Results of Total Hip Arthroplasty after Core Decompression with Tantalum Rod for Osteonecrosis of the Femoral Head

Porous Tantalum Acetabular Cups in Primary and Revision Total Hip Arthroplasty: What Has Been the Experience So Far?-A Systematic Literature Review

BACKGROUND

The global population, especially in the Western world, is constantly aging and the need for total hip arthroplasties has rocketed, hence there has been a notable increase in revision total hip arthroplasty cases. As time has passed, a considerable developments in science and medicine have been attained which have also resulted in the evolution of both surgical techniques and implants. Continuous improvements have allowed large bore bearings to be utilized which provide an increased range of motion, with ameliorated stability and a very low rate of wear. The trend for almost the last two decades has been the employment of porous tantalum acetabular cups. Several studies exist comparing them with other conventional methods for total hip arthroplasties, exhibiting promising short and midterm results.

METHODS

The Preferred Reporting Items for Systematic Reviews and a Meta-Analysis (PRISMA) were used to identify published studies in a comprehensive search up to February 2023, and these studies were reviewed by the authors of the article. Specific rigorous pre-determined inclusion and exclusion criteria were implemented.

RESULTS

Fifty-one studies met our inclusion criteria and were involved in the systematic review. Sixteen studies examined postoperative clinical and radiological outcomes of using a tantalum cup in primary and revision total hip arthroplasty, whilst four biomechanical studies proved the superiority of tantalum acetabular components. Five articles provided a thorough comparison between tantalum and titanium acetabular cups, while the other studies analyzed long-terms results and complication rates.

CONCLUSIONS

Porous tantalum acetabular cups appear to be a valuable option in revision total hip arthroplasty, providing clinical improvement, radiological stability, and promising long-term outcomes. However, ongoing research, longer follow-up periods, and careful consideration of patient factors are essential to further validate and refine the use of tantalum in various clinical scenarios.

Femoral Head Core Decompressions: Characterization of Subsequent Conversion to Total Hip Arthroplasty and Related Complications

BACKGROUND

Core decompression is a minimally invasive joint-preserving approach for early-stage osteonecrosis. The rate at which core decompression patients require total hip arthroplasty (THA) and rates of perioperative adverse outcomes have not been well-characterized.

METHODS

Adult patients undergoing core decompression and/or THA with osteonecrosis of the femoral head were identified from the 2015 to 2021 Q3 PearlDiver M157 database. Those undergoing THA without or with antecedent core decompression were identified and matched 4:1 on age, sex, and Elixhauser Comorbidity Index. Postoperative 90-day adverse events were compared with multivariable analysis. Five-year rates of revision, dislocation, and periprosthetic fracture were compared by the Kaplan-Meier curve and log-rank tests.

RESULTS

Core decompressions were identified for 3,025 patients of whom 387 (12.8%) went on to THA within 5 years (64% within the first year). The median time from initial core decompression to THA was 252 days. For THA, 26,209 adults were identified and 387 had prior core decompression. After matching, there were 1,320 without core decompression and 339 with core decompression. No statistically significant differences were observed in 90-day postoperative adverse events or 5-year rates of revision, dislocation, or periprosthetic fracture.

CONCLUSION

Core decompression may be an option for patients with osteonecrosis and does not seem to affect THA outcomes if required later.

Bone marrow edema of the hip: a narrative review

Bone marrow edema (BME) of the hip is a radiological-clinical condition with symptoms ranging from asymptomatic to severe, and it is characterized by increased interstitial fluid within the bone marrow, usually at the femur. Depending on the etiology it can be classified as primary or secondary. The primary cause of BME is unknown, while the secondary forms include traumatic, degenerative, inflammatory, vascular, infectious, metabolic, iatrogenic, and neoplastic etiologies. BME could be classified as reversible or progressive. Reversible forms include transient BME syndrome and regional migratory BME syndrome. Progressive forms include avascular necrosis of the femoral head (AVNH), subchondral insufficiency fracture, and hip degenerative arthritis. The diagnosis can be difficult, because at the beginning, the outbreak of hip pain, typically acute and disabling without any prior trauma or exceptional physical activity, is poorly supported by radiographic findings. MRI is the gold standard, and it shows an area of intermediate signal on T1-weighted MRI scans and a high signal on T2-weighted scans, usually lacking sharps margins. In the reversible form, BME is typically self-limiting, and it can be managed conservatively by means of pharmacological and physical therapy. Surgery is generally required for progressive forms in patients who failed non-operative treatment, and it ranges from femoral head and neck core decompression to total hip arthroplasty.

Bone tissue engineering for treating osteonecrosis of the femoral head

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

Familial Thrombophilia Is Associated With Primary Multifocal Osteonecrosis: A Case-Control Study of 40 Patients

To characterize pathoetiologic associations of heritable thrombophilia-hypofibrinolysis with idiopathic (primary) multifocal osteonecrosis (ON) (≥3 ON anatomic sites), we prospectively studied 28 women and 12 men with primary multifocal ON compared with 27 women and 24 men with primary nonmultifocal ON (<3 sites) and 110 healthy controls without ON. The 40 cases with primary multifocal ON differed from controls for 3 familial thrombophilias: Factor V Leiden heterozygosity (6 of 40 [15%] vs 2 of 109 [2%], P=.002), G20210A prothrombin gene heterozygosity (6 of 40 [15%] vs 3 of 110 [3%], P=.011), and high (>150%) Factor VIII (8 of 40 [20%] vs 7 of 103 [7%], P=.031). These case-control familial coagulation differences paralleled those in 51 concurrently evaluated cases with primary nonmulti-focal ON, 7 of 51 (14%) of whom had Factor V Leiden heterozygosity vs 2% of controls (P=.005) and 14 of 44 (32%) of whom had high Factor VIII vs 7 of 103 (7%) of controls (P=.0002). Recognition of familial thrombophilia as a common pathoetiology of primary multifocal ON provides an opportunity for early anticoagulation (before joint collapse), allowing both prophylaxis and therapy aimed at relieving pain and slowing or stopping progression of the disease to joint collapse. [Orthopedics. 202X;XX(X):xx-xx.].

Hip Resurfacing Arthroplasty after Failure of Tantalum Rod Insertion in Patients with Osteonecrosis of the Femoral Head

Purpose

The purpose of this study was to examine the clinical outcomes and efficacy of hip resurfacing arthroplasty (HRA) in patients with osteonecrosis of the femoral head after the failure of porous tantalum rod insertion without rod removal.

Materials and Methods

Conversion to hip resurfacing arthroplasty was performed in 10 patients (11 hips) with a mean period of 14.9 months after the primary surgery. The mean follow-up period was 73.7 months. Analysis of pre and postoperative range of motion (ROM), University of California at Los Angeles (UCLA) activity score, modified Harris hip score, and visual analog scale (VAS) pain score was performed. Radiographic analysis of component loosening and osteolysis was performed.

Results

The postoperative ROM showed significant improvement (P<0.05), excluding flexion contracture. The modified Harris hip score showed improvement from 65.82 to 96.18, the UCLA score showed improvement from 4.18 to 8.00, and the VAS pain score was reduced from 6.09 to 1.80. All scores showed statistically significant improvement (P<0.05). No component loosening or osteolysis was detected by radiographic analysis.

Conclusion

Satisfactory results were obtained from conversion hip resurfacing arthroplasty after failure of porous tantalum rod insertion without rod removal. The findings of this study demonstrate the advantages of HRA, including no risk of trochanteric fracture and no bone loss around the tantalum rod. In addition, the remaining porous tantalum rod provided mechanical support, which reduced the potential risk of femoral neck fracture or loosening. This technique can be regarded as a favorable treatment option.

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

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

Does prior core decompression have detrimental effect on subsequent total hip arthroplasty for osteonecrosis of the femoral head: A systematic review and meta-analysis

BACKGROUND

Core decompression (CD) is effective in relieving pain and delaying the progression to total hip arthroplasty (THA) for osteonecrosis of the femoral head (ONFH). However, the influence of CD on subsequent THA has not yet been established. Therefore, we performed this systematic review to answer: does prior CD have detrimental effect on subsequent THA for ONFH, especially with regards to survivorship and functional results, as well as perioperative and postoperative complications.

PATIENTS AND METHODS

After registration on PROSPERO (CRD42019118861), literature published up to and including November 2018 was searched in the PubMed, Embase and Cochrane library databases with predetermined terms. Comparative studies on the clinical outcomes between conversion to THA with prior CD (the Prior CD group) and primary THA (the Control group) for ONFH were included. The outcomes of interest included survivorship free from revision, the postoperative functional performance, perioperative and postoperative complications. Data was extracted systematically and a meta-analysis was performed.

RESULTS

Overall, 5 retrospective cohort studies with 110 hips were identified for the Prior CD group and 237 hips were identified for inclusion in the Control group. All of the studies were of high quality in terms of the Newcastle-Ottawa Scale. No difference in the rate of revision between the two groups (2/42 (4.8%) vs. 4/160 (2.5%); RR=1.92; 95% CI=0.34 to 10.75; p=0.46) was detected after a minimum two-year follow-up. The mean postoperative Harris Hip Score was similar between the two groups in all 5 studies. The two groups experienced similar blood loss (Mean difference=12.17ml; 95% CI= -15.28 to 39.61ml; p=0.38). Moreover, intraoperative fracture was increased in the Prior CD group, though this did not reach statistical significance (3/31 (9.7%) vs. 0/55 (0.0%); RR=7.05; 95% CI=0.82 to 60.78; p=0.08). Similarly, osteolysis or radiolucent lines were more likely to occur in the Prior CD group without statistical significance (9/81 (11.1%) vs. 6/200 (3.0%); RR=3.14, 95% CI=0.98 to 10.06; p=0.05).

DISCUSSION

The present evidence indicated that prior CD does not detrimentally affect the survivorship nor hip scores of subsequent THA. Attention should be paid, however, to the potential for intraoperative fracture, postoperative osteolysis or radiolucent lines.

LEVEL OF EVIDENCE

III; systematic review and meta-analysis of level III retrospective comparative studies.

Outcomes of conversion THA after failed porous tantalum implant for osteonecrosis of the femoral head: a comparative matched study

BACKGROUND

As a joint-preserving surgery, porous tantalum implantation (PTI) provides an additional treatment option for osteonecrosis of the femoral head (ONFH). However, conversion to a total hip arthroplasty (THA) after failed PTI is considered a challenging procedure. The purpose of this study was to compare the clinical and radiologic outcomes and complications of THA after failed PTI with those of primary THA without any previous surgery for ONFH.

METHODS

This retrospective study included 32 patients undergoing THA after failed PTI and 25 age, sex, and body mass index matched patients who underwent primary THA without any previous surgery for ONFH between December 2009 and March 2014. All patients were followed for at least 36 months. The postoperative clinical and radiological evaluations were based on Harris Hip Score (HHS) and plain radiographs. The independent sample test and the chi-square test were used for the statistical analysis.

RESULTS

The HHS in the PTI group was similar to that in the primary group at the latest follow-up (p = 0.274), but longer operation time and greater intraoperative blood loss were observed in the PTI group (p < 0.001, respectively). No significant differences in radiological parameters and postoperative complications were found between the 2 groups (p > 0.05).

CONCLUSIONS

THA after PTI showed similar clinical and radiological outcomes to primary THA except for longer operation time and greater intraoperative blood loss.

A silk-based high impact composite for the core decompression of the femoral head

Core decompression of the femoral head is a recommended head-conserving strategy for early-stage osteonecrosis of the femoral head. However, no ideal filling material has been found so far. In this study, we fabricated a "solid core-porous coating" composite scaffold, which is a silk fibroin/hydroxypropyl methylcellulose (SF/HPMC) scaffold, by a "two-step" process. The solid core scaffold possesses a sufficient compression modulus (860 MPa) for support, while the porous coating scaffold with controllable pore size and porosity provides a suitable microenvironment for the osteoblast cell to adhere and proliferate. Moreover, the porous coating scaffold was mineralized by adding different contents of hydroxyapatite crystal to further enhance its osteoinductivity, according to the simulated body fluid (SBF) biomineralization assay. To demonstrate the biocompatibility and osteoinductivity of such composite scaffolds, a series of in vitro experiments were performed, indicating the MC3T3-E1 pre-osteoblast cells grew and differentiated well on the mineralized porous coating scaffolds. The mechanical testing results also proved that the mechanical property of the solid core scaffold varied (230-1600 MPa) with different solid contents of SF/HPMC, as expected. Furthermore, the rabbit femoral head core decompression model was adopted and confirmed the excellent mechanical performance of the solid core scaffolds, as well as the satisfied osteoinductivity of the porous coating scaffold, by inserting the composite scaffolds into the bone tunnel in vivo. All of the preliminary results implied that the novel biodegradable composite scaffold has an outstanding prospective for the clinical use of core decompression of the femoral head.

Long-term Anticoagulation Prevents Progression of Stages I and II Primary Osteonecrosis of the Hip in Patients With Familial Thrombophilia

The authors prospectively assessed long-term anticoagulation outcomes (≥3 years) for 9 patients meeting 4 inclusion criteria: pretreatment Ficat stage I or II primary hip osteonecrosis (ON), factor V Leiden or prothrombin G20210A heterozygosity, no contraindication to anticoagulation, and 90-day participation in an initial enoxaparin 60 mg/d protocol. The primary endpoint was prevention of hip collapse (Ficat stage III or IV). The secondary endpoint was pain relief. After 90 days of enoxaparin 60 mg/d, anticoagulation was continued for 8 patients: 4 receiving warfarin (international normalized ratio targeted to 2 to 2.5; 11.5, 13, 14.5, and 21 years), 1 receiving enoxaparin 120 mg/d (11.5 years), and 3 receiving novel oral anticoagulants (5, 6, and 8 years). Radiographs were obtained before treatment; at 3 to 4, 6 to 8, and 12 to 14 months; and then annually. By selection, 8 patients had factor V Leiden heterozygosity and 1 had prothrombin G202010A heterozygosity. Of their 13 hips (Ficat I or II at entry), 12 remained Ficat I or II after 12±5 years (range, 5.5-21 years) of continuous anticoagulation and follow-up; 1 hip radiographically normalized. None of the 13 hips progressed to collapse (Ficat III or IV). Six patients became symptom free after the first 3 months of receiving enoxaparin, 1 after 6 months of anticoagulation, and 1 after 10 months of anticoagulation; all 8 patients remained symptom free with anticoagulation. Anticoagulation for primary hip ON before hip collapse in patients with familial thrombophilia may change the natural history of ON because most untreated patients with ON have joint collapse and total joint replacement within 2 years of original symptoms. [Orthopedics. 2020;43(4):e208-e214.].

Osteonecrosis of femoral head in young patients with femoral neck fracture: a retrospective study of 250 patients followed for average of 7.5 years

Objective

To investigate the risk factors for osteonecrosis of the femoral head (ONFH) after the treatment of femoral neck fracture in patients under 60 years old.

Methods

A total of 250 cases of femoral neck fracture treated at 3 hospitals in Xuzhou from January 2002 to January 2016 were studied. The patients were followed up for 1~15 years, and the clinical data on femoral head necrosis after the femoral neck operation were analysed retrospectively. Risk factors were recorded, including age, gender, preoperative traction, time from injury to operation, reduction method, type of reduction, BMI, ASA classification, and quality of reduction. Logistic regression analysis was used to evaluate the independent risk factors for ONFH after treatment of femoral neck fracture.

Results

The duration of follow-up was 1~15 years, with an average of 7.5 years. None of the 250 patients had fracture non-union, but 40 (16%) had necrosis of the femoral head. The time to necrosis of the femoral head was 1~7 years after the operation, with an average of 3.8 years. Univariate analysis showed that the type of fracture, the quality of reduction, the removal of internal fixation, BMI and ASA classification were risk factors affecting necrosis of the femoral head in patients with femoral neck fracture, and the difference was statistically significant (P < 0.05). Multivariate analysis showed that internal fixation, fracture type (displacement), reduction quality (dissatisfaction), BMI (> 25), and ASA grade (III + IV) were independent risk factors affecting femoral head necrosis in patients with femoral neck fracture.

Conclusion

A variety of high-risk factors for femoral head necrosis are present after surgery with hollow compression screws for femoral neck fracture in adults. Removal of internal fixation, type of fracture, quality of reduction, BMI, and ASA classification were the most important risk factors influencing the development of femoral head necrosis. During treatment, there should be some targeted measures to reduce the incidence of necrosis of the femoral head.

Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today?: A 5-Year Update

➢. Clinicians should exercise a high level of suspicion in at-risk patients (those who use corticosteroids, consume excessive alcohol, have sickle cell disease, etc.) in order to diagnose osteonecrosis of the femoral head in its earliest stage. ➢. Nonoperative treatment modalities have generally been ineffective at halting progression. Thus, nonoperative treatment is not appropriate in early stages when one is attempting to preserve the native joint, except potentially on rare occasions for small-sized, medially located lesions, which may heal without surgery. ➢. Joint-preserving procedures should be attempted in early-stage lesions to save the femoral head. ➢. Cell-based augmentation of joint-preserving procedures continues to show promising results, and thus should be considered as an ancillary treatment method that may improve clinical outcomes. ➢. The outcomes of total hip arthroplasty in the setting of osteonecrosis are excellent, with results similar to those in patients who have an underlying diagnosis of osteoarthritis.

The Comparative Analysis of Antegrade Versus Retrograde Approach for a Failed Porous Tantalum Rod Removal During Conversion to Total Hip Arthroplasty

Background

The failure of porous tantalum rods applied to patients with osteonecrosis of the femoral head (ONFH) has been increasingly reported during the last few years. Very few studies have reported methods for implant removal. This study aimed at comparing 2 procedures used for the removal of a failed tantalum rod during conversion to total hip arthroplasty (THA).

Material/Methods

A total of 65 patients (65 hips), who underwent THA after failed implantation of a tantalum rod between June 2007 and December 2016, were retrospectively evaluated. These patients were classified into 2 groups depending on whether the antegrade approach (removal of the tantalum rod from the tip to the butt at the lateral femoral cortex, n=27) or retrograde approach (removal of the tantalum rod from the butt at the lateral femoral cortex to the proximal tip, n=38) was used for rod extraction. These 2 groups were compared for incision length, operation time, blood loss, fracture, tantalum debris, Harris hip scores, and the presence of osteolysis and/or radiolucency.

Results

These 2 groups did not present any significant differences in terms of Harris hip score and incision length. However, the operation time (P=0.000), blood loss (P=0.000), amount of tantalum debris (P=0.000), and presence of radiolucency (P=0.046) were greater for the retrograde approach than for the antegrade approach.

Conclusions

The risk of conversion to THA following failed tantalum rod implantation is high. In such cases, the antegrade procedure was found to be a simple and efficient method for removing the trabecular metal rod with the use of a trephine.

Comparison of core decompression and porous tantalum rod implantation with conservative treatment for avascular necrosis of the femoral head: A minimum 18 month follow-up study

Porous tantalum rod implantation is a novel surgical method that is used to treat avascular necrosis (AVN) of the femoral head (hip). In the present study, the results of core decompression and tantalum rod implantation were compared with non-surgical treatment for AVN, and the survivorship of the femoral head was evaluated. In total, 60 patients with AVN femoral head were recruited and analysed. Non-surgical treatment was selected by 30 patients (41 hips), 7 with a Ficat score of I and 23 with a score of II. Non-surgical treatment included celecoxib, salvia miltiorrhiza and tetramethylypyrazine and a reduction in weight-bearing activities. Surgical treatment and porous tantalum rod implantation were selected by 30 patients (41 hips), 10 with a Ficat score of I and 20 with a score of II. After follow-up (average: 33.5 months), patients were evaluated by assessing post-operative complications, radiology, hip survivorship and Harris hip score. In the surgical group, pre-operative symptoms were significantly alleviated. No complications, including infection, delayed healing or fractures were reported. Final follow-up rates of femoral head survivorship were 4.9% in the non-surgical group and 36.7% in the surgical group. The Harris hip score was significantly improved following surgery when compared with non-surgical treatment (P<0.05). The results indicated that core decompression and porous tantalum rod implantation are beneficial short- and mid-term treatment methods for AVN of the femoral head.

Comparison of Total Hip Arthroplasty after Two Types of Failed Hip Preserving Procedures with Primary Total Hip Arthroplasty

Objective

Porous tantalum implantation (PTI) and bone impaction grafting (BIG) through a window at the femoral head neck junction are known as two types of joint‐preserving procedures. They provide an alternative option in the treatment of osteonecrosis of the femoral head by providing strong structural support to the subchondral plate. However, when earlier joint‐preserving treatments fail, conversion to a total hip arthroplasty seems to be the final treatment of choice. This emphasizes the importance of joint‐preserving procedures that do not hinder the clinical results of a subsequent total hip arthroplasty. The results of conversion total hip arthroplasty after failed PTI and BIG are still controversial. The purpose of this study was to compare the clinical and radiological outcomes of total hip arthroplasty after failed PTI or BIG surgery with primary total hip arthroplasty.

Methods

Patients at our institution between 2010 and 2014 who underwent total hip arthroplasty after failed PTI or BIG surgery compared to primary total hip arthroplasty were retrospectively reviewed. A total of 27 patients (30 hips) who underwent total hip arthroplasty after failed PTI surgery (group I) were matched according to age, gender and BMI index with 28 patients (30 hips) who underwent total hip arthroplasty after failed BIG surgery (group II) and 30 patients (30 hips) who underwent primary total hip arthroplasty (group III). The clinical results included preoperative and postoperative Harris Hip score, surgery duration, blood loss volume and clinical complications. Radiological follow‐up results included abduction angle and anteversion angle of the acetabular cup, periprosthetic osteolysis, and prosthesis subsidence.

Results

There was no significant difference in the preoperative and postoperative Harris Hip score among the three groups at the latest follow‐up (P = 0.247). The surgery duration was longer and intra‐operative blood loss volume was higher in group I than in group II and group III (P < 0.05, respectively). There was no difference in surgery duration and blood loss volume between group II and group III (P > 0.05). There was no significant difference in radiological follow‐up results among the three groups (P > 0.05). Varying degrees of residual tantalum debris were seen on postoperative radiographs of all group I patients. There was no difference in the incidence of complications among the three groups (P > 0.05).

Conclusions

PTI group had higher blood loss volume and surgery duration than BIG group and primary total hip arthroplasty group. BIG group had no significant differences with primary total hip arthroplasty group in clinical and radiological follow‐up results. There were no significant differences between the three groups in the Harris Hip score and radiological follow‐up results.

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

Background

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

Methods

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

Results

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

Conclusions

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

Total hip arthroplasty following failure of tantalum rod implantation for osteonecrosis of the femoral head with 5- to 10-year follow-up

BACKGROUND

Total hip arthroplasty (THA) with failure of tantalum rod implant for osteonecrosis of the femoral head (ONFH) will be the only choice for patients. However,it remains unknown whether tantalum rod implantation has an adverse effect on the survival time of implants following conversion to THA. The aim of this study was to retrospectively evaluate the clinical and radiographic outcomes of conversion to THA in patients who were previously treated with implantation of a tantalum rod.

METHODS

This study included 31 patients (39 hips), who underwent conversion to THA due to failure of core decompression with an implanted tantalum rod. Among these 31 patients, 26 patients were male and five patients were female. The mean age of these patients was 49.3 years old (range: 36-64 years old). The control group included 33 patients (40 hips), who underwent total hip replacement without tantalum rod implantation. The hip Harris score, implant wear, osteolysis, radiolucencies and surgical complications were recorded during the follow-up. The distribution of tantalum debris in the proximal, middle and distal periprosthetic femoral regions, radiolucent lines and osteolysis were analyzed on post-operative radiographs.

RESULTS

There were no significant differences in Harris score, liner wear and complications between the two groups (P > 0.05). Osteolysis and radiolucent lines more likely occurred in patients with tantalum debris distributed in three regions than in one or two regions (P < 0.05).

CONCLUSIONS

The mid-term clinical outcome of patients who underwent THA with tantalum rod implantation was not different from those without a tantalum rod, suggesting that tantalum debris did not increase the liner wear rate. However, the distribution of periprosthetic tantalum debris in the proximal, middle and distal femoral regions may increase the risk of femoral osteolysis and radiolucent lines.

Clinical therapy of hyaluronic acid combined with platelet-rich plasma for the treatment of knee osteoarthritis

Knee osteoarthritis is the most common degenerative disease of the joints caused by articular cartilage injury, degradation of the joint edge and subchondral bone hyperplasia. Various treatments are used to alleviate the symptoms of patients with knee osteoarthritis, including analgesics and intra-articular injections. Platelet-rich plasma (PRP) is an autologous and multifunctional platelet concentrate of the blood, which stimulates the cartilage healing process and improves the damage caused by articular disease. Hyaluronic acid (HA) is an effective treatment for patients with knee osteoarthritis. In the current study, the effectiveness of PRP and HA combination therapy administered via intra-articular injections for patients with knee osteoarthritis was analyzed. A total of 360 patients with knee osteoarthritis were randomized into four different treatment groups as follows: Double-blind treatment with PRP (2-14 ml); double-blind treatment with HA (0.1-0.3 mg); combination therapy of PRP and HA; and placebo groups. Following treatment, all patients were evaluated using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Common Toxicity Criteria. The most common treatment-emergent adverse events were hypertension and proteinuria. The current study demonstrated that PRP and HA treatment significantly improved arthralgia, and PRP treatment was determined to be significantly more effective than HA treatment using the WOMAC pain score (P<0.05). PRP and HA combination treatment significantly improved arthralgia, reduced humoral and cellular immune responses and promoted angiogenesis, which improved the patients' histological parameters compared with PRP or HA treatment alone. These results suggested that PRP and HA combination treatment may be a potential treatment option for patients with knee osteoarthritis in the future.

What is the rate of patients undergoing a total hip arthroplasty after core decompression and insertion of a tantalum rod in osteonecrosis of the femoral head: a systematic review

PURPOSE

Core decompression (CD) may be effective when performed during the early stages of osteonecrosis of the femoral head (ONFH). Tantalum may be added as a rod that would allow putting some mechanical constraints on the femoral head. We aimed to estimate the rate of total hip arthroplasty after CD and insertion of a tantalum rod during early stages of OFNH.

METHODS

We searched systematically Medline via PubMed and the Cochrane Library. Our primary endpoint was the rate of patients undergoing a total hip arthroplasty after CD and insertion of a tantalum rod. Secondary endpoints were the delay between the initial surgery and the arthroplasty, the functional improvement, and the rate of complications.

RESULTS

We included seven  studies reporting the results of 232 patients (297 hips) that were operated on by CD and insertion of a tantalum rod. At a mean follow-up of 26.97 months, 24.63% of the included hips underwent a hip arthroplasty (6-56%, SD = 17.34%). The mean delay between the initial surgery and the arthroplasty was 14.94 months (10.20-22.90; SD = 5.25), the mean improvement of Harris Hip Score was 27.66 (20.20-36.90; SD = 6.48), and the mean rate of femoral fracture was 2.43% (0-13%, SD = 4.89%).

CONCLUSION

CD and insertion of a tantalum rod may represent a solution in order to improve the mechanical support and to give a rate of conversion in arthroplasty that is acceptable.

Coating of Sandblasted and Acid-Etched Dental Implants With Tantalum Using Vacuum Plasma Spraying

PURPOSE

The objective was to prepare tantalum (Ta)-coated sandblasted and acid-etched (SLA) dental implants using vacuum plasma spraying (VPS) and to analyze their morphologies.

MATERIALS AND METHODS

Twelve SLA implants were coated with Ta using VPS. The topographies of the coatings and Ta/SLA surface interfaces were examined using scanning electron microscopy. The thickness at 4 locations for 6 Ta-coated and 6 uncoated SLA implants and pore sizes of the neck, central, and root areas of Ta-coated implants were measured. SPSS v20.0 was used for statistical analysis.

RESULTS

The Ta coatings were rough and consisted of pitted structures with various pore sizes; no cracks were observed. The Ta/SLA surface interface was tightly bonded. The 95% confidence interval of the Ta coating thickness was (114.0759, 129.3574). The maximal pore diameter was concentrated at 200 to 400 nm.

CONCLUSION

SLA dental implants were successfully coated with Ta using VPS. The nanoporous structure of these implants may facilitate osseointegration compared with uncoated SLA implants.

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.

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.

Platelet-rich plasma shows beneficial effects for patients with knee osteoarthritis by suppressing inflammatory factors

Knee osteoarthritis is a degenerative disease that may develop due ageing, obesity, strain, congenital abnormal joints, joint deformity or trauma. It is caused by many factors, such as degradation of articular cartilage injury, joint edge and subchondral bone hyperplasia of reactivity. Platelet-rich plasma (PRP) is an autologous blood sample that contains highly concentrated platelets and multiple cell growth factors. PRP promotes synovial cell proliferation and differentiation and may recover cartilage morphology. In the present study, the clinical efficacy of PRP was investigated in patients with knee osteoarthritis aged between 18 and 30 years in a phase-III clinical study. Following an 8-week baseline, patients with knee osteoarthritis were randomized into once-weekly, double-blind treatment with PRP (2-14 ml) or placebo groups. The results indicated that patients with osteoarthritis treated with PRP had modulated plasma concentrations of inflammatory factors and pro-angiogenic factors compared with the placebo group. Treatment responses were assessed by median percent reduction in inflammatory and pro-angiogenic factors and these improved with PRP treatment compared with the placebo. Clinical data indicated that PRP alleviated knee osteoarthritis and reduced humoral and cellular immune responses that led to beneficial effects on histological parameters. Inflammation was significantly alleviated in patients receiving PRP compared with the placebo group. The most common treatment-emergent adverse events in the presence of PRP were hypertension and proteinuria. In conclusion, treatment with PRP for patients with knee osteoarthritis presented beneficial effects in alleviating joint inflammation, cartilage destruction and bone damage, and repairing joint tissue. These results suggested that PRP may be a potential therapeutic agent for knee osteoarthritis.

An evidence-based guide to the treatment of osteonecrosis of the femoral head

Non-traumatic osteonecrosis of the femoral head is a potentially devastating condition, the prevalence of which is increasing. Many joint-preserving forms of treatment, both medical and surgical, have been developed in an attempt to slow or reverse its progression, as it usually affects young patients. However, it is important to evaluate the best evidence that is available for the many forms of treatment considering the variation in the demographics of the patients, the methodology and the outcomes in the studies that have been published, so that it can be used effectively. The purpose of this review, therefore, was to provide an up-to-date, evidence-based guide to the management, both non-operative and operative, of non-traumatic osteonecrosis of the femoral head. Cite this article: Bone Joint J 2017;99-B:1267-79.

Case report: primary osteonecrosis associated with thrombophilia-hypofibrinolysis and worsened by testosterone therapy

Background

Familial and acquired thrombophilia are often etiologic for idiopathic hip and jaw osteonecrosis (ON), and testosterone therapy (TT) can interact with thrombophilia, worsening ON.

Case presentation

Case 1: A 62-year-old Caucasian male (previous deep venous thrombosis), on warfarin 1 year for atrial fibrillation (AF), had non-specific right hip-abdominal pain for 2 years. CT scan revealed bilateral femoral head ON without collapse. Coagulation studies revealed Factor V Leiden (FVL) heterozygosity, 4G/4G plasminogen activator inhibitor (PAI) homozygosity, high anti-cardiolipin (ACLA) IgM antibodies, and endothelial nitric oxide (NO) synthase (eNOS) T786C homozygosity (reduced conversion of L-arginine to NO, required for bone health). Apixaban 5 mg twice daily was substituted for warfarin; and L-arginine 9 g/day was started to increase NO. On Apixaban for 8 months, he became asymptomatic. Case 2: A 32-year-old hypogonadal Caucasian male had 10 years of unexplained tooth loss, progressing to primary jaw ON with cavitation 8 months after starting TT gel 50 mg/day. Coagulation studies revealed FVL heterozygosity, PAI 4G/4G homozygosity, and the lupus anticoagulant. TT was discontinued. Jaw pain was sharply reduced within 2 months.

Conclusions

Idiopathic ON, often caused by thrombophilia-hypofibrinolysis, is worsened by TT, and its progression may be slowed or stopped by discontinuation of TT and, thereafter, anticoagulation. Recognition of thrombophilia-hypofibrinolysis before joint collapse facilitates anticoagulation which may stop ON, preserving joints.

3D printing of Mg-substituted wollastonite reinforcing diopside porous bioceramics with enhanced mechanical and biological performances

Mechanical strength and its long-term stability of bioceramic scaffolds is still a problem to treat the osteonecrosis of the femoral head. Considering the long-term stability of diopside (DIO) ceramic but poor mechanical strength, we developed the DIO-based porous bioceramic composites via dilute magnesium substituted wollastonite reinforcing and three-dimensional (3D) printing. The experimental results showed that the secondary phase (i.e. 10% magnesium substituting calcium silicate; CSM10) could readily improve the sintering property of the bioceramic composites (DIO/CSM10-x, x = 0-30) with increasing the CSM10 content from 0% to 30%, and the presence of the CSM10 also improved the biomimetic apatite mineralization ability in the pore struts of the scaffolds. Furthermore, the flexible strength (12.5-30 MPa) and compressive strength (14-37 MPa) of the 3D printed porous bioceramics remarkably increased with increasing CSM10 content, and the compressive strength of DIO/CSM10-30 showed a limited decay (from 37 MPa to 29 MPa) in the Tris buffer solution for a long time stage (8 weeks). These findings suggest that the new CSM10-reinforced diopside porous constructs possess excellent mechanical properties and can potentially be used to the clinic, especially for the treatment of osteonecrosis of the femoral head work as a bioceramic rod.