-OHdG levels were significantly increased in the SIONFH group compared to the healthy control group. Plasma 8-OHdG level of pre-collapse patients was higher than that of post-collapse patients, the decreased plasma 8-OHdG level was related to higher ARCO stages.

CONCLUSION

Plasma 8-OHdG may represent potential biomarkers during SIONFH at different stages. Higher plasma 8-OHdG levels indicated early stage of SIONFH. The current study provided new clues for early diagnosis and treatment for SIONFH.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Dose–Response Meta-Analysis of Corticosteroid Effects in SARS Outbreak: A Model for Risk Stratification and Screening Strategy for Osteonecrosis of Femoral Head Post-Corticosteroid Therapy for COVID-19

Corticosteroids (CS) have been used in the management regimens for COVID-19 disease to mitigate the cytokine storm and ill effects of the pulmonary inflammatory cascade. With the rampant use of CS, clinicians started reporting the occurrence of osteonecrosis of the femoral head (OFH). In this systematic review, we aim to analyze the literature and identify the definitive cumulative dose and duration of CS needed for the development of OFH based on the SARS model and generate a risk-based screening recommendation for OFH in convalescent COVID-19 patients to facilitate early identification and management. An electronic database search was conducted until December 2022 in PubMed, Web of Science, Embase, and CNKI (China Knowledge Resource Integrated Database). Studies involving CS therapy and osteonecrosis data in SARS patients were included. Three authors independently extracted the data from the included studies and a dose–response meta-analysis was performed for various doses and duration of CS utilized in the included studies. We selected 12 articles with 1728 patients in the analysis. The mean age was 33.41 (±4.93) years. The mean dosage of CS administered was 4.64 (±4.7) g which was administered for a mean duration of 29.91 (±12.3) days. The risk of osteonecrosis increases at pooled OR of 1.16 (95% CI 1.09–1.23, p < 0.001) per 2.0 g increase in the cumulative dose of CS usage. Similarly, the risk increases at pooled OR of 1.02 (95% CI 1.01–1.03, p < 0.001) per 5 days of increase in the cumulative duration of CS usage. A cumulative dosage of 4 g and a duration of 15 days were determined as the critical cut-off for the non-linear dose–response relationship observed. Appropriate and frequent screening of these individuals at regular intervals would help in the identification of the disease at an early stage in order to treat them appropriately.

Optimal drilling at femoral head-neck junction for treatment of the femoral head necrosis: Experimental and numerical evaluation

BACKGROUND

Advanced core decompression (ACD) is a relative new technique for treatment of early stages of avascular femoral head necrosis. Although it is a promising treatment option, there is a need to modify this technique for achieving higher hip survival rates. An idea was to combine this technique with the lightbulb procedure in order to get a complete removal of the necrosis. This study aimed at evaluating the fracture risk of the femora treated by the combined Lightbulb-ACD technique as the basis for clinical application.

METHODS

Subject-specific models were generated from CT scan data of five intact femora. Several treated models were then created from each intact bone and simulated during normal walking activity. Biomechanical testing was additionally performed on 12 pairs of cadaver femora to confirm the simulation results.

FINDINGS

The finite element results revealed that the risk factor of the treated models with a 8 mm-drill increased, but was not significantly greater than that of their corresponding intact models. However, for the femur treated with a 10 mm-drill, the risk factor increased significantly. Fracture always initiated on the femoral neck, i.e. it was either subcapital or transcervical fracture. Our biomechanical testing results correlated well with the simulation data which confirmed the usefulness and effectiveness of the bone models.

INTERPRETATION

The combined Lightbulb-ACD technique using a 10 mm drill increased the fracture risk of femur postoperatively. A drill of up to 8 mm at the anterior head-neck junction did not however lead to the weakening of the femur so that full load bearing may be possible.

Comparison of minimally-invasive fibular supporting of T-type with traditional bloody iliac flap metastasis for osteonecrosis of the femoral head at ARCO stage II

Purpose

Our research mainly evaluates the clinical efficacy of two surgical methods in the treatment of osteonecrosis of the femoral head (ONFH) at ARCO stage II, aiming to provide optimal hip-preserving treatment of ONFH.

Method

From October 2018 to September 2020, 48 patients (59 hips) met the inclusion criteria and randomized. 24 cases (29 hips) in experimental group were treated with minimally-invasive fibular supporting of T-type; 24 cases (30 hips) in control group were treated with traditional bloody iliac flap metastasis. We will compare some intraoperative and postoperative conditions.

Result

The operation time in experimental group was 37 (6) minutes, in control group was 130 (21.75) minutes; the length of surgical incision in two groups was 3.7 (0.7) cm and 12.85 (2.68) cm. The intraoperative blood loss in two groups was 69 (21) ml and 363 (87) ml; the postoperative VAS score of the experimental group on day 1, day 3, day 7 after surgery was 5.5 (2), 3.5 (1), 0 (1); the control group was 6 (1.75), 4 (1), 3 (1). The data differences between above groups have statistically significant. The follow-up time of two groups was (33.86 ± 5.66) months and (35.67 ± 4.69) months. The bone graft healing time in two groups was (14.21 ± 1.93) months and (13.83 ± 2.34) months. The Harris hip scores of two groups at the last follow-up were 90 (7.5) and 86.5 (8.5). The survival rates of two groups were 79.31% (23/29) and 76.67% (23/30). The difference was no statistically significant in above groups (P > 0.05).

Conclusion

The two different bone graft implantation showed satisfactory early outcomes. Compared to the control group, the experimental group has the advantages of lesser pain, lesser blood loss, lesser trauma and shorter operation time. It may be a choice as bone graft for the treatment of ONFH at early stage.

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.

[Expert consensus on clinical diagnosis and treatment technique of osteonecrosis of the femoral head (2022 version)]

Osteonecrosis of the femoral head (ONFH) is a common and refractory disease in the clinic. Although the exact pathophysiological mechanism is not fully understood, it is believed to be closely related to the interruption of intra-bone circulation and eventual bone tissue death. The prevention and treatment of ONFH is always a great challenge for orthopedists. The diagnostic level of ONFH has been continuously improved with the development of imaging techniques such as MRI and the in-depth understanding of the disease in recent years.There are many treatment methods for ONFH, which are generally considered individually and comprehensively according to factors such as the patient's age, osteonecrosis stage, classification, and compliance with joint-sparing treatment. There is currently no unified standard. ONFH staging and classification play an important reference value for doctors to choose treatment options. In recent years, based on the characteristics of ONFH in Chinese people, the academic community has proposed Chinese staging and China-Japan Friendship Hospital (CJFH) classification. The consensus also introduces them together with the international Association Research Circulation Osseous (ARCO) staging to provide guidance for individualized treatment of ONFH. In order to further standardize the diagnosis of ONFH and expand the treatment of ONFH, the Association Related to Circulation Osseous, Chinese Microcirculation Society (CSM-ARCO) organized domestic experts in the field of ONFH to jointly formulate the expert consensus, in order to provide reference for the standardized diagnosis of ONFH and the selection of individualized diagnosis and treatment techniques.

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.

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.

Composite indices of femoral neck strength predicts the collapse of steroid-associated osteonecrosis of the femoral head: a retrospective study

PURPOSES

The purpose of this study was to investigate the predictive effect exerted by composite indices of femoral neck strength (compressive strength index (CSI), bending strength index (BSI) and impact strength index (ISI) on the femoral head collapse in steroid-associated ONFH patients.

METHODS

Nonoperative steroid-associated osteonecrosis of the femoral head (ONFH) patients from 2017 to 2019 were selected. The patients fell into the collapsed group and the non-collapsed group according to whether the femoral head collapsed. CSI, BSI and ISI were calculated. Moreover, bone turnover markers were measured. The statistical analysis was conducted on the predictive effects of composite indices of femoral neck strength and bone turnover index on ONFH collapse.

RESULTS

A total of 62 patients were included. The mean CSI, BSI and ISI were significantly lower in the collapsed group than those in the non-collapsed group (P < 0.05). CSI, ISI,t-P1NP and β-CTx were suggested as the protective risk factors for the femoral head collapse in ONFH patients. The ISI area under the curve values was 0. 878.The mean survival time of the hips of patients with ISI greater than 0.435 was greater (P < 0.05) than that of patients with ISI less than 0.435.

CONCLUSION

The composite indices of femoral neck strength can predict steroid-associated ONFH femoral head collapse more effectively than the bone turnover markers. The ISI value of 0.435 is a potential cut-off value, lower than this value can predict the early collapse of steroid-associated ONFH.

Network-Based Pharmacology and Bioinformatics Study on the Mechanism of Action of Gujiansan in the Treatment of Steroid-Induced Avascular Necrosis of the Femoral Head

Objective

To investigate the main pharmacological basis and mechanism of action of Gujiansan in the treatment of steroid-induced avascular necrosis of the femoral head (SANFH).

Methods

The active constituents and targets of Gujiansan were screened by using TCMSP and other databases, and relevant disease targets were obtained by analyzing the microarray of SANFH in the GEO database. The intersection of the two was taken to obtain the potential targets of Gujiansan for the treatment of SANFH, and key active constituents were screened with the “active constituent-target” network constructed by the Cytoscape software; then, the STRING database was used to construct the protein interaction network to screen the key targets. The Gene Ontology and Kyoto Encyclopedia of Genes and Genomes enrichment analyses of key targets were performed by the DAVID database, and the relationship between the “key active constituent-key target-key signaling pathway” was explored. Finally, the molecular docking between key active constituents and key targets was verified. In addition, qPCR detection technology was used to evaluate the preventive and therapeutic effects of key active constituents of Gujiansan in a rat osteoblast model of SANFH to verify the possible mechanism of the effect of Gujiansan in the treatment of SANFH.

Results

(1) 106 active constituents and 55 targets were obtained for the treatment of SANFH. (2) Quercetin, luteolin, kaempferol, cryptotanshinone, and naringenin were the key active constituents for the treatment of SANFH. (3) IL1B, STAT3, CAT, PTGS2, and MAPK3 were the key targets for the treatment of SANFH. (4) IL1B, STAT3, CAT, PTGS2, MAPK3, and HMOX1 are key targets in the protein interaction network. (5) DAVID enrichment analysis mainly covers the regulation of DNA-binding transcription factor activity, positive regulation of cytokine production, and response to oxidative stress and other biological processes, involving IL-17, AGE-RAGE, C-type lectin receptor, and other signaling pathways. (6) Gujiansan is a multitarget and multisignaling pathway for the treatment of SANFH. (7) Good binding activity exists between key active constituents and key targets.

Conclusion

This study analyzes the potential mechanism of action of Gujiansan in the treatment of SANFH with network pharmacology, which can provide a reference for the further study of its pharmacological basis and targets.

Biomechanical analysis of the drilling parameters for early osteonecrosis of the femoral head

BACKGROUND AND OBJECTIVE

Core decompression is a surgical procedure commonly used to treat the early osteonecrosis of the femoral head. However, It is not known whether different drilling parameters affect postoperative biomechanical strength. This study aimed to analyze the mechanical stability of different drilling locations and diameters of core decompression using finite element analysis.

METHODS

Finite element models were established based on computed tomography images obtained from five healthy participants, including the different drilling locations (Lesser trochanter: Above, Parallel, and Below) and diameters. Biomechanical parameters including stiffness and stress were evaluated under slow running loads.

RESULTS

At the same drilling diameter, the femoral stiffness was highest (p < 0.05) in the Above group and lowest in the Below group, while the maximum equivalent stress of the entry area and the necrotic area was highest (p < 0.05) in the Below group and lowest in the Above group. With the increase of drilling diameters, the stiffness decreased and its decreased percentage comparing the preoperative: Above (1.06-8.82%), Parallel (2.51-13.61%), and Below (3.99-15.06%). The maximum equivalent stress of the entry area and necrotic area increased as the drilling diameter increased, and its increased percentage comparing the preoperative, for the entry area: Above (14.11-219.58%), Parallel (35.91-306.37%), and Below (46.12-240.98%); for the necrotic area: Above (13.64-114.69%), Parallel (29.37-187.76%), and Below (44.76-202.10%). The range of safety drilling parameters (SDP) was obtained (Below<9 mm, Parallel<11 mm, and Above<13 mm) by comparing the maximum equivalent stress of two areas and its yield strength. For patients of different sizes and normal bone mineral density (BMD), the maximum equivalent stress of the two areas did not exceed its yield strength using the range of SDP, except for the patients with abnormal BMD (Osteoporosis) or high body mass index (BMI≥28 kg/m²).

CONCLUSIONS

The biomechanical properties of early osteonecrosis of the femoral head deceased with increasing drilling diameters parameters, especially at the location below the lesser trochanter. The SDP (Below<9 mm, Parallel<11 mm, and Above<13 mm) is a suitable reference for most patients to perform slow running postoperatively, while it may be not suitable for patients with osteoporosis or obesity.

Impact of Femoral Neck Cortical Bone Defect Induced by Core Decompression on Postoperative Stability: A Finite Element Analysis

Objective

To analyze the impact of femoral neck cortical bone defect induced by core decompression on postoperative biomechanical stability using the finite element method.

Methods

Five finite element models (FEMs) were established, including the standard operating model and four models of cortical bone defects at different portions of the femoral neck (anterior, posterior, superior, and inferior). The maximum stress of the proximal femur was evaluated during normal walking and walking downstairs.

Results

Under both weight-bearing conditions, the maximum stress values of the five models were as follows: femoral neck (inferior) > femoral neck (superior) > femoral neck (posterior) > femoral neck (anterior) > standard operation. Stress concentration occurred in the areas of femoral neck cortical bone defect. Under normal walking, the maximum stress of four bone defect models and its increased percentage comparing the standard operation were as follows: anterior (17.17%), posterior (39.02%), superior (57.48%), and inferior (76.42%). The maximum stress was less than the cortical bone yield strength under normal walking conditions. Under walking downstairs, the maximum stress of four bone defect models and its increased percentage comparing the standard operation under normal walking were as follows: anterior (36.75%), posterior (67.82%), superior (83.31%), and inferior (103.65%). Under walking downstairs conditions, the maximum stress of bone defect models (anterior, posterior, and superior) was less than the yield strength of cortical bone, while the maximum stress of bone defect model (inferior) excessed yield strength value.

Conclusions

The femoral neck cortical bone defect induced by core decompression can carry out normal walking after surgery. To avoid an increased risk of fracture after surgery, walking downstairs should be avoided when the cortical bone defect is inferior to the femoral neck except for the other three positions (anterior, posterior, and superior).

Lack of Conclusive Evidence of the Benefit of Biologic Augmentation in Core Decompression for Nontraumatic Osteonecrosis of the Femoral Head: A Systematic Review

PURPOSE

To assess whether biologic augmentation in addition to core decompression (CD), compared with CD alone, improves clinical and radiographic outcomes in the treatment of nontraumatic osteonecrosis of the femoral head (ONFH). Our hypothesis was that biologic augmentation would reduce the progression of osteonecrosis and therefore also the rate of conversion to total hip arthroplasty (THA).

METHODS

A systematic review was performed in accordance with the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) statement. Six databases were searched: Central, MEDLINE, Embase, Scopus, AMED, and Web of Science. Studies comparing outcomes of CD versus CD plus biologic augmentation (with or without structural augmentation), with a reported minimum level of evidence of III and ≥24 months of follow-up, were eligible. Procedural success was conceptualized as (1) avoidance of conversion to THA and (2) absence of radiographic disease progression. Risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklists. A quantitative analysis of heterogeneity was undertaken.

RESULTS

We included studies reporting on 560 hips in 484 patients. Biologic augmentation consisted of bone marrow stem cells in 10 studies, bone morphogenic protein in 2, and platelet-rich plasma in 1. Three studies used additional structural augmentation. The median maximum follow-up time was 45 months. Only 4 studies reported improvement in all clinical scores in the augmentation group. Seven studies observed a reduction in the rate of radiographic progression, and only 5 found reduced rates of conversion to THA when using augmentation. A high risk of bias and marked heterogeneity was found, with uncertainty about the study designs implemented, analytical approaches, and quality of reporting.

CONCLUSION

Current evidence is inconclusive regarding the benefit of biologic augmentation in CD for nontraumatic ONFH, because of inconsistent results with substantial heterogeneity and high risk of bias.

LEVEL OF EVIDENCE

III, systematic review of level I, II, and III studies.

Do biomarkers allow a differentiation between osteonecrosis of the femoral head and osteoarthritis of the hip? - a biochemical, histological and gene expression analysis

OBJECTIVE

Osteonecrosis of the femoral head (ONFH) is a devastating disease of the hip joint. Its early diagnosis is crucial to increase the chances of joint preserving, yet difficult due to similarities with osteoarthritis (OA) of the hip in its clinical appearance. The purpose of this study was to enhance the understanding of ONFH and its pathologic processes in contrast to OA and to identify serum biomarkers helping to improve the diagnosis of the disease.

DESIGN

Bone and bone marrow samples were collected from 24 patients diagnosed with OA and 25 patients with ONFH during total hip replacement surgery. RNA was isolated, histological examination, determination of free reactive oxygen species as well as gene expression and biomarker analysis were performed.

RESULTS

Histological analysis revealed differences in the structural and cellular pattern between the groups. Gene expression analysis revealed a significant upregulation for the genes ASPN, COL1A1, COL2A1 and IL6 and a significant downregulation for HIF1A in ONFH compared to OA group. Analysis of serum biomarkers showed significant differences between the groups for asporin and adiponectin. A final logistical regression model including the parameters adiponectin, asporin and HIF 1α was overall significant, explained 34.5 % of variance and classified 74.5 % of the cases correctly.

CONCLUSION

The combination of adiponectin, asporin and HIF 1α as serum biomarkers revealed a classification accuracy of 74.5 %. The information provided in this study may help to enhance the understanding of pathologic processes in ONFH and to elaborate further aspects of prediction and treatment.

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.

Pulmonary Embolism after Core Decompression of the Femoral Head Using Injectable Bone Graft Substitute: A Case Report

The authors report a rare complication regarding the case of an 18-year-old female with bilateral osteonecrosis of the femoral head (ONFH) secondary to the treatment and hematopoietic stem cell transplant (HSCT) of an acute lymphoblastic leukemia (ALL). The patient underwent a bilateral necrotic bone debridement and core decompression (CD) surgery with injectable synthetic bone graft, which unfortunately caused a pulmonary injectable bone graft substitute embolism.

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.

Modified Kerboul Angle Predicts Outcome of Core Decompression With or Without Additional Cell Therapy

BACKGROUND

Core decompression is the most common procedure for early-stage osteonecrosis of the femoral head (ONFH). This study investigated outcomes of core decompression with/without bone marrow aspirate concentrate (BMAC), based on the Kerboul combined necrotic angles using magnetic resonance imaging.

METHODS

We reviewed 66 patients (83 hips) with early ONFH, Association Research Circulation Osseous stages I-IIIa, who underwent core decompression alone (26 patients, 33 hips) or in combination with BMAC (40 patients, 50 hips). Survival rate and progressive collapse were analyzed using the Kaplan-Meier method, and conversion to total hip arthroplasty (THA) was evaluated. Subgroup analyses based on the modified Kerboul angle were performed: grade I (<200°), grade II (200°-249°), grade III (250°-299°), and grade IV (≥300°).

RESULTS

Mean follow-up was 36 ± 23 months. Femoral head collapse with BMAC (16 hips, 32%) was significantly lower than without BMAC (19 hips, 58%, P = .019). Conversion THA was significantly lower with BMAC (28%) than without (58%, P = .007). Survival rates among groups showed significant differences (P = .017). In grade I, 0/12 hips with BMAC collapsed while 3/9 (33%) without BMAC collapsed (P = .063); in grade II, 2/16 hips (12%) with BMAC collapsed while 7/13 (54%) without BMAC collapsed (P = .023). There was no significant difference in collapse with (64%) or without (82%) BMAC in grade III-IV hips (P = .256).

CONCLUSION

Core decompression with/without BMAC had a high failure rate, by increasing disease progression and the necessity for THA, for combined necrotic angles >250°. In our study, addition of BMAC had more reliable outcomes than isolated core decompression for precollapse ONFH if the combined necrotic angles were <250°.

Treatment of aseptic osteonecrosis of the femoral head: Historical aspects

The treatment of aseptic osteonecrosis (ON) of the femoral head has been the subject of numerous therapeutic and surgical proposals due to the absence of medical treatment with proven efficacy. For many years, the goal of surgical treatment was to avoid total hip replacement (THR) with uncertain survival in patients considered too young (30-50 years) for this procedure. Numerous conservative treatments were thus proposed: core decompression with numerous variants, non-vascularized and vascularized bone grafts, intertrochanteric and rotational transtrochanteric osteotomies, cementing. The lack of a common classification and a lack of knowledge of natural history complicated the interpretation of the results for a long time. Nevertheless, it appeared that these treatments were effective only in the very early stages and among these in the limited ONs, medial rather than central and especially lateral, with discrepancies according to etiologies apart from sickle cell disease recognized by all as being pejorative. For the same reason, partial arthroplasties have been attempted and abandoned in turn: femoral head total and partial resurfacing and femoral prosthesis. The most recent advances are stem-cell-enhanced core decompression and progress in total arthroplasty, whose reliability has made it possible to extend the indications to increasingly younger patients seeking treatment with guaranteed or near-guaranteed efficacy. Most of the other interventions have disappeared or almost disappeared because of their lack of effectiveness especially in extensive and post-fracture ONs, sometimes because of their complexity and the length of their post-operative management, and also because they complicate and penalize a future total arthroplasty. This argues for early detection of ON at an early stage where the "head can be saved" by stem cell augmented core decompression, a minimally invasive treatment that leaves the chances of success of a THR intact.

[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.

Percutaneous autologous impaction bone graft for advanced femoral head osteonecrosis: a retrospective observational study of unsatisfactory short-term outcomes

Background

Half of osteonecrosis of the femoral head (ONFH) patients suffer femoral head collapse at initial diagnosis, and more than half are bilaterally affected. This study developed a percutaneous autologous impaction bone graft (IBG) technique as a modification of core decompression (CD). We also summarized the short-term results and treatment efficacy of percutaneous autologous IBG in advanced ONFH.

Methods

Twenty patients (12 males, 8 females) with nontraumatic, postcollapse ONFH except one case underwent CD (10-mm core diameter) and reverse IBG. Radiological changes of the ONFH stage and type were analyzed. Survival analysis using Kaplan–Meier estimates was performed with conversion to total hip arthroplasty (THA) as the endpoint. In addition, the Harris hip score (HHS) and University of California, Los Angeles (UCLA) activity rating scale were evaluated.

Results

Percutaneous autologous IBG was performed successfully, with an average operation time of < 1 h and small blood loss, and 7 patients (35%) needed conversion to THA at an average of 17 months postoperatively. We observed radiological progressive change in 60% of the patients during a mean observation period of 3 years. The mean clinical scores, except data recorded, after THA significantly improved (before vs. after 3 years: UCLA activity score, 3.7 vs. 5.2 [P = 0.014]; HHS, 57.6 vs. 76.5 points [P = 0.005]). In addition, 6 patients showed radiological progression but no clinical deterioration.

Conclusions

Percutaneous autologous IBG was technically simple and minimally invasive, but short-term results were unsatisfactory for advanced ONFH. Indications for this procedure should be carefully examined to improve it in order to enable bone formation.

Combining Platelet-Rich Plasma Instillation With Core Decompression Improves Functional Outcome and Delays Progression in Early-Stage Avascular Necrosis of Femoral Head: a 4.5- to 6-Year Prospective Randomized Comparative Study

BACKGROUND

Avascular necrosis of femoral head is a debilitating disease frequently progressing to femoral head collapse and joint destruction. The efficacy of core decompression (CD) remains controversial.

METHODS

About 40 consecutive age-matched and gender-matched patients (53 hips) were randomized into 2 groups by computer-generated algorithm table in a prospective randomized double-blinded comparative study. Group A (platelet-rich plasma [PRP] with CD) included 19 patients (25 hips), and group B (CD only) included 21 patients (28 hips). Postoperative Harris Hip Score and magnetic resonance imaging to quantify the necrotic area by using modified Kerboul angle were done and evaluated. Mean follow-up was 64.3 months (range, 54-72) and 63.7 months (range, 56-72) in groups A and B, respectively.

RESULTS

There was statistically significant difference between PRP and control groups in pain score (P = .00), functional score (P = .02), and Harris Hip Score (P = .00) at final follow-up. There was no progression in stage 1 disease. Stage 2 disease showed 24% progression in group A and 43% progression in group B. The difference was statistically significant (P = .025). Survivorship from femoral head collapse, any procedure, and total hip arthroplasty was 84%/68% (P = .00), 76%/57% (P = .02), and 92%/78% (P = .01) in 2 groups, which was statistically significant.

CONCLUSION

PRP use after CD provides significant pain relief, better midterm functional outcome, retards the progression, and enhances the survivorship free from reoperation for hip arthroplasty and femoral head collapse in early stages of avascular necrosis of hip than CD alone.

Treatment of Femoral Head Osteonecrosis (Stages 2B, 3 Ficat) Through Open Direct Core Decompression by Allograft Impaction and Light Bulb Technique

Background

Femoral head avascular necrosis is the cause of paralyzing status of youth population. Initial diagnosis is the main element in treating the disease. Bone grafting and core decompression are the approved cures at the early steps of the disease. Hip replacement in a total manner is the common cure in the final stages. The optimal treatment in the intermediate stages is partially disputable. We investigated several patients with femoral head osteonecrosis cured with impacted cancellous allograft and open core decompression using the lightbulb technique.

Methods

A total of 46 patients (58 hips) suffering from femoral head osteonecrosis were evaluated in this cross-sectional study. Patients were classified into two groups: A (stage 2B Ficat) and B (stage 3 Ficat) to be treated with the impaction of cancellous allograft and by open core decompression. Radiographic results, demographic data, and range of hip joint motions were recorded. The patients were assessed through employing the Harris hip score (HHS) and visual analogue scale (VAS) index prior to operation and over five years following surgery. We also studied radiographic alterations of femoral head.

Results

The means of HHS and VAS were developed following the operation. Radiographic outcomes promoted in both groups, however, it was better in group A. 12 (40%) and six (22%) hips (40%) in groups A and B, respectively displayed developed stages following the operation. The hip ROM was enhanced with the mean of 15-20 degrees (P<0.005).

Conclusion

Open core decompression combined with allograft impaction sounds to be influential in the developing steps of femoral head necrosis and leads to joint discomfort and diminished pain improving ROM of the hip joint and meanwhile procrastinating the worsening of the disease.

Deep Learning Improves Osteonecrosis Prediction of Femoral Head After Internal Fixation Using Hybrid Patient and Radiograph Variables

Femoral neck fractures (FNFs) are a great public health problem that leads to a high incidence of death and dysfunction. Osteonecrosis of the femoral head (ONFH) after internal fixation of FNF is a frequently reported complication and a major cause for reoperation. Early intervention can prevent osteonecrosis aggravation at the preliminary stage. However, at present, failure to diagnose asymptomatic ONFH after FNF fixation hinders effective intervention at early stages. The primary objective of this study was to develop a predictive model for postoperative ONFH using deep learning (DL) methods developed using plain X-ray radiographs and hybrid patient variables. A two-center retrospective study of patients who underwent closed reduction and cannulated screw fixation was performed. We trained a convolutional neural network (CNN) model using postoperative pelvic radiographs and the output regressive radiograph variables. A less experienced orthopedic doctor, and an experienced orthopedic doctor also evaluated and diagnosed the patients using postoperative pelvic radiographs. Hybrid nomograms were developed based on patient and radiograph variables to determine predictive performance. A total of 238 patients, including 95 ONFH patients and 143 non-ONFH patients, were included. A CNN model was trained using postoperative radiographs and output radiograph variables. The accuracy of the validation set was 0.873 for the CNN model, and the algorithm achieved an area under the curve (AUC) value of 0.912 for the prediction. The diagnostic and predictive ability of the algorithm was superior to that of the two doctors, based on the postoperative X-rays. The addition of DL-based radiograph variables to the clinical nomogram improved predictive performance, resulting in an AUC of 0.948 (95% CI, 0.920-0.976) and better calibration. The decision curve analysis showed that adding the DL increased the clinical usefulness of the nomogram compared with a clinical approach alone. In conclusion, we constructed a DL facilitated nomogram that incorporated a hybrid of radiograph and patient variables, which can be used to improve the prediction of preoperative osteonecrosis of the femoral head after internal fixation.

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.

Diagnosis of Osteonecrosis of the Femoral Head: Too Little, Too Late, and Independent of Etiology

BACKGROUND

Joint preservation is more effective in early-stage osteonecrosis of the femoral head (ONFH); thus, prompt diagnosis when the femoral head is still salvageable is important. We report a 20-year retrospective study that summarizes age at presentation, etiology, and Association Research Circulation Osseous stage at diagnosis.

METHODS

Our database was reviewed to identify patients younger than 65 years of age who were diagnosed with atraumatic ONFH between 1998 and 2018. Demographic characteristics of patients were evaluated and categorized into different subgroups.

RESULTS

Four hundred thirteen patients were identified. At initial presentation, 23% were diagnosed with early-stage ONFH, while 77% were diagnosed with late-stage ONFH. Forty-nine percent had a history of corticosteroid use, of which 13% were diagnosed with hematologic malignancy and 8% were diagnosed with lupus. Ethanol abuse, idiopathic, sickle cell disease, and human immunodeficiency virus were present in 11%, 30%, 3%, and 3%, respectively. The mean age of patients with corticosteroid use (40 ± 14 years) was significantly younger than ethanol use (46 ± 11 years, P = .014) and idiopathic causes (48 ± 11 years, P < .001), but significantly older than sickle cell disease (32 ± 11 years, P = .031). There was no difference in the age of presentation for early-stage and late-stage ONFH by etiology.

CONCLUSION

Nearly 80% of the patients presented with late-stage ONFH. Hence, we have a narrow window of opportunity for hip preservation surgery before femoral head collapse. A multidisciplinary approach to improve screening awareness for early detection by focusing on the etiologic identification and patient education might reduce the incidence of hip arthroplasty in young patients.

What are the outcomes of core decompression in patients with avascular necrosis? Protocol for a systematic review

Background: Core decompression is a hip preserving surgical procedure that is used to treat avascular necrosis (AVN) of the femoral head. The eventual clinical and radiological outcome following this procedure is varied in literature. Also, the time to a total hip replacement (THR) from the index procedure and the percentage of patients subsequently undergoing a THR is controversial. Furthermore, there are multiple surgical methods along with multiple augmentation techniques and various classification and staging systems described. The purpose of this systematic review, therefore, is to analyse the outcomes following decompression only, excluding any augmentation techniques for non-traumatic AVN of the femoral head. Methods: This protocol is being developed in line with the PRISMA-P guidelines. The search strategy includes articles from Medline, Embase, Google Scholar, CINHAL and Cochrane library. The review and screening will be done by two independent reviewers. Review articles, editorials and correspondences will be excluded. Articles including patients with sickle cell disease and with core decompression where augmentation is used will be excluded. The risk of bias and quality of articles will be assessed using the Joanna Briggs Institute Critical Appraisal Checklist for the different study designs included. Discussion: This study will be a comprehensive review on all published articles having patients with AVN of the femoral head and undergoing core decompression surgery only. The systematic review will then define the outcomes of the core decompression surgery based on clinical and radiological outcomes. Each outcome will include the different stages within it and finally, the total mean time to THR will be calculated. This will then be followed by assessing the cumulative confidence in evidence from all the data collected using the GRADE tool.   Registration: This systematic review is registered in the International Prospective Register for Systematic Reviews and Meta-analysis (PROSPERO) under the registration number:  CRD42018100596.