Mid-term results of concentrated autologous bone marrow aspirate transplantation for corticosteroid-associated osteonecrosis of the femoral head in systemic lupus erythematosus

Autologous concentrated bone marrow injection for precollapse osteonecrosis of the femoral head concurrent with contralateral total hip arthroplasty: protocol for a clinical trial

INTRODUCTION

The femoral head contralateral to the collapsed femoral head requiring total hip arthroplasty (THA) often manifests in the precollapse stage of osteonecrosis of the femoral head (ONFH). It is not yet demonstrated how autologous concentrated bone marrow injection may prevent collapse of the femoral head concurrent with contralateral THA. The primary objective is to evaluate the efficacy of autologous concentrated bone marrow injection for the contralateral, non-collapsed, femoral head in patients with bilateral ONFH, with the ipsilateral collapsed femoral head undergoing THA.

METHODS AND ANALYSIS

This is a multicentre, prospective, non-randomised, historical-data controlled study. We will recruit patients with ONFH who are scheduled for THA and possess a non-collapsed contralateral femoral head. Autologous bone marrow will be collected using a point-of-care device. After concentration, the bone marrow will be injected into the non-collapsed femoral head following the completion of THA in the contralateral hip. The primary outcome is the percentage of femoral head collapse evaluated by an independent data monitoring committee using plain X-rays in two directions 2 years after autologous concentrated bone marrow injection. Postinjection safety, adverse events, pain and hip function will also be assessed. The patients will be evaluated preoperatively, and at 6 months, 1 year and 2 years postoperatively.

ETHICS AND DISSEMINATION

This protocol has been approved by the Certified Committee for Regenerative Medicine of Tokyo Medical and Dental University and Japan's Ministry of Healthy, Labour and Welfare and will be performed as a class III regenerative medicine protocol, in accordance with Japan's Act on the Safety of Regenerative Medicine. The results of this study will be submitted to a peer-review journal for publication. The results of this study are expected to provide evidence to support the inclusion of autologous concentrated bone marrow injections in the non-collapsed femoral head in Japan's national insurance coverage.

TRIAL REGISTRATION NUMBER

jRCTc032200229.

An exploratory clinical trial for concentrated autologous bone marrow aspirate transplantation in the treatment of osteonecrosis of the femoral head

PURPOSE

This study evaluated the efficacy and safety of a novel treatment for osteonecrosis, in which concentrated autologous bone marrow aspirate transplantation (CABMAT) is followed by low-intensity pulsed ultrasound (LIPUS) stimulation for 3 months. The study was designed as a prospective, uncontrolled, open-label phase II clinical study.

METHODS

This study included 16 cases of osteonecrosis of the femoral head (ONFH), including 26 hips. Patients were transplanted with concentrated bone marrow and periodically evaluated for infection and neoplasm development. Moreover, clinical and radiological examinations were conducted to confirm the treatment efficacy.

RESULTS

No infections were observed during the course of this study nor tumours developed at the treatment site 24 months after transplantation. At a mean 48 (30-56) months post-transplantation, the onset or progression of collapse was noted in four hips, of which one hip underwent total hip arthroplasty.

CONCLUSION

Treatment with CABMAT combined with 3-month LIPUS stimulation was safe, and further randomised clinical studies are needed to determine the efficacy and feasibility of this treatment.

TRIAL REGISTRATION

UMIN Clinical Trials Registry (UMIN000020940, 9/2/2016).

Grafting of autologous concentrated bone marrow processed using a point-of-care device for patients with osteonecrosis of the femoral head: A phase 1 feasibility and safety study

Introduction

Materials and methods

Results

Conclusion

•

There are accumulated evidence of concentrated bone marrow grafting for hip osteonecrosis.

•

A “point-of-care device” for concentrated bone marrow (CBM) grafting has been developed.

•

This study has confirmed the feasibility and safety of CBM grafting using BioCUE system.

•

A further study aiming for the authorization of this procedure should be conducted in the future.

Total Hip Arthroplasty After Failed Hip-Preserving Surgery with Concentrated Autologous Bone Marrow Aspirate Transplantation for Osteonecrosis of the Femoral Head: A Retrospective Study

PURPOSE

Since 2003, a hip-preserving technique-concentrated autologous bone marrow aspirate transplantation (CABMAT)-has been applied to treat osteonecrosis of the femoral head (ONFH). We investigated intraoperative and postoperative outcomes of total hip arthroplasty (THA) in patients who underwent CABMAT as hip-preserving surgery for ONFH but developed secondary hip osteoarthritis after progressive femoral head collapse.

METHODS

A total of 456 hips in 282 patients underwent CABMAT in our hospital between April 2003 and December 2018; 108 hips required THA (THA conversion rate, 23.7%). We enrolled 60 hips (26 hips in 20 men and 34 in 26 women) with a follow-up of over 2 years. We retrospectively analyzed patient background data, time to THA, surgical procedure, postoperative complications, and clinical outcomes from medical records.

RESULTS

The disease was steroid-related, alcohol-related, and idiopathic in 48, seven, and five hips, respectively. The mean age at THA was 45.7 years, and mean conversion time was 2.7 years. Cementless THA was performed in all cases; the mean operating time and blood loss were 82.7 min and 210 g, respectively. Postoperative complications were observed in four cases; intraoperative fracture, two cases; superficial infection, one case; and dislocation, one case. The mean follow-up period was 5.7 years; no loosening or deep infections occurred. No patients required revision arthroplasty.

CONCLUSION

We noted no complications related to CABMAT. After a minimum 2-year follow-up, the clinical outcomes were good. CABMAT was found to be an useful hip-preserving surgery, with little effect on conversion to THA, and THA outcomes were good.

Osteonecrosis in systemic lupus erythematosus: Systematic insight from the epidemiology, pathogenesis, diagnosis and management

Osteonecrosis (ON) is one of the serious and well recognized complicationscausing severe pain and disability in patients with systemic lupus erythematosus (SLE), and its manifestation and pathogenesis are only partially understood. This review provide an update of the recent progress in etiology, pathogenesis, diagnosis, and treatment of systemic lupus erythematosus related osteonecrosis (SLE-ON). Despite the concomitant use of corticosteroids, alcohol and obesity, the dysregulated immune micro-environment and the complex pathogenesis of SLE synergistically play important roles in the development of ON. Osteonecrosis of femoral head (ONFH) is the most often involved joint in SLE. The current classification and staging system of ONFH is based on imaging techniques, particularly relating to MRI and CT, for the identification and quantification of necrotic lesions. For SLE-ONFH patients, both SLE specific clinical symptoms and ONFH imaging findings should be comprehensively evaluated. Even though advances concerning bone grafting and arthroplasty procedures have resulted in improved clinical outcomes, early pharmacological treatment at the pre-collapse stage may prevent joint collapse and reduce the joint arthroplasty rate, and this needs to be accounted. Although some progress has been made, considerably more research is needed before we fully understand SLE-ONFH. Future treatments of SLE-ONFH may involve genetic or cell-based therapies that target potential biomarkers, and this will lead to effective measures for saving thefunction of hip joint and preventing osteonecrosis.

Glucocorticoid-induced osteonecrosis in systemic lupus erythematosus patients

Osteonecrosis (ON) is a complex and multifactorial complication of systemic lupus erythematosus (SLE). ON is a devastating condition that causes severe pain and compromises the quality of life. The prevalence of ON in SLE patients is variable, ranging from 1.7% to 52%. However, the pathophysiology and risk factors for ON in patients with SLE have not yet been fully determined. Several mechanisms for SLE patients' propensity to develop ON have been proposed. Glucocorticoid is a widely used therapeutic option for SLE patients and high-dose glucocorticoid therapy in SLE patients is strongly associated with the development of ON. Although the hips and knees are the most commonly affected areas, it may be present at multiple anatomical locations. Clinically, ON often remains undetected until patients feel discomfort and pain at specific sites at which point the process of bone death is already advanced. However, strategies for prevention and options for treatment are limited. Here, we review the epidemiology, risk factors, diagnosis, and treatment options for glucocorticoid-induced ON, with a specific focus on patients with SLE.

Core decompression with bone marrow aspirate concentrate in post collapse avascular necrosis of hip: A systematic review and meta-analysis

BACKGROUND

Avascular necrosis (AVN) of femoral head is commonly seen in middle age groups and in its advanced stages, it is a common indication for total hip replacements (THRs). These patients invariably require revision surgeries in their lifetime and modalities to delay the first arthroplasty are necessary. Core decompression (CD) with bone marrow aspirate concentrate (BMAC) have proved successful in early stages of AVN, but their role in advanced stages remains unclear. The present review was done to assess the same.

RESEARCH QUESTION

Is CD and BMAC combination effective in delaying radiographic progression and THRs in post collapse stages of AVN hip?

METHODOLOGY

A systematic review and meta-analysis was conducted to determine the overall efficacy of CD and BMAC in post collapse stages of AVN hip and to specifically compare primary outcomes like radiographic progression along with need of THR, with CD alone.Three data bases (PubMed, EMBASE and SCOPUS) were searched to identify relevant articles.

RESULTS

The present review included 12 studies with 3 studies included in the meta-analysis. There were 270 hips across the 12 studies out of which 196 hips were treated with CD + BMAC.

PRIMARY OUTCOMES

39.8% cases worsened from stage 3 to stage 4, while the overall incidence of THR in stages 3 and 4 was 38.3%. On comparison with CD alone the combination of CD + BMAC did not show any enhanced efficacy in either delaying progression (Odds ratio of 1.41 (95% CI = 0.55-3.62) or in conversion to THR (Odds Ratio: 0. 92; 95% CI = 0.41-2.06).

CONCLUSION

CD can be considered in stage 3 of AVN in younger population to delay the need of arthroplasty, before severe head distortion and arthritis sets in, and can be supplemented with bone strut grafts or tantalum rods, for supporting the articular cartilage. BMAC that has shown better results in early AVN, has not shown any additional benefits when compared to CD alone in advanced cases.

Concentrated autologous bone marrow aspirate transplantation versus conservative treatment for corticosteroid-associated osteonecrosis of the femoral head in systemic lupus erythematosus

Objective: To compare the outcomes of steroid-associated osteonecrosis of the femoral head in patients with systemic lupus erythematosus who underwent conservative treatment and concentrated autologous bone marrow aspirate transplantation

Methods: Osteonecrosis of the femoral head was classified according to the Japanese Investigation Committee system. Concentrated autologous bone marrow aspirate transplantation was performed by aspirating the bone marrow from both iliac crests and then transplanting it to the necrotic area after the core decompression. Patients with >2-year follow-up after the concentrated autologous bone marrow aspirate transplantation in our institution (Group I) and those with >2-year follow-up after the first hospital visit in a cooperative institution (Group II) were included in this study. After a randomized matching based on age, sex, type, stage, and etiology, the collapse rate in pre-collapsed stages and total hip arthroplasty conversion rate in all stages were compared between the two groups.

Results: After the matching adjustment, 33 pairs of hips were included. Preoperatively, 1, 2, 16, and 14 hips were classified as types A, B, C1, and C2, respectively, and 15, 13, 2, and 3 hips were classified as stages 1, 2, 3A, and 3B, respectively. The collapse rates in the pre-collapsed stages were 68% and 39% in Groups I and II, respectively. Total hip arthroplasty conversion rates were 33% and 45% in Groups I and II, respectively. However, Group I had significantly higher and lower conversion rates in stages 1 and 3, respectively (both P<0.05).

Conclusion: Conservative treatment may be preferable in stage 1 hips. In addition, concentrated autologous bone marrow aspirate transplantation may prevent further collapse in stage 3.

Efficacy and safety of stem cell therapy for the early-stage osteonecrosis of femoral head: a systematic review and meta-analysis of randomized controlled trials

Background

Osteonecrosis of femoral head (ONFH) is a seriously degenerative disease with no effective therapies to slow its progression. Several studies have reported short-term efficacy of stem cells on early-stage ONFH. However, its long-term effect was still unclear especially on progression events. This study was performed to evaluate the long-term efficacy and safety of stem cells and analyze its optimal age group and cell number.

Methods

Our review was registered on PROSPERO (http://www.crd.york.ac.uk/PROSPERO), registration number CRD42020136094. Following PRISMA guideline, we searched 8 electronic databases on January 5, 2020, and rigorous random controlled trials (RCTs) utilizing stem cell therapy on early-stage ONFH were included. Quality and bias were analyzed. Pooled analysis was performed to assess difference between various outcomes.

Results

A total of 13 RCTs (619 patients with 855 hips) were included. The application of stem cells significantly delayed collapse of femoral head(I², 70%; RR, 0.54; 95% CI, 0.33 to 0.89; P < .00001) and total hip replacement (THR) (I², 68%; RR, 0.55; 95% CI, 0.34 to 0.90; P = .02) in the long term. It effectively decreased the events of collapse of femoral head (≥ 60 months) (I², 0%; RR, 0.37; 95% CI, 0.28 to 0.49; P < .00001) and THR (> 36 months) (I², 0%; RR, 0.32; 95% CI, 0.23 to 0.44; P < .00001). There existed a beneficial effect for patients under 40 (Collapse of femoral head: I², 56%; RR, 0.41; 95% CI, 0.23 to 0.76; P = .004) (THR: I², 0%; RR, 0.31; 95% CI, 0.23 to 0.42; P < .00001). In addition, quantity of stem cells at 10⁸ magnitude had better effects on disease progression events (I², 0%; RR, 0.34; 95%CI, 0.16 to 0.74; P = .007). Besides, there were no significant differences on adverse events between the stem cell group and control group (I², 0%; RR, 0.82; 95% CI, 0.39 to 1.73; P = .60).

Conclusion

Our findings build solid evidence that stem cell therapy could be expected to have a long-term effect on preventing early-stage ONFH patients from progression events, such as collapse of femoral head and total hip replacement. Furthermore, patients under 40 may be an ideal age group and the optimal cell number could be at 10⁸ magnitude for this therapy. Further studies including strict RCTs are required to evaluate a clear effect of stem cells on ideal patient profile and the procedures of implantation.

Intra-articular pathology affects outcomes after joint preserving surgery for osteonecrosis of the femoral head

PURPOSE

Currently, knowledge regarding the intra-articular pathology and its relationship to outcomes after joint-preserving surgery in patients with osteonecrosis of the femoral head (ONFH) is lacking. The purposes were to evaluate the intra-articular pathology and its relationship with outcomes of joint-preserving surgery in ONFH.

METHODS

We reviewed 41 hips with ONFH in 41 patients (27 women; mean age, 34.9 years old) who underwent intertrochanteric curved varus osteotomy. Radiographic evaluations were based on pre-operative imaging studies, including radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). Intra-articular pathology was evaluated by arthroscopic inspection of the femoral head, labrum, and acetabular cartilage during surgery. In addition, we performed radiographic measurements of the hip, including the collapse of the femoral head and minimal joint space width at three  years post-operatively and at final follow-up.

RESULTS

Arthroscopy revealed damage to the acetabular cartilage and labrum in 22 (54%) and 13 patients (32%), respectively. However, these lesions could be detected on imaging in only 13 (32%) and ten patients (24%), respectively. The change in joint space width after surgery was significantly higher in patients with cartilage degeneration and labral injury (P = 0.02, P = 0.02). Logistic regression analysis for subsequent progression of osteoarthritis showed an association with degenerative changes of articular cartilage and the labral tear as independent predictors (P = 0.001, P = 0.03).

CONCLUSIONS

Our data demonstrate the presence of labral and acetabular cartilage lesions in ONFH patients, while images do not reveal the full extent of the tissue damage. These intra-articular pathologies can be associated with the outcomes after joint-preserving surgery.

Silencing MicroRNA-137-3p, which Targets RUNX2 and CXCL12 Prevents Steroid-induced Osteonecrosis of the Femoral Head by Facilitating Osteogenesis and Angiogenesis

The main pathogenesis of steroid-induced osteonecrosis of the femoral head (SONFH) includes decreased osteogenic capacity of bone marrow-derived mesenchymal stem cells (BMSCs) and damaged blood supply to the femoral head. MicroRNAs (miRNAs) have been shown to play prominent roles in SONFH development. However, there is no report that a specific miRNA targeting two genes in two different pathogenic pathways has been applied to this disease. The present study investigated the effects of transplantation of miR-137-3p-silenced BMSCs on the prevention and early treatment of SONFH. First, western blotting and dual luciferase assays were employed to verify that miR-137-3p directly targets Runx2 and CXCL12. Then, silencing of miR-137-3p was found to facilitate osteogenic differentiation of BMSCs, which was confirmed by alkaline phosphatase (ALP) staining, alizarin red staining and qRT-PCR. Silencing of miR-137-3p also promoted angiogenesis by human umbilical vein endothelial cells (HUVECs) in the presence or absence of glucocorticoids. Thereafter, overexpression of Runx2 and CXCL12 without the 3′ untranslated region (3′UTR) partially rescued the effects of miR-137-3p on osteogenesis and angiogenesis, respectively. This finding further supported the hypothesis that miR-137-3p exerts its functions partly by regulating the genes, Runx2 and CXCL12. We also demonstrated that SONFH was partially prevented by transplantation of miR-137-3p-silenced BMSCs into a rat model. Micro-CT and histology showed that the transplantation of miR-137-3p-silenced BMSCs significantly improved bone regeneration. Additionally, the results of enzyme-linked immunosorbent assays (ELISA) and flow cytometry suggested that stromal cell-derived factor-1α (SDF-1α) and endothelial progenitor cells (EPCs) participated in the process of vascular repair. Taken together, these findings show that silencing of miR-137-3p directly targets the genes, Runx2 and CXCL12, which can play critical roles in SONFH repair by facilitating osteogenic differentiation and mobilizing EPCs.

Ten-year results of concentrated autologous bone marrow aspirate transplantation for osteonecrosis of the femoral head: a retrospective study

BACKGROUND

Idiopathic osteonecrosis of the femoral head (ONFH) occurs at a relatively younger age. It is therefore important to prevent the resultant femoral head collapse and requirement of total hip arthroplasty in these patients. In 2003, we initiated concentrated autologous bone marrow aspirate transplantation (CABMAT), a joint-preserving treatment for ONFH, at our institution. Here, we report the long-term results of CABMAT treatment.

METHODS

We retrospectively collated and analyzed the demographic and treatment data of 69 patients (109 hips) with idiopathic ONFH treated with CABMAT between April 2003 and April 2008.

RESULTS

Totally, 44 patients (21 men, 23 women, 80 hips) completed the 10-year follow-up. The follow-up rate was 73.4%, and the mean follow-up period was 12.0 (range, 10.0-15.4) years. The mean age of the patients was 42.2 (range, 16.3-70.5) years. Using the Association Research Circulation Osseous (ARCO) classification system for preoperative analysis, 12, 31, 32, and 5 hips were classified as stages 1, 2, 3, and 4, respectively. The overall rate of conversion to total hip arthroplasty (THA) was 34% (27/80 hips). In a multivariate regression analysis, the preoperative stage of ONFH and the body mass index were found to correlate significantly with conversion to THA. Totally, 43 hips (of 80) were classified as belonging to the pre-collapse stage (i.e., stages 1 or 2). The overall collapse rate and the THA-conversion rate of these hips were estimated to be 49% (21/43) and 14% (6/43), respectively.

CONCLUSIONS

On the basis of our long-term findings, the minimally invasive and feasible CABMAT therapy can be utilized as one of a joint-preserving treatment for ONFH.

Unusual indication of Cell therapy for hip osteonecrosis after pregnancy

PURPOSE

Osteonecrosis is a rare event during or after pregnancy. Due to the low number of cases, there is no report of long-term results after conservative surgery in this population.

METHOD

From 1992 to 2010, 145 consecutive female patients with unilateral symptomatic (94 stage I and 51 stage II) left hip osteonecrosis (ON) related to pregnancy were treated between 4 and 16 months after delivery with percutaneous mesenchymal stem cell (MSC) injection obtained from bone marrow concentration. The average total number of MSCs (counted as number of colonies forming units-fibroblast) injected in the hip was 185 000 ± 65 000 cells (range 95 000-240 000 cells).

RESULTS

At the most recent follow-up (average 15 years after hip surgery, range 8-25 years), among the 145 hips included in the study, 4 hips (2.7%) had collapsed and were treated with total hip arthroplasty (THA). Thirty-two of the 94 stage I had progressed to stage II; and 4 of the 51 stage II had progressed to stage III and collapse. The other 141 hips (97.3%) were without collapse and pain free. On MRI, as percentage of the volume of the femoral head, the osteonecrosis had decreased from 34.5% pre-operatively to 6% at the most recent follow-up. For women who had other children after treatment, a subsequent pregnancy was not associated with osteonecrosis.

CONCLUSION

Patients with hip osteonecrosis following pregnancy had a low conversion rate to THA when treated early with cell therapy.