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

Conservative Treatment in Avascular Necrosis of the Femoral Head: A Systematic Review

INTRODUCTION

Avascular necrosis (AVN) of the femoral head is a pressing orthopedic issue, leading to bone tissue death due to disrupted blood supply and affecting the quality of life of individuals significantly. This review focuses on conservative treatments, evaluating their efficacy as mainstay therapies. Enhanced understanding of AVN's pathophysiology and advancements in diagnostic tools have rekindled interest in non-surgical interventions, emphasizing personalized, multidisciplinary approaches for improved outcomes.

MATERIAL AND METHOD

A systematic search was conducted on PubMed, SCOPUS, and Google Scholar databases from January 2020 to August 2023, with the objective of focusing on conservative treatments for AVN of the femoral head. Eligible studies, including original research, case reports, and observational studies, were examined for relevant, well-documented patient outcomes post-conservative treatments, excluding non-English and surgically focused articles without comparative conservative data.

RESULTS

A systematic search yielded 376 records on AVN of the femoral head across multiple databases. After de-duplication and rigorous screening for relevance and quality, 11 full-text articles were ultimately included for a comprehensive qualitative synthesis, focusing on conservatively managing the condition.

CONCLUSIONS

This review evaluates the effectiveness of conservative treatments such as pharmacological interventions and physical modalities in managing AVN of the femoral head. Despite promising results in symptom alleviation and disease progression delay, variability in outcomes and methodological limitations in studies necessitate further rigorous, randomized controlled trials for a robust, patient-centric approach to optimize therapeutic outcomes in AVN management.

Automatic planning and geometric analysis of the drilling path in core decompression surgery for osteonecrosis of the femoral head

BACKGROUND AND OBJECTIVE

Core decompression surgery is an effective treatment method for patients with pre-collapse osteonecrosis of the femoral head (ONFH). The treatment relies on accurately predrilling the wire into the necrotic lesion. However, the surgical planning of this drilling path remains unclear. This paper aims to develop a framework to automatically plan the drilling path and analyze its geometric parameters.

METHODOLOGY

The proposed system consists of two stages. The first stage is to detect the key points. Besides the entry point and target point for the drilling path, the center of the femoral head (FH) and the boundary points of the necrotic lesion are also detected for the subsequent geometric analysis. In the second stage, the geometric parameters of the drilling path are analyzed, including the size of the necrotic lesion, the length from the entry point to the target point, the relative location between the FH center and the necrosis center, and the angular range of the drilling path in the anterior-posterior (AP) direction and superior-inferior (SI) direction.

RESULTS

All of the drilling paths designed by the proposed system were considered successful, starting from the proximal subtrochanteric region, terminating at the center of the necrotic lesion, and remaining within the femoral neck. The relative coordinates of the centers of the femoral head and necrotic lesion were (-0.89,5.14,2.63) mm for the left femurs and (1.55,5.92,2.63) mm for the right femurs, on average. The angular range of the drilling path was 39.99±29.58 degrees in the SI direction and 46.18±40.73 degrees in the AP direction.

CONCLUSION

This study develops a framework that allows for automatic planning and geometric analysis of the drilling path in core decompression surgery. The target point of the drilling path primarily resides in the lateral-anterior-superior region relative to the femoral head center. Surgeons and researchers can benefit from our unified framework while still maintaining the flexibility to adapt to variations in surgical cases.

Application of Biomaterials in Treating Early Osteonecrosis of the Femoral Head: Research Progress and Future Perspectives

Osteonecrosis of the femoral head (ONFH), a progressive pathological process of femoral head ischemia and osteocyte necrosis, is a refractory orthopedic disease caused by multiple etiologies and there is no complete cure at present. With the extension of ONFH duration, osteocyte apoptosis and trabecular bone loss can decrease the load-bearing capacity of the femoral head, which leads to the collapse of the articular cartilage and subchondral bone. Therefore, an urgent clinical need exists to develop effective treatment strategies of early-stage ONFH for maintaining the hip joint function and preventing femoral head collapse. In recent years, extensive attention has been paid to the application of diverse biomaterials in treating early ONFH for sustaining the normal morphology and function of the autologous femoral head, and slowing disease progression. Herein, we review the research progress of bone grafts, metallic materials, bioceramics, bioglasses and polymer materials for early ONFH treatment, and discuss the biological mechanisms of bone repair and regeneration in the femoral-head necrotic area. We propose suggestions for future research directions, from a special perspective of improving the local microenvironment in femoral head by facilitating vessel-associated osteoclasts (VAOs) generation and coupling of bone-specific angiogenesis and osteogenesis, as well as inhibiting bone-associated osteoclasts (BAOs) and BAO-mediated bone resorption. This review can provide ideas for the research, development, and clinical application of biomaterials for treating early ONFH. STATEMENT OF SIGNIFICANCE: We believe that at least three aspects of this manuscript make it interesting to readers of the Acta Biomaterialia. First, we briefly summarize the incidence, pathogenesis, risk factors, classification criteria and treatment of early osteonecrosis of the femoral head (ONFH). Second, we review the research progress in biomaterials for early ONFH treatment and the biological mechanisms of bone repair and regeneration in femoral-head necrotic area. Third, we propose future research progress on improving the local microenvironment in femoral head by facilitating vessel-associated osteoclasts generation and coupling of bone-specific angiogenesis and osteogenesis, as well as inhibiting bone-associated osteoclasts and bone resorption. We hope this review can provide ideas for the research, development, and clinical application of biomaterials for treating early ONFH.

Denosumab Can Prevent Collapse in Patients with Early-Stage Steroid-Induced Osteonecrosis of the Femoral Head by Inhibiting Osteoclasts and Autophagy

OBJECTIVE

The osteoclastic bone resorption inhibitors might have positive effect in preventing femoral head collapse in patients with osteonecrosis of the femoral head (ONFH). However, as a novel osteoclastic inhibitor, whether denosumab can prevent collapse in steroid-induced ONFH remains unknown. This study aims to evaluate the treatment effect of denosumab and the potential protective mechanism.

METHODS

This was a retrospective study. A total of 161 patients with steroid-induced ONFH who underwent denosumab treatment were reviewed, and 209 untreated patients were selected as controls. Their clinical characteristics and radiological exam results were obtained. Patients were treated with 60 mg denosumab every 6 months for 2 years. The primary outcome was the incidence of femoral head collapse at 2 years after the initial diagnosis of ONFH. Secondary outcomes included the Harris hip score, progression of osteosclerosis, increase in necrotic area, bone marrow oedema relief, and bone mineral density increase in the femoral head. The Mann-Whitney U test and chi-square tests were performed to identify the differences between the continuous and categorical variables, respectively. A multivariate logistic regression model was built to identify the factors associated with the treatment effect of denosumab.

RESULTS

The incidence of femoral head collapse was 42.24% (68/161) in the denosumab group and 54.07% (113/209) in the control group (χ²  = 5.094, p = 0.024; relative risk = 0.787, 95% CI = 0.627-0.973). The excellent-good rates of the Harris hip score were 63.98% (103/161) in the denosumab group and 44.98% (94/209) in the control group (χ²  = 13.186, p < 0.001). The incidence of osteosclerosis progression in the denosumab group was 55.28% (89/161), which was significantly higher than that in the control group (43.54%, 91/209, χ²  = 5.016, p = 0.025). Meanwhile, a significant increase in bone mineral density was identified in 29.19% (47/161) and 7.18% (15/209) of patients in the denosumab and control groups, respectively (χ²  = 31.600, p < 0.001). The osteoclastic cytoplasm expression of LC3-II was more positive in the control group than in the denosumab group (immunohistochemistry scoring: 3.58 ± 2.27 vs 6.33 ± 2.64, Z = -2.684, p = 0.007). A total of three independent factors were considered to be associated with the positive treatment effect of denosumab, the time of first denosumab administration (OR = 2.010, 95% CI = 1.272-3.177), osteosclerosis (OR = 1.583, 95% CI = 1.024-2.445), and the necrotic area before denosumab administration (medium necrotic area: OR = 2.084, 95% CI = 1.245-3.487; large necrotic area: OR = 2.211, 95% CI = 1.255-3.893).

CONCLUSIONS

The current study demonstrated that denosumab had a positive effect on preventing femoral head collapse in patients with steroid ONFH. This effect might be closely associated with the inhibition of osteoclasts and their autophagy.

Combination of hyperbaric oxygen and core decompression therapies improve outcomes in the treatment of hip osteonecrosis

INTRODUCTION

To investigate whether combined treatment of hyperbaric oxygen (HBO) and core decompression (CD) result with better outcomes and have an additional influence on health quality scores when compared with HBO alone.

METHODS

63 consecutive patients' 80 hips (43 male, 20 female, 17 bilateral), diagnosed with Stage II Osteonecrosis of the femoral head were included in our study. The mean age at presentation in the HBO and CD + HBO groups were 39.9 years and 39.2 years, respectively. The mean follow-up was 39.8 months (24-56 months) for HBO group and 43.1 months (24-58 months) for the CD + HBO group. Standard radiographs and MRI were performed initially and during controls. Clinical outcomes were assessed using the modified Harris Hip Score (HHS), the visual analogue score (VAS) and SF-36 life quality score.

RESULTS

52 hips (65%) were Ficat Stage IIa and 28 hips (35%) were IIb. Totally, 46 hips (30 hips IIa, 16 hips IIb) were in HBO alone group and 34 hips (22 hips IIa, 12 hips IIb) were in CD + HBO group. Both VAS and HHSs were improved in each group after treatment (p < 0.001). When both groups were compared, this improvement was more distinct and evident in CD + HBO combination group than HBO alone group (p < 0.001). The physical function and pain components of SF-36 survey were found to be different in between two groups (p < 0.005).

DISCUSSION

HBO treatment decreases pain, increases functional scores for Ficat Stage II patients. Addition of HBO treatment to decompression of the femoral head improves the results better than HBO alone. In particular, reduction of pain is more prevalent for Stage IIa patients than IIb with combination of HBO and CD therapies.

[Short hip stem for THA in avascular necrosis of the femoral head]

INTRODUCTION

Osteonecrosis of the femoral head or avascular necrosis of the femoral head (HKN) is a complex disease that, without treatment, leads to infraction of the femoral head in most cases. In these cases, only replacement of the hip joint will help, although there is no clear recommendation of an arthroplasty type. In the last two decades, the treatment of primary and secondary coxarthrosis with short-shaft prostheses with different anchoring philosophies has increased. Since short-shaft fitting is a possible option especially in younger patients, the question arises about possible fittings of advanced HKN with these stem types, especially with metaphyseal anchorage. The aim of this study was to review the existing literature on the results of short stem prosthesis in HKN and to present the advantages and disadvantages of short stem prosthesis in osteonecrosis of the femoral head.

MATERIAL AND METHODS

This review analyzes the existing studies on short stem arthroplasty for HKN.

RESULTS

Only a few studies exist that have analyzed clinical and radiologic outcomes of short stem replacement in HKN.

CONCLUSION

The existing short- and medium-term results show mostly good outcomes. However, it is difficult to draw a general conclusion due to differences in stem design and fixation. Short stems with primary diaphyseal fixation do not show an increased risk of failed osseointegration or loosening. Constructions with primary metaphyseal fixation should undergo MRI to rule out the possibility of necrosis extending beyond the femoral neck.

Lycium barbarum polysaccharide protects against osteonecrosis of femoral head via regulating Runx2 expression

BACKGROUND

Osteonecrosis of femoral head (ONFH) is a pathological state caused by lack of blood supply in femoral head. This study aimed to explore the function of Lycium barbarum polysaccharide (LBP), an antioxidant agent extracted from L. barbarum, on ONFH.

METHODS

Osteonecrosis rat model was generated using lipopolysaccharide (LPS) and methylprednisolone followed by examination of body weight, blood glucose, morphology, and BMSC osteoblast differentiation. The effect and underlying mechanism of LBP on the proliferation, apoptosis, and osteoblast differentiation of BMSC were determined with or without LPS or hypoxia treatment using CCK-8. Alizarin Red S staining, flow cytometry, and western blot, respectively.

RESULT

LBP could protect against glucocorticoid-induced ONFH in rats, resulting in improved sparse trabecular bone, empty lacunae and bone cell coagulation. Moreover, LBP promoted the proliferation and osteoblast differentiation of bone mesenchymal-derived stem cells (BMSCs) in a dose-dependent manner. Furthermore, LBP enhanced osteoblast differentiation of BMSCs under hypoxia condition. Mechanistically, we found that LBP treatment enhanced Runx2 and ALP expression in BMSCs. LBP restored the expression of Runx2 and ALP under hypoxia, suggesting that LBP might be involved in regulating Runx2/ALP expression and contributed to osteoblast differentiation. Knockdown of Runx2 significantly inhibited BMSCs proliferation, while LBP treatment did not rescue the osteoblast differentiation ability of BMSCs with Runx2 knockdown.

CONCLUSION

Our findings suggested that LBP protects against ONFH via regulating Runx2 expression, which could be utilized to treat patients suffering ONFH.

An injectable hydroxypropyl-β-cyclodextrin cross-linked gelatin-based hydrogel loaded bone mesenchymal stem cell for osteogenic and in vivo bone regeneration of femoral head necrosis

An injectable hydroxypropyl-β-cyclodextrin (HPβCD) cross-linking of gelatin (Gel) based hydrogel was embedded with BMSC in vivo bone regeneration of femoral head necrosis. This HPβCD-Gel hydrogel possesses quick gelation within 6 min; a high-water uptake resulted in faster biodegradation, high swelling, and a 3D porous network that strengthened its mechanical, surface, and morphological properties. The results indicated that BMSC showed high cell viability (>90%) during measurement; HPβCD-Gel hydrogels induced BMSC differentiation into osteocytes within 14 days more efficiently than the osteogenic medium. The HPβCD-Gel/BMSC hydrogels that were injected into the necrosis site of the femoral head in the vessels were measured for 2 weeks. In addition, the vessel density and mean vessel diameters increased in the next 2-8 weeks followed by increased new bone formation, according to the in vivo analysis. Overall, our findings show that this method is a promising strategy for improving femoral head necrosis bone regeneration.

Quantitative Magnetic Resonance Imaging of Femoral Head Articular Cartilage Change in Patients with Hip Osteonecrosis Treated with Extracorporeal Shock Wave Therapy

BACKGROUND

Multiple reports have demonstrated the therapeutic potential of extracorporeal shock wave (ESWT) in osteonecrosis of the femoral head (ONFH). However, few studies reported the changes in hip articular cartilage after the intervention. This study aimed to investigate the effect of ESWT on femoral head cartilage using a novel technique, quantitative T2-mapping magnetic resonance imaging.

METHODS

A total of 143 eligible patients with unilateral early-stage ONFH were randomized into the ESWT group and control group. Seventy-three patients in the ESWT group received two sessions of ESWT with oral drug treatment, while seventy patients in the control group received oral drug treatment only. The visual analog pain scale (VAS) and Harris hip score (HHS) at 3-month, 6-month, and 12-month follow-up were used as the clinical evaluation index. The radiological evaluation index used the T2 mapping values, necrotic size, and China-Japan Friendship Hospital (CJFH) classification.

RESULTS

A total of 143 patients (62 females and 81 males) were finally included, and the characteristics before treatment were comparable between the two groups. At the last follow-up (12 months), the T2 values and ΔT2 changes in the ESWT group were all smaller than those in the control group (p=0.042; p=0.039), while the CJFH classification of ONFH and necrotic lesion size were not statistically significant. At 3 months and 6 months, the VAS in the ESWT group was lower than that in the control group (p=0.021; p=0.046) and the HHS in the ESWT group was higher (p=0.028; p=0.039). However, there were no significant differences in the VAS and HHS at 12 months between the ESWT and control groups.

CONCLUSIONS

The results of the current study indicated that, based on drug treatment, ESWT is an effective treatment method for nontraumatic ONFH, which could result in significant pain relief and function restoration. Furthermore, it could delay the injury of femoral head cartilage during the progression of ONFH.

Aseptic Necrosis of Femoral Head - Clinical Study

Femoral head osteonecrosis is a disease characterized by the decrease of blood vascularization in the femoral head, which leads to death of the osteocytes, demineralization and resorption of bone spans, change of trabecular architecture, with the reduction of the bone mechanical resistance and collapse of the articular surface in the femoral head. Left untreated, the disease may have a rapid progression, leading to severe symptoms, with significant articular dysfunction, functional impotence and a serious impact on the patient’s quality of life. The prevalence of the disease is ever growing all over the world, affecting mainly people in their 30s, 40s or 50s. In the present study, we analyzed a number of 76 patients with femoral head osteonecrosis with severe symptoms that required a surgical treatment. There was observed that more than ¾ of the investigated patients were males, while 81.58% were younger than 60 years old. Among the identified risk factors, smoking came first, followed by alcohol intake, obesity and chronic administration of corticosteroids. A very high percentage of patients (84.21%) were diagnosed in stages III and IV of the disease.

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.

Analysis of MR Signs to Distinguish Between ARCO Stages 2 and 3A in Osteonecrosis of the Femoral Head

BACKGROUND

MRI is the most effective diagnostic tool of osteonecrosis of the femoral head (ONFH), especially for early diagnosis, but its detection of subchondral or cortical fractures is less accurate than CT. Therefore, it is difficult to accurately stage ONFH in the peri-collapse period by MRI.

PURPOSE

To improve the accuracy of MR for distinguishing between Association Research Circulation Osseous (ARCO) stages 2 and 3A in ONFH.

STUDY TYPE

Retrospective.

SUBJECTS

One hundred and fifty five cases of ARCO stage 2/3A of ONFH underwent MR examinations, M/F = 72/83. CT was used as reference standard for collapse, which was decided by an orthopedist and a radiologist in consultation.

FIELD STRENGTH/SEQUENCE

3 T/axial and coronal T₁ -weighted Turbo Spin Echo (T₁ W TSE) sequence, axial T₂ -weighted fat-saturated (T₂ W FS) TSE sequence, and coronal proton density-weighted imaging (PDWI)-FS-Dixon fat/water image.

ASSESSMENT

Five potential MR signs (the maximum width of the necrotic-viable interface, bone marrow edema (BME), irregular articular surface of the femoral head, T₂ heterogeneous high signal, and the absence of a necrotic-viable interface with the morphology of closed loop) were evaluated blindly by five radiologists independently and the total scores of different combinations of MR signs were calculated.

STATISTICAL TESTS

Mann-Whitney U test and Chi-square test were used to evaluate age, gender, and MR signs differences between the two groups. ROC curve was used to access the distinguishing value of MR signs. The consistency of the five radiologists was analyzed by intraclass correlation coefficient.

RESULTS

The area under the curve of the combined MR signs 2 for distinguishing between ARCO stages 2 and 3A was the greatest (0.967), sensitivity and specificity were 100.00% and 88.71% respectively, and greater than 1 was the threshold.

DATA CONCLUSION

Combined MR signs 2 has great values in distinguishing between ARCO stages 2 and 3A in ONFH, thus helping clinical therapy.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY: Stage 2.

Diagnostic value of necrotic lesion boundary in bone collapse of femoral head osteonecrosis

PURPOSE

Our research developed a novel approach to quantitatively evaluate the boundary of necrotic lesions in osteonecrosis of the femoral head (ONFH) and to explore its diagnostic value in predicting bone collapse of the femoral head.

METHODS

A retrospective cross-sectional study was conducted in our institution, and 146 hips (121 cases) identified as ONFH were recruited. The anterior and lateral boundaries of each enrolled subject were measured in standard anteroposterior (AP) view and frog-leg (FL) view of plain radiographic images, the intact rate of which was then calculated and presented as the anteroposterior view intact ratio (APIR) and frog-leg view intact ratio (FLIR), respectively. Univariate and multivariate logistic regression analyses were performed to identify risk factors for collapse. A receiver operating characteristic (ROC) curve analysis was performed to determine the sensitivity, specificity and cutoff value of the APIR and FLIR. A Kaplan-Meier (K-M) analysis was applied to calculate the survival rate of the femoral head, and bone collapse of the femoral head was regarded as the endpoint.

RESULTS

Femoral head collapse was observed in 61 hips during the follow-up period. Patients with or without femoral head collapse were categorized into the collapse group and non-collapse group, respectively. The mean follow-up time was 3.7 years (2-9) for the collapse group and 7.7 years (5-20) for the non-collapse group. Univariate and multivariate logistic regression analysis and ROC analysis showed that APIR (< 25.61%) and FLIR (< 24.43%) were significantly associated with femoral head collapse. The K-M survival curves indicated that the overall survival rate of APIR (≥ 25.61%) was 94.8% at 7.5 years and 76.6% at 10 years, while that of FLIR (≥ 24.43%) was 87.3% at 7.5 years and ten years.

CONCLUSION

The present study demonstrates that APIR and FLIR are of high diagnostic value in the early and middle stages of ONFH. APIR and FLIR can be used to predict the occurrence of femoral head collapse in patients with JIC classification types B and C1. The measurement of these two parameters in plain radiography images may contribute to the selection of a proper hip preservation strategy.

Administration of mircoRNA-135b-reinforced exosomes derived from MSCs ameliorates glucocorticoid-induced osteonecrosis of femoral head (ONFH) in rats

Exosomes were found to exert a therapeutic effect in the treatment of osteonecrosis of the femoral head (ONFH), while miR-135b was shown to play an important role in the development of ONFH. In this study, we investigated the effects of concomitant administration of exosomes and miR-135b on the treatment of ONFH. A rat mode of ONFH was established. TEM, Western blotting and nanoparticle analysis were used to characterize the exosomes collected from human-induced pluripotent stem cell-derived mesenchymal stem cells (hiPS-MSC-Exos). Micro-CT was used to observe the trabecular bone structure of the femoral head. Real-time PCR, Western blot analysis, IHC assay, TUNEL assay, MTT assay and flow cytometry were performed to detect the effect of hiPS-MSC-Exos and miR-135b on cell apoptosis and the expression of PDCD4/caspase-3/OCN. Moreover, computational analysis and luciferase assay were conducted to identify the regulatory relationship between PDCD4 mRNA and miR-135b. The hiPS-MSC-Exos collected in this study displayed a spheroidal morphology with sizes ranging from 20 to 100 nm and a mean concentration of 1 × 10¹² particles/mL. During the treatment of ONFH, the administration of hiPS-MSC-Exos and miR-135b alleviated the magnitude of bone loss. Furthermore, the treatment of MG-63 and U-2 cells with hiPS-MSC-Exos and miR-135b could promote cell proliferation and inhibit cell apoptosis. Moreover, PDCD4 mRNA was identified as a virtual target gene of miR-135b. HiPS-MSC-Exos exerted positive effects during the treatment of ONFH, and the administration of miR-135b could reinforce the effect of hiPS-MSC-Exos by inhibiting the expression of PDCD4.

Platelet-rich plasma promotes bone formation, restrains adipogenesis and accelerates vascularization to relieve steroids-induced osteonecrosis of the femoral head

Steroid-associated necrosis of the femoral head (SANFH) is one of the most common and refractory chronic diseases with increasing incidence. The typical pathological changes of SANFH include decreased osteogenic differentiation, enhanced intramedullary adipocytes deposition and impaired osseous circulation. In this study, we investigated the effects and potential mechanisms of Platelet-rich plasma (PRP) on SANFH. Sixty Sprague-Dawley rats were randomly divided into the control, PRP donor, model, and PRP groups. Compared to the model group, PRP treatment significantly increased the hemorheological indexes and serum levels of bone gla-protein (BGP) and vascular endothelial growth factor (VEGF), while decreased the levels of triglyceride (TG) and total cholesterol (TC). Meanwhile, Micro-CT and histopathological stain (Hematoxylin-eosin and Alcian blue-hematoxylin/orange G staining) were performed on the femoral head for morphological and histopathological evaluation, indicating that bone trabecular microstructure and bone mineral density (BMD) were significantly improved after PRP treatment. Immunohistochemical analysis revealed that PRP remarkably up-regulated the expression of osteogenic markers including β-catenin and alkaline phosphatase (ALP), angiogenic markers containing VEGF and platelet endothelial cell adhesion molecule-1 (CD31), while down-regulated adipogenic markers involving fatty acid-binding protein (FABP-4), and peroxisome proliferator-activated receptor gamma (PPAR-γ) in SANFH rat models. In summary, for the first time, PRP was demonstrated to prevent the development of SANFH through stimulating bone formation and vascularization as well as retarding adipogenesis.

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

BACKGROUND

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

OBJECTIVE

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

Single approach to double-channel core decompression and bone grafting with structural bone support for treating osteonecrosis of the femoral head in different stages

BACKGROUND

We created a novel method-single approach to double-channel core decompression and bone grafting with structural bone support (SDBS)-to treat early-stage osteonecrosis of the femoral head (ONFH) by improving the Phemister technique. This study aimed to evaluate the results of SDBS for early-stage ONFH.

METHODS

Altogether, 53 patients (73 hips) were treated using SDBS during 2016-2018. Bilateral (20 patients) and unilateral (33 patients = 18 left hips, 15 right hips) ONFH was diagnosed. According to the Association Research Circulation Osseous classification stages, the femoral heads were staged as IIB (n = 15), IIC (n = 19), IIIA (n = 34), IIIB (n = 4), and IIIC (n = 1). The Harris hip score was used to evaluate the hips' clinical function, computed tomography to evaluate subchondral fractures, and plain radiography to assess the extent of femoral head collapse.

RESULTS

The average follow-up was 20.71 ± 6.65 months (6-36 months). At the patients' last follow-up, 4 hips were found to require arthroplasty. Thus, the overall femoral head survival rate was 94.52% (69/73). Also, the overall Harris score (84.44 ± 14.57) was significantly higher than that preoperatively (77.67 ± 14.37) (P = 0.000). The combined excellent and good rate (76.71%) was significantly higher than that preoperatively (38.36%) (P = 0.000). Imaging showed that 16 femoral heads had some ONFH progression. The average length of stay was 6.15 ± 0.86 days. The average incision measured 2.69 ± 0.30 cm. Intraoperative blood loss was 61.20 ± 4.81 ml. There were no complications during or after the operation.

CONCLUSION

SDBS is an effective method for treating early-stage ONFH. It is a hip-preserving surgical approach to slow/prevent ONFH progression.

Comparison of surgical dislocation and impacting bone graft and surgical dislocation and rotational osteotomy for the treatment of ARCO III femoral head necrosis

Hip preserving procedures are still a challenge in late-stage osteonecrosis of femoral head (ONFH) patients. We aimed to compare the clinical outcomes of surgical dislocation and impaction bone graft and surgical dislocation and rotational osteotomy for treatment of ONFH in Association Research Circulation Osseous (ARCO) stage III patients.We retrospectively reviewed 30 ARCO stage III patients (33 hips) who had surgical dislocation and impaction bone graft or surgical dislocation and rotational osteotomy in our center from June 2012 to December 2017. Baseline characteristics, clinical evaluation using Harris score and radiologic evaluation up to 12 months after surgery were recorded and compared.Fifteen patients (17 hips) were in the surgical dislocation and impaction bone graft group and 15 patients (16 hips) were in the surgical dislocation and rotational osteotomy group. No significant differences in age, gender, etiology, ARCO stage, duration of illness, operation time, and length of hospitalization were observed between the 2 groups. Compared to preoperation Harris score, the Harris score of 6 months postoperation and 12 months postoperation significantly improved. At 12 months postoperation, the excellent and good rate was 76.5% in the impaction bone graft group and 87.5% in the rotational osteotomy group. No significant difference in Harris scores was detected in the 2 groups.Surgical dislocation and impaction bone graft and surgical dislocation and rotational osteotomy had satisfactory 1-year efficacy for ARCO III ONFH patients. Surgical dislocation and rotational osteotomy had better short-term efficacy than surgical dislocation and impaction bone graft.

Changed cellular functions and aberrantly expressed miRNAs and circRNAs in bone marrow stem cells in osteonecrosis of the femoral head

The present study aimed to detect the correlations between altered cellular functions in bone marrow stem cells (BMSCs) and osteonecrosis of the femoral head (ONFH). By profiling the aberrant expression of miRNAs and circRNAs in BMSCs isolated from ONFH patients, the present study aimed to further explore the potential regulatory mechanisms of action of circRNAs in ONFH using integrated bioinfor-matics analysis. BMSCs were isolated from seven ONFH patients and seven controls. Cellular functions, including proliferation, apoptosis and differentiation, were compared. miRNA and circRNA sequencing were conducted using RNA samples of three ONFH patients and three controls to identify differentially expressed circRNAs and miRNAs. The expression of hsa_circ_0000219, hsa_circ_0004588 and hsa_circ_0005936 were validated by qPCR. Target miRNAs were also predicted and validated by qPCR and circRNA-miRNA co-expression networks were constructed. BMSCs of ONFH patients displayed decreased proliferation and increased apoptosis during in vitro culturing. In addition, reduced osteogenesis and enhanced adipogenesis were found in the ONFH group. A total of 129 miRNAs and 231 circRNAs were detected to be differentially expressed. The expression levels of hsa_circ_0000219, hsa_circ_0004588 and hsa_circ_0005936 were significantly decreased in BMSCs of ONFH patients. A number of target miRNAs related to cell proliferation, apoptosis and differentiation were predicted for hsa_circ_0000219 and hsa_circ_0005936. The expression levels of miR-144-3p and miR-1270 were found to be elevated in ONFH patients, which was consistent with miRNA sequencing data and competitive endogenous RNA hypothesis. Time-dependent expression patterns of hsa_circ_0000219, hsa_circ_0004588, hsa_circ_0005936, miR-144-3p and miR-1270 were also validated during osteogenic and adipogenic differentiation in BMSCs. The results of the present study substantiated the involvement of BMSCs in ONFH development. hsa_circ_0000219 and hsa_circ_0005936 may regulate the progression of ONFH by mediating the proliferation and differentiation of BMSCs by sponging miRNAs.

Primary stability of calcar-guided short-stem total hip arthroplasty in the treatment of osteonecrosis of the femoral head: migration analysis using EBRA-FCA

INTRODUCTION

Osteonecrosis of the femoral head (ONFH) is a disabling condition that often results in secondary arthritis necessitating total hip arthroplasty (THA). Short-stem THA has constantly gained popularity. It remains controversial, whether ONFH represents a risk factor for failure after the implantation of short stems with pronounced metaphyseal anchorage. The potential spread of the osteonecrotic area and bone marrow edema into the metaphyseal bone might result in compromised stability. Early implant migration is considered predictive of subsequent aseptic loosening. The purpose of this study was a migration analysis of a modern, calcar-guided short-stem implant in patients with ONFH in a mid-term follow-up.

MATERIALS AND METHODS

This retrospective analysis investigated the migration pattern of 45 calcar-guided short stems in patients with ONFH, using Einzel-Bild-Roentgen-Analyse Femoral-Component-Analysis (EBRA-FCA). Influencing factors such as ARCO categories, age, gender, body weight and BMI were analyzed. Complications and adverse events were documented.

RESULTS

At mid-term [48.1 months (SD 20.7 months)], mean axial migration was 1.56 mm (SD 1.77 mm). Mean migration rate stabilized after 2 years. No influence of ARCO categories, age and BMI was found. A tendency of increased axial migration was observed in male patients and in overweight patients. No revision surgeries had to be performed during follow-up.

CONCLUSION

The results indicate a migration pattern comparable to that of primary osteoarthritis patients with slight initial migration under full load followed by subsequent stabilization in the metaphyseal femur. The 100% survival rate at mid-term supports the usage of this short-stem design in patients with ONFH.

One-stage simultaneous hip-preserving surgeries for the management of bilateral femoral head osteonecrosis: a mean 7.0-year follow-up

Background

A retrospective study was conducted to evaluate and compare the clinical and radiological outcomes of one-stage fibular impaction allografting and vascularized greater trochanter flap autografting for the treatment of bilateral osteonecrosis of the femoral head (ONFH).

Methods

Patients who underwent one-stage aforementioned hip-preserving surgeries due to bilateral ONFH were retrospectively reviewed from January 2008 to December 2013. Sixty-nine patients (138 hips) with a mean age of 31.5 years and mean follow-up of 7.0 years were included. Hips that underwent fibular impaction allografting and vascularized greater trochanter flap autografting were assigned as group A and group B, respectively. Harris Hip Score (HHS) and Visual Analogue Scale (VAS) were used for clinical evaluation, and a series of X-ray images were used for radiological assessment. For inter-group analysis, the paired t test was used for continuous data, and the Wilcoxon rank sum test was used for non-parametric data, while the Mann-Whitney U test was used for intra-group analysis.

Results

The HHS and VAS in both groups A and B had a substantial advancement when compared with the preoperative level (p < 0.01). Fibular impaction allografting can achieve more pain relief (p < 0.01), though no clinical difference was found in terms of minimal clinically important difference (MCID < 10 points). Group A showed better radiological results than group B (p = 0.04). It was discovered that the appropriate indication for each procedure was patients with Association for Research on Osseous Circulation (ARCO) stages II and III, respectively.

Conclusion

One-stage hip-preserving surgeries for the management of bilateral ONFH could obtain good medium and long-term outcomes. It was recommended that fibular impaction allografting is more suitable for patients in ARCO stage II, while for patients in ARCO stage III, vascularized greater trochanter flap autografting is a better preference.

Trial registration

Retrospectively registered.

Vitamin C Prevents Hydrocortisone-Induced Injury in HMEC-1 through Promoting Bestrophin-3 Expression

OBJECTIVE

To investigate the protective effects and underlying mechanisms of Vitamin C (VC) on hydrocortisone (HC)-induced cell injury in human microvascular endothelial cells (HMEC).

METHODS

Cell viability was measured by CCK-8 assay and the expression of Best-3 was detected by Western blotting assay. The experiment was divided into normal control, HC injury group, VC treatment groups, HC + Best-3 siRNA group, HC + VC + Best-3 siRNA group, HC + pcDNA3.1 Best-3 group, and HC + VC + pcDNA3.1 Best-3 group.

RESULTS

HC inhibited HMEC-1 cell viability was balanced with lower expression of Best-3 in a dose-dependent manner. Conversely, VC promoted HMEC-1 cell viability was paralleled to higher expression of Best-3 in a dose-dependent manner. Silencing Best-3 with Best-3 siRNA inhibited HMEC-1 cell viability, however, over-expression of Best-3 with pcDNA3.1 Best-3 promoted HMEC-1 cell viability. Moreover, VC and over-expression of Best-3 prevented HC-induced HMEC-1 cell apoptosis; however, silencing Best-3 further enhanced HC-induced HMEC-1 cell apoptosis. HC reduced Best-3 expression, which was alleviated by VC treatment. HC treatment decreased Bcl-2 expression, facilitated Bax expression. Both of VC and over-expression of Best-3 promoted Bcl-2 expression and decreased Bax expression. Additionally, VC and Best-3 expression have a synergistic effect.

CONCLUSIONS

VC can efficiently attenuate HC-induced HMEC-1 cell injury, which may be related to promote Best-3 expression.

Huo Xue Tong Luo capsule, a vasoactive herbal formula prevents progression of asymptomatic osteonecrosis of femoral head: A prospective study

Background/objective

A prospective cohort study aimed to evaluate the clinical efficacy of a specific vasoactive herbal formula, Huo Xue Tong Luo capsule (HXTL capsule), for the treatment of patients with asymptomatic osteonecrosis of femoral head (ONFH).

Methods

We evaluated a clinical trial of 55 patients (59 hips) with asymptomatic ONFH (no joint collapse) evaluated by Steinberg staging system and necrosis range classification criteria. Then, they were given HXTL capsule under specific protocol. Among them, 39 males and 16 females with an average age of 36.4 ± 10.1 years were followed up for an average of 4.38 years during treatment. The aggravation of clinical and imaging results was assessed by initial pain and joint collapse. The clinical and imaging outcomes of these patients were compared with those of a historical control group from the literature under critical inclusion criteria.

Results

At the latest follow-up, initial pain occurred in five of 59 (8.5%) hips of patients taking HXTL capsule compared with 31 of 81 (38.3%) controls (p < 0.001), and joint collapse occurred in 13 of 59 (22.0%) hips of patients taking HXTL capsule compared with 26 of 81 (32.1%) controls (p < 0.001). There was no association between joint collapse and multiple key factors of ONFH. Only the location of type C2 necrotic lesions (hazard ratio, 4.12; 95% confidence interval, 2.64–18.91) and the extent of large necrotic lesions (hazard ratio, 3.39; 95% confidence interval, 1.43–16.21) predicted joint collapse.

Conclusion

As an agent formulated by vasoactive herbals, HXTL capsule with specific protocol is an effective medicine for relieving hip pain and preventing joint collapse in patients with asymptomatic ONFH.

The translational potential of this article

The translation potential of this prospective cohort study is that the initially officially approved clinical indication for HXTL capsule for treatment of ONFH is due to its possible effect of revascularization on angiogenesis of necrosis. It is has been now proven to be effective for a new clinical application.

Using Naive Bayes Classifier to predict osteonecrosis of the femoral head with cannulated screw fixation

Predictive models permitting personalized prognostication for patients with cannulated screw fixation for the femoral neck fracture before operation are lacking. The objective of this study was to train, test, and cross-validate a Naive Bayes Classifier to predict the occurrence of postoperative osteonecrosis of cannulated screw fixation before the patient underwent the operation. The data for the classifier model were obtained from a ambispective cohort of 120 patients who had undergone closed reduction and cannulated screw fixation from January 2011 to June 2013. Three spatial displaced parameters of femoral neck: displacement of centre of femoral head, displacement of deepest of femoral head foveae and rotational displacement were measured from preoperative CT scans using a 3-dimensional software. The Naive Bayes Classifier was modelled with age, gender, side of fractures, mechanism of injury, preoperative traction, Pauwels angle and the three spatial parameters. After modelling, the ten-fold cross-validation method was used in this study to validate its performance. The ten-fold cross-validation method uses the whole dataset to be trained and tested by the given algorithm. Two of the three spatial parameters of femoral neck (displacement of center of femoral head and rotational displacement) were included successfully in the final Naive Bayes Classifier. The Classifier achieved good performance of the accuracy (74.4%), sensitivity (74.2%), specificity (75%), positive predictive value (92%), negative predictive value (42.9%) and AUC (0.746). We showed that the Naive Bayes Classifier have the potential utility to be used to predict the osteonecrosis of femoral head within 5 years after surgery. Although this study population was restricted to patients treated with cannulated screws fixation, Bayesian-derived models may be developed for application to patients with other surgical procedures at risk of osteonecrosis.

Clinical and Radiological Outcomes of Extracorporeal Shock Wave Therapy in Early-Stage Femoral Head Osteonecrosis

Objective

Femoral head osteonecrosis is a progressive clinical condition with significant morbidity and long-term disability. Several treatment modalities including both surgical and nonsurgical options have been used with variable levels of success. High-energy extracorporeal shock wave therapy is a nonoperative treatment option that has been described for early-stage disease. We aimed to assess the functional and radiological outcomes of extracorporeal shockwave therapy (ESWT) in the treatment of osteonecrosis of the femoral head (ONFH).

Methods

Thirty-three hips of 21 patients were included in this study. Adult patients with ONFH of any etiology and in the precollapse stage were included. Clinical (visual analogue scale [VAS] and Harris hip score [HHS]) and radiological (plain radiographs and magnetic resonance imaging [MRI]) evaluations were performed before and after intervention. We used 3000–4500 pulses in a single session performed under general anesthesia.

Results

At an average of 8 months after ESWT, pain scores and HHS were significantly improved compared with the preintervention scores (p<0.001). The overall clinical outcomes were improved in 21 hips (63.3%), unchanged in 5 hips (15.15%), and worsened in 7 hips (21.2%). A trend toward a decrease in the size of the ONFH was observed although not of clinical significance (p=0.235). MRI revealed significant resolution of bone marrow edema (p<0.003). Regression was observed in 9 lesions (42.9%) and progression in 1 lesion (4.7%); no change was observed in the remaining 23 lesions (52.4%).

Conclusion

ESWT is a viable noninvasive treatment option for early-stage ONFH. It significantly improves clinical outcomes and may halt or delay the radiographic progression of the disease in the precollapse stage.

Collagen type V a2 (COL5A2) is decreased in steroid-induced necrosis of the femoral head

Collagen is essential for bone adhesion and formation. In the present study, proteomic analysis suggested that collagen type V a2 (COL5A2) was significantly decreased in the necrotic area of patients with steroid-induced necrosis of the femoral head (ONFH). In vitro, the effects of methylprednisolone (MP) on the proliferation and differentiation of human bone marrow-derived mesenchymal stem cells (hBMSCs) were investigated. The expression of the osteogenic-related proteins, Runx2, alkaline phosphatase (ALP), osteocalcin (OC) and COL5A2 was significantly downregulated post-MP treatment. In vivo analyses revealed that post-MP treatment, rats showed typical signs of ONFH by micro-CT scanning and hematoxylin and eosin (H&E) staining. Immunohistochemical staining demonstrated that the expression of COL5A2 and vascular endothelial growth factor (VEGF) was significantly decreased post-MP treatment. In conclusion, the expression COL5A2 was lower in patients with steroid-induced ONFH, hence COL5A2 may be a promising therapeutic target for steroid induced ONFH treatment.

Interest of short implants in hip arthroplasty for osteonecrosis of the femoral head: comparative study "uncemented short" vs "cemented conventional" femoral stems

PURPOSES

Osteonecrosis of the femoral head (ONFH) is a dramatic condition resulting in joint destruction in the late stages. Total hip arthroplasty allows function recovery with satisfactory implant survival. Recently, the use of uncemented short stems has been suggested to improve the conservation of bone stock.

METHODS

We performed a retrospective study on 16 hip arthroplasties-11 patients-implanted for ONFH between 2008 and 2017. We aimed to compare the outcomes of the two types of arthroplasty-"uncemented short" vs "cemented conventional" femoral stem-in terms of pain (visual analogue scale), function (Harris Hip Score), and survival (radiography).

RESULTS

We included six  "uncemented short" and ten "cemented conventional" femoral stems. Mean pre-operative EVA was 7.5 and the mean HHS was 40.3. At last follow-up of seven years, mean VAS was 1.2 (SD ± 0.83) in the "uncemented short" group and 1.6 (SD ± 0.97) in the "cemented conventional" group. Mean HHS was 94 (SD ± 0.81) in the "uncemented short" group and 92.6 (SD ± 2.69) in the "cemented conventional" group. However, radiographic analysis revealed a lower stress shielding in the "uncemented short" stem group. One complication occurred (hip dislocation in the "cemented conventional" stem group).

CONCLUSION

Uncemented short stems total hip arthroplasties may be an interesting alternative to more conventional implants with similar functional results but less stress shielding and a bone stock economy in this young population of patients.

Bone morphogenetic protein-2 exhibits therapeutic benefits for osteonecrosis of the femoral head through induction of cartilage and bone cells

Osteonecrosis of the femoral head is an orthopedic disease caused by femoral head damage or insufficient blood supply, which leads to the death of bone cells and bone marrow. Osteonecrosis of the femoral head leads to changes in the structure of the femoral head, femoral head collapse and joint dysfunction. Bone morphogenetic protein-2 (BMP-2) exhibits beneficial effects on bone formation, repair and angiogenesis at the femoral head. In the present study, the therapeutic effects of recombinant human BMP-2 containing an Fc fragment (rBMP-2/Fc) were investigated on a steroid induced mouse model of osteonecrosis of the femoral head. Bone cell viability was used to determine the in vitro effects of rBMP-2/Fc. The therapeutic efficacies of rBMP-2/Fc on mice with osteonecrosis of the femoral head were evaluated using clinical arthritis scores. The expression levels of inflammatory factors in the mice were analyzed by reverse transcription-quantitative polymerase chain reaction. Histological analysis was used to evaluate the effects of rBMP-2/Fc on the femoral head. The results revealed that rBMP-2/Fc treatment significantly increased the IL-6, IL-10, vascular endothelial growth factor and macrophage colony-stimulating factor expression levels in synovial cells compared with the control group (P<0.01). Furthermore, it was observed that rBMP-2/Fc significantly improved the viability and growth of synovial cells (P<0.01) through the nuclear factor (NF)-κB signaling pathway. Treatment with rBMP-2/Fc significantly decreased receptor activator of NF-κB ligand expression levels. Furthermore, in vivo experiments demonstrated that rBMP-2/Fc treatment markedly relieved the arthralgia and damage caused by osteonecrosis of the femoral head. In conclusion, rBMP-2/Fc treatment may be beneficial for articular cartilage repair by the upregulation of angiogenesis factors through the down regulation of the NF-κB signaling pathway in mice with osteonecrosis of the femoral head. This preclinical data suggests that rBMP-2/Fc may be a promising novel agent for treatment of osteonecrosis of the femoral head.

Effectiveness of various hip preservation treatments for non-traumatic osteonecrosis of the femoral head: A network meta-analysis of randomized controlled trials

BACKGROUND

Non-traumatic osteonecrosis of the femoral head (ONFH) is a refractory osteonecrosis disease caused by an abnormal blood supply to bone tissue. However, therapeutic hip preservation strategies are diverse, and the therapeutic outcomes are not ideal.

OBJECTIVE

A network meta-analysis was performed to assess the effect of hip preservation treatments on non-traumatic ONFH.

METHODS

We searched public electronic databases through May 15, 2017 using the following keywords: "femoral head necrosis osteonecrosis"; "femoral head osteonecrosis"; "osteonecrosis of femoral head"; "avascular necrosis of femoral head"; "necrosis of femoral"; and "random*". The primary outcome in the present analysis was the treatment failure rate. Secondary outcomes included the Harris hip and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores.

RESULTS

We included 21 articles assessing a total of 1415 hips in our analysis. In the network meta-analysis, the treatments were ranked by the surface under the cumulative ranking curve (SUCRA). Core decompression (CD) plus cytotherapy was most likely to reduce the treatment failure rate (SUCRA score = 18.9%), followed by alendronate treatment (SUCRA score = 17.8%), cocktail treatments (SUCRA score = 15.6%), extracorporeal shock wave therapy (ESWT) plus alendronate (SUCRA score = 15.4%), and avascular biomaterials plus cytotherapy (SUCRA score = 13.8%) in a frequentist framework; similar results were obtained in a Bayesian framework. For the secondary outcomes, ESWT was most likely to improve the Harris hip score (SUCRA score = 33.7%), followed by ESWT plus alendronate (SUCRA score = 33.1%) and cocktail (SUCRA score = 19.6%) treatments in a frequentist framework. A traditional analysis showed that the effect of CD plus cytotherapy was significantly better than the effect of CD alone in improving the WOMAC score (SMD, -6.01; 95% CI, -7.81 to -4.22; p < 0.001).

CONCLUSION

CD plus cytotherapy is a relatively superior treatment for reducing treatment failure rates in early and intermediate ONFH patients, and ESWT is the most effective treatment for improving Harris hip scores.

Platelet-rich plasma has beneficial effects in mice with osteonecrosis of the femoral head by promoting angiogenesis

Platelet-rich plasma (PRP) is autologous and multifunctional. Platelet concentrate from blood contains highly concentrated platelets and various types of cells, including growth factors. PRP promotes the recovery of cell proliferation and differentiation. Osteonecrosis of the femoral head is a disease caused by femoral head damage or an insufficient blood supply, which leads to the death of bone cells and abnormal bone marrow composition. The subsequent repair of bone cells may result in changes to the structure of femoral head, femoral head collapse and joint dysfunction. PRP may promote the repair of injured articular cartilage in patients with joint diseases through the removal of harmful inflammatory factors. In the present study, the therapeutic effects and primary mechanism of PRP action were investigated using a glucocorticoid-induced femoral head osteonecrosis mouse model. Dexamethasone (DEX) and phosphate-buffered saline were used as controls. The therapeutic efficacy of PRP to treat osteonecrosis in murine femoral heads was evaluated by assessing clinical arthritis scores. The present study indicated that mice with osteonecrosis of the femoral head treated with PRP exhibited downregulated expression of interleukin (IL)-17A, IL-1β, tumor necrosis factor-α, receptor activator of nuclear factor κ-B ligand, IL-6 and interferon-γ in the inflammatory tissue. In addition, the levels of hepatocyte growth factor, intercellular adhesion molecule-1, osteopontin, platelet-derived endothelial cell growth factor, vascular endothelial growth factor, platelet-derived growth factor, insulin-like growth factor-1 and transforming growth factor-β were increased following treatment with PRP. Joint tissue histological staining demonstrated that PRP alleviated osteonecrosis of the femoral head and reduced humoral and cellular immune responses that promoted beneficial effects on the histological parameters. Furthermore, the concentration of glucocorticoids were significantly decreased in the serum of PRP-treated mice with osteonecrosis compared with the DEX group (P<0.01). Notably, PRP promoted beneficial effects in mice with osteonecrosis of the femoral head by stimulating angiogenesis. Therefore, the present study indicated that treatment with PRP promotes beneficial effects by preventing joint inflammation, cartilage destruction and bone damage, and stimulating the repair of joint tissue in mice with osteonecrosis of the femoral head. These preclinical data suggest that PRP may be developed as a novel method of treating osteonecrosis of the femoral head.

FGF2 and FAM201A affect the development of osteonecrosis of the femoral head after femoral neck fracture

Osteonecrosis of the femoral head (ONFH) is a common orthopedic disease associated with high disability, and femoral neck fracture (FNF) is one of the most common reasons for traumatic ONFH. This study was designed to reveal the mechanisms underlying ONFH. Using fastx_toolkit and prinseq-lite tools, quality control was conducted for the sequencing data. The differentially expressed genes (DEGs, including both mRNAs and lncRNAs) between ONFH and FNF samples were identified using the edgeR package in R, and were then subjected to enrichment analysis using the BioCloud platform. Subsequently, protein-protein interaction (PPI) networks were constructed using Cytoscape software. After the target genes of DE-lncRNAs were predicted based on Spearman's rank correlation coefficient, lncRNA-gene coexpression network was visualized using the Cytoscape software. Furthermore, functional enrichment analysis was carried out for the target genes using the clusterprofiler package in R. Additionally, the key genes were detected by quantitative real-time polymerase chain reaction (qRT-PCR). A total of 2965 DEGs were identified from the ONFH samples, including 602 DE-lncRNAs (such as downregulated FAM201A). In the PPI networks, eight upregulated genes (including FGF2, IGF1, SOX9, and COL2A1) and 11 downregulated genes were among the top 20 genes according to all of the scores, such as degree centrality, closeness centrality, and betweenness centrality scores. Functional enrichment analysis showed that IGF1, SOX9, and COL2A1 were significantly enriched during skeletal system development. Moreover, qRT-PCR experiments detected the upregulation of FGF2 and downregulation of FAM201A in ONFH samples. FGF2 and FAM201A were correlated with the development of ONFH. Besides, IGF1, SOX9, and COL2A1 might also affect the pathogenesis of ONFH.

Analysis of early stage osteonecrosis of the human femoral head and the mechanism of femoral head collapse

We explored the mechanism of early stage osteonecrotic femoral head collapse by analyzing and comparing different regions in human osteonecrotic femoral head samples. Eight osteonecrotic femoral heads (ARCO II-III) were obtained from patients undergoing total hip arthroplasty. Bone structure was observed and evaluated by micro-computed tomography (CT) scans and pathology. Osteoblast and osteoclast activities were detected by tartrate-resistant acid phosphatase, alkaline phosphatase, and immunofluorescent staining. Some trabeculae had microfractures in the subchondral bone and necrotic region, which had lower bone mineral density, as well as trabecular thickness and number, but greater osteoclast activity. A sclerotic band had already appeared in certain samples which had greater trabecular thickness and number, bone mineral density, and osteoblast activity. The appearance of the femoral head did not change significantly in the early stage of osteonecrosis of the femoral head. However, osteoblast and osteoclast activities had already changed in different regions of the osteonecrotic femoral head, which may lead to eventual collapse of the femoral head. Therefore, osteonecrosis of the femoral head must be treated during the early stage. In addition, osteoblast activity should be promoted and osteoclast activity inhibited as early as possible to prevent collapse of an osteonecrotic femoral head.

Prognostic analysis of different morphology of the necrotic-viable interface in osteonecrosis of the femoral head

PURPOSE

The purpose of this study was to investigate the collapse progression in different morphologies of the necrotic-viable interface in osteonecrosis of the femoral head (ONFH).

METHODS

A total of 168 patients (202 hips) with Association Research Circulation Osseous (ARCO) stage II ONFH were included. Ending with the collapse of the femoral head, all patients received conservative treatment but without surgical intervention and were followed for three to 91 months. Bilateral hip-joint radiographs and magnetic resonance imaging (MRI) were examined, and the largest layer of necrosis within the coronal section of MRI images was selected together with its anteroposterior radiograph to observe the morphology of the necrotic-viable interface. The morphology was divided into four types: I, type transverse; II, type "V"; III, type zigzag; IV, type closed. The collapse rate and the time to collapse in different morphologies were assessed.

RESULTS

A total of 120 hips collapsed in two years or less, 61 were type-I, 51 were type-II, and 8 were type-III. Non-collapse occurred in all 17 hips with type-IV ONFH during long-term follow-up. In 202 hips with ARCO stage-II ONFH, the collapse rate in type-I ONFH was significantly higher than that of type-II and type-III ONFH (P < 0.01 for both). The time to collapse was markedly shortened.

CONCLUSIONS

The risk of ONFH-induced collapse is influenced by the morphology of the necrotic-viable interface. Effective mechanical support for preventing the collapse of the femoral head is necessary when the morphology of the necrotic-viable interface is type transverse.

Association between plasminogen activator inhibitor gene polymorphisms and osteonecrosis of the femoral head susceptibility: A case-control study

This study aimed to analyze the correlation of the plasminogen activator inhibitor (PAI-1) gene polymorphisms (rs6092 and rs7242) with susceptibility of osteonecrosis of the femoral head (ONFH).This case-control study included 106 ONFH patients and 151 healthy controls. PAI-1 polymorphisms were genotyped by polymerase chain reaction (PCR) with direct sequencing. The genotype distribution of polymorphism in the control group was checked with the status of Hardy-Weinberg equilibrium (HWE). The χ test was applied to compare the genotypes of polymorphisms between the case and control groups. The association intensity between PAI-1 polymorphisms and ONFH risk was estimated by odds ratios (ORs) and 95% confidence intervals (95% CI). The linkage disequilibrium of PAI-1 polymorphisms was analyzed by Haploview.We found that the genotypes and alleles of PAI-1 rs6092 and rs7242 polymorphisms had no obvious association with the risk of ONFH (P >.05). But the strong linkage disequilibrium existed between rs6092 and rs7242 polymorphisms and haplotype G-T was significantly associated with the decreased risk of ONFH occurrence (OR = 0.666, 95%CI = 0.445-0.998).PAI-1 rs6092 and rs7242 polymorphisms are not associated with ONFH development, but haplotype G-T may be a protective factor of ONFH.

Short stem total hip arthroplasty for osteonecrosis of the femoral head in patients 60 years or younger: a 3- to 10-year follow-up study

Background

In young patients with osteonecrosis of the femoral head (ONFH), short-stem total hip arthroplasty (THA) could allow a potential advantage in preserving metaphyseal bone-stock, when revision surgery might become necessary. However, only a few studies have evaluated the outcome of short-stem THAs in ONFH. We reviewed the prospectively collected data of a cementless partial neck-retaining short-stem with ceramic-on-ceramic bearings in ONFH patients.

Methods

Thirty patients (37 hips) younger than 60 years (mean age at surgery, 51.5 years) underwent THA with the NANOS® stem (Smith and Nephew, Marl, Germany) from January 2006 to December 2012. All patients received a 32-mm or 36 mm ceramic femoral head. Harris hip score, WOMAC and UCLA activity score were recorded. Postoperative radiographs were evaluated for bone-implant fixation and osteolysis. Further analysis correlated clinical findings with implants characteristics and patient demographics at mean 5.6 years’ follow-up (range, 3–10 years).

Results

The clinical and functional results improved significantly (p < 0.001). At latest follow-up, mean HHS, WOMAC, and UCLA activity scores were 90 (range, 71–100), 94 (range, 76–100), and 6.3 (range, 4–10) points, respectively. The diameter of the femoral head did not influence the clinical outcome (p = 0.661). All hips showed bone ingrowth fixation of the acetabular and femoral components. No patients showed osteolysis. No revision for any reason was performed during the study period.

Conclusions

The excellent clinical results and fixation pattern at mean 5.6 years’ follow-up reveal this implant as a reliable option in advanced stage of ONFH either. Further investigations are crucial to determine the long-term durability and to assess whether the association of ceramic-on-ceramic bearings, can be useful to achieve longer survivorship and lower complications rates.

Trial registration

Registry number: ISRCTN 91336248; date of registration: 04/07/2017.

Predicting the collapse of the femoral head due to osteonecrosis: From basic methods to application prospects

Collapse of the femoral head is the most significant pathogenic complication arising from osteonecrosis of the femoral head. It is related to the disruption of the maintenance of cartilage and bone, and results in an impaired function of the vascular component. A method for predicting the collapse of the femoral head can be treated as a type of clinical index. Efforts in recent years to predict the collapse of the femoral head due to osteonecrosis include multiple methods of radiographic analysis, stress distribution analysis, finite element analysis, and other innovative methods. Prediction methods for osteonecrosis of the femoral head complications originated in Western countries and have been further developed in Asia. Presently, an increasing number of surgeons have chosen to focus on surgical treatments instead of prediction methods to guide more conservative interventions, resulting in a growing reliance on the more prevalent and highly effective total hip arthroplasty, rather than on more conservative treatments. In this review, we performed a literature search of PubMed and Embase using search terms including "osteonecrosis of femoral head," "prediction," "collapse," "finite element," "radiographic images," and "stress analysis," exploring the basic prediction method and prospects for new applications.

Potential diagnostic role of diffusion tensor imaging in early-stage osteonecrosis of the femoral head

The present study aimed to explore the potential diagnostic role of diffusion tensor magnetic resonance imaging (DTI) in the early stage of modified corticosteroid-induced osteonecrosis of the femoral head (ONFH). A total of 20 beagles were randomly classified (1:1) into either an experimental group (LM), which were intramuscularly injected with lipopolysaccharide (LPS) and methylprednisolone (MPS) on three consecutive days, or control (CON) group, which were injected with saline. Magnetic resonance imaging (MRI) and DTI were performed at pre-induction and 8 and 12 weeks post-induction. Apparent diffusion coefficient (ADC) values in the range of interest in the femoral head were quantified using DTI. Proximal femora were examined for ONFH at 8 and 12 weeks. The results demonstrated that ONFH developed in four beagles at 8 weeks and in six beagles at 12 weeks, whereas no ONFH was detected in the CON group. No abnormalities were detected by MRI and DTI, and no mortality occurred. In beagles with ONFH in the LM group, the ADC values were 4.7±0.2×10^-4 and 4.8±0.3×10^-4 mm²/sec at 8 and 12 weeks, respectively, which were significantly increased compared with the CON group (2.5±0.3×10^-4 and 2.4±0.3×10^-4 mm², respectively) and the LM group without ONFH (2.6±0.4×10^-4 and 2.4±0.3×10^-4 mm², respectively) (P<0.05). The results of the present study indicated that intramuscular injection of LPS and MPS may lead to early-stage ONFH in beagles. As such, the detection of locally elevated ADC values in the femoral head may aid in the early diagnosis of ONFH.

Treatment of Pre-Collapse Stages of Osteonecrosis of the Femoral Head: a Systematic Review of Randomized Control Trials

BACKGROUND

Treatment for osteonecrosis of the femoral head (ONFH) remains controversial. Current reviews include low-level evidence studies evaluating the treatment of both pre-collapse and collapse stages of the disease.

QUESTIONS/PURPOSES

The purpose of the current study is to systematically review the literature evaluating core decompression (CD) with bone marrow mesenchymal cells (BMMCs), CD alone, and bisphosphonate treatment in pre-collapse ONFH by focusing just on randomized clinical trials (RCTs) reporting functional and radiologic outcomes. We aim to determine if the literature provides evidence supporting any single approach.

METHODS

Using PubMed and EMBASE databases, we reviewed the clinical evidence of treatments for pre-collapse ONFH following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve RCTs met the inclusion criteria.

RESULTS

Results showed that CD with BMMCs has lower risk of femoral head collapse when compared to the CD alone excluding hips lost to follow-up (relative risk (RR) [95% CI]:0.25 [0.11, 0.60]; p = 0.002) and when assumed that hips lost to follow-up experienced collapse (RR [95% CI]: 0.11 [0.03, 0.47]; p = 0.003). Neither CD nor bisphosphonate treatments showed lower risk to femoral head collapse when compared to control treatments (p = 0.46 and 0.31, respectively).

CONCLUSION

Current literature shows that there is a lower risk of femoral head collapse in patients with ONFH treated with CD combined with BMMCs when compared to CD alone; however, there is no robust evidence to determine the effect on functional outcomes. More RCTs assessing new combination therapies and using standardized outcome measures are required.

The Efficacy of Bisphosphonates with Core Decompression and Mesenchymal Stem Cells Compared with Bisphosphonates Alone in the Treatment of Osteonecrosis of the Hip: a Retrospective Study

INTRODUCTION

Osteonecrosis of the femoral head (ONFH) is a devastating disease with complete collapse of the femoral head often reported in greater than 70% of patients within 3 to 4 years of diagnosis. Early intervention prior to collapse may improve the chance of success of joint preserving procedures.

QUESTIONS/PURPOSES

The purpose of this study was to evaluate whether core decompression with mesenchymal stem cells combined with bisphosphonate therapy can improve the clinical outcomes and reduce the risk of hip replacement when compared to treatment with bisphosphonate therapy alone.

METHODS

Between 2006 and 2014, 84 consecutive patients who were diagnosed with ONFH were identified from our institution's registry. Of these 84 patients, 49 patients (62 hips), fit inclusion/exclusion criteria. Twenty-nine patients (40 hips) were treated with bisphosphonate therapy only. Twenty patients (20 hips) were treated with bisphosphonates, core decompression, and mesenchymal stem cells. Functional outcomes were assessed using the Modified Harris Hip Score (MHHS), the visual analog score (VAS), and evaluation of support system. Clinical failure was defined as deterioration of the MHHS/VAS scores and support system used severe enough to require THR. Radiologic outcome measures included the XR and MR imaging staging of the hip. Survival analysis was performed with total hip replacement as the end point failure. Collapse was defined as progression from Ficat stage I or II to stage III and from Steinberg I, II, III to IV, V, VI.

RESULTS

Failure requiring THR occurred in 21/40 (52.5%) of bisphosphonates (BP)-treated hips at a mean follow-up of 25.3 ± 11.5 months and 5/22 (22.73%) of BP + CD + MSC-treated hips at a mean follow-up of 22.7 ± 19.5 months. The median (Q1, Q3) time to collapse was 24.9 (7.4, 33.0) months in BP-treated hips and 27.3 (27.3) months in BP + CD + MSC-treated hips. There was no evidence of a difference in functional outcomes between the two treatment groups. After adjusting for baseline Ficat stage, age, and sex, an unreplaced hip treated with BP + CD + MSC had 0.42 (95% CI 0.11, 1.57) times the risk of being replaced in the next moment compared to an unreplaced hip treated with bisphosphonates only (P = 0.196).

CONCLUSION

Our results demonstrate that treatment with BP alone or BP + CD + MSC can postpone the need for total hip arthroplasty (THA) in the first 24 months in patients with ONFH compared to previously reported data, but there is no statistically significant difference between the two treatment groups. Combination therapy of BP + CD + MSC may be more effective in delaying the progression of collapse in early stage ONFH. Future prospective studies are warranted to determine the efficacy of these treatment strategies in the long term.

Joint-preserving regenerative therapy for patients with early-stage osteonecrosis of the femoral head

Osteonecrosis of the femoral head is an intractable disease often occurring in patients aged 30–40 years that can cause femoral head collapse, pain, and gait disturbance. Background factors, including corticosteroid use, alcohol intake, and idiopathic causes, have been indicated. It is estimated that 70–80 % of osteonecrosis patients experience femoral head collapse, for which total hip arthroplasty is considered the most effective treatment, even in young patients. Thus, there is a crucial need for developing a minimally invasive regenerative therapy as a preventive surgery for femoral head collapse: this has been an important area of research in the past decades. Core decompression, the most popular minimally invasive surgery for osteonecrosis of the femoral head, has been used for a long time; however, it has been insufficient to prevent femoral head collapse. For further improvement in therapeutic efficacy, cell transplantation and the use of artificial bone and growth factors have been proposed in addition to core decompression. Since 2000, newer therapies such as autologous bone marrow cell transplantation and the embedding of metal implant rods have been developed in Europe and the USA; however, these approaches have yet to become a global standard. This practical review summarizes applied state-of-the-art regenerative therapy-based core decompression. We introduce the clinical application of recombinant human fibroblast growth factor (rhFGF)-2-impregnated gelatin hydrogel for patients with precollapse osteonecrosis of the femoral head. Radiography and computed tomography have confirmed bone regeneration inside the femoral heads around the region of rhFGF-2 gelatin hydrogel administration. With further development, the minimally invasive method, which can be expected to promote bone regeneration in necrotic areas, could become a useful early-stage treatment for osteonecrosis of the femoral head. Patients can resume their daily routine soon after surgery, and the procedure is inexpensive. As such, it is a promising regenerative therapy that can be actively employed in osteonecrosis of the femoral head before femoral head collapse.

Hydrogen-rich saline attenuates steroid-associated femoral head necrosis through inhibition of oxidative stress in a rabbit model

A growing body of evidence suggests that hydrogen is a novel, selective antioxidant that exerts a protective effect against organ damage. The present study investigated the effect of hydrogen-rich saline on corticosteroid-induced necrosis of the femoral head in an animal model established using prednisolone. A total of 30 healthy, male, adult New Zealand white rabbits were randomly divided into two groups: Hydrogen-rich saline (treated with hydrogen-rich saline via intraperitoneal injection) and placebo (treated with normal saline). At the set time-points, the structure of the femoral head was examined using a microscope; the concentrations of glutathione (GSH), lipid peroxide (LPO), vascular endothelial growth factor (VEGF) and thrombomodulin (TM) in the plasma were measured and the microvessel density was quantified. The results showed that hydrogen-rich saline significantly decreased the levels of VEGF, TM and LPO and increased the GSH level in steroid-associated necrosis of the femoral head in the rabbit model. A significant increase in the microvessel density was observed in the hydrogen-rich saline group. Histopathological staining confirmed the results of the biochemical analysis. The present study demonstrates that hydrogen treatment may alleviate steroid-associated osteonecrosis by inhibiting oxidative stress. Hydrogen-rich saline may provide an alternative treatment for steroid-associated necrosis of the femoral head.

Review of various treatment options and potential therapies for osteonecrosis of the femoral head

Size and location of the lesion, subchondral collapse occurrence, and articular cartilage involvement are general disease progression criteria for direct osteonecrosis of the femoral head (ONFH) classifications. Treatment options for ONFH are usually based on individual factors and lesion characteristics. Although spontaneous repair of ONFH occurs in some cases, untreated ONFH is unlikely to escape the fate of subchondral collapse and usually ends up with total hip arthroplasty. Operations to preserve the femoral head, e.g., core decompression and bone grafting, are usually recommended in younger patients. They are helpful to relieve pain and improve function in the affected femoral head without subchondral collapse, however, poor prognosis after surgical procedures remains the major problem for ONFH. Pharmacological and physical therapies only work in the early stage of ONFH and have also been recommended as a supplement or prevention treatment for osteonecrosis. Following advances in basic science, many new insights focus on bone tissue engineering to optimize therapies and facilitate prognosis of ONFH. In this review, disease classifications, current treatment options, potential therapies, and the relevant translational barriers are reviewed in the context of clinical application and preclinical exploration, which would provide guidance for preferable treatment options and translation into novel therapies.

Short-stem hip arthroplasty in osteonecrosis of the femoral head

INTRODUCTION

Osteonecrosis of the femoral head (ONFH) is a locally destructive and complex disorder. Without treatment, infraction of the femoral head is likely. There is also a lack of consensus in the literature about the most appropriate arthroplasty method in patients with progressive ONFH. During the last decade, the number of short-stem prostheses has increased. Some short-stem designs have a metaphyseal anchorage. It is questionable whether ONFH represents a risk factor for failure after implantation of short stems. The aim of this study was to review existing literature regarding the outcome of short-stem arthroplasty in ONFH and to present the pros and cons of short-stem hip arthroplasty in osteonecrosis of the femoral head.

MATERIALS AND METHODS

This review summarises existing studies on short-stem hip arthroplasty in osteonecrosis of the femoral head.

RESULTS

Few studies have analysed the clinical and radiological outcome of short-stem THA in patients with ONFH. Only a handful of studies present clinical and radiological outcome after implantation of a short-stem arthroplasty in patients with the underlying diagnosis of osteonecrosis of the femoral head.

CONCLUSION

The short- to medium-term results show predominantly good outcomes. However, due to differences in the design of short stems and their fixation, it is hard to draw a general conclusion. Short stems with primary diaphyseal fixation do not reveal a high increased risk of failed osseointegration or loosening. For designs with a primary metaphyseal anchorage, an MRI should be conducted to exclude that the ostenecrosis exceeds the femoral neck.

Comparison of core decompression and conservative treatment for avascular necrosis of femoral head at early stage: a meta-analysis

The purpose of the current meta-analysis was to compare the efficacy of core decompression (CD) and conservative treatment (CT) for saving femoral heads in patients with avascular necrosis of femoral head (ANFH). Four RCTs and two CCTs involving 323 hips with 24- to 48-months follow-up were included in this review. Our results suggested CD had a trend of favorable results in contrast to other CT (OR 3.28; 95% CI 0.77-14.02; P = 0.11) but saved much less hips compared to biophysical treatments [odds ratio (OR) 0.37; 95% CI 0.18-0.74; P = 0.005]. In the stratified survival rate analysis by ANFH stage, interestingly, CD group got a significantly higher successful rate of hip joint conservation than other CT group in both stage I and stage II-III (stage I: OR 4.43; 95% CI 1.34-14.65; P = 0.01; stage II-III: OR 6.75; 95% CI 2.18-20.90; P = 0.0009). In the biophysical stimulation subgroup, however, an even higher frequency of survived hips were observed compared to CD group at stage II-III (CD vs. biophysical stimulation: OR 0.34; 95% CI 0.17-0.67; P = 0.002). In conclusion, performing CD for ANFH is effective for preventing femoral collapse within a short-term follow-up, but an even higher successful rate were expected by biophysical stimulations. Nevertheless, the short-term follow-up, the small sample size of the current meta-analysis only provide limited quality of evidence, which required confirmation from further large-scale, well-designed RCT with longer follow-up.