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

Investigational regenerative medicine for non-traumatic osteonecrosis of the femoral head: a survey of registered clinical trials

INTRODUCTION

Osteonecrosis of the femoral head (ONFH) is a refractory disease requiring joint replacement in young patients. Regenerative therapies have been developed.

AREAS COVERED

This study surveyed clinical trials on regenerative medicine for ONFH. We extracted clinical trials on non-traumatic ONFH from the websites of five publicly available major registries (EuropeanUnion Clinical Trials Register ([EU-CTR],ClinicalTrials.gov, Chinese ClinicalTrial Registry [ChiCTR], University Hospital Medical InformationNetwork - Clinical Trial Registry [UMIN-CTR] and Australian New Zealand Clinical Trials Registry [ANZCTR]).The trials were classified into six categories based on purpose: surgical treatment, non-drug conservative treatment, conservative drug treatment, therapeutic strategy, diagnosis and pathogenesis, and regenerative therapy.) We extracted 169 clinical trials on ONFH. Of these, 37 were on regenerative medicine, including 29 on cell therapy. Surgical treatment was the most common treatment, followed by regenerative therapy.There were 9 clinical trials registered in the EU-CTR, with 5 on regenerative medicine; 79 trials registered on ClinicalTrials.gov, with 24 on regenerativemedicine; 54 trials registered in the ChiCTR, with 6 on regenerative medicine.

EXPERT OPINION

The focus of the joint-preserving surgery has shifted to regenerative therapy based on using cell therapy in early-stage ONFH. The global standardisation of regenerative therapy is still ongoing.

Invasive electrical stimulation in the treatment of avascular osteonecrosis of the femoral head - mid-term results

The study aimed to evaluate the outcomes of osteonecrosis of the femoral head (ONFH) in adults after surgical treatment including invasive electromagnetic osteostimulation (E-Stim). Further, the influence of disease stage and several comorbidities on the joint preservation rate should be examined. Sixty patients (66 hip joints) with ONFH were included in this retrospective cross-sectional analysis (mean follow-up: 58 months, 19-110 months). Potential ONFH risk factors and comorbidities (ONFH stage, age, sex, alcohol, smoking, cortisone medication, chemotherapy) were recorded. The influence of specific parameters on the joint preservation rates was evaluated by a multivariate logistic regression analysis. Finally, patients with preserved hip joints underwent an assessment of their last available X-rays. The joint preservation rate depended on the initial ONFH Steinberg stage (I+II: 82.8%, III: 70.8%, ≥ IVa: 38.5%). Initially collapsed ONFH (p ≤ 0.001) and cortisone therapy (p = 0.004) significantly decreased the joint preservation rates. In case of progressed ONFH, the presence of ≥ 2 risk factors resulted in higher THA conversion rates (stage III: OR 18.8; stage ≥IVa: OR 12). In 94% of the available X-rays, the ONFH stage improved or did not progress. No complications could be attributed to the E-Stim device or procedure. The present surgical protocol including minimally invasive E-Stim revealed high joint preservation rates for non-collapsed ONFH after mid-term postoperative follow-up. Especially in progressed ONFH, the-risk profile seems to be crucial and hence, for joint preserving surgery, careful patient selection is recommended.

Treatment of osteonecrosis of the femoral head with multiple drilling and bone marrow mesenchymal stem cells expanded ex vivo plus biomolecules derived from platelet-rich plasma: a case report

Osteonecrosis of the femoral head (ONFH) is a debilitating condition that predominantly affects young individuals, resulting in disability and involving significant healthcare costs. Therefore, it is crucial to develop an effective therapeutic strategy to treat this debilitating disease. In this context, autologous bone marrow-derived mesenchymal stem cells (auto-BM-MSCs) have emerged as a promising approach for treating ONFH. In this case report, we applied this therapy to a patient with ONFH and evaluated both its safety and therapeutic benefits. The treatment consisted of the administration of a single dose of 4×107 ex vivo-expanded auto-BM-MSCs combined with biomolecules derived from platelet-rich plasma. These therapeutic agents were injected into the necrotic zone after accessing it through the technique of multiple small drillings. Subsequently, the progression of ONFH was assessed after 18 months of the auto-BM-MSC administration. Radiographic evaluation showed that the initial femoral head flattening persisted, but no further progression or coxofemoral arthritic changes were observed. Nevertheless, magnetic resonance imaging (MRI) demonstrated a significant improvement in the affected femoral head's area, resulting in a Kerboull angle of 80°, without evidence of flattening or a notable collapse compared to the preoperative condition. Furthermore, the patient exhibited a remarkable functional improvement, as evidenced by a modified Harris hip score of 90 points. The absence of any additional surgery reinforces the positive outcomes achieved through this therapeutic intervention. In conclusion, our case study provides evidence for using the ex vivo-expanded auto-BM-MSCs in combination with platelet-rich plasma-derived biomolecules as a viable and safe treatment for ONFH. However, further research and clinical trials are necessary to validate these promising findings.

Volume and location of bone regeneration after autologous expanded mesenchymal stromal cells in hip osteonecrosis : a pilot study

AIMS

Successful cell therapy in hip osteonecrosis (ON) may help to avoid ON progression or total hip arthroplasty (THA), but the achieved bone regeneration is unclear. The aim of this study was to evaluate amount and location of bone regeneration obtained after surgical injection of expanded autologous mesenchymal stromal cells from the bone marrow (BM-hMSCs).

METHODS

A total of 20 patients with small and medium-size symptomatic stage II femoral head ON treated with 140 million BM-hMSCs through percutaneous forage in the EudraCT 2012-002010-39 clinical trial were retrospectively evaluated through preoperative and postoperative (three and 12 months) MRI. Then, 3D reconstruction of the original lesion and the observed postoperative residual damage after bone regeneration were analyzed and compared per group based on treatment efficacy.

RESULTS

The mean preoperative lesion volume was 18.7% (SD 10.2%) of the femoral head. This reduced to 11.6% (SD 7.5%) after three months (p = 0.015) and 3.7% (SD 3%) after one year (p < 0.001). Bone regeneration in healed cases represented a mean 81.2% (SD 13.8%) of the initial lesion volume at one year. Non-healed cases (n = 1 stage progression; n = 3 THAs) still showed bone regeneration but this did not effectively decrease the ON volume. A lesion size under mean 10% (SD 6%) of the femoral head at three months predicted no ON stage progression at one year. Regeneration in the lateral femoral head (C2 under Japanese Investigation Committee (JCI) classification) and in the central and posterior regions of the head was predominant in cases without ON progression.

CONCLUSION

Bone regeneration was observed in osteonecrotic femoral heads three months after expanded autologous BM-hMSC injection, and the volume and location of regeneration indicated the success of the therapy.Cite this article: Bone Joint Res 2022;11(12):881-889.