Combined tantalum implant with bone grafting for the treatment of osteonecrosis of the femoral head

Bone tissue engineering for treating osteonecrosis of the femoral head

Osteonecrosis of the femoral head (ONFH) is a devastating and complicated disease with an unclear etiology. Femoral head-preserving surgeries have been devoted to delaying and hindering the collapse of the femoral head since their introduction in the last century. However, the isolated femoral head-preserving surgeries cannot prevent the natural progression of ONFH, and the combination of autogenous or allogeneic bone grafting often leads to many undesired complications. To tackle this dilemma, bone tissue engineering has been widely developed to compensate for the deficiencies of these surgeries. During the last decades, great progress has been made in ingenious bone tissue engineering for ONFH treatment. Herein, we comprehensively summarize the state-of-the-art progress made in bone tissue engineering for ONFH treatment. The definition, classification, etiology, diagnosis, and current treatments of ONFH are first described. Then, the recent progress in the development of various bone-repairing biomaterials, including bioceramics, natural polymers, synthetic polymers, and metals, for treating ONFH is presented. Thereafter, regenerative therapies for ONFH treatment are also discussed. Finally, we give some personal insights on the current challenges of these therapeutic strategies in the clinic and the future development of bone tissue engineering for ONFH treatment.

Efficacy of various core decompression techniques versus non-operative treatment for osteonecrosis of the femoral head: a systemic review and network meta-analysis of randomized controlled trials

Background

Various Joint-preserving therapy (JPT) methods have been performed and tried in recent decades, but their results and efficacy were inconsistent and controversial. The purpose of this study is to evaluate its effectiveness and whether there are statistical differences in treatment between different interventions based on published RCT studies.

Methods

Following the PRISMA-NMA checklist, Medline, EMBASE, Web of Science, and Cochrane Library databases were searched and collected related RCT studies. The sources were searched from inception up to October 30, 2020. The primary outcomes including the rate of radiographic progression and conversion to THA and the secondary outcome -Harris Hip Scores (HHS) were extracted and compared in a Network meta-analysis.

Results

Seventeen RCT studies involving 784 patients (918 hips) with seven interventions including CD (core decompression), CD + BG (bone graft), CD + TI (tantalum rod implantation), CD + CT (Cell therapy), CD + BG + CT, VBG (vascularized bone graft), and nonsurgical or conservative treatment for ONFH were evaluated. In the radiographic progression results, CD + CT showed a relatively better result than CD, CD + BG and non-surgical treatment, the surface under the cumulative ranking curve (SUCRA) plot displayed that CD + CT (96.4%) was the best, followed by CD (64.1%).In conversion to THA results, there were no significant differences between the JPT methods and non-surgical treatment. In HHS, there was also no significant difference, other than CD + BG showed a statistical difference than non-surgical treatment only in terms of Cis, but the SUCRA was highest in non-surgical treatment (80.5%) followed by CD + CT (72.8%).

Conclusions

This Net-work meta-analysis demonstrated that there was no statistical difference in the outcome of radiographic progression and conversion to THA, also in HHS, other than CD + CT showed a relatively superior result in radiographic progression than nonsurgical treatment, namely, it’s maybe an effective method for delaying disease progression or reducing disease development based on current evidence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04808-2.

Blood biomarkers related to osteonecrosis of femoral head by internal fixation after Garden I femoral neck fracture: a cohort study

BACKGROUND

Internal fixation is currently considered the gold standard in treatment for femoral neck fractures in adults. However, osteonecrosis of the femoral head (ONFH) after internal fixation would occur in quite proportion of patients with femoral neck fracture, even in Garden I femoral neck fracture. The purpose of this study was to determine the association between the blood biomarkers (serum albumin, pre-albumin, total protein and total lymphocyte count) and ONFH following internal fixation of Garden I femoral neck fracture in adults.

METHOD

This is a single center cohort study, in which each patient who sustained a Garden I femoral neck fracture had been treated with internal fixation, and had adequate preoperative blood examinations. The serum albumin was categorized as ≥ 40g/L or < 40g/L. The pre-albumin was categorized as ≥ 22mg/dL or < 22mg/dL. The total protein was categorized as ≥ 65g/L or < 65 g/L. The total lymphocyte count was categorized as ≥1.1× 10⁹ /L or <1.1×10⁹ /L. Multivariate cox proportional hazards analysis was used to assess the association between blood markers and the osteonecrosis of femoral head during the 2-years follow-up period controlling the confounders.

RESULT

A total of 10 cases of ONFH were identified. Multivariate Cox regression analysis revealed that low total lymphocyte count and hypertension state were significant independent risk factors for ONFH after internal fixation for Garden I femoral head fractures.

CONCLUSION

Blood biomarkers were potential predictors for ONFH after internal fixation Garden I femoral neck fractures. We suggest that routine laboratory tests might can be used to assist surgeons to identify patients at great risk of ONFH.

Porous tantalum implant for treatment of early-stage osteonecrosis of the femoral head: a minimum 5-year follow-up study

BACKGROUND

To evaluate the survival rate of porous tantalum rod implantation in the treatment of osteonecrosis of the femoral head (ONFH), evaluate its clinical effect and imaging results.

METHODS

From January 2008 to December 2013, porous tantalum rod implantation for ONFH was performed in two institutions. Statistical analysis of operation data, including operation time, blood loss and blood transfusion were recorded.

RESULTS

52 hips received complete follow-up, the average follow-up time was 85.7 months (60-132 months). 24 hips turned to THA at the end of follow-up (46.2%), the average time was 44.3 ± 32.8 months, and the average Harris hip score before THA was 57.1 ± 7.6. Cox proportional-hazards model revealed that Association Research Circulation Osseous (ARCO) stage (P = 0.017), bone marrow edema (P = 0.006) and age > 40 years (P = 0.043) were independent risk factors for conversion to THA.

CONCLUSION

ARCO stage, age and bone marrow edema were risk factors for the failure of porous tantalum rod implantation to convert to THA.

Porous tantalum rod implantation is associated with low survival rates in patients with type C2 osteonecrosis of the femoral head but has no effect on the clinical outcome of conversion total hip arthroplasty: a retrospective study with an average 8-year follow-up

Background

Our study aimed to investigate the clinical outcomes and survival rates following porous tantalum rod surgery (PTRS) and conversion total hip arthroplasty (THA) subsequent to failed PTRS.

Methods

A total of 38 subjects (40 hips) with osteonecrosis of the femoral head (ONFH) were included in this retrospective study between January 2008 and December 2011. All subjects were evaluated before surgery by using the Association Research Circulation Osseous (ARCO) classification system, the Japan Investigation Committee (JIC) classification and the Harris hip score (HHS). The endpoint of this study was set as final follow-up (including the survival time of PTRS and conversion THA). The rates of radiological progression were also evaluated. Patients who received conversion THA were further followed and compared to a control group of 58 patients with ONFH who underwent primary THA.

Results

The mean follow-up time was 120.7 ± 9.2 (range, 104–143) months, and the overall survival rate was 75% at 96 months (ARCO stage II: 81.5%; stage III: 38.5%; JIC type C1: 83.3%; C2: 30%). The HHS before surgery was 59 (55–61), in contrast to 94 (91–96) at 96 months follow-up (P < 0.01). HHS in stage III show a significant poorer result compared to stage II at 24 months. HHS in Type C2 group show no significant difference compared to HHS before surgery at 24 and 60 months follow up (P = 0.91, P = 0.30). Twelve hips requiring secondary THA were followed for 66.9 ± 31.7 months, and control hips that underwent primary THA was followed for 75.4 ± 14.9 months. The HHS in the conversion group was 89 (86–93) and that in the primary THA group was 92 (79–95, P = 0.09) at the 5-year follow-up.

Conclusion

In the mid-term follow-up, porous tantalum implants showed an encouraging survival rate in symptomatic patients in early stages (ARCO stage II) or with limited necrotic lesions (JIC type C1). In addition, our results did not demonstrated any difference between primary THA and conversion THA.

Outcome of tantalum rod insertion in the treatment of osteonecrosis of the femoral head with minimum follow-up of 1 year: a meta-analysis and systematic review

Osteonecrosis of the femoral head (ONFH) is a debilitating disease that can cause deformity and collapse of the femoral head, thus leading to the development of degenerative joint disease that can incapacitate the patient with pain and reduction in hip mobility. This study aims to determine the safety and efficacy of tantalum rod insertion in the treatment of ONFH with a minimum follow-up period of 1 year. A multi-database search was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Data from studies assessing the clinical and radiological outcomes as well as complications of tantalum rod insertion in the treatment of ONFH with a minimum follow-up period of 1 year were extracted and analyzed. Ten studies were included in this meta-analysis, consisting of 550 hips. There was a statistically significant increase in HHS (MD = 30.35, 95% CI: 20.60-40.10, P < 0.001) at final follow-up versus pre-operative scores. The weighted pooled proportion (PP) of radiographic progression of ONFH was 0.221 (95% CI: 0.148-0.316), while that of progression into femoral head collapse was 0.102 (95% CI: 0.062-0.162). Conversion to total hip arthroplasty (THA) had a PP of 0.158 (95% CI: 0.107-0.227) with a mean weighted period of 32.4 months (95% CI: 24.9-39.9 months). Subgroup analysis of conversion to THA when tantalum rods were used in conjunction with bone grafting (PP = 0.150, 95% CI: 0.092-0.235) showed a marginal risk reduction than when compared with subgroup analysis of tantalum rods being used alone (PP = 0.154, 95% CI: 0.078-0.282). Tantalum rod is a safe alternative option to the current joint-preserving procedures available in the treatment of ONFH. However, more studies are needed to investigate and identify the most appropriate patients who would benefit most and the synergistic effect brought on by the use of complementary biological augmentation of bone grafting or stem cells with tantalum rods.

Guidelines for clinical diagnosis and treatment of osteonecrosis of the femoral head in adults (2019 version)

Osteonecrosis of the femoral head (ONFH) is a common and refractory disease in orthopaedic clinics. The number of patients with ONFH is increasing worldwide every year. There are an estimated 8.12 million patients with nontraumatic osteonecrosis in China alone. Treatment of nontraumatic osteonecrosis has always been a clinical challenge for orthopaedic surgeons. To further standardize diagnosis and treatment of ONFH, these guidelines provide not only basic diagnosis, treatment, and evaluation systems for ONFH but also expert advice and standards in many aspects, including epidemiology, aetiology, diagnostic criteria, pathological staging, prevention and treatment options, and postoperative rehabilitation. The aetiological factors of ONFH can currently be divided into two major categories: traumatic and nontraumatic; however, the specific pathological mechanism of ONFH is not completely clear. Currently, the staging system of ONFH formulated by the Association Research Circulation Osseous is widely used in clinical practice. Based on the changes in the intraosseous blood supply at different stages, the corresponding nonsurgical and surgical treatments are recommended, and when there are risk factors for possible ONFH, certain preventive measures to avoid the occurrence of osteonecrosis are recommended. These guidelines provide brief classification criteria and treatment regimen for osteonecrosis. Specification of the aetiology, treatment plan based on comprehensive consideration of the different stages of osteonecrosis, hip function, age, and occupation of the patients are important steps in diagnosis and developing treatment strategies.

TRANSLATIONAL POTENTIAL OF THIS ARTICLE

New advances in the epidemiology, etiology, pathophysiology, imaging, diagnosis and treatment of ONFH have been renewed in this revision. This guideline can be used for reference by orthopedic professionals and researchers, and for standardized diagnosis and treatment management under the clinical guidance, which is conducive to the prevention, treatment and further research of ONFH, improving the diagnosis and treatment level, making patients' symptoms under good control, and improving their quality of life.

Outcome after a new porous tantalum rod implantation for treatment of early-stage femoral head osteonecrosis

Background

Tantalum rods have been used in osteonecrosis of the femoral head (ONFH) for several years, while Zimmer trabecular metal implants have been proposed as the best choice. The aim of this study was to evaluate the effect of a new porous tantalum rod on the treatment of early ONFH.

Methods

From July 2014 to December 2015, 19 patients (21 hips) were treated with Runze tantalum rod, and 20 patients (20 hips) received Zimmer tantalum prosthesis. All patients were followed up for at least 3 years.

Results

There was no significant difference in demographic characteristics and the Harris Hip Score (HHS) improvement between the two groups. Kaplan-Meier analysis did not show any statistically significant difference in survival rates. One case in the Runze group had persistent pain and required conversion to total hip arthroplasty (THA) 8 months post-surgery. Histological evaluations revealed the presence of abundant new bone ingrowth into pores of the tantalum. The osteonecrosis observed in other patients was almost unchanged. At final follow-up, progressive collapse of the femoral head or the apparent joint space narrowing had not occurred.

Conclusions

Compared with the traditional implants, implantation of the Chinese tantalum rod in the treatment of Association Research Circulation Osseous (ARCO) stages I, and II ONFH demonstrated highly encouraging clinical results.

Real-time computerised tomography assisted porous tantalum implant in ARCO stage I-II non-traumatic osteonecrosis of the femoral head: minimum five-year follow up

PURPOSES

This study was established to investigate the medium-term clinical effect of real-time CT assisted porous tantalum implant for the treatment of ARCO stage I-II non-traumatic osteonecrosis of the femoral head (ONFH).

METHODS

This study comprised 24 ONFH patients (29 hips) who were treated with intra-operative real-time CT accurate rapid positioning assisted drilling decompression, lesion removal and porous tantalum implant. Harris score, VAS score and imaging in pre-operation and follow-up period were recorded.

RESULTS

The average operative time and intra-operative blood loss were 72.6 min and 158.8 ml, respectively. The mean follow-up was 5.4 years. No femoral head penetrating, wound infection, and death occurred. Harris and VAS score improved significantly (73.78 vs. 88.11; 7.13 vs. 2.66) at last follow-up (P < 0.05). The functional improvement and pain relief rate was 100% at six months after operation. The effective rate was 86.21% at 12 months after operation and last follow-up. Five pre-operative ARCO stage I hips had no radiographic progress. Meanwhile, four among the 24 ARCO stage II hips progressed into stage III between eight and 12 months after surgery, among which two progressed into stage IV and two remained in stage III at the last follow-up. The average value of Kerboul combined necrotic angle was 263.24°. There was no progress in Kerboul combined necrotic angle among the grades 2 and 3 patients. However, among the six cases at grade 4, four cases with post-operative progress, two patients converted to THA.

CONCLUSIONS

Our technique is safety and effective in the treatment of ARCO stage I-II non-traumatic ONFH.

Chinese Guideline for the Diagnosis and Treatment of Osteonecrosis of the Femoral Head in Adults

The treatment of adult osteonecrosis of the femoral head (ONFH), with 8.12 million patients in China, remains a challenge to surgeons. To standardize and improve the efficacy of the treatment of ONFH, Chinese specialists updated the experts' suggestions in March 2015, and an experts' consensus was given to provide a current basis for the diagnosis, treatment and evaluation of ONFH. The current guideline provides recommendations for ONFH with respect to epidemiology, etiology, diagnostic criteria, differential diagnosis, staging, treatment, as well as rehabilitation. Risk factors of non-traumatic ONFH include corticosteroid use, alcohol abuse, dysbarism, sickle cell disease and autoimmune disease and others, but the etiology remains unclear. The Association Research Circulation Osseous (ARCO) staging system, including plain radiograph, magnetic resonance imaging, radionuclide examination, and histological findings, is frequently used in staging ONFH. A staging and classification system was proposed by Chinese scholars in recent years. The major differential diagnoses include mid-late term osteoarthritis, transient osteoporosis, and subchondral insufficiency fracture. Management alternatives for ONFH consist of non-operative treatment and operative treatment. Core decompression is currently the most common procedure used in the early stages of ONFH. Vascularized bone grafting is the recommended treatment for ARCO early stage III ONFH. This guideline gives a brief account of principles for selection of treatment for ONFH, and stage, classification, volume of necrosis, joint function, age of the patient, patient occupation, and other factors should be taken into consideration.

Porous Tantalum Implant in Treating Osteonecrosis of the Femoral Head: Still a Viable Option?

The purpose of this study is to evaluate the survivorship and risk factors for radiographic progression and conversion to total hip arthroplasty (THA) after porous tantalum implant surgery in the treatment of osteonecrosis of the femoral head (ONFH). The study comprised 90 ONFH patients (104 consecutive hips) who were treated with a porous tantalum implant combined with bone grafting between June 2008 and December 2013. The patients were 19–61 years of age (mean age, 38 years). The mean follow-up was 42 months. The outcome measures included Harris hip score (HHS), radiographic outcome measures, and survivorship analysis with conversion to THA as the endpoint. The mean postoperative HHS was significantly lower than the mean preoperative HHS (P < 0.001). The Cox proportional hazards model showed that age and Association Research Circulation Osseous (ARCO) stage were independent risk factors for conversion to THA, while age, China-Japan Friendship Hospital (CJFH) type, and ARCO stage were independent risk factors for radiological progression. Ultimately, only 52.9% hips survived. Porous tantalum implant surgery combined with bone grafting is not a viable option for treating ONFH, especially in patients >35 years of age with preoperative ARCO stage III and CJFH type L3.

Combination treatment of biomechanical support and targeted intra-arterial infusion of peripheral blood stem cells mobilized by granulocyte-colony stimulating factor for the osteonecrosis of the femoral head: a randomized controlled clinical trial

The objective of this study was to determine the benefits of combination treatment with mechanical support and targeted intra-arterial infusion of peripheral blood stem cells (PBSCs) mobilized by granulocyte-colony stimulating factor (G-CSF) via the medial circumflex femoral artery on the progression of osteonecrosis of the femoral head (ONFH). Fifty-five patients (89 hips) with early and intermediate stage ONFH were recruited and randomly assigned to combination treatment or mechanical support treatment (control group). All hips received mechanical support treatment (porous tantalum rod implantation). Then, hips in the combination treatment group were performed targeted intra-arterial infusion of PBSCs. At each follow-up, Harris hip score (HHS) and Association Research Circulation Osseous (ARCO) classification were used to evaluate the symptoms and progression of osteonecrosis. Total hip arthroplasty (THA) was assessed as an endpoint at each follow-up. At 36 months, 9 of the 41 hips (21.95%) in the control group progressed to clinical failure and underwent THA whereas only 3 of the 48 hips (6.25%) in the combination treatment group required THA (p = 0.031). Kaplan-Meier survival analysis showed a significant difference in the survival time between the two groups (log-rank test; p = 0.025). Compared to the control group, combination treatment significantly improved the HHS at 36 months (p = 0.003). At the final follow-up examination, radiological progression was noted in 13 of 41 hips (31.71%) for the control group, but in only 4 of 48 hips (8.33%) for the combination treatment group (p = 0.005). The overall collapse rates were 15.15% (5/33 hips) and 8.11% (3/37 hips) in the control and combination treatment groups, respectively. Targeted intra-arterial infusion of PBSCs is capable of enhancing the efficacy of biomechanical support in the treatment of ONFH. This clinical trial confirmed that the combination treatment might be a safe and feasible choice for the treatment of early or intermediate stages of ONFH.

Steroid-associated osteonecrosis: Epidemiology, pathophysiology, animal model, prevention, and potential treatments (an overview)

Steroid-associated osteonecrosis (SAON) is a common orthopaedic problem caused by administration of corticosteroids prescribed for many nonorthopaedic medical conditions. We summarised different pathophysiologies of SAON which have adverse effects on multiple systems such as bone marrow stem cells (BMSCs) pool, bone matrix, cell apoptosis, lipid metabolism, and angiogenesis. Different animal models were introduced to mimic the pathophysiology of SAON and for testing the efficacy of both prevention and treatment effects of various chemical drugs, biological, and physical therapies. According to the classification of SAON, several prevention and treatment methods are applied at the different stages of SAON. For the current period, Chinese herbs may also have the potential to prevent the occurrence of SAON. In the future, genetic analysis might also be helpful to effectively predict the development of ON and provide information for personalised prevention and treatment of patients with SAON.

Summary of the various treatments for osteonecrosis of the femoral head by mechanism: A review

Osteonecrosis of the femoral head (ONFH), also known as femoral head avascular necrosis, is a pathological state with a number of possible etiologies including steroid administration, alcohol abuse, traumatic events, vascular injury and idiopathic origins. ONFH causes a reduction in the vascular supply to the subchondral bone of the femoral head, which results in osteocyte death and the collapse of the articular surface. Treatments for ONFH include non-weight-bearing therapy, physical support, the promotion of osteoclast apoptosis, and the reduction of osteoblast and osteocyte apoptosis. The aim of the present review was to summarize the treatments for ONFH by mechanism from a new perspective and to describe the condition with an emphasis on treatment options.